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Archive for the ‘rhinoplasty’ Category

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

Techniques in Costal Harvest in Rib Graft Rhinoplasty

Thursday, April 13th, 2017

 

The use of rib cartilage in rhinoplasty is that it provides a virtual unlimited amount of graft material. Its use is most commonly indicated for significant nasal augmentations particularly in certain ethnic noses that lack overall nasal projection as well as in major nasal reconstructions. It is probably underutilized as a donor site as many rhinoplasty surgeons may not feel that comfortable with its harvest and patients are often not enthused about its use either.

In the March 2017 issue of the JAMA Facial Plastic Surgery Journal in the Surgical Pearls section, an article was published entitled ‘Technique to Reduce Time, Pain and Risk in Costal Cartilage Harvest’. In this paper the authors describe their technique which fundamentally involves two steps for improving costal harvest in rib graft rhinoplasty. First, don’t take a full thickness cartilage graft. It is an in situ technique where the rib is sectioned longitudinally at a partial thickness level of the rib between a proximal and distal cartilage cuts. Secondly, intercostal and soft tissue injections are done using a long-lasting local anesthetic (Exparel) to decrease postoperative pain.

The risk of pleural violation and potential pneumothorax are the dreaded complications of rib harvest. But the reality is that risk varies depending upon where on the chest wall that rib is being harvested. This is a real risk above the level of rib #6 but not down at the level of ribs #s7, 8 or 9. In smaller rib grafts any form of in situ rib harvest makes it both safer and easier to do. But in larger rib graft harvests an in situ approach may not allow for an adequate graft harvest. But, when possible, it is a good technique and I have used it many times. I usually take a triangular wedge along the graft length which can more easily be cut with a standard #15 scalpel blade.

The more recent use of Exparel injections for a prolonged time period of pain relief in the early recovery phase over the traditional use of Marcaine injections has its merits. This is one of the few areas in plastic surgery that has proven to me that Exparel is truly more effective. Having done many bony rib removals for body contouring (6 or ribs at at a time) Exparel has shown remarkable effectiveness in this ‘ultimate test’ of pain relief in aesthetic surgery. Thus it would be equally useful when just one subtotal cartilaginous rib is being harvested for rhinoplasty. It has a significant cost increase over that of Marcaine in the aesthetic patient but I have never found that to be a rate limiting step for its use in any aesthetic patient.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Tip Rhinoplasty

Sunday, April 2nd, 2017

 

Background: The shape of the nose is controlled completely by the shape of the osteocartilaginous framework underneath the skin. Nowhere on the nose is this more apparent than on the nasal tip. The complex scrolled shape of the lower alar cartilages and how they meet in the middle controls the shape of the lower third of the nose.

While the size of the lower alar cartilages controls how big the tip of the nose is, their symmetry influences how uniform it looks. Tip asymmetry is one of the most common aesthetic nasal deformities. It can be caused by a variety of anatomic derangements from a caudal septal deviation, buckling of the medial footplates, dome width asymmetry and alar length discrepancy to name a few.

While many rhinoplasty surgeries treat the whole nose, it is not always necessary. A tip rhinoplasty treats just the lower third of the nose and always involves some manipulation of the lower alar cartilages. Whether it is decreasing its size, changing its projection or degree of rotation, or just correcting asymmetry, the tip rhinoplasty leaves the bony structure of the nose alone. It a cartilaginous rhinoplasty as opposed to a more complete osteocartilaginous rhinoplasty.

Case Study: This young female was bothered by the shape of her nasal tip. It was bulbous as well as was asymmetric with a noticeable bump on the left side of the done. She was happy with her bridge and the nasal profile above the tip area.

Under general anesthesia and through an open rhinoplasty approach, the lower alar cartilages underwent an asymmetric cephalic trim and was reshaped with transdomal and lateral crural spanning sutures

Her three months after surgery results showed better tip symmetry and shape and a tip profile that fit better her the rest of her nose.

Some nose reshaping procedures only need an isolated tip rhinoplasty. If the rest of the nasal profile and frontal shape of the bridge and middle vault is satisfactory then only tip work is necessary. Preoperative planning has to take into account on the patient’s profile what happens if tip deprojection is planned as this create a need to lower the entire profile up through the nasal bones.

Highlights:

  1. The cartilages of the nasal tip have the most complex anatomy of the nose.
  2. Nasal tip asymmetry occurs as a result of a discrepancy in the size or shape of the lower alar cartilages.
  3. An open rhinoplasty allows the best visual assessment and manipulation of nasal tip cartilages.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Bilateral Cleft Rhinoplasty

Friday, March 24th, 2017

 

Background: The bilateral cleft lip and palate deformity poses major reconstructive challenges. At its root cause is the shortage of tissue that has resulted from the cleft as well as scar tissue that has occurred from prior surgeries.

The bilateral cleft nose has many typical features from a wide and blunt nasal tip, an underdeveloped underlying septal support, a columellar shortage of skin and wide flaring nostrils.

A more complete rhinoplasty is done in the bilateral cleft patient during their teenage years when they are past puberty. There is some debate as to whether it should be done before or after an upper jaw advancement which is eventually needed in more than half of bilateral cleft patients. That would depend on when the jaw advancement is planned and how much forward movement is needed. But in most cases it is best done six months or longer after the LeFort I osteotomy has been done.

Case Study: This 17 year-old teenage male had multiple previous surgeries for a bilateral complete cleft lip and palate birth defect. He had completed his upper jaw surgery one year previously. He had a good occlusion and adequate upper lip support. His nose showed a strong and high dorsal line, wide nasal bones and a blunted and ill-defined nasal tip.

Bllateral Cleft Septorhinoplasty result side view Dr Barry Eppley IndianapolisUnder general anesthesia he had an open septorhinoplasty performed. The nasal bridge was lowered slightly and the nasal bones narrowed. A septal cartilage graft was used to create a strong columellar strut onto which the tip cartilages could be reshaped. The nostrils were also brought inward.

Bilateral Cleft Septorhinoplasty result oblique view Dr Barry Eppley IndianapolisBilateral Cleft Septorhinoplasty result front view Dr Barry Eppley IndianapoliosHis after surgery results show definite improvement in his overall nasal shape. But like mamy cleft rhinoplasty surgeries the result always leaves one hoping for more.

Highlights:

  1. The bilateral cleft nose poses a reconstructive challenge due to both tissue hypoplasia and tissue scar.
  2. The bilateral cleft rhinoplasty should be done after an upper jaw advancement =has been completed and healed to provide good skeletal support.
  3. The most important reconstructive element in the bilateral cleft nose is to achieve a strong columellar support onto which the nasal tip can be built.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty Dressing Removal

Friday, March 17th, 2017

 

Rhinoplasty is the most common facial reshaping procedure with a long and rich surgical history. While techniques for reshaping the nose have changed and evolved over the years, the one issue that has persisted is the need for some form of postoperative compression. It is viewed as an essential element of the surgery and can have a major impact in the final result.

The purpose of postoperative nasal compression is two-fold. The most obvious reason for its use is to keep down the swelling of the nose which will occur. Control of such swelling has great value in an operation that both sits in the middle of your face and is well known to take up to a year to fully go away. Its second purpose, and one of equal value, is to help adapt the skin back down to the reshaped osteocartilaginous nasal framework. If fluid and eventual scar develops underneath the skin, the external appearance of the nose will not show the details of how the new nasal structure actually looks.

The use of tapes and a variety of splints is applied at the end of the operation and usually maintained in placed for a week after surgery. Different types of nasal tapes and splints exist and there are no proven advantages to one method/material over another. What is important is some compression is better than no compression.

Rhinoplasty splint removal side view Dr Barry Eppley IndianapolisWhat to expect after the nasal dressings is removed is important for patients to understand. The moment the nasal dressing comes off is not a ‘TV’ moment. This is not the final result and the recovery process is not over. The nose has been maximally compressed and, while it may show some positive changes and almost always does, the nose is still distorted from swelling and compression.

Rhinoplasty Splint Removal front view Dr Barry Eppley IndianapolisOnce the rhinoplasty dressing is removed one can expect some rebound swelling to occur since it is not longer compressed. It will swell up a little bit and the nose may look somewhat bigger and puffy. It will take another one month or so until the nose starts to look as ‘small’ as it did when the dressing was removed. How soon this occurs depends on the natural thickness of one’s nasal skin. The final outcome of the nose shape awaits a full sic to twelve weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Hanging Columella Correction Rhinoplasty

Sunday, March 12th, 2017

 

Background: The columella is the strip of skin and cartilage between the nostrils. It provides a smooth connection between the tip of the nose and the upper lip. Its shape is controlled by the cartilages which run within the skin as well as the septum behind it. A ‘good’ columella is really one that does not stand out in any way and sits obscurely at the bottom of the nose. A ‘bad’ columella is one that is noticeable either because it is deviated or sticks out too far.

The hanging columella is when it extends down to far, creating exaggerated columellar show. This is most noticeable in the profile view where too much of it is seen and sits too far below the rim of the nostrils. It can occur as a natural result of nasal growth with a long septum that pushes it too far forward. The medial footplate cartilages that compose it can also be too long or wide.

The hanging columella can also result from a prior rhinoplasty where the medial footplate cartilages have been overly weakened, making them prone to bending or notching. (and a columellar strut has not been used) Conversely it can also be caused by a columellar strut graft that has become or was placed too far forward.

Case Study: This 52nyear-old female presented with a columellar protrusion that had developed from an open rhinoplasty several years before. She felt it look like something was hanging out of her nose all the time.

Hanging Columellar Rhinoplasty correction side view Dr Barry Eppley IndianapolisUnder sedation and local anesthesia and using her existing columellar scar for access, the protrusive medial foot plate cartilages were trimmed. They were then used as a miniature columellar strut graft to support straightening using suture plication.

Hanging Columella Rhinoplasty result submental view Dr Barry Eppley IndianapolisHanging Columella Rhinoplasty correction result front view Dr Barry Eppley IndianapolisHer three months after surgery result showed elimination of the protrusion, a smooth curve in profile and a straight columella. While many isolated hanging columellas can be treated without an open approach technique, her prior rhinoplasty surgery made the decision to do so create a more assured and complete correction.

Highlights:

1) A hanging columella can occur from either natural nasal growth or from a prior rhinoplasty.

2) The hanging or protrusive columella that results from a prior rhinoplasty usually causes a columellar deviation and notching.

3) The revision rhinoplasty columellar correction removes the excessive medial footplate cartilage and straightens and stabilizes it with sutures.

Dr. Barry Eppley

Indianapolis, Indiana

ePTFE-Coated Silicone Nasal Implants

Monday, February 6th, 2017

 

ePTFE (expanded polytetrafluoroethylene) offers a facial implant material that is very biocompatible and also induces some tissue adherence. Due to the microfibrillar nature of its surface, ePTFE has some surface porosity where fibroblasts can attach and induce collagen attachments. ePTFE, however, does not come in any solid preformed facial implants and they have to be hand carved during surgery out of a block of the material.

For nasal implants, ePTFE offers a fairly easily and quick carving to get the desired length and shape. But it would still be preferable if a performed version of an ePTFE nasal implant existed.

ePTFE Composite Nasal Implant Dr Barry Eppley IndianapolisIn the February 2016 issue of the Annals of Plastic Surgery, a paper was printed on this very topic entitled ‘Silicone-Polytetrafluoroethylene Composite Implants for Asian Rhinoplasty’. Over a four year period, 177 Asian patients underwent rhinoplasty using a dorsal composite nasal implant.  (about 2/3s primary rhinoplasty and 1/3 secondary rhinoplasty) The average dimenions of the ePTFE coated silicone nasal implants was 1.5 to 5 mm thick and 3.8 to 4.5 cm long. Autologous cartilage was used for tip coverage in every case. Glabellar augmentation was also performed in 11% of the  patients.

There was an 11% complication rate which included implant malposition/deviation (5%), persistent redness (2%) and actual infection. (1%) There were no cases of extrusion. There was a 9% revision rate either due to malposition or inadequate dorsal height from the patient’s perspective. There were no complication differences between use of the implant in primary or secondary rhinoplasty.

The use of an implant, whether it is solid silicone or solid ePTFE, are mainstays of Asian rhinoplasty. They both havge their own distinct advantages and disadvantages…silicone offers a performed shape while ePTFE offers some tissue adherence. Silicone-polytetrafluoroethylene (PTFE) composites have a silicone core and a thin ePTFE coating. They appear to offer the advantages of silicone and ePTFE in a single implant. Despite that they have been around now for several years, there have been no published reports in them.d alternatives for rhinoplasty because of a lack of relevant reports. This clinical study shows that the short-term ouotcome is similar to that of ePTFE alone and can be effectively used for both primary and secondary augmentation rhinoplasty in Asians.

One of the keys to the use of any nasal implant is to keep it from putting too much pressure on the nasal tip skin. Thus the use of a cartilage graft over the tip area.

Dr. Barry Eppley

Indianapolis, Indiana

Improving Closed Reduction of Nasal Fracture Outcomes

Wednesday, February 1st, 2017

 

The broken nose is the most common facial fracture and references to its treatment date back a thousand years. It is usually viewed as a simple problem that is easily fixed by  trying to push back into place the displaced nasal bones. But the reality is that nasal fractures are underdiagnosed and untreated and there is a much higher incidence of secondary deformities from them that is appreciated.

In the January 2017 issue of the journal Plastic and Reconstructive Surgery a paper on this topic was published entitled ‘Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity’. In this paper the authors looked retrospectively at 90 patients who underwent closed reduction of nasal fractures over a seven year period using a standard protocol. Postoperative deformities occurred in 16% of them with persistent displaced nasal bones and avulsion of the upper lateral cartilage as frequent secondary deformities.

Nasal fractures can be classified into four categories; type 1 unilateral bone fracture, type 2 bilateral nasal fractures, type 3 comminuted bone fractures and 4) combined nasal bone and septal fractures. Making the proper diagnosis is important and types 1 through 3 can be treated by closed reduction only. But a type 4 nasal fracture may require more of an open approach. Treatment of nasal fractures by closed reduction can be done under local anesthesia but many patients will find it more comfortable and better results may be obtained under deeper forms of anesthesia.

Closed Reduction Nasal Fracture Dr Barry Eppley IndianapolisThe closed reduction protocol initially consists of initial mucosal vasoconstriction with Afrin packing. The Boies straight elevator is used as a bimanual technique for elevation and repositioning the nasal bones. The Asch straightening forceps is used reposition the deviated septum followed by septal splinting. Once nasal bone and septum displacements have been reduced, nasal packing with vaseline gauze is done. Externally the nasal bridge is taped and splinted. Because of the nasal packing patients are placed on oral antibiotics. The nasal packing is removed by 3 days after surgery. The tapes and splint are removed after one week.

The closed treatment of nasal fractures is not complex. But it is also not as simple as just ‘popping the bone(s) back in place’. Most nasal fractures don’t have just one large piece of bone displaced, the bone fractures are typically comminuted. A more through bimanual reduction and applied support afterwards helps reduce the historic high incidence of secondary deformities and the need for further nasal surgery.

Dr. Barry Eppley

Indianapolis, Indiana

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


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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