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Archive for the ‘plastic surgery case study’ Category

Case Study – Severe Double Chin Correction

Friday, August 25th, 2017

 

Background: The lower face is perceived by the shape and projection of the chin and the cervicomental angle. A fairly well defined neck angle and a discernible chin are positive facial features regardless of age, gender or ethnicity. This speaks to the popularity of such plastic surgery procedures like chin augmentation and neck liposuction which strive to achieve these individual facial improvements.

A well known lower facial aesthetic deformity is the double chin. This does not occur because one really has two chins, it just looks like one does. The real chin is usually horizontally short but creates the upper part of the double chin. The second ‘chin’ is a fat and skin roll in the upper neck that sits below the bony chin. It is more recessed than the bony chin and thus creates a double roll in profile, like a set of stairs, into the lower neck. The double chin often appears as part of an overall facial lipodystrophy in its more severe form.

Case Study: This 25 year-old female had a rounder fuller face and a double chin in profile. The chin was horizontally short due to a more recessed lower jaw and a high mandibular plane angle. She also had a hyperactive mentalis muscle due to the short chin.

Under general anesthesia, a 10mm sliding genioplasty was performed from an intraoral approach to improve her chin projection and stretch out the submental area. Submental/neck liposuction and buccal lipectomies were also done to help deround her face as well,.

Her result shows the dramatic change that can occur from the diametric movements of increased shin projection and decreasing the cervicomental angle.While both tissue movements are concurrently helpful, the biggest influence is from the sliding genioplasty.

As the chin bone is brought forward it carries with it the genioglossus and geniohyoid muscle. This creates a tissue stretch in the upper neck and helps elevate the ‘second chin’ of the double chin. This is an effect that is not created by the placement of a chin implant on the bone. Which is why in cases of severe double chin cortrection the sliding genipoplasty is the preferred approach to implants even though it is far less initially appealing to do so.

Highlights:

  1. The double chin is always associated with a short lower jaw projection and a thicker fatty neck.
  2. ]The diametric movements of stretching out the chin and pulling back on the neck creates the best double chin correction.
  3. The best chin augmentation for the severe double chin is a sliding genioplasty as the bone movement lengthen the neck muscles as well.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Cranial Bone Graft Rhinoplasty with Medial Canthoplasties

Sunday, August 20th, 2017

 

Background: Fractures to the nose most commonly result in nasal deviations as the direction of the force usually comes from the side. (e.g.,fists) But direct trauma to the nose results in impaction injuries which push the nose inward resulting in loss of bridge height and a collapsed nasal appearance.

The most severe type of nasal impaction injury comes from high velocity forces such as motor vehicle accidents. This not only pushes the nose in but the extension of the fracture lines and bony displacement extends to the medial orbits as well. This results in not only the nose being pushed inward but the attachments of the eyelids (medial canthi) end up being  displaced laterally. These traumatic nose and eye changes create what is known as a traumatic hypertelorism effect. (technically pseudohypertelorism) This can be very hard to correct during the initial fracture repair and often requires secondary surgery for a more complete correction.

Case Study: This teenage female was involved in an ATV accident where she sustained blunt trauma to her face at the frontonasal area by striking a tree. She sustained a severe naso-ethmoid fracture pattern as well as other facial bone fractures. She underwent primary facial fractures repair any another facility, part of which was done through a coronal scalp incision. When seen six months after her initial injury and repair, she had a telecanthic appearance with indentation of her nasal bridge.

Under general anesthesia, her original coronal scalp incision was opened and  the scalp reflected down to the nasofrontal junction. A split-thickness outer table cranial bone graft was harvested from the left posterior forehead region which had a minimal curvature to it. The graft was shaped to fit the length of the nose and inserted into a nasal pocket and secured at its superior end with a 2.0 molar screw. The graft donor site was reconstructed to contour with hydroxyapatite cement. Medial canthoplasties using 3o0 gauge wires was also done, passing it under the cranial bone graft.

At five years after her secondary nasal reconstruction, her dorsal nasal height remained stable and straight. The bone graft showed no signs of resorption.

Her eyes appears closer together which was probably as much the result of a heightened nasal bridge as the medial canthoplasties.

Highlights:

  1. One graft option in nasal reconstruction is cranial bone due to its anatomic proximity.
  2. Cranial bone grafts to the nose usually undergo minimal long-term resorption
  3. Through a coronal scalp incision, a cranial bone graft to the nose can be done with medial canthoplasties in the treatment of traumatic hypertelorism.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Hydroxyapatite Granule Skull Reconstruction

Sunday, August 20th, 2017

 

Background: The skull, while often perceived as a solid piece of bone, is not. It is actually composed of three layers, very much like an Oreo cookie. There are the outer and inner solid cortical layers (the cookie) and then there is a thinner inner layer which is softer known as the diploid or marrow space. (the filling)

Many skull defects occur as a result of injuries caused by fractures of varying degrees of the bone’s thickness. When the skull fracture does not significantly displace the inner cortical table and does not disrupt the dura, there is no need for surgical reduction. But such fractures often do displace the outer cortical table resulting in contour defects. The soft tissue will eventually follow the depressed bone inward as scar contracture and healing ensure.

Case Study: This 24 year-old male was involved in a car accident in which he sustained blunt trauma to his right upper forehead. He sustained a full thickness skull fracture with a small underlying epidural bleed. He was not treated surgically and he went on to a full recovery. As he healed he developed a circular indentation over the fracture site. A 3D CT scan showed that it was due to a bone indentation caused by his previous skull fracture.

Under general anesthesia, a semicircular hairline incision was made for access and the defect exposed. The fractured bone was stable and no effort was made to elevate the fracture segments. The defect was filled with hydroxyapatite granules and covered with a 1m thick resorbable plate with screws for containment.

His after surgery result showed the restoration of a smooth external forehead/skull contour.

The use of hydroxyapatite bone substitute today in skull reconstruction, and for almost the past twenty years now, has been with using it in a bone cement form. This provides the best method of application as it is contoured into the defect site and then sets before wound closure. But hydroxyapatite can be still used in granular form which allows for true fibrovascular ingrowth and even some bone ingrowth as well. Its use is restricted to a completely contained skull defect with an underlying floor and walls.

Highlights:

  1. Small skull defects can be treated by a wide variety of cranioplasty materials.
  2. In a small partial-thickness skull defect, hydroxyapatite granules can be used to fill the defect and create a smooth cranial contour.
  3. A resorbable cover can be used as a roof for a hydroxyapatite granule skull reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Multiple Lipoma Excisions in Familial Lipomatosis

Saturday, August 19th, 2017

 

Background: Familial multiple lipomatosis (FLM) is a well known condition that is associated with the lifelong development of lipomatous tumors. These lipomas occur almost exclusively on the trunk and extremities with the head, neck and shoulders usually being spared. It has been identified as an autosomal dominant condition that has been associated with chromosome 12q15.

The typical lipoma has a surrounding capsule and appears as a solitary lesion of various sizes. But the lipomas that occur in FLM are multiple, are often in clusters or a chain and have been described as more rubbery in feel. While most are asymptomatic, their location and size often make them painful.

The surgical treatment of the lipomas in FLM is excision. These excisions are usually done periodically throughout the patient’s life based on those that are associated with pain or significant cosmetic deformity. While the excisions may cure those that are removed, new lipomas will likely develop in contiguous locations in the future.

Case Study: This 60 year-old male with known FLM presented for a more comprehensive approach to his lipoma excisions. He had been through multiple lipoma excisions up to this point in life but were always limited to a handful at a time.

Under general anesthesia, 85 lesions sites of the upper arms, stomach and thighs were treated through an ‘expressive excision’ technique. This is where the skin incision is relatively small through which blunt undermining around the lipoma(s) is done. Then manual pressure is applied to basically squeeze the lipomas out through the small incision. With this method over 235 lipomas were removed over a three hour operation.

While a comprehensive approach to multiple lipomas requires a lot of incisions and resultant scars, the expressive excision technique keeps the length of each incision relatively small with a very low risk of infection or bleeding.

Highlights:

  1. Familial lipomatosis creates the need for recurrent excisions of symptomatic lipomas throughout the patient’s life.
  2. In removing large numbers of lipomas an ‘expressive excision’ technique is the most efficient method.
  3. While excision is not a cure for FLM lipomas, single session large number removals can provide long periods of symptom relief.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Teenage Male Cleft Rhinoplasty

Friday, August 11th, 2017

 

Background: Of all the difficult cases in rhinoplasty surgery, the cleft  nose remains one of the most challenging. While this challenge is magnified in the bilateral cleft nose, it is only slightly less in the unilateral cleft lip and palate patient. The challenge its not in understanding the deformity but working with nasal tissues that are both deformed and often congenitally deficient.

While the cleft nasal cartilages are deformed due to the asymmetry caused by the cleft that runs up through its nasal floor, the overlying skin also poses limitations. The affected nasal alar rim is always pulled down and the skin is often restricted by a recessed nasal base. Equally importantly the internal vestibular tissues usually have a web that is both limiting in elevation and for which a satisfactory solution remains elusive.

While many cleft patients undergo limited nasal reshaping procedures as an infant or child,  the more formal septorhinoplasty awaits until after puberty. When that should be done can be debated but it is most accepted that it awaits until after any jaw surgery may be done or the determination made that it is not needed. A stable maxillary base that will  to change in the future is a prerequisite for rhinoplasty surgery.

Case Study: This teenage left cleft lip and palpate male has been through all of his primary cleft lip and palate repairs as well as secondary alveolar bone grafting. He had also had a tip rhinoplasty as a child as well.

Under general anesthesia, an open seiptorhinoplasty was performed. Septal cartilage was used for a columellar strut, left middle vault spreader graft and left alar batten graft. Bilateral subtotal inferior turbinectomies were also done.

In a cleft rhinoplasty some of the most important goals are to improve the shape of the nasal tip and cleft-sided nostril deformity. To do so requires septal correction and in the process the harvest of cartilage grafts to provide the structural rigidity that is needed to do so.

Highlights:

  1. The cleft nasal deformity is a combination of structural deformity and structural deficiency.
  2. Cleft septorhinioplasties almost always needs to be done with an open approach and usually requires cartilage grafting as well.
  3. The nasal tip deformity in the cleft nose can never be normalized completely but it can have major improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Lifting Effect of Breast Implants

Wednesday, August 9th, 2017

 

Background: Many women who present for breast augmentation have varying degrees of breast ptosis or sagging. Some have the belief that a breast implant has the capability to lift the sagging breast and avoid the need for some type of breast lift. Unfortunately this is almost never the case much to the chagrin of the patient.

Burt there are cases where with right size off breast implant and with a breast sag that is not too severe that a breast augmentation procedure by itself can lift up a sagging breast. The key is the type of breast sag. As breast ptosis is defined as the position of the nipple relative to the breast (inframmammary) fold, a breast sag where the nipple is just at the level of the fold is a preoperative sign that an implant alone will suffice.

Case Study: This 38 year-old female presented for breast augmentation. She had small breasts but had lost most of her breast volume after having children.

Under general anesthesia, an inframammary incisional approach was used to place 400cc high profile silicone breast implants in a dual plane position. As judged by her after surgery side view picture comparisons of her elevated nipple position caused by the breast mound enlargement.

Nipple positions at or above the level of the inframmary fold will be elevated from the placement of breast implants. This will occur even when the implant is placed in the submuscular position. The size of the breast implant also plays a role with ‘larger’ implants being more effective than smaller ones. To some degree there is the effect of the ratio of implant to natural breast mound tissue. The greater this ratio the more effective the lift will be.

In some cases when the implant to natural mound tissue is more even, the initially uplifted breast tissue can ‘fall off’ of the implant over time. This is because the weight of the breast tissue is not well supported by the implant size. This is not the case int this example but can be in more marginal patients who are better off having a lift with the implant placement.

Highlights:

  1. Breast implants do not have a great ability to lift up a sagging breast.
  2. A good size implant in the properly selected patient can have some breast lifting effect.
  3. Over time the augmented ‘breast lifted’ patient may have some glandular tissue slide off the implant due to gravity and tissue stretch.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Large Buffalo Hump Reduction

Thursday, August 3rd, 2017

 

Background: The buffalo hump is a descriptive term that universally applies to a discrete collection of fat on the back of the neck. Looking at the American bison it is easy to see why it has its name with the massive shoulders of the animal being amongst its most distinct features. But unlike the bison, the human buffalo hump is not muscle but fat.

The dorsocervical collection of fat in humans both unusual and distinct for two reasons. First, it is not a typical location for fat to deposit as it is not known for being a metabolic depot site. It may reflect the congenital location of brown fat which is known to be present in newborns but diminishes with age. Secondly what activates the enlargement of the dorsocervical fat pad is not precisely known. Certain medications and illnesses are associated with its development but it can also occur in people who do have these drug or disease associations.

Case Study: This 22 year-old male presented for treatment for his large buffalo hump deformity. He was a large adult man (almost 300lbs) but he did not have any of the associated triggers for its development. It caused him neck pain and restricted his neck extension. He was also socially embarrassed by it.

Under general anesthesia and in the prone position,  a three-hole liposuction approach was used. Using power-assisted liposuction with baskets as well as smooth round-tipped cannulas the very dense fibrofatty tissue was aggressively treated with an aspirate volume of just under one liter. (900ccs)

His immediate result during surgery showed the degree of improvement which largely made the back of his neck flat again. Unfortunately there are no good methods of after surgery compression for the back of his neck so he will have considerable swelling which will take more than a month to return to this intreoperative result.

The traditional method of buffalo hump reduction was open excision. Due to its very dense fibrofatty tissue it was felt that liposuction could not get an adequate reduction. And if one was using traditional ‘elbow-driven’ liposuction this would still hold true. But today’s many power-driven liposuction technologies make it possible to reduce denser and more fibrous fatty areas like the buffalo hump. While not every case has such dense fibrous fat many buffalo humps do.

Highlights:

  1. The buffalo hump deformity is an abnormal development of fat in the dorsocervical fad pad.
  2. It is a often a dense fibrofatty tissue that requires a mechanized or energy-driven liposuction method for removal.
  3. An open excision of the buffalo hump can usually be avoided.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Linear Custom Jawline Implant

Wednesday, August 2nd, 2017

 

Background: Augmentation of the total lower third of the face is historically and most commonly done using standard implants. The combination of chin and jaw angle implants, a three implant approach, provides enhancement of the three corners of the lower face. While theoretically appealing and a good solution for many jawline needs, it can be unsuccessful for a variety of reasons. These include implant asymmetry, the inability of standard implants to provide the desired aesthetic result and the lack of connection between all three implants.

A custom jawline implant connects the chin and jaw angle regions in either a linear or non-linear fashion.The size or thickness of the connection between the chin and jaw angles of the implant determines whether there is a smooth or linear look going from the chin back to the jaw angles or whether the chin and jaw angles stand out more than what connects between them. (non-linear look)

Designing a custom jawline implant with existing indwelling implants is ‘easier’ and more helpful than if no implants were there at all. Knowing what the aesthetic effects of existing implants creates, even if undesired, helps guide a new implant design that may produce a better result. While the custom implant design process is greater from the standpoint of fit to the bone, symmetry of both sides of the implant and creating a unified look, the computer or surgeon has no way of knowing exactly what implant dimensions can exactly achieve the patient’s goals.

Case Study: This 45 year-old male had Medpor chin and jaw angle implants previously placed which did not produce the jawline look that he had hoped. Fundamentally it did not give the jawline angularity that he seemed and did not have a smooth connection between the chin and the jaw angles. In the implant design process his existing implants were digitally removed and a one-piece jawline implant designed.

Under general anesthesia and through a combined intraoral and submental existing incisions, his Medpor chin and jaw angle implants and their numerous large screws were removed.

His new custom jawline implant was placed using a split implant technique. Due to the size of the implant jaw angles and concerns about injury to the mental nerve when passing the implant from front to back as a single piece, the implant is first sectioned in the midline of the chin in a geometric interlocking pattern. This then permits the implant to be placed in two sections from back to front and then reconnected in the middle. This is safer for the mental nerve as the sizes of the implant that must pass underneath it is smaller.

His one day results show an immediate improvement in his jawline shape in a more connected fashion. (linear jawline look) There is also more angularity evident in the chin and jaw angle corners. While he will go on to have some tremendous swelling that will take up to month or more to fully resolve, his very early jawline result looks more favorable to his aesthetic goals.

Highlights:
1) Jawline augmentation by three separate preformed implants often does produce a satisfactory or desired shape of the lower third of the face.
2) With existing chin and jaw angle implants in place, a custom jawline implant can be designed for an improved facial outcome.
3) Contrary to popular perception, Medpor implants can be successfully removed although it is more traumatic to the tissues than that of silicone implant removal.

Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Vertical Breast Lifts with Implants

Monday, July 31st, 2017

 

Background: The sagging of the female breast is a common sequelae to age, pregnancies and weight loss. The shape of a woman’s breast is rarely a static structure over their lifetime being subject to a variety of forces that work to make the breast mound lose its shape. Stretching of the mound skin and loss of breast volume are the anatomic reasons for ‘the breasts heading south’.

Correction of breast sagging, therefore, necessitates addressing the loose skin and lack of adequate volume. Various types of breast lifts combined with a large range of breast implant sizes creates options for rejuvenating the sagging breast mound.

The use of a combination breast lift and implant placement is a common breast reshaping procedure. But mixing the type of breast lift and the size of implant defies an exact scientific method to do so and not every women can get any breast implant size with their lift that they desire.

Case Study: This 34 year-old female had developed significant sagging and loss of breast volume after four pregnancies. She needed as much of a breast lift as she did that of more breast volume.

Under general anesthesia, she underwent a combined vertical breast lift with the placement of 400cc silicone breast implants. Her results shows that the size of the breast lift chosen can dictate how much of a breast lift result can be obtained.

In the combined breast lift and implant surgery, also known as an implant mastopexy, the effects of the two procedures often are at a conflict. Since a breast lift achieves its effect to some degree by skin removal and tightening and an implant exerts its effect by skin expansion, it is easy to see how combining these procedures often creates the need for compromise. For more of an uplifted and perky breast, a smaller implant must often be chosen. For larger implant volumes the amount of lifting effect will often not be as great.

Highlights:
1) Breasts lifts are often done at the same time as the placement of breast implants in certain amounts of breast sagging.
2) Large amounts of breast sagging or the desire for large breast implants may necessitate a staged approach to lifting and implant placement.
3) The use of breast implants in the sagging breasts may often be to just maintain upper pole fullness.

Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Female Custom V-Line Jaw Implants

Sunday, July 23rd, 2017

 

Background: The shape of the jawline has taken on great aesthetic importance in contemporary society. This is not just for men but for females as well. But the desired shape of the female jawline is different from that of men. It is desirous to be more tapered from back to front and have more of a triangular or V-shape. While some women have this jaw shape naturally, most do not.

The well known V-line jaw surgery comes from Asia where it is commonly done. The Asian face often has a bigger lower jaw with larger jaw angles as part of an overall wider and flatter facial shape. Dramatic reductions in the jawline through amputation of the jaw angles and jawline combined with a T-shaped chin reduction creates the V-line effect.

But in many Caucasian faces such reductions of the jaw will not produce the same reshaping effect or can not be done with a smaller jaw size. The opposite approach, augmentation of the jawline, may be needed to create a V-line effect.

Case Study: This 26 year-old female wanted to have a more tapered jawline look. She had a prior chin implant placed but it did not create the desired effect. Her 3D CT scan showed a chin implant sitting high on the chin bone  way above the edge of the chin bone. She also had high jaw angles.

Her 3D CT scan was used to make vertical lengthening jaw angle implants (with minimal width) and a v-shaped chin implant that created a completely central augmentation.

Under general anesthesia, her chin implant was initially removed and replaced through a submental incisional approach. This was to ensure that the implants sat down on the bone as low as it was designed and to place screw fixation. The jaw angle implants were placed through an intraoral approach using posterior vestibular mucosal incisions. Because it was a vertical lengthening implant, where half of the implant sits off the bone, double screw fixation was used.

A more tapered and shaped jawline is not always obtained by bone reduction. In some non-Asian jaws augmentation of the jaw angle and chin points may suffice.

Highlights:

  1. V-line jaw reshaping is classically done by chin and jaw angle bine reduction/reshaping.
  2. In the Caucasian face augmentation of the chin and jaw angles may be needed to create the V-line effect.
  3. Custom chin and jaw angle implants can be designed to create a more tapered jawline shape.

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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