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Archive for the ‘rhinoplasty’ Category

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

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


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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