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.
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.
Background: There are a wide variety of congenital ears deformities that involves either deformed or missing natural cartilage structures of the ear. One such well known deformity is that of the Stahl’s ear. This consists of an ear that has a pointy shape due to an extra fold or third crus in the scapula. It is often referred to as a Spock part in reference to the Star Trek TV character.
Stahls’ ear is primarily caused by the ear cartilage being misshapen. The upper ear usually has two distinct folds known as a superior and inferior crus. But in Stahl’s ear a third crus or fold occurs. This causes the outer rim of the upper ear to fold inward giving it a pointed shape.
If recognized very early after birth, external ear molding devices (e.g., Earwell) can correct the misshapen ear as the young ear cartilage is very flexible and moldable. But once one passes six to weeks after birth the ear loses its responsive to external molding forces and surgery becomes the only treatment option.
Case Study: This 12 year-old male had misshapen ears that he disliked. The upper outer helical rim was bent over or folded in. This created a pointed shape to his upper ears. He had been given the diagnosis of Stahls’ ear although it was not a classic presentation of it.
Under a general anesthesia an incision was made on the back surface of the ears. This allowed the helical rim skin to be dissected off the cartilage and expose the upper ear cartilage shape over the deformed area. Radial cuts were made in the cartilage to allow it to unfurl and create a more defined outer helical rim. To support this new shape a cartilage graft from a small piece of rib #9 was used by suturing it on the inside of the newly formed helical rim. On the right ear a small wedge of cartilage and skin was removed to bring down the height of the helix.The skin was then pulled back over the reconstruction and closed with dissolvable sutures.
His immediate intraoperative result showed improvement in the shape of ear through recreation of a more defined outer helical rim. While many techniques for Stahl’s ear correction have been described they all rely on innate cartilage reshaping alone. Add a small cartilage graft can help support these cartilage reshaping efforts.
Stahl’s ear is a congenital deformity marked by an abnormal fold in the upper ear which makes it pointy.
Reconstruction they deformed upper ear requires cartilage reshaping which often requires the use of a cartilage graft for support.
A small piece of rib #9 can be used for a strong and curved cartilage graft.
The most common method of permanent midface augmentation is that of the cheek implant. Cheek implants have been around for decades and have evolved into a wide variety of styles and sizes. Their fundamental designs have been to augment the prominence of the cheek bone (malar region), the underside of the cheek bone (submalar region) or both. (combined malar-submalar shell or midface implant).
Despite being an adjoining anatomic region to the cheeks and having a smooth skeletal connection, the infraorbital region (undereye area) has been relatively neglected. While there are tear trough implants that can augment the front of the lower eyelid rim, they do not create a smooth and seamless flow into the cheeks nor do they sit on top of the infraorbital rim and increase its vertical height.
The combined infraorbital rim-malar implant augments the anterior cheek (malar region) and the infraorbital rim. For those patients that have a tired look due to an infraorbital-malar skeleta) deficiency (undereye hollows), a unified one-piece implant can be a good solution. It provides a smooth connection along the lower orbital rim into the cheek and provides a more complete correction of the undereye hollow problem. It is best placed through a lower eyelid incision to get optimal fit along the infraorbital rim which is best done from a superior approach.
While there are numerous injectable materials to fill in undereye hollows, which can be very effective for many patients, an implant can provide an alternative treatment option. But not just any implant design will do and there are no standard undereye hollows implant designs currently available. This special design of mine, technically known as the infraorbital-malar design or undereye hollows implant, can provide an effective and permanent option in the properly selected patient. It provides a more complete correction of the underlying skeletal cause of undereye hollows.
Background: The facelift is a well known surgical rejuvenative procedure that primarily creates a smoother jawline and a more defined cervicomental angle. For some facelift patients the addition of a chin implant, if their chin is short, helps improve the jawline by adding increased projection at its anterior edge. This is why many facelifts particularly in women also include a chin augmentation.
While chin augmentation provides an aesthetic benefit to the front end of the jaw during a facelift, the rest of the jawline remains neglected. Some aging patients have weak or high jaw angles. Pulling the facial skin back up and over a weak posterior jaw angle fails to make it more defined. It often only gives it a sweeped look from the skin pull.
Like chin implants, jaw angle implants have a role to play in facial rejuvenation and facelift surgery. Their only drawback is that they will cause a moderate amount of facial swelling over the posterior part of the face during the early recovery period. Good compression facial dressings during the first few days after surgery is very helpful in this regard.
Case Study: This 68 year-old female wanted a lower facelift to remove loose skin along the lower part of her face and give her a more defined jawline. But she had a high and ill defined jaw angle area and opted for the placement of jaw angle implants at the time of her facelift.
Under a general anesthesia and through an intraoral approach, small vertical lengthening jaw angle implants were initially placed. Thereafter a lower facelift was performed with SMAS plication. Her long-term results show improved jaw angle definition and a well defined jawline from chin back to the ear.
Like chin implants, jaw angle implants are aesthetically beneficial in a minority of facelift patients. But in the properly selected patients and in thinner faces, they can add bony definition of the lower face which has a distinct rejuvenative facial effect.
Augmentation of the jawline at the time of a facelift or after has long been recognized as an aesthetic benefit.
Creating a more defined jaw angle builds up the back part of the jawline.
Most jaw angle enhancements in aging require a vertical jaw angle implant style.
Background: Ear reconstruction is most commonly done using autologous graft materials. Whether it is microtia reconstruction using rib cartilage in children or adult ear reconstruction using cartilage grafts and pedicled skin flaps, the patient’ own tissues offer the least risk of postoperative complications and should be done when possible.
The use of synthetic frameworks or implants for ear reconstruction has its origin and current use with Medpor material. Most commonly done as an alternative to the use of rib cartilage in congenital microtia deformities in children, it offers a premade and well shaped ear implant. As a substitute for a hand-carved rib cartilage ear framework, it requires vasculrized tissue cover using the temporalis fascial flap (TPF flap) covered with a split-thickness skin graft. Its benefits is that it usually creates a much better shaped ear in the end and does so in less operative time with no need for a rib graft donor site.
While Medpor ear frameworks are effective, the material itself does not replicate very well the physical characteristics of natural ear cartilage. It is much more stiff (in fact rigid) and lacks any substantial flexibility. While creating a nice ear shape it does not create a good feeling ear. This stiffness can make the Medpor framework ear prone to occasional discomfort and skin breakdown due to pressure or trauma.
Case Study: This 78 year-old male has multiple basal cell skin cancers on his left ear on both front and back ear surfaces. It was decided that the best treatment for his ear cancer was near amputation. He was interested in a synthetic ear implant as opposed to a rib graft. Under general anesthesia he had a subtotal ear resection preserving the superior helical root, concha and earlobe.
Using an ePTFE coated composite ear implant, it was carved into a shape replicating the portion of the ear cartilage removed. This was then sutured to the remaining ear cartilage.
A TPF flap was raised through a vertical incision above the ear. It was folded down over the ear framework, preserving its temporal vascular pedicle, and sewn into the tissue edges around the remaining ear. A split-thickness skin graft was harvested from the thigh and laid over the TPF flap and sewn into place.
With healing time and tissue contraction, the details of the ear framework will eventually become more apparent through the applied vascular cover. In the long run the reconstructed ear will have a more natural feel due to the inherent softness of the ePTFE material.
Synthetic ear reconstruction relies on the use of a Medpor ear framework covered by a fascial flap and skin graft.
A new synthetic ear implant made of a composite silicone and ePTFE coating offers a softer and more flexible design.
Composite ePTFE ear frameworks offer a carving feel that is identical to that of natural rib.
Background: Males almost always have much more pronounced brow bones than females due to a greater pneumatization effect of the frontal sinuses. Numerous studies have shown that the male frontal sinus is bigger, usually asymmetric and has a bigger left side than that of the right. This is clinically evident in the external shape of the forehead with greater supraorbital protrusions than females.
Why some men get much bigger and disproportionately larger frontal sinuses and subsequent brow bone protrusions is not known. Whether this is due to hormonal influence, masticatory loading forces or an increased developmental effort to separate the brain from the eyes are theories that have all been espoused. Regardless of its cause, the enlarged male brow bone often produces a dramatic effect that can be enhanced by a backward sloping forehead.
The male brow bone is reduced with several basic tenets in mind. First, simple burring is inadequate for a major brow bone protrusion. The anterior table of bone is not thick enough to allow for a significant reduction and the maintenance of a bony covering of the frontal sinus air cavity. Second, the male brow bone should be so reduced that the foreflat has a completely flat profile. Some degree of brow bone break into the upper forehead needs to be maintained.
Case Study: This 30 year-old male had been bothered for a long time by the shape of his forehead. He had a very strong brow bone with two very distinct paired brow protrusions with a midline glabellar groove. The size of the brow bones was magnified by a backward forehead inclination of almost 45 degrees.
Under general anesthesia and using a near complete coronal scalp incision, his forehead and brow bones were exposed. A reciprocating saw was used to remove the anterior table of the frontal sinuses at the level of the surrounding forehead. Osteotomes were used to make the final bone elevation to preserve as much of the underlying sinus mucosa as possible. Burring was then done all around the bone edges as well as down into the frontonasal angle.
The removed bone segments were thinned and reshaped and the put back into the frontal sinus. (setback) They were secured using small plates and screws to maintain bone contact as well as prevent any inward displacement.
The immediate change in the forehead profile was evident but not over flattened.
The osteoplastic setback technique for male brow bone reduction is the gold standard by which it is done. Whether it can be done by a single piece of bone across the frontal sinuses or whether it needs to be done by two separate bone pieces depends on the patient’s anatomy.
Most brow bone reductions in men require an osteoplastic setback technique.
Removing the anterior table of bone from the frontal sinus by osteotomy with surrounding burring produces the best brow bone reduction effect.
Male brow bones should be only reduced to the point of leaving some brow bone break to avoid overfeminization of the forehead.
The use of rib cartilage in rhinoplasty is that it provides a virtual unlimited amount of graft material. Its use is most commonly indicated for significant nasal augmentations particularly in certain ethnic noses that lack overall nasal projection as well as in major nasal reconstructions. It is probably underutilized as a donor site as many rhinoplasty surgeons may not feel that comfortable with its harvest and patients are often not enthused about its use either.
In the March 2017 issue of the JAMA Facial Plastic Surgery Journal in the Surgical Pearls section, an article was published entitled ‘Technique to Reduce Time, Pain and Risk in Costal Cartilage Harvest’. In this paper the authors describe their technique which fundamentally involves two steps for improving costal harvest in rib graft rhinoplasty. First, don’t take a full thickness cartilage graft. It is an in situ technique where the rib is sectioned longitudinally at a partial thickness level of the rib between a proximal and distal cartilage cuts. Secondly, intercostal and soft tissue injections are done using a long-lasting local anesthetic (Exparel) to decrease postoperative pain.
The risk of pleural violation and potential pneumothorax are the dreaded complications of rib harvest. But the reality is that risk varies depending upon where on the chest wall that rib is being harvested. This is a real risk above the level of rib #6 but not down at the level of ribs #s7, 8 or 9. In smaller rib grafts any form of in situ rib harvest makes it both safer and easier to do. But in larger rib graft harvests an in situ approach may not allow for an adequate graft harvest. But, when possible, it is a good technique and I have used it many times. I usually take a triangular wedge along the graft length which can more easily be cut with a standard #15 scalpel blade.
The more recent use of Exparel injections for a prolonged time period of pain relief in the early recovery phase over the traditional use of Marcaine injections has its merits. This is one of the few areas in plastic surgery that has proven to me that Exparel is truly more effective. Having done many bony rib removals for body contouring (6 or ribs at at a time) Exparel has shown remarkable effectiveness in this ‘ultimate test’ of pain relief in aesthetic surgery. Thus it would be equally useful when just one subtotal cartilaginous rib is being harvested for rhinoplasty. It has a significant cost increase over that of Marcaine in the aesthetic patient but I have never found that to be a rate limiting step for its use in any aesthetic patient.
Dr. Barry Eppley
Posted in rhinoplasty | Comments Off on Techniques in Costal Harvest in Rib Graft Rhinoplasty
Temporal augmentation is most commonly done by injection techniques using synthetic fillers or fat. While offering a non-surgical approach, their results are often not permanent and the temporal contour may be uneven or asymmetric. More recently developed temporal implants offer an assured volume and a smooth temporal contour result. Placed through a small incision inside the temporal hairline, they are inserted and positioned in the subfascial plane on top of the temporalis muscle.
While the temporal area is not dimensionally complex, it does have two distinct aesthetic zones which are important to distinguish before surgery. In mild to moderate cases of temporal hollowing, the indentation is seen lower right next to the side of the lateral orbital rim and down to the zygomatic arch. This is known as a Zone 1 temporal deficiency, the most common seen, and is treated by a standard temporal implant. When the temporal hollowing is more severe the deficiency will go all the way up the temporal line at the side of the forehead. This upper aesthetic temporal area is known as Zone 2. Some patients refer to Zone 2 as the ‘side of the forehead’ although anatomically it is the upper temporal zone. Its augmentation requires an extended temporal implant that covers both Zones 1 and 2.
The extended temporal implant has a greater vertical length than the standard temporal implant. It provides augmentation from the side of the forehead down to the cheek. It is a complete temporal implant. It is still placed through a small vertical temporal hairline incision. It is also easily adjustable to reduce its vertical length, shape or thickness as needed.
It is of critical importance to preoperatively determine the patient’s temporal augmentation needs by zone to avoid having an inadequate temporal augmentation by using the wrong implant style.
Background: Aesthetic skull deformities occur in a very wide degree of severities and presentations. While many think that such skull shape issues are probably large and obvious, I have found that some are quite small and often obscure to the casual observer. But to the patient smaller skull defects can be just as disturbing as those that can be clearly seen.
One of the common areas of the skull that is often bothersome is the back of the head. While complaints may be of its size, too big or too flat, there are an equal number that relate to its symmetry. One side of the back of the head being flatter than other, often referred to as plagiocephaly, is a condition that I commonly treat. Whether the patient can see it because they have a shaved head or closely cropped hair or whether they can simply feel it through good hair cover, I have seen patients opt for treatment in either an exposed or camouflaged skull shape.
It is not clear why a skull area that is the hardest for some patients to see can be a source of aesthetic anxiety, but it can be. Since custom implants is now the standard way to treat any broad-surfaced area skull deformities, it becomes possible to effectively treat even the smallest of such skull shape deformations.
Case Study: This 57 year-old male had been bothered for a long time by the shape of the back of his head. There was a dip on the upper right occipital skull and a modest protrusion on the left side. Using a 3D CT skull scan, a small right occipital skull implant was designed to precisely fill the bone dip.
Under general anesthesia and in the prone position, a bilateral occipital skull reshaping procedure was performed through a 7 cm long low horizontal scalp incision. On the left side the bony prominence was reduced by burring along the nuchal ridge. On the right side the custom skull implant was inserted and oriented through implant markers and secured with two microscrews.
Small skull contour defects can often be the hardest to improve without creating other aesthetic issues. As a general rule the smaller the defect the more precise the contour restoration must be. Anything short of near perfection can just be another aesthetic concern. Custom designing the implant creates the best chance of minimizing these potential iatrogenic aesthetic concerns.
Rejuvenation of the aging face can be done by a variety of treatment strategies. This is no better illustrated than in the differences between the traditional facelift, that has been around for over one hundred years, and the more newly marketed ‘liquid facelift’.
The traditional or truly surgical facelift works by removing excess skin and tightening the underlying layer of tissues in the neck and along the sides of the face. It remains the gold standard in surgical facial rejuvenation because it treats the primary cause of droopy necks and sagging facial tissues. Its effects can be dramatic albeit surgical with all the risks and recovery that goes with the process.
The liquid facelift has emerged as a result of the widespread use of synthetic injectable fillers which explains it as a more recent treatment offering. Adding volume under the skin through a wide variety of filling techniques and materials remains the backbone of how it works. By plumping up the skin from the jawline to the cheek and even up into the brows the skin is pushed outward and to some degree upward. This plumping effect is what creates any amount of a facelifting effect and is done so in a non-surgical fashion as an office procedure without recovery and minimal downtime.
The liquid facelift has evolved into many variations that differ based on each physician’s own protocol. These can include mixing the injectable fillers with fat or platelet-rich plasma. (PRP) Various topical therapies are often done at the same to treat the overlying skin such as Botox injections, laser resurfacing, chemicals peel and microneedling.
The liquid facelift is usually best done on younger patients who have the early signs of aging and often serves a ‘bridge’ until a surgical facelift is needed when one is older or is ready for a more invasive procedure. It is not an advised primary treatment for older patients with significant loose tissue in the neck or on the sides of the face. This is where a traditional facelift is indicated and produces far superior effects and is a better return on one’s investment. Patients that have had a traditional facelift that needs some maintenance treatments, however, may be good candidates for a liquid rejuvenative approach.
Like any form of a facelift, none produce permanent effects. They treat the symptoms of aging but do not cure the fundamental problem. Any facelift that removes tissue and/or resuspends it will have results that persist for years. Liquid facelift have far shorter facial rejuvenative effects often limited to the duration of the injected filler material. (one year or less for many injected fillers)
Dr. Barry Eppley
Posted in facelift | Comments Off on Liquid Facelift vs Surgical Facelift
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.