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Archive for the ‘plastic surgery case study’ Category

Case Study – Custom Occipital Skull Implant for Plagiocephaly Correction

Monday, January 22nd, 2018


Background: Plagiocephaly is the medical term used to describe a diagonal asymmetry of the head. It is meant to refer to a flatness on either the back or front of the head. But in reality there is always a contralateral flattening opposite the dominant flat part due to the way the skull develops. Hence plagiocephaly is more accurately described as a twisted skull shape where both front and back are affected in varying degrees.

The back of the head is most frequently involved in plagiocephaly. Having seen lots of these cases it affects the right side of the occiput more frequently than that of the left. The flat side of the back of head pushes the ear forward which can be clearly seen from above. The contralateral side of the back of the head may have normal projection or may have some slight overprojection as compensation. Usually, however, the non-flat side of the back of the head is normal in projection.

As an adult the only treatment for occipital plagiocpehaly is surgical. That surgery can only consist of an external augmentation of the bone. The most accurate method is to build an implant for the asymmetry correction based on the shape of the opposite normal side.

Case Study: This young male had a noticeable asymmetry of the back of his head. Even though he had a full head of hair and had never shaved his head, he was well aware its flatness. A 3D CT scan showed the significant amount of right occipital flattening.

From this scan a custom occipital skull implant was designed by mirroring the opposite right side. The thickness of the implant was 14mms over the flattest part.

Under general anesthesia and in the prone position, an 8cm long skin incision was made paralleling the nuchal ridge. The subperiosteal pocket was created and the implant prepared by placing multiple perfusion holes as well etch wedge line internally to permit it to be maximally rolled for insertion. The implant was inserted and positioned using the compass marker on the inferior portion of the implant in the midline.

His immediate intraoeprative result from the prone position shows the complete correction of the occipital asymmetry,


1) Plagiocephaly always involves the back of the head creating an occipital skull asymmetry.

2) A custom occipital skull implant is the most accurate method of correcting an asymmetric skull projection.

3) Such an implant can be placed through a small horizontal incision placed over the nuchal line on the back of the head.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Cheek Implant Seroma

Sunday, January 21st, 2018


Background: A seroma is a well known postsurgical phenomenon that every surgeon from every discipline has seen and treated. This fluid collection typically occurs when a pocket has been created in surgery for access or implant placement. It is the creation of a pocket or dead space as it is often called that provides a place for the fluid to collect. While typically absorbed in small amounts, large outputs of serous fluid overwhelm the body’s ability to absorb it. Such seromas may then necessitate removal to avoid a culture medium for infection or relieve symptoms of pain caused by fluid distention and external contour deformity.

Seroma fluid is principally plasma from the blood that leaks out of small cut blood vessels. It is also mixed with inflammatory fluid from injured cells. Despite knowing what serum fluid is and how it is created, there is much about its causes and treatment that even today is still not well understood. In plastic surgery the development of symptomatic seromas are most well known in tummy tuck and breast reconstructive surgery. While one involves an implant and the other doesn’t the large dead space is the culprit and method to make the dead space smaller, such as drains or quilting sutures, are employed to prevent the development of a serum.

Seromas in the face are very uncommon despite large skin flaps being raised (e.g., facelift) or the use of synthetic implants placed all over the face. The small size of the face, its superior location for downhill drainage and its superb blood supply may alb reasons that facial serums are rarely seen particularly around facial implants.

Case Study: This young female has a history of elective primary cheek augmentation with implants four months previously placed through an intraoral approach. Due to an undesired facial effect she was taken back to surgery for the replacement of her implants with new cheek implants of a different style. (large male shells according to the patient) When the swelling resolved she was pleased with the aesthetic outcome.

One month after the cheek implant replacement surgery, she bumped the right side of her face and the cheek implant area swelled. After a few days it stabilized but remained the same over the past six weeks. Her cheek area was marked swollen, but not red, was dramatically different ins she and shape from the other side, was tender to the touch and radiated pain up into the temporal area.

The lack of any facial redness and a well healed intraoral incision with no drainage make the diagnosis of a serum likely. Through an anesthetized intraoral approach, an 18 gauge was inserted into the implant space from which 3.5cc of a serosanguinous fluid was extracted. Her right cheek immediately deflated to match the her left side and provided a relief of her uncomfortable symtoms.

Why a seroma develops from the capsule (scar) tissue that surrounds a facial implant, either early after the initial surgery or years later, is an interesting question. The capsule is a form of healed scar tissue that develops as a normal bodily response to any implant material. Borrowing from what is well known in breast implant capsules, it is a collagen fiber layer who under microscopic examination have cytoplasmic processes at the surface layer. These long cytoplasmic processes contain vacuoles ultrastructurally which have phagocytic capabilities. The extracellular matrix of the surface layer is an amorphous immature fibrillar protein. This demonstrates that the capsule is far from a static collagen layer and events like trauma or infection can lead to an egress of serous fluid.

Will this lady’s cheek implant seroma be resolved by a single aspiration? This remains to be seen. If not surgical intervention will be required.


1) Cheek implants vary rarely can develop a seroma.

2) Trauma and infection of a cheek implant can induce the capsular lining to leak serous fluid.

3) The initial treatment for a confirmed or suspected cheek implant serum is needle aspiration.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Extra Large Testicle Implants

Sunday, January 21st, 2018


Background: Testicle implants are most commonly used when a testicle has been removed. (testicular replacement) But there are patients who desire larger testicles even with having an existing pair. (testicular enhancement) In these cases the decision is whether implant are made to wrap around the existing testicles (bivalved implant design) or to simply place implants and push aside the existing testicles. This is feasible if the existing testicles are small enough. Otherwise encasing most of the existing testicle with an implant wrap should be done.

Regardless of the technique used for testicular enhancement, there are limits to the implant size that can be placed given the stretch of the scrotal sac. In my experience large testicle implants of a size up to 5.5/6.0cms (length of ovoid shape) is the usual limit that can be placed or that men want. But some men want live larger sizes and, with a custom design process, extra large testicle implants be made.

Case Study: This middle-aged man had a history of prior testicle implant surgery of a custom 6.0cm size placed six months previously. While he was very pleased with this size increase and it gave better penile-scrotal proportion, he wanted to go up just one size more.

Under general anesthesia and through an existing midline scrotal incision, his indwelling custom implants were removed. Capsulotomies were performed to stretch out the scrotum and new custom 7.0cm testicle impacts placed with not wound closure tension.

Like all implants throughout the face and body, extra large implants almost always require a prior implant history. A soft tissue stretch with relaxation must first be created to accommodate the extraordinary implant size. This is as true in testicle implants as it is in breast implants for example.


1)  Testicle implants can be placed in scrotums that have existing small testicles

2) The largest standard testicle implants are in the range of 5.5 to 6cms in size.

3) Extra large testicle implants (7cms) can be implanted if there has been a prior implant in place to provide soft tissue scrotal expansion.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Senior Skull Augmentation with Two-Stage Custom Occipital Implant

Thursday, January 18th, 2018


Background: Flattening of the back of the head is one of the common aesthetic skull deformities. Many of these are mild and are likely caused by how one slept as an infant.  But others are more severe and are caused by a genetic tendency based on ethnicity or familial tendencies or even from lambdoidal synostosis. These more severe flattening of the back of the head are known as brachycephaly and look like the back of the head has been cut off.

While brachycepahaly can be treated by cranial vault remodeling as an infant, the time available to do such bone-based surgery passes quickly. As an older child, teen or adult, such bone-based surgery is not an option. At these ages the concept becomes one of stretching out the overlying scalp by adding to the bone on top of it. While only bone cements have been used in the past to do so, they have numerous limitations and have been replaced by custom made implants based one the patient’s 3D CT scan. Such an approach offer a much better result (smoothness and contour) with a smaller incision length to do so.

A large skull implant augmentation and the amount of increased projection that can be achieved is ultimately determined by the amount of stretch that the scalp will permit. This will vary by a number of factors (scalp thickness, natural elasticity and incisional length access) but, as a general rule, the scalp can safely accommodate a 10 to 12mm immediate increase in central projection. (with a long side taper) Greater amounts of implant projection will require a first stage scalp expansion to accommodate it.

Case Study: This 70 year-old man had been bothered his whole life by the flatness of the back of his head. A 3D CT scan showed  how flat the back of his hand was with a complete lack of convexity. He wanted a significant amount of projection which he estates would be close to an inch.

A custom occipital skull implant was designed from his 3D CT scan based on giving him a  a more pleasing convexity. This measured out to be 22mms of central projection. Because of this amount of increase a first-stage scalp tissue expander was placed. Over a six week period a total expander volume of 200cc was instilled. This correlated with the 200c volume that the custom implant had.

As a second stage procedure the tissue expander was removed and the custom skull implant placed. The amount of scalp expansion was the perfect amount needed for an implant of this size that allowed for a competent scalp incision closure. His immediate after result showed the amount of projection added to the back of his head.

Besides the good improvement obtained in back of the head projection increase is that the patient was willing to do so at 70 years of age. This is a testament to the degree of how much this congenital skull deformity bothered him and the lengths he was willing to go to improve it.


1)  Severe flattening of the back of the head is known as brachycephaly.

2) For significant increased projection of the back of the head a first stage tissue expander is needed.

3) A second state custom skull implant can increase the projection of the back of the head by 25mm or an inch.

4) Age is not a limitation for skull augmentation surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Effects of Breast Implants on Stretch Marks

Monday, January 15th, 2018


Background: Many women that undergo breast augmentation surgery have had children. As a result of pregnancy and breast engorgement, stretch marks commonly develop. They occur in a radiating fashion from the nipple in a perpendicular orientation to the relaxed skin tension lines of the breast,

Since so many women have breast stretch marks, it is a common question as to how they will appear after the breast is markedly increased in size. There has never been a definitive study of this question although plastic surgeons have an inordinate amount of anecdotal experience with this observation.

Since stretch marks represent incomplete tears of the underlying dermis, it would be reasonable to expect them to get wider as the breast mound inflates with an implant. This is much like the areola as its diameter increases as a result of breast augmentation surgery. But does this stretch mark widening persist and does it look worse on a long-term basis?

Case Study: This young female had two children previously. As a result she lost much of her breast volume and acquired a large number of stretch marks. With a loose and deflated breast mound the stretch marks were not that noticeable.

Under general anesthesia saline breast implants were placed through a transaxillary incisional approach. The implant size was 300cc inflated to 350ccs. Her 6 weeks after surgery rests show that her stretch marks has relax to the point that they looked no worse than before surgery.

Most of the time stretch marks after breast augmentation return to their presurgical appearance. With rare exception stretch marks can appear worse if their color turns red. This is somewhat dependent on implant size and how much stretch is placed on the breast mound.


1)  Many women that undergo breast augmentation surgery have stretch marks.

2)  Like the entire breast mound, stretch marks get bigger with with the push of underlying implants.

3) But with skin relaxation after surgery stretch marks return to their preoperative state.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Subcostal Rib Contouring for Protrusion Removal

Thursday, January 11th, 2018


Background: The ribs occupy a large amount of one’s torso, encompassing substantial surface area coverage on the chest and back. With twelve pairs of ribs (sometimes one less or more) , these 24 body parts provide structural support  and protection for the any organs that keep us alive. While seemingly simple in their design , their location and composition (bone vs cartilage) make for a variety of potential ribcage deformities.

One of the most common areas for such aesthetic deformities is the subcostal rib region. This lower chest area is composed of the merging of the mainly cartilaginous ribs #7, 8 and 9 from the side of the chest into the sternum. When deformities in this area occur, they are especially noticeable but also can cause discomfort in this very palpable area.

The subcostal rib region is prone to deformities particularly from injury. It’s lower margin often sticks out and becomes a prominent target for traumatic events. Because these rib portions are cartilaginous and, more importantly, have an osseo-cartilaginous junction brunt trauma can cause shape deformities. Partial separation of the osseo-cartilaginous junction, subperichondrial hematoma and partial rib cartilage fractures can all make for a prominent subcostal rib protrusion.

Case Study: This middle-aged male developed a very prominent bump along the right subcostal rib margin. It was not present at birth or through the earlier years of his life.  It developed without specific recollection of any traumatic event. While he had overall prominent subcostal rib margins due to his very the body frame, there was a very distinct prominent bump on the right subcostal margin along rib #8. It was medial to the osseo-cartilaginous junction.

Under general anesthesia a small 3 cm incision was made directly over the rib bump. The rectus muscle was vertically separated and the prominent cartilage bump exposed. It was shaved down with a scalpel as much as possible within the limits of what the incision would permit. Then a rotary handpick and burr was used to take it down further and feather into the surrounding rib edges. (rib contouring)

Prominent subcostal rib bumps or protrusions can be very successfully reduced through a small direct incisional approach. While this patient’s case represents the smallest example of subcostal rib contouring, the technique is effective nonetheless.


1) One reason for rib contouring surgery is for prominent and painful rib protrusions.

2) The anterior subcostal ribs margin is a common place for cartilaginous protrusions.

3) Depending on the size of the protrusion, rib shaving reduction is a good technique for its treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Rhinoplasty for the Long Thin Nose

Monday, January 8th, 2018


Background: Rhinoplasty changes the shape of a wide variety of noses. This is why a large number of nasal reshaping techniques exist and the ‘cookie cutter’ approach to rhinoplasty surgery will leave some patients wanting. Besides identifying what anatomic structures create the nasal shape seen, it is also important to recognize what effects modifying the structural support of a nose will do. Failure to do ends up with indentations  and asymmetries long term as scar tissue contraction distorts a weakened cartilage structure.

One such nose that poses a challenge is the long skinny nose. It has excessive cartilage length but at the same time the lower alar cartilages are thinner and structurally weak. The nasal skin is almost always very thin revealing any irregularities underneath it. Shortening the tip of such a nose is fraught with the potential for lower alar collapse and notching.

Case Study: This petite young female presented for rhinoplasty with the following aesthetic deformities; a small nasal hump, an overprotected nasal tip, an irregular dorsal line, nasal asymmetry, left middle vault collapse, alar rim retraction and widely flaring nostrils. She had no breathing difficulties.

Under general anesthesia an open rhinoplasty approach was used to perform the following maneuvers. A eptoplasty to straighten it as well as harvest grafts, angled resection of caudal septum, hump reduction by cartilage shave and bony rasping (no osteotomies), bilateral spreader grafts, tip shortening by medial footplate resection, medial cephalic trim of lower alar cartilages,  tip suturing, columellar strut grafts, alar rim grafts and alar flaring reduction.

In many rhinoplasties the concept of what is added is just as important as what is removed. While not true for all aesthetic nasal surgery, many patients need a redistribution of cartilage structure rather than a removal of cartilage alone.


1) The long thin nose is a challenge in rhinoplasty that requires both reduction as well as adding structural support.

2) Deprojecting the kong thin tip must be done carefully to avoid over rotation and weakening of the low alar crura.

3) Spreader grafts can help widen the middle vault in a thin nose as well as improve asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Jawline Implant Replacement for Malpositioned Chin and Jaw Angle Implants

Sunday, January 7th, 2018


Background: Jawline augmentation today usually refers to enhancement of its three primary aesthetic points, the chin and two jaw angles. There are a variety of standard preformed chin and jaw angle implants to achieve this effect and, with proper implant style and size, satisfactory results can be achieved.

But beyond the challenge of selecting the right implant style and size for three different bony jaw areas, there is the need to place them in the proper bony location to exert their desired external effects. The latter is often taken for granted by the patient but not by the surgeon. Placing three implants at different locations on the jawline without being able to reference one to the other due to the limitations of incisional access makes this part of the operation more difficult than it seems. This is far more challenging than placing a single chin implant or even paired cheek implants.

As a result the incidence of implant malposition and asymmetry is not all that uncommon in a three implant approach to jawline augmentation. This risk is magnified when the patient has pre-existing jaw angle bony asymmtetry which may or may not have been recognized before surgery.

Case Study: This middle-aged male had total jaw augmentation previously with a standard anatomic chin and widening jaw angle implants. While the patient recognized that his jaw was asymmetric after the surgery, his surgeon assured him the implants were in good position. A 3 D CT scan showed that the chin implant was positioned too high and to the left and the jaw angle implants were in completely different positions, neither of which was in ideal position.

Using this 3D CT scan a one-piece jawline implant was designed to correct his asymmetries. The dimensions of his existing implants (projections) served as a good guideline as to the size of the various ‘corners’ of the jawline implant.

Under general anesthesia and using an external submental skin incision combined with bilateral posterior vestibular incisions, his chin and jaw angle implants were removed. The new one-piece jawline implant was able to be inserted as the intact piece by which it was designed. His results with pictures taken years later showed good jawline/lower facial asymmetry and better chin and jaw angle projections.

There are many patients in whom standard chin and jaw angle implants work well. But it is not easy to successfully place three independent jaw implants in a perfectly symmetric fashion. Even with a lot of surgical experience it can still happen. When a three-piece jaw implant approach has not been successful, a custom jawline implant will offer improved results by its ‘one implant’ design.


1) Total jawline augmentation done with standard implants has a relaltively high risk of malposition/asymmetry of at least one of the implants since there are three implants used.

2)  A 3D CT scan can confirm standard jawline implant positions as well as be used for a one-piece total jawline implant.

3) Indwelling implants provide dimensional guidelines in designing a custom jawline implant.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Choosing Earlobe Reduction Techniques

Saturday, January 6th, 2018


Background: Earlobes elongate over time because they have no structural support. They are the only part of the ear that does not contain cartilage. As a result the effects of gravity do make true the old adage that the ‘ears do grow longer as we age’. (although stretching of soft tissue, a passive process, should not be confused with an active growth process that makes new tissue) Certain external factors can exaggerate this natural elongation of the earlobes such as heavy ear ring wear and even facelift surgery if not well done.

Large or long earlobes are unattractive because they are disproportionate to the size of the rest of the ear but can also be viewed as a sign of aging. Earlobes can be very effectively reduced by a variety of tissue excision techniques.While many types of earlobe reductions have been described, they fundamentally come down to a wedge excision through the body of the earlobe or an elliptical excision oriented across the bottom of the earlobe. Each approach has its own advantages and disadvantages.

Case Study: This young female was bothered by the large size of her earlobes. Even though she was fairly young, she had an earlobe length that was  1/3 or greater of her vertical ear height. (as measured from the intertragal notch superiorly down to the bottom of the earlobe or subaurale)  She had two earlobe holes from piercings. The lower one she wanted removed as it had a chronic infection. The second or upper one she wanted to keep and have it moved more anteriorly to replace the removed lower one. Her earlobes had an unattached facial connection.

In considering the removal of the lower half of the earlobe, the inferior helical rim excision technique, the first ear piercing may or may not be completely removed. But a small vertical excision can be done to ensure that it is at the same time. The second ear piercing, however, will remain and will do so in the same position that it currently sits. This technique maximally reduces the earlobe as well as can maintain an unattached earlobe connection. (inverted V)

The wedge excision technique, with the anterior limb placed at the facial junction, will both remove the anterior piercing as well as move the second piercing hole much further forward. How much it moves will depend on the size of the wedge and the location of the posterior limb of the excision. It does not shorten the earlobe as much as the inferior helical rim technique and creates an attached earlobe connection. (regardless of what it was before)

The aesthetic advantage and disadvantages of each earlobe technique must be considered. In this case the patient opted for the wedge excision as it was important to have the posterior piercing hole moved forward. Even though the tradeoff to do was less of a vertical reduction and the change to an attached earlobe connection.


1) Earlobe reductions are done by a different excisonal tissue patterns.

2)  The location of piercing holes and whether the earlobe is attached or unattached will influence the type of earlobe reduction done.

3)  Wedge excision earlobe reductions  maintain or create an attached earlobe to the face.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Chin Asymmetry Correction

Saturday, January 6th, 2018


Background: The chin is the most projecting part of the lower face. As the most anterior projecting point of the mandible, the chin puts the overlying soft tissue under the most tension of any area of the face other than the nose. As a result the shape of the symphyseal chin bone is readily seen. Whether the chin bone is round or more square or whether a cleft occurs in the bone, its shape is reflected on the overlying soft tissue pad between the mouth and the neck.

While having a clear idea of the shape of the chin bone can be aesthetically advantageous in some people, it is not so when chin bone asymmetry exists. It is striking that even small amounts of differences in the shape of the chin between the two sides can be so readily seen. Such asymmetry, like that of the nose, draws the eye right to it.

The origin of such bony chin asymmetry impacts the treatment needed to correct it. Many such asymmetries come from a developmental issue of the lower jaw and the chin part of the asymmetry is really just a symptom of the overall problem. Other chin asymmetries are more discrete and are isolated just to the chin bone itself. They often occur from trauma to the chin, usually at a younger age, and is the result of a subperiosteal bleed and ossification of this subperiosteal collection of fluid over time.

Case Study: This young male had chin asymmetry that occurred from a fall as a child. He otherwise had a symmetric face and a normal occlusion.The left side of his chin stuck out more than the right and appeared like a bump projecting outward and downward.

Under general anesthesia a 3 cm submental incision was made. After wide superiosteal undermining that exposed both sides of the chin, a reciprocating saw was used to remove the excessive horizontal and vertical components of the longer asymmetric side of the chin. A handpiece and burr was then used to smooth out any sharp edges.

In chin asymmetry the first consideration is which is the preferred side, which is what looks best to the patient. If the smaller shorter side is preferred then reduction must be done to the larger side. Such reductions rarely are one-dimensional. Think of the asymmetric bone as a three-dimensional problem. (horizontal projection, vertical lengthening and excessive width) With that in mind the next consideration is the surgical approach. (intraoral vs submental) While avoiding a scar, when possible, is always preferred it should not supersede the ability to do a complete 3D reshaping. This is why I prefer the submental incision in many chin asymmetry cases.


1) Most chin asymmetries are bony in origin with the overlying soft tissue mirroring the shape of the underlying bone.

2)  A chin asymmetry often has a 3D component to it and this must be considered in the treatment planning.

3)  Discrete bony chin asymmetries are optimally treated through a submental incision with a shaving technique to the bone reshaping.

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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