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Archive for the ‘OR snapshots’ Category

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

OR Snapshots – Browlift Temporal Implants

Monday, December 19th, 2016

 

Temporal augmentation has become a popular facial area of augmentation due to injectable fillers and fat. While these injectable methods offer a non-surgical treatment method, their volume retention and smoothness of contour is far from assured.

Temporal implants offer a facial augmentation method that is both permanent and straightforward to place. It is an implant unlike other facial implants as it is intended to augment muscle and not bone. As a result, the implant is very soft and flexible, feeling very much of the consistency of muscle. Another key element to its success is that the implant is placed in the subfascial position and at the subcutaneous level. Sitting on top of the muscle and under the fascia avoids any visible outline of the implant which would occur with eventual soft tissue contraction around the implant had it been placed just under the skin.

temporal-implant-placement-through-browlift-incision-dr-barry-eppley-indianapolisTo place temporal implants under the temporalis fascia, the typical approach is a small vertical incision placed back in the temporal hair. This allows easy access to the deep temporalis fascia which is entered through an additional incision in it. But there are other access incisions through which these implants can be placed. One of these is a hairline incision which is commonly used in browlift surgery. Coming from above, an incision in the temporalis fascia is made superiorly through which the implant pocket is developed and the implant placed.

Temporal implants can be used in conjunction with a browlift for a more complete forehead and temporal rejuvenation. The incision for the browlift provides direct access to the subfascial temporal pocket.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Rib Removal Surgery

Sunday, December 18th, 2016

 

Rib removal is an effective surgery for anatomic waistline reduction. It is reserved for those women who have tried every other non-surgical and surgical method to narrow their waistlines and are seeking the last resort to do so. It is clearly for the most motivated of women who are willing to accept small back scars to do so.

Removal of the lower ribs does work to narrow the waistline by eliminating some structural support that helps hold the wasitline out. The lowermost two ribs, #s 11 and 12, are called the floating ribs because they are attached only to the vertebrae and not to the sternum or cartilage of the sternum. These ribs taper down to a cartilaginous tip where soft tissues attach. The floating ribs are often called small and delicate but they are not really either. Having taken out many of them they are much longer and stouter than one would think or diagrams show.

rib-removal-12-angulation-dr-barry-eppley-indianapolisWhat is interesting about the free floating ribs is their orientation to the rest of the ribcage. If one looks carefully at a diagram or skeletal representation, it becomes apparent how much of a downward angulation they have. They are oriented more than 60 degrees at a downward angle which is always impressive when they are exposed surgically.

Seeing their downward angulation during surgery allows for an appreciation of why it works for anatomic waistline narrowing. They do go as far down as almost the iliac crest which provides some support to the width of the waistline. It is also clear why some people may complain that they feel their ribs touch their hip bones when they bend to the side…because they in fact do.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Brow Bone Reduction by Burring

Sunday, December 18th, 2016

 

Brow bone reduction is useful for both men and women who have frontal sinus development that creates an unaesthetic appearance. It is far more commonly done in men whether it be for reduction of very prominent brow bone protrusions or as part of an overall facial feminization surgery for male to female transgender patients.

In most of these types of brow bone reductions a significant change is needed and this requires an osteoplastic setback technique. This is where the complete outer table of bone over the frontal sinus air cavity is removed, reshaped and put back in a more recessed position.

But brow bone reduction can also be done by a burring technique albeit for a more limited result. This is where a hand piece and rotary burr are used to shave down the bone as much as possible but without actually going through the bone into the sinus. The amount of reduction possible is controlled by the thickness of the outer table of bone overlying the sinus. This is relevant over the inner half of the brow bones as this is where the frontal sinus lies. Over the outer half or tail of the brow bones one can burr away as it is solid bone.

brow-bone-reduction-burring-techniquie-dr-barry-eppley-indianapolisBrow brow reduction by burring has the advantage that it can be done through more limited access. An incisional approach such as a pretrichial or hairline browlift provides good linear access for the instrumentation to reach the brow bones from side to side. It also allows adequate visualization of the supraorbital nerves so they are not injured during the bone reduction.

Brow bone reduction by burring works best in those men that just want a little taken off the brow bones or for women who have developed a small brow bone prominence and want it reduced.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Septal Graft Dorsal Augmentation Rhinoplasty

Saturday, December 17th, 2016

 

Augmentation of the nose can be successfully done by a variety of materials. While each  autologous and alloplastic material has their own advantages and disadvantages, one’s own cartilage will always have the superior biologic edge. While cartilage is from one’s own body and is well accepted like all other autologous grafts, it has the unique property of being relatively inert. A cartilage graft put in today will look the same when seen years later. (which is very much unlike most other autologous grafts)

The need for cartilage grafts in rhinoplasty is greatest when dorsal augmentation is needed. Significant dorsal augmentation requires substantial cartilage graft material. Of the three sources of cartilage graft harvest, only the septum offers an assured straightness which is of paramount importance in dorsal augmentation rhinoplasty.

rib-graft-rhinoplasty-intraop-dr-barry-eppley-indianapolisThe septum can be a rich source of graft material when it is primarily harvested. It is usually of adequate length in many patients and can be layered to create 3 to 4mms of dorsal height by so doing. This is usually more than adequate to meet the needs of some primary and most revisional rhinoplasty surgeries.

But once the septum has been harvested it is no longer of any value for dorsal augmentation. When really significant amounts of dorsal augmentation are need, such as in Asian and African-American rhinoplasties, an autologous dorsal augmentation will usually require a rib graft harvest.

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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