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.
August 15th, 2016
Temporal muscle removal has been shown to be effective at head width reduction. By removing the posterior temporal muscle belly, which is much smaller than the larger anterior temporal muscle and sits above the ears, a round or convex head shape can be narrowed. Interestingly the removal of this portion of the temporal muscle has no adverse effects on jaw function.
But for those who have a wide head width, the anterior temporal muscle may also be too thick. This creates a temporal convexity by the side of the eye in which a slight temporal hollowing is often aesthetically preferred. Such anterior temporal convexities seem to be an exclusive male aesthetic trait that is often seen in certain ethnicities. (e.g., Asians, Blacks)
The treatment of a large anterior temporal muscle is with Botox injections rather than surgery. Debulking the anterior temporal muscle is much more potentially problematic than that of the posterior temporal muscle. It is a hard area to access without more prominent incisions and the thickness of the muscle makes thinning it difficult.
One approach to anterior temporal reduction is that of a temporal lipectomy. There is an extension of the buccal fat pad that does reach up into the anterior temporal region. But it is often not that large and usually only affects the lower temporal region.
An alternative approach is a high temporal release along the bony temporal line. This is the transition between the true bony forehead and the lateral muscular forehead. (high anterior temporal region) This distinct bony ridge is where the temporalis fascia attaches and the muscle ends. By disinserting the fascia and releasing the muscle attachments at this level, the temporal muscle will develop some atrophy and thinning. This will occur at the upper portion of the anterior temporal area and not down by the zygomatic arch. This can be done through a small scalp incision just behind the frontal hairline.
This high frontal approach to anterior temporal reduction is most appropriate for those patients who are bothered by fullness to the side of the forehead. It will not reduce temporal fullness down by the zygomatic arch where eyeglasses would traverse.
Dr. Barry Eppley
August 14th, 2016
Skull reconstruction in young children is almost always done by bone reshaping operations. For common craniofacial deformities like numerous forms of craniosynostosis, the deformed bones are removed and put back in a reshaped fashion to allow for brain growth to continue to mold the developing skull shape. But once the child reaches several years of age treating many skull shape issues is beyond what bone reshaping can reliably do both technically and risk-wise.
This issue of what to do with abnormal skull shape issues, either unoperated on or persistent issues after reconstruction, has always been a bit of a dilemma. In essence how to treat skull contour issues that can not or do not justify a craniotomy and bone reshaping approach. Ideally one would want to use bone grafts but they are both unreliable as a contour method and require a harvest site.
The synthetic bone substitute, hydroxyapatite cement, offer an alternative to the use of bone grafts. As a synthetic calcium phosphate material, it avoids the need for a harvest site and is an easily moldable putty that is applied and allowed to harden. It has been around from various manufacturers for over twenty years. It was originally and still is FDA-approved for inlay (partial or full-thickness) cranial defects. While it is widely used as an onlay bone contouring material as well I am not aware that it has ever been formally FDA-approved to be used as such.
I have used hydroxyapatite cement in children as a cranial contouring materials now for almost two decades. I have found it to be very useful as skull contouring technique and have never seen a single postoperative problem develop from its use. My original animal studies from way back in 1996 showed that bone started to develop growth along the sides of the material in less than three months after its application. But there has always been the unknown issue of what is its fate decades later and does it in any way cause skull growth issues? The assumption has been that it becomes surrounded by natural bony overgrowth and grows along with the surrounding bone.
A recent patient experience provides some insight into the long-term fate of hydroxyapatite cement. I performed a hypertelorism repair in a 3 year-old child back in 1996. One year after that surgery he has some additional contouring of the brow bones and lower forehead using hydroxyapatite cement. Almost twenty years later he reappeared and wanted some additional forehead, brow and nose contouring surgery. Using his original scalp incision the forehead and brows were exposed and the original hydroxyapatite cement sites were examined. They looked like perfectly normal bone. In comparing the original intraoperative pictures to the present day ones, the hydroxyapatite cement seems to have turned into bone.
While I did not dig into the original implanted site to know for sure, I would think the cement had developed bony overgrowth rather than was replaced by bone. At the least this shows that hydroxyapatite cement in growing children’s skulls appear to be very well tolerated without any adverse growth or bone effects. While this is just a single case observation it does support my original assumption about the long-term fate of hydroxyapatite cements when used as an onlay contouring material in growing skull sites.
Dr. Barry Eppley
August 14th, 2016
Background: Faces are well known to come in a wide variety of shapes. One of the well known facial shapes is the square one. The square facial shape is created mainly by the influence of the facial bones. One has to have strong cheek and jawline bones to make such a facial shape….at least in younger and weight appropriate patients. The cheeks and their zygomatic arch extensions must match the width of a strong jawline and jaw angles to create a facial ‘box’ appearance
In women the square facial shape can be very attractive and there are numerous examples of famous women who have such a facial shape. It is undoubtably the strong jawline that adds to this attraction. But the one soft tissue feature that they all share is that there is a concavity between the cheeks and the jawline. This is caused by a relative lack of substantial fat in the subcutaneous and deeper tissue planes. In essence the face has a fairly skeletonized appearance.
The aesthetics of the square facial shape can be marred if it has an intervening convexity between the cheeks and the jawline. Such ‘fullness’ can make the square face look less attractive than if there was a convexity present.
Case Study: This 23 year-old female requested fat removal from her face to give a more contoured look. She had a square facial shape with a straight line profile between her cheeks and jawline. She was very weight appropriate for her height.
Under general anesthesia a combination of buccal lipectomies and perioral mound liposuction were done through two separate intraoral incisions. A subtotal buccal lipectomy removed 3 cm diameter fat pads. The microcannula liposuction removed just over 1cc of fat per each side.
At 6 weeks after surgery, her square facial shape shows the desired concavity between the cheeks and jawline. This can her face a more sculpted look. It really takes the combination of both facial fat sites to be removed to create the full effect over the vertical distance between the cheeks and jawline.
1) Thinning of the more square facial shape can be done by decreasing soft tissue volume between the convex skeletal shapes.
2) Creating a facial concavity can be done by buccal lipectomies and perioral mound liposuction.
3) Such facial thinning effects creates a subtle but noticeable facial shape improvement.
Dr. Barry Eppley
August 13th, 2016
Synthetic implants are widely used and important for many types of facial augmentation. Without them many aesthetic facial procedures would not be possible or would be far more difficult to perform and have higher risks. The risk of infection with facial implants is acknowledged by surgeons and patients alike. Fortunately facial implant infections are very low due to the highly vascularized tissues of the face with a risk probability of 1% to 2%. The cause of facial implant infections, like implants infections anywhere else on the body, is the development of a biofilm layer on the implant.
What is a biofilm? In a wet environment bacteria can organize and attach to a solid surface. Once attached they can multiple and create a biofilm layer. The bacteria excrete a material known as an extracellular polymer substance (EPS) which encases the bacteria and helps protect it. It also offers an increased resistance to antibiotics as well as to the bodies own immune responses. This resistance makes it frequently necessary to remove the implant for resolution of the infection.
In the July/August 2016 issue of the JAMA Facial Plastic Surgery journal, a paper entitled ‘Analysis of Facial Implants for Bacterial Biofilm Formation Using Scanning Electron Microscopy’ was published. In this clinical study an analysis was done on seven (7) facial implants that were extracted. This included four (4) silicone and (3) porous polyethylene (Medpor) Implants, most of which were from the nose. (6 out of 7). Scanning electron microscopy images was done to assess for the presence or absence of biofilm formation. All porous polyethylene implants showed biofilm formation to various degrees, some areas were classified as severe. The only 2 implants without any evidence of biofilm were silicone implants. Of the other 2 silicone implants, they had varying degrees of moderate to severe biofilm formation.
This study suggests that smoother surfaced facial implants are less inclined to develop biofilm layers than non-smooth surfaces…and the layer may be less severe. This is well known and undoubtably accounts for the very low of silicone facial implant infections. It should be noted that these are very small numbers of implants evaluated and were almost exclusively from the nose.
It also speaks to the fact that once a facial implant develops, antibiotics alone are not likely to solve it because of the persistent biofilm layer. Either the implant has to be removed or it needs to be removed, cleaned/re-sterilized and then immediately re-inserted for a successful infection resolution.
Dr. Barry Eppley
August 10th, 2016
Background: The appearance of the female nose is quite different from that of men. While it is usually smaller when patient size is relatively comparable, it is more than just a size difference. The female nose is known to have shape changes as well with a lower dorsum, a more narrow tip and an increased nasolabial angle. Often perceived as a more refined nasal appearance it fits better with most feminine faces.
Many females that present for rhinoplasty do not have ‘major’ problems with their nose. They seek a few small changes to have a more refined or slimmer appearance to their nose. While smaller nose changes may appear easier or simpler, that is not necessarily so. The technical aspects of the surgery may be less than in more major septorhinoplasties, but expectations of the result are also more demanding. The patient will be more scrutinizing of every detail and one can not always completely control how the skin will redrape over reshaped tip cartilages or the rotation of the tip.
Case Study: This 23 year-old female requested a rhinoplasty to have a more slim nose. She wanted to get rid of her nasal hump and have a thinner and more upturned nasal tip. She was looking for a more feminine nose.
Under general anesthesia an open rhinoplasty was performed. The nasal hump was reduced, the nasal bones narrowed and the tip cartilages reshaped by suture and the caudal septum trimmed to allow for tip rotation.
At 6 weeks after surgery, her nose shows all of the improvements she was seeking. It will take a full year for the most subtle of nose changes to appear. Although at 6 weeks she probably has about 90% of the results she can expect. the upward rotation of the tip goes a long way in making the dorsal profile lower. While it is not classic rhinoplasty teaching to aim for a concave or more ‘swooped’ dorsal profile, this is nevertheless what some women want for their nose shape.
1) The degree of changes that a rhinoplasty offers to a patient depends on their anatomy and how much change they want to see.
2) For many noses small changes on numerous areas produces an improved and slimmer nose appearance.
3) Rhinoplasty can make the nose appear thinner with a slightly more upturned tip for a more feminine appearing nose shape.
Dr. Barry Eppley
August 10th, 2016
Background: There are many benefits to tummy tuck surgery including a better shaped waistline due to the elimination of loose skin and extra fat. One of the ‘smaller’ benefits is in the creation of a new umbilicus. (belly button) A distorted and misshapen belly button often occurs due to the development of loose skin around it. As a result it can become stretched and lose its original taut and smaller appearance.
The final step in tummy tuck surgery is the creation of new umbilicus. Often referred to as getting a new belly button, this is only partially correct. Actually the original stalk of the belly button is maintained albeit shortened. What is new is the hole that is made through the overlying abdominal skin to bring it back up to the surface of the external abdominal wall.
Located in the center of the stomach, the appearance of the umbilicus is an important aspect of a tummy tuck result. While the size and shape of the belly button has aesthetic appeal, its midline and vertical orientation can be judged to be most important. No matter how good its shape may be, a belly button that is off center or sits too high or low can look odd. For this reason great attention is paid to getting the correct alignment for the placement of the delivery point of the old umbilical stalk. Getting it wrong can be problematic as belly buttons can be very difficult to reposition.
Case Study: This 55 year-old female had previously undergone a full tummy tuck. She was unhappy with the appearance of her new belly button as she felt it was too low. Her skin had relaxed somewhat in the year since her surgery.
Under general anesthesia a ‘mini tummy tuck’ skin excision was performed in the shape of an inverted T. The skin excision pattern included the location of the belly button. The sin closure created a tighter lower abdomen. A new belly button (neoumbilicoplasty) was created at a higher level in the midline of a horizontal line drawn between the iliac crests. The neoumbilicoplasty technique used was a four-flap method tacking the corners of the flaps down to the abdominal fascia. The skin flaps were secured down by a tie-over bolster which stayed in placed for ten days.
All skin flaps survived to create a new belly button in exactly the location where she wanted it. It shows that in some cases the creation of a completely new belly button is better than trying to work with a misplaced and/or distorted one.
1) The umbilicoplasty portion of a tummy tuck is one of the most visible aspects of the result.
2) A malpositioned belly button can be a very difficult problem to solve after a tummy tuck due to the tight skin and the shortened umbilical stalk.
3) In some cases of umbilical deformity a complete new belly button has to be created to put it in the right position. (neoumbilicoplasty)
Dr. Barry Eppley
August 8th, 2016
Augmentative rhinoplasty requires either a graft or implant to perform. In most cases the use of the patient’s own septum or ear donor site is adequate. In more substantative dorso-columellar augmentations consideration must be given to either rib grafts or synthetic implants to achieve the desired effect. In some cases even an amalgamated approach can be used combining an implant (dorsal) with a cartilage graft. (tip)
There are well known advantages and disadvantages to both rib grafts and implants. Neither one is perfect. Rib grafts require a donor site and can be prone to warping. (if not diced) Implants have a higher risk of infection and can become displaced over time.
A third alternative does exist, however, that marries the benefits of both rib grafts and implants….that of cadaveric costal cartilage grafts. Harvested from cadavers through the Musculoskeletal Transplant Foundation (MTF), this allograft costal cartilage has several advantages. It eliminates the need for a donor harvest site which decreases operative time and lessens patient’s postoperative pain and scarring. They are minimally processed which helps preserve their biologic and mechanical integrity. (unlike irradiated or freeze-dried rib grafts from the past)
What is really surgically convenient and for the patient’s benefit is how the form in which the grafts are prepared. They come in either segments or sheets in a variety of lengths, widths and thicknesses. The costal cartilage sheets are greater than 3cms in length, 1 to 2 cms in width and around 2mms in thickness. The costal cartilage segments are greater than 3 cms, have widths up to 3 cms and thicknesses up to 20mms. It has a comparative cost to that of many nasal implants.
The costal cartilage allograft is another augmentative rhinoplasty option between rib grafts and synthetic nasal implants.
Dr. Barry Eppley
August 7th, 2016
The Ideal implant is the first truly new idea in breast implants that has come along in decades. Its innovative internal baffle and dual chamber design allows a saline-filled implant to act more like a silicone breast implant. It has a fairly natural feel and does not develop rippling but also offers the piece of mind of being saline-filled device for those so concerned about silicone. It also will undergo complete deflation if there should be a disruption in the shell due to its two internal chambers.
The FDA has recently changed the Ideal Implant name from saline-filled to that of a ‘Structured Breast Implant’. This name change helps make for a clear distinction between that of the traditional saline breast implant. Now there are officially three types of breast implants; saline, structured and silicone gel.
The Ideal Implant or structured breast implant does not come in every size that is available with the more traditional saline and silicone implants…as of yet. But it does come in a fairly wide variety of sizes from 210cc to 635cc. A new 675cc size will be available shortly. Since one can slightly overfill the implant the range of implant sizes is virtually identical to that of silicone breast implants.
Dr. Barry Eppley
August 6th, 2016
Background: The sliding genioplasty is a well known chin augmentation procedure that is often viewed as a substitute for a chin implant. While this is certainly true in some patients, for other patients it is a better alternative as both an autologous operation and because it can offer some dimensional chin changes that an implant has historically not been able to do.
One dimensional limitation of this bony genioplasty operation is that the amount of horizontal augmentation obtainable is controlled by the thickness of the bone. To ensure bony healing as well as survival of the downfractured chin segment, bone contact must be maintained. This means that the maximal amount of horizontal bone movement is that the back cortex of the mobilized chin segment must stay in contact with the front cortex of the intact chin bone above it.
Because of this anatomic limitation not every sliding genioplasty can achieve ideal chin projection. This leaves the role of a chin implant to achieve an even better chin augmentation result.
Case Study: This 25 year-old female had previously undergone a sagittal split mandibular advancement with a sliding genioplasty. Even with these two combined lower jaw movements, her chin projection remained aesthetically deficient.
Under general anesthesia an intraoral approach was used to access her chin. A extended medium chin implant was placed below the existing metal plate from her prior sliding genioplasty. The implant was positioned lower on the chin bone to help create some vertical lengthening as well. (8mms forward and 3mm down) The implant was secured in its position with two 1.6mm screws at the superior aspect of the implant.
There is no reason that an implant can not be placed on top of a prior sliding genioplasty. This would be the simplest way to improve a prior bony chin augmentation procedure. With the many styles of chin implants now available many alloplastic options exist to change the shape of the prior remodeled chin bone.
1) A sliding genioplasty does not always create the ideal horizontal position of the chin particularly in significant lower jaw deficiences.
2) A chin implant can be a secondary addition to a prior sliding genioplasty.
3) The extended wings of a chin implant can help camouflage any bony irregularities along the jawline from the prior sliding genioplasty.
Dr. Barry Eppley
August 4th, 2016
In Asians double eyelid surgery is extremely common. It is also frequently done in conjunction with medial epicanthoplasty to eliminate the webbing of skin across the inner aperture of the eye. (epicanthal fold) But because many Asian eyes have a short horizontal length from the inner to outer eye corners, extending out the lateral length of the corner of the eye through lateral canthoplasty procedures is also done.
Unlike the medial epicanthoplasty, which does not really touch the inner corner of the eye, efforts at lateral canthoplasty do. Thus they have a higher rate of potential complications that involve separation of lid contact with the eyeball. (e.g. lid margin eversion, webbing) These risks are increased when the horizontal eye length is very short or has a high upturned out corner of the eye.
In the July 2016 issue of the Archives of Plastic Surgery, an article was published entitiled ‘Effective Lateral Canthal Lengthening with Triangular Rotation Flap’. In this paper, the authors describe a lateral canthal lengthening procedure that us both effective and has a very low rate of complications. In this technique a triangular flap 4mm or so away from the lateral canthus was incised and rotated 45 degrees laterally maintaining the continuity of the lower eyelid gray line. A new lateral canthus was created by suturing the rotation flap to the lateral orbital rim maintaining a triangular shape. The procedure was judged successful in 95% of the patients with visible lateral extension. The continuity of the gray line on the lower lid was maintained with a natural-looking triangular shape. The average amount of lateral extension was 3mms. Some minor complications did occur, such as wound dehiscence, webbing, and scarring, but these were stated to be easily corrected.which were easily corrected.
This lateral canthal lengthening technique uses a triangular flap that rotates 45 degrees out laterally to create its effect. Its simplicity avoids most complications and does not need to have a canthotomy to exhibit its effects.
Dr. Barry Eppley