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Archive for the ‘technical strategies’ Category

Technical Strategies – Pennant Corner of Mouth Lift

Sunday, February 26th, 2017

 

The lips play a major role in the appearance of the lower third of the face. Their size and shape gives indications of gender, expression and age. The lips are well known to be affected by age with thinning of the amount of vermilion show, lip lines and downturning of the corners of the mouth. The inversion of the smile line is caused by the overall southern slide of the facial tissues from the cheeks down to the jawline. This pushes the sides of the mouth downward while the central portion of the lips remains stable.

The correction of downturned mouth corners to a more horizontal position is done by a corner of mouth lift procedure. This is a rather old anti-aging mouth procedure that employs a wedge of skin excision just above the downturned mouth corner. In a triangular or heart-shaped pattern, the removed skin allows a place for the depressed  mouth corner to be elevated and inset. While effective it leaves an incision line on the skin that trails away from the mouth corner in the direction of the ear.

Pennant Corner of the Mouth Lift Dr Barry Eppley IndianapolisI have never liked this resultant skin scar from the traditional corner of mouth lift. As a result I have devised a new variation of this operation that eliminates this skin scar. The excision pattern is done using a ‘pennant’ skin excision/incision line pattern. The skin above the mouth corner is removed in a triangular pattern but there is an incision line that goes down along the lower lip vermilion-cutaneous junction. This allows the corner of the mouth to be excised and the mucosal mobilized. A wedge of orbicularis muscle is also removed and sutured upward to create a deeper corner of the mouth elevation. The corner of the mouth is then elevated and inset into the skin removal site.

Corner of Mouth Lift result front viewCorner of Mouth Lift result Indianapolis Dr Barry EppleyThis mouth corner mucosal transposition flap effectively raises the mouth corner but keeps all the incision lines at the vermilion-cutaneous junctions. It does lengthen the horizontal smile line a few millimeters per side but this is often an aesthetic benefit. If one so desires the mouth corner can be elevated even higher above the traditional horizontal level into a more upward turn. (lip curls)

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Intraoral Chin Implant Placement

Wednesday, February 1st, 2017

 

Chin augmentation through the use of an implant is an historic procedure that dates back over fifty years and is still commonly performed today. It is typically done with a silicone chin implant due to its wide variety of styles and sizes and its smooth surface which facilitates its insertion and placement.

A chin implant can be inserted from either above or below the chin, each with its own distinct advantages and disadvantages. The submental or under the chin technique uses a  skin incision to access the chin bone to make the subperiosteal pocket. It has the advantage of not disrupting the origin of the mentalis muscle attachments, has a lower risk of potential implant contamination and ensures a more desired lower implant position on the bone. Its lone disadvantage is the concern about the scar appearance which usually heals very well. It is the more commonly use chin augmentation technique.

The intraoral chin implant technique approaches the chin bone from above. Its lone advantage is that it is a scarless chin augmentation. It has to disrupt the mentalis muscle bone attachments to create the subperiosteal pocket down to the bottom of the chin bone. Without  screw fixation there is a risk of the implant sliding upward towards the direction from whence it was placed after wound closure. In theory it is the more contaminated approach although there are no studies that validate the intraoral approach is associated with a higher rate of infection than the submental route.

Intraoral Chin Implant placement Dr Barry Eppley IndianapolisOne technical strategy in using the intraoral route for implant placement is to use a vertical muscle splitting approach. Rather than disrupting the complete mentalis muscle attachments through a horizontal degloving incision, the muscle is split vertically below its attachment point and the subperiosteal pocket created in a more blind instrumented fashion. The implant can then be inserted and rotated into position and secured in the desired location.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Buccal Fat for Lip Injections

Tuesday, January 31st, 2017

 

Lip augmentation by injections is one of the most common injectable filler treatments of the face. It has been done since synthetic collagen fillers were introduced way back in 1981. Since then many different injectable filler materials have been used but the ideal lip augmentation material remains as yet undiscovered.

Fat would seem to be an ideal soft tissue injection material given its autologous source and as a natural part of many soft tissue sites. Its main disadvantage is how well it survives the transplantation process which is highly variable. Of all areas of the face into which fat is transplanted the lips are known to have a low rate of success. There are no proven reasons why this is so but it has been conjectured that the high movement and distortion of the lips contributes to injected fat absorption. It could also be that there is little natural fat in the lips and that makes it a poor recipient bed.

Buccal Lipectomy intraop Dr Barry Eppley IndianapolisThe donor source of the fat for lip augmentation may also be a contributing factor. Most fat harvests are taken somewhere on the trunk, usually the abdomen or the inner thighs. Whether this is optimal fat for facial transplantation us unknown. This is ‘body’ fat which may not be ideal for use in the face but it does offer convenience and a relatively large supply. Another option for lip augmentation is the buccal fat pad. It offers more than enough fat for the lip  and is easily harvested through an intraoral approach.

Buccal Fat Pad Lip Injections Dr Barry Eppley IndianapolisSince the buccal fat pad is a solid source of fat rather than obtained by liposuction, its use  as an injectable source of fat may be overlooked. But the buccal fat pad can be sectioned into small pieces and placed into a syringe. Between two connected syringes it can be passed back and forth to create a more injectable consistency.

Whether buccal pad survives better in the lips is not known although in my fat injection lip augmentation experience it does. Its only drawback is that there has to be an aesthetic reason to harvest the buccal fat pads so no adverse facial effect is seen.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Interlocking the Custom Wrap Around Jawline Implant

Monday, January 16th, 2017

 

A custom wrap around jawline implant offers an unparalled approach to jawline augmentation. Made from a 3D CT scan it is designed to provide varying amounts of chin and jaw angle dimensional changes that are connected as a single piece implant. Because it is one larger implant it usually has to be placed through a three-incisional technique, one around the chin and the other two intraorally back by the jaw angles.

Because each incision is much smaller than the length of the implant, the sides of the implant must be initially introduced through the chin incision. The sides of the implant are then fed through the side tunnels back into the jaw angle area. The flexibility of the implant permits such a placement technique through the comparatively small incisions.

The ability to thread a custom wrap around jawline implant from front to back depends the size of the jaw angle portions. If the back portion of the implant is fairly big, trying to pass it through a subperiosteal tunnel below the mental nerve risks a stretch or tear injury to it. In these implant sizes it is better to split it in the middle and thread it from back to front. The smaller chin portion is safer to pass under the mental nerves.

Custom Jawline Implant modification Dr Barry Eppley IndianapolisReuniting the split custom wrap around jawline implant in the midline once positioned can be done with sutures or screws. Getting two vertically split midline implant sections perfectly together can be challenging. An alternative strategy is to create an interlocking connection down the midline when the implant is sectioned.

Custom Jawline Implant Re-assembly Dr Barry Eppley IndianapolisWhen reuniting these interlocking midline segments, like lenticular puzzle pieces, the precision of the implant design is re-established over the chin.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Stacked Jaw Angle Implants

Sunday, January 8th, 2017

 

Jaw angles implants are designed to add size and shape to the mandibular ramus area. They are a companion and complement to the more commonly performed and well known chin implant. Together chin and jaw angle implants create a complete jaw augmentation approach.

While selecting the style and size of chin implants is fairly easy, doing so with jaw angle implants is not. Since the chin is a projecting structure on the edge of the jaw, the amount of horizontal projection is frequently the most important dimensional consideration. This is both easy to see, measure as well as perform computer imaging. Jaw angle implants, however, are not an edge enhancement procedure. Rather they provide augmentation to the side of the jaw/face where measurements and even computer imaging is harder to do in a reliable fashion.

Because of the more imprecise nature of jaw angle implant size selection, it is very helpful to be prepared during surgery with multiple implant sizes. Most of the time standard sizes will work (small, medium and large) but this is not always the case. How an implant looks in place can be less than what one would anticipate and there is always the issue of asymmetry which is very common in the jaw angle area.

stacked-jaw-angle-implants-technique-dr-barry-eppley-indianapolisIf necessary it is always possible to stack jaw angle implants together to create the desired augmentation effect. Unlike many other facial implant types, angle implants fit together fairly well… a little bit like nesting dolls. Some trimming does need to be done but the implants can be stacked fairly securely. This will increase the width of the jaw angle augmentation over what any one single implant can do.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Hairline Approach to Temporal Implants

Thursday, September 8th, 2016

 

Temporal implants offer the only method of permanent temporal augmentation…that is also easily reversible. Placed in the subfascial plane on top of the anterior temporalis muscle, there is no risk of facial nerve injury nor visible edges of the implant.The skin incision to place them is done back behind the temporal hairline so it is easily hidden in the hair. This also provides an easy point of access to the subfascial plane.

But one can also place temporal implants through a hairline incision as well. I recently had a patient who came in for a variety of facial procedures including temporal implants. She happened to have had a facelift by another surgeon where a hairline incision was carried away from the ear up along the front edge of the temporal hairline. Thus an existing temporal hairline scar was present.

hairline-approach-to-temporal-implants-intraop-1-dr-barry-eppley-indianapolisHer temporal implants were placed through the anterior hairline scar. A 3.5 cm length of the scar was opened and the deep temporalis fascia exposed. The fascia was opened and a subfascial pocket developed to the lateral orbital rim anteriorly, the zygomatic arch inferiorly and just below the anterior temporal line superiorly.

hairline-approach-to-temporal-implants-intraop-2-dr-barry-eppley-indianapolisBecause she wanted a more complete temporal augmentation, a standard temporal implant was turned into a vertical orientation. The implant was slipped into the pocket with the back edge of the implant easily seen given the anterior incisional access used.

hairline-approach-to-temporal-implants-intraop-3-dr-barry-eppley-indianapolisThe fascia, dermis and skin were then closed with dissolveable sutures. This leaves her with the same hairline temporal scar that she already had.

While the hairline or pretrichial approach to temporal implants does place the fine line scar in a more visible location, it does have several advantages. It offers easier access to the subfascial pocket and allows visible assessment of the implant placement. Because there is less tissue disruption than when the incision is placed further back in the temporal hair, the procedure is also less ‘traumatic’.

For the properly selected patient, the hairline approach to temporal implant placement could be a preferred technique.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Parietal Eminence Skull Reduction

Thursday, September 8th, 2016

The reduction of skull lumps and bump is a not uncommon request in skull reshaping surgery. Raised areas of the skull can occur for a variety of reasons although the most common is congenital, being just the way that the skull formed.

One unique type of skull lump is not really a lump at all. Known as the parietal eminence it develops from the parietal bone. This skull bone is situated on the sides and roof of the skull, is quadrilateral in shape and has four borders and four angles. Its external shape is convex and near its center is the parietal eminence from which it is formed by ossification. This ossification process begins about the eighth week in utero and gradually extends outward in a radial pattern from the eminence to the margins of the bone.

Because the parietal eminence is the epicenter of the parietal bone it can appear as a prominent bump. Roughly the size of a quarter it can discerned in oblique profile views and, even with hair, can be easily palpated.

parietal-eminence-reduction-by-burring-dr-barry-eppley-indianapolisParietal eminence skull reduction is a form of ‘spot’ cranioplasty. Using a handpiece and drill the prominent high spot of the bone can be satisfactorily reduced. In doing so there are two key components of the procedure. The first important technique is how the bone is reduced. A small skull problem deserves a small incision. Using a high speed handpiece and burr around hair through a small incision runs the real risk of getting hair entangled and pulled out  by the rotation of the burr. Guarding the full length of the burr with a rubber guard allows a smooth reduction to be safely done without risk of hair injury.

parietal-eminence-reduction-incision-dr-barry-eppley-indianapolisWhen making an incision for parietal eminence skull reduction, the incision need to be vertical in orientation and only about 4.5 cms long. But rather than just a straight line, it is aesthetically better to create an irregular zigzag line with a few sharp angles placed between the visible hair shafts. This allows the incision to heal amongst the hair in the most inconspicuous manner.

Parietal eminence skull reduction is a very effective procedure that can be done with limited scalp and hair trauma that leaves an inconspicuous scar.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – The Versatile Temporal Implant

Sunday, May 8th, 2016

 

Augmentation of temporal hollowing has become a popular aesthetic procedure. While synthetic fillers and fat offer simplicity, they do not create a permanent treatment solution. Temporal implants fill that need and can be placed through a relatively minor surgical procedure.

Temporal Implant Design Dr Barry Eppley IndianapolisThe first generation standard temporal implants are of a soft flexible silicone material that is designed to simulate muscle tissue. It has a shape that simulates the lateral orbital rim anteriorly, the zygomatic arch inferiorly and then tapes superiorly and laterally into a tapered edge. It is longer horizontally than vertically and is designed to treat the deepest part of temporal hollowing which is at the lower half of the anterior temporal region between the eye and the temporal hairline.

Temporal Implants modifed use Dr Barry Eppley IndianapolisBut some patients have temporal hollowing that extends up higher and desire a temporal augmentation effect that is vertically longer. In these cases the standard temporal implant can be rotated 90 degrees so that it is placed with the longer horizontal part vertically and the vertical part horizontal. It is also important that the right and left temporal implants be switched when making this implant re-orientation. In other words, a right temporal implant is used on the patient’s left side that is rotated 90 degrees in orientation n the left temporal hollow.

The standard temporal implant offers some versatility in how it can be used to create its temporal augmentation effect. In the subfascial location, it offers two options for the extent of its effect based on how the implant is oriented.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Diced Rib Graft Injection in Rhinoplasty

Tuesday, April 12th, 2016

 

Primary or secondary correction of nasal bridge deformities is now well known to be corrected by injectable fillers. The use of hyaluronic acid-based (HA) injectable fillers provides a quick and very directed approach to a wide variety of nasal contour deformities. While effective, no HA filler to the nose provides a permanent contour correction in the vast majority of patients.

I have run across a handful of patients that stated they had gotten one HA injection to the nose years ago and the result was sustained. But it is hard to know whether this is merely cosmetic accommodation or was indeed a ‘permanent’ result. I suspect that of the nasal contour issue was significant, such a permanent result would not have been seen. I know from injecting a lot of dorsal hump patients with HA fillers to camouflage it (placing filler above the hump to create a straight dorsal line) that such filler volumes are not sustained in the nose.

Diced Rib Graft Injection Preparation Dr Barry Eppley IndianapolisAn alternative and permanent options for larger primary or secondary dorsal line defects is that of a diced cartilage graft injection. This is a concept that, while injected, must be differentiated from that of HA filler injections. This is where cartilage grafts from either the septum, ear or rib are processed to make them injectable. This is done by cutting (dicing) them into small 1 x 1mm cubes (or smaller) and placing them into an open barrel 1ml syringe.

Diced Rib Graft Injection Preparation 2 Dr Barry Eppley IndianapolisThrough an intranasal (intercartilaginous) incision, a tunnel is made on the dorsum up onto the upper dorsal defect area. (frontonasal junction, radix, nasal sidewall) The syringe is introduced and the compressed cartilage grafts are injected in the desired amount and shaped externally. The grafted area is taped to hold the desired shape for 7 to 10 days.

While many diced cartilage are traditionally wrapped in surgical or fascia, there is a role in smaller nasal dorsal defects for direct injection of the cartilage. The small nasal tunnel and confinement of the syringe allow the cartilage particles to be precisely delivered.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Large Skull Reduction

Saturday, April 2nd, 2016

 

skull layersWhile there are many different types of skull reshaping surgeries, the most limiting is the desire to have an overall smaller head. Because of the skull’s thickness, there are limits as to how much of the skull thickness that can be reduced. While there are great variabilities in the thickness of the human skull, safe reduction is limited to removal of the outer cortical layer. The skull is exactly like an Oreo cookie with three layers, two outer hard layers (cortex) and an inner softer marrow layer. (diploic space) For reasons of brain protection and bleeding, aesthetic reduction should go no further than the outer layer of the ‘cookie’.

The typical outer coretx of the skull is anywhere, on average, from 4 to 7mms thick in humans. This thickness is affected by gender, age and ethnicity. While reduction of such a  ‘limited’ amount of skull thickness may not seem like much, it can appear much bigger than one would think when a broad surface area of it is removed. This is particularly true across the top of the skull between the temporal lines and in the forehead and back of the skull. Reduction along the sides of the skull is more greatly impacted by muscle reduction than it is by bone removal.

When doing large skull reduction areas, a burring technique is used as the most efficient and safest bone removal method. Burring allows for a controlled bone removal method so one can judge how when one is getting close to the diploic space of the skull. But when burring large skull areas it can be difficult to get it perfectly smooth and even across its convex surface. The procedure is also tedious and time consuming.

Skull Reduction technique 1 Dr Barry Eppley IndianapolisSkull Reduction surgical technique 2 Dr Barry Eppley IndianapolisThe technique that I have developed for large skull reductions is a ‘checkerboard’ method. A horizontal cut with a burr is first made to establish the depth of the reduction from one temporal line to another. Then additional horizontal lines are made over the desired skull reduction area. Then vertical burr cuts are also made to create a grid or checkerboard appearance.

Skull Reduction surgical technique Dr Barry Eppley IndianapolisSkull Reduction surgical technique 4 Dr Barry Eppley IndianapolisThis checkerboard skull pattern then allows one to reduce each individual square sequentially. This helps ensure that the overall bone reduction is done as even as possible and allows one to do it faster and very safely. Always knowing where the diploic space is located gives the surgeon better control of the bone being removed.

Any large skull reduction done for aesthetic purposes is accomplished by removing the outer cortex through bone burring. This checkerboard technique allows for both precision and safety.

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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