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Archive for the ‘OR snapshots’ Category

OR Snapshots – The Open Rhinoplasty

Sunday, January 8th, 2017

 

Rhinoplasty surgery requires incisional access to perform osteocartilaginous reshaping. The most common historic technique was the ‘closed approach’ where all incisions were placed inside the nose. Because this provided limited visual access it took a lot of experience to master aesthetic nasal surgery. This was the standard in rhinoplasty until the 1990s were it was surpassed in usage by the ‘open approach’.

open-rhinoplasty-indianapolis-dr-barry-eppleyThe open approach degloves the skin off the tip of the nose and permits complete visual access to the entire underlying nasal structures. What makes it possible to expose the nose is the mid-columellar incision. This extra 6mms of skin incisional length connects with intranasal mucosal incisions to allow the nasal tip skin to be lifted off of the lower alar cartilages. While once controverial, the open rhinoplasty has become the standard technique in rhinoplasty today as it produces consistent and more reliable surgical outcomes.

Patients are often understandably concerned about a visible nasal scar with the open nasal approach. But the columellar skin heals so well that such a scar is virtually invisible in most patients. It rarely causes a scar problem and I have never seen a hypertrophic or keloid columellar scar. The only occasional columellar scar problem seen is a stepoff or notch along one of its sides due to less than perfect closure or premature incisional separation.

Interestingly, the widespread use of the open approach has led to a re-emergence of the closed approach. Now known as the ‘scarless’ rhinoplasty, the use of the closed approach is refinding a role in certain types of nasal reshaping surgeries.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Abdominal Panniculectomy (Apron Removal)

Tuesday, January 3rd, 2017

 

The abdominal panniculectomy procedure is well known to be a ‘big’ operation. It is the supersized version of the traditional tummy tuck and is often judged by the weight of the pannus removed. The largest abdominal pannus I have ever removed is 85lbs and that was back in the pre-bariatric surgery era…when the abdominal panniculecomy was the only form of bariatric or weight loss surgery.

abdominal-panniculectomy-surgery-dr-barry-eppley-indianapolisOne of the challenges in this operation is to manage the considerable soft tissue mass, removing the most abdominal tissue that one can while still being able to close the wound without creating after surgery healing problems. When removed the abdominal pannus looks even bigger than when it is attached and hanging on the patient. The term ‘pannus’ is often associated with the word ‘apron’. It is easy to see why it might have that name as seen in this intraoperative picture where it could be worn like an apron once removed.

Beyond the light-hearted clothing analogy, the abdominal panniculectomy produces a dramatic improvement for the patient in many ways. It eliminates chronic skin infections and sores that develop underneath it and removes stressful weight from the back and knees that have to support and carry it around. It also allows the patient better clothing options, often allowing them to find outfits that fit better.

The abdominal panniculectomy is often thought of as a tummy tuck…and it is. But it is an operation that is much bigger in magnitude than most traditional tummy tucks as can be seen by the type of patient on which it is performed. White it is associated with a relatively significant rate of complications, like fluid collections and wound healing issues, these are often self-resolving issues and do not ultimately detract from the huge benefit that patients receive as a result from undergoing the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Injectable Diced Cartilage Grafting Technique

Monday, January 2nd, 2017

 

Rib grafts are a well known autologous graft in rhinoplasty for significant augmentation. The rib graft can be used as either a solid piece (en bloc) or can be diced into very small cubes and turned into a sausage-like wrap. Both rib graft methods have their advantages but the diced technique effectively eliminates any chance of graft warping, the most common aesthetic complication of onlay rib grafting in the nose.

diced-cartilage-graft-rhinoplasty-preparation-dr-barry-eppley-indianapolisBut the wrap containment method is not the only way to use a rib graft. For smaller dorsal defects diced rib cartilage can be placed through an injection method. If one has enough septal cartilage this can also be used similarly. In this method the diced cartilage is loaded into a 1cc syringe with an open barrel. (this has to be cut that way) This creates a loaded injectable cartilage graft syringe.

The key to using this cartilage grafting method is that it has to be placed through a narrow tunnel to the dorsal defect site. The tunnel serves as the containment method. Once inside the tunnel the graft is injected on withdrawal. It can then be molded into shape although the tunnel itself has already made most of the graft shape. The shape is held by the application of external tapes/splint.

It is easy to see that this is a linear grafting method that works by the alignment of the syringe for graft placement. This makes it best used for dorsal line defects from the radix down to the tip.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Aesthetic Temporal Artery Ligations

Saturday, December 31st, 2016

 

Prominent bulges in the temporal region are almost always caused by the temporal arteries. The superficial temporal artery comes off the facial artery in the neck and courses upward in front of the ear. Once it reaches a typical landmark point of 1 cm in front of the ear and 2 cms about that point, it bifurcates in to a Y pattern. The front part of this takeoff is the anterior branch of the superficial temporal artery and it continues towards the forehead in a very tortuous pattern.

This anterior branch of the temporal artery is fairly superficial and is prone to becoming visibly enlarged. Why it does so is not precisely known but it occurs far more commonly in men. (although it does occur in women as well) It can become quite noticeable with exercise, heat, alcohol intake and a low head position.  It can sometimes be associated with temporal headaches as well.

When the procedure of temporal artery ligation is considered, what is done for prominent temporal arteries is quite different than the historic approach of simple ligation. The original temporal ligation procedure, also known as a temporal artery biopsy, was done to diagnose arteritis or autoimmune conditions. This is where an incision was made behind the temporal hairline and a section of the artery is removed. This is a single incision which is fairly large by aesthetic standards.

temporal-artery-ligation-dr-barry-eppley-indianapolisThe aesthetic temporal artery ligation procedure is a multi-incisional technique that strategically places ligation points at select points along the course of the artery into the forehead. This is always at least two points and often three. These are very small incisions that take into account the wrinkle lines of the forehead when placed in that location. They heal exceptionally well and leave little to no trace of a scar.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Diced Rib Graft Rhinoplasty

Saturday, December 31st, 2016

A significant build-up of the nose requires a combination of bridge and tip augmentation. In primary rhinoplasty this is usually needed in many ethnic patients who lack nasal projection from the face. This may also be required in revision rhinoplasty when over reduction has been done from a prior procedure. In such cases the key element of the surgery is an adequate volume of cartilage grafts.

The most common source of an undisputed volume of cartilage is a rib graft. The ribs offers an unlimited amount of cartilage for the nose no matter where on the ribcage it is harvested. Despite this huge advantage, rib cartilage has a major disadvantage….it is not straight. Nowhere on the rib cage is a cartilaginous section perfectly straight. In addition it almost always has to be carved, removing perichondrium in the process. This further potentiates the risk of graft warping after surgery.

diced-rib-graft-rhinoplasty-dr-barry-eppley-indianapolisThe one proven method to eliminate the risk of rib graft warping in rhinoplasty is diced modification. Rather than place one single solid piece of rib, the graft is cut into many small pieces or small cubes. The diced rib is cut down to as small as 1 x 1mm pieces. The diced rib is then wrapped in either fascia, cadaveric dermis or collagen to create a moldable sausage-like implant. This wrapping contains the diced graft so it can be inserted and molded once placed onto the dorsum of the nose.

Diced rib grafting offers not only a customizable approach to significant nasal augmentation but a rapid integration/healing of the graft. The many small cartilage pieces allow for early and substantial fibrovascular ingrowth into the graft. This is evidenced by the very firm feel of the diced rib graft just a few weeks after the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Liposuction and Boiling Fat

Thursday, December 29th, 2016

 

Liposuction is one of the most common and recognized procedures in plastic surgery. By the way it looks in watching the procedure and how it is commonly perceived by the public, liposuction appears to be as simple as ‘sucking fat out’. But the reality is that it is a more complex extraction process than its name alone implies.

The obvious part of liposuction is the insertion of a hollow stainless steel cannula under the skin. Traditionally a back and forth motion of the cannula is done which essentially cuts tunnels through the fat layers often from multiple different directions. (known as cross tunneling) The cannula is attached by tubing to a vacuum pump which then pulls out the cut or loose fat as well as introduced and other bodily fluids.

boiling-fat-in-liposuction-dr-barry-eppley-indianapolisBut working more occultly are several basic principles of physics that really make liposuction work. One of these can be occasionally observed in the fat collection canister. Looking carefully, or sometimes not very carefully, one can see bubbles coming up from the bottom of the fluid collection to its surface. Sometimes there are so many bubbles it appears that the fat is ‘boiling’.

This bubbling action in the collected fat aspirate occurs because of the vapor pressure of water. All liquids at any temperature exert a certain vapor pressure. This can be thought of at the point where liquid molecules are escaping into the vapor phase. This transition is highly influenced by temperature, the higher the temperature the more the molecules become active and can break free of their intermolecular bonds and escape into the atmosphere. (exceeding the atmospheric pressure pushing down on it). This is well known in water where at roughy 212 degrees F at sea level the vapor pressure is large enough that bubbles are formed.

This is where the influence of atmospheric pressure plays a critical role. At standard atmospheric pressure (1 atmosphere), water boils at 212 degrees F. In essence the vapor pressure of water at 212 degrees is 1 atmosphere. At higher elevations where the atmospheric temperature is lower, water boils at a lower temperature as there is not as much pressure on the liquid water as the water vapor reaches that pressure at a lower temperature.

The vacuum pump of liposuction creates a negative pressure in the collection cannister. The normal negative pressure setting is at least -20cm of water or – 1 atm. This will dramatically lower the boiling point of water or, thinking of it non-thermally, will allow the liquid water to escape into a gas. (bubbles) This is what is happening at a fluid temperature that is somewhere just below body temperature. The collected fat and fluid is truly boiling!

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Total Ear Reconstruction with TPF Flap

Monday, December 26th, 2016

 

Loss of the ear through either traumatic amputation or from tumor resection poses major reconstructive challenges. There is not only the replacement of the supporting ear cartilage that is responsible for making the ear look like an ear. But there is also the replacement of the lost skin that covers the underlying ear framework. The latter is more challenging then the former.

The choice of an ear framework replacement always comes down to either that of an intraoperatively assembled rib graft construct or a preformed synthetic Medpor framework. Each method has their own distinct advantages or disadvantages. In the older patient where the rib cartilages are more calcified, a synthetic ear framework creates a more reliable ear shape.

But the real challenge in recreating a vascularized soft tissue cover over whatever framework is chosen. Without a living skin cover that has some thickness, the choice of ear framework reconstruction is irrelevant. Any exposure of an ear framework, even that of rib cartilage, will result in infection and loss of it.

temporoparietal-flap-in-ear-reconstruction-dr-barry-eppley-indianapolisIn total ear reconstruction the only choice for a well vascularized soft tissue cover is a pedicled temporoparietal fascial flap. (TPF flap)  This is a well known pedicled flap that is an extension of the subcutaneous musculoaponeurotic system (SMAS) inferiorly and the galea aponeurotica superiorly.  It provides a thin sheet of vascularized fascia based on the posterior branch of the superficial temporal artery and vein. It is raised high up into the temporal region and then turned down to cover the chosen ear framework material. The TPF flap is then covered by a thin skin graft to complete the soft tissue cover.

The TPF flap works because the incoming vascular supply comes in inferiorly allowing the flap to be safely turned down over the ear framework and it still remains alive.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Puffy Nipple Areolar Gynecomastia Reduction

Sunday, December 25th, 2016

 

Gynecomastia is a well known breast enlargement condition that occurs in men of all ages. Like the broad age range that it affects, gynecomastia also occurs in a wide variety of expressions or degrees of breast enlargement. While often perceived as the appearance of an actual breast mound, most gynecomastias present as much smaller masses.

The smallest presentation of gynecomastia is areolar enlargement or a type 1 gynecomastia. This is also known by how it appears as a puffy nipple. While this can mean a long or protruding nipple, it usually refers to a small growth of breast tissue that sits right under the nipple. It appears as a small hard lump that can be felt under the nipple and causes the nipple-areolar complex to protrude. It may or may not be associated with an elongated nipple as well.

puffy-nipple-areolar-gynecomastia-reduction-with-nipple-reduction-dr-barry-eppley-indianapolisThe treatment of the puffy nipple areolar gynecomastia is open excision. The hard lump can not be moved by liposuction. The inferior areolar incision heals very well and should not be avoided because of scar concerns. The amount of breast tissue removed is usually no bigger than the size of a quarter. But its removal will instantly reduce the protruding areola. If needed, subtotal or complete nipple reduction can be safely done at the same time as well for a more complete nipple-areolar flattening effect.

Open excision of small gynecomastias is an art form and the amount of tissue to be removed is an intraoperative judgment. On the one hand over resection is to be avoided so a crater deformity does not result. Conversely under resection, although aesthetically safer, will create less areolar projection but will not make it completely flat. This results in my experience for a 10% to 20% revision rate for this type of male breast reduction surgery to get the most symmetric and complete nipple flattening effect.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – TMJ Glenoid Fossa Implant Removal

Saturday, December 24th, 2016

 

The temporomandibular joint (TMJ) creates the articulation between the lower jaw and the skull. It allows the mandible to open and close and creates the capability for the only moveable bone in the entire craniofacial skeleton. The TMJ is about the size of one’s thumb and is composed of a ball (condyle of mandible) and socket. (glenoid fossa of the temporal bone) Hence the term, temporomandibular joint)

Like all joints in the body, the TMJ is equally prone to degenerative changes by age-related osteoarthritis and the more aggressive immunologic disorder of rheumatoid arthritis. When significant condylar erosion has occurred, the joint may need to be rebuilt. This can be done by either an autologous approach using costocbondral rib grafts or the prosthetic approach of a total TMJ joint replacement system.

The TMJ joint replacement system borrows from the orthopedic joint replacement world with a metal condylar prosthesis and a high density polyethylene-based glenoid fossa insert. This glenoid fossa implant is attached along the temporal bone in front of the ear and has a cup shape that sits in and replicates that natural bony glenoid fossa. The metallic condylar prosthesis then fits into the fossa implant, recreating the ball and socket of the TMJ.

This 73 year-old female had a total TMJ replacement done 15 years for her severe rheumatoid arthritis and jaw dysfunction. Over the past year she developed some intermittent pain and drainage from the left ear canal. Multiple ENT physicians examined her ear and could not find any source for her ear drainage and pain.

tmj-joint-replacement-removal-dr-barry-eppley-indianapolisKnowing that she had a prosthetic TMJ replacement right in front of her ear canal, a connection was suspected between it and the ear canal problems. The prosthetic glenoid fossa implant was removed and a fistulous tract was found between its posterior flange and the ear canal. A dermal-fat graft was placed into space left by the glenoid fossa implant.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Microtia Rib Graft Ear Reconstruction

Friday, December 23rd, 2016

 

The ear is composed of two basic structures, cartilage and skin. The cartilage component of the ear is considerable as only the earlobe is not supported by it. The cartilage is solely responsible for the very complex shape of the ear with its many hills, valleys, ridges and curves that are seen externally. How it gets this shape is an embryological marvel as six hillocks fuse in utero to ultimately create what we see as the external ear.

While cartilage supports all the convexities and concavities of the ear, its most important contribution is to its elevations or convexities. (helical rim, superior and inferior crus, antihelix, tragus and antitragus) Cartilage can be removed from any of the concave areas and the shape of the ear would not change. This is well known from the common harvesting of ear cartilage in rhinoplasty from the concha, the largest ear concavity which looks the same both before and after graft harvest.

rib-graft-microtia-ear-reconstruction-dr-barry-eppley-indianapoliosThe greatest illustration of the role of cartilage in the shape of the ear is in microtia reconstruction. For children born with parts or all of the external ear missing, the traditional ear reconstruction method is done with rib cartilage. Portions of ribs 6, 7, and 8 are used to create a cartilage ear framework for insertion under the skin. In making his ear framework the complete concept of the ‘hills and valleys’ of the ear must be artistically created by carving and assembling the pieces of rib cartilage. The eventual shape of the ear is seen many months after surgery as the overlying skin shrinks into and around its cartilage shape.

Of all the shaping procedures that are done in plastic surgery throughout the body, making an ear out of rib cartilage in microtia reconstruction certainly qualifies as a sculpting surgery.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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