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Archive for the ‘rhinoplasty’ Category

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

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


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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