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Archive for the ‘OR snapshots’ Category

The ‘Customizable’ Custom Jawline Implant

Saturday, September 16th, 2017

 

Bony augmentation of the face has been done by a variety of commonly used facial implants. While many of these implants work fine for standard aesthetic problems of the chin and cheeks, many other facial areas require a customized implant approach. This is particularly relevant when jawline augmentation is needed. Due to the amount of surface area coverage and the thickness and complex shape of the implant, total jawline  augmentation requires the creation of an implant design from a 3D CT scan.

Custom jawline implants are one of the most common types of 3D designed facial implants in my experience. Made from the patient’s 3D CT scan, its design can be planned employing chin and jaw angle measurements and how to make the connection between them. While the implant can be designed to any specifications, the question always is what should those exact dimensions be? The answer to that question for each patient is not precisely known. There is no software program that can tell us how to make the implant for the exact type of facial change the patient seeks. This remains the art form of any custom facial implant design.

As a result there are certainly circumstances where both the patient and the surgeon may question whether the final design chosen and the manufactured implant will best serve their aesthetic needs. Such questioning may exist right before surgery (on the part of the patient) or during surgery. (on the part of the surgeon) The good news is that any custom implant, even larger jawline implants, can be changed or modified during surgery. Using large scalpel blades and experience in doing it, the custom implant can be reduced in size and its shape modified prior to placement.

This customizable custom jawline implant approach allows for shape changes that either have become apparent during surgery or for modifications that the patient desires right before surgery. Such changes do not violate the integrity of the implant or makes it lifelong durability any less.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Bone Fixation of the Hairline Lowering Flap in Forehead Reduction

Saturday, September 9th, 2017

 

The forehead occupies a major portion of one’s face, up to one third of its vertical height. But when the forehead occupies too much real estate of the face, greater than one-third, it can be too overwhelming and look out of proportion to the rest of the face. By definition the vertical length of the forehead is between the frontal hairline and the eyebrows. (in bald or shaved men the amount that the forehead should occupy no longer applies)

The only method to reduce the vertical length of the forehead (forehead reduction) is a hairline advancement. This is essentially a scalp mobilization procedure that changes the location of the front edge of the hair-bearing scalp through forehead skin removal. Its success depends on how much natural elasticity one’s scalp has. Lowering of the hairline with this procedure can usually be done anywhere from 1 to 2.5 cms in most people.

Since such a forehead reduction is a scalp advancement flap, there will be some tension on the incision line. One of the goals of a hairline advancement is to minimize the tension on the skin closure to avoid postoperative scar widening. Such scar widening would be very obvious as a visible white zone at the edge of the frontal hairline.

A good technique to reduce the tension of the scalp advancement flap is skull fixation. Using outer table burr holes placed with a handpiece and burr, sutures can be placed through the bone tunnels to secure the scalp flap. There are placed at the front edge of the desired advancement edge to maintain its position. This then allows the closure to the forehead flap to be done with little to no tension on it as well as preventing any scalp relapse.

Once the advanced scalp flap is secured by bone fixation, the forehead skin flap is draped over it to determine the amount of forehead skin to be removed. This prevents over resection of forehead skin and serves as the second technique to ensure the best possible frontal hairline scar outcome.

IDr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Goretex Chin Implant Removal

Monday, September 4th, 2017

 

Chin augmentation has been one of the most popular facial reshaping procedures for decades. Since its inception in the 1950s, a wide variety of materials have been used for chin implants. Despite this diversity of implanted materials, the silicone chin implant remains the primary implant used due to large number of different styles and sizes, ease of insertion and ease of removal if needed.

One of the chin implant materials used in the late 1990s and early 2000s was that of Goretex, also known as expanded polytetrafluroethylene. Its value as a facial implant material is that it does allow some tissue adherence to develop once implanted. Its microporous surface combined with a fluorine-containing composition allows for tissues to stick to it. This tissue adherence is not as great as Medpor, for example, but is better than that of silicone. Despite these material benefits, it never enjoyed widespread popularity before the product line and the company that made it eventually disappeared into the annals of plastic surgery history.

Every now and then a patient will appear who requests the removal of a Gore-tex chin implant that was placed a long time ago. The request for removal is not usually because it is having any specific medical problems but due a desire to return to their original chin shape before they had the implant placed. This is actually not rare as what one may have wanted at one point in life may change years to decades later.

Gortex chin implant removal can be done uneventfully and it can be removed intact with gentle dissection around all implant surfaces first before attempting extraction. Such chin implants are easily recognizable by both its white color as well as the layered composition which represents the layers of Goretex material which have been compressed together and then machined into the implant’s shape.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Batten Rib Graft Rhinoplasty

Saturday, September 2nd, 2017

 

The use of cartilage grafts in rhinoplasty are done for a wide variety of reasons. While all cartilage grafts add support, some of these effects are to improve the shape of the nose while others are to improve its breathing function. Of all cartilage graft placements, the nasal tip is the most common area in which they are used.

Cartilage grafts in the lower third of the nose are most frequently placed in the central tip area. Whether it is a columellar strut graft or a wide variety of tip augmentation/shaping grafts, increasing tip projection and/or support is critical to resist the potentially displacing effects of the overlying skin.

But the side walls of the nasal tip, or lateral alar regions, can occasionally need cartilage grafts as well. The lateral alar cartilages are responsible for keeping the nostrils more open for breathing and play a critical role in the shape of the nostrils as well. Extending from the tip down to the nasal base they encompass almost the full length of the nostrils like a spanning bridge. Weak lateral alar cartilages can result in their collapse when breathing in. This can often occur after a rhinoplasty when too much cartilage has been taken due to an aggressive cephalic trim.

Support to the lateral alar can be done with cartilage, known as batten grafts. As the name implies a batten graft provides support to either help the collapsed lateral alar cartilages be brought back out as in a secondary rhinoplasty or as a preventative maneuver to prevent potential collapse after surgery in a primary rhinoplasty. The most common batten grafts comes from the septum since it is straight and fairly strong. But when a rib graft is being harvested anyway, it can be cut into thin batten grafts that are even stronger than that from the septum. The stiffness of these grafts is best done in noses with thicker skin.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Vertical Ear Reduction with Scaphal Resection

Saturday, September 2nd, 2017

 

Changing the shape of the ear is most commonly done by a traditional otoplasty or ‘ear pinning’. While the size of the ear may seem to get a bit smaller in otoplasty as it moves the ear closer to the side of the head, the actual ear size does not really change.

True ear size reduction involves a vertical change in the length of the ear from the superior helix down to the bottom of the earlobe. The most recognized ear reduction procedure is that of earlobe modification. The earlobe can be reduced by a variety of techniques but, regardless of which method is used, they all create some reduction in its vertical length as all large earlobes hang too low.

The most dramatic way to reduce a large ear is to cut out a portion off its middle, bringing the upper and lower thirds of the ear closer together. But the scar that is created by doing so would be aesthetically unacceptable and such ear reductions are only usually done in skin cancer resections.

The often overlooked or unknown ear reduction technique involves that of the upper third of the ear. Known as a scaphal flap reduction technique, skin and cartilage are removed from inside the helical rim above the antihelix and superior crus. There is a backlit across the helical rim at the middle portion of the ear which controls the amount of vertical ear height reduction. This is also the only location of a visible scar.

While often combined with ear reduction for maximal ears height reduction as in macrotia reduction surgery, the scaphal flap reduction technique can be done alone if the earlobe is already small enough. Int its use it is important to remember that its effect is in reducing the size of the upper third of the ear.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Transpalpebral Brow Bone Reduction

Saturday, September 2nd, 2017

 

Brow bone reduction surgery reduces the prominence of the supraorbital ridges of the forehead and can be done in both men and women. Whether done for males to reduce the ‘Neanderthal’ brow or in male to female transgender facial feminization procedures, the main direction of reduction is in the horizontal dimension. Reducing the brow bone prominence generally means reducing its projection.

But horizontal brow bone reduction is not the only dimension of the brows that can be changed…or may need changed based on the patient’s aesthetic desires. Brow bones can also be reduced vertically to increase the orbital aperture and give the eyes a more open look or reduce a heavy appearance.

While both horizontal and vertical brow bone reduction can be done through a long coronal scalp incision, a purely vertical reduction of the bone does not need to be done so. It can be done through an upper eyelid incision (transpalpebral approach) which provides a direct and short route to the lower edge of the brow bone.Using a handpiece and burr the brow bone edge can be raised 5 to 7mms if desired from side to side. It also can be reduced horizontally if desired on the outer 2/3s of the brow bone.

The transpalpebral approach is an often overlooked method for brow bone reduction. While it does not provide enough access for the more significant osteoblastic flap reduction technique and is limited for central or glabellar reductions, it does provide direct visual access to the tail of the brow bone where burring reduction can be done. It is an excellent technique for secondary or revisional brow bone procedures and can be used for primary reductions that need changes in the outer half of the brow bone only.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Sagittal Crest Skull Reduction

Sunday, August 13th, 2017

 

A bony ridge that runs down the midline of the head is known as a sagittal crest. This is a palpable raised ridge of bone that when high enough can cause a peak-shape to the head from the front view. The normal more convex shape off the head becomes more triangular shaped. This is most commonly an aesthetic concern in the male that either has very short hair or shaves their head.

Reduction of the sagittal crest skull deformity is done with a burring technique. Using a high speed handpiece and carbide burr, the bone is shaved down to a smooth contour. The bony ridge is thicker than normal skull bone so it can be safely reduced. But because this is an aesthetic deformity thoughtful consideration must be given to the incision needed to do the burring.

Working through a small scalp incision using a high speed handpiece safely requires protection of the surrounding hair and skin edges. This is best done by stapling gauze sponges along the edges of the scalp incision as well as placing a rubber guard over the length of the shaft of the burr. This prevents any risk of hair getting caught up in the rapidly rotating burr or its shaft. It is also important to only operate the handpiece when totally inside the subperiosteal tissue tunnel along the bony sagittal ridge.

Sagittal crest skull reduction can be done both effectively and safely through a fairly small scalp incision. This incision is usually placed perpendicular to the sagittal crest. In posterior sagittal crests the incision is placed on its most posterior end. But in long or more extensive sagittal crests the incision is placed at its midpoint to provide equal access to both ends of the bony deformity.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Custom Occipital Skull Implant

Saturday, August 12th, 2017

 

There are over fifteen types of aesthetic skull deformities. But the most common amongst them is various forms of flattening of the back of head. Perhaps because the back of head is exposed to various pressures in utero and after birth more than any other area of the head, it is prone to deformational pressures that can cause its shape to be flatter. This flatness can affect just one (plagiocephaly), both sides (brachycephaly) or even subtotal portions of either side.

The most effective treatment for flat back of the heads, regardless of its size, is a custom occipital skull implant. Made from the patient’s 3D CT scan, the implant design can be made to cover all flat areas and match any asymmetries between the right and left sides. The flexibility of a silicone implant allows the precisely-designed implant to be inserted through the smallest possible scalp incision usually placed at the mid-portion of the occipital scalp.

In surgery the flatness of the head can be fully appreciated. With the patient asleep in the prone position, wetting of the hair allows the back of the head shape to be completely seen. Laying the custom implant on it allows one to see how much the contour can be improved. Because it is not under the scalp its size looks smaller than the bone area that it will cover and shows more projection that will be actually achieved.

Recovery from skull implant surgery is fairly quick. One can expect some swelling and bruising in the temporal areas on the sides where the implant is primarily placed. This is to be expected due to the subperiosteal dissection needed to make the implant pocket. Since the dissection is done under general anesthesia in the prone position, combined with effects of gravity, such tissue fluids work their way towards the face. The facial swelling and bruising resolves by ten days after the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Fate of the Cut Muscle Edge in Temporal Reduction

Sunday, August 6th, 2017

 

Temporal reduction is an effective method for narrowing the wide head. The wide head is defined as the area above the ears that has too much convexity or fullness. Extreme fullness at the sides of the head occurs when the width of the head gets near a vertical line drawn up superiorly from the inside of the superior helix of the ear. But many affected patients may feel they have too much convexity even when its width is well inside the profile of the ear.

While many feel that temporal bone reduction is the key to head width reduction, it actually is not. The thickness of the posterior temporal muscle is what constitutes a significant part of the side of the head. Its removal makes an immediate and visible reduction in its convexity, changing it to a completely or near complete flat profile. Surprisingly the removal of the posterior temporal muscle has no functional impairment on lower jaw motion or function.

In the technique of temporal reduction by myectomy, which is usually performed through a postauricular incision, a vertical cut through the temporal muscle is made from the attachment of the ear superiorly to the temporal line at the top of the skull. All muscle behind this line is removed leaving the overlying fascia in place. With muscle thicknesses averaging 7 to 9mms in thickness this leaves a very palpable and sometimes visible step-off in the temporal contour. The posterior cut edge of the large remaining anterior temporal muscle is cauterized for both hemostasis and in the belief that muscle atrophy will eventually smoothest the shape of the cut edge of the muscle.

I had the opportunity to validate what happens to the back edge of the cut temporalis muscle. Three years previously as part of awn overall skull reshaping procedure, the posterior temporal muscle was resected in a full-thickness vertical fashion from the bony temporal line inferiorly down to the ear. In a more recent skull reshaping procedure on the same patient, the temporal regions were inspected. It was observed that the original cut edge of the muscle does thin out and recontour with healing as suspected.

 

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Extended Arch Cheek Implants Replacement

Sunday, July 16th, 2017

 

Cheek implants can be the most difficult to decide preoperatively as to their style and size. Because the cheek is an oblique structure and not a profile one, it defies any exact measured target to achieve. The cheek does have very specific zones of augmentation, four to be exact, and it becomes important to consider these cheek zones when selecting the implant style that can achieve the patient’s desired midface look.

Most cheek implant styles focus on augmenting either the malar body and/or the submalar region underneath it. These are the central zones of the cheek. While effective for some patients, they are prone to creating a bulge or bump effect particularly if the size of the implant is too big. This is because the cheek, also known as the ZMC (zygomatico-maxillary) complex, is a bony structure that has three visible legs or extensions to it that emanate out from its main body. To look more natural many cheek implants should flow into these extensions more fully.

One newer cheek implant option is the malar-arch style. As the name implies it is a midface implant that augments the malar body but has a long posterior tail to it that goes back along the zygomatic arch. It extends back along the curved arch and stops before it reaches its temporal attachment. This provides a gentle sweeping augmentation across the cheek area and achieves a more complete and natural cheek enhancement. It is also the type of cheek look seen in many models, for example, whether that is their natural look or has been created by makeup or photo editing.

It has not uncommon that I see a ‘standard’ cheek implant patient who is dissatisfied with just augmentation of the malar-submalar cheek area. Exchanging these standard implants for an extended arch style usually provides a more desired midface enhancement effect. It is the creation of a more horizontal line across the side of the face that is often sought out today.

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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