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Archive for the ‘plastic surgery case study’ Category

Case Study – Custom Skull Implant Replacement for Crown Augmentation

Sunday, July 2nd, 2017

 

Background: The use of custom skull implants for a wide variety of aesthetic head shape concerns has proven to be a a successful treatment strategy. Using a computer design process on the patient’s 3D CT of their skull, the surface area coverage and thickness of the implant can be precisely made. Such designs must take into consideration how much the overlying scalp can stretch to accommodate the implant. But beyond this physical constraint the design of a skull implant has no limitations.

While the computer can design the implant based on the dimensions provided by the surgeon, it can not determine whether that will produce a satisfactory aesthetic outcome. Perhaps one day the computer will be able to tell us how a design relates to outcome but, until that day comes, the surgeon must create the dimensions based on experience and interpretation of patient goals.

For females the most common aesthetic head shape concern is a deficient crown area. The crown of the skull is at the junction of the top and back of the head. This is an area externally that is well known to women as they often manipulate hairstyles to make it appear fuller. For those women so affected the underlying skill area is flatter and lacks adequate projection. A custom skull implant is the ideal way to surgically improve the fullness in this head area.

Case Study: This 42 year-old female presented with a history ion having had two prior skull implant surgeries to improve the fullness of her crown area by another surgeon. She initially had a custom skull implant made from a 3D CT scan placed. While she had an uncomplicated postoperative course, the amount of projection was inadequate. She then had a second surgery where an unknown material was placed underneath and around the implant to try and build it up further. This results in an unnatural bump-like feel and appearance to the crown area of her head.

A new custom skull implant was designed that had a much broader area of surface coverage and was thicker.

In comparing the new custom implant design to the indwelling skull implant the changes in the amount of skull surface area coverage and thickness could be appreciated. A old design (what didn’t work well) always helps in making a new design which will work better.

Under general anesthesia the composite skull implant was removed. The added material was thick layers of Gore-tex, one larger piece and one smaller piece. These were replaced with the larger custom skull implant after dissecting out a larger subperiosteal pocket. The scalp was able to be closed over the new implant without undue tension.

In designing custom skull implants it is important to realize that they need to cover a broader surface areas than one would initially thi\nk. On the design they must look like a natural shape to the skull even though they are added on to it. If they look unnatural or do not blend in well in the design they will appear so on the patient after surgery.

The one indirect benefit of a prior inadequately designed skull implant is that it does serve as a prior tissue expander. A larger implant can be placed as a result of it being there that if no such implant was there at all.

Highlights:

  1. Skull implants must cover a broad surface area to avoid creating a prominent bump.
  2. Trying to build up a deficient skull implant by placing materials underneath it will not lead to a improved outcome.
  3. Custom skull implant replacements are helped in their design by the indwelling implant shape and thickness.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Cupid’s Bow Upper Lip Reduction

Friday, June 23rd, 2017

 

Background: Unlike the lower lip, the upper lip has a prominent shape feature known as the Cupid’s bow. This is a very recognizable lip feature which has a double curve in its central portion that derives its name because it resembles the bow of Cupid the Roman god of love. The height of the double curve aligns with the bottom end of the bilateral raised philtral columns which gives the lip ma bow appearance.

The degree of definition or prominence of the Cupid’s bow varies widely amongst individuals. To some degree the visibility of the Cupid’s bow is correlated to the natural size of the lip. (amount of vermilion fullness) The thinner the upper lip the flatter are the peaks of the bow and vice versa. Most  Cupid;’s bows have a rounded upper shape although some people have a sharper or more triangular bow form.

In the vast majority of women that seek upper lip augmentation, enhancement of the Cupid’s bow is desired. Having a fuller upper lip bow appearance is felt to be more attractive and sensual. Rarely is a request to have a flatter bow shape where the upper lip has a more homogenous shape like the lower lip.

Case Study: This 42 year-old female wanted to get rid of her upper lip Cupid’s bow. She wanted a smooth vermilion-cutaneous border from one mouth corner to the other.

Under local anesthesia the height of the Cupid’s bow was marked as two small wide-based triangles. The vermilion triangles were excised and the skin edges were advanced downward, making for a smooth vermilion-skin border.

Reduction of the Cupid’s bow is an uncommon upper lip reshaping request. But it can be done effectively through triangular vermilion excisions under local anesthesia.

Highlights:

  1. The shape of the cupid’s bow is the most noticeable and attractive feature of the upper lip.
  2. Reduction of the shape of the cupid’s bow is an uncommon upper lip reshaping request but can be done.
  3. Flattening of the prominence of the cupid’s bow can be done by vermilion peak excision.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Augmentation with Nipple Lift for Asymmetry Correction

Friday, June 23rd, 2017

 

Background: Many women that present for breast augmentation surgery do not have perfectly symmetric breasts. Women that have never had breast implant surgery rarely have symmetric breasts either. Yet, understandably, the woman who undergoes elective aesthetic breast surgery seeks the most symmetric result possible.

Of all the aesthetic breast deformities that exist, asymmetry is the most common and comes in many forms. The breast mound may be smaller on one side, there may be more sagging on one breast versus the other and/or the nipple may be lower. Since every women has some degree of asymmetry it behooves the surgeon and the patient to take careful note of it before surgery when a plan for intraoperative management can be done.

Differences in the horizontal level of the nipple is a very important asymmetry to note before surgery as breast augmentation will almost always make it worse. It is also often correctable by an adjustment done directly on the nipple. Known as a superior crescent mastopexy (SCM), ity is better referred to as a superior nipple lift. The superior half of the lower nipple can be lifted upward by about a centimeter or so through a crescent-shaped skin excision pattern.

Case Study: This 36 year-old female wanted a better breast shape. She was aware of her breast asymmetry with the right breast being bigger with greater skin sag and a resultant lower nipple position.

Under general anesthesia and through inframammary incisions, 400cc high profile breast implants were placed in a dual plane position. A right nipple lift was then performed through a half-moon shaped skin excision that was 1 cm at its central area.

Horizontal nipple asymmetry can and should be corrected at the time of breast augmentation with a nipple lift on the lower breast mound. Good implant sizing can overcome breast mound differences but will not on its own correct nipple level differences and may even make them worse. The superior areolar scar can heal quite well in most cases and does not create an aesthetic distraction.

Highlights:

  1. Breast asymmetry is the most common ‘deformity’ in prospective breast augmentation patients.
  2. Implants alone can not be counted on for correcting breast size or shape issues.
  3. A superior nipple lift on the more ‘saggy’ breast side during breast augmentation can help correct asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Occipital Skull Implant Markers

Monday, June 19th, 2017

 

Background: A flat back of head is one of the most common aesthetic skull problems that is treated. It is best augmented with a custom skull implant made from the patient’s 3D CT scan. This lessens dramatically the aesthetic risks of implant irregularities and edge transitions as well as asymmetry of the contours of the augmentation. There is a huge advantage to controlling the shape and thickness of the implant before surgery. This then leaves the role of the surgeon during surgery to ‘merely’ position it on the skull as it was designed.

The other major benefit to a custom implant that is flexible is that it can be inserted through a smaller scalp incision than that of the diameter of the implant. Every cm of scalp incision (or less thereof) can be of valuable aesthetic consequence. This also speaks to the value of a preformed implant whose shape and thickness can not be altered by the insertion process.

While a smaller scalp incision is of aesthetic benefit, it also severely limits a view of the implant’s position on the skull bone. Not seeing the circumference of the implant’s position on the skull bone can potentially create implant malposition. A curved implant on a curved bone surface under the compression of the overlying scalp can make it seem that just about any implant position is correct.

Case Study: This 57 year-old female had long been bothered by the flatness of the back of her head. (crown area or upper occipital region) Using a 3D CT scan, a custom occipital skull implant was designed to maximally augment the deficient skull area within the constraints of what the scalp stretch would allow.

Under general anesthesia and in the prone position, a 9cm long irregular scalp incision was made over the nuchal ridge. From this incision wide subperiosteal undermining was done with instruments up over the crown way into the top of the skull towards the forehead. The custom skull implants was inserted by folding the sides under creating a more narrow rolled tube. Once inserted the folded sides were unrolled and the implant flattened into the shape by which it was designed. It was then properly positioned by using the compass marker manufactured into the back edge of the implant to get both the midline positioning as well as having no right or left tilt. It was then secured with two small microscrews and the incision closed.

Most custom skull implants benefit in positioning with an embossed compass marker, regardless of what skull area they cover. The limited view of the implant with discrete scalp incisions requires visible registrations to aid in its orientation.

Highlights:

  1. A custom occipital skull implant is the most effective way to build up a flat back of the head.
  2. Proper  positioning of a skull implant in which the scalp incision. permits limited visibility requires a registration mark on the exposed part of the implant.
  3. A compass marker provides a 3D orientation method for skull implant positioning.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Older Maximum Breast Reduction

Monday, June 19th, 2017

 

Background: Reduction of large breasts is one of the most common body contouring procedures in plastic surgery. It has been around in various forms for almost one hundred years. It is a uniformly successful procedure for reducing the back, neck and shoulder pain that typically accompanies large sagging breasts as well as positioning the breasts back up on the chest wall.

By the way it is designed every breast reduction procedure is also a breast lift. While a breast lift can be done without a breast reduction, the reverse is not true. A reduced amount of breast tissue means that the skin that contains it also must be less. The markings made on the skin before surgery is the breast lift part and is a very mathematical and precise part of the procedure. The reduction of the breast tissue is internal and is much more of an artistic technique rather than one that lies on measurements of angles and linear distances.

Breast reduction in older mature women. often has a slightly different flair to it. Women that have had large breasts all their life, and who have finally come to the point of wanting them smaller, usually want a more aggressive reduction. The need for symptomatic paint relief and the desire to look less matronly mandate that larger amounts of breast tissue be removed.

Case Study: This 65 year-old female had large breasts her whole life. (DD + cup size) She had three children and her breasts always ended up looking about the same afterwards albeit a bit more droopy. She was ‘over’ having large breasts and wanted the freedom in its clothing and exercise to have more freedom of choice.

Under general anesthesia an inferior pedicle breast reduction was performed with the removal of approximately 800 grams per side. Her nipple-arolear complex was raised 9 cms from a 30 cm length from the sternal notch to the nipple to a 21 cm length.

Older women are almost always more concerned about having a ‘maximal’ reduction procedure on their breasts than they are about having a fuller lifted shape. As  long as they sit much higher up on they chest wall with a more centered nipple with a low volume, they will enjoy the benefits of less to no musculoskeletal discomfort and the freedom should they so choose to even go without a bra.

Highlights:

  1. Breast reduction in older women is often a ‘maximum’ reduction and lift procedure.
  2. Getting reduced breast tissue back up on the chest wall is ultimately what causes a reduction in musculoskeletal symptoms.
  3. The inferior pedicle breast reduction technique offer a reliable and safe method for larger breast size reductions.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Cleft Lip Revision with Buccal Fat Graft

Monday, June 19th, 2017

 

Background: Repair of a primary cleft lip deformity is one of the common pediatric plastic surgery procedures performed in infants. Usually done around three to four months of age, its repair is usually done by the rotation-advancement technique. This well established cleft lip repair procedure works by derotating the shortened medial lip element and bringing in the lateral lip element in its wake. Once in alignment the lip vermilion is then debulked and put together for a smoother and more uniform red part of the lip.

But despite how good a cleft lip repair may look at 6 months or one year of life, the effects of growth and scarring/wound contracture are often not kind. Over time many well-executed cleft lip repairs will change in appearance. The most common changes are shortening of the philtral length, notching of the vermilion lower lip edge and mismatching of the vermilion-cutaneous border at the Cupid’s bow area. As a result the need for secondary cleft lip revisions is the norm rather than the exception.

While there are numerous detailed techniques in cleft lip revision, one of the major ones used is the correction of a notched vermilion and to improve its projection/fullness. Realignment  of the vermilion and mucosal V-Y advancements are useful secondary vermilion enhancement methods. One very effective method for improving vermilion full ness with a scar revision/realignment is a fat graft. Fat grafts not only bring in volume but healthy tissue as well.

Case Study: This 16 year-old female teenager was born with a right complete cleft lip and palate deformity. She had primary cleft lp and palate repairs as well as a secondary alveolar bone graft. As a teenager her initial cleft lip repair showed vertical philtral length shortening, an inverted V notch at the lower edge of the upper lip and lack of adequate projection/protrusion.

Under general anesthesia a V-Y mucosal advancement was done, rolling out the lip mucosa to help correct the inverted V notch deformity. To prevent its contraction with healing and to help add some lip volume a free fat graft was placed prior to its closure. The fat graft was harvested from the opposite buccal fat pad through an intraoral incision. Only a small piece of the buccal fat pad was needed. (much less than even a subtotal buccal lipectomy.

Many cleft lip revisions have a need for increased volume. Autologous fat is a logical soft tissue graft that can be incorporated into many cleft lip revisions. The buccal fad pad is both a regionally convenient and hardy fat source which can be harvested without scarring. The volume removed is minimal but still should be taken from the non-cleated side of the face since the buccal fat pad on the cleft is already slightly smaller in most cases.

Highlights:

  1. Very few primary cleft lip repairs ever do not need a secondary revision.
  2. One of the most common secondary cleft lip issues is a lack of vermilion volume.
  3. One source of adding additional volume is with the use of free fat grafts, specifically that from the buccal fat pad.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Costo-Iliac Impingement Syndrome Treatment by Rib Removal

Monday, June 12th, 2017

 

Background: The Costo-Iliac Impingement Syndrome, also known a the Rib Tip Syndrome, is a well known syndrome of back and hip pain caused by the touching of the 12th rib against the iliac crest. It most commonly occurs in patients who have had osteoporosis of the spine and loss of vertebral height. This allows the spine to curve and bend towards one side. It can also occur in patients with congenital scoliosis as well as younger patients who have a naturally longer 12 rib or an accentuated angulation downward at its takeoff from the spine or from a previous fracture.

Diagnosis can be done by physical examination and history as most patients can tell you that they know the rib is touching their hips. Deep palpation can feel the length of the 12th rib on its course downward.  The pain can be provoked by lateral flexion on the affected side. Ribcage x-rays can confirm the diagnosis. Definitive treatment is subtotal resection of the 12th rib on the affected side. Few clinical series exist but the few that have been published report relief of symptoms 100% of the time.

The free floating ribs (#s 11 and 12) have a different angulation from the spine than that of the superior ten ribs. Because their anatomy is not to wrap around the waistline or chest, they have a more downward angulation rather than a horizontal one. While many anatomic representations show the 11th and 12 ribs, I am often impressed how significant this downward rib angulation is in the many posterior rib removal surgeries that I have done. It is often 60 to 75 degrees downward in many cases, greater than what textbook illustrations would led you to believe. It is easy to see how it is possible that it could touch the hips in flexion in some short-waisted patients.

Case Study: This 30 year-old female was bothered by left hip/back pain on flexion to that side in numerous body positions. She was well aware that it was probably rib-related. Palpation revealed a long 12th rib that was at the level of the iliac crest. On bending to that side the discomfort could be elicited. For purposes of symmetry and any waistline reduction benefits, bilateral rib removals were planned.

Markings done before surgery showed the relationship of the 12 rib to the height of the iliac crest. Bilateral subtotal 11 and 12th ribs were done through 4.5 cm long oblique back incisions.

Provided a proper diagnosis is done before surgery, one can expect a near complete resolution of hip and back pain from the Costo-Iliac Impingement Syndrome with subtotal rib removal. Whether one chooses to add rib 11 along with 12 depends on the preoperative physical findings and the patient’s goals. If any doubt about rib length or angulation a 3D ribcage CT scan should be preoperatively done. This will remove all doubt about the shape of the lower ribcage anatomy.

When removing any rib for aesthetic or functional purposes, preservation of neurovascular bundle at the inferior edge on the rib is important. Injury to the intercostal nerve during its dissection could potentially end up trading off one source of pain for another.

Highlights:

  1. The Costo-Iliac Impingement Syndrome is due to a long or severely angulated 12th rib that touches the top of the iliac crest in flexion or sitting.
  2. An effective treatment for this syndrome is subtotal removal of the 12th rib and even the 11th rib if necessary.
  1. For purposes of waistline symmetry, bilateral subtotal rib removals can be done.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Two-Stage Skull Augmentation with Custom Implant

Sunday, June 11th, 2017

 

Background: The size of one ’s head is a personal matter based on how one sees it. Some people feel their head is too big while others feel it is too small. While there are specific ratios and numbers for head to face size, what ultimately matters is how the person themselves see it. I have seen a lot of patients with concerns about their head size and in most the cases their concerns are visibly evident.

A larger head is hard to hide but a smaller head size can be camouflaged through a variety of head wear and hairstyles. Women can camouflage a smaller head size using their hair. Fuller hairstyles give the illusion of a bigger head. But eventually some women tire of the effort of making their hair a certain way or their hair becomes damaged by continually doing so.

The small head can be augmented to some degree using custom skull implants. The thickness of the skull bone can be doubled in many cases to create an overall larger head size. How much a skull implant can do so depends on the natural stretch of the scalp, which can not be precisely determined beforehand.  My experience has shown that about 12mms of central implant thickness can be tolerated in most people. The scalp can safely stretch over an implant and allow for a comfortable incisional closure. More implant thickness or volume requires a first-stage scalp expansion procedure.

Case Study: This 30 year-old female ha done been bothered by the small size of head. She wanted a head that was taller and face her better balance to her face. A 3D CT scan showed a skull shape that  was normal but did not have a convex shape to the top. It has more of a flatter profile from front to back.

Her 3D CT scan was used to make a custom skull implant that added a lot of height (1t5mms) as well as broader coverage over the rest of her skull. Given its desired size it was felt that her scalp would not stretch enough to be placed without a first stage expansion.

A scalp tissue expander was placed in a first operation with a remote port placed under the skin above the right ear. She was able to place 110cc of saline volume into the expander over the next six weeks.

During a second operation the custom skull implant was placed  through a minor extended scalp incision that was limited to just across the top of her head. The scalp closure was tight but closed comfortable with metal clips.

Her results at just two weeks after surgery showed a nice increase in her head height and a well healing scalp incision.

Larger or more extreme skull augmentation require scalp expansion first. At the time of the implant placement the capsule from the expander misty bone removed from the bone as well as from the edges of the expander capsule. This will allow the scalp to fully maximize its expansion through these scar releases.

Highlights:

  1. The size of any skull implant depends on the stretch of the soft tissue to accommodate it.
  2. Larger skull augmentations require a first-stage skull expansion to ensure that there will be enough scalp to close over it.
  3. The timing between the placement of a scalp tissue expander and the secondary placement of a skull  implant is usually around six weeks.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Teenage Cleft Rhinoplasty

Wednesday, June 7th, 2017

 

Background: A cleft through the upper lip always affects more than just the lip. As the cleft cuts through the nasal sill on its way back through the alveolus and palate, the nasal structures above it are altered in very predictable ways. The internal septum deviates towards cleft side, the contralateral inferior turbinate enlarges, the ipsilateral lower alar cartilage slumps, the nostril base widens and retracts inward, and the columella and tip of the nose tilts to the cleft side. Even high up above the cleft the nasal bone on the cleft side  is affected, being wider and lower.

A cleft rhinoplasty to be successful must address many of these structural disturbances. Supporting the tip of the nose and nostrils against overlying skin which has historically been distorted, and even deficient, requires the creation of cartilaginous structures to push out on the skin and resists its memory. Cartilage grafting is paramount and the best grafts as possible need to be obtained. A septum that has never been operated on is ideal but this is not always the case. When in doubt a small rib graft is always the go to graft in cleft rhinoplasty.

Cartilage grafting in the nose has a variety of well known graft locations and names. But in the end the tripod construct is what is needed ensuring that a columellar strut, spreader/dorsal grafts and batten or alar rim grafts are needed to help create a better shaped and projecting nasal tip. Even with the creation of the best underlying cartilage framnework, cleft rhinoplasty results can be very humbling.

Case Study: This 15 year-old female was born with a right complete cleft lip and palate deformity. She has been through primary lip and palate repairs as an jnfant  as well as secondary alveolar bone grafting and tip rhinoplasty as a young child. As a teenager she sought a more definitive nose reshaping procedure.

Under general anesthesia and through an open rhinoplasty approach, the septal deviation and cartilages were obtained coming down through the anterior septal angle.  The contralateral inferior turbinate was also reduced. Spreader, columellar strut and cleft- sided batten cartilage grafts were used. The right nasal base was also moved down and inward.

Her longer-term results shows definite improvement in the shape of the nasal tip and nostrils. But her thicker nasal skin precludes as much refinement as one would have hoped.

Highlights:

  1. A more formal cleft rhinoplasty can be done as easily as the mid-teens.
  2. Most cleft rhinoplasties need cartilage grafts and the septum is the best source of strong straights grafts if possible.
  1. Rebuilding/add support to the cleft nostril is the cornerstone to rhinoplasty in most cleft patients.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Abdominal and Waistline Power-Assisted Liposuction

Tuesday, June 6th, 2017

 

Background: Fat removal by liposuction remains the most common body contouring surgery, particularly if one looks at body surface areas treated. Having been around for over 35 years liposuction has undergone many technologic advancements. The vast majority of these improvements have been in the equipment needed to perform it from cannula design to the devices used to free and remove the fat.

While liposuction has been historically powered by ‘elbow grease’, manually moving the cannula back and forth, this is the least efficient and most laborious technique for performing it. Many energy-based devices have been developed to make the fat particulation part of the process more efficient and effective. Using energies of focused light (laser), ultrasonic waves and high flow water, various manufacturers have put forth their machines for commercial use. Understandably all claim their superiority for improved liposuction results.

One low tech but popular liposuction technology is that of a power-assisted method. What this means, and is unique amongst all liposuction technologies, is that the tip of the cannula moves back and forth thousands of time a minute using ana electric motor. This is a miniature form of manually moving the cannula back and forth but being done by a machine. This creates much more action at the end of the cannula that could ever be done manually and spares fatigue on the operator as well.

Case Study: This 39 year-old female wanted to reduce some fullness across her abdomen and around her waistline into her back. (flanks) She was at a good weight but was un able to shed this fat layer.

Under general anesthesia and using a tumescent infiltration fluid, a 4mm cannula was used on a power-assisted device. A total of 2,150cc of fat aspirate was obtained from the entire abdomen and waistline. At six weeks after surgery she had a complete recovery and  the treated areas showed substantial contour improvement.

Power-asssisted liposuction is one of the many contemporary liposuction technologies. It offers more efficient cannular fat extraction with less surgeon fatigue than traditional liposuction. These features are attractive to patients as well as less surgeon fatigue means greater sustained intraoperative efforts…which is often the key to good liposuction results regardless of the technology used.

Highlights:

  1. Liposuction remains the single best method for fat removal in the trunk.
  2. Many different technologies exist for performing liposuction, the ideal method remains to be determined.
  1. Power-assisted liposuction (PAL) is an effective liposuction method that uses an oscillating tip to reduce operator fatigue and improve efficiency.

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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