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Archive for the ‘technical strategies’ Category

Technical Strategies – Biceps Implants

Wednesday, February 10th, 2016

 

tricep muscleAugmentation of the upper arm is a combination of development of the biceps and triceps muscles. The biceps is the most recognized of the two upper arm muscles and the most pursued in terms of exercise development and arm flexing. The biceps muscle is a two-headed muscle that extends on the anterior surface of the upper arm from the shoulder down to the elbow. The muscle originates on the scapular bone and inserts across the elbow on the upper forearm bones. Its main function is to flex and rotate the forearm

While weight training and other forms of exercise are the best way to develop a larger and more prominent biceps muscle, there are biceps implant surgeries to bypass the natural augmentation methods. Biceps implants can be placed in the subfascial location over the muscle to enhance its muscular profile.

Biceps Implants Markings and Incision Dr Barry Eppley IndianapolisThe location of biceps implants is placed over the length of the muscle. But it is very important when making the implant location markings that it takes into account the shortening or contraction of the muscle. The distal length of the muscle should be marked when the muscle is maximally contracted when the elbow is bent at 90 degrees and the forearm is supinated.

Biceps Implants Incision and Pocket Dissection Dr Barry Eppley IndianapolisBiceps implants surgery is done in the supine position through an incision placed high in the armpit. This is the identical incision used for the placement of pectoral implants. Iyt does not need to be more than 3.5 to 4cms in length. This iincision is up under the lateral edge of the pectoralis muscle so it will be fairly hidden when it heals.

Biceps Implants Incision and Closure Dr Barry Eppley IndianapolisThe biceps muscle fascia can be identified under the fat underneath the incision down towards the arm. The fascia is incised and the subfascial pocket is dissected with a long smooth instrument down to just above elbow. A silicone contoured carving block (Implantech) is used and carved to length as needed. The implant is easily inserted along the full length of the subfascial pocket.

The fascia is closed and the overlying skin closed in two layers. An ace wrap along the full length of the arm is used as the only dressing.

Biceps implant surgery produces an instant muscle enhancement effect.The subfascial pocket approached from an axillary incision avoids any major neurovascular structures and enters the fascia where the two heads of the biceps muscle become unified.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Triceps Implants

Saturday, February 6th, 2016

 

Silicone implants are available for male muscle augmentation at a variety of body sites. The most well known male body implants are the pectoral and calf implants. Implants for the arms and shoulders can also be done but they are far less well known and performed. Arm implants can be done for the bicep and tricep muscles and are most commonly done together.

tricep muscleThe triceps muscle, technically known as the triceps brachii muscle (three headed muscle of the arm), is the single large muscle on the back of the arm. Its contraction is what causes the straightening of the arm by extension of the elbow joint. Aesthetically the triceps muscle is not thought of as important as the anterior biceps muscle. But augmentation of the biceps muscle can not really be done without triceps enlargement to keep a well balanced muscular upper arm.

Triceps Implants Incision Dr Barry Eppley IndianapolisThe placement of triceps implants is best done under general anesthesia in the prone position. With the arms extended out on arm boards and the elbows bent at 90 to 120 degrees, good access is obtained to the back of the arm. With this positioning, a 3.5 cm skin incision can be made in the posterior axillary skin crease.

Triceps Implants Insertion Dr Barry Eppley IndianapolisTriceps Implants Insertion 2 Dr Barry Eppley IndianapolisDissection is carried down to the triceps  fascia through a moderate layer of subcutaneous fat. There are no major nerves or blood vessels that are in the path of this dissection. The fascia is incised and a subfascial plane is easily dissected down the whole back of the arm  to within a few centimeters of the elbow. A soft flexible silicone triceps implant (contoured carving block, Implantech) is sized, cut to length, and then thread into the subfascial pocket. It is important that the implant is positioned exactly on the back of the arm and stays passively below the fascial incision.

Triceps Implants Incision Closure Dr Barry Eppley IndianapolisAfter the implant is adequately positioned, the triceps fascia is closed as well as the dermis of the overlying skin. The skin is then closed with a subcuticular suture.

The surgical technique for triceps implant placement is highly aided by properly positioning the patient so that unimpeded access is provided to the back of the arm.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Endoscopic Browlift Fixation with LactoSorb Screws

Friday, January 1st, 2016

 

Endoscopic Browlift Supraorbital Nerve Dissection Dr Barry Eppley IndianapolisThe most common surgical treatment today for sagging brows is the endoscopic browlift. As opposed to browlifts that involve long incisions and remove forehead or scalp tissue to create the lifting effect, the endoscopic technique uses minimal incisions and removes no tissue. It achieves a browlifting effect through a deep subperiosteal brow tissue release and a superior forehead and scalp backward tissue shift.

This relocation of the entire soft tissue of the forehead up and back, known as an epicranial shift, must be initially held in place to create the brow lift. A wide variety of endoscopic browlift fixation methods have been described since this browlifting technique was introduced about twenty years ago. Fixations methods including metal pins, metal screws, transosseous bone tunnels and resorbable grids or platforms. Each of these devices and methods have their advantages and disadvantages and the fact that so many endobrow fixation methods exist indicates that there is no perfect way to do it.

LactoSorb Endoscopic Browlift Screw Dr Barry Eppley IndianapolisHaving used all of these endobrow fixation methods, there is one that I found to be my favorite over the twenty years of performing the procedure. The use of LactoSorb resorbable screws offers a simple and very reliable soft tissue fixation method. This is a low profile 2.0mm screw made out of PLLA-PGA material which is naturally resorbed after 6 months of placement. It is a special resorbable screw that has a hole placed though its head and a pushpin design rather than that of a threaded shaft.

LactoSorb Endoscopic Browlift Drilled Screwhole Dr Barry Eppley IndianapolisLactoSorb Endoscopic Browlift Screw Suture and Lift Dr Barry Eppley IndianapolisThis fixation method issued by initially placing an outer cortical bone hole at the back end of the endo scalp incision. A suture is initially passed through the screwhead and then the screw is pushed into the bone hole. A snug fit allows the introducer for the screw to be removed. With the screw in place holding the suture, the uplifted scalp and forehead tissues are grasped with a bite of the suture and tied down. The overlying scalp incision is then closed.

Between the temporal lines of the skull, LactoSorb Endobrow resorbable screws can be used for central brow fixation. They are slightly palpable for a few months but their profile eventually flattens as they resorb over time. The time needed for natural fixation by healing of the elevated periosteum back down to the bone is reported to be a but a few weeks. So the months of fixation provided by the resorbable screw is more than adequate.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Fat Grafting Chin Dimples

Tuesday, December 29th, 2015

 

Chin dimples are a not uncommon but anatomically perplexing facial feature. Sitting as a round central depression on the soft tissue chin pad, it serves no functional purpose other than a distinctive facial adornment. Like all facial dimples the cause has been shown to be caused by an underlying muscle deformity, specifically that of the mentalis muscle. Unlike its close cousin, the vertical or Y-shaped chin cleft, there is not an associated underlying bony deformity. Chin dimples and clefts are known to be an inherited trait on a dominant gene with variable penetrance.

The most common treatment to reduce or eliminate a chin dimple is by using an injectable filler. All of the commercially available injectable fillers can be used although their results will not be permanent. The use of silicone oil offers a permanent injection method although it is not FDA-approved for any facial augmentation procedure. Before placing any injectable filler a saline injection test should first be done to ensure that the dimple will be pushed out rather remaining indented and creating a ‘doughnut’ deformity.

Chin Dimple Release Dr Barry Eppley IndianapolisOne potentially permanent injection treatment option is that of fat grafting. Since injected fat is far more viscous than any injectable filler and does not have good linear flow, the bed into which it is injected should first be released. This can be done by using an 18 gauge needle placed in the center of the dimple and then rotating it around 360 degrees. The beveled edge of the needle will act like a small scalpel blade releasing the skin from its deeper attachments.

Chin Dimple Fat Injections Dr Barry Eppley IndianapolisOnce the chin dimple is released, a small amount of fat can be injected into the released subcutaneous space. This usually takes anywhere from .2ml to .5ml of concentrated fat. No one can predict with certainty how well injected fat takes so it is possible a second injection treatment may be needed. Three months should be allowed to pass to judge the retained injected fat volume.

There are alternative approaches to treating the chin dimple indentation done through an intraoral approach with muscle repair, but injection fat grafting offers a minimally invasive technique that has a high rate of success.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Intraoperative Shaping of Calf Implants

Sunday, December 27th, 2015

 

The use of calf implants to achieve improved fullness of the lower legs is the most reliable body contouring procedure of the lower legs. Calf augmentation is done for men that want to improve the overall size of their calf muscles. Women are often trying to put their calfs in better aesthetic balance to their thighs. The most common reconstructive use of calf implants is in the congenital club foot deformity to improve calf symmetry (unilateral) or have some semblence of calf muscle mass. (bilateral)

indianapolis calf implants dr barry eppleyCalf implants are made of a pliable and shapeable solid silicone material that feels a lot like muscle tissue. The implants come in three standard sizes which is defined by their length and volume of augmentation. (Implantech calf implants – 15 cms/75cc, 20cms/135cc and 24cm/185cc) The selection of calf implant size is affected by both of these considerations but one of the most important is the length of the patient’s gastrocnemius muscle.

lower leg musclesSince calf implants are placed in a subfascial location, they can not extend below the most inferior level of the gastrocnemius fascia where it meets with the soleus fascia/muscle and achilles tendon. The fascia overlying the junction of these two muscles and tendon is very tight and is easily disrupted. Trying to subfascially dissect and place calf implants that are too long will result in disruption of their fascial covering and a lower end of the implant that is in the subcutaneous location. This will result in a calf deformity and pain.

Intraoperative Calf Implant Sizing Dr Barry Eppley IndianapolisCalf Implant Size Adjustments Dr Barry Eppley IndianapolisWhen the size of the calf implant chosen is too long for the patient’s gastrocnemius muscle length, the implant can be intraoperatively trimmed. The silicone material can be easily and quickly reduced and shaped by scissors. Calf implants can be shorted and the lower end retapered. With the implant in the subfascial location, any small irregularities on the implant’s outer surface will not be seen.

I have yet to see a circumstance where the width of a calf implant needed to be reduced. But it is not rare to have to reduce the standard lengths of the medium and large calf implants to optimize the amount of calf augmentation effect.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Endoscopic Custom Forehead Implant Placement

Monday, November 30th, 2015

 

Forehead Implant Design Dr Barry Eppley IndianapolisAesthetic forehead augmentation to correct a sloped, irregular or deficient frontal bone can be done by a variety of materials placed on top of the bone. Having used every one of them, they each have their merits and each material type can be successfully used in experienced hands. But the forehead augmentation method that has the best results is that of a custom forehead implant.

Endoscopic Custom Forehead Implant incision Dr Barry Eppley IndianapolisBesides being able to create the exact shape and thickness desired before surgery, a preformed custom forehead implant can also be inserted through the smallest scalp incision. While the use of bone cements require a full coronal incision to be placed in most cases, a custom forehead implant can be inserted through an incision that is limited to between the bony temporal lines. This avoids extending the incision onto the temporal area on the sides of the head where the scar can be more easily detected and always gets wider than that across the top of the head.

Endoscopic Custom Forehead Implant positioning Dr Barry Eppley IndianapolisThe biggest concern about placing a custom forehead implant is to get it low enough over the brow bones if that is the way it was designed. Placing a forehead implant that does not involve the brow bones is far easier and adequate positioning is almost never an issue.   But placing a complete custom forehead implant that must go over the brow bones first requires a subperiosteal release and supraorbital nerve dissection. This must be done with an endoscope given the limited size of the scalp incision. Once the forehead implant is inserted checking its placement with an endoscope can also be done.

The use of the endoscopic technique in a custom forehead implant is to ensure as best as possible the extent of the subperiosteal pocket and protection of the supraorbital nerves. It is not used because it can limit the extent of the scalp incision like is done is more traditional endoscopic browlift surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Male Direct Brow Bone Reduction

Thursday, November 26th, 2015

 

Brow bone reduction can be done by two basic techniques. A burring reduction of the outer table of the frontal sinus wall is one option. The amount of reduction achieved will be limited by the thickness of the outer table bone which can be anywhere from 2 to 5mms. The other method of brow bone reduction is removal of the entire outer table of the frontal sinus, reshaping it and putting it back in place. This method of brow bone reduction produces a more dramatic result with further setback than what can be achieved  by more simple burring methods.

But regardless of the method of brow bone reduction used, an open approach is always needed for the best result. While more limited incision approaches using an endocope have been described, they produce a very minimal reduction in brow bone prominence at best. While this open incisional access is less of an issue for women it is of major consideration in men…who coincidentally make up more than half of patients seeking brow bone reduction.

Male Direct Brow Bone Reduction markings Dr Barry Eppley IndianapolisOne option for male brow bone reduction is the mid-forehead incision. Using a prominent  horizontal wrinkle line identified by raising of the eyebrows preoperatively, a central forehead incision can be used. It is important to keep the location of the incision limited to the central third of the forehead between lines drawn up vertically between the pupils. By so doing the major branch of the supraorbital nerve is preserved so much of forehead sensation is saved.

Male Direct Brow Bone Exposure and Bone Flap Removal intraop Dr Barry Eppley IndianapolisMale Direct Brow Bone Reduction Bone Flap Fixation Dr Barry Eppley IndianapolisThrough this limited incision, the anterior table of the frontal sinus can be successfully removed by a combination of a reciprocating saw and osteotome technique. The frontal bone flap can be removed, reshaped and replaced by small plate and screw fixation. Once the incision is closed in layers with small resorbable skin sutures, an imperceptible scar results.

Male Direct Brow Bone Reduction Skin Closure Dr Barry Eppley IndianapolisMale brow bone reduction can be successfully done through a limited forehead incision. The result achieved is comparable to what can be done through a longer pretrichial or full coronal scalp incision. Given the state of many men’s hairlines and their potential regression with aging, a well healed mid-forehead incision can be considered a good option for brow bone reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Intraoral Chin Implant Placement

Sunday, November 22nd, 2015

 

Chin implants are the most common permanent method of facial augmentation. Chin implants of various materials have been used for almost fifty years. Whatever the material composition of the implant is and its shape and size, chin implants can be introduced from either a superior approach (intraoral mucosal incision) or from below. (submental skin incision) There are advantages and disadvantages of either incisonal approach as well as surgeon advocates for either chin implant introduction technique.

The submental incision for chin implants offers the most direct access to the bottom of the chin bone where the implant should be properly placed. It also provides a pocket which eliminates the risk of any upward migration of the implant provided the pocket is not made too high. Firm fixation of the implant can also be done to the bottom edge of the bone to ensure its midline positioning. Because of a sterile skin prep, it also has a very low risk of infection. From a recovery and potential complication standpoint it also does not disrupt the superior attachment of the mentalis muscle. Its only real downside is that it does create a scar under the chin which can be objectionable to some patients.

The intraoral approach offers a scarless method for chin implant augmentation as its main advantage. Because of going through the mouth (although this is not exactly true because the lower lip is pulled out and away from the oral cavity) and detachment of the superior mentalis muscle, many surgeons feel that it is associated with a higher rate of complications. Superior malposition of the chin implant is actually the most common problem with the intraoral approach.

Intraoral Chin Implant Placement Technique Dr Barry Eppley IndianapolisIntraoral Chin Implant Placement Technique 2 Dr Barry Eppley IndianapolisSeveral modifications of the intraoral approach can avoid most of the potential chin implant problems. First the intraoral incision should be vertical in orientation, paralleling the fibers of the mentalis muscle. This splits the mentalis muscle but does not separate the mentalis muscle attachments. With the lip pulled away from the teeth, it provides the angle to develop the subperiosteal pocket along the inferior edge of the anterior mandible.  Secondly, implant sizers are used to ensure that the pocket has been properly developed prior to inserting the formal chin implant. Lastly, the implant is inserted, positioned and then secured in its midline position with a single 1.5mm microscrew to prevent superior implant migration.

The intraoral approach for chin implants is sometimes preferred by patients with more pigment in their skin, females and any patient that wants to avoid an external skin scar. The incisional technique should be different than that needed for a sliding genioplasty and other chin surgeries with a more limited and less dissected approach By so doing all of the potential disadvantages of the intraoral chin implant approach can be avoided.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Minimal Incision Temporal Reduction Technique

Tuesday, November 3rd, 2015

 

Reduction of an undesired temporal convexity is becoming increasingly requested as it becomes aware that a procedure exists to do it. For a head that is too wide or convex above the ears, a technique has been developed to help narrow it. While such a temporal convexity is often perceived as being due to bone, the anatomy of the area indicates that the posterior belly of the temporalis muscle makes the greater contribution.

Resection of the posterior temporalis muscle can make a dramatic change in the shape of the side of the head. It can alter a convexity to a straight line as the thickness of the muscle is greater than one would think. In men the posterior belly of the temporalis muscle can be 7mm or more in thickness. Reduction of both sides of the head can thus result in a total width change of the head of up to 1.5 cms. Interestingly loss of the posterior temporalis muscle does not result in any loss of mouth opening.

Limited Incision Posterior Temporal Reduction technique Dr Barry Eppley IndianapolisLimited Incision POsterior Temporal Reduction technique 2 Dr Barry Eppley IndianapolisThe traditional method of posterior temporal reduction is done through a vertical scalp incision above the ears. Initially I made a 4.5 cm incisional length to remove the muscle. Having done the procedure many times I have been able to shorten the length of the incision down to 3 cms. This allows a subfascial approach to the head width in this area, reducing it by taking it out as a single piece of muscle.

left posterior temporal reduction result intraop dr barry eppley indianapolisTo demonstrate how effective posterior temporal reduction can be, here is an intraoperative view of the left side having been compared to the right side where the muscle still remains.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Custom Jawline Implants

Monday, October 26th, 2015

 

Custom Jawline Implant Dr Barry Eppley IndianapolisWhile individual chin and jaw angle implants make up the majority of lower facial augmentations, the use of custom jawline implants is steadily growing in use. Offering a total jawline approach, these wrap around implants cover the entire lower jaw from angle to angle crossing the chin anteriorly. No other implant approach can rival the changes that  an implant that covers this much skeletal surface area can do.

Custom Jawline Implant insertion Dr Barry Eppley IndianapolisBut a custom jawline implant by virtue of its size can make its placement challenging. When placed onto the face it can seem daunting as to how it should be surgically placed as a single piece unit. It seems too big to be introduced through just a single submental or intraoral incision. So how does one place a custom wrap around jawline implant as a single piece unit?

The proper placement of a custom jawline implant is through a three incisional approach. The anterior incision can be either a submental or an anterior intraoral vestibular incision.  But two or bilateral posterior intraoral vestibular incisions are needed to properly place the jaw angle portion of the implant. It is extremely important to check the position of the jaw angle portion to be certain it is properly seated against the bone. Only direct inspection can assure that it is.

Custom Jawline Implant submental approach Dr Barry Eppley IndianapolisBecause a silicone custom jawline implant is flexible when not on the bone, it can be folded and threaded through a soft tissue tunnel below the exit of the mental nerve. Whether this will he successful or not depends on the size and thickness of the jaw angle portion of the custom jawline implant design. Very thick and large jaw angle portions may necessitate a split of the implant into two pieces threaded in from back to front and the joined in the middle. But if the jaw angle portions are not to big, they can be folded in front the front and kept as a single one piece wrap around implant which can be fixed at the chin with a single screw.

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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