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Archive for the ‘plastic surgery case study’ Category

Case Study – Submental Technique for Bony Chin and Jawline Asymmetry Correction

Wednesday, October 25th, 2017

 

Background: Lower facial asymmetry is most commonly associated with the shape of the jawline. While patients often present with chin asymmetry, closer inspection often reveals that it extends back along the jawline as well. With the chin asymmetry the jawline on the longer chin side is lower and conversely it is higher on the shorter chin side. A debate can be had about which is the normal side and whether the condition is hypoplasia or hyperplasia which has great relevance when it comes to treatment planning.

True lower facial bony asymmetry has soft tissue asymmetries as well which would be consistent with that of a developmental origin. The lips will be tilted with different horizontal positions of the mouth corners. The base of the nostrils will be tilted and even the eyes may have subtle differences in the horizontal lines between the inner and outer canthi. Most of these soft tissue asymmetries are far less correctable than that of the underlying bone

Correction of chin and jawline asymmetry must take into consideration numerous anatomic factors. In the chin area the short length of the tooth roots do not pose any restrictions for the amount of bone that can be removed. But in the jawline behind the chin the location of the inferior nerve as it courses through the bone is, however, a potential surgical restriction. When vertical bone reduction is indicated (facial hyperplasia) preoperative x-rays are needed to determine the limits of these bony changes.

Case Study: This young female presented with chin asymmetry with a longer right side and a visible tilt of the chin to the left. Physical and radiographic examinations  showed that a right facial hyperplasia was the cause with vertical elongation of the entire jawline which drove the position of the chin to the opposite side. This was evident at facial rest but more apparent when smiling. A panorex x-rays showed the amount of bony differences between the two sides with the jaw angles and intrabony nerves highlighted.

Under general anesthesia a submental approach to the chin and right jawline resha[ing was used. Initially the chin asymmetry was addressed by an inferior border shave across the bone, horizontal deprojection and a left corner angled reduction. The right jawline ws reduced by an inferior border shave of 7mms back to the anterior attachment of the master muscle. Redundant soft tissue was removed over the chin area and the muscles reattached along the chin with sutures suspended to bone holes.

The immediate intraoperative view of the chin showed he improved symmetry as well as an overall rounding effect to ‘desquare’ the chin as well. The cant of the smile line and occlusion above the chin will remain the same as before surgery as would be expected.

The aesthetic management of the chin and jawline asymmetry from hyperplasia that does not include occlusal adjustments is based on removing bone along the inferior and/or inferolateral border. The submental approach offers a direct line of sight method doing so with the greatest accuracy and safety to the inferior alveolar nerve. The fine line scar under the chin is a reasonable aesthetic tradeoff for these more predictable any changes. Radiographic surgical planning is essential and, while 3D CT scans have the most visual appeal, a traditional panorex x-ray offers a vert measurable method to determine a safe amount of vertical bony reduction along the inferior borders.

Highlights:

  1. 1) Chin asymmetry is often associated with jaw asymmetry as well.
  2. 2) The submittal approach offers the most effective reshaping of the chin and jawline due to line of sight visual access.
  3. 3) The location of the metal nerve and tooth roots can limited the extent of bony symmetry that is possible to achieve.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Augmentation in Widely Spaced Breasts

Sunday, October 22nd, 2017

 

Background: The outcome of breast augmentation is affected by many variables that go far beyond the implant itself. The shape and position of the breast mound and its nipples profoundly impact how they will look when the implants are placed behind them. Too often patients believe that the enlarging their breasts will correct many of their undesired flaws.

One undesired feature of some breast augmentation patients is the wide spacing between the breast mounds. This wide sternal gap can be caused by a horizontally wide bony sternum, breast mounds that are positioned very lateral on the chest wall or a combination of both. The position of the nipples is the giveaway as to why the breasts are wide. If the nipple is at ir more lateral than a vertical line drawn down from the mid-clavicular point, then it is the laterally positioned breast mounds that are at fault.

Getting the breast mounds closer with implants can provide improvement. This is better achieved with implants in the subglandular position as the medializing effects of submuscular implants is limited by the position of the origin of the pectorals major muscles at the edge of the sternum.

Case Study: This 25 year-old female presented for breast augmentation surgery. Her biggest concern was that she did not like the wide spacing between her breast mounds.

Under general anesthesia she had smooth silicone breast implants placed through inframammary incisions. The implants were of 325cc size. Her after surgery results show less width between the breast mounds and a filled in effect of the medial poles of the breasts. But the nipples still look very lateral on the breast mounds.

It is important in preoperative counseling of the breast augmentation patient that wide spacing between the breasts will not be completely eliminated. Equally relevantly the nipples of the augmented breast mound will remain at the lateral edge of the breast mound and their position will remain unchanged regardless of implant size.

Highlights:

1) Widely spaced breasts poses aesthetic challenges in breast augmentation.

2) While the inner breast mounds can be enlarged and create decreased mound spacing, the position of the nipples will not change.

3) The fundamental concept in breast augmentation is that implants merely take what the natural anatomy is and make it bigger…but it is not a total reshaping of the breast.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Power-Assisted Liposuction Buffalo Hump Reduction

Saturday, October 21st, 2017

 

Background: The buffalo hump deformity is a well known collection of fat in the back of the neck. It is a seemingly unusual place to develop a fatty collection given that it is a body area that is associated with becoming ‘fat’. But there is a congenital fat pad in the upper back known as the dorsocervical fat pad and an increase in its size may be a sign of excessive weight, a symptom of some diseases or a drug side effect.

Drug side effects that are known to increase cause lipodystrophy of the dorsocervical fat pad, the most recognized of which are some AIDS-treating medications. The other much more used drug that causes this effect are steroids including prednisone. Through an induced redistribution effect fat is directed to accumulate in the dorsocervical fat pad.

The formation of an increased upper back fat  pad causes multiple aesthetic and functional symptoms. The aesthetic deformity is obvious even though it is on the back rather than in the front of the neck. A hump in the upper back is not natural nor aesthetically pleasing. Its mass effect also causes neck movement restrictions and discomfort. In some patients they complain about difficulty sleeping due to the mass on the back of their neck.

Case Study: This 50 year-old female had developed a modest buffalo hump after years of taking steroids for her pulmonary condition. (asthma) While she was able to get  off this medication, the fatty collection did not recede. While it was not as large as many buffalo humps, it was still aesthetically disturbing.

Under general anesthesia and in the prone position, the upper back/neck fat collection was treated with power-assisted liposuction. (PAL) This was done in a cross-tunneling technique, removing a total of 225cc of fatty aspirate.

Regardless of the cause, buffalo humps do not recede or go away even when its etiology is eliminated. Liposuction is preferred over open excision as it is just as effective and avoids the risk of serum formation.

Highlights:

1) Buffalo humps come in a variety of sizes and causes.

2) Long term steroid use is known to cause more modest buffalo hump deformities.

3) Power-assisted liposuction is an effective aspiration technology for the fibrofatty tissue of buffalo humps.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Refining Rhinoplasty

Sunday, October 15th, 2017

 

Background: The popularity of rhinoplasty is a combination of the prominence of the nose on the face and the successful outcomes possible from the procedure. It is hard to know the exact gender distribution that undergoes this type of facial surgery but it seems like more females than males have the surgery.

While the nose shapes in women are highly variable, there are common features of the nose that they wish to change. Almost first and foremost is that of the nasal hump or bump. At the least women prefer a straight dorsal line and some even prefer more of a saddle nose or swoop their dorsal profile. The second feature is that of the nasal tip. A wide or drooping nasal tip is not a flattering nasal shape in a female. 

Recovery from rhinoplasty its highly influenced by the thickness of the nasal skin. The thinner the skin is, the less swelling of the nose after surgery that will occur…and the sooner the final result is realized. The percentage of female noses that have thinner skin than men is not precisely known but it seems that it is so. The young thin Caucasian female that comes in for a rhinoplasty often has thinner nasal skin.

Case Study: This young female in her mid-20s presented for rhinoplasty. Her two basic nasal dislikes were the small hump and the wideness of the nasal tip. She had fairly thin nasal skin.

Under general anesthesia, she had an open rhinoplasty in which the nasal hump was reduced to a straight dorsal line and osteotomies done to make a less nasal base beneath the hump. In addition, the nasal tip was narrowed by a cephalic trim and transdomal sutures.

Her 3 month results show a smooth dorsal line and a more narrow tip. The nasal bridge still remains sensitive as expected as bony healing takes much longer for complete healing.

Highlights:

  1. Many women seek nose reshaping changes that are for refinement of small disproportionate features.
  2. Small hump reductions and nasal tip narrowing are two common nasal reshaping requests.
  3. Females with thin skinned noses respond quickly to nasal reshaping surgery that only takes a few months to see the final result.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Hydroxyapatite Reconstruction of Large Pediatric Skull Defects

Sunday, October 15th, 2017

 

Background: The correction of congenital skull deformities with early cranial vault reconstruction is a well established surgical therapy. Such early skull manipulations are based on two fundamental principles of the infant’s skull. First, the bone is thin and can fairly easily be removed, reshaped and re-inserted. Secondly, the osteogenic regenerative power of the dura at such early ages allows any bone defects around the bone reconstruction to fill in with new bone.

But despite the potential osteogenic capability of the dura in infants, full-thickness bone defects still do occur. Often they are small and are at the junction of reassembled skull bone pieces from the initial reconstruction. But in rare cases the skull defects may be much bigger, reflective of bone defects left behind from large bony advancements from contour expansions.

The reconstruction of skull defects in children can be done by a variety of methods. While bone may be considered an ideal material, the successful splitting of cranial bone in children is not an assured outcome. A variety of synthetic materials and implants are available to ‘patch’ such skull defects. Each has their own unique handling characteristics.   

Case Study: This 9 year-old female was originally born with bilateral coronal craniosynostosis for which she underwent a fronto-orbital advancement at 11 months of age.  At five years of age it could be seen that large full-thickness defects remained that never filled in with bone from the wake of the fronto-orbital advancements.

Under general anesthesia, the skull and bone defects were exposed through her original coronal scalp incision. The bone defects were lined with resorbable mesh plates by separating the dura from the bony edges so the plates could be slide under and be held into place. Hydroxyapatite cement was applied onto the plates and built up to the surrounding bone edges for a smooth skull contour.

After surgery x-rays show the hydroxyapatite cement, which while containing the inorganic mineral hydroxyapatite, is actually more dense than bone even if it is structurally weaker. The long-term of such hydroxyapatite cements is not resorption and replacement with bone. Rather it will serve as as substrate onto which bone will grow across its outer surface, re-establishing a bony bridge across the defects.

Highlights:

  1.   Full thickness skull defects are not rare after infantile cranial vault reconstruction surgery.
  2. While hydroxyapatite cement may be the best reconstructive material choice for the pediatric skull, its weak biomechanical properties are not favorable to be used alone.
  3. Creating a stable floor with resorbable mesh plates allows hydroxyapatite cement to be successfully applied in full thickness skull defects in children.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Knobby Knee Liposuction

Saturday, October 14th, 2017

 

Background: Excess fat collections can occur all over the body. Some may occur from excess calories (e.g., abdomen) while others occur as part of one’s development. (e.g.,

arms) But regardless of its source, most fatty areas can be successfully treated by liposuction for contour improvement.

Liposuction of the lower extremities is the second most common area requested for treatment after the abdominal/waistline area. This is almost exclusively a female request and historically consisted of the inner and outer thighs. But as liposuction has become more advanced, contour reduction and shaping has extended to the knees down to the ankles. It is no surprise that successful lower extremity liposuction shaping works just as below below the knees as it does above it.

The knees may be a small body area but they have an important aesthetic role in the lower extremities. Being situated midway between the upper and lower leg, they provide an aesthetic breakpoint in the leg. Their inner and outer contours provide a break in the linear line of the leg. A slight outward curve of the knee provides an appealing curvature as long as it is not too prominent. When fatty collections of the inner knee become excessive, they are known as knobby knees.

Case Study: This 42 year-old female wanted to reshape her ‘knobby knees’. Even though she was not overweight she always had  prominent inner knees which stuck out.

Under general anesthesia, she had power-assisted liposuction (PAl) using a 3mm cannula performed on the inner knee. Fat removal extended upward into the inner thigh and into the concavity of the area between the knee and the upper calf muscle for optimal contouring. A total of 200cc of aspirate was removed in each inner knee.

The Inner knees is often overlooked or forgotten as a liposuction treatment area. In reality it is one of the most successful body areas to treat with liposuction because there is little chance of creating a contour deformity and there is also little risk of loose skin afterwards. Conversely the biggest aesthetic risk is under resection leaving too much fat and an inadequate reduction.

Highlights:

  1. The inner knees is a small but effective body area to treat wth liposuction.
  2. An aggressive liposuction approach to treating knee lipodystrophy is needed to make a visible difference.
  3. The area above the knee  as well as below above the calf muscle is need to create shape to the inner knee contour.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Limited Facelift Concept

Monday, October 9th, 2017

 

Background: One of the most recognized anti-aging facial procedures is that of the facelift. While commonly recognized it is not commonly understood by the public. Many misconceptions exist about this operation from how it is performed, its immediate and long-term facial effects and to who may even be a good candidate for it.

The facelift procedure has been around for over 100 years and its medical name, rhytidectiomy or the removal of facial wrinkles, speaks to its age. In its original use it was designed to remove wrinkles from the face by cutting out skin in front of the ear or temple area. The operation has certainly evolved since its inception, due to improved anesthesia and surgical techniques, and it has become as much about repositioning of lax facialk tissues as it is about cutting them out.

Despite the evolution of the modern day facelift and its myriad of technical maneuvers within the operation, there are still some basic components to it. The extent of skin flap elevation in the face, how the SMAS layer is managed and how much central neck work is done allows for the facial procedure to be divided into three types or levels whose application depends on the extent of the patient’s aging facial tissues.

The limited or mini-facelift, aka level 1 procedure, has become popularized under a variety of marketing names. Because it is a more limited operation it has become promoted for its quicker recovery, shorter operative times and execution under more limited anesthesia methods. By definition such intra- and postoperative sequelae occur because the operation is less invasive. Less surgery is done, thus making everything about this type of facelift ‘less’ even including cost.

Case Study: This 45 year-old female wanted to reverse some adverse changes that had occurred in her neck and jawline. She had developed some jowls as well as some neck skin laxity occur with some platysmal banding.

Under general anesthesia, she had a limited facelift performed with short skin flaps raised in front of the ear and down into the neck but did not extend to the central neck. A short SMAS flap was raised with suture suspension. A submental incision was made to release and tighten the platysmas bands. Her six week results show a smoothing of the jawline and an improved neck angle.

Any ‘limited facelift’ technique is, by definition, a limited version of its more complete form. What makes it easier in every aspect is that it is less surgery. While that may seem obvious it it important for patients to understand that, while everything about the operation is appealing, it will not create the same result as its much larger form. It works best when the operation is matched to the anatomic problem. For patients with greater neck sag, jowls and overall tissue descent, this operation will not meet one’s expectations. In short a limited facelift is not a full facelift.

Highlights:

  1. A facelift is a variable operation whose extent is based in the aging anatomy that it needs to treat.
  2. A limited or mini-facelift is usually defined as a procedure that does not include the full neck dissection and/or has limited skin flap elevations.
  3. Most more limited facelifts are best done ion younger patients who have earlier rather than advanced signs of facial aging.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Sliding Genioplasty Combined with Chin Implant

Friday, October 6th, 2017

 

Background: Routine chin deficiencies are well managed by with an implant or a sliding genioplasty. The concept of a routine chin augmentation, in my experience, generally falls into a horizontal chin position movement of 10mms for less. Once the aesthetic need becomes greater than a centimeter there is undoubtably an overall lower jaw skeletal deficiency that should ideally managed by a combined orthodontic-orthognathic surgery approach.

But some lower jaw deficient patients will never undergo movement of the entire lower jaw and teeth positions for a variety of reasons. They may appear just for chin augmentation only as a camouflage approach to their lower facial deficiency.

While a large chin implant can be used, most standard chin implants do not provide more than 10mms of horizontal advancement. While larger custom chin implants can be made, such a load of synthetic material on the chin may exceed the soft tissue stretch to safely accommodate it. The projection off such a large chin implant may also appear unnatural with a much thinner jawline behind it.

A sliding genioplasty can usually exceed 10mms if the bone thickness will allow it. I have seen it often go to 14 to 16mms. But in such large tiny chin movements there will be pronounced stepoffs on their sides and the labiomental fold will definitely get much deeper as the bone underneath it has become deeper as the lower chin point comes forward.

Case Study: This young male has a large chin deficiency with a skeletally short lower jaw. From an ideal chin projection standpoint for a male (vertical line dropped down from the lips) he was 22mms horizontally short. Orthognathic surgery was not an option that he wanted to pursue.

Under general anesthesia, an intraoral sliding genioplasty was performed with 14mms of horizontal advancement based in the limits of maintaining bone contact. (lingual cortex of lower chin segment with buccal cortex of upper chin segment) To add a little extra to the what moving the bone achieved a 5mm extended anatomic chin implant was placed in front of the front edge of the chin bone. The wings of the implant went back along the sides of the advanced chin segment across the step off area. Due to the large step-off created an hydroxyapatite block was placed to prevent a severe deepening of the labiomental fold. (the fold is always going to get deeper in larger chin augmentations, you just want to try and lessen that effect)

The need for a combined sliding genioplasty and implant for aesthetic chin augmentation is rare and is avoided by the traditional use of orthographic surgery. The value of such a chin implant is three-fold; 1) its a small amount of additional horizontal augmentation, 2) its wings can cover up the indentation along the sides of larger sliding genioplasty movements (the concave jawline deformity) and 3) it keeps the chin from looking too thin in the frontal view.

It is not a mortal surgical sin to combine two chin augmentation methods that are often viewed as competitive procedures. Each has their own distinct aesthetic effects and in rare cases may be used synergistically to create a better aesthetic outcome than either one can achieve alone.

Highlights:

  1. Large chin deficiencies are often beyond what a sliding genioplasty or a chin implant can effectively treat alone.
  2. Combining a sliding genioplaty with a chin implant can maximize the amount of horizontal advancement and cover bony step offs on the sides. 
  3. Large sliding genioplasty movements will require fill of the step-off to avoid a severe deepening of the labiomental fold.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Helical Rim Lengthening in Setback Otoplasty

Monday, October 2nd, 2017

 

Background: The shape of the ear is complex and its affected by how its cartilage structure becomes formed during its embryologic development. With its array of folds and concavities the ear assumes a unique shape for each person. In addition to its shape,  its size and orientation to the side of the head affects how visible it is when seen in the frontal view.

The most visible part of the ear is its outer edge known as the helical rim. Formed from contributions of the embryologic Hillocks of Hiss #s 3,4 and 5, the outer rim becomes the leading edge and the most protruding level of the ear.  The length of the helical rim affects both the size and protrusion of the ear.  As an encircling anatomic feature, the smaller the helical rim is the smaller the ear may be for it may make it stick out more, depending upon how shortened it is.

In the protruding ear there is always some degree of helical rim shortening although much more minor than in the truly constricted ear. This perceived effect is caused by the lack of a well defined antihelical fold. Without an antihelical fold the outer helical rim becomes folded over or shortened.

Case Study: This teenage female was bothered by ears that stuck out  and they were a source of embarrassment for her. She had a well formed concha which was not excessive.

Under general anesthesia bilateral otoplasties were performed with the total focus on improving the shape and definition of the antihelical fold. Using permanentt horizontal mattress sutures through a postauricular incision, the creation of the antihelical fold brought back the ear into better alignment with the side of the head.

With a setback otoplasty achieved through antihelical fold creation, the length of the helical rim actually becomes longer. Such helical rim elongation allows the ear to set back further against the side of the head in a less conspicuous manner.

Highlights:

  1. Otoplasty surgery is most commonly done in children and teenagers to correct protruding ears.
  2. The most important principle in protruding ear correction is elongating the helical rim to move its outer portion closer to the side of the head.
  3. Antihelical fold  manipulation is the only technique for helical rim elongation.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Temporal Skull Reconstruction with Hydroxyapatite Cement

Saturday, September 23rd, 2017

 

Background: Access to the brain and its lining requires the removal of part of he skull. Known as a craniotomy flap, the bone is usually removed in he shape of a semicircle or a full circle. Once the intracranial work is complete the bone flap is put back into place. But because the bone edges are vertical and a thin rim of bone at its perimeter has been removed in its creation, such bone flaps are well known to fall in or sink down creating an external bone contour deformity of the skull.

To avoid craniotomy flap sinking, plate and screw fixation is commonly used. A variety of differently shaped plates have been developed to rigidly hold the bone flap up as it heals. But despite such metal fixation, not all bone flaps always stay up as much as desired usually due to the failure of good bone healing across the surrounding bone flaps.

Treatment of a depressed craniotomy bone flap can be done by two fundamental approaches…either reposition the bone flap or leave it in place and contour on top of it. Both methods can be effective but employ very different technologies to perform.

Case Study: This middle-aged male had a left temporal craniotomy performed due to a traumatic injury and the need for treatment of a subdural bleed. Six months after the procedure, he had a very noticeable temporal depression that made him look like a piece of his head was missing from certain angles. The anatomy of his temporal depression was more than just the sinking of the bone flap, it was also due to the atrophy of the temporalis muscle as well.

Under general anesthesia the depressed bone flap was exposed through his original scalp incisions. It could be seen to be sunken in despite the use of plates and screws. The depressed bone flap had some mobility so a more rigid floor won top of the bone was created using a very shapeable hexagonal mesh material. On top of the mesh layers of hydroxyapatite cement was used to build up the bone contour including some compensation of the loss of muscle as well.

His after surgery results showed a much improved temporal and head shape contour. Because if the contouring capability of hydroxyapatite cement, one could argue that it is a superior approach than trying to reposition the bone flap in skull reconstruction particularly in the temporal region where muscle adds to its natural contour..

Highlights:

  1. Temporal craniotomy bone flaps can become depressed despite rigid fixation.
  2. One approach to craniotomy flap reconstruction is to leave the depressed bone flap in placed and build out the contour to the level of the surrounding bone.
  3. The combination of hydroxyapatite cement and a mesh floor  can be used to augment a depressed craniotomy bone flap.

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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