Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?
Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.
The use of a custom jawline implant is the most effective technique to reshaping the lower face. Its one-piece design allows the changes in the front of the jaw (chin) and the back of the jaw (jaw angles) to be connected in a smooth linear fashion.
While the one-piece design of the implant has numerous aesthetic advantages, it does pose a unique intraoperative challenge. How does such a jawline implant get inserted? The sheer size of the implant is completely different than much smaller chin and jaw angle implants which are placed through single incisions.
The custom jawline implant is usually placed through a three incisional approach. There is the two intraoral posterior vestibular incisions and the anterior chin incision. The chin incision can be done either through the skin under the chin or from inside the mouth. Through these three incisions a subperiosteal tunnel is made that connects them going under the exit of the mental nerve from the bone. The custom jawline implant is positioned into place by passing the back parts of the implant through the chin incision
The size of the jaw angle part of the implant determines how easy or hard the custom jawline implant placement technique is. If the jaw angle implant part is very large it may be impossible to pass it under the tunnel that connects the chin and the jaw angle without significant risk of injuring or even tearing the mental nerve.
In these cases the custom jawline implant is split in the middle and each half passed from back to front. Since the chin segment is smaller it passes easier through the subcutaneous tunnel and poses less risk of injury to the mental nerve. The implant halves are then reunited in the midline using either sutures or screws.
Background: Facial reshaping surgery is a broad collection of bone augmentation and reduction procedures. Almost all of the facial bone augmentation procedures are done by some form of onlay augmentation, most commonly preformed by preformed implant styles. Of all available facial implants the four most common areas augmented are the chin, nose, cheek and jaw angles. All of these represent facial projection points where augmentation can make a big difference on the perception of the face.
Of all available facial implants the hardest ones to choose a proper style and then surgical place are the cheeks and jaw angle locations. Cheek implants are technically easier to place but getting the right style of implant can be difficult as they are major gender aesthetic differences in this part of the midface. Jaw angle implants have less style choices but is very hard to place and position on the bone properly and are highly prone to malposition.
The success of facial implants is most fundamentally controlled by the style and size of the implant chosen. A perfectly performed facial implant placement that heals without complications may be viewed as a surgical success. But if it fails to meet the patient’s facial change goals it is still an aesthetic failure. Case Study: This 36 year-old male had a prior history of standard cheek and jaw angle implants placed one year previously. The implant creased undesired facial shape changes. The submalar cheek implants created a more feminine ‘apple cheek’ look rather than the high cheekbone look he desired. He had high jaw angles but widening jaw angle implants were used. This made his face look look wide and fat. A 3D CT scan showed that the implants were well placed but they simply were the wrong style and size. New custom cheek and jaw angle implants were made that were designed to create a high cheekbone look and vertical lengthening of the jaw angles. The differences between the old and the new custom implants can be seen in the 3D overlay. Under general anesthesia a complete intraoral approach was used to remove the old implants, perform capsulectomies, extend the pockets and place the new implants. The horizontal portion of the chin part of the jawline was removed as that the chin ended up more square but did not additional horizontal projection.
How to choose proper facial implant style and size is not only not an exact science, it is really not something that any plastic surgeon learns to do in their training. It is still a judgment by the surgeon who tries to understand the patient’s facial goals and then makes an aesthetic judgment about implant selection. Highlights:
1) Facial reshaping surgery often includes cheek and jaw implants.
2) Incorrect styles of cheek and jaw angle implants can lead to undesired facial shape changes.
3) Certain types of facial reshaping changes requires custom cheek and jaw implants to achieve the patient’s desired aesthetic result.
Dr. Barry Eppley
There are a variety of aesthetic ribcage modification procedures that are not well known. When people speak of ‘rib removal’ this is commonly perceived as a procedure for waistline reduction through removal of portions of ribs #11 and 12. (and sometimes #10) While this is certainly true this is not the only rib removal procedure done for aesthetic body contouring benefits.
Another type of rib removal is that of the ‘rib shave’. This is technique that is used almost exclusively on the anterior ribs along the subcostal margin. The subcostal rib area is composed of ribs #7, #8 and #9 and makes up the bottom of the curved ribcage at the upper abdominal region. In some individuals the subcostal rib may protrude out in an abnormal fashion. When present this often occurs only one side creating an obvious asymmetry.
Reduction of a prominent subcostal margin can be done by either rib removal or a rib shave. Which approach is most appropriate depends the amount and location of the subcostal protrusion. The more medial (closer to the sternum) the protrusion is or the minor that it is a rib shave is usually most effective. The more lateral or larger the subcostal protusion is then removal of portions of ribs #8 and #9 may be needed. In some cases of subcostal protrusions a combination of rib removal and rib shave may be needed.
In a rib shave a very small subcostal incision (3 cms) can be used right along the prominent area. Once through the rectus muscle by a splitting technique the subcostal rib margin is easily accessed for modification.
Dr. Barry Eppley
Posted in rib removal | Comments Off on OR Snapshots – Subcostal Rib Shave
Background: Osteomas are the most common bony tumor of the craniofacial skeleton. They are benign bone growth that is typically seen growing on another piece of bone. They appear as an outcropping or ‘mushroom’ of slowly growing bone and are easily disinguishable by appearing as a hard bump on an otherwise smooth bone surface. This makes them very identifiable on the skull where such bumps appear evident even when they are small.
Their are various causes of osteomas but the most common one is a history of prior trauma. Low impact blunt trauma to the skull is common since the head is a large object that frequently is inadvertently hit. If the head is struck in just the right location with enough force a perforating blood vessel may bleed and create an external bruise.When blood gets under the periosteum it can serve as a trigger for bone growth.
Case Study: This 56 year-old female had a large bump of the left brow bone that began over 17 years when she was accidentally struck by an attic door on her forehead. She developed a large bruise from which a small bump eventually grow to the big bump now seen. It has finally gotten big enough that she could no longer hide it. A CT scan showed that it was an outcropping of bone emanating from the outer cortex of the brow bone.
Under general anesthesia the brow bone osteoma was approach through a hairline (pretrichial) incision directly above it. Through a subperiosteal tunnel of the forehead skin the osteoma was exposed and dissected off of the overlying scalp tissues and the supraorbital nerve. An osteotome was used to separate it from the normal surrounding bone. The osteoma was composed of poorly calcified bone that was softer than normal skull bone.
The removal of forehead osteomas are often dramatic as the removal of a large bump on the upper face resumes a normal appearance. The removal of a benign bony tumor should be done, if possible, through a discrete incision to avoid creating any adverse aesthetic trade-offs. Incisional approaches include a direct incision (right over it) and the remote approaches of a pretrichial or scalp incision.
1) Osteomas are benign bony tumors that are common in the craniofacial region.
2) Forehead osteomas are often the result of prior trauma and are slow growing over many years.
3) Forehead osteomas can be removed through either a hairline incision or an endoscopic approach further back in the scalp.
Background: Breast implants are known to have a limited lifespan due to potential disruption of the implant shell. But as long as the implant shell remains intact the volumetric effect of the implants persist. Yet while breast implants remain stable the long-term effect of the appearance of the breast changes many years or decades later.
Whether a woman has an implant in or not, the breast tissue and skin envelope changes. Breast tissue may be lost and the skin will develop some sag. This effect is accentuated with pregnancies and weight gain/loss. The presence of implants may delay or blunt these body-related changes but they almost always occur. Over time the natural breast tissue may slide off of the implant as the tissues weaken and the breasts will look much less perky.
With these breast changes women may seek to exchange their breast implants for larger ones to get a breast rejuvenation effect. The question is what size increase is needed to see a visible change.
Case Study: This 44 year-old female had 350cc saline breast implants placed twelve years ago. She had two subsequent children and then lost some weight as she became much more of a fitness enthusiast. While her saline implants remained intact her breasts had developed some sag and she felt they had lost overall size. She wanted new breast implants that produced a dramatic change in implant size and upper pole fullness.
Under general anesthesia through her existing areolar incisions, her saline implants were removed and replaced with 700cc ultra high silicone implants into her existing submuscular pockets.
When replacing breast implants for a larger and fuller look, it takes more increased volume than one would think. Of course it depends on what final breast size one wants but anywhere from a 50% to 100% volume increase is needed. That could be anywhere from 150 to 300ccs for most women.
1) As long as breast implants remain intact, they maintain a persistent volume.
2) The tissue around breast implants does change over time through some loss of volume and tissue sag off of the implants.
3) To re-expand saggy breasts with new implants a much larger breast implant size must be chosen than one may think.
A gummy smile or excess gingival exposure is well known to be the result of vertical maxillary bony excess. Corrective methods include a maxillary impaction procedure or soft tissue lowering gummy smile procedures. Both approaches have their indications and are most commonly used in Caucasian patients.
In the December 2016 issue of the Annals of Plastic Surgery an article entitled ‘Correction of Midface Depression Using An Inverted M-Shaped Expanded Polytetrafluoroetylene Implant Improves Gingival Exposure’. The authors have previously observed a correlation between gingival excess and midfacial depression in Asian patients. Over an eight year period they treated 42 patients with excessive gingival exposure with varying degrees of midface depression with an inverted M-shaped ePTFE implant placed at the base of the pyriform aperture at the bone level.
Based on before and after pictures as well as measurements of upper lip length, nasolabial angle, and facial convexity angle, the results of the midface implant was assessed. The average maximum gingival exposure was around 5.5mms (± 1.5 mm) before surgery which was significantly decreased to less than 2mms at 6 months after surgery. The nasolabial angle was improved from 85° to 95° in some patients. Most patients rated their postoperative results as highly improved. Temporary and typical postoperative findings were upper lip numbness, foreign body sensation, and a stiff smiling. These symptoms resolved after three months. No infections or implant extrusions were seen.
This paper shows that in cases of midface depression excessive gingival exposure can be reduced by pyriform aperture implant augmentation. This approach appears to offer a safe and effective treatment option with a high level of patient satisfaction.
Dr. Barry Eppley
Posted in facial implants | Comments Off on Pyriform Aperture Implant for Excess Gingival Show
Background: An aesthetically displeasing size of the head can occur at various skull areas. One such area is at the side of the head most commonly located above the ears. When it is too wide there is a noticeable convexity or bowing out of the temporal region above the ears. A more aesthetically pleasing shape at the side of the head is more of a straight line or one with a minimal convex shape to it.
Because the temporal region is located on the side of the skull it is logical to assume that it is bone and can only narrowed by bone reduction. But careful analysis of many CT scans reveals the thickness of the posterior temporal region above the ears is about 50:50 bone and muscle. The thickness of the posterior temporal muscle is a lot thicker than most would think. In men it is 7 to 9mm thick while in women it can be 5mm to 7mms thick.
Thus removal of the posterior temporalis muscle offers an effective treatment strategy for narrowing the side of the head. It can also be done with less scar that would be required for temporal bone reduction.
Case Study: This 36 year-old male wanted to reduce the fullness on the sides of his head. A CT scan revealed that the side of the head above the ears had a sufficiently thick muscle layer that could allow for a significant reduction.
Under general anesthesia a straight 5 cm long scalp incision was made just above the ears. The temporalis fascia was split through which the entire posterior temporalis muscle was removed. Closure of the incision made for an inconspicuous scar line.
Bilateral removal of the posterior temporalis muscle bellies changed the shape of the sides of his head from convex to straight. With muscle thicknesses that average 7mms, bilateral removal can result in a transverse head width reduction of up to 1.5 cms. This demonstrates that temporal bone removal may not be necessary to achieve a visible head width shape change.
1) The wide side of the head is aesthetically determined by an increased convexity above the ears.
2) An increased head width above the ears is caused by both increased bone thickness and muscle thickness.
3) Head width or temporal reduction is best done by removal of the entire belly of the posterior temporal muscle.
There are numerous options for elective plastic surgery of the male genital region. Various penile lengthening and enlargement procedures, testicular implants and scrotal lifts are all options for the man who seeks penoscrotal enhancements.
The size of the scrotum is largely determined by what lies within. The size of the testicles is largely responsible for the scrotal sac size. But the size of the testicles can not be increased naturally through hormone supplementation or other non-surgical methods. There is the concept of wrapping a shelled out testicular implant around the existing testicle to increase its overall size as one surgical option.
The other surgical option for scrotal enlargement are fat injections. Just like fat injections are used all over the body for soft tissue augmentation, they can be safely inject intothe scrotum as well. The scrotum is not known as a large repository of fat but it does have fat amongst its various tissue layers.
Given its relatively small body size and the low volume of fat that need to be injected, fat survival in the scrotum would be expected to be high. Using blunt cannulas and low pressure injection, fat can be safely placed through the scrotum without injury to testicles or the vas deferens.
Besides scrotal enlargement, one other invaluable use of fat injections to the scrotum would be in preparation for testicular implant placement when one has had prior irradiation. Fat injected into tissues that have been irradiated is well known to improve its vascularity and make it more amenable to surgical manipulation with a lowered risk of healing and infectious complications.
The use of implants for chin augmentation is the most popular method to achieve enhanced projection of the lower face. Many materials have been used for chin implants and today it usually comes down to the use of either a silicone or Medpor material. There are surgical advocates for both types of chin implants and both can be successfully used under the right circumstances.
Where silicone and Medpor chin implants differ dramatically and unequivocally is if the patient wants the implant removed. The aggressive tissue ingrowth into the Medpor material makes its removal difficult and fairly traumatic to the surrounding tissues. I have read some surgeons who say the material can’t be removed. This is not true, it is just that it is much more difficult than the easy removal of silicone implants.
If a Medpor chin implant is removed, there is often the need to replace it. The question is what should that be. That depends on why the implant was originally placed, its size and shape, and what the patient’s aesthetic goals.
In this example a small petite female with a very short chin and high jaw angles had a Medpor chin implant placed. The implant produced numerous adverse aesthetic sequelae including a wide and elongated chin. Through an intaoral approach the Medpor chin implant, which was secured by 6 screws, was able to be removed in many pieces. The tissue ingrowth of the wings of the implant had adhered to the mental nerves which required careful separation to avoid nerve avulsion. The chin augmentation replacement was a sliding genioplasty. This brought the chin forward, made it less wide and vertically shortened it as well.
While chin implants are made of different materials, their effectiveness is best determined by the selection of implant style and size. It is important that chin augmentation in females is seen as aesthetically different than that of men. The type of chin implant style that works well in men often does not in females.
Septal perforations are a risk of any nasal surgery in which septal cartilage is removed. Whether it is done for correcting a septal deviation or harvesting a septal graft for support in rhinoplasty surgery, loss of the cartilage ‘wafer‘ between the two sides of the mucosa risks a through and through defect to occur
While not all septal perforations are symptomatic or need repair, when they do they are very challenging to do successfully. The many methods described for septal perforation repair from synthetic buttons to grafts, and their varying rates of success, speak to this challenge.
In the November 2016 issue of JAMA Facial Plastic Surgery, an article was published entitled ‘Use of Costal Perichondrium as an Interpositional Graft for Septal Perforation Closure’. In 51 nasal septal perforation patients, the use of costal perichondrium as an interpositional graft with bilateral mucosal flaps was used for the repair. Forty-four (44) of these patients actually underwent closure with this technique which was successful in 42 patients (95%) over an 18 month followup period. Regardless of the septal perforation size treated, costal perichondrium as an interpositional graft aided in the rate of successful closure of the treated septal perforations.
While the technique and experience of the surgeon should not be minimized in the treatment of the septal perforation problem, what is it about costal periochndrium that may make it better than other autologous or allogeneic grafts? Since it requites a small chest incision to harvest it had better have some favorable biologic characteristics.
Costal cartilage is a composite structure composed of cartilage surrounded by a dense tendon-like perichondrium. Costal perichondrium is very different than nasal perichondrium because it is much thicker as it provides some mechanical benefits to the ribcage. Studies have shown that it adds up to 50% more resistance to bending forces across the costochondral junction. This stoutness means it is thick, can hold sutures if needed and be more quickly revascularized than thinner fascial or thicker cadaveric dermal grafts. This means that it may hold up well even if the mucosal flaps break down.
Dr. Barry Eppley
Posted in rhinoplasty | Comments Off on Nasal Septal Perforation Repair
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.