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Archive for the ‘plastic surgery case study’ Category

Case Study – Custom Chin Implant

Wednesday, February 8th, 2017

 

Background: Chin augmentation has been around for a very long time and many implant materials and sizes have been used to do it. From this experience has come standard implant sizes that work for the vast majority of people seeking chin enhancement surgery.

But some patients seek changes that exceed what these standard size can create or have discovered through prior surgery that their expectations have not been met. In these cases only a custom designed implant may suffice.

Custom Square Chin Implant Design Dr Barry Eppley IndianapolisCase Study: This 35 year-old male had a prior history of multiple chin procedures including a square chin implant and a sliding genioplasty. While all of these procedure produced a better chin, they fell short of his ideal chin shape and size goal. Therefore a custom chin implant was designed that brought the chin forward 25mm and gave it a very square shape without having any lateral wings.

Custom Square Chin Implant placement Dr Barry Eppley IndianapolisUnder general anesthesia and through a existing submental incision the custom chin implant was placed over the end of the chin bone after removal of the indwelling implant. It was secured with a single 2.0mm titanium screw.

Custom Square Chin Implant front view Dr Barry Eppley IndianapolisCustom Square Chin Implant result oblique view Dr Barry Eppley IndianapolisAt six months after surgery his chin shape was more square with some increased projection. He was pleased and had finally reached his aesthetic chin shape goal.

While custom chin implants can be made to any size and shape, it is important to consider how the soft tissue chin pad will drape over it. (or whether it will) While not all custom chin implants are of large dimensions, many are. The chin soft tissues will not adapt well with large amounts of spontaneous horizontal projection. This often causes tight tissues, lower lip stiffness and an abnormal appearance. It helps to have the chin soft tissues stretched out from prior chin augmentation procedures which is often the case before many patients seek a custom chin implant solution.

Highlights:

1) A custom chin implant is needed when the dimensions of standard chin implants can not create the desired effect.

2) An implant that provides significant horizontal projection with limited width requires a  custom design.

3) Very large chin implants require previous soft tissue expansion from prior chin augmentation procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Weight Loss Tummy Tuck

Tuesday, February 7th, 2017

 

Background: Weight loss creates a lot of external body changes that is usually most manifest in the trunk region. In the anterior abdominal region the deflated skin hangs often hangs over the waistline tethered by the belly button attachment. How mucb skin overhangs the waistline depends on how much weight loss one undergoes and what one looked like before the weight loss.

The tummy tuck is the standard treatment in the weight loss abdomen. Depending upon how much skin needs to removed the length of the horizontal can range from hip to hip or can extend completely around the waistline in a circumferential manner. When the extent of the tummy tuck matches the magnitude of the loose skin present, the abdominal contour change can be dramatic.

Case Study: This 23 year-old Hispanic female lost 60 lbs through diet and exercise over a one year period. (185lbs down to 125lbs) This left her with a central mound  of loose skin that was mainly restricted to the anterior abdomen.

MO Tummy Tuck result front viewUnder general anesthesia, a full tummy tuck as performed through a wide horizontal excision of skin with umbilical transposition. It was not necessary to extend the tummy tuck incision further back into the flanks areas.

MO Tummy Tuck result oblique viewMO Tummy Tuck result side viewAt one year after her surgery, her abdomen was reasonably flat. Her tummy tuck scar healed beautifully, being barely detectable even in her darker skin. She still had a fair amount of stretch marks but these were expected since they were outside the zone of the skin excision pattern.

Many weight loss tummy tucks produce good scars. The the skin closure, even though it is under tension,  heals favorably because of the loss of skin elasticity from the weight gain/loss on the dermal architecture of the skin.

Highlights:

1) Large amounts of weight loss causes unsightly loose skin on the abdomen.

2) A full tummy tuck removes much of the loose abdominal skin but can not remove all the stretch marks.

3) The stretched out abdominal skin heals well and creates a good tummy tuck scar.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Male Forehead Implant

Monday, February 6th, 2017

 

Background: The shape of the forehead is well known to be gender specific. Besides the prominent brow bones, the male forehead has a slight backward slope to it and is broader than that of a females. This slight backward slope contributes to the prominence of the brow bones with increasing slopes making the brow bones look bigger. (pseudo brow bone projection)

While there can be an acceptable retroinclination to the male forehead there comes a point when it slopes back too far and becomes aesthetically undesireable. What the exact angle is as to how much backward slope is aesthetically excessive defies a specific number but it is in the range of greater than 15 to 20 degrees.

3D Forehead Deficiency Dr Barry Eppley IndianapolisCase Study: This 45 year-old male was bothered by the backward slope to his forehead. While much of his forehead was covered by hair, he knew that beneath the hair the forehead sloped backward with two specific grooves heading back into the hairline along the temporal lines. A 3D CT scan of his forehead revealed its slope and lateral deficiency.

Custom Forehead Implant design Dr Barry Eppley IndianapolisCustom Foreheasd Implant design 2 Dr Barry Eppley IndianapolisA custom forehead implant was designed to decrease his forehead slope and make the whole forehead wider. At its thickest point the central thickness of the design was 5mm while the lateral thickness was 7mm before it tapered into the temporal muscle.

Custom Forehead Implant placement Dr Barry Eppley IndianapolisUnder general anesthesia, a 9cm long scalp incision behind his hairline was made. Subperiosteal dissection was done down to the brow bones and out onto the temporalis muscle fascia to accommodate the width of the implant. Multiple perfusion holes were placed into the implant prior to its insertion. After central positioning and making sure the edges were unfolded and laying properly, the scalp incision was closed in multiple layers with resorbable sutures.

A custom male forehead implant is the best way to create an overall contour change of the upper third of the face. It ensures the smoothest result from side to side as well as the smoothest transition possible into the temporal regions. Equally importantly it also allows for the smallest insertion scalp incision possible which is of critical importance in a male.

Highlights:

1) The male forehead has less of an inclination and is wider than that of a females.

2) A custom forehead implant in a male offers the smallest incision for its placement.

3) Thicknesses of only a few millimeters that cover a broad surface area like the forehead can make a visible difference.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Dermal-Fat Graft Chin Reconstruction

Monday, February 6th, 2017

 

Background: Soft tissue deformities of the chin are not uncommon and are created by a variety of etiologies. Trauma is the most common cause but developmental chin deformities also occur from hemifacial microsoma and autoimmune diseases from linear scleroderma for example.

Treatment of any soft tissue defects of the face are done by fat injections today. Their ability to introduce a natural soft tissue graft and to do so in a non-incisional method has a lot of appeal. The downside of injectable fat grafting is the unpredictability of its survival or persistence. But the potential need for multiple injection sessions is still worth the lack of creating incisional scars in most cases.

The dermal-fat graft is the original fat grafting procedure that dates back to World War I.  Technically the original technique was an enbloc fat graft. (without the dermis) A dermal-fat graft works because the blood vessels are hooked back up quickly within days to a week after implantation. It also helps that fat cells have minimal working parts to them. (just a nucleus) But their success is restricted to smaller graft sizes. Their disadvantages are that they require a donor site harvest and an incision for their placement.

Soft Tissue Deformity of ChinCase Study: This 45 year-old female suffered a traumatic injury to her chin which resulted in soft tissue atrophy due to the resultant hematoma. The left side of her chin was thinner and had soft tissue contraction and an obvious external deformity. She has some numbness of the mental nerve distribution on that side but a normal working marginal mandibular branch of the facial nerve.

to chin intraopUnder general anesthesia, a 4 x 6 cm dermal fat graft was harvested from the lower abdomen. Through an intraoral approach, a vestibular incision made dissecting out branches of the mental nerve. The chin soft tissues were released and a pocket made. The dermal-fat graft was inserted into the pocket and trimmed. A mucosal closure was done over the graft.

Dermal Fat Graft Chin Reconstruction result front view Dr Barry Eppley IndianapolisDermal-Fat Graft Chin reconstruction result oblique view Dr Barry Eppley IndianapolisHer three month after surgery result showed a near normal chin contour that was fairly soft and supple. No further surgery was required.

The dermal-fat graft is often overlooked in today’s plastic surgery where the injectable fat graft dominates soft tissue reconstruction. While the dermal-fat graft has its limitations, in the properly selected patient it can offer a one-time soft tissue grafting method of reconstruction.

Highlights:

1) Soft tissue deformities of the chin are best treated by fat injections.

2) Fat injections do not always survive and multiple injection sessions may be needed.

3) A dermal-fat graft provides a large soft tissue grafts that can be placed through an intraoral approach with good survival.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Forehead Reconstruction with Hydroxyapatite Cement

Sunday, February 5th, 2017

 

Background: Many well known congenital skull deformities (craniosynostoses) are treated by early surgery, usually under one year of age. While this allows the developing brain more space to grow and have it help shape the overlying skull, the final shape of the skull is rarely ideally normal. Scar, growth potential and genetics all play a role in preventing a consistent and reliably formed convex skull shape.

Such secondary skull deformities are most manifest in the forehead. Between its visible large contribution to the face and the frequent bone irregularities and temporal hollowing that develops from prior surgeries, the forehead can lack a smooth and pleasing shape. Forehead recession and narrowing along with temporal depressions makes for a commonly seen disproportionate forehead contour. Many of these patients will also have small metal plates and screws across the forehead and brow bones as well as some full-thickness bone defects.

Case Study: This 22 year-old female was originally born with a bilateral coronal craniosynostosis. She has previously undergone both early and several subsequent fronto-orbital reconstructive procedures. Her forehead had a recessed and inverted shape and the temporal areas at the side of the forehead had marked hollowing. There were also several areas of tenderness over the forehead underneath which were palpable metal hardware.

Hydroxyapatite Cement Forehead Augmentation Dr. Barry Eppley IndianapolisUnder general anesthesia and using the full extent of her existing coronal scalp incision, the forehead and temples were fully exposed. Over a dozen plates and thirty small screws were removed. Numerous full thickness bone defects were encountered with intact dura. Using over 150 grams of hydroxyapatite cement,  the forehead, brows and temporal region were built up to more normal contour. All full thickness skull defects were also covered at the same time.

NN Forehead Augmentation with Hydroxyapatite Cement result oblique view Dr Barry Eppley IndianapolisNN Forehead Augmentation withj Hydroxyapatite Cement result front view Dr Barry Eppley IndianapolisHer forehead and temporal areas showed much improved contours once all the swelling had resolved. This fronto-temporal augmentation improved what looked like a constriction band around the forehead just above the brow bones.

The use of hydroxyapatite cement is largely restricted to such procedures as forehead reconstruction due to its high cost. ($100/gram) Its working properties also make it most easily and consistently used with wide open exposure of the bone site. These two reasons keep hydroxyapatite cement from more frequent use in aesthetic skull reshaping surgery.

Highlights:

1) Forehead reconstruction of large contour defects from congenital skull deformities is best treated by hydroxyapatite cement.

2) Hydroxyapatite cement offers a smooth and highly biocompatible contouring material for long-term persistence.

3) The high cost of hydroxyapatite cements makes their use more common in reconstructive forehead reconstruction and not aesthetic forehead augmentations.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Inner Ankle Liposuction

Sunday, February 5th, 2017

 

Background: The distribution of fat throughout the body is highly variable and is affected by numerous factors including gender, body habitus, weight, lifestyle and genetics. While excess fat (lipodystrophy) is commonly associated with a variety of central trunk areas, it can occur in the extremities as well. When occurring in the extremities without truncal adiposity, it occurs not because of diet but because of congenital lipodystophy. (just the way one was born and developed)

When excess fat occurs in the lower extremities at the ankles, it is commonly called ‘cankles’. This unflattering description signifies that there is little to no difference in diameter between the calfs and the ankles. While this is often associated with patients that are overweight, smaller amounts of ankle lipodystropy can occur in patients of normal weight.

Case Study: This 42 year-old male has long been bothered by the lack of shape of his ankles. He was of normal weight but has excess fullness on the inner side of his ankled between he ankle bone and the lower end of the calf muscle on each side.

Inner Ankle Liposuction Dr Barry Eppley IndianapolisInner Ankle Liposuction result Dr Barry Eppley IndianapolisUnder general anesthesia and in the supine position, local anesthesia with epinephrine was first injected into the marked inner ankle areas. Using a small 3mm cannula the inner ankles were aspirated of 65cc of fat per side with a total of 130cc removed. (this picture shows the difference between one inner ankle treated and the other not yet treated) For the ankle area in an otherwise thin person this is a lot of fat for such a small extremity area. Compression wraps were placed for dressing.

Inner Ankle Liposuction result front view Dr Barry Eppley IndianapolisIn the properly selected patient I have always been impressed with with ankle liposuction can accomplish. The area has to be treated aggressively with the intent of leaving little fat between the skin and the underlying muscle fascia and achilles tendon. Because it is doing liposuction around a functionally loaded and moving joint, the patient should expect that there will be some prolonged swelling and walking discomfort. Because the ankles are in the most dependent position on the body, they will take months for all the swelling to completely resolve and see the final result.

Highlights:

1) Excess fat collections due to congenital fat distribution can affect non-overweight patients.

2) Small cannula liposuction can be very effective at removing fat from the inner and outer ankles.

3) While it is a small area of liposuction it takes the ankle area longer to recover than one would think.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Male Occipital Knob Skull Reduction

Wednesday, February 1st, 2017

 

Background: The occipital bone of the skull is the very back part that is shaped like a dish and covers the occipital lobes of the cerebellum. Near the bottom of the visible occipital bone is a series of curved horizontal lines known as the nuchal ridges onto which are attached various ligaments and muscles. In the very center of these lines sits a prominence known as the external occipital prominence.

external occipital protuberanceThe highest point of the external occipital prominence is known as the inion. Onto the inion is attached the nuchal ligament and trapezius muscle fibers. It is an enlarged external occipital protuberance that creates the the occipital knob or bun skull deformity. Why it occurs is not known but the fact that it appears to be largely a male skull anomaly suggests it is related to more or stronger muscle attachments onto the bone.

cmoccipital knob 1Case Report: This 26 year-old male noticed a hard lump on the back of his head since he began to wear his hair shorter. He always knew he had a bump on the back of his head but it never bothered him until it became visible with shorter hairstyles. It did not cause him any pain but he did not like the big knob that stick out from the back of his head as it made him self conscious.

Occipital Knob Bone Reduction intraop Dr Barry Eppley IndianapolisUnder general anesthesia and in the prone position, a 7 cm horizontal skin incision was made in the skin crease just below the bony bump. The occipital knob was exposed and had a 13mm projection above the surrounding occipital skull surface with a distinct horseshoe-shape to it. The bony prominence was burred down to be completely flush with the surrounding skull surface. It was solid cortical bone with few vascular channels.

CM Occipital Knob Reduction intraop result Dr Barry Eppley IndianapolisThe occipital knob skull deformity appears to occur exclusively in men, I have never seen it in a female. (It may occur in women it is just I have never seen it yet) It is caused by excessive thickening of the cortices of the bottom of the occipital skull bone. It can reduced completely by a burring bone reduction technique through a fairly small horizontal scalp incision that heals very well. It is a surgery that is performed in an hour with minimal recovery.

Hightlights:

1) The occipital knob or occipital bun skull deformity has become more common as more men shave their heads at even younger ages.
2) It is caused by a central prominence of increased bone thickness which can have various shapes.
3) Occipital knob skull reduction is a very safe and effective skull reshaping surgery that provides a permanent contour flattening effect on the back of the head.

Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Large Custom Skull Implant Replacement

Wednesday, February 1st, 2017

 

Background: Many areas of the face and the body can be augmented for aesthetic purposes. While the skull is not usually perceived as also be able to be enlarged, it can be done as well. The tightness of the overlying scalp is more restrictive than other body areas so there are limits as to how much skull augmentation can be done.

The implant materials used for aesthetic or onlay skull augmentation are either bone cements or custom made implants. Each can be effective but in larger surface area augmentations a custom implant becomes more effective with far less risk of contour irregularities or edge transition issues. The use of a custom skull implant becomes particularly advantageous when it become necessary to replace a medically or aesthetically compromised large bone cement cranioplasty.

Large PMMA Skull Augmentation 3D CT imagesCase Study: This 35 year-old Asian male had previously been through a large PMMA bone cement skull augmentation procedure that went from the brow bones back to the bottom of the occiput. It provided a good amount of the desired augmentation (a little strong in the forehead) and had no obvious palpable edges. But he did develop a chronic infection that had been controlled for some time with oral antibiotics. As a result it became necessary to have it replaced. A 3D CT scan shows the extent of the cranioplasty. It makes the bone cement look very irregular and not smooth which it actually was not, this is just imaging artefact.

Large Custom Skull Implant design Dr Barry Eppley IndianapolisLarge Custom Skull Implant dimensions Dr Barry Eppley IndianapolisLarge Custom Skull Implant design color mapping Dr Barry Eppley IndianapolisA new large custom skull implant was designed using the outline of the indwelling PMMA bone cement. The forehead was reduced in thickness as the patient requested. The largest area of augmentation was in the occipital region of almost 25mms. Due its large size over a long convex surface, it was designed to be placed in two pieces.

Remove and Replace Large Skull Augmentation intraop Dr Barry Eppley IndianapolisTwo Piece Custom Skull Implant Dr Barry Eppley IndianapolisTwo piece large custom skull implant top view Dr Barry Eppley IndianapolisUnder general anesthesia and using his existing coronal incision, his PMMA bone cement cranioplasty was removed in three large pieces.  It was rigidly fixed to the skull and no fluid or purulence was found. A slime layer was present on both its outer and inner surfaces consistent with a chronic infection. The bone and overlying underside of the scalp was thoroughly debrided and washed. The two-piece custom implant was reassembled on the patient’ skull and screwed in place with a perfect fit. The overlying scalp closure was tight but could still be competently closed in two layers.

When adequate scalp space exists from a prior implant, a large custom skull implant can be accommodated. This is relevant when the need to replace an existing onlay cranioplasty exists and a full coronal incision is present. This permits a lot of scalp mobility although pericranial releases may be needed due to the development of an implant capsular scar.

Highlights:

1) Large skull augmentations cover the forehead in front and go back to the occipital area on the back of the head.

2) The use of bone cements as a cranioplasty method over a large skull surface area is prone to irregularities and a non-smooth contour.

3) A custom skull implant is the best way to cover large skull areas and be a superior replacement for a prior alloplastic augmentation cranioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Vertical Inner Thigh Lifts

Saturday, January 28th, 2017

 

Background: Large amounts of weight loss, whether from bariatric surgery or through non-surgical diet and exercise, has an overall body deflation effect. This is manifest as loose skin which can be seen from the neck down to below the knees. All of this loose skin has created a whole spectrum of new body contouring procedures which are really extensions or expanded forms of traditional body lifting techniques.

The thighs are a well known area for the development of loose skin which is largely seen in the inner thigh area. The traditional horizontal groin crease thigh lift is not remotely adequate for most weight loss patients. Extended inner thigh lifts are what is usually needed and are done by either a T-shaped or inverted L-shaped skin excision pattern. While effective, the horizontal skin closure often poses problems of postoperative wound dehiscence, wide scarring and scar drift downward from the groin crease line.

A vertical inner thigh lift concept avoids the use of a groin crease excision/closure line. It is done by creating a larger vertically-oriented elliptical excision of skin from the inner thighs. Its use is reserved for those patients who on a preoperative pinch test produces little to no bunching at the upper end of the planned incision at the groin crease.

Case Study: This 28 year-old female had lost over 60 lbs and had previously been through breast augmentation and a tummy tuck to improve the loose skin in these area. She had loose skin on the inner thighs but it was largely along the inner thighs along a vertical line from the groin creaser to above the knees..

Right Vertical Inner Thigh Lift result Dr Barry Eppley IndianapolisVertical Inner Thigh Lifts immediate results both legs Dr Barry Eppley Indianapolis plastic surgeonUnder general anesthesia and in the frog-legged supine position, a large vertical ellipse of skin was marked out on the inner thighs. The widest margin of skin excision was central as determined by a preoperative pinch test and measured 14 cms. The skin was excised preserving the saphenous vein and closed in a single fine vertical line. No drains were used.

vertical inner thigh lift gap result Dr Barry Eppley IndianapolisThe vertical inner thigh lift will not work for every weight loss patient and depends on how much loose skin one has on their inner thighs. But when possible its uses avoids the potentially problematic horizontal groin crease incision and an intersecting horizontal and vertical skin closure.

Highlights:

1) Loose skin after large amounts of weight loss affects the body from neck to knees

2) Inner thigh lifts usually require a 3D removal of skin in both vertical and horizontal dimensions to be effective.

3) Vertical inner thigh lifts involve a 2D removal of skin and avoids horizontal groin crease scars.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Upper Inner Calf Implants

Saturday, January 28th, 2017

 

Background: The shape of the lower leg is most commonly defined by the contours along its inner half. The knee, calf muscle and ankle provide a curvilinear shape that has a well known pleasing set of convexities and concavities.This undulating shape is highly influenced by the size of the medial gastrocnemius muscle well as the thickness of the subcutaneous fat layer over it.

Typically there is a concavity in the line of the lower leg between the inner knee and the most prominent bulge of the calf muscle. Without this concavity the lower leg looks thicker and ill-defined. If it is not distinct such a concavity can be created by medial calf muscle augmentation, liposuction between the knee and muscle or a combination of both.

In rare cases this inner leg concavity can actually be too deep. This makes the inner calf muscle look like it is too big even though it is of normal size.

Case Study: This 55 year-old female was embarrassed about the shape of her lower legs and refused to even wear shorts. She felt that her inner leg concavity was too deep and made her legs look too muscular.

Inner Upper Calf Implant Technique Dr Barry Eppley IndianapolisUnder general anesthesia and in the prone position, modified calf implants were placed through an incision on the back of the knee into this inner leg concavity. A small size calf implant was cut down to a smaller size to fit this area. Through a 3.5cm incision located along a popliteal skin crease, a superficial subfascial pocket was created above the bulge of the inner calf muscle to soften the depth of the concavity.

Upper Inner Calf Implants result front view Dr Barry Eppley IndianapolisUpper Inner Calf Implants result back view Dr Barry Eppley IndianapolisHer six week after surgery check showed a pleasing improvement in the inner half shape of her leg just below the knee. Her results show that calf implants can be used in creative ways to create more than just a larger calf muscle prominence.

Highlights:

1) Calf implants are typically used to augment the body of the inner or outer heads of the gastrocnemius muscles.

2) A deep concavity of the inner leg contour between the knee and the inner calf muscle can be augmented by a modified calf implant.

3) Such a modified calf implant needs to be placed in a subcutaneous pocket above the head of the muscle.

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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