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Archive for the ‘plastic surgery case study’ Category

Case Study – Unilateral Cleft Lip Repair

Saturday, May 6th, 2017

 

Background: The term, cleft lip and palate, refers to a spectrum of congenital clefting conditions that emanate out from the mouth area. In its most common presentation, it  involves both the cleft lip and palate (technically cleft lip-alveolus-nose-palate) but it can also occur as an isolated cleft lip or an isolated cleft palate.

These common orofacial clefts occur in about 1 per 1,000 births but the frequency changes based on race. Asians have roughly twice this number while African-Americans have half this number. These different occurrence rates appear to be due to the forward projection of how the face forms amongst the races as one major contributing factor. Interestingly cleft lip occurs more frequently in males while isolated cleft palate is more common in females.

The surgical treatment of cleft lip and palate is like a golfing event. It will take 18 holes (years) to complete and each hole’s score (year of age and surgery) impacts the final game’s score. (fully grown result) The first hole is the initial cleft lip repair.

Case Study: This 3 month old male infant was born with a left complete cleft lip and palate deformity. The cleft ran through the lip, base of the nose, alveolus and hard and soft palate. There was no prior history of facial clefts on either side of the parents. He was otherwise healthy.

Left Cleft Lip Repair Dr Barry Eppley Indianapolis At 4 months of age and at 14 lbs,, a cleft lip and nose repair was done using a rotation-advancement technique under general anesthesia. Continuity of the orbicularis msucle was established as well as rotating the medial lip element down and advancing into alignment the lateral lip element. The slumped lower alar cartilage-nostril was treated by the placement of a small resorbable plate to give it an uplift and support.

He went on to have a cleft palate repair at 9 months of age. When seen at two years of age, he had good alignment of his lip and fullness to the vermilion. His nasal base and nostril shape was reasonable albeit far from perfect. His next surgery would be alveolar bone grafting somewhere between ages 6 to 8 depending on his permanent tooth eruption pattern.

The foundation of the surgical treatment of cleft lip and palate is the initial cleft lip repair. It sets the tone for how the eventual facial result can look but a lot of facial and oral development as well as other surgeries will take place before the ‘course’ is completed.

Highlights:

  1. Cleft lip and palate is a common congenital facial deformity that isomer than just two facial segments that did not come together.
  2. Primary cleft lip repair is done within 3 to 4 months after birth and often involves some manipulation of the nose as well.
  1. Primary cleft lip and nose repair is never the last corrective procedure performed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Occipital-Parasagittal Skull Implant

Tuesday, May 2nd, 2017

 

Background: The skull is a unique collection of bones (plates) that are interconnected and developmentally affect each other. The most common example of his relationship is that of the congenital condition known as craniosynostosis. When a cranial suture prematurely fuses, bone growth perpendicular to the suture is impeded. Thus in sagittal craniosynostosis, for example, the skull becomes long and narrow as transverse bone growth is impeded.

While not as dramatic, microforms of sagittal craniosynostosis will show similar but smaller areas of surrounding bone deficiencies. These are manifest as skull indentations around the original sagittal suture and back around its back edge at the site of the original posterior fontanelle. In the many sagittal ridge skull reductions I have done, most of which involve the posterior aspects of the ridge in front of the posterior fontanelle, show this pattern of bone indentations.

When evaluating a patient for a sagittal ridge reduction it is important to determine the contour of the surrounding bone. This is important as one has to determine if the sagittal ridge can be satisfactorily reduced to the level of the surrounding bone to give a nice rounded skull shape. Or does the surrounding bone need to be built up to meet the level of the maximal reduced ridge to get the desired shape?

Case Study: This 26 year-old male had a previous history of a high posterior sagittal ridge that was effectively burred down. This procedure was done through an existing small sagittal scar that was present from a prior biopsy of the area by prevjous doctors. The sagittal ridge had been burred down as much as possible and he was initially happy with the result. Over time he subsequently decided to build the surrounding bone as well.

Utilizing a 3D CT scan a custom skull implant was designed to fill in the parallel parasagittal contour defects as well as cover over the depressed indentation at the back end of the original sagittal ridge. (the original posterior fontanelle)  The custom skull implant had a U-shape and was fairly thin.

Under general anesthesia the custom skull implant had multiple 4mm perfusion holes placed through it. It was then inserted in a folded fashion though the original small sagittal scalp incision. Once under the scalp the implant was unfolded and positioned as designed. Two small micro crews were placed to prevent any potential of any implants shifting.

The custom occipital-parasagittal skull implant can be a good aesthetic adjunct in the sagittal ridge reduction patient. It can be placed at the same time as the reduction or can be done secondarily if the patient is uncertain as to its contour benefit.

Highlights:

  1. A prominent sagittal ridge often is accompanied by a surrounding upper occipital-parasagittal skull deficiency.
  2. A. custom occipital-parasagittal skull implant can fill in the skull deficiency at the time of or after a sagittal ridge skull reduction.
  1. Such a custom skull implant can be inserted through the same small incision used for sagittal ridge reductions.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Extreme Upper and Lower Lip Advancements with Mouth Corner Lifts

Sunday, April 30th, 2017

 

Background: Lip augmentation is one of the most popular non-surgical facial enhancement procedures. Done primarily by synthetic injectable fillers the size of the lips can be increased for the duration of the filler’s persistence. When skillfully done injectable fillers can create a myriad of perioral effects from lip size increase, correction of lip asymmetries and corner of the mouth lifts.

The effectiveness of fillers in the lip is based on having enough vermilion height so it can be expanded superiorly as well as outward. When the lips are very thin with a small amount of vermilion show, the push of the fillers is going to more outward than upward. This creates the dreaded ‘ducklip’ effect in which the lips are disproportionately balanced between their projection and height.

With poor responses to fillers in thin lips, changing the location of the vermilion border is the most effective approach. This his known as a lip advancement procedure and can be done on both the upper and lower lips. It is particularly effective in vermilion height asymmetries due to the ability to precisely change the location of the vermilion-skin border line.

Case Study: This 35 year-old female wanted bigger lip but also correction of her natural upper lip asymmetry. She previously had a congenital nevus removed from the left side of her upper lip which further contributed to her natural lip asymmetry. She had injectable fillers placed into her lips numerous times in the past but didn’t want to continue with that recurring expense.

Under local anesthesia with infraorbital and mental nerve blocks, lip advancements were performed. A 3mm lower lip advancement and an asymmetric 5/3.5mm upper lip advancement were performed combined with corner of the mouth lifts through a triangular skin excision. At the end of the procedure, the instantaneous size increase and improved lip symmetry could be seen. Between the use of local anesthetic and swelling, the lips looked enormous in size at the completion of the procedure but this will recede to a more normal appearance in 10 to 14 days later.

Highlights:

  1. Lip advancements are the most powerful surgical form of lip augmentation as they affect the whole lip from corner to corner.
  2. Lip advancements are the most effective form of lip asymmetry correction whether it is a partial or complete advancement.
  1. Upper and lower lip advancements done together create the most dramatic effects even at 3mm to 4mms of advancement per lip.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Extreme Two-Stage Vertical Chin Lengthening

Saturday, April 29th, 2017

 

Background: The sliding genioplasty is a well known chin augmentation technique for horizontal advancement of a short chin. It is used most commonly for the horizontally deficient bony chin. With these forward movements some vertical change can also be affected, either opening it slightly or even vertically shortening it.

A lesser known use of the bony genioplasty is to vertically lengthen the chin. This its actually the simplest movement of the inferior chin segment as it is opened up and elongated using the posterior bony wings as a cantilever. The amount of elongation is based on the vertical width of the bony gap created between the upper and lower segments. The gap is stabilized by a spanning titanium plate with two screws above and below for form fixation. When the bony gap gets to 8mm to 10mms an interpositional bone graft is used to ensure bony healing.

How much one needs to aesthetically lengthen the chin can be determined by preoperatively opening the jaw, find the best chin lengthening effect and then measuring  the distance between the upper and lower teeth edges. (minus any upper incised overbite)  If the vertical distance exceeds 10mm to 12mms, one will ned to consider a two-stage vertical chin lengthening approach.

Case Study: This young male wanted to vertically lengthen his chin. It was determined that 10mm was a good and maximal distance. The horizontal osteotomy was made and the 10mm opening wedge gap stabilized with an 8mm chin step plate that was flattened out. A cadaveric block bone interpositional bone graft was placed in the gap.

Six months later a panorex x-ray shows complete bony consolidation across the graft site as well as at the end of the original osteotomy bone cuts. The bony spaces between the bone graft and the ends remained incompletely filled.

He wanted an additional 10mms of vertical chin lengthening  so a second bony genioplasty was performed. The metal plate and screws were easily removed (non-bony overgrowth) and the chin bone was solid. A horizontal bone cut was made across the original osteotomy line and the chin easily downfractured. It was dropped down another 10mms, fixed with a flattened out 12mm step chin plate and secured with screws. Another interpositional bone graft was placed on both sides of the bony gap.

Interestingly at 20mms of vertical chin lengthening, no lower lip incompetence of strains occurred. Presumably this was because it was a staged bony lengthening approach.

Highlights:

  1. Vertical lengthening genioplasty lengthens the lower third of the face by an opening wedge osteotomy.
  2. When the vertical lengthening of the chin is at 8 to 10mms a cadaveric interpositional bone graft is needed for bony healing
  3. A second vertical lengthening genioplasty can be successfully done after the first one with a final lower third of the face increase of 20mms.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Female Swoop Rhinoplasty

Tuesday, April 25th, 2017

 

Background: The nose is made up of many angles, lines and shapes and represents the most aesthetically complex structure on the face…despite its proportionately small size. How all of these various geometries (subunits) fit together changes based on what view or angle that the nose is being assessed. The most basic of all these nasal aesthetic considerations is that of the  dorsum and is one of the most commonly manipulated and requested nasal features.

The dorsum is a central subunit of the nose that extends from the frontonasal angle superiorly down to the tip. In the front view it has aesthetic or side lines that create a smooth flow, or lack of the flow, down the length of the nose connecting the inner brows into the tip. In the side view, and a view that is of highest significance to patients, is the dorsal line. This profile line of the nose is a dominant aesthetic feature and has long been one of the most basic motivations for having rhinoplasty surgery as well as how the result is judged.

The dorsal line of the nose is gender specific. Man desire a straight or even the persistence of a small hump at the osteocartilaginous junction. Conversely women either prefer a straight dorsal line, or more commonly, a dorsal line that has a slight concavity to it. Men almost never want such a dorsal line shape.

Case Study: This 33 year-old female wanted to change the shape of her nose. She had a slight nasal hump and a tip that had too much projection. The shape of her nose from the side profile was her most important motivation for having the surgery.

Under a general anesthesia an open rhinoplasty approach was done. The small osteocartilaginous hump was shaved down and smoothed. Her nasal tip cartilages were shortened and narrowed by excision and suturing techniques. Shortening the nasal tip also created the need for further reduction in the height of septum along the middle vault.

Her six month postoperative result showed an improved and more ‘feminine’ dorsal line with a tip that has a better length for her nose. Her dorsal line had the requested concavity or swoop between the forehead and the nasal tip. The columellar scar from the open approach had healed to the point that it could not be seen.

Why is it that women prefer such a nose shape? While fashion and celebrities help drive many a facial look, the desire for a small and perkier nose is a decided sign of femininity. It is also the antithesis of aging…it is a sign of youth and ‘cuteness’.

Highlights:

  1. The desired profile result for a female in rhinoplasty is almost always different than that of a male.
  2. Many women desire a dorsal line profile that has a slight concavity or swoop to it.
  3. Obtaining a swoop to the dorsal line is also highly influenced by the degree of tip rotation and/or shortening.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Tracheal Augmentation

Sunday, April 23rd, 2017

 

Background: One of the many head and neck features that are distinctly masculine is that of the thyroid cartilage or Adam’s Apple.  A prominent thyroid cartilage creates a distinct bump in the neck that is associated and aesthetically acceptable in men. While it is often reduced in facial feminization surgery as a tracheal shave procedure in the male to female transgender patient, the reverse has not yet been described.

How to build a more prominent thyroid cartilage has only recently been described for masculinization in a female to male transgender patient. In this solitary description onlay cartilage grafts from the rib were used for tracheal augmentation. Since the Adam’s Apple is a cartilaginous structure it is logical that cartilage grafting would be an effective technique.

But not every such patient may want a rib graft harvested for a tracheal augmentation procedure. Like much of the face, one wonders if an implant can not be effectively used instead of a cartilage graft.

Case Study: This 35 year-old make wanted to improve the shape of his chin and neck. He had a mild short chin, submental fullness and a smooth neck contour. He had a first stage procedure of chin augmentation and a submentoplasty (liposuction and direct defatting with muscle plication) Afterwards he inquired about making his Adam’s Apple more prominent.

In a second procedure the trachea augmentation was planned using a Medpor nasal implant. The shape of the nasal implant is like a saddle (inverted v) which seemed like it would create a tracheal prominence and could be secured onto the front edge of the tracheal cartilage. A v-shaped notch was made in its upper portion to replicate the natural shape of the thyroid cartilage. Medpor nasal implants come with inserts to place under it for increased augmentation which was also done in its use as a tracheal implant. This gives it more outward projection from the anterior surface of the natural thyroid cartilage. Through a small skin incision, the synthetic framework was sutured to the cartilage, the overlying skin flap of fat (to allow more of the framework projection to be seen) and the skin closed.

The combination of chin augmentation, submental reduction and tracheal augmentation produced a more masculine lower face/neck profile. Tracheal augmentation can be done successfully using a properly shaped synthetic implant. The material composition is not an important as its ability to be shaped and secured to the natural thyroid cartilage base.

Highlights:

1) A prominent thyroid cartilage is a male characteristic.

2) Masculinization of the neck can be done by tracheal augmentation.

3) A synthetic tracheal implant can be used to create more projection of the upper V

portion of the thyroid cartilages.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Stahl’s Ear Correction with Rib Cartilage Graft

Saturday, April 22nd, 2017

 

Background:  There are a wide variety of congenital ears deformities that involves either deformed or missing natural cartilage structures of the ear. One such well known deformity is that of the Stahl’s ear. This consists of an ear that has a pointy shape due to an extra fold or third crus in the scapula. It is often referred to as a Spock part in reference to the Star Trek TV character.

Stahls’ ear is primarily caused by the ear cartilage being misshapen. The upper ear usually has two distinct folds known as a superior and inferior crus. But in Stahl’s ear a third crus or fold occurs. This causes the outer rim of the upper ear to fold inward giving it a pointed shape.

If recognized very early after birth, external ear molding devices (e.g., Earwell) can correct the misshapen ear as the young ear cartilage is very flexible and moldable. But once one passes six to weeks after birth the ear loses its responsive to external molding forces and surgery becomes the only treatment option.

Case Study: This 12 year-old male had misshapen ears that he disliked. The upper outer helical rim was bent over or folded in. This created a pointed shape to his upper ears. He had been given the diagnosis of Stahls’ ear although it was not a classic presentation of it.

Under a general anesthesia an incision was made on the back surface of the ears. This allowed the helical rim skin to be dissected off the cartilage and expose the upper ear cartilage shape over the deformed area. Radial cuts were made in the cartilage to allow it to unfurl and create a more defined outer helical rim. To support this new shape a cartilage graft from a small piece of rib #9 was used by suturing it on the inside of the newly formed helical rim. On the right ear  a small wedge of cartilage and skin was removed to bring down the height of the helix.The skin was then pulled back over the reconstruction and closed with dissolvable sutures.

His immediate intraoperative result showed improvement in the shape of ear through recreation of a more defined outer helical rim. While many techniques for Stahl’s ear correction have been described they all rely on innate cartilage reshaping alone. Add a small cartilage graft can help support these cartilage reshaping efforts.

Highlights:

  1. Stahl’s ear is a congenital deformity marked by an abnormal fold in the upper ear which makes it pointy.
  2. Reconstruction they deformed upper ear requires cartilage reshaping which often requires the use of a cartilage graft for support.
  3. A small piece of rib #9 can be used for a strong and curved cartilage graft.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Facelift with Jaw Angle Implants

Sunday, April 16th, 2017

 

Background: The facelift is a well known surgical rejuvenative procedure that primarily creates a smoother jawline and a more defined cervicomental angle. For some facelift patients the addition of a chin implant, if their chin is short, helps improve the jawline by adding increased projection at its anterior edge. This is why many facelifts particularly in women also include a chin augmentation.

While chin augmentation provides an aesthetic benefit to the front end of the jaw during a facelift, the rest of the jawline remains neglected. Some aging patients have weak or high jaw angles. Pulling the facial skin back up and over a weak posterior jaw angle fails to make it more defined. It often only gives it a sweeped look from the skin pull.

Like chin implants, jaw angle implants have a role to play in facial rejuvenation and facelift surgery. Their only drawback is that they will cause a moderate amount of facial swelling over the posterior part of the face during the early recovery period.  Good compression facial dressings during the first few days after surgery is very helpful in this regard.

Case Study: This 68 year-old female wanted a lower facelift to remove loose skin along the lower part of her face and give her a more defined jawline. But she had a high and ill defined jaw angle area and opted for the placement of jaw angle implants at the time of her facelift.

Under a general anesthesia and through an intraoral approach, small vertical lengthening jaw angle implants were initially placed. Thereafter a lower facelift was performed with SMAS plication. Her long-term results show improved jaw angle definition and a well defined jawline from chin back to the ear.

Like chin implants, jaw angle implants are aesthetically beneficial in a minority of facelift patients. But in the properly selected patients and in thinner faces, they can add bony definition of the lower face which has a distinct rejuvenative facial effect.

Highlights:

  1. Augmentation of the jawline at the time of a facelift or after has long been recognized as an aesthetic benefit.
  2. Creating a more defined jaw angle builds up the back part of the jawline.
  3. Most jaw angle enhancements in aging require a vertical jaw angle implant style.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – ePTFE Ear Implant Reconstruction

Saturday, April 15th, 2017

 

Background: Ear reconstruction is most commonly done using autologous graft materials. Whether it is microtia reconstruction using rib cartilage in children or adult ear reconstruction using cartilage grafts and pedicled skin flaps, the patient’ own tissues offer the least risk of postoperative complications and should be done when possible.

The use of synthetic frameworks or implants for ear reconstruction has its origin and current use with Medpor material. Most commonly done as an alternative to the use of rib cartilage in congenital microtia deformities in children, it offers a premade and well shaped ear implant. As a substitute for a hand-carved rib cartilage ear framework, it requires vasculrized tissue cover using the temporalis fascial flap (TPF flap) covered with a split-thickness skin graft. Its benefits is that it usually creates a much better shaped ear in the end and does so in less operative time with no need for a rib graft donor site.

While Medpor ear frameworks are effective, the material itself does not replicate very well the physical characteristics of natural ear cartilage. It is much more stiff (in fact rigid) and lacks any substantial flexibility. While creating a nice ear shape it does not create a good feeling ear. This stiffness can make the Medpor framework ear prone to occasional discomfort and skin breakdown due to pressure or trauma.

Case Study: This 78 year-old male has multiple basal cell skin cancers on his left ear on both front and back ear surfaces. It was decided that the best treatment for his ear cancer was near amputation. He was interested in a synthetic ear implant as opposed to a rib graft. Under general anesthesia he had a subtotal ear resection preserving the superior helical root, concha and earlobe.

Using an ePTFE coated composite ear implant, it was carved into a shape replicating the portion of the ear cartilage removed. This was then sutured to the remaining ear cartilage.

A TPF flap was raised through a vertical incision above the ear. It was folded down over the ear framework, preserving its temporal vascular pedicle, and sewn into the tissue edges around the remaining ear. A split-thickness skin graft was harvested from the thigh and laid over the TPF flap and sewn into place.

With healing time and tissue contraction, the details of the ear framework will eventually become more apparent through the applied vascular cover. In the long run the reconstructed ear will have a more natural feel due to the inherent softness of the ePTFE material.

Highlights:

  1. Synthetic ear reconstruction relies on the use of a Medpor ear framework covered by a fascial flap and skin graft.
  2. A new synthetic ear implant made of a composite silicone and ePTFE coating offers a softer and more flexible design.
  3. Composite ePTFE ear frameworks offer a carving feel that is identical to that of natural rib.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Male Brow Bone Reduction

Friday, April 14th, 2017

 

Background: Males almost always have much more pronounced brow bones than females due to a greater pneumatization effect of the frontal sinuses. Numerous studies have shown that the male frontal sinus is bigger, usually asymmetric and has a bigger left side than that of the right. This is clinically evident in the external shape of the forehead with greater supraorbital protrusions than females.

Why some men get much bigger and disproportionately larger frontal sinuses and subsequent brow bone protrusions is not known. Whether this is due to hormonal influence, masticatory loading forces or an increased developmental effort to separate the brain from the eyes are theories that have all been espoused. Regardless of its cause, the enlarged male brow bone often produces a dramatic effect that can be enhanced by a backward sloping forehead.

The male brow bone is reduced with several basic tenets in mind. First, simple burring is inadequate for a major brow bone protrusion. The anterior table of bone is not thick enough to allow for a significant reduction and the maintenance of  a bony covering of the frontal sinus air cavity. Second, the male brow bone should be so reduced that the foreflat has a completely flat profile. Some degree of brow bone break into the upper forehead needs to be maintained.

Case Study: This 30 year-old male had been bothered for a long time by the shape of his forehead. He had a very strong brow bone with two very distinct paired brow protrusions with a midline glabellar groove. The size of the brow bones was magnified by a backward forehead inclination of almost 45 degrees.

Under general anesthesia and using a near complete coronal scalp incision, his forehead and brow bones were exposed. A reciprocating saw was used to remove the anterior table of the frontal sinuses at the level of the surrounding forehead. Osteotomes were used to make the final bone elevation to preserve as much of the underlying sinus mucosa as possible. Burring was then done all around the bone edges as well as down into the frontonasal angle.

The removed bone segments were thinned and reshaped and the put back into the frontal sinus. (setback) They were secured using small plates and screws to maintain bone contact as well as prevent any inward displacement.

The immediate change in the forehead profile was evident but not over flattened.

The osteoplastic setback technique for male brow bone reduction is the gold standard by which it is done. Whether it can be done by a single piece of bone across the frontal sinuses or whether it needs to be done by two separate bone pieces depends on the patient’s anatomy.

Highlights:

  1. Most brow bone reductions in men require an osteoplastic setback technique.
  2. Removing the anterior table of bone from the frontal sinus by osteotomy with surrounding burring produces the best brow bone reduction effect.
  3. Male brow bones should be only reduced to the point of leaving some brow bone break to avoid overfeminization of the forehead.

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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