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Archive for the ‘technical strategies’ Category

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

Technical Strategies – Submental Tracheal Reduction

Saturday, August 5th, 2017

 

The reduction of a prominent Adam’s Apple is known as a tracheal shave. Done directly over the tracheal prominence through a small skin incision the V-shaped thyroid cartilage is reduced, as the name indicates, by shaving it down with a scalpel blade. Since the prominence is composed of cartilage it can be reduced in layers with the sharp edge of a blade. As patients age the thyroid cartilage becomes stiffer and more calcified and may have to be burred down for an effective reduction.

While the skin incision for a tracheal shave is small and often heals exceedingly well, the risk of a visible scar always exists. While the procedure will always require a skin incision, an alternative location would be higher in the submental region under the chin. This distant incision location requires the creation of a subcutaneous tunnel down the midline from the chin to the thyroid prominence. Using a fiberoptic retractor the prominent cartilage can be seen and dissected free of overlying tissues.

Because the thyroid cartilage is a mobile structure, trying to shave it down with a scalpel blade from a remote incision is difficult. For this reason I prefer to use a handpiece and drill and burr the cartilage prominence down. This works just as well on soft cartilage as it does on harder cartilage. A small round or tapered carbide burr removes cartilage structure rapidly. Within the tight space of this subcutaneous tunnel it is important to be careful with a rapidly rotating burr to not inadvertently engage the surrounding soft tissues.

Because of the more limited visibility from this remote incision, a submental reduction should not be used when larger tracheal shaves are needed. Better control of the shape of thyroid prominence can be obtained by a direct incisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – The Vertical Opening Wedge Genioplasty

Friday, August 4th, 2017

 

Chin asymmetry is easily seen as the most projecting part of the lower face is shifted off of the facial midline. The central chin point is shifted to one side or the other and can occur for variety of reasons. The most common reason is developmental or traumatic where the sides of the jaw have different lengths, most commonly because there is a shorter side due to developmental deformities or from traumatic injuries/fractures.

In cases of chin asymmetry due to shortening of one side, realignment of the chin can be done by a unilateral lengthening of the shorter side. This is called an opening wedge genioplasty which is performed through an intraoral approach. Just like a traditional sliding genioplasty a horizontal bone cut is done well below the mental foramens and at a low anteroposterior angle as possible. Once the bone is down fractured (mobilized) the the longer or normal side is fixed with a single small two-hole plate and screws with bone to bone contact. This becomes the hinge point at which the opposite shorter side is opened.

The opening wedge distance on the shorter chin side that it is vertically lengthened is determined by the distance the central chin point is off the facial midline. In theory this is a 1:1 ratio, although like an obtuse or scalene triangle, the opening wedge usually has to be slightly greater than the amount of midline asymmetry.

The opening wedge is then stabilized with a much longer plate than was used on the opposite hinge point. Cadaveric corticocancellous bone pieces are used to fill in the empty intrabony wedge space to ensure healing. It is important to fill out the wedge defect all the way out to the inferior border to avoid a step-off deformity.

The vertical opening wedge bony genioplasty is a useful technique for those chin asymmetries which are caused by a shorter sided jaw segment.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Mouth Widening in Scar Contractures

Sunday, July 23rd, 2017

 

The width of the mouth and the flexibility of the lips are important for food intake and oral hygiene. They not only permit the lower jaw to open fully but also allow mobility of the adjacent facial soft tissues with expression. Having a ‘loose’ oral sphincter is taken for granted until one doesn’t have that normal stretch of the lips.

Tight or contracted mouth corners occur for a variety of reasons but the most common is that of trauma. Burns, avulsive tissue loss and surgery can create scarring around the lips which can cause banding or tightness across the once flexible mouth corners. No matter how soft the rest of the lips are, loss of stretch at the corners where the upper and lower lips meet will limit oral opening and access.

Opening up or releasing the mouth corners is a surgical procedure known as a commissuroplasty. But its name does not convey exactly how it is done. There are a variety of mouth releasing procedures but most are based on scar contracture release just as is done anywhere on the body. The most well known of these would be the z-plasty,  the transposition of two triangular skin flaps. The incisions are designed to create a Z shape with the central line of it being placed with the part of the scar that needs lengthening.

In the contracted mouth corner, however, the line of tightness is not straight. It occurs at angled intersection of the junction of the upper and lower lip lines. This requites a modification of the classic z-plasty to include a backcut at the center of the ‘central’ limb along the line that the mouth corner need to be extended out laterally.

With the cutting of these flaps, the lower vermilion-mucosal flap is transposed out into the most lateral extent of the newly created corner position. The superior skin flap is then rotated along the vermilion-cutaneous line of the lower lip. Some trimming of this skin flap is usually needed. This creates an increased mouth corner position of 1 cm or more ion each side.

This type of mouth widening procedure is used in scar contracture releases. It its not the technique that would be used in cosmetic mouth widening or commissure lengthening.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Rib Graft Shaping in Rhinoplasty

Saturday, July 15th, 2017

 

Rib grafts are the material of choice for many larger augmentative rhinoplasties and complex nasal revisions. They offer a virtually unlimited amount of cartilage graft material that can be used anywhere on the nose from the bridge down to the tip and columella. Because cartilage is softer than bone and relatively easy to carve, it is a versatile graft material that can be shaped for a wide variety of nasal reconstructive needs.

Besides the need for a donor site, the other downside to a rib graft is that it is rarely completely straight. Much of the shape of the ribs is largely curved as it bends around the side of the chest to join into the sternum. When harvesting cartilage the surgeon tries to take the straightest piece possible but, more times than not, a sizable rib graft harvest is likely to have a bit of a curve to it. Thus some form of graft manipulation/reshaping is needed.

The most common form of rib graft reshaping is to carve it like one would a bar of soap. A scalpel is use to carve it into the desired graft shape. In doing so it is well recognized to be aware of the bend of the rib and the attachments of the perichondrium. Since the perichondrium exerts a pulling force on the surface of the rib, it is important to keep the perichondrium attached on the convex side away from the curve and to remove the perichondrium and cartilage on the concave side of the curve.

Another useful or additive technique is to score the cartilage on the opposite side of the curve even though the perichondrium is left intact. Then multjple through and through sutures are placed to bend it straight or to ensure that it stays straight. This can work well in slight bends and if one is concerned about postoperative warping. Usually two to four transverse scores are needed for a long dorsal augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Shortening Vestibuloplasty

Saturday, July 1st, 2017

 

Soft tissue malposition of the anterior lower face is manifest in several presentations. Chin ptosis or sagging refers to the hanging of the soft tissue chin pad off the end of the bone. It most commonly occurs from some type of chin surgery that has stretched out the soft tissue attachments. Chin implant removal is a classic example of its cause although not the only one. It can also occur from a sliding genioplasty setback, multiple intraoral chin surgeries and aging associated with alveolar bone loss.

Chin ptosis may also be associated with lower lip incompetence. As the chin pad tissue slides off of the bone it may pull down on the lower lip, creating lack of lip closure at rest and lower teeth show. This creates a dual negative perioral effect.

The most well known treatment for chin ptosis and/or lower lip incompetence is mentalis muscle resuspension. This well chronicled procedure reattaches the bony origin of the muscle higher up on the bone often at a position between the incisor tooth roots. The muscle drags up with it the overlying soft tissues of the chin pad correcting chin pad ptosis and pushing up the lower lip. While these effects of muscle manipulation often look good during surgery, they unfortunately are often not maintained as well as one would like particularly that of the lower lip.

As a result other adjunctive procedures are commonly done with mentalis muscle resuspension to help improve its long-term success rate. One of these procedures is a vestibuloplasty, specifically a shortening vestibuloplasty. The anterior mandibular vestibule is the lined space between the teeth and the lower lip. The depth of the vestibule is usually a reflection of the superior position of the mentalis muscle on the bone. With a deep vestibule the superior muscle attachment is located lower and often so is that of the lower lip.

In a shortening vestibuloplasty the mucosal lining of the depth of the vestibule is removed and a layered closure is done. This raises the height of the vestibule (shortens its depth) and helps provides support to the elevated lip.

Dr. Barry Eppley

Indianapolis, Indiana

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


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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