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.
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
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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.
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.
Calf augmentation is one of the most infrequently performed of all body contouring procedures. Part of the reason for its low rate of performance is patient demand. The other reason is that most plastic surgeons are uncomfortable performing the procedure having never seen it done or been trained to do it.
The widespread use of fat grafting has increased the number of calf augmentation being performed. This is a much simpler method that requires no surgical method and avoids the use of an implant. But is far from reliable in creating assured volume and in many calf augmentation patients is not an option due to lack of adequate fat donor sites or tight calf tissues.
In the March 2017 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Safety and Efficacy of Subfascial Calf Augmentation’. In this paper the authors review their 12 year experience with 134 cases of either primary or revisional calf implant surgery. In all primary cases they performed a subfascial implant placement technique. In revisional cases injectable fat grafting and/or implant repositioning was done. The authors conclude that the placement of calf implants is a safe and easy procedure to perform, has a rapid recovery period and a low complication rate. (< 1%)
Of the three possible calf implant tissue locations (subcutaneous, subfascial and intramuscular, the subfascial is the best. While originally described in its introduction back in the late 1970s as an intramuscular technique, the risk of nerve injury and the induced muscle trauma favors a more superficial location. While a subcutaneous pocket dissection is very easy it is prone to visible encapsulation and implant show. The subfascial location offers good implant coverage, a lower risk on capsular contracture and a more natural appearance.
While subfascial calf implant placement is preferred, there are several important technical maneuvers to have an uncomplicated outcome. The incisional access must be in a popliteal skin crease and be fairly small in length. Once past the incision the actual fascia covering the calf muscles is lower than one would initially think. The fascia immediately beneath the incision is that of the hamstring tendons. On the inner knee these are the semimembranous and semitendinous tendons. On the outer knee it is the biceps femoris tendons. One must go past these tendons and look lower for calf muscle fascia.
The subfascial dissection should be carried out with a flat broad instrument that is long enough to reach calf muscle-soleus junction which is located at the midway point between the knee and the ankle. Here the fascia becomes adherent and the implant can not extend below this level. If the fascia is inadvertently perforated here and the implant is placed in a combined subfascial/subcutaneous location it will cause persistent postoperative discomfort.
The remaining key is the calf implant itself. Besides having the right shape and length, it needs to be made of an ultrasoft solid silicone material that has an outer shell layer on it. (Implantech) This allows the implant to be inserted through a small incision without tearing of the implant. Soft silicone calf implants without this coating are prone to tearing or fracture during insertion potentially leading to long-term tissue reactions.
Dr. Barry Eppley
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Rib removal is done for a variety of waistline concerns. Such concerns must be divided into anterior and posterior aesthetic waistline issues. The most common perception of the aesthetic benefits of ribs being removed is for horizontal waistline reduction where ribs #10, 11 and 12 may be reduced through a posterior or back approach. `This allows the sides of the waist to fall in at the level of the belly button, contributing to more of an hourglass figure.
But other forms of aesthetic ribcage modification exist. Vertical waist shortness can be caused by a short length between the subcostal rib margins and the hips. The subcostal ribs, made up of the cartilaginous portions of ribs #7,8 and 9, create the downward slope of the ribcage out to the sides. With a low or prominent subcostal rib margin the waistline can be seen as vertically short. In some cases it is not that the subcostal margin is too low but that it may stick out prominentl either on one side or both.
The subcostal ribs are cartilaginous, thus they are softer than bone and can be effectively reduced by either shaving or complete removal of their prominences. While this can be done through a relatively small skin incision over them, it is also possible to remove them at the same time as as tummy tuck. The tummy tuck has to be of a full variety, but the subcostal rib margins can be accessed by splitting the rectus fascia and muscle from below. (the same anatomic dissection one has to do from the external skin incision)
From this approach ribs #7 and 8 can be separated from their sternal locations and taken back to the bony junction at the sides of the chest wall. Along the way the cartilaginous portions of ribs #9 and 10 can be removed as well.
Background: Few faces are perfectly symmetric and most of us have some noticeable differences between the right and left sides. Such facial side differences are usually well tolerated or may not even be known. We all recognize that ‘no one is perfect’ and everyone has a little bit of facial asymmetry which is seen within the range of normal.
But asymmetry of the eyes is often different because it is so easily recognized and almost impossible to visually ignore. While there are different types of eye asymmetry, many of which are related to the eyelids, one of the most recognized causes of is that of orbital dystopia. Orbital dystopia is bone-based with the orbital bony box being at different levels between the two sides. The most common type of orbital dystopia is vertical and the affected side is almost always lower than the normal side.
In vertical orbital dystopia, the affected eye sits lower which can be seen and measured by the horizontal positioning of the pupil of the eye. The eye sits lower because the orbital floor, including the circumferential orbital rims and cheek bone, sit lower. In more minor cases the orbital dystopia is isolated to the eye area. But in more significant cases the entire side of the face from the eyebrows down to the jawline is lower.
Case Study: This 43 year-old male presented for cheek augmentation for which a custom designed approach was chosen. He had always been by a mild degree of eye asymmetry as well which was most apparent in pictures. A 3D CT scan shows that the affected eye had a vertical dystopia of around 3mms. The lower infraorbital rim and malar eminence as well as more inferiorly positioned orbital floor could be seen as the bony origin of the vertical dystopia.
His custom cheek implants designs included a component on the affected side that wrapped over the infraorbital rim and onto the orbital floor to create the needed amount of globe elevation.
Under general anesthesia and through a subciliary eyelid incision, the custom orbital floor-rim-cheek implant was placed and secured to the orbital rim with two microscrews. An orbicularis muscle rsuspension and lateral canthopexy was performed at closure.
His one year after surgery results showed improvement in the symmetry between the eyes. As is often the case in vertical orbital dystopia raising up the eye reveals the other components of the dystopia including the more inferiorly positioned upper eyelid and eyebrow. These are planned for adjustment in the future. (right upper blepharoplasty with ptosis repair and transpalpebral browlift.
One cause of eye asymmetry is a malpositioned orbital box which causes the eye to sit at a lower horizontal level than the normal side.
Orbital floor and infraorbital rim augmentation is one technique in the treatment of vertical orbital dystopia but it will not correct every aspect of the eye asymmetry.
The orbital floor-rim augmentation implant is best made from a 3D CT scan in a custom implant fashion.
Dysfunction of the temporomandibular joint (TMJ) is one of the most common causes of head and neck pain. Inside the joint is a working relationship between the condylar head (ball) and the glenoid fossa (socket) which is separated by a meniscus or disc. This thick fibrous structure allows the ball of the joint to rotate within as well as move out of the bony socket. Disruption of smooth meniscal movement is what causes clicking or joint noise to occur which can cause pain and, in more severe cases, limitation of condylar movement affecting mouth opening.
Treatment of these internal menisco-condylar derangements of the TMJ is mainly conservative. Anti-inflammatory drugs, rest, physical therapy and oral splints eventually resolve most symptoms. But some few patients will not improve and will progress to more significant internal joint problems such as meniscal sticking or dislocation which can ultimately require surgery.
TMJ surgery for meniscal dysfunction is most popularly treated by arthroscopy. Arthroscopy, however, has significant limitations in a joint that is about the size of your thumbnail. Such a small space limits what can be done to mainly fluid infusion to hopefully create release of adhesions. (adhesiolysis) In my experience an open TMJ arthroplasty is more versatile and allows a greater number of technical manuevers to e done to both the meniscus and the bone.
Open TMJ arthroscopy is more invasive than arthroscopy but if done well and in experienced hands it has no greater risks. A well placed incision offers an aesthetic outcome that would make the surgery very hard to detect. Borrowing from the preauricular portion of facelift surgery, the incision is made in a retrotragal fashion. This keeps the central portion of the resultant scar hidden both during the healing phase as well as with the final healed scar. (three week incision line results using a dissolveable suture closure)
By good incision placement in the natural attachments of the ear to the face, TMJ arthroplasty surgery can be done with good aesthetic results.
Background: The columella is the strip of skin and cartilage between the nostrils. It provides a smooth connection between the tip of the nose and the upper lip. Its shape is controlled by the cartilages which run within the skin as well as the septum behind it. A ‘good’ columella is really one that does not stand out in any way and sits obscurely at the bottom of the nose. A ‘bad’ columella is one that is noticeable either because it is deviated or sticks out too far.
The hanging columella is when it extends down to far, creating exaggerated columellar show. This is most noticeable in the profile view where too much of it is seen and sits too far below the rim of the nostrils. It can occur as a natural result of nasal growth with a long septum that pushes it too far forward. The medial footplate cartilages that compose it can also be too long or wide.
The hanging columella can also result from a prior rhinoplasty where the medial footplate cartilages have been overly weakened, making them prone to bending or notching. (and a columellar strut has not been used) Conversely it can also be caused by a columellar strut graft that has become or was placed too far forward.
Case Study: This 52nyear-old female presented with a columellar protrusion that had developed from an open rhinoplasty several years before. She felt it look like something was hanging out of her nose all the time.
Under sedation and local anesthesia and using her existing columellar scar for access, the protrusive medial foot plate cartilages were trimmed. They were then used as a miniature columellar strut graft to support straightening using suture plication.
Her three months after surgery result showed elimination of the protrusion, a smooth curve in profile and a straight columella. While many isolated hanging columellas can be treated without an open approach technique, her prior rhinoplasty surgery made the decision to do so create a more assured and complete correction.
1) A hanging columella can occur from either natural nasal growth or from a prior rhinoplasty.
2) The hanging or protrusive columella that results from a prior rhinoplasty usually causes a columellar deviation and notching.
3) The revision rhinoplasty columellar correction removes the excessive medial footplate cartilage and straightens and stabilizes it with sutures.
Temporal artery ligation has been a surgical procedure done for decades. It has been historically used as a medical procedure to diagnose temporal arteritis as a biopsy technique. In this operation a section of the anterior branch of the superficial temporal artery is removed behind the front edge of the temporal hairline.
More recently, temporal artery ligation is being done for aesthetic purposes. Almost always men, prominent or protruding arterial patterns from the temporal area up onto the forehead can be seen as an aesthetic liability. These vessels can become quite large as they dilate from exercise, heat and alcohol intake. While such temporal artery prominences can occur in women, they appear to occur far less frequently. This may be due to hormonal differences but also in the differing thicknesses of the muscular walls between the genders.
The aesthetic treatment of prominent temporal arteries requires a dynamic knowledge of the anatomy of the superficial temporal artery. (STA) The STA arises from the external carotid artery where it courses in front of the ear towards the temporal region. As it passes the ear and into the temporal hairline it splits into a Y about at a point 1 cm anterior to the root of the ear and the 2 cms above that point. The frontal or anterior branch of the STA is what extends into the forehead and is the source of vessel prominence.
In looking at its anatomy, two observations are extremely relevant when considering ligation for aesthetic reduction in its size. First, the anterior branch turns into numerous smaller arteries whose patterns are both tortuous and unpredictable as it goes into the forehead. Thus what one sees as prominent is often an incomplete reveal of the complete arterial branching pattern. Secondly, there is a vast anastomotic pattern into the scalp with numerous interconnections between them. This means that the consideration of backflow must be factored into the location and number of ligation points.
The anatomy of the STA shows that simply tying off the main trunk of the STA will not likely work and, even if it does, its results will likely be temporary. Blood flow through the numerous superior branches will find its way back down and the vessels again. The first ligation point must be just after the take-off at the Y junction. Then one, two or three more distal ligations points must be done in an effort to cut off the backflow into the visible vessels. These can be determined by either their visibility or palpabiity. Sometimes they are not easy to initially locate but one had to look for them as they are the key to a successful long-term result.
The presence of a discernible chin has always been an important aesthetic feature of the lower face in both men and women. While the desired amount of projection will vary between the genders, it is clear that having some chin projection is better than having little or none.
While the chin has always been perceived as an important facial feature, the perception of the entire jawline has taken on greater aesthetic significance today. This means the shape and projection of the back part of the jaw, known as the mandibular ramus or jaw angle, also gives the lower face a fuller and more pleasing appearance. Just like the chin that projects the front part of the lower face, the jaw angles project the back part of the lower face.
While stronger jaw angles have been historically associated with men, it also equally applies to women today as well. This can be seen in many well known female celebrities such as Angela Jolie, Olivia Wilde and Hiliary Swank, to name just a few. They all have a distinct and well defined jawline because they have a vertically long and almost squared shaped jaw angle. It does not necessarily have to be very wide but it is its vertical length and defined posterior and inferior ramus outlines of the bone that give a ‘cut look’ to the jawline. In essence it makes the jaw stand out distinctly from the neck below it.
A strong and defined jaw angle is associated with a low mandibular plane angle. The mandibular plane angle is a measurement introduced in orthodontics many decades ago to assess the steepness of the jaw in relation to the base of the skull. (normal is around 30 degrees) It is the anterior angle formed by the intersection of the Frankfort horizontal plane and a tangent to the lower border of the jawline. (in orthodontics it is the angle formed by the intersection of SN and GoGn) The Frankfort-mandibular plane angle is affected by the vertical development and length of the mandibular ramus.
The high and indistinct jaw angle can be treated by a vertical lengthening jaw angle implant. This is a special jaw angle implant that drops down the jaw angle by the lengthening provided by the implant. Most women need the vertical jaw angle implant as opposed to the more traditional widening jaw angle implant. While the implant does not look very big, it is surprising how powerful an effect it can have on the shape of the lower face.
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.