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Archive for the ‘plastic surgery case study’ Category

Case Study – Bilateral Cleft Rhinoplasty

Friday, March 24th, 2017

 

Background: The bilateral cleft lip and palate deformity poses major reconstructive challenges. At its root cause is the shortage of tissue that has resulted from the cleft as well as scar tissue that has occurred from prior surgeries.

The bilateral cleft nose has many typical features from a wide and blunt nasal tip, an underdeveloped underlying septal support, a columellar shortage of skin and wide flaring nostrils.

A more complete rhinoplasty is done in the bilateral cleft patient during their teenage years when they are past puberty. There is some debate as to whether it should be done before or after an upper jaw advancement which is eventually needed in more than half of bilateral cleft patients. That would depend on when the jaw advancement is planned and how much forward movement is needed. But in most cases it is best done six months or longer after the LeFort I osteotomy has been done.

Case Study: This 17 year-old teenage male had multiple previous surgeries for a bilateral complete cleft lip and palate birth defect. He had completed his upper jaw surgery one year previously. He had a good occlusion and adequate upper lip support. His nose showed a strong and high dorsal line, wide nasal bones and a blunted and ill-defined nasal tip.

Bllateral Cleft Septorhinoplasty result side view Dr Barry Eppley IndianapolisUnder general anesthesia he had an open septorhinoplasty performed. The nasal bridge was lowered slightly and the nasal bones narrowed. A septal cartilage graft was used to create a strong columellar strut onto which the tip cartilages could be reshaped. The nostrils were also brought inward.

Bilateral Cleft Septorhinoplasty result oblique view Dr Barry Eppley IndianapolisBilateral Cleft Septorhinoplasty result front view Dr Barry Eppley IndianapoliosHis after surgery results show definite improvement in his overall nasal shape. But like mamy cleft rhinoplasty surgeries the result always leaves one hoping for more.

Highlights:

  1. The bilateral cleft nose poses a reconstructive challenge due to both tissue hypoplasia and tissue scar.
  2. The bilateral cleft rhinoplasty should be done after an upper jaw advancement =has been completed and healed to provide good skeletal support.
  3. The most important reconstructive element in the bilateral cleft nose is to achieve a strong columellar support onto which the nasal tip can be built.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Transcoronal Temporal Reduction

Friday, March 24th, 2017

 

Background: The width of the head is controlled by the thickness of tissues above the ears. This consists of skin, fat, muscle and bone. Of these four tissue elements, it is surprising for most people to know that the muscle layer is the thickest of all of them. The posterior belly of the temporal muscle is a lot thicker than is usually appreciated often being 7mm to 9mms in thickness.

The temporal or head width reduction procedure that I have developed uses the removal of full thickness muscle to achieve its effect. While most patients and surgeons want to grind down the bone, it is this soft tissue reduction that has the greatest effect. Removing this portion of the temporalis muscle sees like it would create functional problems with lower jaw opening, but it does not. This is because the bulk of the temporalis muscle is located in the anterior belly and there are other muscle (pterygoid and masseter muscles) that play a role in jaw motion as well.

Temporal reduction is usually done through limited incisions that are hidden as much as possible. This is because most patients that have heads that are perceived as being too wide or convex are men who have close cropped hairstyles or shave their heads. Small temporal or postauricular incisions are usually used. In rare cases where a coronal scalp scar already exists or other procedures are being done that necessitate such a long scalp incision will it be done with such open exposure.

Case Study: This young middle-aged male had a prior history of brow bone reduction and an existing full length coronal scalp scar. He was bothered by the width at the sides of his head and its protruding convex shape.

Posterior Temporal Muscle Resection and Parietal Skull reduction intraop bnefore and after Dr Barry Eppley IndianapolisBecause he already had a full coronal scalp incision, a full open approach was done for wide open access to the posteror temporal areas above his ears. The full thickness of the muscle and the overlying fascia were removed.

Temporal Muscle Reduction result front view Dr Barry Eppley IndianapolisHis after surgery results show a reduction in the width of the sides of his head with less convexity. He had no jaw motion restriction or pain even right after the surgery.

Highlights:

  1. A wide side of the head can be reduced by temporal muscle reduction.
  2. The most significant temporal reduction of muscle can be done through an open scalp incision
  3.  Complete temporal muscle removal usually results in significant head width narrowing.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Forehead Asymmetry Surgery

Friday, March 24th, 2017

 

Background: The forehead occupies a full third of the human face and sometimes than that based on the location of the frontal hairline. While the forehead does not draw one’s attention, like the lower two-thirds of the face due to the sphincteric motion of the eyes and mouth, its broad surface can not be overlooked.

Forehead asymmetries are not that uncommon and can result from a variety of causes. One of the most common is that from plagiocephaly where the twisting of the entire skull creates well known front and back of the head asymmetries.  It is also seen in varying degrees of isolated frontal facial asymmetries with the smaller facial side having less forehead projection and a lower brow bone position.

Another less common cause of forehead asymmetry is iatrogenic from prior surgery. In performing brow bone reduction or more superior frontal bone reshaping, slight bony shaoe differences may exist or be created between the two sides. While not apparent during the actual operation, these slight differences may become revealed after surgery as the tissues contract down around the expanse of the broad forehead.

Forehead AsymmetryCase Study: This young middle-aged male had a prior history of brow bone and forehead reduction surgery. While it took months after surgery to see the final shape of his forehead, it eventually showed a forehead/brow bone asymmetry that was confirmed by a 3D CT scan. The left brow bone, in particular, and the upper forehead were flatter than that of the right side.

Intraoperative Custom Forehead Implant 2 Dr Barry Eppley IndianapolisIntraoperative Custom Forehead Implant for Asymmetry Dr Barry Eppley IndianapolisBecause he already had a full coronal scalp incision, a full open approach was done for wide open access to the forehead. Using PMMA bone cement a thinly design implant was fashioned to visually match that of the right side. The edges were burred down to be very thin at their perimeters. It was secured into place with two small microscrews.

Left Foreheasd Augmentation Dr Barry Eppley IndianapolisHis after surgery results show improvement in his forehead shape between the two sides. Careful inspection shows just a hint of the outline of the bone cement application which is surprising given its paper thin edges and the thickness of his scalp tissues. Whether he may eventually undergo a revision for this aesthetic tradeoff remains to be determined.

Highlights:

  1. Forehead asymmetry can be created by brow bone and forehead reduction surgery.
  2. One method of bone augmentation for forehead asymmetry surgery is that of the use of bone cements which requires a wide surgical access for application.
  3. Any method of forehead augmentation requires the smoothest transition between the material and the natural tissues to avoid any visible lines of transition.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: 18 Year Old Silicone Breast Augmentation

Friday, March 24th, 2017

 

Background: The use of silicone implants for breast augmentation has now been done since 2006 when this implant filler material was re-introduced as an implant option. One of the stated restrictions with their use was that patients had to be 22 years or older. This was a position imposed on the manufacturers as issued by the FDA. As a result this is on the package inserts as indications for clinical use.

This silicone breast implant guideline from the FDA causes considerable confusion. Many breast augmentation patients under 22 years old want silicone rather than saline implants but feel they can not have them. Plastic surgeons may also follow this guideline rigidly feeling that they don’t want to be violation with the FDA. They may also feel that implanting young patients with these devices may invalidate the manufacturer’s warranty.

There is some debate as to why the FDA imposed this clinical guideline. One belief is that there were no patients under 22 years old in the submitted clinical study used for FDA evaluation. This would seem to be the most logical explanation but apparently there some such patients in the study. It is more likely that there was simply not enough patients in this age group to draw the same conclusions as the older patients.

Case Study: This 18 year-old female wanted breast implants but preferred silicone over a saline implant fill. She developed little natural breast tissue and had small but visible breast mounds.

Young Breast Augmentation results front view Dr Barry Eppley IndianapolisUnder general anesthesia and through a transaxillary approach, 375cc high profile silicone implants were placed in a submuscular position. The implants were inserted using a funnel device to minimize any handling of the implants as well as to allow them to be placed in a ‘scarless’ fashion through a small hidden incision.

Young Breast Augmentation results oblique view Dr Barry Eppley IndianapolisYoung Breast Augmentation results side view Dr Barry Eppley IndianapolisHer after surgery results show excellent symmetry of the implants with an expected rounder shape to the enlarged breast mounds.  She had wide sternal spacing of the implants but this was to be expected based on her preoperative anatomy.

There is no clinical difference in the use of silicone breast implants whether one is older or younger than the age of 22 years old. Their use should be based on surgeon discretion and presurgical patient education.

Highlights:

  1. Per manufacturer guidelines, silicone breast augmentation is for patients 22 years and older.
  2. Silicone breast augmentation can be done on women as young as age 18.
  3. The tight skin of young patients will create more of a round breast look with implant placement.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Hydroxyapatite Cement in Pediatric Skull Reconstruction

Friday, March 17th, 2017

 

Background: Skull defects occur in children for a variety of reasons. But one of the most common causes is early surgery for congenital skull deformities. When reshaping large portions of the skull their complete healing depends on the natural osteogenic capability of the underlying dura. This is usually very robust at very young ages but fades quickly after the first few years of life.

Reconstructing skull defects in children can be done by several techniques. One method is to use the patient’s own bone to do so. This is the most logical approach but its disadvantages is that one has to create another skull defect site and such bone does not always heal smoothly. The next option would be to use allogeneic or cadaver bone grafts. This saves a donor site but does not get around how smoothly, or non-smoothly, the resultant skull contour will be.

The third skull contouring material is that of hydroxyapatite cements. These synthetic calcium phosphate materials have a long history of use in craniofacial surgery for skull defect and contouring reconstructions. They are less well known for use in children but their value in these pediatric skull applications is no less significant.

Case Study: This 9 month-old infant male cild initially underwent reconstruction for a unilateral coronal craniosynostosis condition. The surgery was performed using supraorbital bar reshaping as well as a barrel-stave technique to expand out the overlying forehead bone.He went on well and when seen years later at age 8 he had a slight flattening of the lateral forehead and a palpable full-thickness bone defect along the original coronal suture line.

Hydroxyapatite Cement Forehead Defect Reconstruction intraop Dr Barry Eppley IndianapolisHydroxyapatite Cement Forehead Reconstruction result Dr Barry Eppley IndianapolisUnder general anesthesia and through his existing coronal scalp incision, the bone defect along the original coronal suture line was exposed. The dura was elevated off of the bone edges entirely around the defect. A Lactosorb mesh plate (resorbable PLLA-PGA) was placed on the underside of the bone and cut to lock in between the dura and the bone edges. Hydroxyapatite cement was applied into the bone defect using the mesh plate as its backing. It was then contoured to be flush with the surrounding skull contours and allowed to set.

Hydroxyapatite cement can be used to both fill in skull defects as well as can be placed as an onlay augmentation material. While more extensively used in adults, it can be just as effectively used in children. There is always the question of what happens to the bone cement as the skull continues to grow. My observation is that the skull bone on top and underneath it and it simply gets pushed out jus like normal skull bone with dow with ongoing appositional skull growth.

Highlights:

  1. Skull defects in children can be treated by either bone grafts or hydroxyapatite cement.
  2. When using bone cements in a full-thickness skull defect, a floor against the dura must be created to support the material.
  3. Bone cements offer a facile material to fill and contour skull defects.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Implant for Vertical Orbital Dystopia

Wednesday, March 15th, 2017

 

Background: Few faces are perfectly symmetric and most of us have some noticeable differences between the right and left sides. Such facial side differences are usually well tolerated or may not even be known. We all recognize that ‘no one is perfect’ and everyone has a little bit of facial asymmetry which is seen within the range of normal.

But asymmetry of the eyes is often different because it is so easily recognized and almost impossible to visually ignore. While there are different types of eye asymmetry, many of which are related to the eyelids, one of the most recognized causes of is that of orbital dystopia. Orbital dystopia is bone-based with the orbital bony box being at different levels between the two sides. The most common type of orbital dystopia is vertical and the affected side is almost always lower than the normal side.

In vertical orbital dystopia, the affected eye sits lower which can be seen and measured by the horizontal positioning of the pupil of the eye.  The eye sits lower because the orbital floor, including the circumferential orbital rims and cheek bone, sit lower. In more minor cases the orbital dystopia is isolated to the eye area. But in more significant cases the entire side of the face from the eyebrows down to the jawline is lower.

Right Orbital Dystopia 3D CT scan Dr Barry Eppley IndianapolisCase Study: This 43 year-old male presented for cheek augmentation for which a custom designed approach was chosen. He had always been by a mild degree of eye asymmetry as well which was most apparent in pictures. A 3D CT scan shows that the affected eye had a vertical dystopia of around 3mms. The lower infraorbital rim and malar eminence as well as more inferiorly positioned orbital floor could be seen as the bony origin of the vertical dystopia.

Orbital Dystopia Orbital Floor Implanty with Custom Cheek Implants design Ddr Barry Eppley IndianapolisCustyom Cheek Implants with Orbital Floor Implant design Dr Barry Eppley IndianapolisHis custom cheek implants designs included a component on the affected side that wrapped over the infraorbital rim and onto the orbital floor to create the needed amount of globe elevation.

Orbitozygomatic Implant placement for Facial Asymmetry Dr Barry Eppley IndianapolisCustom Orbitozygomatic Implant Placement incision closure Dr Barry Eppley IndianapolisUnder general anesthesia and through a subciliary eyelid incision, the custom orbital floor-rim-cheek implant was placed and secured to the orbital rim with two microscrews. An orbicularis muscle rsuspension and lateral canthopexy was performed at closure.

Orbital Floor Augmentation result front view Dr Barry Eppley IndianapolisHis one year after surgery results showed improvement in the symmetry between the eyes. As is often the case in vertical orbital dystopia raising up the eye reveals the other components of the dystopia including the more inferiorly positioned upper eyelid and eyebrow. These are planned for adjustment in the future. (right upper blepharoplasty with ptosis repair and transpalpebral browlift.

Highlights:

  1. One cause of eye asymmetry is a malpositioned orbital box which causes the eye to sit at a lower horizontal level than the normal side.
  2. Orbital floor and infraorbital rim augmentation is one technique in the treatment of vertical orbital dystopia but it will not correct every aspect of the eye asymmetry.
  3. The orbital floor-rim augmentation implant is best made from a 3D CT scan in a custom implant fashion.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Hanging Columella Correction Rhinoplasty

Sunday, March 12th, 2017

 

Background: The columella is the strip of skin and cartilage between the nostrils. It provides a smooth connection between the tip of the nose and the upper lip. Its shape is controlled by the cartilages which run within the skin as well as the septum behind it. A ‘good’ columella is really one that does not stand out in any way and sits obscurely at the bottom of the nose. A ‘bad’ columella is one that is noticeable either because it is deviated or sticks out too far.

The hanging columella is when it extends down to far, creating exaggerated columellar show. This is most noticeable in the profile view where too much of it is seen and sits too far below the rim of the nostrils. It can occur as a natural result of nasal growth with a long septum that pushes it too far forward. The medial footplate cartilages that compose it can also be too long or wide.

The hanging columella can also result from a prior rhinoplasty where the medial footplate cartilages have been overly weakened, making them prone to bending or notching. (and a columellar strut has not been used) Conversely it can also be caused by a columellar strut graft that has become or was placed too far forward.

Case Study: This 52nyear-old female presented with a columellar protrusion that had developed from an open rhinoplasty several years before. She felt it look like something was hanging out of her nose all the time.

Hanging Columellar Rhinoplasty correction side view Dr Barry Eppley IndianapolisUnder sedation and local anesthesia and using her existing columellar scar for access, the protrusive medial foot plate cartilages were trimmed. They were then used as a miniature columellar strut graft to support straightening using suture plication.

Hanging Columella Rhinoplasty result submental view Dr Barry Eppley IndianapolisHanging Columella Rhinoplasty correction result front view Dr Barry Eppley IndianapolisHer three months after surgery result showed elimination of the protrusion, a smooth curve in profile and a straight columella. While many isolated hanging columellas can be treated without an open approach technique, her prior rhinoplasty surgery made the decision to do so create a more assured and complete correction.

Highlights:

1) A hanging columella can occur from either natural nasal growth or from a prior rhinoplasty.

2) The hanging or protrusive columella that results from a prior rhinoplasty usually causes a columellar deviation and notching.

3) The revision rhinoplasty columellar correction removes the excessive medial footplate cartilage and straightens and stabilizes it with sutures.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Large Cankle Liposuction

Wednesday, March 8th, 2017

 

Background: Undesirable fat collections around the body, medically known as lipodystrophy, are usually caused by excess calories and results from their storage. But in some people and in certain locations of the body, fatty collections are more congenital in origin and are aggravated by weight gain. Even at a patient’s ideal weight these fat collections persist.

One such congenital lipodystophic condition is that of cankles. This urban term refers to the shape of the leg that is virtually the same from the knees down to the ankles. It occurs because there is a thicker than normal subcutaneous fat layer between the calfs and the ankles. This creates a uniform leg thickness below the knees with no defined or curvilinear leg shape. Whether it occurs in an overall larger leg or in a much smaller leg, the appearance of cankles is unmistakeable.

Case Study: This 36 year-old female presented for cankle liposuction. Despite her fairly short stature, she has a large body frame. She has lost a lot of weight but the thickness of her lower leg did not change. She was unable to wear boots and had to wear pants that were too big at the waist to get her lower legs to fit into them.

Under general  anesthesia and using a tumescent technique, her calfs and ankles ere treated with small cannula liposuction. Different entrance sites were done behind and below the knees as well as on the inside and outside of the ankles. Each lower leg had about 1,500cc per side.

Large Cankle Liposuction result front view Dr Barry Eppley IndianapolisLarge Cankle Liposuction back view Dr Barry Eppley IndianapolisIt took several months until most of her swelling resolved and almost 4 months until her legs felt completely soft and supple again. Her results show substantial size reduction and  the semblence of some better leg shape. She was now able to wear boots which she could not do before the procedure.

Cankle liposuction can be a very effective procedure for lower let reshaping even in extremely large lower legs. The amount of circumferential skin limits as to how much size reduction can be achieved.

Highlights:

1) Large collections of fat in the lower extremities is a congenital condition that not be reduced in size by diet or exercise.

2) Cankles refers to a consistent thickness from below the knee right down to the feet.

3) Large volume liposuction of the lower extremities would be considered any amount over 1,000cc per leg.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Asymmetry Augmentation

Monday, March 6th, 2017

 

Background: While few women have symmetric breasts, it is not rare that many breast augmentation patients expect symmetric looking breasts after surgery. This common expectation has led to the plastic surgery phrase ‘breasts are sisters and not twins’, which is usually provided as part of the preoperative counseling.

While most breast asymmetries are caused by pregnancy and weight loss/gain and can be relatively minor, more significant breast asymmetries are congenital in origin. The breasts  simply developed differently. There will be differences in the size of the breast mounds and with that comes horizontal nipple-areolar and inframammay fold position differences.

In placing implants in more significant breast asymmetries, there is the obvious issue of implant size (in ccs) and whether two similar or different implant volumes should be used. But managing the nipple-areolar and breast fold differences is often of equal if not greater importance in some cases.

Case Study: This 21 year-old Indian female presented for breast implants. She had previously tried fat injections for breast size increase but the result was too modest. She now wanted implants to achieve a more profound breast size increase. The right breast mound was noticeably smaller with a lower nipple position and a higher inframammary fold level. Her right breast was really a variant of a constricted breast deformity.

Breast Asymmetry Augmentationresult front view Dr Barry Eppley IndianapolisUnder general  anesthesia and through a transaxillary incisional approach, 400cc high profile silicone breast implants were placed in a dual plane (partial submuscular) position. Her postoperative results at three months a much improved mound symmetry and level of the inframammary folds. Her nipple-areolar asymmetry remained unchanged, no better or worse.

Breast Asymetry Augmentation result oblique view Dr Barry Eppley IndianapolisBreast Asymmetry Augmentation result side view Dr Barry Eppley IndianapolisBreast asymmetries can be effectively improved by the placement of implants alone. If the preoperative differences in the breasts are not too great it is usually best to use identically sized implants.  Mound and breast fold differences can be improved but horizontal differences in the level of the nipples will not. This can be improved by either a simultaneous superior crescent nipple lift performed either at the breast implant surgery or deferred to later where it can be performed in the office under local anesthesia.

Highlights:

1) Breast asymmetry is a common preoperative finding in breast augmentation surgery.

2) Breast implants may improve or even make worse the appearance of breast asymmetry based on its anatomic basis.

3) Breast mound differences are usually improved by the placement of implants.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Asian Otoplasty

Sunday, March 5th, 2017

 

Background: The most common congenital malformation of the external ears is that of excessive protrusion. Technically defined as the auriculo-cephalic angle, how open this angle is defines creates the appearance of ears that stick out too far. While the normal angle is up to 30 degrees, what really counts is the patient perception of their ear position.  If the patient thinks their ears stick out too far, then they do.

Ear deformities are common with all ethnicities and genders. I have performed otoplasty correction on many different types of ethnic patients from Hispanic to Burmese. It does appear to be more common in Asians, presumably due to the increased bitemporal skull widths and less projecting occiputs. This may force the conchal position of the ear more outward.

While the fundamental components of an otoplasty to decrease the auriculo-cephalic angle are the same for all patients, the Asian otoplasty has a few anatomic issues to consider. Their thicker skin that is more prone to hypertrophic scarring makes the location and length of the incision important. Also their ear cartilages can be thicker with greater stiffness which may make them less easily moldable to a simple suture or two. Cartilage softening manuevers may be needed.

Case Study: This 30 year-old female had protruding ears all of her lift. She usually wore her hair down because of being self-conscious about their appearance.

Asian Otoplasty results front view Dr Barry Eppley IndianapolisUnder local anesthesia and through a limited postauricular incision (no skin as removed), the posterior surface of the ear cartilage was exposed. The stiffness of the conchal cartilage was reduced using a grid-pattern (checkerboard) full-thickness cartilage cuts with a scalpel. Using a combination of horizontal mattress cartilage sutures and concha-mastoid cartilage-fascia sutures, the ears were reshaped and pulled back into a less protrusive position along the sides of the head.

Asianj Otoplasty results back view Dr Barry Eppley IndianapolisHer result could be be critiqued as being slightly overdone with the ears pulled back too far. She, however, was satisfied with the outcome. What is most interesting about her result is how her face became much more prominent. Her well structured and strong skeletal facial shape seems much more apparent after the otoplasty surgery. It is clear that her face was there all along. But when the focus of the eyes turns away form the prominent ears to just that of her face. its beauty becomes much more apparent.

Highlights:

1) Ear malformations are common amongst all ethnic groups although it may be more prominent in Asians due to their natural skull shape.

2) Otoplasty surgery for prominent ears in Asians must factor in their thicker skin and often stronger ear cartilages.

3) Asian otoplasty allows an increased emphasis on the face where angular and stronger skeletal features are more evident.

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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