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Archive for the ‘technical strategies’ Category

Technical Strategies – Z-Plasty Medial Epicanthoplasty

Monday, May 22nd, 2017

 

The shape of the eyes is affected by many anatomic structures. While much focus is on the larger eyelids, the inner corner of the eyes has a significant impact on eye appearance. While they may the small the inner and outer corner of the eyes affects eye width as well as the angulation of the eyelids.

The epicanthal fold or epicanthus refers to a visible skin fold that covers the inner corner of the eye. While everyone has some degree of an inner eye skin fold, the prominent epicanthal fold is most commonly associated with the Asian eye. (although many other ethnicities have it as well) They can also occur in Down’s syndrome as well as fetal alcohol and Turner’s syndrome. The height of the bridge of the nose is also a factor in its occurrence. Low nasal bridges have a high association with the epicanthal fold while high nasal bridges do not, presumably due to the stretch of the skin between the eye and the nose.

The epicanthoplasty is a procedure done to change the shape of the epicanthal fold. While it is most commonly associated with double eyeliod surgery, it can also be done as an isolated procedure in patients with a distinct upper eyelid fold. In these patients the most common technique is a z-plasty. This eliminates the downslanting fold as well as creates a horizontal orientation of the inner eye.

The inner eye z-plasty is carefully marked with its long axis along the fold and the back cuts at 45 to 60 degrees. The limbs must be marked so the switch of the skin flaps creates the change of the fold. Once cut the skin flaps need to be released of any fibrous attachments to the medial canthal tendon. Small dissolvable sutures are used for the skin closure.

The medial epicanthoplasty has a role to play in the non-Asian eye. It can effectively change the inner eye corner from a down slanting to a horizontal orientation.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Splitting the Custom Jawline Implant

Tuesday, May 16th, 2017

 

A custom jawline implant has become the premiere method of total jawline augmentation. Being able to control the dimensions of the three corners of the jawline (chin and jaw angles) as well as its connections through the body of the mandible creates the opportunity for a complete lower facial skeletal makeover.

This type of facial implant is very powerful because it covers a broad surface area. This creates a naturally stronger effect than ‘spot’ augmentation alone of just the chin or jaw angles. (or even both) But with larger implants comes the challenge of how to insert it into the subperiosteal jawline pocket.

Just because a custom jawline implant is bigger, the size and location of the incisions toinsert it do not have to be. Like all silicone implants their flexibility permits insertion through still small incisions. But the real issue with their insertion is passing underneath the mental nerve on each side where the subperiosteal tunnel is the narrowest. While this can be accomplished in such implants with smaller jaw angle components, the risk of nerve injury is always present.

I have developed a two-piece approach to placing custom jawline implants that substantially reduces the risk of mental nerve injury. Rather than passing the jaw angle portions of the implant as a single piece in a front to back direction (which also makes for a bigger submental or intraoral incision) the implant is split in the midline and then passed in a back to front direction. This allows the smaller chin segment to pass through the subperiosteal tunnel under the nerve. The implant is then reunited in the midline once positioned. I usually use interlocking midline split design which helps ensure that segments are not rotated once reunited.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Temporal Artery Ligation

Wednesday, May 3rd, 2017

 

Temporal artery ligation is traditionally a medical procedure done as a diagnostic procedure for temporal arteritis. In this procedure it is done at the edge of the temporal hairline through a cm. or large incision in which a section of the artery is removed and sent to pathology for histologic examination. Technically this procedure should be called temporal artery biopsy, two end ligation is a necessary part of the procedure but not its main intent.

Conversely, true temporal artery ligation is a cosmetic procedure to specifically reduce the flow in the superficial temporal artery system and lessen or eliminate the prominent appearance of the vessels. This procedure does not remove a section of the artery nor is it necessary to do so to have its aesthetic effects. Rather it lies on point ligation of inflow and back flow points that contribute to inflow into the prominent vessel.

Temporal artery ligation first requires a precise mapping of the prominent vessel and any back flow points. An anterograde and retrograde ligation point should be initially marked. On any single vessel at least two points of ligation will be needed. This is done by digital palpation or an ultrasound doppler can be used. In some cases the path of the vessel is visible evident. But this is usually less evident as the vessel takes a tortuous course out into the forehead. In most cases at least one ligation point will be needed on the forehead which is always placed in a horizontal wrinkle line.

Unlike temporal artery biopsy, the size of the incision in temporal artery ligation is much smaller. It usually is no bigger than 5mm or 6mms. The artery is located and often teased out of the incision where a double ligation with a small permanent suture is used. (5-0) The incisions are closed with small resorbable sutures. (6-0)

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Jaw Angle Implant Screw Fixation

Saturday, April 22nd, 2017

 

Jaw angle implants are one of the most unique facial augmentation techniques given its posterior jaw location. Placed under the thick masseter muscle and having a remote and limited access to do so from inside the mouth, the placement of the implant on the exact and symmetric position on the jaw angle bone can be challenging. This is made even more challenging with new implant styles such as the vertical lengthening jaw angle implant in which a portion of the implant is deliberately designed to sit off the lower edge of the bone.

Beyond intraoperative implant positioning concerns, there is also the potential for the implant to move from its desired position. Such implant displacements always occur in an anterior and superior towards the location of the vestibular incisions. Undesired implant movements naturally occur towards the direction in which they were inserted.

To prevent jaw angle implant displacement, screw fixation is almost always used. Over the years I have developed a screw fixation technique that is both reliable and rapid to perform. Trying to insert screws from inside the mouth is both difficult and cumbersome to perform. What works best is a percutaneous technique.

Using a 1.5mm screwdriver, it is inserted through a small 3mm skin nick through the masseter muscle in a perpendicular orientation to the bone’s surface. Once inside the implant pocket it is turned and pointed out of the mouth. A self-tapping screw is placed on the screwdriver blade which is self-retaining. The screwdriver is pulled back into the mouth and turned towards the bone where it its inserted through a superior edge of the implant and driven into the bone. This same technique is repeated for as many screws as one needs to place for optimal implant security. (I have never placed more than two screws

With this jaw angle implant s crew fixation technique, which takes just a few minutes to perform for both sides, one can be assured that the implants will not shift from where they were positioned on the bone.

Dr. Barry Eppley

Indianapolis, Indiana

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


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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