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Archive for the ‘technical strategies’ Category

Technical Strategies – Intraoperative Positioning Guides for Custom Jawline Implants

Sunday, February 18th, 2018

 

Custom jawline implants offer an unparalleled ability to reshape the entire jawline and the lower face. Combining chin and jaw angle augmentation in a connected fashion can have a powerful effect given the surface area of the lower jaw that it covers. Because of this surface area coverage even small amounts of implant thickness create an external shape change that is more than I would think.

While the appeal of such a lower jaw implant is obvious, it is not a perfect technology. The design process remains subjective since the software can not yet tell us how to design the implant to achieve any patient’s specific desired look. The surgeon must provide that information to the best of his/her ability and hope the implant’s shape and various thicknesses throughout achieve what the patient wants.

In addition to design considerations, just because an implant is custom designed for the face does not mean that its surgical positioning will match exactly how it was designed to fit on the bone. While this is one of the obvious surgical goals, there is always the chance of implant malposition. Custom facial implants are not like Lego blocks, they do not snap fit together. (I wish they did as it would make the surgery a lot easier) The surgeon still has to place a smooth slippery implant on a smooth bone surface under indirect vision.Through small incisions and pockets that are not fully visualized, the surgeon must position the implant. This is a lot harder to do than how the implant design appears on the 3D skeletal model.

In some patients who have had prior osteotomies (sagittal split ramus osteotomy and sliding genioplasty), the indwelling hardware is actually very helpful. The implant can be designed around or over the hardware which serves as an intraoperative guide for its surgical placement as this hardware is always seen through the incisions.

But most patients don’t have these handy intraoperative guides. As a result it is very helpful to incorporate some intraoperative positioning guides on the implant’s design. I do this by making an extended tab of material that goes up to the ascending ramus opposite the 2nd/3rd molar teeth. Since this can easily be seen through the posterior vestibular incision, it provides a guide as to how the posterior and inferior aspects of the angle portion of the implant is positioned in the bone. (since this part of the implant can not be seen)

Once the custom jawline implant is positioned and secured his tab of material can be removed. It is always best to have any implant material as far removed from being directly under the incision as possible.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Geometric Broken Line Scar Revision of Complex Facial Scars

Friday, February 9th, 2018

Background: Scar revision is an inherent part of plastic surgery and is one of its most recognized and historic procedures. While scars occur all over the body, those on the face are the most frequently and successfully improved by various scar revision techniques. While there is a role for the more simpler linear excision and closure of facial scars, more frequently the concept of changing a more linear scar line into a non-linear one is used. This is seen as more effective at both an improved scar appearance and less recurrence of scar widening.

The reason for breaking up a facial scar into a non-linear pattern is based on two fundamental concepts. A linear scar line that runs askew from the relaxed skin tension lines on the face is better hidden when it has an irregular pattern, making the scar harder for the eye to follow. Secondly by having the edges of the scar line interdigitate in an irregular pattern throughout its length the forces of wound contraction are better dispersed through greater surface area contact than having a straight line. This results in a decreased chance of scar widening.

The most common techniques for changing an adverse linear facial scar are based on various geometries such as Z-plasties, running W-plasties and the geometric broken line scar revision. Each of these has a role to play in scar revision and they do not all apply to every facial scar. The geometric broken line scar revision technique is the most common that I use because it offers the greatest disruption of any scar line and this the greatest amount of camouflage.

Case Study: This male had a history of a facial scars from a knife injury from years before which developed some wide scarring. These scars were all the more visible because of their lighter color on skin of a darker pigment.

Under general anesthesia a geometric broken one closure pattern was marked out using preformed plastic templates. These plastic templates ensure a good matching of both sides of the scar excision and can be repeated with longer scars. Then using deeper dermal sutures and small removeable skin sutures the edges of the excised. skin were put together to create the irregular closure line.

The initial facial scar revision already shows a significant improvement if for no other reason than the wide white scar had been removed.  It remains to be seen if secondary scar widening occurs but this would be unlikely. It will take up to 6 months after the procedure to appreciate the final scar appearance.

Highlights:

1) Severe linear facial scars are best improved by a geometric broken line scar revision technique.

2) The geometry of the scar revision closure pattern is not as important as that there is one for both improved camouflage and less tension on the closure.

3) Geometric broken line closure improves a scar’s appearance but it can not make it completely invisible.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Perioral Mound Microliposuction

Friday, February 9th, 2018

 

Defatting of the face is very different than the body. Due to the location of vital motor nerves, the more fibrous nature of facial fat and its very discrete locations, facial fatting is much more limited. While it is possible to selectively remove small areas of facial fat, it is not possible to have a more generalized and significant effect.

One such facial area that can be defatted is the perioral mound area. Often confused with the location of the buccal fat pad, this is a small collection of subcutaneous fat overlying the buccinator muscle just to the side of the mouth. It merges into the more inferior jowl fat which is also a subcutaneous fat layer. Patients often do not like the fullness that it creates in this facial area.

The perioral mound area can be treated by liposuction. Entering through a small incision just inside the corner of the mouth the area is easily accessed and treated. The key is that the traditional size liposuction cannula should not be used as it is too big. Even cannulas used for the neck can remove fat too much quickly or leave an irregular contour.

I prefer to perform perioral mound liposuction with a very small size cannula at the diameter of 1 to 1.5mm. The best cannula to use is actually not a liposuction aspiration cannula at all but a fat injection cannula. With just one hole on one side of the end of the cannula, it can be remarkably effective at removing fat from a small area like the perioral mounds with little to no risk of causing surface irregularities. This can be called therefore perioral mound microliposuction.

While the volume of fat extraction from the perioral mounds is small (1 to 3ccs per side) it can have a very visible reductive effect.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Interpositional Grafting in Vertical Chin Lengthening Osteotomies

Thursday, February 8th, 2018

 

While much thought goes into the horizontal projection of the chin, and numerous chin augmentation procedures exist to change it, much less interest is in its other dimensions. One often overlooked deficiency of the chin is its vertical length. A short vertical chin is usually associated with a flatter mandibular plane angle where the horizontal position of the chin and jaw angle points are almost on the same line.

While some vertical chin deficiencies are part of  an overall underdeveloped chin (both vertical and horizontal shortness) some chins may have an isolated vertical deficiency. The chin may have enough forward projection but just looks short. This is usually very apparent when the classic vertical thirds of the face are considered.

Vertical lengthening of the chin as an isolated change can be done by an opening wedge bony genioplasty. Just like the osteotomy used in the classic sliding genioplasty the same intraoral bone cut is made. But instead of moving the bone forward, the front edge of the bone is dropped downward. With the back wings of the inferior bone segment staying in contact with the bony jawline, the front part of the chin is vertically lengthened by the size of the opening wedge. (bony gap) This gap and the vertical chin lengthening it creates is maintained by plate and screw fixation.

This opening wedge of the chin creates a bony gap. If this bone defect is not too big, bone will naturally fill it in over a period of up to six months after surgery. The exact size of a horizontal bone gap in the chin that can heal on its own is not precisely known. But the general rule that I use is that I don’t graft this gap when it is less than 5 or 6mms. But when the gap is closer to 8 to 10mm it is of benefit to do so.

Interpositional grafting of an opening wedge genioplasty can be one by a variety of materials. The use of allogeneic or cadaveric blocks or granules is an effective. A large solid block placed in the center grafts the biggest part of the defect and the sides can be left alone to heal in on their own.

Vertical chin lengthening helps to put the face in better balance and fixes an uncommon chin deficiency that is best appreciated in the frontal view.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Funnel Insertion Method for Buttock Implants

Sunday, February 4th, 2018

 

Of all body implant augmentations buttock implants are the most challenging in many ways. From the dissection of the implant pocket to the patient’s recovery, such buttock augmentations requites a complex interplay of many factors to go well for a successful outcome.

One of the essential intraoperative factors is getting the buttock implants into the dissected pocket. This seems like a trivial maneuver to those who have never seen the surgery, but given the size of the implant vs the the linear length of the incision this can look daunting. This is not an uncommon observation about almost all face and body implants which is why deformability of the implant is a critical characteristic of its material.

All buttocks implants are made of a solid but very soft silicone material of which is fairly deformable. Breast implants are even softer and more deformable but they also can rupture which buttock implants can not. (this deformability is why in some countries breast implants are used as buttock implants) This ability for the implant to fold allows many buttock implants to be pushed through the incision. But this digital manipulation also creates the possibility of creating tears or holes in the implant material.

Like breast implants the best method for inserting buttock implants is to use the funnel device. This creates a more smooth deformation of the implant in which no specific pressure point (like the tip of a finger) can be created in the implant to cause permanent shape deformation or actual fracturing of the implant.

The other advantage of the funnel insertion method is that it minimizes the contact of the gloved surgeon’s hand and other instruments from coming into contact with it. This helps reduce the risk of implant infection.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Six Pack Etching in Custom Skull Implants

Thursday, February 1st, 2018

Custom skull implants provide a reliable and safe method for augmenting flat or deficient areas of the head. Like all face and body implants that are placed for aesthetic purposes, the surgery is fundamentally about placing a performed implant into the desired tissue pocket through the smallest incision as possible that will permit it. This is important because a scar is an aesthetic tradeoff and one that should not be overly noticeable and detracts from the augmentative effect of the implant.

To allow this implant principle to be effective, it requires a feature of the implant that is important…the implant must be deformable to pass through an incision that is smaller in diameter than the implant. This is easy to understand in a silicone breast implant, for example, and is the exact reason why the funnel insertion device was made to insert them through a very small skin incision. But it is a feature of a skull implant that is also needed to place it through a scalp incision. While a long coronal scalp incision can be used to place a skull implant, and the implant would not have to be deformable, few patients however want this scar burden for an elective aesthetic skull reshaping procedure.

Custom skull implants have a unique feature that is not shared by any other implants in the body. Their surface area coverage compared to the size of the body part in which it is placed is comparatively large. Thus it must be fairly deformable. While a solid silicone skull implant can be bent fairly easily, this bending must be in the form of a tight roll. The thickness of the implant determines how tight this insertion roll can be. To help make the roll even tighter and smaller in cross-sectional diameter is to cut wedges out of its internal surface. I call this a Six Pack Etching technique, borrowing the name from a liposuction method used on the abdomen to create visible inscription lines.

The six pack etching technique removes material from the internal surface of the implant which allows it to be rolled more easily for insertion through a small scalp incision.

Dr. Barry Eppley

Indianapolis, Indiana

Techical Strategies – The Upside Down Otoplasty

Thursday, February 1st, 2018

 

Otoplasty is a well known ear reshaping procedure. Pinning the ears back, as it is often called, changes the shape of the ear cartilage through sutures and sometimes cartilage excisions. Done from an incision on the back of the ear it is often combined with other facial procedures due to surgical proximity and convenience. But it is always done in the supine position on the operating table and each ear is accessed by turning the head from side to side. The success and symmetry of the ear reshaping is then judged from the frontal view as the patient would see it.

There are some uncommon situations, however, when the performance of an otoplasty can be done from a different viewpoint or angle. This would be the ‘need’ to do an otoplasty in the prone or face down position. I have done this numerous times when performing simultaneous occipital skull implant and webbed neck corrective procedures. Both types of deformities have a high association with ear deformities particularly of the protruding type.

I call this type of ear reshaping an Upside Down Otoplasty. It is an interesting perspective to do the procedure because you have the best visual access to the cartilage on the back of the ear and how the auriculocephalic angle is changed. A good side view of the ear can also be seen. One does not, however, see the ear from the front view which is of course the most important one. But an experienced plastic surgeon can tell based on the side and back views how the ear may look from the front.

When performing an Upside Down Otoplasty one must be careful to not over correct or pull the ear back too far. This is fairly easy to do since closing done the angle of the ear to the side head is easily seen. But as long as the helium to mastoid skin distance is at least 15mms the ear will not become too pulled back. Another favorable sign is if the antihelical rim is not seen sticking out beyond the helical rim.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Botox Injections for a Brow Lift Effect

Wednesday, January 24th, 2018

 

One of the most common uses for the well known aesthetic drug, Botox, is injection into the forehead. While it is most commonly used to treat horizontal forehead lines and vertical glabellar rhytids, it is also used to create a chemical brow lift. While such injections can be very effective, it it not uncommon for some patients to develop adverse aesthetic effects such as brow asymmetry and even the opposite effect of brows getting lower rather than elevated.

Like all facial injections there is an art form to doing them. But it really based on an understanding of the anatomy of the muscles and how they work. Brow shape and position one the brow bone is because of an interactive relationship between the multiple inner and outer depressor muscles and the one main forehead elevator. (frontalis muscle) Thus to create a complete brow lift the inner and outer depressor muscles must be theoretically injected.

In the January 2018 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘The Impact of Botulinum Toxin on Brow Height and Morphology: A Randomized Controlled Trial’. The authors evaluated the effects of injecting both inner and outer depressor muscles (Group 2) or just the lateral depressor muscles (Group 1)on brow height and shape. Fifteen patients (30 eyebrows) were done in each injected group with 25 units injected into the lateral depressors and 10 units into the medial depressors.

Their results showed that the brow was elevated up to 2mms across the entire brow in Group 1. In Group 2 the brows elevated up to 1.7mms in the outer half of the eyebrow with no change in its inner 1/3.

These study results initially seem counterintuitive. How could injecting both sides of the eyebrow result in electing only its outer portion? And how could just injecting the outer depressors result in more complete brow elevation? The authors hypothesis that there is diffusion of the drug into the lower frontalis muscle with injection into the medial depressors leading to partial deactivation. This results in no change in the medial brow position but increased resting tone of the frontal, raising the lateral brow.

These study findings provide guidance as to how to inject Botox for eyebrow elevation to meet patient expectations. For those seeking lateral brow elevation along, both the inner and outer depressors should be injected. But for those seeking total brow elevation only the lateral depressors should be injected.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Funnel Insertion Technique for Pectoral Implants

Sunday, January 21st, 2018

 

Pectoral implants are the male equivalent of breast implants for women. While done far less frequently, as men can build their pectoral muscles by exercise, they are very effective at enhancing the size of the pectoral muscle through placement behind it. They are actually done more often in men that workout than in men who don’t contrary to popular perception.

Unlike breast implants, the only aesthetically acceptable incision for pectoral implant insertion is through the axilla. A high transaxillary incision is used as, it not only keeps the scar off the chest wall, but is the shortest distance to the submuscular space under the pectoralis major muscle. At this point close to the arm the pectorals major muscle is most widely separated from the pectorals minor muscle. This allows for the easiest entrance to the submuscular space without having to disrupt any of the lateral pectoral muscle attachments except right next to the axilla. This ability alone is paramount as this is the key difference in pocket creation between pectoral implants in men and breast implants in women.

The size of the transaxillary incision for pectoral implants is larger than when used for the insertion of breast implants. It will usually be about 5 cms for most standard pectoral implant sizes. But as more and more custom pectoral implants are being used, their larger sizes makes keeping the incision a reasonable length more difficult. This is where borrowing a concept from breast implants is useful, the funnel insertion technique.

The well known funnel device allows a soft gel-filled breast implant to be inserted through a small incision by controlling its deformation through uniform compression out a smaller end hole than the diameter of the implant. This concept works equally well for pectoral implants. While a pectoral implant is more solid than a gel-filled breast implant it works equally well. The pectoral implant is folded onto itself and placed in the funnel.

By inserting the end of the funnel under the pectorals major muscle lateral border, it is squeezed through the incision and into the sub muscular space.

Once into the pocket it is necessary to manually unfold and position the implant. Since most pectoral implants do not have a completely symmetric shape their orientation is important in the pocket to achieve the desired external effect. (this is unlike round breast implants whose orientation is irrelevant) The funnel insertion technique for pectoral implants not only keeps the axillary incision size not unduly long but also prevents potential tearing of the soft durometer material.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Improved the Rolling Capability of Custom Silicone Skull Implants

Saturday, January 20th, 2018

 

A custom made implant is the best method to correct aesthetic contour deformities of the skull. It can be made in any shape and size provided there is enough scalp stretch to be able to close over it. Despite these implant benefits, unlike reconstructive skull surgeries, there is a much greater importance on limiting the length of the incision to do the surgery. This is of particular relevance given that almost 70% of aesthetic skull surgeries are done in men who often have limited or no hair cover. It is of no less significance, however, even in female patients that have good hair cover.

Limiting the length of scalp incisions using custom skull implants is based on their ability to be introduced through them. This optimally requires that they be deformable, much like a breast implant, so they can be reduced in size for insertion through the incision and then expanded back to its desired size and shape once inside the created subperiosteal scalp pocket.

This deformability requirement is why skull implants made out of solid silicone are so desirable. While they may be flexible/bendable when held in space, they become and feel as solid as bone when placed on the skull. The method of deformability of solid silicone skull implants for insertion is to roll it into a tubular shape. How successfully this is accomplished depends on the amount of central thickness that it has. Once this exceeds 10mms or more the ability to make a tight roll of the implant becomes more difficult.

One solution to make a better rolled shape in thicker skull implants is to remove partial-thickness longitudinal (to the direction of the roll) wedges of material. These multiple internal wedges allows a greater folding capability because of the removal of some material. But because they are not full-thickness no loss in the integrity or smoothness of the outer implant’s shape occurs.

These inner wedges or grooves also created a secondary benefit as well. As the scar tissue/capsule grows up into them this creates another source of implant fixation and migration prevention as well.

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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