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Double Eyelid Surgery with Epicanthoplasty

Tuesday, May 24th, 2016

 

Double Eyelid Surgery Dr Barry Eppley IndianapolisIn Asian blepharoplasty, more commonly known as double eyelid surgery, the influence of the fold at the inner eye (epicanthus) can affect the aesthetic outcome. As a result many double eyelid surgeries are combined with a medial epicanthoplasty for an improved aesthetic appearance. While the epicanthus is a small structure, there is a large number of operations described for its correction. There does not appear to be a universally agreed upon method for the epicanthoplasty which suggests that all of them have some downside.

Z-Epicanthoplasty Dr Barry Eppley IndianapolisHistorically, some surgeons have avoided epicanthoplasty because of the fear of visible scar formation at the inner eye. But the Z-epicanthoplasty has proven to be a safe and effective technique for eliminating the epicanthal fold during double-eyelid operations without problematic scarring at the medial canthal area. They are numerous small variations of the Z-epicanthoplasty most of which focus on  hiding the scar line in the inner cants area.

In the January 2016 issue of the journal Aesthetic Plastic Surgery, an article was published entitled ‘A Modified Method Combining Z-Epicanthoplasty and Blepharoplasty to Develop Out-Fold Type Double Eyelids’. In this paper the authors describes his technique for combining double eyelid surgery with a Z-epicanthoplasty in over 1100 women. The goals of the surgery was to create a parallel double eyelid fold with an exposed inner canthus and lacrimal caruncle. The upper eyelid incision is carried out to the new inner canthus location and the skin excised. The muscle fibers that adhere to the inner canthal ligament are severed to release any tension on the epicanthal skin flap. A small z-plasty is then performed on the inner canthal skin flaps. The revision rate was eight patients. (less than 1%)

Double Eyelid Surgery and Lower Eyelid Love Band Surgery Dr Barry Eppley IndianapolisThe Asian upper eyelid has a characteristic single fold with an epicanthus and saggy skin. When an epicanthus is not present, a double eyelid surgery alone can suffice. But with an  epicanthal fold present, double eyelid surgery will create a short and narrow double fold appearance. Thus combining double eyelid surgery with an epcanthoplasty is now common practice. This allows for a smooth connection between the double fold eyelid and the inner canthus. The goal of the Z-epicanthoplasty is to relieve the tension on the medial cantonal area which contributes to the epicanthal fold being present and prevent any adverse scarring in this highly visible area.

Dr. Barry Eppley

Indianapolis, Indiana

First U.S. Penis Transplant

Monday, May 23rd, 2016

The first U.S. penis transplant was performed in Boston on May 8 and 9th by a team lead by a plastic surgeon. This is the third such penis transplant in the world. The 64 year-old male patient had his penis previously removed due to cancer. The operation took 15 hours over two days with the penile transplant coming from a deceased donor. The transplant surgery was part of a research program whose ultimate goal is to aid combat veterans with significant pelvic injuries as well as those men who have had penile resection due to cancer and penile amputations due to trauma.

Like all organ transplant surgeries, they are a marvel and plastic surgery has been at the leading edge of many of them for decades. While face transplants have gotten the most attention over the past few years, it is a far more complex type of tissue transplantation than that of a solid organ like the penis.

penile anatomyBut a penis transplant is still a challenge and this single operation belies the work that lead up to it. The hospital team spent several years preparing for the penile transplant which involved a lot of cadaver work to learn the intricate details of the anatomy as well as becoming proficient at harvesting a penis from a donor. Like so many things in life, a  single event if it is to be successful comes with a lot of preparation. Every new type of tissue transplant has required thousands of hours of preparation for the actual event. While microsurgery and reattaching blood vessels and nerves has been around for over 25 years, performing it on a new organ still requites a lot of forethought.

Plastic surgery continues to develop new techniques for reconstructive and aesthetic surgery. What will be learned for performing a pioneering surgery like penis transplants will one day translate into other more everyday surgical techniques. That has been the history of plastic surgery over the past 100 years.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Temporal Artery Ligation

Monday, May 23rd, 2016

 

Background: The superficial temporal artery is a branch of the external carotid artery. It runs up along the back line of the lower jaw and curves anteriorly where it crosses teh back part of the zygomatic arch at its junction with the temporal bone. Once it crosses the  zygomatic arch, it splits into a Y into two divides in two terminal branches. The anterior branch, also called the frontal branch, ascend obliquely across the upper temporal region into the forehead. The posterior branch, also called the parietal branch, courses posteriorly above the ear.

The frontal branch of the superficial temporal artery is prone to develop extreme visibility in some people which they find bothersome. The reasons why it does so are not clear. I have only seen it in men and have never received a concern about its appearance from women. The typical symptoms are that it can not be present at all or slightly present at ‘rest’ but numerous activities make the pathway of the vessel dilate and become very prominent. Such activities includes exercise, heat, excitability, and drinking alcohol.

Treatment of the prominent anterior branch of the superficial temporal artery is by surgical ligation.While ligating the takeoff of the anterior branch would seem a logical approach, there is always the issue of backflow into it which would still leave it prominent. Thus at least a two point ligation should be done with the distal point on the forehead before it branches and goes into the frontal hairline.

Temporal Artery LIgation mapping Dr Barry Eppley IndianapolisCase Study: This middle-aged male had visible anterior branches of the superficial temporal artery at rest on both sides of his temples. These became more so with increased activity and heat. Their irregular course was clearly visible from the edge of the temporal hairline up into the forehead. Their wavy irregular course, which is common, was clearly seen and marked.

Right Temporal Artery LIgation immediate result Dr Barry Eppley IndianapolisLeft Temporal Artery LIgation immediate result Dr Barry Eppley IndianapolisUnder local anesthesia small incisions (6mms) were made just inside the temporal hairline and at the end of an upper forehead wrinkle just below the frontal hairline on both sides. Double ligations were performed in all four areas with 5-0 prolene suture. While the palpable inflow was immediately reduced (pulsations were no longer felt), the prominent of the vessels initially remained. With further observation they did reduce somewhat but an additional ligation was done along the temporal hairline area above the initial ligation point.

The success or temporal artery ligation depends on elimination of the inflow AND subsequent collapse of the vessels. Even with two ligation, which should theoretically work, the visibility of the arteries may not always be completely eliminated. Unseen feeder vessels between the two ligation points and strength of the vessel walls (they are arteries so their walls contain muscle) may cause the vessel prominence to persist although less so than before ligation.

The other issue about the success of temporal artery ligation is whether such flow can eventually return. Loss of the ligature points (which is why I double tie) and backflow dilation of any unseen takeoff branches could all be reasons for potential recurrence.

Highlights:

1) A prominent anterior branch of the superficial temporal artery can create an undesired aesthetic line along the sides of the forehead.

2) Two-point temporal artery ligation can reduce and, in some cases, eliminate the appearance of the temporal vessels.

3) The aesthetic success of temporal artery ligation depends on whether unseen feeders flow into the visible nerve branch and how much the artery will shrink after flow into it is eliminated.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Large Abdominal Panniculectomy

Monday, May 23rd, 2016

 

Background: The abdominal pannus is a well known medical condition of a large overhanging apron of skin and fat that extends well beyond the waistline. Technically the proper term is a panniculus but it is far more commonly referred to as a pannus. What defines a pannus is how large the actual overhang is.

There are five degrees of an abdominal pannus from a grade 1 that rests on the mons pubis to a grade 5 that hangs down to the knees. While no abdominal pannus is pleasant for the patient the grade 5 pannus is the most disabling. It not only obstructs the urinary stream and causes associated hygiene issues but its sheer weight makes mobility difficult. It causes tremendous strain on the back and knees and leads to early deterioration of both.

An abdominal panniculectomy procedure should not be confused with a more traditional tummy tuck. The scope of the problem being treated would indicate such but how the operation is performed and under what circumstance is also vastly different. This is no more manifest than in the massive type 5 abdominal panniculectomy operation.

Case Study: This 40 year-old male reached out from Canada because he could not find a surgeon to perform his abdominal panniculectomy procedure.  He had a prior gastric bypass which dropped his weight from over 500 lbs down to 325lbs.  This resulted in the creation of a massive type 5 pannus. Surprisingly he had no otherwise medical problems. Because of chronic skin infections and urinary obstruction he had been to the hospital numerous times. But despite his obvious need for a surgical solution, he stated that no one would take on his case because it was too dangerous or difficult.

Large Abdominal Panniculectomy flaps intraop Dr Barry Eppley IndianapolisLarge Abdominal Panniculectomy tissue removals initraop Dr Barry Eppley IndianapolisUnder general anesthesia a large portion of his abdominal pannus was removed in two sections.  Its total weight was 40 lbs.  It was determined before surgery not to reconstruct his umbilicus. The long umbilical stalk and the umbilical hernia created by its removal were repaired. Closure was done over a large single drain.

Large Abdominal Panniculectomy result intraop Dr Barry Eppley IndianapolisLarge Abdominal Panniculectomy result intraop right oblique view Dr Barry Eppley IndianapolisLarge Abdominal Panniculectomy intraop result left oblique view Dr Barry Eppley IndianapolisHe stayed overnight in the facility and was released to a hotel the morning after. He remained in town for one week for monitoring and flew back to Canada thereafter. His drain will be removed at home after two weeks.

Large abdominal panniculectomies are challenging for a variety of reasons. Their sheer size makes intraoperative positioning and maneuvering difficult. There are many large blood vessels that supply the abdominal pannus and intra- as well as postoperative bleeding is always a risk. The operation needs to be performed as expeditiously as possible to get the patient off the operating room table as soon as possible. When performing the operation as just an overnight stay, the patient must have few other medical problems and be motivated to get up and moving as soon as possible after surgery. Drains are always needed and should stay in at least several weeks. For the out of town patient this means that they will have to get some medical care at home to get it removed.

Highlights:

1) Large abdominal panniculectomies can be safely done in an outpatient surgery center if the patient is otherwise healthy.

2) Enough abdominal pannus is removed to relief the obstruction on the pubic area and eliminate any overhang on the groin creases.

3) The most likely complication from any abdominal panniculectomy is a seroma or fluid collection.

Dr. Barry Eppley

Indianapolis, Indiana

The Custom Midface Implant

Sunday, May 22nd, 2016

 

Facial balance is composed of aesthetic relationships between the three thirds of the face. Most commonly perceived from the profile view, there are various known projections of each facial third that makes it aesthetically appealing. When one of the facial thirds is out of balance it makes the other two–thirds of the face look larger and disproportionate.

Lack of adequate midface projection, or midface hypoplasia, occurs for a variety of reasons. Most commonly this occurs due to natural development and is more prone to occur in certain ethnicities. (e.g., Asians) But other causes include traumatic injuries as well as congenital facial birth defects. (e.g., cleft lip and palate) Lack of adequate midface projection can create a variety of clinical conditions such as negative orbital vectors, class III malocclusions and an overall flatter facial profile even in the face of a satisfactory bite relationship.

There are numerous surgical procedures that are designed to increase midface projection in selective areas. A LeFort I osteotomy moves the lower maxillary level forward. Cheek or infraorbital-malar implants increase fullness in the upper midface area of the inferior orbital rims and cheeks. Fat injections can be used to create a more complete midface augmentation effect but their take and persistence is highly variable.

Custom Midface Implant design Dr Barry Eppley IndianapolisCustom Midface Mask Implant Dr Barry Eppley IndianapolisUsing an onlay bone augmentation approach, the custom midface implant can create complete middle third of the face projection. Made from the patient’s 3D CT scan, the custom midface implant provides projection from the infraorbtial rim down to the anterior nasal spine. Its design looks very much like a mask with larges holes made in it for the relief of the infraorbital nerves. The implant provides augmentation of every midface bony surface in a forward projecting manner. Its thickest part is usually around 7mm and that is around the nasal base. It becomes thinner as it progresses upward over the orbital rims.

Custom MIdface Implant intraop Dr Barry Eppley IndianapolisCustom MIdface Implant intraop placement Dr Barry Eppley IndianapolisThe custom midface implant is placed through an intraoral maxillary vestibular incision.  good cuff of musculomucosal tissue is left inferiorly. The implant is placed by cutting the infraorbital holes superiorly so that can fit around the nerve. Multiple 4mm perfusion holes are placed throughout the implant to allow through and through tissue ingrowth. The implant is secured into position using four 1.5mm screws.

Custom MIdface Implant thicknesses Dr Barry Eppley IndianapolisThe custom midface implant offers complete midface projection without affecting the bite since it is an onlay bone method. While it looks big and overwhelming on the 3D model, it is much smaller when placed onto and into the patient. It provides central augmentation of the midface without increasing the width of the cheeks. It effectively ‘pulls’ out the middle part of the face.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Silicone Testicle Implant Surgery

Sunday, May 22nd, 2016

 

Background: While many body parts can be partially replaced or augmented, few can be completely replaced in their totality by a single prosthesis. Such is the case with the testes undoubtably due to its small size and location in the hollows of the scrotal sac. While a testicular implant will not resume the functions of the natural testicle, it can create the external appearance that a pair is present.

The physical and aesthetic requirements of a testicular implant are fairly simple. It should replicate in size and shape that of the opposite testicle. It should also feel soft and supple, not only to match the feel of the opposite testicle, but be easily compressible given its near continuous exposure to external forces.

Testicular Replacement Implant Dr Barry Eppley IndianapolisThe solid but very soft silicone material fulfills all requirements needed for a testicle implant. It is extremely compressible with a very low durometer silicone composition. It is available in sizes up to 5 x 4 cms which will work for most men. A custom testicle implant can be made for even larger sizes.

Case Study: This 55 year-old male lost his right testicle at fourteen years of age due to an unknown pathology. He had a long scar on his right scrotal sac that went its full vertical length. He had always felt inadequate and embarrassed his entire life with a missing testicle and was often referred to as ‘single shot’ throughout his life. He was completely unaware that a testicle implant even existed until very recently.

Right Scrotal ScarTesticular Implant intraoperative sizing Dr Barry Eppley IndianapolisUnder general anesthesia the upper portion of his scrotal scar was reopen and a pocket made into the right scrotal sac. The skin was very elastic and a pocket of adequate size was easily made. The largest size silicone testicle implant was used which matched well to his opposite left normal testicle. The scrotal sac was closed in layers and dissolveable sutures used for the skin.

Right Testicular Implant Reconstruction result Dr Barry Eppley IndianapolisHis immediate intraoperative result showed a good match between the implant and the normal testicle. They had a very similar feel externally.

The use of a silicone testicle implant provides a natural feeling and looking testicle that creates good scrotal sac symmetry. It is a procedure that has minimal discomfort afterward with a rapid recovery. One can return to all normal activities within a few weeks after the procedure.

Highlights:

1) Testicular implants can be done at any age no matter how long ago the natural testicle  was lost.

2) A soft silicone testicular implant provides the most natural feeling replacement prosthesis.

3) Recovery from testicular implant surgery is rapid with a return to all normal activities in a few weeks.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Rib Removals for Waistline Narrowing

Saturday, May 21st, 2016

 

Background: Rib removal surgery has been done so infrequently that it is a highly misunderstood cosmetic body contouring procedure. While it sounds extreme, and it is certainly for the most motivated, it is neither a dangerous or a radical operation. It is a procedure that is based on an understanding of the lower shape of the ribcage.

Rib Removal Surgery Dr Barry Eppley IndianapolisThe concept behind most rib removal surgeries is to create a more narrow waistline that has an hourglass shape. This is possible when one looks at the anatomy of the lower ribcage. The lower two ribs, known as free floating 11and 12 ribs, are not attached to any ribs above them. In fact careful inspection of their shape shows that they actually point downward more than the ribs above which assume a more horizontal orientation as they wrap around the side of the body. These more vertically oriented ribs point down toward the hip and cross the horizontal level of the anatomic waistline at the level of the umbilicus.

For those women who seek a much more narrow anatomic waistline, these lower two ribs can serve as a vertical physical block for that effect to occur. This can be demonstrated by pushing it at the side of the waistline and feeling the bony obstruction.

Case Study: This young transgender male to female patient wanted a more feminine waistline rather than the torso of a male which is more straight up and down at the sides. She also wanted to improve the hip indentations by fat injections at the same time.

Lateral Waistline Rib Removal Dr Barry Eppley IndianapolisUnder general anesthesia and initially in the supine position the full abdomen and waistline areas in the back were harvested of fat. Then in the prone position, the flanks and upper intergluteal area were also harvested of fat. After concentration of the fat, a total of 200cc was injected into the hip indents. Then through a 4 cm incision oriented over rib #11 that did not come further to the side that the posterior axillary line, the ends of ribs 10, 11 and 12 were removed.

Lateral Wasitline Narrowing result intraop Dr Barry Eppley IndianapolisWhen viewed from behind the combination of rib removals, liposuction and fat injections to the hips made for a more hourglass torso shape. This effect will become greater over time as the waistline reduces as the swelling subsides and the tissues shrink inward.

Rib removal surgery for waistline narrowing is a bit of a misnomer. It should be called ribcage modification by removing of smaller portions of the obstructing ribs. While the pleura of the lung can be found at the level of ribs 10 and 11, careful technique can avoid its violation.

Highlights:

1) Posterior rib removals are for helping create a more narrow anatomic waistline.

2) The removal of the outer or distal portions of ribs 10, 11 and 12 removes the anatomic obstruction to the outer waistline profile

3) Rib removal is best thought of as ribcage modification as complete rib removal is never actually done.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Chin Implant Revision

Saturday, May 21st, 2016

 

Background: Chin augmentation is one of the original facial reshaping surgeries and has been performed for decades. Whether done through the mouth or done from an incision below the chin, the fundamental concept is that an implant is placed over the central aspect of the lower chin bone. (pogonion)

While the basic technique for chin augmentation has not changed over the years, the styles of chin implants has. Chin implant shapes have evolved to be large with long lateral wings. Known as anatomic chin implants, these lateral wings are added to the implant to allow it to transition more smoothly into the lower border of the jaw behind the chin.

While this lateral wing concept has its merits, it is also prone to creating chin implant asymmetry. Even slight amounts of chin implant rotation can cause the end of the wings to be asymmetric. The higher wing can even be felt inside the mouth as it encroaches into  the vestibule and may even put pressure on the mental nerve.

Chin Implant MalpositionCase Study: This 67 year-old female had two previous chin implants. An initial larger implant was placed two years ago and subsequently downsized due to dissatisfaction with its size. Once the swelling subsided the patient noticed an asymmetry of the chin with a higher wing on the right side.  The implant asymmetry was seen externally across her chin. She could feel it inside her mouth at the gumline on the right side which caused intermittent tingling and numbness sensations on the right side of her lip.

Chin Implant Malposition surgery Dr Barry Eppley IndianapolisChin Implant Repositioning surgery Dr Barry Epley IndianapolisUnder general anesthesia, her chin implant was approached through her existing submental incision. The chin implant was found to be located about 1 cm above the lower border of the chin bone and the midline shifted to the right with obvious canting of the implant. The implant was removed, the lateral wings reduced and the implant pocket adjusted. The chin implant was out back in a central position lower on the bone and secured with a single 1.5mm screw.

Chin implant malposition is especially prone when a large implant is replaced with a smaller one. The smooth surface of silicone implant makes it especially prone to sliding around on the smooth underlying capsular layer. This is where the value of placing a single screw ca be invaluable in its prevention and/or correction.

Highlights:

1) Chin implant malposition is not an uncommon complication of chin augmentation surgery.

2) With today’s winged chin implants, asymmetry of the lateral wings of the implants can easily occur.

3) Chin implant revision surgery creates a new pocket for the implant and secures it centrally with a screw placed in the midline.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Sagittal Ridge Skull Reduction

Thursday, May 19th, 2016

 

Background: Perhaps to the surprise of many, men make up a significant percent of aesthetic skull reshaping patients. This is due to the show of the skull shape that occurs with shaved heads, closely cropped hairstyles and thinning hair cover. Men become exquisitely aware of any prominent bony areas or indentations or deficiencies.

One of these aesthetic skull shape issues is that of the prominent sagittal ridge. This midline raised ridge, which occurs mainly along its posterior aspect, is easily seen as the highest part of the skull. The ridge creates a peaked or more triangular shape to the top of the head rather than that of more of a convex shape.

Sagittal skull ridge reduction is done by a burring technique. While this technique is very straightforward, its effects are limited by two factors. The bone can not be reduced by than just into the diploic space. Once the diploic space is entered significant bleeding occurs and this can lead to fluid collections that develop under the scalp after surgery. Because of the visibility of the scalp on the top of the head, the incision used to access the sagittal ridge must be limited. This can influence the extent that the sagittal ridge can be reduced.

Case Study: This 35 year-old male presented with a prominent sagittal ridge closer to the crown of the head. On the most posterior aspect of the sagittal ridge there was an indentation or dip between two areas of the raised sagittal ridge.

Sagittal Ridge Skull Reshaping plan Dr Barry Eppley IndianapolisUnder general anesthesia, a curved scalp incision of 7cms was made perpendicular to the sagittal ridge on its back third. Through this incision the sagittal ridge was reduced by 5ms along its length. At the area of the dip, 2ccs of hydroxyapatite bone cement was applied to raise it up to the surrounding skull contour.

Sagittal Ridge Skull Reshaping result front view Dr Barry Eppley IndianapolisSagittal Ridge Skull Reshaping result side view Dr Barry Eppley IndianapolisA head dressing and drain was removed the following day. The change was immediately seen in the skull contour with a successful sagittal ridge skull reduction.

Highlights:

1) The prominent sagittal ridge is an almost exclusive male skull shape concern.

2) The limits of the sagittal skull ridge reduction is the thickness of the bone and the length of the incision permitted by the patient.

3) Sagittal skull ridge reductions can usually be reduced from 5mm to 7mms.

Dr. Barry Eppley

Indianapolis, Indiana

Lateral Approach to Temporal Migraine Surgery

Wednesday, May 18th, 2016

Zygomaticotemporal nerveTemporal headaches are one of the four known regional migraine areas. The etiology is compression of the zygomaticotemporal nerve (second division of the trigeminal nerve), the auriculotemporal nerve (third division of the trigeminal nerve) or both. Decompression or avulsion of these nerves is a known effective treatment in the properly qualified temporal migraine surgery patient.

The surgical approach to the zygomaticotemporal nerve has historically been from an endoscopic technique where the dissection is done from above. This is often combined with supraorbital nerve decompression and explains why a superior approach has been advocated.

In the My 2016 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘ A Novel Surgical Approach to Chronic Temporal Headaches’.  In this report, the authors used a temporal hairline incision to access the zygomaticotemporal and auriculotemporal nerves for decompression or avulsion. Through a small 3.5 cm incision, the zygonaticotemporal nerve located above the deep temporal fascia. If the nerve was healthy, the fascia was opened and the sentinel vein cauterized. If the nerve appeared non-viable it was transected and the cut end buried in the muscle. The auriculotemporal nerve located closer to the incision was treated simlarly. At one year after surgery the Mean Migraine Headache Index dropped from an average of 131 to 52. Almost 90% of the patients experienced a 50% reduction in their headache symptoms. Almost 40% had a complete cure of their migraines. Three patients (roughly15%) had no substantial improvement.

Auriculotemporal Nerve Migraine Trigger Site Dr Barry eppley IndianapolisThe novelty of this temporal migraine approach is that it is closer to where the zygomaticotemporal nerve is located and allows concurrent access to the auriculotemporal nerve as well. It is a perfectly safe approach that stays below the frontal branch of the facial nerve. The more direct approach better allows the treatment option of  decompression or avulsion under better visual access.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

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.

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