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Archive for the ‘plastic surgery case study’ Category

Case Study – Custom Extended Square Vertical Lengthening Chin Implant

Friday, January 5th, 2018

 

Background: Chin implants come in a wide variety of styles and sizes. They have the greatest number of standard options available amongst all facial implants. This is because they have been clinically used for decades, longer than any other facial implant, and they are the most commonly performed facial implant augmentation.

But despite these options, standard chin implants do not work for everyone.  Certain aesthetic dimensional needs of the chin remain largely unserved by standard chin implants. This is most relevant for the vertical dimension. For those patients seeking vertical chin lengthening it almost always not a true vertical drop. It is more of a 45 degree downward angulation, a combination of both a vertical and horizontal increase. This type of chin implant is unique because it sits on the edge of the bone rather than completely on it.

While one style of a vertical lengthening chin implant does exist, it has a rounded or anatomic shape. For the male seeking a more square vertical lengthening chin implant a custom implant approach is needed. Such an approach allows for the degree of squareness to match that of the patient’s mouth width as well as allow long posterior extensions to augment the jawline in a tapering fashion backward.

Case Study: This male wanted to increase the vertical dimension of his lower face. He also wanted a more square chin as opposed to his current rounded one. With a 45 degree projection downward from the chin (7mms), it was necessary to extend the posterior wings of the implant back along the sides of the jawline for a natural flow of the implant into the bone. This also added some width to the center of the jawline which is important to prevent the chin from looking too square.

Under general anesthesia a small submental incision was made through which a subperiosteal pocket was made from the chin back to the attachment of the master muscle. Despite the long span of the implant, its flexibility allows it to be inserted through a smaller submental skin incision that most would believe possible.

Highlights:

1) Custom chin implants can be designed with long jawline extensions back to the anterior attachment of the masseter muscle.

2)  Most chin implants that require vertical lengthening ned to be custom designed so they flow smoothly back into the jawline behind it.

3)  The degree of squareness in a custom designed chin implant for a male can be designed based on the patient’s mouth width.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Partial Thickness Jaw Angle Reduction Surgery

Monday, January 1st, 2018

 

Background: Reduction of the width of the lower face refers to jaw angle reduction. The ramus of the mandible (aka the jaw angles) creates the widest part of the lower face due to the outward flare of the jaw as it moves from the chin in front backward. Reduction of this part of the jaw helps narrow the lower face in the front view as well as can change at the shape of a prominent jaw angle from  the side view.

The traditional approach to jaw angle reduction is that of full-thickness bone removal. Known as an amputation technique, the angle of the jaw is cut away as the full-thickness bone cut comes forward below the level of the inferior nerve into the lnferior border anteriorly. This type of jaw surgery has its origins from the Pacific Rim where the often very large and protruding angels of the Asian face, particularly in females, requites a aggressive type of bone reduction.

As such jaw reduction has gained popularity around the world, it has become used in many non-Asian faces for jawline slimming. While effective for some patients it does not produce as successful a result in Caucasian jaw angles that do have a large amount of flare or bone thickness. It often leads to creating a whole new set of aesthetic problems from over-resection and loss of soft tissue support. I have seen numerous Caucasian patients that have gone overseas for this surgery to come in later for reconstruction of their removed jaw angles.

While jaw angle reduction can still be done in non-Asian mandibles, patient selection is key as well as the choice of surgical technique to do it..

Case Study: This young female wanted to reduce the squareness of her jaw angles. Despite being very small in stature she had a square jaw angle. Her jaw was angular even though her mandible was not overly big.

Under general anesthesia an inttraoral approach was done using posterior vestibular incisions. The entire outer cortical layer of bone was removed over the angle area using a handpick and burr. Over the most posterior angle point the tip of the angle was burred away in a full-thickness fashion.

The partial-thickness jaw angle reduction method is often more appropriate for the Caucasian jawline. Burring can reduce up to half of the thickness of the jaw angles. It can also be used to blunt the jaw angle point. It creates a noticeable change without risking a soft tissue sag later from loss of bony support. It is also safer technique with risks of bleeding or nerve damage In the properly selected patient, it is an effective jaw contouring method.

Highlights:

1) Jaw angle reduction can be done using either a partial-thickness or a full-thickness approach.

2) The advantages of a partial thickness technique is that the soft tissue support over the jaw angles is maintained.

3)  Blunting of the jaw angle point can still be done without a completely full-thickness bony cut.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Transaxillary Saline Breast Augmentation

Saturday, December 30th, 2017

 

Background: One of the considerations in breast augmentation surgery is the choice of the incision. While it is important to remember that the incision is just a method of access to the making of the desired breast pocket, and what is done on the inside remains the same regardless of the incision used, it is big preoperative focus for many patients. That choice can also affect certain other aspects of the breast implant operation.

One incisional option is that of placing it in the armpit, known as the trasnaxillary breast augmentation approach. On the surface it offers the obvious advantage of being ‘scarless’ at least from a breast standpoint. It is also a scar location that heals exceptionally well as it is placed in the moist and thinner hair bearing skin of the axilla.

But it has advantages as well. It offers the most direct approach to getting into the submuscular plane for making the implant pocket. The axillary incision is directly right under the thickest part of the pectorals major muscle being just a few centimeters away. Once into the pocket the entire submuscular pocket can be easily elevated to all corners of the breast to make a good implant pocket. The only disruption of really firm tissue attachments that are needed is laterally beyond the edge of the muscle. This is the reason bruising often occurs in this chest wall area after surgery.

Case Study: This young female wanted to improve her breast size by a modest amount. She was a small B and wanted to be either a full B cup or a small C cup.

Under general anesthesia a transaxillary approach was used to place 225cc saline implants that were filled to 275ccs on each side. Even at just one month after surgery her axillary incisions were healing well and will fade to near obscurity in the next few months.

Because of the small size of transaxillary incisions (usually around 3 cms) this approach was originally used for saline implants. Because saline implants are placed deflated and in a rolled configuration,  they can be inserted through such small incisions without any difficulty regardless of the implant’s size. They are then inflated through a connecting tube once in place to the desired volume. But because of the use of funnel insertion devices today, silicone implants can also be inserted through such incisions. Such axillary incision may be a little bigger (3.5 to 4 cos) but silicone implants up to 550ccs can be placed through them.

Highlights:

1) The use of saline breast implants is the origin of the transaxillary breast augmentation incisional approach.

2) It is a blunt submuscular dissection approach that offers the shortest operative time .

3) While it causes the most swelling immediately after surgery, it also offers the quickest recovery time.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Square Chin Implant

Wednesday, December 27th, 2017

 

Background: Most men that seek chin augmentation by an implanted device are satisfied with rounded anatomic implant shapes. With a large variety of such implant shapes and size from which to choose, patient satisfaction can be high. But there is a subset of men that seek a more square chin augmentation result. For these patients square chin implants have been developed and used for almost twenty years.

Square chin implants are available in two basic styles that are separated by the square widths that the implants provide. One is 45mm (style 1) while the other is 55mms. (style 2) With horizontal projections up to 9mms, this will satisfy most men seeking a more square and stronger looking chin.

But more than half of the men seeking square chin augmentation will not be satisfied by standard implant dimensions in my experience. Either the degree of squareness is too small or the amount of horizontal projection available is inadequate. then there is always the issue of whether more vertical lengthening is needed as well. Getting a good 3D square chin effect may require a custom design.

Case Study: This male wanted chin augmentation that provided increased horizontal projection as well as some vertical lengthening. This is makes for an augmentation effect that extends down from the chin at a 45 degree angle. In addition he wanted a strong square chin look which fit his more overall broader facial shape.

A custom square chin implant was designed that had 52mm of width, 7mm of horizontal projection and 5mm of vertical lengthening. This also required longer wings of theat went back along the sides and inferior border of the jaw to the anterior edge of the masseter muscle.

Under general anesthesia the custom square chin implant was placed through a small submental incision that was less than half the width of the front edge of the implant. With a chin implant that adds considerable volume to the edge of the chin it is important to make the incision far enough back under the chin ti allow for some soft tissue roll up.

Highlights:

1) Standard square chin implants will satisfy most male patient’s chin reshaping needs.

2) A custom square chin implant is needed when the width and horizontal projection of the desired chin augmentation exceeds what standard styles can create.

3) It is important with larger square chin implants that there is adequate soft tissue chin pad for coverage.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Buttock Implant Replacements

Wednesday, December 27th, 2017

 

Background: Buttock augmentation is most commonly and appropriately done by fat transfer. (BBL) But not every buttock augmentation patient has the needed amount of fat to do a successful procedure nor does fat always survive in a predictable manner. For the thin patient with little fat, buttock implants are the only alternative treatment option. For the failed BBL patient implants also become the alternative approach.  I don’t know what percentage of fat injected buttock enhancement patients go on to have implants. But having seen it more than a few times, it clearly is not zero.

While the biggest issue of debate in buttock implants usually revolves around whether their placement should be above (subfascial) or in the muscle (intramuscular) position, this issue actually becomes secondary to implant size. With larger buttock implants sizes, the intramuscular position becomes moot as they simply will not fit into the pocket. And even if they do the muscle over them will atrophy with the pressure and the implant will end up in the subfascial position anyway. While the absolute number on implant size for the intramuscular position differs amongst patients based on their body and buttock size, the range of 400c to 450cc is a good guideline for the upper limit of intramuscular buttock implant size.

If larger buttock implants are desired based on the patient’s goal and the subfascial position is where they will need to be, the issue then becomes the buttock implant itself. Is it if adequate size and shape? While a variety of gluteal implants sizes and shapes exist, some patients may find that their aesthetic needs can not be met by them.

Case Study: This young female had buttock implants placed previously in the subfascial location. While she had no medical problems with them, she did not like their ‘shelving’ effect due to their round profile. Custom implants were designed that were 19 cms in height, 15.5 cms in width and 4.5 cms maximum projection with a total implant volume of almost 620cc. They were anatomic in shape with the maximum projection point being located 1/3 vertical distance from the bottom edge of the implant.

Under general anesthesia the new custom buttock implants replaced her indwelling wound implants with pocket expansion as well. The immediate effects of the implant exchange were obvious with lessening of the round buttock implant look to a more natural shape.

The dimensions of relevance in buttock implants are its size (total volume), shape (round vs anatomic) and the footprint or outline of the implant. Externally what matters is how big does the patient want the buttocks to be, do they want a high round shape or a lower anatomic shape and does the implant go far enough outward towards the hips. When standard buttock implants by their placement has not met the patient’s aesthetic needs, custom replacement implants should able to do so.

Highlights:

1) Custom buttock implants may be needed in some cases of buttock implant replacements to meet the patient’s aesthetic needs.

2) Anatomic buttock implants are useful to decrease a very round buttock shape from prior implants.

3) Custom buttock implants are made in prior implant patients based ink knowing what the indwelling implant dimensions are.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Otoplasty Surgery for Ear Reshaping

Monday, December 25th, 2017

 

Background: The protruding ear stands out from the side of head in an exaggerated fashion which is what makes it too visible. One of the features of a good looking ear is that it does not stand out in any conspicuous way. The increased auriculocephalic angle of the protruding ear is not due to a cartilage deficiency in volume. Rather the ear has a normal amount of cartilage but it just does not have the right shape.

Reshaping of the protruding ear through otoplasty surgery involves a variety of cartilage manipulation techniques. One of these and the one that is inherent in about every such ear surgery is the creation of a more defined antihelical fold. This is a natural fold in the ear that is the secondary cartilage fold that sits just inside the outer helical fold. Its relevance to the protruding ear is that when this fold of ear cartilage is absent or ill-defined the outer edge of the ear sticks out further.

While the results from otoplasty surgery for the protruding ear are always shown from the front or back view, it is also important to consider what the ear looks like from the side view. This has relevance during surgery as if an overcorrection occurs it can also be appreciated by an inadequate lengthening of the ear from front to back. (tragus to outer helix)

Case Study: This young female had ears that stuck out due exclusively to the absence of an antihelical fold of cartilage. Under general anesthesia an otoplasty procedure was performed from an incision on the back of the ears. Permanent horizontal mattress mattress sutures were used to create a more defined antihelical fold which pulled the ears in closer to the side of the head.

As the ear is pulled back further inward to the sides of the head by helical rim repositioning, the length of the ear from front to back (tragus to helical rim) increases. This anteroposterior ear change should look natural and not ‘scrunched’ which is a sign of over correction.

Highlights:

1) Traditional otoplasty surgery is about reducing the protrusion of the ear as seen in the frontal view.

2) Most reshaping procedures for the protruding ear involves creating a more defined anti helical fold.

3) The side view of the reshaped ear in otoplasty shows an increased length of the ear from front to back.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study -Breast Implants for Improved Mound Shape and Asymmetry Correction

Monday, December 25th, 2017

 

Background: The primary goal of breast implants for every patient is an increase in breast size. Such an effect is always achieved as one would expect from placing a permanent implant into the breast mound. But some women also desire that they have a breast lifting effect which is not nearly as predictable or should even be expected in most patients.

It is commonly stated that all breast implants do is take the existing shape of the breast and make it bigger. And this is certainly true when it comes to the shape of the breast. If one has a good mound with tight skin and a centered nipple then a very pleasing shape will occur afterwards. If one has a saggy breast with a low nipple position, breast implants will usually not create an improved shape and may well make the undesired shape more so albeit wth a bigger breast mound.

Case Study: This young female wanted a modest increase in her breast size. She wanted  a full B or small C cup size. She has tight breast skin with a short nipple to inframammary fold distance. This made her nipples point slightly downward. In addition she had asymmetry with the left breast mound being slightly smaller and with a lower nipple position.

Under general anesthesia she had high profile round smooth 300cc silicone breast implants placed in a dual plane position through small 3.5cm inframammary incisions. The implants were inserted using a funnel device.

Despite her small and tight breast mounds with asymmetry, her after surgery results showed improved symmetry and better shaped breast mounds. This effect is caused primarily by the influence of the increase in the fullness of the lower breast pole which is where two-thirds of the influence of the implants occur. If the skin is tight enough and the nipple position is still above the fold, no matter how slight, the effect of the implants will create a minor breast lifting effect.

Highlights:

1) Breast implants create a volumizing effect which may have a lifting effect.

2) The lifting effect of implants come from filling out the lower pole of the breast which drives the nipple forward and up.

3) The tightness of the breast skin and the size of the implant will determine whether a breast lifting effect is achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Aesthetic Correction of the High Angle Jaw Deformity

Saturday, December 23rd, 2017

 

Background: The shape of the jawline consists of various anatomic zones that has numerous dimensions. While the most common aesthetic concerns are a chin that does not have enough horizontal projection or jaw angles that are not wide enough, there are many other types of aesthetic deformities of the jawline.

One such undesired jawline shape is that of the ‘high angle jaw deformity’. This is a jawline shape that has high vertically short jaw angles at the back end and a vertically long chin on the front end. The resultant slope of the jawline creates a high mandibular plane angle. The mandibular plane angle is traditionally described by cephalometrics as the angle formed by the intersection of the Frankfort horizontal line with a line drawn through the mandibular plane. (Frankfurt Mandibular Plane Angle or  FMPA) The normal range for the mandibular plane angle is around 22 degrees +/- 5 degrees.

Short of doing an x-ray analysis, the alternative way is to measure the interaction of the mandibular plane line with that of horizontal line drawn for the lowest chin point back. This will roughly create a similar angle number as that of the FMPA.

The high angle jaw deformity creates a hyperdivergent face where the chin can look and actually be long, the back of the jaw looks deficient/missing and the face can seem long and narrow. Creating an improved lower facial shape requires elongating the jaw angles and shortening the chin.

Case Study: This young female was bothered by the shape of her jaw, feeling that her chin was long and her jaw angles too high. This gave her a steep mandibular plane angle and a long thin face.

The concept for her aesthetic jaw surgery was to elongate the jaw angles with implants and vertically reduce the chin bone.

Under general anesthesia an intraoral approach was used to perform a wedge reduction bony genioplasty. A 5mm wedge of bone was removed and the downfractured chin segment put back together with small plates and screws. Through intraoral posterior vestibular incisions custom jaw angle implants were placed that lowered the jaw angles by 10mms (5mm width) and had long anterior wings that came forward to the back of the bony genioplasty cut.

Short of orthognathic surgery correction of a high angle jaw deformity requires alteration of the front and back ends of the bony jaw. While bone removal can vertically shorten the chin, custom designed implants are needed to drop the jaw angles down.

Highlights:

1) A high jaw angle can be associated with a vertically long chin.

2) Reshaping the high mandibular plane angle jaw consists of vertically lengthening the jaw angles and vertically shortening the chin.

3) Custom jaw angle implants are needed to create the smoothest jawline that joins with the reduced chin.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Male Custom Forehead Implant for Upper Facial Reshaping

Wednesday, December 20th, 2017

 

Background: The upper third of the face has well known gender differences. The shape of the male forehead is distinctly different than that of a female.  It is usually wider and vertically longer than in women, there is a slight backward slope to it as it ascends into the hairline and there is the presence of brow bone protrusions with a suprabrow break before heading upwards into the forehead.

Studies have shown that the angle of the curvature of the forehead is higher in women than in men which supports that the rounder forehead in the female and the more backward slope of the forehead in males. The acceptable aesthetic degree of backward angulation in the male forehead is not precisely established but what matters on a practical basis is whether the person finds it acceptable or not. One factor that has a major influence on the appearance of the slope of the male forehead is the vertical skin length. The further the hairline sits back, or even its complete absence, will affect how much of the forehead stands out.

Augmenting the male forehead is more challenging in men than women due to the frontal hairline location and the anterior scalp hair density. For most men the historic use of bone cements is often not practical since these require an almost full coronal scalp incision for proper placement and contouring. The best method today is the use of custom forehead implants made from the patient’s 3D CT scan. This allows their placement through a much smaller scalp incision and assure the smoothest forehead contour and desired shape due to preoperative designing.

Case Study: This young male was bothered by the shape of his forehead which was wider, flatter and sloped back more then he desired. A custom forehead implant was designed that, staying within the anterior temporal lines, gave his forehead a more rounder look and less of a backward slope into his hairline.

Under general anesthesia a 7 cm scalp incision placed behind the frontal hairline was used for implant placement. Endoscopic dissection permitted the subperiosteal elevation of the pocket across the brow area with preservation of the supraorbital neurovascular bundle. The implant wad folded, inserted through the scalp incision, unfold and positioned and secured into this position with two microscrews.

The immediate effects of the custom forehead implant could be seen intraoperatively. All patients will develop some temporary swelling and bruising around the eyes which can take up to a full month after surgery to completely resolve.

Highlights:

1) A excessively backward sloping forehead  is not an aesthetically desirable male forehead shape.

2) Forehead augmentation can be done while leaving the brow bone areas alone.

3)  A custom forehead implant can be placed through a relatively small scalp incision.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Remove and Replace Custom Jawline Implant

Sunday, December 17th, 2017

 

Background: The jawline for men and women is the key feature of the lower face. While once all focus was on the chin, this perspective is short-sighted today. While many patients will still benefit by chin augmentation alone, a growing number of patients want/need a total jawline approach to achieve their aesthetic facial goals.

Total jawline augmentation consist of changing the chin and the paired jaw angles, the three points of the jaw. There are numerous standard preformed chin and jaw angle implants that are available to do so and the ‘three corner’ jawline technique will work for many patients. But for those patients seeking a linear jawline effect that connects the three corners or who have dimensional needs that may exceed what standard implants can do, a custom jawline implant is the  other option for total jawline augmentation.

Designed and made from the patient’s 3D CT scan a one-piece implant is created from jaw angle to jaw angle. It has the advantage that as a connected piece it is less prone to implant positioning asymmetries than that of three implants. But like all other facial implants, jaw implants included, what the dimensions should be to achieve the patient’s goals is not an exact science.

Case Study: This young male had a prior history of a custom jawline implant. While providing improvement it was not dimensionally adequate and there was jaw angle implant asymmetry. A new 3D CT scan was used to determine the implant’s position and shape.

Having any jaw implants, custom or standard, is an enormous help in knowing how to design a custom jawline implant. Knowing the inadequacies of one implant design provides insight into how to make the next one better. From that information a new custom implant designed. Increased chin projection and vertical lengthening of the jaw angles were additional desk features.

Under general anesthesia and through a three incisional approach, the existing implant was removed and replaced with the newly designed implant. The improvements in the jawline shape were consistent with the implant design improvements.

The effects of a custom jawline implant are based on how it is designed and its position on the bone. Unfortunately there is no exact method to determine before surgery what external facial effect any implant design will create. When the first implant design ‘fails’ it still provides useful information as to how to make the next implant better.

Highlights:

1) A custom jawline implant has the best chance to create a more angular and well-defined jawline….provided the dimensions are correct.

2) Most custom jawline implant designs have to be ‘over exaggerated’ as their effect is blunted by the overling soft tissue cover.

3)  A second custom jawline implant can be done to replace a first one if the dimensions are not adequate.

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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