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Archive for the ‘rhinoplasty’ Category

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

OR Snapshots – Rhinoplasty with Septal Cartilage Graft

Thursday, October 27th, 2016

 

One of the fundamentals principles in rhinoplasty is the use of cartilage grafts. Since much of the nose is composed cartilage, its reconstruction or aesthetic augmentation is often done using cartilage grafts. There are three harvest sources of cartilage in rhinoplasty including the nose itself (septum), the ear and the ribs.

The septum is the most frequently harvested cartilage site because of its proximity and that it offers perfectly straight grafts. Septal cartilage grafts are not only straight but have significant structural rigidity. This makes them easier to shape and carve and apply to a wide variety of nasal implantation sites.

rhinoplasty-with-septal-cartilage-graft-dr-barry-eppley-indianapolisAugmentation of the dorsum of the nose is commonly done for aesthetic augmentation or correction of saddle nose deformities due to either trauma or prior rhinoplasty surgery. Septal cartilage grafts are perfect for dorsal augmentation because they are straight and can be precisely shaped. As long as one has not had a prior septoplasty it is the preferred cartilage donor site. It can offer more than an adequate amount of graft material to perform most dorsal augmentations.

This is an example of a male patient who had an over resected dorsum from a rhinoplasty that included a large hump reduction. A male that has a concave dorsal line dos usually find that to be an aesthetically pleasing nose. His original surgeon performed a nasal bone augmentation using ear cartilage. The middle vault down to the tip was left ungrafted and created a significant indentation. His septum has never been used as a cartilage donor site and served as a perfect donor site to use all the advantages of the septal cartilage for dorsal augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Injections for Nasal Contractures

Sunday, October 2nd, 2016

 

Rhinoplasty using an implant for augmentation is most commonly done around the world on Asian patients. With such large numbers of noses being implanted, it is inevitable that a certain percentage of complications will arise from their use. This is usually manifest as infection requiring implant removal. The sequelae of this process is a nose that has developed thick scar tissue that ultimately must be released/excised in a subsequent revision rhinoplasty. In more significantly affected cases the nose becomes severely contracted due to involvement of both the skin and the underlying cartilage framework.
In the September 2016 issue of Plastic and Reconstructive Surgery, an article was published entitled ‘Correction of Severely Contracted Nose’. In this paper the authors report on 59 patients with severe nasal contractures that were treated by adipose-derived stromals cell to soften the nasal skin prior to revision rhinoplasty. The total injection volume was 0.5ml with cell counts of 10,000,000/ml. The lower alar cartilages were released from the scar for advancement with rib grafts used mainly for the cartilage graft reconstruction.
Over an average 10 month followup period, 86% (51 out of 59) of the patients were satisfied with their result. Two patients (3%) subsequently developed infections and cosmetic issues arose with the cartilage grafts in eight patients. (14%) Nine of the patients (15%) need secondary injections into the tip of the nose.
When an implant needs to be removed from the nose due to infection, the question is when should revisional surgery be performed. There is no consensus as to when that should be when the infection appears to be cleared.
fat-injections-to-the-nose-dr-barry-eppley-indianapolisRather than waiting until the nose becomes scarred and contracted down a good argument can be made for early soft tissue intervention. In this paper stromal cell concentrates were used. Other surgeons, as have I, use concentrated fat grafts. Whether one injectate is better than the other is not currently known. For the purposes of cost concentrated fat injections would be preferred. In either case the goal is to soften scar tissue and improve the overall health and vascularity of the nasal skin envelope in preparation for secondary cartilage grafting.
Dr. Barry Eppley
Indianapolis, Indiana

Technical Strategies – Nasal Base Fixation

Monday, September 26th, 2016

Smiling is the single most important facial expression. It takes a lot of facial muscles to smile and their pull causes surrounding facial structures to move beyond that of just the lips. The superiorly positioned nose can move when one smiles as the upper lip elevates. The flexible tip of the nose is what can change at either the tip or the nostrils.

nasal-base-retraction-with-smilingWhile nasal movement with smiling is usually regarded as incidental and not aesthetically bothersome, there are certain nasal movements that can be. The most common is the downturning of the nasal tip caused by a hyperactive depressor septi muscle. The more rare adverse aesthetic movement is an undesired elevation of the base of the nostrils. This is an upward and inward movement of the nostrils where they attach to the face. This is caused mainly by the quadratus labii superioris muscle.

This muscle has two portions, the medial and lateral heads. The medial head is known as the levator labii superioris alaeque nasi muscle. This slip of the muscle originates from the frontal process of the maxilla and comes downward to insert into the alar cartilage and the skin of the nostril attachment to the face. (another slip of the muscle goes on to insert into the upper lip. Since muscles pull towards their origins it is this action that pulls the base of the nose upward.

Counteracting the action of the legator labii superiors alaeque nasi muscle can be done by disinsertion of the muscle from the nose. But to be absolutely certain that the action of the muscle is countered an addition technical maneuver can be helpful. Securing the base of the nose in a downward direction to the bone provides a point of fixation that can resist any residual muscle action.

nasal-base-fixation-technique-dr-barry-eppley-indianapolisintraoral-nasal-base-fixation-technique-dr-barry-eppley-indianapolisThis is done by a bone anchoring technique to the pyriform aperture. Using a permanent 4-0 Tevdek suture attached to a 1.5mm x 5mm titanium microscrew, the anchor is initially placed into the bone through a small intraoral incision. The needle of the suture then takes a bite of tissue just under the nostril attachment. The suture is tied down loosely, making it tight but not cinching it down enough that it pulls the nostril inward.

This intraoral bone anchoring technique provides firm fixation to prevent the nasal base from pulling upward when smiling. It is a useful adjunct to muscle release and provides a two-way approach to the nasal animation problem.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Thick Skinned Revision Rhinoplasty

Monday, September 19th, 2016

 

Background: Rhinoplasty involves changing the nasal shape through changes in the underlying bone and cartilage support. The only location for skin removal in a rhinoplasty is when the nostril width is reduced through various patterns of tissue excision.Thus in the large nose any reductive efforts and their results are heavily impacted by how well the overlying soft tissue shrinks down and around the reduced structural framework. This is also why in any rhinoplasty it may take up to a year to see the final result as the skin adaptation process can take this long to fully occur.

In the thick skinned nose, regardless of ethnicity, it can be a real challenge to achieve the rhinoplasty results many such patients want. This is particularly true when the overall goal is to make the nose smaller and have a more refined shape. This challenge is magnified when the patient has already had prior rhinoplasty surgery. The best chance for the nasal skin’s ability to shrink down is the first time before scarring forever limits what can occur with subsequent manipulations.

Case Study: This 35 year-old female presented with a history of two prior rhinoplasties by another surgeon. It was not clear what changes were done inside the nose but she felt that her nose was actually bigger after these two efforts than before any surgery was done. Her initial and revision rhinoplasties were done 15 and 9 months previously.

thick-nose-revision-rhinoplasty-result-front-view-dr-barry-eppley-indianapolisUnder general anesthesia an open rhinoplasty was performed. The nasal skin in the tip area was defatted and scar tissue removed. The lower alar cartilages were completely sewn together up to the middle vault without any evidence of resection. The lower alar cartilages were separated and releases, cephalic resections done and reshaped by dome suturing after the placement of a septal columellar strut cartilage graft. Nasal osteotomies were also performed.

thick-nose-revision-rhinoplasty-result-oblique-view-dr-barry-eppley-indianapolisthick-nose-revision-rhinoplasty-result-side-view-dr-barry-eppley-indianapolisHer results at just six weeks after revision rhinoplasty already show improvement in nasal shape even at this early postoperative time period. Further healing over the next year should continue to favorably improve the shape of the nasal tip.

The thick skinned revision rhinoplasty is a challenge and there are limits as to how much further improvement can be obtained. Thinning out the soft tissues of the nasal tip and proper supportive nasal tip cartilage reshaping can offer some improvement over prior rhinoplasty efforts.

Highlights:

1) The thickness of the nasal skin in any form of rhinoplasty poses limitations as to the quality of results seen.

2) Revision rhinoplasty in the thick skinned nose poses significant challenges in getting a smaller and more refined nasal shape result.

3) Defatting of the nasal tip and avoiding over resection or over plication of the lower alar cartilages can provide some narrowing of the thick skinned nose.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Rhinoplasty for the Pinocchio Nose

Thursday, September 1st, 2016

 

Background: The long protruding nose is well known in rhinoplasty and has been referred to as the ‘Pinocchio Nasal Deformity’. Such a description has been cited in plastic surgery articles all the way back to 1974. More anatomically described as an over projecting nose, it is the result of an elongated cartilaginous framework from the septum and lower alar cartilages. These three cartilage structures merge at the nasal tip making the lower third of the nose look way out of proportion to the nose and face behind it.

The correction of the Pinocchio nose was originally described by a radical tripartite cartilage excision of the nasal tip and the subsequent reduction of the nose above it to fit the new tip position. In essence this means that the the tripod cartilage unit at the end of the nose is resected and set back. This may or may not involve some degree of tip rotation. Once the nasal tip is set back it often becomes evident that there is a nasal hump above the new lowered dorsal line that also needs to be addressed.

While cartilage and bone can be reduced and reshaped, the same can not be said for the skin. What happens to the now excessive skin depends on its natural ability to shrink back down to a smaller underlying supportive cartilage framework. Fortunately in many case of the over projecting nose the skin is thinner and does this fairly well. But thicker nasal skin patients may not have the same soft tissue response.

Case Study: This 43 year-old female presented for rhinoplasty surgery. She had a very long and thin nose that also had significant tip asymmetry due to buckling of the tip cartilages.

Pinocchio Nose Rhinoplasty result side view Dr Barry Eppley IndianapolisUnder general anesthesia and using an open rhinoplasty approach, the caudal end of the septum was resected and the lower alar cartilages shortened by a dome division/resection technique. The septum was straightened and cartilage grafts harvested. The now apparent nasal hump was reduced and middle vault spreader grafts placed.

Pinocchio Nose Rhinoplasty result oblique view Dr Barry Eppley IndianapolisPinicchio Nose Rhinoplasty result front view Dr Barry Eppley IndianapolisAt one year after surgery the dramatic improvement in the appearance of her nose could be appreciated. It is not an ideal result as there remains some residual fullness and asymmetry on the left side of the nasal tip.

The over projecting nose illustrates what happens when the cartilage structure of the nose becomes overgrown. Driven by the midline septum, the growth center of the nose, its elongated development drives the upper and lower alar cartilages with it. This creates the Pinocchio nose deformity.

Highlights:

1) The pinocchio nose deformity is the result of an elongated septum and long lower alar cartilages.

2) Shortening the long nose requires cartilage reduction and tip reshaping manuevers to pull the nose back toward the face.

3) How much shortening the nasal tip that can be obtained partially depends on how well the overlying skin shrinks down to the shortened cartilage framework.

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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