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Dr. Barry Eppley

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Archive for the ‘OR snapshots’ Category

OR Snapshots – Injectable Diced Rib Graft Rhinoplasty

Sunday, October 29th, 2017


Cartilage grafting to the nose is most commonly done using anatomically convenient graft sites. This usually means the septum which offers straight graft dimensions or the ear which offer curved or shaped grafts. For many traditional rhinoplasty surgeries these graft sites are sufficient both in size and shape.

But in rhinoplasties that require larger amounts of augmentation, almost always that of the dorm, facial graft sites are too small in volume and do not have the right shape. This is where rib graft harvesting does into play if one wants avoid an implant or a cadaveric cartilage source.

While rib grafts in rhinoplasty offer plenty of volume, they usually have some shape issues. Occasionally a rib graft may actually be harvested that is straight or it can be carved to be straight. But rib graft carving must take into consideration the perichondrial lining and the ever present risk of postoperative warping.

A well known technique of avoiding rib graft warping in rhinoplasty is to change it from a solid graft to a particulated one. By dicing the rib graft into very small pieces or cubes and containing it in some form of a wrap, a very moldable cartilage graft is obtained. The debate in the use of diced rib grafts is whether it should be wrapped in autologous fascia, a very thin piece of allogeneic dermis or a bovine collagen mesh wrap (Surgicel) There is no standard consensus on the ideal wrap material.

Another method to place the diced rib cartilage graft is to not wrap it at all. The placement/containment method is a small syringe from which it can be injected. This requires a precise soft tissue pocket over the dorsum and can be done through either an open or closed rhinoplasty. The diced graft is injected and then digitally molded into the desired shape. Tapes and a metal splint are placed over it to help maintain its shape.

This injectable rhinoplasty technique allows for rapid tissue ingrowth into the diced cartilage graft. Within a few weeks it becomes very firm and maintains its shape. My and other clinical experiences show that significant graft resorption does not occur.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Double Stacking Chin Implants

Wednesday, September 27th, 2017


Chin implants are the original and still today the most common form of facial skeletal augmentation. Having been around for over fifty years in various forms, chin implants have undergone many evolutionary changes in their shapes to satisfy a wide variety of aesthetic chin needs. Because of its history and frequent use, they have the greatest number of different styles and sizes off any type of facial implant.

But even with such a diversity of standard options, not every patient will do well with an off-the-shelf implant shape. This is where the role of custom implants comes into play where any dimensional need can be addressed through patient specific designing for unique chin dimensional augmentations. While extremely effective custom facial implants come at an increased cost over standard ones that may be a limiting factor for some patients.

While chin implants can be modified by hand carving them during surgery, adding to them is a different matter. There is no recognized method for increasing the size or shape of a standard chin implant. In some situations I have found it effective to marry together two different implant styles to get the desired effect. This is an example where a prejowl implant is added to an anatomic implant to get wider wings for more prejowl augmentation. By suturing the implants together in multiple locations, shifting or one implant sliding off of the other is prevented.

It is acknowledged that the use of 3D imaging and implant designing is best for most unique chin augmentation needs. But in the right circumstances it is possible to create a ‘semi-custom’ chin implant using standard implants in a stacking technique with suture fixation.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Customizable Custom Skull Implant

Wednesday, September 27th, 2017


Custom made skull implants are the best way to perform almost any type of skull augmentation. Covering potentially large surface areas of the skull in a smooth manner is very difficult when attempted by traditional bone cement materials. The computer designing process does what no surgeon can do as well with the naked eyes and their own hands. While the computer design process can make whatever implant dimensions the surgeon chooses, the question is always what exact aesthetic will it create and whether this aesthetic result meets the patient’s head shape goals.

In some rare cases the patient may desire some reductive modifications to their skull implant. (additive modifications usually require a new implant) This is most likely to occur after the implant is in place or after the patient has ‘worn it for awhile’. Like all other facial implants such modification is possible through an implant shaving process. Unlike facial implants, however, the skull implant has a much large surface area which makes it more challenging to make the changes smooth and even on a curved surface. This requires a larger than normal scalpel blade and good experience in such implant manipulations.

Most commonly reduction of a custom skull implant is to reduce a certain area of thickness or to remove one of its contours. Such reductions need to be done over a much larger surface area of the implant than one would think. As a result it also requires a wider amount of incisional exposure than one may want to do. But good results from such implant modifications come from not trying to do so from limited exposures where visibility is compromised and the pocket for instrument manipulation is too restrictive.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – ePTFE Implant Framework in Ear Reconstruction

Sunday, September 24th, 2017


Reconstruction of the lost ear requires a two-layer approach. The base la\yer is the firm and shaped framework which replaces the missing natural cartilage. The choices for the framework are either rib cartilage or synthetic framework.  The second layer is the need for vascularized tissue coverage which, in cases of large amounts of ear loss, would be a temporoparietal fascial flap and a skin graft.

While there are debates about the merits of a cartilage or an implant base layer, the one huge advantage that a synthetic framework has is the avoidance of a donor site. Historically the biomaterial porous polyethylene its what has been used for synthetic ear reconstruction frameworks. It has the advantage of surface porosity and good soft tissue adherence. But it is a difficult material to shape and assemble its preformed pieces. It is also a very stiff and inflexible material of which natural ear cartilage is not.

An innovation in ear reconstruction implants is the combination of 3D design/printing and the use of a softer implant material. In unilateral ear loss or deformities a 3D CT scan can be used to make an exact replica of the opposite normal ear cartilage. Usually this will include the soft tissue earlobe as well as that is difficult to surgically create. From this auto design an implant can be fabricated. This its then made from a newer material, a solid silicone base covered with an ePTFE coating. The silicone provides the shape and flexibility that more closely resembles ear cartilage and the ePTFE coating allows for soft tissue adherence.

An ear framework that is computer generated saves operative time and ensures the best potential ear shape result. It still needs to be covered by a vascularized soft tissue layer. But that need is necessary regardless of the material composition of the ear framework. 

Dr. Barry Eppley

Indianapolis, Indiana

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

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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