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Archive for the ‘plastic surgery case study’ Category

Case Study- Hump Reduction Rhinoplasty

Tuesday, December 12th, 2017

 

Background: The surgical reduction of a nasal hump is one of the oldest techniques in rhinoplasty. It has been done since the nasal reshaping procedure was introduced and, historically, defines what a rhinoplasty was. It has long been recognized that a raised or convex profile to the dorsum of the nose is not an aesthetically desirous nasal feature for most people. In addition it can he perceived as an ethnic nasal feature and in trying o achieve better nasal shape its removal can also make the nose more ethnically neutral.

The upper third of the nose is commonly known as the bridge. While often perceived as being bony in composition, it is really a combination of bone (nasal bones) and cartilage. (septum and upper lateral cartilages) This becomes apparent when a hump is present and its removal is requested. Taking down a dorsal hump on the nose always requires removal of both bone and cartilage of which cartilage usually makes up the greatest percentage of the hump.

The standard goal in most hump reduction is to change the profile of the nose to a straight line. This linear dorsal profile is most commonly accepted and is one that optimally maintains nasal airway function. But it is not the only dorsal profile that is requested. Some females may want a more concave dorsal profile while some men may want to maintain a bit of convexity to it or the semblance of a small dorsal hump.

Case Study: This young female had several features of her nose that she wanted changed for a slimmer more feminine nose. One was the long dorsal hump that covered the entire distance of her nasal profile.

Under general anesthesia an open rhinoplasty was done to completely remove the nasal hump to a straight nasal profile as well as thin out the tip and give it a slight upturn.

Because most hump reductions are usually not done in isolation, an open rhinoplasty approach is most commonly used. This is the most assured approach for a smooth dorsal line that is optimally reduced.

Highlights:

1) The presence of a hump on the nose is the most common reason patients seek rhinoplasty surgery.

2) A straight dorsal line is the most desirous shape that those with a hump reduction seek.

3) Hump reduction consists of both bone and cartilage removal for which ‘rasping’ alone is not an adequate treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Transgender Vermilion Advancements of the Lips

Monday, December 11th, 2017

 

Background: The lips frame the mouth and are an important facial feature. What is seen on the lips is the dry vermilion with a little wet vermilion, known as the red part of the lips. The amount of vermilion seen determines the size of the lips. The junction of the vermilion and the skin, particularly the upper lip, determines their shape.

The lips are an important gender identifying feature. (even without makeup) As a general rule, desirable lips in women are fuller and have a more defined Cupid’s bow. It is not as important in men that lips necessarily be full. And most men do not have a well defined Cupid’s bow shape. While many women do have thin lips with little shape, often with aging, youthful feminine lips are associated with significant vermilion size and shape.

While there are many facial feminization surgery procedures, lip augmentation  is often a very important one. In achieving this change, a vermilion advancement is an effective and powerful procedure to do so. Changing the position of the vermilion-cutaneous junction through skin removal allows for much increased vermilion exposure. In the process the arc of the vermilion and the strength of the Cupid’s bow portion of the upper lip can be enhanced.

Case Study: This middle-aged male to female transgender patient was to undergo a fairly complete facial feminization procedure. The lips were thin (less than 7mms of exposed vermilion) and the mouth corners were turned down

As part of an overall nine hour facial feminization surgery, upper and lower lip advancements were performed. The size of the skin removed from the upper and lower lips was 3mms. The Cupid’s bow of the upper lip was sharpened. (stronger points) The two weeks result showed how dramatic such vermilion lip advancements can be.

Lip advancements may be a small in size facial feminization surgery procedure but its effects are significant. It does create a fine line scar at the vermilion-cutaneous junction but this heals extremely well particularly in genetic male facial skin that is naturally thicker with beard hairs.

Highlights:

1)The size and shape of the lips is a major feminine facial feature.

2) Vermilion advancements are the most powerful lip augmentation procedure because it can change both size and shape.

3) In the transgender male to female patient changing the mouth area with a surgical lip augmentation is a small but important facial change.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Male Elbow Lifts

Monday, December 11th, 2017

 

Background: Loose skin develops over time around joints due to their repetitive motion. The skin around knees and elbows must be flexible to allow the range of motion needed for all forms of physical activity. But this tissue flexibility and repetitive motion adds up over time to create rolls of skin above the joints.

Removal of this excess skin (knee and elbow lifts) involve the excision of skin rolls above the joint. While that can be effectively done, the tradeoff of the scar must be very carefully considered. A wide scar or a postoperative wound dehiscence would likely create an aesthetic result that would not be viewed as better than the original skin rolls.

The key to a successful lift around a joint is the preoperative markings. They must be done with the motion of the joint considered into the amount of the skin excision pattern. Without this consideration it is easy to remove too much skin and create adverse healing and scarring.

Case Study: This middle-aged male was bothered by skin rolls that had developed above the elbows on the back of his arm. He had a lean body frame and the skin rolls could be pinched up to two inches of excess skin.

Preoperative markings were done both in a conservative excision (solid upper line) and maximally with the pinch test. (dotted upper line)

Under general anesthesia (he was having many other procedures as well) the elbow skin excisions were done slightly inside that of the original conservative markings. This was done as the elbow was bent at 120 degrees, accounting for any range of motion after surgery in the healing process.

Elbow lifts do create scars. But as long as they stay very narrow and do not extend any further than the medial and lateral epicondyles of the elbow, they will create minimal scarring.

Highlights:

1) Excess skin can occur around the elbow in both women and men.

2) Preoperative elbow markings must be done with the arm both fully extended and flexed.

3) The skin removed should be conservative and within the skin makings to prevent adverse scar widening or even wound dehiscence.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Subcostal Protrusion Correction by Rib Shaving

Sunday, December 10th, 2017

 

Background: The ribcage is formed by a collection of twelve (12) ribs of various lengths, locations and compositions. The first seven (7) ribs are called the true ribs because they run between the spine to the sternum through a direct curvilinear connection. Ribs #s 8, 9 and 10 are called the false ribs because they are indirectly connected to the sternum through long curved cartilaginous connections to the seventh rib. Lastly the floating ribs are #s 11 and 12 because they have no sternal connection at all.

Besides the midline sternum and the shape of the adjoining upper chest, the other distinguishing ribcage feature is that of the subcostal region. Everyone knows this ribcage area well because you can put your hand up under it and even move it a bit. This is formed by the cartilaginous connections of the false ribs as they come around and upward to connect to rib #7. It is somewhat mobile because of its cartilage composition and can create its own aesthetic issues if it is too prominent.

One potential cause of an acquired subcostal ribcage protrusion deformity is trauma. Like all ribs, with the exception of #s1, 11 and 12, there is a bone-cartilage junction. (costochondral junction) This junction can be prone to separation from trauma as it is the ‘weak’ link along the entire length of the rib. Such costochondral disruptions can create a change in the subcostal shape.

Case Study: This middle-aged male developed a right subcostal protrusion after a traumatic event when he was struck by an object on that side of his chest. It was presumed that this caused a separation of the costochondral junction of ribs #s 8 and 9 and a resultant  deformation of the subcostal ribcage.

Under general anesthesia a 4 cm skin incision was made directly over the ribcage protrusion. The rectus muscle was vertically split for access to the protruding cartilaginous ribs. The protruding rib portion was shaved down with a large scalpel blade until the protrusion was eliminated and only a thin layer of cartilage was left. Some shaving was also carried over onto rib #10. After injection of Marcaine local anesthetic into the muscle and intercostal nerves, the muscle and skin were closed with dissolvable sutures.

Shaving is a very effective form of rib removal/reduction that is only useful in the subcostal ribcage because of its cartulaginous composition. With enough shaving as much rib can be removed as if it was removed as a whole piece. It has the benefit of creating a smoother contour than en bloc rib resection and helps avoid direction of the back side of the rib which requires additional tissue elevation and increased risk of intercostal nerve injury and even

pneumothorax.

Highlights:

1) The ribcage is prone to traumatic deformities particularly at the costochondral junctions

2)  Subcostal ribcage protrusions can be reduced through a direct incisional approach.

3) Cartilage shaving of subcostal protrusions is an effective contouring technique that avoids sharp edge demarcations.

Dr. Barry Eppley

Indianapolis, Indiana

Case Report – Correction of Pixie Ear Deformity by Secondary Facelift

Saturday, December 9th, 2017

Background: The surgical origin of a facelift is what transpires around the ears. Making skin incisions around and in (retrotrgal) the ear creates the access needed to both mobilize and reposition loose skin but also to treat the deeper tissue layers. Closing a facelift is about bringing the shape of the ear back out through skin excision and layered tissue suturing.

While much thought and discussion gets into whether and how the SMAS is manipulated in a facelift, incision placement and closure around the ear is often overlooked or taken for granted. One of the underlying principles in removing and redraping facial skin around the ear is to avoid any tension on the lower half of the ear. Since the earlobe contains no supportive cartilage, it is susceptible to being stretched if the skin that is reattached to it is under any tension.

Such elongation of the earlobe after a facelift is known as the pixie ear deformity. While this is a well known term to describe this type of ear deformity, actual pixie ears have elongation of the upper third of the ear and not the lower third. But that issue aside, the vertical lengthening the earlobe and the stretching of the scar around it represents an undesired form of tissue expansion of a once smaller earlobe.

Case Study: This 62 year-old female had a facelift twelve years previously. As time had progressed she ha lost the benefits of the facelift and was in need of repeat jowl and neck reshaping. One aspect of her original facelift she didn’t like was how it make her ears look. Shortening and reshaping the earlobes was a necessity for her next facelift.

Under general anesthesia her original facelift and submental incisions were used to perform a secondary facelift with SMAS flap resupension.. As part of the procedure the skin beneath the earlobe was cradled up against the ear cartilage and the earlobes shortened and reattached to it.

While more minor forms of the pixie ear deformity may be treated by release and vertical skin closure, this will not be effective when the earlobe lengthening is more than 50% of its original length. (unless one can accept a long vertical scar extending down from the earlobe) Wide re-elevation of the facial skin flaps is needed (secondary facelift) for a complete correction with hidden scars.

Highlights:

1) The ear is intimately involved in any facelift procedure.

2)  The earlobe contains no cartilage and is susceptible to being elongated after a facelift if any skin tension is placed on it.

3) The severe pixie earlobe deformity is most effectively corrected by a secondary facelift.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Microplate Fixation of Transgender Brow Bone Reduction

Tuesday, December 5th, 2017

 

Background: Brow bone reduction is one of the more recognized forms of forehead reshaping. Outside of tumor, fracture or asymmetry issues, brow bone reduction is done in two main patient populations. Male patients seek treatment for very strong brow bones to eliminate the ‘Neanderthal’ look. The transgender male to female patient seeks to feminize their upper facial appearance by softening and rounding their forehead shape.

What makes brow bone reduction unique in aesthetic forehead bone surgery is that the underlying frontal sinus must be taken into consideration when considering how much reduction is desired. For minimal brow bone reduction a burring technique can be used but this is limited by the thickness of the anterior table bone of the frontal sinus and rarely produces a satisfying result. Significant brow bone reduction requires the removal of the complete anterior table of the frontal sinus with its rehaping and re-insertion. (bone flap setback)

While the removal of the anterior table of the sinus bone and is setback seems responsible for the brow reduction result, this is an overlying simplistic view. Numerous accompanying bone reshaping procedures are needed. These include the reduction of the surrounding edges of the forehead/brow bone that remains, the midline bony septum between the two calfs of the frontal sinus, the frontonasal junction as well as the thinning out/flattening of the removed bone segment. This maneuvers allow the straightened bone flap to set back into the frontal sinus.

Case Study: This 60 year-old male to female transgender patient was to undergo a variety of  facial feminization procedures of which brow bone reduction was but one of them. Other concomitant forehead procedures included a hairline advancement and brow lift.

Under general anesthesia and through a frontal hairline incision extending down into he temporal region, the forehead and brow bones were exposed. A reciprocating saw was used to cut off the anterior table of the frontal sinus flush with the surrounding forehead bone. The outer perimeter of bone, the septum and the frontonasal junction was also reduced. The removed bone flap was made straighter by thinning its inner and outer surfaces. It was placed back over the frontal sinus using 1.0mm micrplate and screws. The outer half of the brow bones was then reduced by burring to change a moe square lower forehead shape into a rounder one.

Microplate bone flap fixation provides the lowest hardware profile and leas than one millimeter. It is nit capable of being felt from the outside through the skin as a result.

The immediate intraoperative effects of this brow bone reduction technique could be readily appreciated.

Long term results from the procedure showed the effective reshaping benefits.

Highlights:

1) The setback bone flap technique in brow bone reduction is the most effective method.

2)  Some form of plate fiction is usually needed to secure the bone flap of which 1.0mm microplane fixation is the smallest.

3) Setting the brow bone flap back into position requires a reduction of the surrounding perimeter of bone and the midline sinus septum of bone.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Submental Chin Reduction Technique for Horizontal Macrogenia

Tuesday, December 5th, 2017

 

Background: While chin augmentation is a very common aesthetic facial reshaping procedure, reduction of a prominent chin is not. Not only are the patient requests for macrogenia reduction far fewer, but the techniques to do so have completely different considerations. In chin implant augmentation the issue is whether there is enough soft tissue to accomodate the amount of augmentation needed. In chin reduction surgery the questions are whether enough bone can be reduced and what happens to the overlying soft tissue in doing so.

Historically, and to some degree today, chin reduction is viewed as the reverse of a sliding genioplasty. If the bone can be cut and moved forward for increased projection it should similarly be cut and moved back for lessening chin projection. But in reducing a chin prominence there is always the issue of managing the ‘extra’ soft tissue which is a non-consideration in the expansile effects of chin augmentation. In reality a sliding genioplasty is a poor method for horizontal chin reduction in most cases as it results in a bulge of soft tissue below the chin as that is where the excess soft tissue ends up pushed back by the bone..

Similarly in an intraorral chin reduction burring technique, there is always the risk of the soft tissue redundancy (and the loosen soft tissue attachments) falling off the end f the bone, creating chin ptosis.

Case Study: This 60 year-old female had been bothered by her prominence chin for many years. She felt it stuck out too far horizontally and she sought a maximal chin reduction effect.

Under general anesthesia and through a submental incision, the soft tissue was degloved from the bony chin. A high speed handpick and burr was used to reduce the projection of the chin by 8mms from side to side and cross the central chin projection. This required removing the outer cortex of bone and exposed the marrow space. Bone wax was used to stop the bleeding from the marrow space and provide a permanent seal.

The soft tissue chin pad was brought back over the flattened bony prominence, excess full-thickness tissue removed as per the preoperative markings and the mentalis muscle sewn to the periosteum on the underside of the inferior border of the chin to tighten down the chin pad. The posterior neck skin edges were then closed to it. (she also had upper and lower lip advancements done)

The combination of bone and soft tissue reduction creates the greatest amount of chin reduction that is possible. Only the submental chin reduction technique treats all components of significant horizontal macrogenia.

Highlights:

1) Macrogenia or chin hyperplasia always affects both bone and soft varying degrees.

2) The submental chin reduction technique is best for when significant chin reduction is needed.

3) Burring reduction of the bony chin from below allows for a lot more bone reduction than can be achieved from any intraoral approach.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Dermal-Fat Grafting Of Buttock Indentation

Monday, December 4th, 2017

 

Background: The buttocks are a frequent site for intramuscular injections due to the large mass and surface area provided by the gluteus maximus muscle. In children it is a particularly preferred injection site. Many different types of injectates can be introduced from antibiotics to vaccinations to steroids. Usually these are few negative side effects from using the buttock injection site.

One known side effect from buttock injections is with the use of steroids. When the dose is too high or placed too superficially the steroid collects in the tissues and creates fat atrophy. This can result in skin dimpling or an indentation. This effect is not seen immediately. It takes several months for it to appear and the progression of its effects may continue for up to six months after the injection.The steroid, triamcinolone (Kenalog), which is widely used is well known to cause this injection site contour deformity.

Reconstruction of buttock injection deformities is one by fat grafting. Whether it would be by injection fat grafting or the use of a composite solid fat graft depends on the size and depth of the indentation.

Case Study: This 19 year-old female had a left deep buttock scar/indentation from having aa steroid injection done as a child.  She had two more superficial ones of the right buttock. The left buttock scar remained deep through her growing years and only became bigger as she got bigger. It was deep and tethered to the underlying muscle.

Under general anesthesia and in the prone position, the buttock scar was excised and the skin widely released. A dermal-fat graft was harvested from the inner infraglutea crease. The overlying epithelium was removed and the grafts was placed dermal side down into the defect. The skin was closed over it. The right buttock scars were treated by fat injections which was harvested from the inner thighs.

Dermal-fat grafting is an almost forgotten form of soft tissue reconstruction. While injectable fat grafting is far more versatile, there remains a role for composite bloc fat grafting. Scars that are deep and tethered respond better to an open release from which a composite fat graft can be placed. It does require donor site and the infragluteal crease is one option.

Highlights:

1) Buttock indentations are commonly the result of injections.

2) Injectable fat grafting is indicated for less deep and broader-based buttock indentations

3) Buttock indentations that are associated with scar contractors are best treated by release and dermal-fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Transaxillary Saline Breast Augmentation

Sunday, December 3rd, 2017

 

Background: Breast augmentation can be done using two different types of implants, saline and silicone.  (technically three if you include the saline-filled Ideal implant) Both type of breast implant has their own unique advantage sand disadvantages Silicone offers the most natural feel and an implant that will probably last longer as it can not undergo a spontaneous deflation. But these benefits come at a higher cost of the implant.

Saline breast implants have as their main advantage that they are the most economical of all breast implants. They also can be inserted with the smallest incision as they are deflated and rolled to pass through the skin entrance site and then are subsequently inflated to the desired volume size. Such characteristics make them appealing to many younger women who may be more financially challenged and are often the most concerned about incisional scars.

Case Study: This 19 year-old female wanted saline breast augmentation. Her mother and her two sisters had prior breast augmentation over ten years ago with saline implants and have never had a problem yet.

Under general anesthesia through a 2.5 cm transaxillary incision, 200cc saline implants with 11.5 cm base diameter were placed in the submuscular position and inflated to 250ccs. This was done in a non-endoscopic fashion.

Her early two week result showed good symmetric implant placement and incisions that already looked good as this early point. In a few months these scars will fade and will probably be very hard to find.

While breast implants and the surgical technique to place them continue to evolve, the ‘old’ transaxillary saline breast augmentation technique continues to produce successful results for the patient who is willing to accept a saline-filled implant.

Highlights:

1) Saline breast implants remain popular particularly amongst young women.

2) The deflated and rolled insertion method for saline implants allows them to be placed through the smallest possible incision.

3) The transxillary incision for saline implants still remains a preferred method for their placement.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Triple Roll Tummy Tuck with Pubic Lift

Sunday, December 3rd, 2017

 

Background: Large amounts of weight loss cause an expected amount of abdominal skin looseness and overhang. The deflation of the abdominal and waistline fat causes a resultant skin excess that hands down. This most commonly results in a single roll of tissue that hangs over the waistline known as an abdominal pannus. In patients with a lot of remaining intra-addominal fat or a thick upper abdominal subcutaneous fat layer, the deletion of weight loss causes a tissue roll above the umbilicus as well as below it. (double roll abdominal deformity)

But a third roll in weight loss patients is also possible but it does not involve the abdomen per se. If one has a large pubic region initially it will partially deflate and sag. This smaller tissue roll is pushed down by the larger tissue roll above it, creating the third roll or the triple roll abdominal deformity.

A large and low hanging pubic ‘pannus’ complicates the tummy tuck design for these larger excisional patients. Should the central part of the lower tummy tuck incision go lower to remove the upper third of the sagging pubic mound or should the tummy tuck markings be done in the standard fashion above the pubic mound and just do liposuction of the pubic mound to further deflate it? Or should some combination of both pubic mound management strategies be done?

Case Study: This 45 year-old female lost over 60lbs on her own but developed the triple roll abdominal deformity. She has a large and full pubic mound that hung down between her inner thighs.

Under general anesthesia she underwent a tummy tuck that included excision of the complete middle abdominal roll, a portion the lower end of the upper abdominal roll and the upper third of the pubic mound or lower pubic roll. Her postoperative result shows substantial improvement although not completely flattening of the entire front torso.

The pubic mound shows a significant lift but not a complete flattening of its profile. The abdominal wall above it is also much better but is similarly not flat. Ideally a second stage procedure is needed primarily focusing on liposuction of the abdomen and pubic mound for further flattening. Some additional skin above and below the tummy tuck scar may also be needed.

The triple roll abdominal deformity is a difficult problem to ideally correct in a one-stage procedure. It often takes a second procedure to improve the results of the first tummy tuck with additional fat and skin removal.

Highlights:

1) The ‘triple roll’ abdominal deformity can happen after a lot of weight loss in certain women.

2) The third roll in this type of abdominal lipodystrophy is the pubic ‘pannus’.

3) The low hanging and full pubic pannus must be factored into the design of the tummy tuck.

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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