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Archive for the ‘plastic surgery case study’ Category

Case Study – The Female Swoop Rhinoplasty

Tuesday, April 25th, 2017

 

Background: The nose is made up of many angles, lines and shapes and represents the most aesthetically complex structure on the face…despite its proportionately small size. How all of these various geometries (subunits) fit together changes based on what view or angle that the nose is being assessed. The most basic of all these nasal aesthetic considerations is that of the  dorsum and is one of the most commonly manipulated and requested nasal features.

The dorsum is a central subunit of the nose that extends from the frontonasal angle superiorly down to the tip. In the front view it has aesthetic or side lines that create a smooth flow, or lack of the flow, down the length of the nose connecting the inner brows into the tip. In the side view, and a view that is of highest significance to patients, is the dorsal line. This profile line of the nose is a dominant aesthetic feature and has long been one of the most basic motivations for having rhinoplasty surgery as well as how the result is judged.

The dorsal line of the nose is gender specific. Man desire a straight or even the persistence of a small hump at the osteocartilaginous junction. Conversely women either prefer a straight dorsal line, or more commonly, a dorsal line that has a slight concavity to it. Men almost never want such a dorsal line shape.

Case Study: This 33 year-old female wanted to change the shape of her nose. She had a slight nasal hump and a tip that had too much projection. The shape of her nose from the side profile was her most important motivation for having the surgery.

Under a general anesthesia an open rhinoplasty approach was done. The small osteocartilaginous hump was shaved down and smoothed. Her nasal tip cartilages were shortened and narrowed by excision and suturing techniques. Shortening the nasal tip also created the need for further reduction in the height of septum along the middle vault.

Her six month postoperative result showed an improved and more ‘feminine’ dorsal line with a tip that has a better length for her nose. Her dorsal line had the requested concavity or swoop between the forehead and the nasal tip. The columellar scar from the open approach had healed to the point that it could not be seen.

Why is it that women prefer such a nose shape? While fashion and celebrities help drive many a facial look, the desire for a small and perkier nose is a decided sign of femininity. It is also the antithesis of aging…it is a sign of youth and ‘cuteness’.

Highlights:

  1. The desired profile result for a female in rhinoplasty is almost always different than that of a male.
  2. Many women desire a dorsal line profile that has a slight concavity or swoop to it.
  3. Obtaining a swoop to the dorsal line is also highly influenced by the degree of tip rotation and/or shortening.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Tracheal Augmentation

Sunday, April 23rd, 2017

 

Background: One of the many head and neck features that are distinctly masculine is that of the thyroid cartilage or Adam’s Apple.  A prominent thyroid cartilage creates a distinct bump in the neck that is associated and aesthetically acceptable in men. While it is often reduced in facial feminization surgery as a tracheal shave procedure in the male to female transgender patient, the reverse has not yet been described.

How to build a more prominent thyroid cartilage has only recently been described for masculinization in a female to male transgender patient. In this solitary description onlay cartilage grafts from the rib were used for tracheal augmentation. Since the Adam’s Apple is a cartilaginous structure it is logical that cartilage grafting would be an effective technique.

But not every such patient may want a rib graft harvested for a tracheal augmentation procedure. Like much of the face, one wonders if an implant can not be effectively used instead of a cartilage graft.

Case Study: This 35 year-old make wanted to improve the shape of his chin and neck. He had a mild short chin, submental fullness and a smooth neck contour. He had a first stage procedure of chin augmentation and a submentoplasty (liposuction and direct defatting with muscle plication) Afterwards he inquired about making his Adam’s Apple more prominent.

In a second procedure the trachea augmentation was planned using a Medpor nasal implant. The shape of the nasal implant is like a saddle (inverted v) which seemed like it would create a tracheal prominence and could be secured onto the front edge of the tracheal cartilage. A v-shaped notch was made in its upper portion to replicate the natural shape of the thyroid cartilage. Medpor nasal implants come with inserts to place under it for increased augmentation which was also done in its use as a tracheal implant. This gives it more outward projection from the anterior surface of the natural thyroid cartilage. Through a small skin incision, the synthetic framework was sutured to the cartilage, the overlying skin flap of fat (to allow more of the framework projection to be seen) and the skin closed.

The combination of chin augmentation, submental reduction and tracheal augmentation produced a more masculine lower face/neck profile. Tracheal augmentation can be done successfully using a properly shaped synthetic implant. The material composition is not an important as its ability to be shaped and secured to the natural thyroid cartilage base.

Highlights:

1) A prominent thyroid cartilage is a male characteristic.

2) Masculinization of the neck can be done by tracheal augmentation.

3) A synthetic tracheal implant can be used to create more projection of the upper V

portion of the thyroid cartilages.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Stahl’s Ear Correction with Rib Cartilage Graft

Saturday, April 22nd, 2017

 

Background:  There are a wide variety of congenital ears deformities that involves either deformed or missing natural cartilage structures of the ear. One such well known deformity is that of the Stahl’s ear. This consists of an ear that has a pointy shape due to an extra fold or third crus in the scapula. It is often referred to as a Spock part in reference to the Star Trek TV character.

Stahls’ ear is primarily caused by the ear cartilage being misshapen. The upper ear usually has two distinct folds known as a superior and inferior crus. But in Stahl’s ear a third crus or fold occurs. This causes the outer rim of the upper ear to fold inward giving it a pointed shape.

If recognized very early after birth, external ear molding devices (e.g., Earwell) can correct the misshapen ear as the young ear cartilage is very flexible and moldable. But once one passes six to weeks after birth the ear loses its responsive to external molding forces and surgery becomes the only treatment option.

Case Study: This 12 year-old male had misshapen ears that he disliked. The upper outer helical rim was bent over or folded in. This created a pointed shape to his upper ears. He had been given the diagnosis of Stahls’ ear although it was not a classic presentation of it.

Under a general anesthesia an incision was made on the back surface of the ears. This allowed the helical rim skin to be dissected off the cartilage and expose the upper ear cartilage shape over the deformed area. Radial cuts were made in the cartilage to allow it to unfurl and create a more defined outer helical rim. To support this new shape a cartilage graft from a small piece of rib #9 was used by suturing it on the inside of the newly formed helical rim. On the right ear  a small wedge of cartilage and skin was removed to bring down the height of the helix.The skin was then pulled back over the reconstruction and closed with dissolvable sutures.

His immediate intraoperative result showed improvement in the shape of ear through recreation of a more defined outer helical rim. While many techniques for Stahl’s ear correction have been described they all rely on innate cartilage reshaping alone. Add a small cartilage graft can help support these cartilage reshaping efforts.

Highlights:

  1. Stahl’s ear is a congenital deformity marked by an abnormal fold in the upper ear which makes it pointy.
  2. Reconstruction they deformed upper ear requires cartilage reshaping which often requires the use of a cartilage graft for support.
  3. A small piece of rib #9 can be used for a strong and curved cartilage graft.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Facelift with Jaw Angle Implants

Sunday, April 16th, 2017

 

Background: The facelift is a well known surgical rejuvenative procedure that primarily creates a smoother jawline and a more defined cervicomental angle. For some facelift patients the addition of a chin implant, if their chin is short, helps improve the jawline by adding increased projection at its anterior edge. This is why many facelifts particularly in women also include a chin augmentation.

While chin augmentation provides an aesthetic benefit to the front end of the jaw during a facelift, the rest of the jawline remains neglected. Some aging patients have weak or high jaw angles. Pulling the facial skin back up and over a weak posterior jaw angle fails to make it more defined. It often only gives it a sweeped look from the skin pull.

Like chin implants, jaw angle implants have a role to play in facial rejuvenation and facelift surgery. Their only drawback is that they will cause a moderate amount of facial swelling over the posterior part of the face during the early recovery period.  Good compression facial dressings during the first few days after surgery is very helpful in this regard.

Case Study: This 68 year-old female wanted a lower facelift to remove loose skin along the lower part of her face and give her a more defined jawline. But she had a high and ill defined jaw angle area and opted for the placement of jaw angle implants at the time of her facelift.

Under a general anesthesia and through an intraoral approach, small vertical lengthening jaw angle implants were initially placed. Thereafter a lower facelift was performed with SMAS plication. Her long-term results show improved jaw angle definition and a well defined jawline from chin back to the ear.

Like chin implants, jaw angle implants are aesthetically beneficial in a minority of facelift patients. But in the properly selected patients and in thinner faces, they can add bony definition of the lower face which has a distinct rejuvenative facial effect.

Highlights:

  1. Augmentation of the jawline at the time of a facelift or after has long been recognized as an aesthetic benefit.
  2. Creating a more defined jaw angle builds up the back part of the jawline.
  3. Most jaw angle enhancements in aging require a vertical jaw angle implant style.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – ePTFE Ear Implant Reconstruction

Saturday, April 15th, 2017

 

Background: Ear reconstruction is most commonly done using autologous graft materials. Whether it is microtia reconstruction using rib cartilage in children or adult ear reconstruction using cartilage grafts and pedicled skin flaps, the patient’ own tissues offer the least risk of postoperative complications and should be done when possible.

The use of synthetic frameworks or implants for ear reconstruction has its origin and current use with Medpor material. Most commonly done as an alternative to the use of rib cartilage in congenital microtia deformities in children, it offers a premade and well shaped ear implant. As a substitute for a hand-carved rib cartilage ear framework, it requires vasculrized tissue cover using the temporalis fascial flap (TPF flap) covered with a split-thickness skin graft. Its benefits is that it usually creates a much better shaped ear in the end and does so in less operative time with no need for a rib graft donor site.

While Medpor ear frameworks are effective, the material itself does not replicate very well the physical characteristics of natural ear cartilage. It is much more stiff (in fact rigid) and lacks any substantial flexibility. While creating a nice ear shape it does not create a good feeling ear. This stiffness can make the Medpor framework ear prone to occasional discomfort and skin breakdown due to pressure or trauma.

Case Study: This 78 year-old male has multiple basal cell skin cancers on his left ear on both front and back ear surfaces. It was decided that the best treatment for his ear cancer was near amputation. He was interested in a synthetic ear implant as opposed to a rib graft. Under general anesthesia he had a subtotal ear resection preserving the superior helical root, concha and earlobe.

Using an ePTFE coated composite ear implant, it was carved into a shape replicating the portion of the ear cartilage removed. This was then sutured to the remaining ear cartilage.

A TPF flap was raised through a vertical incision above the ear. It was folded down over the ear framework, preserving its temporal vascular pedicle, and sewn into the tissue edges around the remaining ear. A split-thickness skin graft was harvested from the thigh and laid over the TPF flap and sewn into place.

With healing time and tissue contraction, the details of the ear framework will eventually become more apparent through the applied vascular cover. In the long run the reconstructed ear will have a more natural feel due to the inherent softness of the ePTFE material.

Highlights:

  1. Synthetic ear reconstruction relies on the use of a Medpor ear framework covered by a fascial flap and skin graft.
  2. A new synthetic ear implant made of a composite silicone and ePTFE coating offers a softer and more flexible design.
  3. Composite ePTFE ear frameworks offer a carving feel that is identical to that of natural rib.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Male Brow Bone Reduction

Friday, April 14th, 2017

 

Background: Males almost always have much more pronounced brow bones than females due to a greater pneumatization effect of the frontal sinuses. Numerous studies have shown that the male frontal sinus is bigger, usually asymmetric and has a bigger left side than that of the right. This is clinically evident in the external shape of the forehead with greater supraorbital protrusions than females.

Why some men get much bigger and disproportionately larger frontal sinuses and subsequent brow bone protrusions is not known. Whether this is due to hormonal influence, masticatory loading forces or an increased developmental effort to separate the brain from the eyes are theories that have all been espoused. Regardless of its cause, the enlarged male brow bone often produces a dramatic effect that can be enhanced by a backward sloping forehead.

The male brow bone is reduced with several basic tenets in mind. First, simple burring is inadequate for a major brow bone protrusion. The anterior table of bone is not thick enough to allow for a significant reduction and the maintenance of  a bony covering of the frontal sinus air cavity. Second, the male brow bone should be so reduced that the foreflat has a completely flat profile. Some degree of brow bone break into the upper forehead needs to be maintained.

Case Study: This 30 year-old male had been bothered for a long time by the shape of his forehead. He had a very strong brow bone with two very distinct paired brow protrusions with a midline glabellar groove. The size of the brow bones was magnified by a backward forehead inclination of almost 45 degrees.

Under general anesthesia and using a near complete coronal scalp incision, his forehead and brow bones were exposed. A reciprocating saw was used to remove the anterior table of the frontal sinuses at the level of the surrounding forehead. Osteotomes were used to make the final bone elevation to preserve as much of the underlying sinus mucosa as possible. Burring was then done all around the bone edges as well as down into the frontonasal angle.

The removed bone segments were thinned and reshaped and the put back into the frontal sinus. (setback) They were secured using small plates and screws to maintain bone contact as well as prevent any inward displacement.

The immediate change in the forehead profile was evident but not over flattened.

The osteoplastic setback technique for male brow bone reduction is the gold standard by which it is done. Whether it can be done by a single piece of bone across the frontal sinuses or whether it needs to be done by two separate bone pieces depends on the patient’s anatomy.

Highlights:

  1. Most brow bone reductions in men require an osteoplastic setback technique.
  2. Removing the anterior table of bone from the frontal sinus by osteotomy with surrounding burring produces the best brow bone reduction effect.
  3. Male brow bones should be only reduced to the point of leaving some brow bone break to avoid overfeminization of the forehead.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Small Custom Occipital Skull Implant

Sunday, April 9th, 2017

 

Background: Aesthetic skull deformities occur in a very wide degree of severities and presentations. While many think that such skull shape issues are probably large and obvious, I have found that some are quite small and often obscure to the casual observer. But to the patient smaller skull defects can be just as disturbing as those that can be clearly seen.

One of the common areas of the skull that is often bothersome is the back of the head. While complaints may be of its size, too big or too flat, there are an equal number that relate to its symmetry. One side of the back of the head being flatter than other, often referred to as plagiocephaly, is a condition that I commonly treat. Whether the patient can see it because they have a shaved head or closely cropped hair or whether they can simply feel it through good hair cover, I have seen patients opt for treatment in either an exposed or camouflaged skull shape.

It is not clear why a skull area that is the hardest for some patients to see can be a source of aesthetic anxiety, but it can be. Since custom implants is now the standard way to treat any broad-surfaced area skull deformities, it becomes possible to effectively treat even the smallest of such skull shape deformations.

Case Study: This 57 year-old male had been bothered for a long time by the shape of the back of his head. There was a dip on the upper right occipital skull and a modest protrusion on the left side. Using a 3D CT skull scan, a small right occipital skull implant was designed to precisely fill the bone dip.

Under general anesthesia and in the prone position, a bilateral occipital skull reshaping procedure was performed through a 7 cm long low horizontal scalp incision. On the left side the bony prominence was reduced by burring along the nuchal ridge. On the right side the custom skull implant was inserted and oriented through implant markers and secured with two microscrews.

Small skull contour defects can often be the hardest to improve without creating other aesthetic issues. As a general rule the smaller the defect the more precise the contour restoration must be. Anything short of near perfection can just be another aesthetic concern. Custom designing the implant creates the best chance of minimizing these potential iatrogenic aesthetic concerns.

Highlights:

  1. Custom skull implants can be made for smaller select skull defects.
  2. One of the most common aesthetic skull deformities is that of plagiocephaly where the back of the head is asymmetric.
  3. Custom occipital skull implants are usually placed through a low horizontal hairline incision on the back of the head.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Tip Rhinoplasty

Sunday, April 2nd, 2017

 

Background: The shape of the nose is controlled completely by the shape of the osteocartilaginous framework underneath the skin. Nowhere on the nose is this more apparent than on the nasal tip. The complex scrolled shape of the lower alar cartilages and how they meet in the middle controls the shape of the lower third of the nose.

While the size of the lower alar cartilages controls how big the tip of the nose is, their symmetry influences how uniform it looks. Tip asymmetry is one of the most common aesthetic nasal deformities. It can be caused by a variety of anatomic derangements from a caudal septal deviation, buckling of the medial footplates, dome width asymmetry and alar length discrepancy to name a few.

While many rhinoplasty surgeries treat the whole nose, it is not always necessary. A tip rhinoplasty treats just the lower third of the nose and always involves some manipulation of the lower alar cartilages. Whether it is decreasing its size, changing its projection or degree of rotation, or just correcting asymmetry, the tip rhinoplasty leaves the bony structure of the nose alone. It a cartilaginous rhinoplasty as opposed to a more complete osteocartilaginous rhinoplasty.

Case Study: This young female was bothered by the shape of her nasal tip. It was bulbous as well as was asymmetric with a noticeable bump on the left side of the done. She was happy with her bridge and the nasal profile above the tip area.

Under general anesthesia and through an open rhinoplasty approach, the lower alar cartilages underwent an asymmetric cephalic trim and was reshaped with transdomal and lateral crural spanning sutures

Her three months after surgery results showed better tip symmetry and shape and a tip profile that fit better her the rest of her nose.

Some nose reshaping procedures only need an isolated tip rhinoplasty. If the rest of the nasal profile and frontal shape of the bridge and middle vault is satisfactory then only tip work is necessary. Preoperative planning has to take into account on the patient’s profile what happens if tip deprojection is planned as this create a need to lower the entire profile up through the nasal bones.

Highlights:

  1. The cartilages of the nasal tip have the most complex anatomy of the nose.
  2. Nasal tip asymmetry occurs as a result of a discrepancy in the size or shape of the lower alar cartilages.
  3. An open rhinoplasty allows the best visual assessment and manipulation of nasal tip cartilages.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Long Term Silicone Testicular Implant Results

Saturday, April 1st, 2017

 

Background: The replacement of a congenitally absent or surgically removed testicle is done historically by a saline implant. Borrowing from saline breast implants, a small fluid-filled shell is used as the testicular replacement. This has been the standard device used as a testicle implant since the early 2000s. It is currently the only FDA approved device for such indications.

While it is a marvel of engineering to make such a diminutive device that can be filled with a few ccs of fluid, it is a conceptually flawed device. The natural testicle is not hard like a fluid filled device nor does it ever have the risk of spontaneous deflation. Its size options are also limited and trying to increase their size by greater fluid fill only makes the implant get even harder.

One unique phenomenon that can happen to testicular implants is that of capsular contracture. While well known in breast implants it can occur in any spherical device that is placed in the body. The surrounding scar layer can thicken and contract, making the implanted device feel firm and potentially distorted. As the only other spherical device placed in the body other than breast implants, this same postoperative problem can develop in testicle implants as well.

Case Study: This younger male had a saline testicle implant placed as reconstruction from a lost testicle from a varicocele. He had it in place for three years but never liked it because it felt too hard, did not move and was smaller than the other side. It also was positioned too high and caused noticeable scrotal asymmetry.

Under general anesthesia and through a high scrotal incision, his existing saline implant was removed. A capsulotomy was performed to extend the pocket back down into the  lower end of the scrotum to match the other side. A larger 5.5cm oval  ultrasoft silicone testicle implant was placed in to the new pocket. His immediate intraop result showed a much improved scrotal asymmetry.

One year results showed a soft implant feel and good scrotal symmetry. No recurrence of the capsular contracture occurred. He was very pleased with his results and had developed new self-confidence.

The ultimate success of a testicle implant is that is matches in size that of the opposite testicle and remains soft and easily moveable. Since it is non-functional its cosmetic characteristics are essential. Ultrasoft silicone implants have numerous advantages over saline, the least of which is that they can never fail or deflate.

Highlights:

  1. Saline testicle implants often feel hard and are too small.
  2. A small hard testicle implant can be prone to capsular contracture, increasing scrotal asymmetry.
  3. Silicone testicle implants offer soft long-term results for a more natural scrotal appearance and feel.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Infraorbital Rim Implants

Wednesday, March 29th, 2017

 

Background: The infraorbital rim is the lower eye socket bone that accounts for the bottom half of the bone that encircles the globe. It is formed by the union of the zygomatic bone laterally and the maxillary bone medially. Between the two bones is a suture line that may or may be present in adults. The location of this inferior orbital rim suture line lies just above the infraorbital nerve foramen.

Augmenting the infraorbital rim can be done in several ways depending upon what one is trying to achieve. The rim can be augmented on its anterior edge to give greater horizontal projection. It can also be augmented vertically to raise up the level of the bony rim for increased lower eyelid support. Or both horizontal and vertical infraorbital rim augmentation can be done if needed.

The only effective method of infraorbital rim augmentation is with implants. One type of infraorbital implant is that of tear trough implants. Designed originally to fill in the classic soft tissue indentation along the medial half of the bony rim, they can be used to augment the entire anterior rim across its entire length. But there are no preformed implants that are actually designed to sit along the rim to built it up vertically.

Bilateral Orbital Rim Fractures 3D CT scan Dr Barry Eppley IndianapolisOld Infraorbital Rim Fractures Dr Barry Eppley IndianapolisCase Study: This 24 year-old female had an uncommon history of having had bilateral infraorbital rim fractures during birth due to a forcep delivery. She never had any fracture repair surgery as could have been predicted as an infant. Now as an adult she had a palpable stepff along the infraorbital rim at the old fracture site at the suture line. (this was undoubtably an original bend in the rim at the location of the suture line from the forceps) Her 3D CT scan shows the lateral orbital rim displacement.

Custom Infraorbital Rim implants design for fracture treatment Dr Barry Eppley IndianapolisCustom Infraorbital Implants design Dr Barry Eppley IndianapolisCustom infraorbital rim implants were fabricated to create a more elevated lower rim out to and around the lateral orbital rim to create a more natural contour.

Under general anesthesia the custom infraorbital rim implants were placed and secured through a lower blepharoplasty incision.

Recreating the height of the infraorbital rim, or at any location of the orbital rim, requires a custom implant approach. Getting the vertical dimension of the orbital rim can be done very effectively or securely with any other type of standard implant design.

Highlights:

  1. There is no true preformed infraorbital rim implants that actually sir or cup the rim itself.
  2. Custom infraorbital rim implants are design to sit along the rim and increase its vertical height.
  3. An infraorbital rim fracture can displace the normal smooth and horizontal shape of the lower bony rim.

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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