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Archive for the ‘technical strategies’ Category

Technical Strategies – Vertical Chin Cleft Creation with Chin Implant Augmentation

Sunday, December 3rd, 2017

 

The chin has few topographic features on an otherwise round convex shape as it covers the projecting chin bone. Chins can have either a dimple or cleft. A chin dimple is a circular central indentation of the soft tissue chin pad. A chin cleft is a vertical indentation through the lower half of the chin pad that extends to the inferior border. While many perceive that these chin indentations are caused by the bone underneath them (particularly a vertical cleft), they are actually anomalies in the soft tissue and not the bone.

The vertical chin cleft is the easiest to understand since the lower jaw is formed by the paired brachial arches that meet in the middle in the embryo. Failure to have a complete meeting in the middle can result in a ‘cleft’ of the overlying soft tissues. Or more likely the union of the tissues developed a very slight separation that resulted in a very minor soft tissue cleft.

When surgically trying to make a chin cleft, making a vertical defect in the bone alone will not work. Or in the case of placing a chin implant, a ‘cleft’ chin implant will also not create the desired effect. It requires soft tissue manipulation, preferably from a submental incision, to make an effective external cleft appearance.

When doing a combined chin implant and vertical cleft creation, the bigger the chin implant the more likely it will be effective. Whether the chin implant is round or square does not matter, it can be done equally well in either one. The key technical points are two-fold. First a wedge of cleft must be made through the center of the implant to create a channel for the soft tissue anchoring. In so doing the implant will need to be secured with screws on each side so it remains positionally stable. Secondly a vertical wedge of soft tissue (muscle and fat)is removed from its underside up to the dermis of the skin. Sutures can then be placed to pul the skin down into the implant cleft. This will create a resultant vertical indentation of the overlying external chin.

A vertical chin cleft can also be created in patients who are not undergoing chin implant augmentation. The technique is the same with the exception that a vertical groove is made into the lower edge of the bone as opposed to that of an implant.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Subcostal Rib Shaving

Sunday, December 3rd, 2017

 

Most of the ribs are near circumferential bone and cartilage ‘fingers’ that provide shape to the chest and abdomen. Some of these ribs can be modified to improve the shape of the torso. In the upper abdominal region is the subcostal portion of the ribcage which is composed of the union of ribs #7 through 10 of its lower portion. This creates an arc of cartilage that is shaped like a stretch out ‘U’.

Normally the subcostal ribcage has a slightly more horizontal projection than the rest of the ribcage above it. But it can have an increased projection due to genetics, congenital deformities or injury. This can create a protrusion of the subcostal ribcage that creates an unaesthetic flare or prominence.

Reduction of subcostal rib protrusions must usually be done through a direct incisional approach to be maximally effective. I have used a tummy tuck approach which can be done if the patient needs a concomitant tummy tuck. I have also approached the subcostal ribs through an inframammary incision but this does not provide good access for optimal rib reduction. The direct incision allows the rectus muscle to be vertically split and the ribs easily exposed.

Unlike posterior rib removal (#s 10, 11 and 12) where the removed ribs are done in a full thickness manner, subcostal rib modifications are often done in a reduction technique and not a removal technique per se. The protrusions can be reduced by a subcostal rib shaving technique. This can be done with a scalpel for the softer cartilaginous portions and a high-speed handpiece and burr for the more ossified cartilage portions or actual bone. The ribs can be shaved down to where there is only a thin layer left protecting the intercostal neurovascular bundle and the pleura underneath should it be located this low on the ribcage.

Subcostal rib shaving also prevents blunt ends of the remaining rib from being seen on the outside should a total resection be done. This is of particular relevance in thinner patients where there is little soft tissue cover. Rib shaving ensures that there remains a smooth shape to the reduced subcostal protrusion. Shaving may seem like it does not remove much rib but when the pieces are put together the amount of rib removed looks more substantial.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Mapping the Multipoint Temporal Artery Ligations

Sunday, November 26th, 2017

 

The superficial temporal artery (STA) is a branch of the facial artery  that crosses in front of the ear and heads northward into the scalp. At a fairly predictable point above the ear it turns into a Y configuration with an anterior branches coursing across the forehead at it turns up into the scalp. It has a very snake-like course along this pattern much like many rivers going through a valley. It is not precisely known why it has this very irregular course when a straighter line would presumably suffice but there is undoubtably some developmental purpose to it.

For reasons that are equally unclear as that of its sinuous course, in some people the course of the artery becomes very apparent due to vessel dilatation. This appears to be almost exclusively in men which I assume is due to their large muscle component of the arterial walls. When exposed to any agent that causes the artery to experience increased flow, such as heat, exercise and alcohol being the common offenders, it bulges out like a thick rope producing a unique and unaesthetic feature of the temples and forehead. In men with hair the dilated artery and its dicta branches are only seen beyond the hairline. But in men who shave their heads or with very short hair, the course of the abnormal vessel may be seen all up along the ear and into the forehead.

The surgical treatment for a prominent STA is ligation. While it is tempting to do so only in a most proximal location, this approach should be avoided. While I have seen cases of that being done and the patient reports some reduction in its prominence, it is not usually completely successful strategy. This is because, while all veins have valves, few arteries do. This allows the high potential for backflow coming across the scalp and back down into the distal portion of the arterial system allowing the vessel to remain prominent. This serves as the basis for a multipoint ligation approach.

In this temporal artery ligation technique, the course of the prominent STA is marked out and a proximal and two or three distal ligation points are marked. The distal locations are either at branch points or linear backflow points  in the forehead and are placed in a horizontal skin crease so that the small incisions can heal in an undetectable manner.

What this temporal artery ligations approach, the success rate is higher with a much lower revision rate. There have been no instances of facial nerve injury or scalp hair loss issues.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Submental Chin Reduction

Saturday, November 25th, 2017

 

Unlike chin augmentation, chin reduction surgery is performed far less commonly. As a result, it is not a well understood procedure in terms of proper diagnosis and technique. While chin reduction is often perceived as an intraoral bony burring procedure, this is a very limited procedure that is rarely effective and often leads to postoperative ptosis problems. There are very indications for it.

Many chin excess problems are a combination of both bone and soft tissue. It is hard to separate the two as bone reduction alone causes a potential lack of overlying soft tissue support creating a tissue sag. While an intraoral osteotomy approach does maintain the attachments of the lower soft tissue chin pad (and this helps in preventing ptosis), the chin osteotomy technique limits what bony dimensional changes are possible and can still not get rid of a large soft tissue pad.

The submental chin reduction technique offers the greatest possibilities for total chin change of both bone and soft tissue. While there is the disadvantage of a scar to do so this is often not as big of a concern to patients (who are mainly female) as many surgeons may think.

Coming from below the bone can be reduced in any dimension one desires by shaving and with virtually no risk of any mental nerve injury. Whether this be in a vertical or horizontal shortening, or often in a combination of both, the end of the chin bone can be reshaped as needed.

As valuable as the versatility of the bony changes are, the submental approach is the only method for adequately dealing with the soft tissue. The soft tissue chin pad can be reduced by a full-thickness crescentic excision or, at the least, a submental tuck of tissues can be done.

One important feature of coming from below in chin reduction is the possibility of resuspending the neck tissues that are often need to be detached when performing a vertical bone reduction. By doing so this prevents a secondary submental fullness which is what occurs when a sliding genioplasty is done in reverse.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Skull Implants with Frontal Hairline Design

Thursday, November 23rd, 2017

 

Skull implants are a versatile treatment strategy for a variety of head augmentation concerns. Made from the patient’s 3D CT scan they can be designed to provide increases in skull projection that are only limited by the stretch of one’s scalp.

One of the not uncommon indications for custom skull implants is to increase the height across  the top of the head. This is requested by both men and women with no significant gender tendency. While such a procedure can be perform equally in either male or female, the male hairline must be considered in the implant’s design is some cases.

While custom skull implants are made with a feathered contoured edge at its perimeter, there is always the risk of a visible transition in non-hair bearing areas. This is most relevant in the forehead and in the any patient where the front edge of the implant extends beyond the hairline. This becomes extremely relevant in the male with a receded/receding hairline which can affect the design of the front edge of the implant.

When possible a skull implant should be designed with the known location of the frontal hairline. But this is not always possible since the hairline is not seen in CT scans and an intraoperative trial fit may reveal that such a deign is not accurate.

In this event it is possible to modify the implant’s shape by carving to get its frontal edge even or behind that of the hairline’s edge. Shaving of the implant’s edge must be carefully done to create a feather edge as much as possible using large scalp blades. While some edge transition may be palpable at least it will not risk visibility.

While the hairline may to be visible in CT scans, preoperative measurements from the lower edge of the brow bones can be useful in making that design consideration.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Webbed Neck Correction with Trapezius Myotomies

Sunday, October 15th, 2017

 

The webbed neck occurs is a wide variety of medical conditions and has variable presentations. While most commonly associated with Turner’s, Noonan and Klippel-Feil syndromes where the webbed necks are severe, they also occur in lesser presentations that may have no specific syndrome associated with them. While non-syndromic neck webbing is less severe, it may be more aesthetically disturbing given that it is a solitary physical deformity.

The traditional methods of webbed neck correction use incisions and tissue rearrangements directly along the neck webs which are aesthetically unacceptable. While effective the visible scarring is not a worthy tradeoff in many cases particularly in the less severe neck webs. For this reason I use a posterior approach that employs a diamond-shaped skin excision. The upper half is in the hairline and the lower half is in the non-hair bearing neck skin. The middle angles of the equilateral parallelogram are placed along the horizontal axis of the maximum amount of inward skin pull needed.

The posterior neck skin is fully excised down to the fascia. It can be surprising how thick the skin and fat is on the back of the neck even in a thin person. Skin flaps are raised out to the lateral neck web lines on each side along the trapezius fascia. The fascia is opened along a linear line that goes out to the neck webs. With the trapezius muscle exposed its fibers are partially released from its lateral border for several centimeters inward. Midline fascial plication is then done on each side pulling in the sides of the muscle.

To complete the webbed neck correction, the skin is closed by changing the diamond-shaped excision into a vertical midline closure. The muscle and fascia work brings in the deeper structures while the skin closure provides the more superficial neck narrowing effect. Skin excision and closure alone will not create a sustained webbed neck corection.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Buccal Fat Grafting of the Labiomental Fold

Wednesday, September 27th, 2017

 

The labiomental fold is a small and often overlooked facial feature. Lying between the lower lip and chin, it is a crease or fold of varying depths amongst different people. Why a labiomental fold even exists at all is a function of many factors including chin projection, the attachment of the mentalis muscle to the bone, the size of the soft tissue chin pad, the depth of the intraoral vestibule and the size and projection of the lower lip.

While often thought irrelevant, it becomes a more important aesthetic issue in chin surgery particularly that of augmentation. Since the labiomental fold is a fixed anatomic structure, its appearance will be affected by increasing chin projection almost regardless of the method to do so. As the inferior chin comes out further, the superior labiomental fold by contrast will look deeper. There is nothing a chin implant or a sliding genioplasty can do, on their own, to make the labiodental fold less deep.

Softening a deep labiomental fold requires a direct approach whether it is an injection technique or an implant. Injecting filler or fat is often not rewarding as the tightness of the fold makes it hard to get a good push outward.

An alternative strategy is to perform a full release of the dermal attachments of the fold above the mentalis muscle through an intraoral approach and then place a soft tissue graft. A fat graft is a good choice for the filler material and can come from a variety of sources including a dermal-fat graft and a solid fat graft like that from the buccal fat pads. (as shown here)

Release of the deep labiomental fold well above the bone level (north of the mentalis muscle and not south of it) is the key for successful fat grafting in efforts to soften it.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Multi-Point Temporal Artery Ligation

Thursday, August 17th, 2017

 

The development of visible temporal arteries in the forehead is not rare. Occurring almost exclusively in men, the frontal or anterior branch of the superficial temporal artery becomes dilated and its course up into the forehead becomes prominent. Often occurring after exercise, heat exposure or alcohol intake, the muscular walls if the artery dilate makes its course very visible. In some patients the size of the artery may decrease but in other patients it may persist for days. While this is largely as aesthetic issue, some patients complain of associated headaches and even visual blurring.

Temporal artery ligation is the surgical treatment for such aesthetic forehead vessel dilatations. It should be not confused, however, with the ligation technique done for temporal arteritis or temporal artery biopsy. While that procedure does ligate (and remove a section) of the vessel, its intent is not to stop the flow through the artery. It is to remove a section of the vessel for pathologic analysis. Any blood flow reduction is an inadvertent side effect.

But aesthetic temporal artery ligation is done with the intent of ceasing flow through the prominent section of the artery. If flood is diminished or eliminated it will no longer be visible. While it may seem like ligating the vessel before it ever enters the non-hair bearing temporal and forehead areas should work, it often by itself does not. This only treats one part of the problem, inflow or anterograde flow. It does not account for back flow or retrograde flow which comes from the cross-connections across the scalp.

The real key to the procedure is to carefully trace the pattern of the vessel forward and look for branching points. At these identified branching points ligations must be done to cut off back flow once forward flow is eliminated. This can be difficult to always completely identify as the artery has a very tortuous pattern in the forehead. Sometimes they are visible but many times it requires careful palpation to find them.

The number of temporal artery ligations points will vary for each patient but can range from two to seven. The average number is three per side. Men who shave the head or have closely cropped hair often undergo more ligation points due to greater vessel exposure along its length. In the forehead area it is also important to place the small incisions in natural skin wrinkle lines which can be found by having the patient raise their eyebrows.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Fishtail Earlobe Reshaping in Otoplasty

Saturday, August 12th, 2017

 

Otoplasty or ear pinning is the most common aesthetic surgery performed on the ear and its cartilages. (technically earlobe repair would be the most common aesthetic ear surgery… but it contains no cartilage)  In repositioning the shape of the protruding ear back towards the side of the head a variety of techniques are used to reshape the underlying supporting ear cartilages. Some of these are suture plications while others involve modification or removal of sections of ill-formed cartilage.

But in ear reshaping surgery consideration must be given to the only non-cartilaginous structure of the ear…the earlobe. This small area of the ear is frequently overlooked in otoplasty and can mar the aesthetic result of an otherwise pleasing reshaped ear. In many cases if the cartilage of the ear its pulled back but the earlobe remains too far forward, the ear will still standout but to a lesser degree. A protruding earlobe disturbs an otherwise smooth helical rim line from the top of the ear downward. Such otoplasty patients with earlobes that need to be simultaneously addressed can be identified beforehand.

As part of an otoplasty I frequently reposition the earlobe as well. I use excision of a segment of skin on the back side of the earlobe in a fishtail pattern. This skin section is removed with care taken to not cut through to the other side. In closing this open area on the back of the earlobe,  the outerearlobe is pulled back but avoids becoming pinched or developing a dogear skin redundancy at its bottom edge. It is the fishtail pattern that prevents the bottom of the earlobe from becoming too pinched. This is effective whether the patient has attached or detached earlobes from the side of the face.

A pleasing otoplasty result must frequently involve earlobe reshaping as well. Establishing a smooth contour from the top of the ear down to the bottom of the earlobe prevents any part of the ear from standing out..which in otoplasty surgery is the main goal. The ears needs to blend into the side of the head in a non-prominent fashion. While the ear has a complexity of hills and valleys and is artistically shaped, it still is not aesthetically pleasing to have it be more dominant than other facial features.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Transcoronal Posterior Zygomatic Arch Osteotomy

Sunday, August 6th, 2017

 

Cheekbone reduction by osteotomies is the only surgical method for narrowing a wide face. While most commonly performed on Asian patients all around the world, I have done an equal number on other ethnicities as well. By performing a bone cut through the main body of the cheek (zygoma) and at the back end of the zygomatic arch, the widest part of the cheeks can be moved inward. Its effect comes from taking the most convex part of the zygomatic arch and changing its widest point to a lower inward position. Once the bone is moved inward it is usually stabilized in its new position by some form of metal fixation.

The front cheekbone reduction osteotomy is done from an intraoral incision and thus is scar free. Conversely the posterior zygomatic arch osteotomy is usually done from an external skin incision at the back side of the sideburn (male) or preauricular tuft of hair. (female) While this small incision always heals well in my experience, there are alternatives points of access to it.

One approach to the posterior zygomatic arch osteotomy is through the same intraoral incision as the anterior osteotomy. Sliding an osteotome along the underside of the arch it can be fractured in a blinded fashion. Plate stabilization is not possible. This is not a technique that I have done but I know other surgeons that do it.

Another approach to the osteotomy its from above, coming underneath the deep temporalis fascia. This could be done if one is concurrently using a coronal scalp incision for other procedures as well. Thin elevators are placed on both the outside and inside of the posterior zygomatic arch just in front of its temporal attachment. An osteotomy is used to make a complete osteotomy through the thin arch bone. It can then be mobilized and pushed inward. Like the intraoral approach plate fixation is not possible.

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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