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.
March 24th, 2017
Brow bone reduction surgery reduces the prominence of the lower forehead bone just above the eyes. It is most commonly done in men for large “Neanderthal’ like brow bone protrusions or in male to female transgender facial feminization surgery. Whether it is done using a bone burring method or a more complete osteoplastic bone flap setback technique depends on the thickness of the anterior wall of the frontal sinus and the amount of projection reduction needed.
One aspect of brow bone reduction surgery that can be overlooked is that of the tail of the brow bone. This is uniquely different from the inner half of the brow bone because it is solid bone with no underlying frontal sinus. Whether it needs to be reduced depends on what gender look one is trying to achieve. A more straight brow bone from one side to the other is more consistent with a male with an outward sweep or upwards arch to the tail of the brow bone is perceived as more feminine in appearance.
While the tail of the brow bone should be reduced, if needed, at the time of an open forehead approach from above, it can also be done from ‘below’. Through an upper eyelid incision the outer half of the brow bone can be surgically accessed. Whether this is done for forward projection reduction or inferior bone border elevation depends on the aesthetic goals.
Elevating the lower border of the tail of the brow bone is done to help open up the eyes. By making the vertical distance between the superior and inferior orbital rims longer, the subsequent retraction of the soft tissue back down to the bone can potentially make the eyes look more open. If the forward projection of the elevated brow is also reduced an upward sweep to the tail of the brow can also be achieved.
Dr. Barry Eppley
March 24th, 2017
Breast augmentation is primarily done using round smooth implants in the vast majority of cases in the U.S. Anatomic or shaped breast implants, while widely used elsewhere in the world, only became approved in the U.S.in 2012. The anatomic shaped implant have gained traction amongst some patients with the belief that they will look more natural. This seems perfectly logical when looking at the shape of the implant with less upper pole fullness to it. (a natural look being defined as less round looking)
But the use of anatomic breast implants is not without their own disadvantages. They cost more, can potentially rotate postoperatively and require some modification in the surgical technique to place them. They also have a textured coating on their outer shell (to prevent rotation) and can feel more stiff or firm than round smooth breast implants.
In the March 2017 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Intraoperative Comparison of Anatomical vs Round Implants in Breast Augmentation: A Randomized Clinical Trial’. In this paper the authors looked at 75 primary breast augmentation patients with a round implant placed in one breast and an anatomical implant of similar dimensions and size placed in the other breast. After intraoperative pictures were taken the anatomical implant was replaced with a round one before closure. The intraoperative appearance of the breasts was then assessed by blinded visual evaluations amongst plastic surgeons and lay reviewers.
The study results showed that no observable difference was observed between the two shapes of breast implants in 43% of the cases reviewed by plastic surgeons and 30% of the cases reviewed by lay reviewers. When a difference between the tow sides was observed plastic surgeons judged the anatomical side better in 51% of the cases. Lay reviewers judged the anatomical side better in 47% of the cases. Plastic surgeons identified the correct implant shape in only 25% of the cases. Based on these findings the authors conclude there is no aesthetic advantage provided by anatomic breast implants.
This study is very unique in that it tests how the two different implants look in the same patient. I initially thought the patient was going to be implanted and maintained with two different implants but ths study is understandably limited to intraoperative observations only. On the surface this study provides compelling evidence that anatomic implants do not offer a more natural result than that of round implants.
But like all clinical studies, it has limitations that makes its conclusion not as compelling as it might otherwise seem. I find three specific issues that the study does not take into consideration which can affect the results. First, the final shape of any implant in the body requires tissue contraction around the implant. (not just swelling resolution) All implant pockets involve elevation of tissues from their natural position. How any implant looks with the tissues have yet to contract back down around the inserted implant can not be accurately predicted during surgery. Second, this study involves relatively small implants. (average size less than 300ccs) At this end of the implant size spectrum shape differences may not be as fully evident as in larger implant sizes. Lastly what the condition of the breast tissues are on top of the implant will affect on how it looks. Such a study variable can only be controlled by using prepregnancy breast tissues without ptosis that otherwise look fairly similar.
The most relevant conclusion from this study for me, and what I tell patients all the time, is that the use of anatomic breast implants should be done for compelling reasons. Such implants have some disadvantages that round implants don’t have. Thus their use should be for good reasons such as the patient’s desire to do everything they can to avoid a round breast augmentation result. This becomes particularly relevant as breast implant size becomes bigger.
Dr. Barry Eppley
March 24th, 2017
Fat removal, primarily by liposuction, is a well known and effective procedure for many body areas. But when it comes to the face there are obviously much smaller volumes of fat to be removed. And there is one additional issue that the rest of the body does not have…motor nerves that can be injured. The face is full of branches of the facial nerve whose injury could have devastating facial consequences.
Thus facial sculpting by fat reduction, by its own anatomy, is a limited procedure. The size and location of the fat in the face provides limited opportunity for any significant external reduction in the shape of the face. While it is limited that does not mean it is impossible.
The facial locations by which fat can be removed are the buccal fat pads and the subcutaneous fat in the perioral mound area.They are safe removal sites because they lie either underneath (buccal fat pads) or below (perioral mound area) the buccal branches of the facial nerve.
These two facial fat removal sites are often confused as to their location and what facial reduction effects they may have. The perioral mound area is often perceived as to the location of the buccal fat pads…or at least as to where its lower extent of that fat pad lies. These are completely different fat locations as well as have different fat cell characteristics.
The buccal fat pad is a large well encapsulated ball of fat that lies deep under the cheekbone. Its removal, while substantial, impacts the submalar region directly under the cheekbone. Its effect does not go any further south than that upper midface location in most patients. Conversely perioral mound fat is a much thinner subcutaneous fat layer whose location is south of the buccal fat pad and more at a horizontal level of the mouth.
To maximize facial fat reduction it is necessary to perform both buccal lipectomies and perioral mound liposuction.
Dr. Barry Eppley
March 24th, 2017
Background: The use of silicone implants for breast augmentation has now been done since 2006 when this implant filler material was re-introduced as an implant option. One of the stated restrictions with their use was that patients had to be 22 years or older. This was a position imposed on the manufacturers as issued by the FDA. As a result this is on the package inserts as indications for clinical use.
This silicone breast implant guideline from the FDA causes considerable confusion. Many breast augmentation patients under 22 years old want silicone rather than saline implants but feel they can not have them. Plastic surgeons may also follow this guideline rigidly feeling that they don’t want to be violation with the FDA. They may also feel that implanting young patients with these devices may invalidate the manufacturer’s warranty.
There is some debate as to why the FDA imposed this clinical guideline. One belief is that there were no patients under 22 years old in the submitted clinical study used for FDA evaluation. This would seem to be the most logical explanation but apparently there some such patients in the study. It is more likely that there was simply not enough patients in this age group to draw the same conclusions as the older patients.
Case Study: This 18 year-old female wanted breast implants but preferred silicone over a saline implant fill. She developed little natural breast tissue and had small but visible breast mounds.
Under general anesthesia and through a transaxillary approach, 375cc high profile silicone implants were placed in a submuscular position. The implants were inserted using a funnel device to minimize any handling of the implants as well as to allow them to be placed in a ‘scarless’ fashion through a small hidden incision.
Her after surgery results show excellent symmetry of the implants with an expected rounder shape to the enlarged breast mounds. She had wide sternal spacing of the implants but this was to be expected based on her preoperative anatomy.
There is no clinical difference in the use of silicone breast implants whether one is older or younger than the age of 22 years old. Their use should be based on surgeon discretion and presurgical patient education.
- Per manufacturer guidelines, silicone breast augmentation is for patients 22 years and older.
- Silicone breast augmentation can be done on women as young as age 18.
- The tight skin of young patients will create more of a round breast look with implant placement.
Dr. Barry Eppley
March 19th, 2017
One of the elements of an attractive face is known to be proportions. While some may argue that symmetry is the most important part of facial beauty, symmetry and proportions are really linked. One doesn’t work well without the other.
Facial proportions can be assessed both horizontally as well as vertically. The classic facial thirds applies to vertical relationships with the upper (hairline to brow), middle (brow to base of nose) and lower (base of nose to bottom of chin) thirds being well known. Facial third disruption can occur at all levels and can make the face appear too long or too short.
One reason for a short vertical face is that the lower third is deficient. This can be associated with a more flat mandibular plane angle. This is reflective of the entire lower border of the jaw being short from back to front. It can also occur when the overall lower jaw is underdeveloped and is associated with a horizontal chin deficiency as well as a high jaw angle.
Lengthening of the vertically deficient lower third of the face can be done one of two ways based on the cause of its shortness. The entire lower jawline can be extended by a custom jawline implant that wraps around the lower jaw from angle to angle. The other method is a vertical lengthening bony genioplasty which elongates the front part of the jaw.
The vertical lengthening genioplasty is similar to the well know sliding genioplasty except that it does not slide. Rather after the bone cut is completed the lower bone segment is opened up like a hinge and a gap is created between the front edges of the bone based on how much lengthening is desired. The size of the gap is maintained by a spanning plate and screws. If the gap is big enough an interpositonal allogeneic bone graft or hydroxyapatite block is placed.
This bone gap in an opening vertical genioplasty will eventually fill in with bone but it will take 6 to 12 months to do so.
Dr. Barry Eppley
March 19th, 2017
Fat grafting as a method of both soft tissue reconstruction and aesthetic augmentation has taken on a dominant role in plastic surgery the past decade. Between the wide availability of donor tissue, its relatively easy harvest and subsequent injectability, it is no wonder that autologous fat transplantation has become so popular. But despite its many favorable features, the predictability of the procedure remains…unpredictable. It is felt that what may have the greatest impact on how well fat survives the injection process is how it has been prepared.
In the March issue of the journal Plastic and Reconstructive Surgery a paper was published on this topic entitled ‘A Comprehensive In Vitro Comparison of Preparation Techniques for Fat Grafting’. The authors harvested fat from the lower stomach region in 14 patients and processed the fat by decantation, centrifugation and membrane tissue filtration. The resultant preparations were examined by electron microscopy and cell viability studies. The number of stem cells present and their character was assessed by cell surface markers and whether they could differentiate into adipose cells.
Their results showed that neither preparation method caused significant cell damage nor were measurable differences seen in overall cell viability. Neither method of preparation showed a significantly higher number of adipocyte-derived stem cells. The maximal amount of adipocyte concentration by water removal was achieved by membrane-based tissue filtration. In conclusion, while the properties of liposuction-aspirated fat were influenced by the processing method they were not significantly different. Centrifugation and membrane-based filtration are preferred when possible when access to such devices exist.
This is just one of many laboratory studies that have looked at how the preparation process influences the eventual fat injectate. Despite many proponents as well as manufacturer claims of the superiority of one processing method over another, in vitro and clinical evidence has provided no conclusive proof of one best method. This paper continues to show that some processing method is better than none. Given the many variables in the fat grafting process it may also be that the preparation method is not the critical element, or at least as important as we think, in improving fat injection survival.
Dr. Barry Eppley
March 17th, 2017
Facial asymmetry often involves the lower jaw. Since the lower jaw defines the border of the face to the neck, any differences between the two sides of the face can be clearly seen. It is usually not difficult to determine which is the normal side and which is the affected side although this is ultimately determined by patient preference.
In cases of facial asymmetry caused by either excessive lengthening or a more inferiorly positioned bony half of the face, the inferior border of the lower jaw is too long. This is most clearly seen in a simple panorex x-ray where the entire lower jaw is laid out in a flat 2D fashion. It is also clearly seen in a 3D CT scan with a side view showing the different heights of the lower border of the mandible.
Removal of the lower inferior border of the mandible is done by a saw cut based on measured differences between the two sides. This usually needs to run from the chin back to the jaw angle. This bony cut is most easily done from a submental incision where it becomes a straight line with the best visualization. While this can be done from an intraoral approach, this makes it much more difficult and has a greater risk of injury to the inferior alveolar nerve.
The straightness of the bony cut (mandibular inferior border shave) from a submental incision can be seen in this before and after x-ray assessment.
Dr. Barry Eppley
March 17th, 2017
Rhinoplasty is the most common facial reshaping procedure with a long and rich surgical history. While techniques for reshaping the nose have changed and evolved over the years, the one issue that has persisted is the need for some form of postoperative compression. It is viewed as an essential element of the surgery and can have a major impact in the final result.
The purpose of postoperative nasal compression is two-fold. The most obvious reason for its use is to keep down the swelling of the nose which will occur. Control of such swelling has great value in an operation that both sits in the middle of your face and is well known to take up to a year to fully go away. Its second purpose, and one of equal value, is to help adapt the skin back down to the reshaped osteocartilaginous nasal framework. If fluid and eventual scar develops underneath the skin, the external appearance of the nose will not show the details of how the new nasal structure actually looks.
The use of tapes and a variety of splints is applied at the end of the operation and usually maintained in placed for a week after surgery. Different types of nasal tapes and splints exist and there are no proven advantages to one method/material over another. What is important is some compression is better than no compression.
What to expect after the nasal dressings is removed is important for patients to understand. The moment the nasal dressing comes off is not a ‘TV’ moment. This is not the final result and the recovery process is not over. The nose has been maximally compressed and, while it may show some positive changes and almost always does, the nose is still distorted from swelling and compression.
Once the rhinoplasty dressing is removed one can expect some rebound swelling to occur since it is not longer compressed. It will swell up a little bit and the nose may look somewhat bigger and puffy. It will take another one month or so until the nose starts to look as ‘small’ as it did when the dressing was removed. How soon this occurs depends on the natural thickness of one’s nasal skin. The final outcome of the nose shape awaits a full sic to twelve weeks after surgery.
Dr. Barry Eppley
March 17th, 2017
Background: Skull defects occur in children for a variety of reasons. But one of the most common causes is early surgery for congenital skull deformities. When reshaping large portions of the skull their complete healing depends on the natural osteogenic capability of the underlying dura. This is usually very robust at very young ages but fades quickly after the first few years of life.
Reconstructing skull defects in children can be done by several techniques. One method is to use the patient’s own bone to do so. This is the most logical approach but its disadvantages is that one has to create another skull defect site and such bone does not always heal smoothly. The next option would be to use allogeneic or cadaver bone grafts. This saves a donor site but does not get around how smoothly, or non-smoothly, the resultant skull contour will be.
The third skull contouring material is that of hydroxyapatite cements. These synthetic calcium phosphate materials have a long history of use in craniofacial surgery for skull defect and contouring reconstructions. They are less well known for use in children but their value in these pediatric skull applications is no less significant.
Case Study: This 9 month-old infant male cild initially underwent reconstruction for a unilateral coronal craniosynostosis condition. The surgery was performed using supraorbital bar reshaping as well as a barrel-stave technique to expand out the overlying forehead bone.He went on well and when seen years later at age 8 he had a slight flattening of the lateral forehead and a palpable full-thickness bone defect along the original coronal suture line.
Under general anesthesia and through his existing coronal scalp incision, the bone defect along the original coronal suture line was exposed. The dura was elevated off of the bone edges entirely around the defect. A Lactosorb mesh plate (resorbable PLLA-PGA) was placed on the underside of the bone and cut to lock in between the dura and the bone edges. Hydroxyapatite cement was applied into the bone defect using the mesh plate as its backing. It was then contoured to be flush with the surrounding skull contours and allowed to set.
Hydroxyapatite cement can be used to both fill in skull defects as well as can be placed as an onlay augmentation material. While more extensively used in adults, it can be just as effectively used in children. There is always the question of what happens to the bone cement as the skull continues to grow. My observation is that the skull bone on top and underneath it and it simply gets pushed out jus like normal skull bone with dow with ongoing appositional skull growth.
- Skull defects in children can be treated by either bone grafts or hydroxyapatite cement.
- When using bone cements in a full-thickness skull defect, a floor against the dura must be created to support the material.
- Bone cements offer a facile material to fill and contour skull defects.
Dr. Barry Eppley
March 16th, 2017
Chin augmentation can be done through either placing an implant on top of the bone or moving the actual bone forward. Both are valid chin enhancement techniques and each has their own unique advantages and disadvantages. While there are strong surgeon advocates for both techniques, it is important to remember that not every patient is appropriate for either one and what matters for good results is matching the solution to the problem and not surgeon preference or familiarity with either surgical method.
There are rare instances where a sliding genioplasty and a chin implant can be combined. There are two indications for this composite chin augmentation approach. The first one is when the amount of horizontal chin augmentation desired is more than what a sliding genioplasty alone can produce. This would occur when the thickness of the chin bone is less than what the amount of horizontal bone movement that is needed to create the desired effect can be done. The additional horizontal projection is achieved by placing the needed implant size in front of the moved chin bone.
The second indication for the composite chin augmentation approach is when one desires a different chin shape than that of the natural bone of the sliding genioplasty. This almost is always when one wants a more square chin shape and the natural chin bone is more round. A more square shaped chin implant, even if it is small, is placed in front of the sliding genioplasty. It is vey difficult, if not impossible in many cases, to make the chin bone more square in external appearance.
When placing an implant in front of the sliding genioplasty, it is important to realize up front, that there will be some eventual implant settling into the bone. This is not bone erosion but simply the body seeking to relieve the pressure from the pushback of the stretched chin soft tissue pad. It is a natural and self-limiting biologic process.
Dr. Barry Eppley