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Archive for the ‘plastic surgery case study’ Category

Case Study – Female Custom Chin Implant

Saturday, February 17th, 2018

 

Background: Chin implant augmentation is the most commonly performed of all facial implants. The procedure has been done for over fifty years and, as a result, a wide variety of chin implant styles have been developed. While often named after the surgeon who developed them (which is not particularly helpful in understanding what they are intended to do), just about every aspect of every external chin change can be accomplished.

It is important to remember that most chin implants have been developed for the ‘average’ facial bones they augment and are based on anatomical skeletal models. As a result they will not fit everyone’s face well and create the exact intended aesthetic result. This becomes particularly evident in cases where the anatomy is abnormal such as in bony chin asymmetry, vertical chin deficiencies, gender specific needs and when the aesthetic demands are ‘extraordinary’.

Surgeons often try to make standard chin implants work in these non-standard augmentation situations through modification of the implant or in its bony position. And while it may work some of the time, there are many instances when it does not. These aesthetic failures create the need for a custom chin implant approach. And also illustrate why a custom implant approach may have been done initially.

Case Study: This female wanted a chin augmentation that was very specific for her small feminine face. She had existing chin asymmetry with the one side of the chin longer than the other. (or one side shorter than the other?)

Her goal was a chin augmentation result that corrected the asymmetry, kept the chin narrow and provided a forward and slightly vertically longer chin. A custom chin implant was designed to create this specific type of changes. While it was a petite chin implant it had very specific dimensional criteria.

Under general anesthesia and through a submental incision, the chin implant was placed and secured with a single microscrew. Chin implants that have some vertical design to them sit more on the edge of the bone, and even though they are custom made, are best secured with small screw fixation.

Just because the area of chin coverage may be relatively small does not mean that there does need to be an exacting design to it. Like the nose the projection nature of the chin makes its shape erasely apparent and scrutinized.

Highlights:

1)  Not all standard chin implants work well for everyone.

2) The most common reasons a standard chin implant is inadequate is when there is bony chin asymmetry, a need for vertical lengthening, dimensions beyond what standard sizes can do or when extensions are needed far back along the jawline.

3) A custom chin implant is most commonly used when a standard chin implant has ‘failed’, unless the surgeon first recognizes how likely a standard implant can work.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Arm Lifts after Weight Loss

Saturday, February 17th, 2018

Background: Large amounts of weight loss is a very positive benefit to one’s health when needed. But the tradeoff for this medical and often needed benefit is the unaesthetic sequelae of loose skin. How significant this new problem is depends on many factors including the amount of weight loss, patient’s age, natural quality of their skin, gender and the specific body area.

One body area that is hit particularly hard when large amounts of weight loss has occurred is the arms. This is particularly true in women. Stretched out skin and fat fall off of the back the arms and hangs. Often referred to as ‘batwings’, these unflattering segments of loose skin also pose problems for clothing wear in addition to their embarrassing appearance.

Arm lift surgery for ‘bat wings’ has been around for decades and is not new. It has been used for body contouring long before bariatric surgery and other forms of weight loss ha come into widespread use. While contemporary arm lift surgery has undergo some advancements (concomitant use of liposuction, incisional placements and the development smaller versions of it), its fundamental premise is the same. One has to be willing to tradeoff a long scar for a complete upper arm reduction/reshaping.

Case Study: This 65 year-old female has lost some weight but her arms never really changed that much. Rather than  having a batwing deformity that involved the whole upper arm, her worst tissue sag was in the upper half of the arm closer to the armpit.

Under general anesthesia and with the back of her arms suspended vertically using a padded cross table bar, a long horizontal ellipse of posterior arm skin and fat was removed. More was excised closer to the armpit than near the elbow.  The incisions were closed by advancing a posterior fasciocutaneous flap to the anterior skin edge. No drains were used and a subcuticular closure was done.

Like all arm lifts there is going to be a dramatic change in the shape of the upper arm. It would he hard to have that happen when such segments of tissue are removed.

While infections and serums are always possible, the most common adverse sequelae of the procedure is the scar. Quite frankly I have seen very few great arm lift scars, it is just a tough area for that to occur given that the long incision runs perpemdicular to the relaxed skin tensions lines of the arm. The best arm lift scars I have ever seen are those that went on to have a secondary scar revision where the skin edges are closed under much less tension.

Highlights:

1)  The posterior or medial arm lift is the only reshaping procedure of the upper arm when skin removal is needed.

2) Arm lifts are very successful procedures that do definitely solve the sagging upper arm problem.

3) All maximally effective arm lifts involve a longitudinal scar that runs between the  armpit and the elbow whose aesthetic appearance is often not ideal.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Crown of the Skull Augmentation with a Custom Implant`

Saturday, February 10th, 2018

 

Background: The shape of the head in a female has important aesthetic significance. While the concept of having a ‘nice round head’ is perceived as an ideal head shape, the ideal woman’s head shape is much more of an oblong shape. But the area over the crown of the head is of particular significance as it should be the highest peak of the skull in women. This is quite unlike men who would view such a location of maximal skull height as an unaesthetic protrusion.

Why women like a more prominent crown of the head is not precisely clear. At the least they do not like a crown area that is flatter or lacks projection. It may be its appeal from is influence on how it pushes the hair upward. This is suggested because many women who undergo crown augmentation talk of the tedious nature of teasing their hair to look like they have a higher crown area of the head.

Creating a higher crown of the head can only be done by building up the skull. Between bone cements and implants, these are the only two effective augmentation options. While fat grafting has become popular for injectable soft tissue augmentation, this technique will not work for skull augmentation as the scalp is too tight to be pushed outward by the soft consistency of fat. Custom made implants from the patient’s 3D CT scan has become the most effective technique to ensure the best augmentation shape and the desired area of skull coverage.

Case Study: This young female was bothered by the flat area over the crown of her head. A 3D CT scan showed how her skull shape sloped downward over the crown area as well as a triangular shape from the front view.

From the 3D CT scan a custom implant was designed to cover the crown area and give a more convex shape. The maximum central projection was set at14mms which was felt to be as much as the scalp could stretch in a one-stage implant augmentation.

Under general anesthesia and in the prone position, a 9 cm horizontal zigzag scalp incision was made over the nuchal ridge of the occiput. A subperiosteal pocket was made way up over the crown area. To keep the incision as limited as possible it is necessary to fold the implant for insertion. In thicker skull implants that are 1cm or over in the area of maximal projection, it is helpful to create a tighter implant roll to remove strips of material on its inner surface parallel to the direction of the implant roll.

The implant is then inserted in a rolled fashion and unrolled and positioned once inside the pocket. The compass marker on the implant serves as a key guide for proper implant positioning and midline alignment as this is the only part of the implant seen through the incision.

A custom skull implant is the most assured method for a higher crown area for women, creating the so called ‘bumpit’ effect. The firm composition of the implant provides the best push on the overlying scalp creating a permanent long-term augmentation effect.

Highlights:

1) The flat back or crown of the head is the common location for aesthetic skull augmentation.

2) The maximum thickness of the implant’s central projection and the amount of skull augmentation possible is controlled by how much the scalp can stretch to accommodate it.

3) Custom skull implants provide a ‘bump it’ effect for females.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Forehead Augmentation using Bone Cement

Monday, February 5th, 2018

 

Background: The forehead occupies a large surface area of the face and the broadest uninterrupted facial contour. Between the brows bone and the frontal hairline, it is a vast expanse of skin that can only be judged by its size and overall shape. While its more superficial features undergo frequent aesthetic manipulations (Botox, injectable fillers and brow lifts), the bony shape of the forehead does not. This, however, does not mean it is not capable of being changed but it is more of a surgical endeavor to do so.

The shape of the forehead can be very gender specific as is well known in facial feminization surgery as well as facial masculinization surgery. Beyond the very gender specific feature of the more prominent male brow bones, the female forehead has a more vertical inclination as seen in the side view and a more rounded shape between the temporal lines on the sides of the forehead best seen in the oblique or superior-inferior views.

Female forehead reshaping to create a more pleasing shape often involves augmentation of the frontal bone in a shape specific manner. There are two surgical techniques to perform it using different materials and incisional approaches. The traditional technique involves the application of bone cements placed through a wide open exposure. Such exposure is needed because bone cements, regardless of their material composition, are applied in a putty-like fashion and then shaped and allowed to set. Such applications can not be disturbed by the pressure of a tight overlying scalp/forehead flap less significant contour deformities be created in the augmentation. Not to mention that getting the right forehead shape initially requires good visualization.

Case Study: This young female had a more recessed and triangular forehead shape with a slight backward vertical inclination.

Under general anesthesia and through a full coronal scalp incision, the forehead was exposed down to the brow bones. Using hydroxyapatite bone cement the forehead was  built up with emphasis on increasing projection between the temporal lines and giving the forehead a rounder shape with more vertical inclination.

These forehead augmentation efforts created a rounder more convex shape that did not increase any brow bone projection.

Hydroxyapatite is one option for a forehead augmentation material. One could argue it is the ideal forehead augmentation as its inorganic hydroxyapatite crystals allows direct bone bonding to it. But because of how it is applied and shaped it requires a full coronal incision to use it properly. In addition at a material cost of $100/gram, and a typical case may require at least 50 to 75 grams, adds considerably to the overall expense of the surgery.

Highlights:

1) The shape of the female forehead is one of greater convexity and a more round shape when viewed from above or below.

2) One method of forehead augmentation is the use of bone cements done through a full coronal scalp incision.

3) Augmenting the lateral or temporal sides of the forehead, with or without increased central projection, creates a more vertically inclined shape that is rounder.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Augmentation in Pseudoptosis

Sunday, February 4th, 2018

 

Background: Since breast augmentation is about increasing breast size it is no surprise that so much thought goes into choosing implant size before surgery. This is the one single issue that patients focus on and are often indecisive about before the surgery. No patient wants to be too big or too small knowing that in the vast selection of breast implant sizes there is the right one for them.

Numerous methods of breast implant sizing have been used and each has their own merits. The one I prefer is the volumetric method using different overlay sizers so the patient can see how different implant volumes affect their breast size. While not a perfect method it has worked as wells anything I have ever used and I have yet to have a patient sho felt their implants were too big with this sizing method.

Between breast base diameter and volumetric sizers, these parameters will work well for most patients. The other breast variable that must be considered is the overlying skin envelope. The volumetric sizers assume the breast skin is tight but when it is loose or has a deflated appearance it is going to take more implant volume to achieve what the volumetric sizers show.

Case Study: This 30 year-old female presented for breast augmentation surgery having lost much of her breast volume from having children. Her nipples were above the inframammary fold but there was some loose skin hanging over it. (pseudoptosis) Volumetric sizers showed she like 350cc implant size.

Under general anesthesia and through inframammary incisions, 425cc moderate plus profile silicone breast implants were placed in a dual plane location.

It is important to remember that the amount of loose skin on the breast will take more volume to expand outward than one may think and should be considered in the implant size selection process. The loose skin has lost elasticity and often has stretch marks. It will take more implant volume to fill it than if the overlying skin were tighter and there was less of it.

Highlights:

1) The amount of loose breast skin does influence how much implant volume is needed to fill it.

2) While there is no exact formula to calculate how much extra implant volume is needed to fill the ‘extra space’, it is best to add 50 to75cc onto the original breast implant sizing estimate.

3) It is best to overfill and not underfill the breast with loose skin when it comes to implant size.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – A Lower Buttock Lift for Sagging

Wednesday, January 31st, 2018

 

Background: The buttocks, like any other bodily structure, is subject to the changes of aging, use and gravity. Buttocks lose volume and develop sagging with age and more prominently with large amounts of weight loss. This flattening effect may occur in isolation but often involves the infragluteal fold as well. Buttock tissue can fall over an intact infragluteal fold or can descend downward with the loss of the fold’s attachment. This creates two different shapes to the lower buttocks but neither one is not deemed aesthetically desirable.

A buttock lift is a broad term that today usually means a brazilian butt lift or fat injections to the buttocks. This is a volumizing procedure and not a true lift. But the original buttock lift procedure was an excisional one that removes tissue from the lower buttock region and was designed to re-establish the lost or displaced infragluteal fold. It has been around for decades but is very uncommon perform today by most plastic surgeons.

Case Study: This thin middle-aged female did not like the look of her buttocks. It was flatter than she liked but what bothered her the most was the sagging tissues on its inferior area with no defined infraguteal folds. It was like the bottom of her buttocks had fallen down.

Under general anesthesia and in the prone position, an ellipse of skin and fat was removed from the inside to the outside of the lower buttocks. It was removed in a curved elliptical fashion along an axis of the desired infragluteal crease location. The dermal edges of both sides of the excision were sutured down to the gluteal fascia, creating a slight inversion of the closure along the desired infragluteal crease line.

Her six month followup showed a well healed scar along the infragluteal crease with elimination of the buttock ptosis and a resultant shortening of the vertical length of the buttocks.

A lower buttock lift could also be called a lower buttock tuck as it actually achieves both.

Highlights:

1) Buttock ptosis or sagging is when the lower buttock tissue falls over an existing fold or the infragluteal fold attachment is lost.

2) A lower buttock lift can either remove overhanging buttock tissue or restore the position of the infragluteal fold.

3) Excision of skin and fat with dermal fold attachment to the gluteal fascia are the key techniques for restoring the shape of the lower buttocks.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The High Cheekbone Look with Custom Infraorbital-Malar Implants

Monday, January 29th, 2018

 

Background: There are a wide variety of cheek looks that patients want from cheek augmentation surgery, most commonly achieved used implants. While typically done in patients that have flat or weak cheek bone prominences, contemporary cheek augmentation patients often seek improvements in their midfacial shapes that do not have any really inherent structural deficiencies.

One of the desires for some cheek enhancement patients is the ‘high cheekbone look’. While this is an aesthetic term that is well known, it has variable interpretations amongst patients and surgeons. What some patients say they want a high cheekbone look, that is often not exactly what they mean.

Technically such a look really refers to having the upper part of the cheekbone augmented throughout its length. Given the natural anatomy of the cheekbone (zygomatico-orbital-maxillary complex) this refers to a linear augmentation from the zygomatic arch across the upper half of the main body of the cheekbone which continues across the infraorbital rim. Such an augmentation must be more modest in most cases to not look unnatural.

Case Study: This young male wanted to enhance his infraorbital rim out across his cheeks, cresting the high cheekbone look. In the spirit of enhancing his natural bony anatomy a custom implant design was done that stayed within the shape of the bone adding a few millimeters of augmentation across the infraorbital rim and cheek.

Under general anesthesia subciliary lower eyelid skin incisions were made with a skin-muscle flap raised down to the bone. A long subperiosteal pocket was made from the nasal bones out past the mid-zygomatic arch suture back to the temporal bone. The implants were inserted and positioned up onto the infraorbital rims and secured with two microscrews per side. The eyelid incisions were closed with lateral canthopexies and orbicularius muscle resuspension sutures.

The high cheekbone look may be open to individual patient interpretation but its actual meaning is a linear augmentation along the cheekbone ‘line’ from the side of the nose to the back of the zygomatic arch.

Highlights:

1) The high cheek look really means a linear infraorbital-malar augmentation.

2) A custom implant can be made that creates a subtle but linear augmentation from the side of the nose back along the zygomatic arch.

3) A custom infraorbital-malar implant is placed through a lower eyelid incision for optimal positioning and fixation.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Crown Skull Implants for Women

Thursday, January 25th, 2018

 

Background: The shape of the head has importance to many people whether they have good hair cover or not. It should be no surprise that men who lack good hair cover or shave their heads make up a greater percent of aesthetic skull augmentation than that of women. At the least their head reshaping goals are usually different than that of women.

The most common head reshaping concern for women is a crown deficiency. The crown of the head starts at the top of the head where it starts to curve downward to the back and ends at a point just above the nuchal ride of the occiput. The center of the crown is usually where the hair often swirl or radiates outward from a central area in the center of it. It is a semicircular area that looks like a cap that is sitting little too far towards the back of the head.

Many women value a good crown skull height. When it is inadequate they often will tease their hair up to create the illusion of a higher natural crown shape. While this can be effective for some women with good hair density, they may fatigue of this practice or may not have he hair density to create a satisfactory illusion.

Case Study: This young female was bothered by the flat top of her head with no crown height. Her 3D CT scan confirmed that she had flat skull height that lacked convexity over the crown area.

A custom skull crown implant was designed to create a more pleasing skull shape with maximal projection of the center of the crown. Its maximal projection was 11 to 12 mms. The see through design images show the difference between her natural skull outline and that of the implant.

Under general anesthesia and in the supine position, a irregular 11cm long scalp incision was made over the top of head. A subperiosteal pocket was widely created. Multiple perfusion holes were placed throughout the implant prior to insertion and closure. The compass marking on the implant allows it to be oriented correctly through the small scalp incision.

Her one year results showed the improvement in the crown height and shape of the top of the head…as well as a happy patient.

The custom crown skull implant is a very satisfying procedure for women. There is a limit as to how much crown height can be obtained based on the limits of how much the scalp can stretch to accommodate the implant.

Highlights:

1)  Crown of the head augmentations are the most common form of aesthetic skull augmentation in women.

2) A custom crown skull implant that covers the intersection of the top and back of the head provides the desired location of female ‘bumpit’ head contouring.

3) Most women’s scalps can accommodate in the range of 12 to 14mms of implant thickness.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Grid Technique for Occipital Skull Reduction

Wednesday, January 24th, 2018

 

Background: The shape of the back of the head is affected by many factors. While flatness and asymmetries are well known to be caused by intrauterine and postnatal head positioning, limiting growth expansions in the compressed area, the origins of bony protrusions are less clear. In a study published in the Journal of Craniofacial Surgery in 2013, occipital protrusions or ‘very round heads’ were seen in only 3% of men studied. Excessive flatness was far more common at over 15%.

Regardless of its percentage of occurrence to those affected a excessive roundness of the back of head is aesthetically bothersome. Such occipital protrusions can be reduced and the extent of its effect is based on the thickness of the bone. Specifically it is based on the thickness of the other table of the skull. This is the layer of skull bone that can be safely removed without undue bleeding or risking making the skull too thin.

The skull is a flat bone (like the sternum and ribs) that forms boundaries of body cavities. (in this case the brain) It is a sandwich of spongy bone between two layers of compact bone. Moving the outer layer can always done and represents about 1/3 of the skull’s thickness. What reductive effect that may have is around 7mms, which may not sound like much, until one considers the broader surface of bone that is removed. Whether this is enough for any patient must be considered on an individual patient basis.

Case Study: This young male was bothered by the protrusion that jutted out from teh back of his head. It was about the size of a hand in shape (my hand) and was located over the central or central-low occipital skull position.

Under general anesthesia and in the prone position, a wavy 9cm long scalp incision was made in a horizontal orientation over the mid-occipital region. To ensure evenness in bone removal, a central vertical and horizontal line of bone removal was first done down to the desired depth of removal. This created four quadrants of bone which could be individually removed mindful of its depth and curvature outward to the top, sides and bottom. This allows the entire outer cortical table of bone to be removed, like harvesting split thickness cranial bone grafts.

The grid technique of skull reduction allows for a regimented approach to reducing a large bone surface and to do so in an even fashion. It allows the most common area for skull reduction, the back of the head, to be satisfactorily reduced for patient bothered by mild to moderate occipital skull protrusions.

Highlights:

1)  Occipital skull protrusions can be reduced twosome degree based on the thickness of the skull bone.

2) The skull reduction of the back of the head is approached through a horizontal wavy scalp incision of around 9 cms.

3) A grid reduction technique is used to remove the outer cortical layer of the skull.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Implants for Jawline Asymmetry after Mandibular Osteotomies

Tuesday, January 23rd, 2018

Background: Jaw asymmetry is one of the most common forms of perceived facial asymmetry. Whether it is localized to the chin or extends back along the jawline to involve the two jaw angles as well affects the magnitude of the deformity. The long length of the body of the mandible and the size of the jaw angles, compared to that of the much smaller chin, usually makes the facial asymmetry more obvious.

Patients undergoing orthognathic surgery frequently have bony asymmetry. When recognized before surgery it is usually built into the surgical plan and some adjustment accounted for by the osteotomy cuts. But such preoperative jawline asymmetries often persist after surgery and others can inadvertently be created by the surgery, particularly when sagittal split osteotomies of the ramus (SSRO) are done. How the bone cuts are made on each side, how the segments are put back together once the occlusion is set in the oral splint and the potential for some postoperative bony resorption due to the tissue stripped off of the bone all create the potential for the postsurgical occurrence or the magnification of presurgical asymmetry.

The treatment of jawline asymmetry, if augmentation is the corrective approach (which it almost always is), is best done with a custom jawline implant. The only relevant preoperative question is whether one or both sides should be treated.

Case Study: This young male had a prior bimaxillary orthognathic surgical procedure. He  acknowledged that facial asymmetry existed prior and was unclear if it was the same or worse than before that surgery. A 3D CT scam showed a tilt to the face with the left side being smaller than that of the right. From the chin back to the jaw angle the left side ws vertically shorter and less wide. His interest was to correct the left-sided facial asymmetry as well as enhance the overall jawline any a modest amount.

From this scan a two implant approach was designed to augment the whole jawline, factoring in the smaller left side, as well as a small cheek implant to augment the more subtle left cheek flatness. Both implants were relatively small as the goal was not to create some dramatic facial change.

Under general anesthesia the custom jawline implant was placed through a completely intraoral approach using three internal incisions. These were used to tread the jawline implant into place. The left cheek implant was placed through a standard intraoral upper lip vestibular incision.

The complete correction of any facial asymmetry is difficult and a perfect result should probably be considered unrealistic. There is always the variable of the surgical placement of the implants whose perfect positioning is never assured. (it is not as easy as the implat designs make it appear)  But custom designed facial implants adds one symmetric variable to an otherwise asymmetric situation and gives the best chance to improve the facial asymmetry as much as possible.

Highlights:

1) Jawline asymmetry is not uncommon after orthographic surgery and may or may reflect presurgical asymmetry.

2) A 3D CT facial scan is the best method to accurately diagnosis the location and extent of the jaw asymmetry.

3) A custom jawline implant can be designed to treat the entire jawline and is always best to create an overall jaw enhancement as well.

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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