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Archive for the ‘plastic surgery case study’ Category

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

Case Study – Custom Jaw Angle Implants and Sliding Genioplasty

Thursday, March 2nd, 2017

 

Background: Jaw angle implants are enjoying a surge in popularity as patients are seeking improved shapes to their jawlines. Filling in the back part of the jaw offers a good complement to well established chin implants to create a more complete jawline augmentation effect.

Like just about every other facial implant, no one size or style fits all. This applies equally well to jaw angle implants. While the widening version has been around for over twenty years, a newer vertical lengthening style now exists. The key to which jaw implant style to use is the natural anatomy of the mandibular ramus. A highly positioned jaw angle and a steep mandibular plane angle are the indications for extending the jaw angle down through the vertical lengthening style.

While the use of three implants (one chin and two jaw angles) is one method of total jawline augmentation, some patients may not prefer their chin augmentation to be done with an implant. A sliding genioplasty can be combined with jaw implants if that is more favorable for the chin. (severe horizontal chin deficiency, lower lip incompetence, mentalis muscle strain) The consideration must then be given to the smoothness of the jawline since the front end of the jaw implant will not cover the back end of the sliding genioplasty bone cut.

Malpositioned Jaw Angle ImplantCase Study: This 43 year-old female previously had a chin implant and two jaw angle implants placed for a total jawline makeover by another surgeon. Unfortunately the right jaw implant became infected and the left jaw implant was severely malpositioned. The chin implant was fairly well placed but she did not like it because it made her chin too wide and did not improve her presurgical lower lip incompetence, mentalis muscle strain and chin dimpling.

Custom Extended Vertical Jaw Angle Imlpants design Dr Barry Eppley IndianapolisCustom Vertical Jaw Angles vs Standard Widening Jaw Angle Implants Dr Barry Eppley IndianapolisIt was decided to remove her chin implant and replace it with a sliding genioplasty which would better address the functional aspects of her chin deficiency. (as well as making her chin less wide) The style of jaw angle implants would also be changed to be more vertical lengthening and to come far enough forward to cover the notch at the back end of the proposed sliding genioplasty. These jaw implants would need to be custom made using a 3D CT scan.

Under general anesthesia and through an intraoral approach, the chin implant was removed and a sliding genioplasty done in its place. The chin was brought forward 8mms and vertically shortened 3mms. The custom jaw angle implants were also placed intraorally and their anterior ends were positioned over the ends of the sliding genioplasty  to create a smooth and unbroken jawline effect.

A sliding genioplasty can be combined with jaw angle implants. In many cases standard jaw implants may suffice. But for a more assured seamless transition from the jaw implants to the bone of the chin advancement, custom jaw angle implants work best.

Highlights:

1) The wrong jaw angle implant style will still be a failure even if it is well placed.

2) Many women need a vertical lengthening jaw angle implant style and not a widening jaw angle implant style.

3) When combining jaw angle implants with a siding genioplasty, a custom implant design approach is often best.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Scalp Tissue Expansion in Aesthetic Skull Augmentation

Wednesday, March 1st, 2017

 

Expansion of the scalp through inflatable devices (‘balloons’) is a well established reconstructive technique. Originally developed to treat lost or missing soft tissues (skin), increasing the size of the surrounding tissues to stretch out and cover what has been lost is the fundamental concept of tissue expansion surgery. Such a concept works best in the scalp where a tissue expander has the greatest stretch on the overlying scalp as it pushes off of the hard skull bone.

Tissue expansion also has a role in aesthetic skull augmentation surgery. With the use of 3D CT design, custom skull implants can be made of almost any design or shape. The limiting factor for such implant placements, however, is whether the scalp can stretch enough to accomodate it. In larger skull implant augmentations, a stage scalp tissue expander must be placed to create the necessary soft tissue coverage.

Scalp Tissue Expander for Skull Augmentation Dr Barry Eppley IndianapolisIn a first state of a two-stage skull augmentation procedure, a scalp tissue expander is placed through a very small incision. It has a remote port placed just above the right ear where the patient can perform the intermittent injections of saline using a needle at home over a six week period.

Unlike traditional tissue expansions in reconstructive scalp surgery, the amount of scalp expansion needed for larger skull implants is much less. It is usually only necessary to stretch the scalp just beyond the look or size of the skull augmentation that the patient wants.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Liposuction Necklift

Monday, February 27th, 2017

 

Background: Aging of the neck is associated with numerous well known changes. The neck droops down as excess skin and fat develop in the center and sides of the neck. The underlying platysma muscle separates and allow the deeper neck tissues to come spilling out. All together a neck wattle or turkey neck is the result.

One of the major components of most neck wattles is fat. While removal of fat can be done by liposuction will that create an adequate ‘necklift’ or neck contouring effort. This is highly age-dependent. At younger ages the lack of  skin redundancy and its good elasticity allows for the neck skin to tighten and lift up. But at older ages neck skin excess and diminished skin elasticity make it more uncertain as to what the neck skin will do.

Case Study: This 57 year-old female was bothered by the shape of her neck. She had a reasonably thick fat layer but her skin was thin with numerous wrinkles in it. If possible she wanted to avoid any major surgery and was willing to see how much improvement liposuction alone could achieve.

Under general anesthesia (she was having other procedures as well) her entire neek was treated with small cannula power-assisted liposuction removing 26cc of fat.

Older Neck Liposuction results side view Dr Barry Eppley IndianapolisCA Neck Liposuction result front viewLiposuction can be a very effective for neck contouring method in the properly selected patient. Usually older patients are less than ideal for just liposuction because of their skin excess and diminished skin quality. But for the patient who wants to limit the extent of the surgery and are willing to accept that the outcome may be suboptimal, neck liposuction can serve as a test to determine if a lower facelift is really needed.

Highlights:

1) A sagging and full neck is a common development as one ages.

2) In the older neck liposuction alone will provide improvement but depends on what the overlying skin will do.

3) Neck liposuction is not a substitute for a lower facelift (necklift) but can be used as a ‘test’ to ultimately determine if one is needed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Older Male Direct Necklift

Sunday, February 26th, 2017

 

Background: The turkey neck is an urban term used to describe a hanging of neck tissue that most commonly occurs as a result of aging. It may occur in younger patients but it would be due exclusively to the loose neck tissue that results from large amounts of weight loss. Regardless of the cause, the turkey neck hangs with a large midline sag as the the tissues along the sides of the face and neck fall towards the midline of the neck.

Men often appear for ‘turkey neck surgery’ because they often present at a much older age. The male trigger to undergo any type of invasive aesthetic facial surgery is usually much higher than that of women (traditionally) as they can endure facial aging changes for longer than most women. Large turkey necks are not uncommon in older men as they approach their 70s and 80s.

One of the challenges in the older male facelift patient is their medical appropriateness for surgery. They often have cardiovascular concerns and, at the least, many are being treated for hypertension. They are at higher risk for intraoperative bleeding and postoperative hematomas. And they have to have a good enough heart to tolerate a 3 to 4 hour facelift/necklift surgery. These concerns are in addition to the placement of incisions around the ears in men who have often inadequate hairlines and hair to hide them well.

Case Study: This 82 year-old male was bothered by his large turkey neck. He had ‘grown’ to the point where it was both embarrassing and problematic for shirt wear. Despite his age he was in good health with no cardiac history or exercise/walking in tolerance.

Direct Necklift operation Dr Barry Eppley IndianapolisUnder general anesthesia, a direct necklift was done with the removal of a large ‘candelabra’ pattern of skin excision. Once the skin is removed, the neck ‘defect’ can look very impressive as the skin on the sides of the neck falls back. Subplatysmal fat was directly removed and midline muscle plication done from under the chin down to the trachea. The neck skin was brought together and closed in the midline with a smaller horizontal component under the chin and a much larger horizontal closure line along the lower neck line below the trachea, Total surgical time was one hour.

Older Male Direct Necklift result Dr Barry Eppley IndianapolisThe direct necklift always creates a significant and usually dramatic neck shape change because it is a direct excisional approach. (as opposed to skin flap relocation) For older men (greater than age 70), the direct necklift offers a shorter operative time, less risk of complications and a complete elimination of the turkey neck. There is the trade-off of a midline neck scar but it usually heals well in beard skin. Many older men would consider this a worthy trade-off .

Highlights:

1) Very senior men with turkey necks can be challenging patients for traditional facelift surgery.

2) The direct necklift avoids most of the issue relating to doing a full facelift in older men.

3) The midline neck scar from a direct necklift does well in older male beard skin.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – V-Line Jaw Reduction Reversal

Wednesday, February 22nd, 2017

 

Background: One of the most popular jawline surgeries around the world, particularly in Asian people, is jaw reduction. Know more commonly as V-Line jaw reduction surgery, it involves removal of wide or flared jaw angle (amputation) and chin reshaping. (narrow and shortening through am intraoral T-shaped ostectomy) For those patients that have a wide jaw and and a lower facial prominence as a result, it can be an effective lower facial reshaping procedure. It is easy to see why this would be of aesthetic predominantly in Asian patients given their natural facial bone shape.

Because the procedure is performed exclusively through an intraoral approach, it can be very difficult to have even and symmetric bone cut lines. There is also the issue of how the bone heals and the smoothness that may or may not result. For this reason, it is really the norm to expect some bone asymmetries between the two sides of the jaw and even at the chin. Fortunately the overlying soft tissues are thick and can help mask such bony asymmetries/irregularities should they result from the procedure.

But like reduction surgery anywhere on the face and body, losing bone support can also cause adverse soft tissue issues. This is an issue primarily in the jaw angle areas in V-line jaw reduction surgery. It is not rare that I hear from a patient who has had jawline reduction surgery that they do not like the subsequent flattening/weakness of the back of their jaw and that they feel the soft tissues now sag along the jawline.

Jawline Deformity after Jaw Angle AmputationJawline Deformity after Jaw Angle Reduction fronkt viewCase Study: This 45 year-old Caucasian female had V-line jaw reduction surgery three years previously. She did not like the subsequent loss of her jaw angles, lack of jawline definition and how it made her lower face too narrow and more aged in appearance. She wanted more defined jaw angles vertically and a smoother and more linear jawline coming forward. A 3D CT scan shows the loss of jaw angles, higher positioned jaw angles, severely increased mandibular plane angle and inferior border jawline asymmetry.

Custom Jawline Implant foir Jawline Reconstruction after Jawline Reduction side view Dr Barry Eppley IndianapolisCustom Jawline Implanty after Jawline Reduction Surgery design front view Dr Barry Eppley IndianapolisA custom jawline implant was designed with the main purpose of re-establishing the jaw angles in a much lower position but without adding any significant jaw angle width. It also established a more symmetric and smooth jawline coming forward to the chin. A little anterior chin projection was added but creating very minimal chin width. Under general anesthesia and through an exclusive intraoral approach, the custom jawline implant was placed.

Custom Jawline Implant design for Jaw Angle Reconstruction Dr Barry Eppley IndianapolisV-line jaw reduction reversal has to be done using some form of implants. Custom jawline implants are best as the multidimensional jaw augmentation needs are very difficult, if not impossible, to adequately address with any standard jaw angle implant shapes.

Highlights:

1) Unfavorable aesthetic results can occur from jawline reduction (V-line jaw surgery) with loss of jawline definition and tissue support.

2) ‘Reconstruction’ of lost jaw angle and chin from V-line surgery requires a vertical lengthening of the shortened jaw angles and widening of the chin.

3) A custom jawline implant is the best approach to V-line jaw surgery reversal.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Double Chin Correction

Tuesday, February 21st, 2017

 

Background: The shape of the chin has a major effect on facial appearance. Since the chin is a projecting facial structure, it highly influences the shape of the face and how defined the neck can look. The shorter the chin becomes the more convex the facial profile becomes and the neck looks increasingly ‘lost’.

A common aesthetic facial concern is that of the Double Chin. This is really an urban term that is a misnomer. It is not really a double chin per se, it is really a chin deficiency or lack of enough chin projection. When combined with even a small amount of excess neck fat, which occurs right under the chin (submental fat), the profile will show two humps or mounds. They may look like two projecting chins but the lower ‘chin’ ir excessive neck fat.

The treatment of the double chin is a classic diametric surgery. Each ‘chin’ change must be in opposite directions to create the best facial profile change. The upper ‘chin’ must be moved forward and requires some type of bony procedure. (implant vs sliding genioplasty) The lower ‘chin’ requires soft tissue reduction using liposuction fat removal. Together the entire lower face is improved as it becomes more ‘pulled out’ and defined.

Case Study: This 45 year-old female was bothered by the increasing size of her double chin as she aged. She has always had a shorter chin but as she had gotten older the ‘double chin’ appeared.

Under general anesthesia an initial small submental incision was made through which the neck was treated by liposuction removing about 12ccs of fat. The submental incision was extended to 1.5 cms and a 7mm thick curvilinear silicone chin implant was placed in a subperiosteal pocket on the bottom of the anterior chin bone. (the implant had no extended side wings)

Double Chin Correction result side view Dr Barry Eppley IndianapolisDouble Chin Correction result front view Dr Barry Eppley IndianapolisHer eight week postoperative result show elimination of the double chin and a much improved facial profile. Between the chin augmentation and the liposuction, it really takes at least six weeks after surgery to see the full benefits of the double chin correction procedures. Depending upon the degree of horizontal (and even vertical) chin deficiency, the chin deficiency may be better done using a sliding genioplasty for a more 3D chin augmentation effect. It also can have a more positive neck reshaping effect as it pulls the underlying neck muscles (roof of the neck) forward and up.

Highlights:

1) The double chin deformity is a combination of excess fat fullness under the chin and insufficient horizontal chin projection.

2) The combination of submental/neck liposuction and chin augmentation effectively treats the double chin deformity.

3) Whether the chin augmentation is best done by a chin implant or sliding genioplasty depends on the degree of horizontal chin deficiency.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Pediatric Otoplasty

Monday, February 20th, 2017

 

Background: The formation of the ear is an amazingly complex embryonic process. That is evident in just looking at the ear with its spiral array of convexities and concavities of cartilage around the ear canal. It is remarkable that it forms properly and does so twice in most people due to its bilateral presence.

But because of its complexity the ear is one of the most commonly misshapen of all facial features. From minor deformities like earlobe clefts and Stahl’s ear to major malformations like microtia there is a wide array of congenital ear malformations that can occur. One of the most common ear anomalies, and it is questionable whether it should be called an anomaly, is that of the protruding ear. All of the ear is present but its sticks out too far from the side of head due to the lack of an antihelical fold, overgrowth of the concha or some combination of both.

Setback otoplasty, also called ear pinning, is the well recognized surgery for the correction of the excessively protruding ear. It is done in both adults and children. The common question in children is at what age is the proper time to perform the surgery. The underlying premise of this question is when can the surgery be done so that it will not adversely affect growth of the ear cartilage.

Case Study: This 6 year-old male child has very prominent ears due primarily to a lack of antihelical fold development. Where the fold was completely absent the ear stuck out the most. Down near the earlobe some sembence of an antihelical fold was present and the ear stuck out less.

Male Child Otoplasty result front view Dr. Batrry Eppley IndianapolisUnder general anesthesia an otoplasty procedure was performed through an incision on the back of his ears. Minimal skin was removed from the back of the ear and the correction was done principally through multiple horizontal mattress sutures (to create the fold) and some concha-mastoid sutures. (to decrease the auriculo-cephalic angle)

Pediatric Otoplasty result back view Dr Barry Eppley IndianapolisPediatric Otoplasty result side view Dr Barry Eppley IndianapolisHis one month results show a good and reasonable symmetric ear reshaping result. A close-up side view of before and after pictures show that the effect was largely achieved by creating an antihelical fold and a more defined superior crus in the upper helix.

Clinical studies have shown that suture cartilage manipulation of the ear can be done as early as age 2 without any negative growth effects on the ear cartilage. While it can be technically done at such as early age (and I have done so numerous times) there is the important question of postoperative compliance and avoidance of unintentional ear trauma. (which could cause suture disruption and partial ear shape relapse) Between lack of any psychosocial developmental issues in children and performing elective surgery at such a young age, it is far more common to have pediatric otoplasty done closer to age 5 or 6.

Highlights:

1) Congenital ear deformities are amongst the most frequently occurring of all facial deformities of which the protuding ear is the most common one seen.

2) Setback otoplasty (ear pinning) achieves its effect primarily by cartilage bending.

3) The age to perform an otoplasty is largely parent driven in children and be effectively done anytime after age 2.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Dermal Graft for Jaw Angle Asymmetry

Tuesday, February 14th, 2017

 

Background: Asymmetry of the lower third of the face is common. While there can be a soft tissue component to it, more times than not it is caused by asymmetry of the bone. the most common location for jaw asymmetries is in the angle area. The mandibular ramus is the L-shaped portion of the jaw and is prone to differences between the two sides in length and/or width.

Jaw angle asymmetry is best appreciated from the front view. Patients particularly notice it in pictures where the face becomes ‘frozen’ and is most easily seen. But because everyone of us knows our faces so well (and more so today because of smart phones and selfies) patients can see it even when others can’t.

The treatment for a jaw angle symmetry due to a deficiency is an implant. Provided the location is known and the implant is the right shape and size, good correction can be expected. But not everyone likes the concept of an implant so alternative options may be considered.

Case Study: This 32 year-old female had a modest jaw angle asymmetry with a deficiency on her left side. The inferior border along the angle lacked the fullness and jawline that the opposite side had. She preferred to use a more ‘natural’ material rather than an implant.

Dermal Graft for Jaw Angle Asymmetry Correction Dr Barry Eppley IndianapolisLeft Jaw Angle Dermal Graft Implant for Asymmetry Dr Barry Eppley IndianapolisUnder general anesthesia an intraoral approach was used to access the left jaw angle bone. Using allogeneic dermis (Alloderm), a 1.5mm thick section was layered into a thicker implant and sutured together to create a linear graft for the inferior border of the jaw angle. It was inserted and laid along the border. No form of fixation was used.

Jaw Angle Asymmetry Correction result Dr Barry Eppley IndianapolisHer 6 month result showed better jaw angle symmetry and an apparently stable result without resorption.

An allogeneic dermal graft would not ordinarily be a preferred facial bone augmentation material. It is a soft tissue augmentation material that purportedly is integrated into the recipient site and replaced by natural tissue. (scar) In my experience it more often behaves like an implant and becomes a well tolerated tissue filler with some fibrovascular ingrowth. For minor facial bone asymmetries where an implant is not preferred, these dermal products can be an option to consider.

Highlights:

1) Lower facial asymmetry is most commonly caused by a bony asymmetry of the jaw.

2) Jaw angle asymmetries can be treated by a variety of implant materials placed on the bone.

3) For patients wary of synthetic implants on the jawline, an allogeneic dermal graft can be used for smaller jaw asymmetries.

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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