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Archive for the ‘rhinoplasty’ Category

OR Snapshots – The Open Rhinoplasty

Sunday, January 8th, 2017

 

Rhinoplasty surgery requires incisional access to perform osteocartilaginous reshaping. The most common historic technique was the ‘closed approach’ where all incisions were placed inside the nose. Because this provided limited visual access it took a lot of experience to master aesthetic nasal surgery. This was the standard in rhinoplasty until the 1990s were it was surpassed in usage by the ‘open approach’.

open-rhinoplasty-indianapolis-dr-barry-eppleyThe open approach degloves the skin off the tip of the nose and permits complete visual access to the entire underlying nasal structures. What makes it possible to expose the nose is the mid-columellar incision. This extra 6mms of skin incisional length connects with intranasal mucosal incisions to allow the nasal tip skin to be lifted off of the lower alar cartilages. While once controverial, the open rhinoplasty has become the standard technique in rhinoplasty today as it produces consistent and more reliable surgical outcomes.

Patients are often understandably concerned about a visible nasal scar with the open nasal approach. But the columellar skin heals so well that such a scar is virtually invisible in most patients. It rarely causes a scar problem and I have never seen a hypertrophic or keloid columellar scar. The only occasional columellar scar problem seen is a stepoff or notch along one of its sides due to less than perfect closure or premature incisional separation.

Interestingly, the widespread use of the open approach has led to a re-emergence of the closed approach. Now known as the ‘scarless’ rhinoplasty, the use of the closed approach is refinding a role in certain types of nasal reshaping surgeries.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Bifid Nasal Tip Rhinoplasty

Saturday, January 7th, 2017

 

The shape of the nose amongst people is as different as that of fingerprints. Between the innumerable size and thicknesses of the bone and cartilage that make up the nose and its thick or thin skin cover, the variability in nose shapes is endless. What rhinoplasty can do is to change the shape and thicknesses of the supporting bone and cartilage framework onto which the skin covers it. The skin of the nose is rarely, if ever, surgically altered by removal.

bifid-tip-rhinoplasty-dr-barry-eppley-indianapolisOne of the classic examples of how the shape of the nose comes from its structural framework is that of the bifid nose. This is where a cleft or groove exists down through the center of the tip of the nose. It separates the nasal tip into two discernible halves. It is not an uncommon nasal tip deformity. It can occur in nasal tips that are both narrow and wide and results from a separation of the lower alar cartilages from the tip down to the base of the columella. In this open rhinoplasty surgery the cause of the groove down the nasal tip can be seen from the wide spacing between the medial footplates of the columellar cartilages.

Repair of the bifid nasal tip is done by closing the gap between the separated cartilages through suture techniques in an open rhinoplasty approach. In some cases a cartilage graft (columellar strut) may also be used to fill in the gap. As the skin follows what the cartilage looks like underneath the groove on the skin disappears after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

ePTFE Nasal Implants

Saturday, January 7th, 2017

 

Augmentation of the nose can be done by a variety of rhinoplasty techniques and materials. When possible, one’s own cartilage is always the best from a biologic standpoint and is preferred if it can provide a satisfactory aesthetic outcome. The use of septum, ear and rib cartilages offer a wide variety of graft choices that can meet almost every type of nasal augmentation need.

But there are circumstances where the use of autologous cartilage in the nose is not an option. It is almost always due to patient preference or convenience as the supply of cartilage from the ribs is virtually endless given the small size of the nose.

nasal-implants-dr-barry-eppley-indianapolisImplants offer a preformed approach to nasal augmentation with emphasis on raising up the dorsum. A silicone nasal implant is the most commonly used facial implant in the world and comes in a variety of shapes and sizes. While implants in the nose has its own risks and disadvantages (as well as its surgeon critics), in the properly selected patient it can create very pleasing aesthetic results that have good long-term persistence and a low rate of complications.

A silicone implant has the advantage of a preformed shape that will never change and it is easy to surgically insert due its smooth surface. Its smooth surface also creates a low rate of bacterial adhesion due to lack of surface attachment points. The disadvantage to its smooth surface is that it does not allow for tissue ingrowth or tissue attachment.  Thus the implant develops a smooth encapsulating layer of tissue into which the implant passively resides. Without being fixed into the recipient tissue bed, there is always the opportunity for implant shifting, tissue thinning and even infection.

eptfe-nasal-implant-on-skull-dr-barry-eppley-indianapolisOne modification that has been useful to the silicone nasal implant is a coating of ePTFE. (expanded polytetrafluoroethylene) Originally known as Gore-tex, ePTFE creates a coating on the implant that has a microporous structure due to its microfibrillar structure. This creates a nasal implant, which has all the advantages of pure silicone, but also creates the opportunity for tissue attachment/adherence.

eptfe-nasal-implant-shape-dr-barry-eppley-indianapolisePTFE nasal implants offers a near perfect dorsal implant for rhinoplasty surgery. Its smooth surface and saddle-like design provides a good fit for most nasal dorms. Its placement ensures that the nose will be straight and smooth and have good aesthetic lines. Soft tissue adherence will stabilize the implant long-term. While the soft tissue adherence is not as good as would occur with cartilage graft, it makes the silicone implant a little more like a graft than an implant.

nasal-implant-rhinoplasty-result-side-view-dr-barry-eppley-indianapolisePTFE nasal implants are a good choice in dorsal augmentation rhinoplasty in which the straightness of the result needs to be most assured. As long as the implant is not too big or stresses the nasal skin excessively an uncomplicated long-term result should occur.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Injectable Diced Cartilage Grafting Technique

Monday, January 2nd, 2017

 

Rib grafts are a well known autologous graft in rhinoplasty for significant augmentation. The rib graft can be used as either a solid piece (en bloc) or can be diced into very small cubes and turned into a sausage-like wrap. Both rib graft methods have their advantages but the diced technique effectively eliminates any chance of graft warping, the most common aesthetic complication of onlay rib grafting in the nose.

diced-cartilage-graft-rhinoplasty-preparation-dr-barry-eppley-indianapolisBut the wrap containment method is not the only way to use a rib graft. For smaller dorsal defects diced rib cartilage can be placed through an injection method. If one has enough septal cartilage this can also be used similarly. In this method the diced cartilage is loaded into a 1cc syringe with an open barrel. (this has to be cut that way) This creates a loaded injectable cartilage graft syringe.

The key to using this cartilage grafting method is that it has to be placed through a narrow tunnel to the dorsal defect site. The tunnel serves as the containment method. Once inside the tunnel the graft is injected on withdrawal. It can then be molded into shape although the tunnel itself has already made most of the graft shape. The shape is held by the application of external tapes/splint.

It is easy to see that this is a linear grafting method that works by the alignment of the syringe for graft placement. This makes it best used for dorsal line defects from the radix down to the tip.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Male Middle Eastern Rhinoplasty

Monday, January 2nd, 2017

 

Background: The shape of the nose is incredibly diverse and no two people have the exact same nose.  But in the world of rhinoplasty surgery, noses are lumped into different categories based on ethnicities. In general any rhinoplasty that is not performed on a Caucasian nose is called an ethnic rhinoplasty.

One such ethnic rhinoplasty is that of the Middle Eastern nose. As the Middle East region has over 17 countries, there is no one unifed nasal shape or deformity. But the most common patient objective is to reduce a large hump or bump on the upper half of the nose. In addition the nasal tip often droops down, creating less than a 90 degree nasolabial angle. The combination of hump reduction and tip elevation constitutes the backbone of the Middle Eastern rhinoplasty.

Frequently the Middle Eastern nose has a thick skin cover. At the least it is on average thicker than that of most Caucasian noses. This can create a challenge for the degree of tip refinement. But in the male patient in particular the goal is to make the nose more balanced but still retaining the ethnicity of the patient’s appearance.

Case Study: This 38 year-old Middle Eastern male desired to improve the shape of his nose. He did not like the large bump on his nose and wanted the tip lifted and thinned a bit. But he did not want the nose too upturned or the bridge area too low.

middle-eastern-male-rhinoplasty-resulys-side-viewmiddle-eastern-male-rhinoplasty-result-front-view-dr-barry-eppley-indianapolisUnder general anesthesia and through an open rhinoplasty, the dorsal hump as reduced requiring lateral osteotomes. The tip was lifted through combined caudal septal resection combined with tip cartilage reduction and suturing. Lastly alar base narrowing was done to stay in balance with the more narrow tip.

middle-eastern-male-rhinoplasty-results-oblique-view-dr-barry-eppley-indianapolisWhile rhinoplasty is changing the shape of the nose, it should not be significant enough for one to lose their Middle Eastern appearance. This is particularly relevant in the male patient where ‘less is often more’.

Highlights:

1) The dominant deformities of the Middle Eastern nose is the hump at the bridge and the drooping nasal tip.

2) The male Middle Eastern rhinoplasty should strive to achieve a straight dorsal line and a nasolabial able of 90 degrees.

3) A more pleasing appearance to the nose but without loss of ethnic appearance are the two important objectives on any ethnic rhinoplasty…unless the patient desires otherwise.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Diced Rib Graft Rhinoplasty

Saturday, December 31st, 2016

A significant build-up of the nose requires a combination of bridge and tip augmentation. In primary rhinoplasty this is usually needed in many ethnic patients who lack nasal projection from the face. This may also be required in revision rhinoplasty when over reduction has been done from a prior procedure. In such cases the key element of the surgery is an adequate volume of cartilage grafts.

The most common source of an undisputed volume of cartilage is a rib graft. The ribs offers an unlimited amount of cartilage for the nose no matter where on the ribcage it is harvested. Despite this huge advantage, rib cartilage has a major disadvantage….it is not straight. Nowhere on the rib cage is a cartilaginous section perfectly straight. In addition it almost always has to be carved, removing perichondrium in the process. This further potentiates the risk of graft warping after surgery.

diced-rib-graft-rhinoplasty-dr-barry-eppley-indianapolisThe one proven method to eliminate the risk of rib graft warping in rhinoplasty is diced modification. Rather than place one single solid piece of rib, the graft is cut into many small pieces or small cubes. The diced rib is cut down to as small as 1 x 1mm pieces. The diced rib is then wrapped in either fascia, cadaveric dermis or collagen to create a moldable sausage-like implant. This wrapping contains the diced graft so it can be inserted and molded once placed onto the dorsum of the nose.

Diced rib grafting offers not only a customizable approach to significant nasal augmentation but a rapid integration/healing of the graft. The many small cartilage pieces allow for early and substantial fibrovascular ingrowth into the graft. This is evidenced by the very firm feel of the diced rib graft just a few weeks after the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

The Role of Rhinoplasty in Facial Feminization Surgery

Sunday, December 18th, 2016

 

Facial feminization surgery changes the structure of the male face to appear more feminine. While procedures from the skull down to the trachea exist to make these modifications, nose reshaping is one of the mainstay operations. That is not only because it sits in the middle of the face but because it has distinct gender differences.

In the December issue of the journal JAMA Facial Plastic Surgery, an article entitled ‘Technical and Clinical Considerations for Facial Feminization Surgery With Rhinoplasty and Related Procedures’ was published. In this paper the authors reported on the role of rhinoplasty and other facial procedures procedures to feminize the nose to the forehead and lower face. A series of 200 consecutive male-to-female transgender patients were objectively evaluated. Frontonasal angles were measured as well as assessment by a five point nose feminization scale. In these 200 patients the mean frontonasal angle increased by a difference of 15 degrees from an average 133 degrees to an average 149 degrees. Patients considered their nose more feminine with a high satisfaction level. (4 out of 5 on the Nose Feminization Scale)

The authors also discussed how a feminizing rhinoplasty was also seen to be enhanced by changing adjacent facial structures as well with inferior lip lifts and superior brow bone reductions and forehead reshaping.

While facial feminization surgery is a compendium of a wide variety of procedures which together create an overall effect, certain of these procedures can be considered more important. Rhinoplasty and brow bone reduction/forehead reshaping would be considered the big two of facial feminization surgery given their central facial location.

frontonasal-angle-in-rhinoplastyThe difference between the male and female nose is more than just size alone. The female nose shape is more narrow, the tip is more refined and upturned (increased nasolabial angle) and the nostrils are smaller. In addition the frontonasal angle is larger and this is helped to be achieved by the effect of brow bone reduction above the radix of the nose to soften this angle. This frontonasal angle change is a critical element in a feminizing rhinoplasty.

In conjunction with forehead reshaping, the refinement of the nose can significantly improve facial gender transition. A rhinoplasty contributes significantly to making the face appear softer and more feminine.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Septal Graft Dorsal Augmentation Rhinoplasty

Saturday, December 17th, 2016

 

Augmentation of the nose can be successfully done by a variety of materials. While each  autologous and alloplastic material has their own advantages and disadvantages, one’s own cartilage will always have the superior biologic edge. While cartilage is from one’s own body and is well accepted like all other autologous grafts, it has the unique property of being relatively inert. A cartilage graft put in today will look the same when seen years later. (which is very much unlike most other autologous grafts)

The need for cartilage grafts in rhinoplasty is greatest when dorsal augmentation is needed. Significant dorsal augmentation requires substantial cartilage graft material. Of the three sources of cartilage graft harvest, only the septum offers an assured straightness which is of paramount importance in dorsal augmentation rhinoplasty.

rib-graft-rhinoplasty-intraop-dr-barry-eppley-indianapolisThe septum can be a rich source of graft material when it is primarily harvested. It is usually of adequate length in many patients and can be layered to create 3 to 4mms of dorsal height by so doing. This is usually more than adequate to meet the needs of some primary and most revisional rhinoplasty surgeries.

But once the septum has been harvested it is no longer of any value for dorsal augmentation. When really significant amounts of dorsal augmentation are need, such as in Asian and African-American rhinoplasties, an autologous dorsal augmentation will usually require a rib graft harvest.

Dr. Barry Eppley

Indianapolis, Indiana

Nasal Septal Perforation Repair

Saturday, November 26th, 2016

 

Septal perforations are a risk of any nasal surgery in which septal cartilage is removed. Whether it is done for correcting a septal deviation or harvesting a septal graft for support in rhinoplasty surgery, loss of the cartilage ‘wafer‘ between the two sides of the mucosa risks a through and through defect to occur

While not all septal perforations are symptomatic or need repair, when they do they are very challenging to do successfully. The many methods described for septal perforation repair from synthetic buttons to grafts, and their varying rates of success, speak to this challenge.

In the November 2016 issue of JAMA Facial Plastic Surgery, an article was published entitled ‘Use of Costal Perichondrium as an Interpositional Graft for Septal Perforation Closure’.  In 51 nasal septal perforation patients, the use of costal perichondrium as an interpositional graft with bilateral mucosal flaps was used for the repair. Forty-four (44) of these patients actually underwent closure with this technique which was successful in 42 patients (95%) over an 18 month followup period. Regardless of the septal perforation size treated, costal perichondrium as an interpositional graft aided in the rate of successful closure of the treated septal perforations.

While the technique and experience of the surgeon should not be minimized in the treatment of the septal perforation problem, what is it about costal periochndrium that may make it better than other autologous or allogeneic grafts? Since it requites a small chest incision to harvest it had better have some favorable biologic characteristics.

rib-grafts-in-rhinoplasty-dr-barry-eppley-indianapolisCostal cartilage is a composite structure composed of cartilage surrounded by a dense tendon-like perichondrium. Costal perichondrium is very different than nasal perichondrium because it is much thicker as it provides some mechanical benefits to the ribcage. Studies have shown that it adds up to 50% more resistance to bending forces across the costochondral junction. This stoutness means it is thick, can hold sutures if needed and be more quickly revascularized than thinner fascial or thicker cadaveric dermal grafts.  This means that it may hold up well even if the mucosal flaps break down.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Nasal Fracture Repair

Saturday, November 5th, 2016

 

nasal-bone-anatomyBackground: The nose is the most frequently fractured bone on the face. This is undoubtably because it is a very projecting structure that makes it easier to hit than other more recessed areas of the face. Even though the nose is two-thirds cartilage in composition, the small bones in the upper nose are highly prone to fracture with trauma.

While the nose can be struck from any angle, the most common cause of nasal fractures is from a side blow. The nasal bones are most frequently displaced in a lateral or side direction. Structurally this is the easiest direction for them to be displaced but also because most people turn their head to get away from the incoming force…resulting in the nose being struck from the side.

The treatment of most nasal fractures is often done acutely in the emergency room by closed reduction or delayed until a specialist is seen days to weeks later. The technique most commonly used is a closed reduction where instruments are used to push the bones back in place in a blind fashion. This can be a very successful procedure provided that the nasal derangement is not complex and involves substantial displacement of other structures such as the septum.

Case Study: This 28 year-old female was struck on the face and seen three days later with swollen and bruised eyes and an obviously deviated nose. The deflection of her nose to the right side of her nose demonstrated that the blow to her face came from the left side and probably from a right-handed assailant.

Two weeks later when most of the swelling had subsided, she underwent a closed reduction relocation of her nasal bones and an open reduction of her dislocated septum. The inwardly displaced nasal bone was moved back outward while the outwardly displaced right nasal bone was moved back inward. Through an internal hemitransfixion incision the fractured and displaced septum was removed, put back together to a resorbable PDS plate and then put back in the midline.

nasal-fracture-repair-dr-barry-eppley-indianapolisHer postoperative result six weeks later showed a straight nose, which presumably looked like it did before, and she had good air exchange through both sides of the nose.

Repair of nasal fractures is often perceived as simple but that is only so if only nasal bone is displaced. Once both right and left nasal bones are displaced the internal septal cartilage by definition is also fractured and malaligned. Treatment of such nasal fractures requires management of the septum as well as the nasal bones to get the best nasal alignment and function after repair.

Highlights:

1) Nasal bone fractures are common and usually treated by closed reduction techniques.

2) The timing of nasal fractures depends on specialist evaluation and the degree of nasal injury.

3) In complex nasal fractures with significant osteocartilaginous displacement, a delayed open nasal fracture repair is usually best.

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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