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Posts Tagged ‘plastic surgery technical strategies’

Technical Strategies – Large Skull Reduction

Saturday, April 2nd, 2016

 

skull layersWhile there are many different types of skull reshaping surgeries, the most limiting is the desire to have an overall smaller head. Because of the skull’s thickness, there are limits as to how much of the skull thickness that can be reduced. While there are great variabilities in the thickness of the human skull, safe reduction is limited to removal of the outer cortical layer. The skull is exactly like an Oreo cookie with three layers, two outer hard layers (cortex) and an inner softer marrow layer. (diploic space) For reasons of brain protection and bleeding, aesthetic reduction should go no further than the outer layer of the ‘cookie’.

The typical outer coretx of the skull is anywhere, on average, from 4 to 7mms thick in humans. This thickness is affected by gender, age and ethnicity. While reduction of such a  ‘limited’ amount of skull thickness may not seem like much, it can appear much bigger than one would think when a broad surface area of it is removed. This is particularly true across the top of the skull between the temporal lines and in the forehead and back of the skull. Reduction along the sides of the skull is more greatly impacted by muscle reduction than it is by bone removal.

When doing large skull reduction areas, a burring technique is used as the most efficient and safest bone removal method. Burring allows for a controlled bone removal method so one can judge how when one is getting close to the diploic space of the skull. But when burring large skull areas it can be difficult to get it perfectly smooth and even across its convex surface. The procedure is also tedious and time consuming.

Skull Reduction technique 1 Dr Barry Eppley IndianapolisSkull Reduction surgical technique 2 Dr Barry Eppley IndianapolisThe technique that I have developed for large skull reductions is a ‘checkerboard’ method. A horizontal cut with a burr is first made to establish the depth of the reduction from one temporal line to another. Then additional horizontal lines are made over the desired skull reduction area. Then vertical burr cuts are also made to create a grid or checkerboard appearance.

Skull Reduction surgical technique Dr Barry Eppley IndianapolisSkull Reduction surgical technique 4 Dr Barry Eppley IndianapolisThis checkerboard skull pattern then allows one to reduce each individual square sequentially. This helps ensure that the overall bone reduction is done as even as possible and allows one to do it faster and very safely. Always knowing where the diploic space is located gives the surgeon better control of the bone being removed.

Any large skull reduction done for aesthetic purposes is accomplished by removing the outer cortex through bone burring. This checkerboard technique allows for both precision and safety.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Biceps Implants

Wednesday, February 10th, 2016

 

tricep muscleAugmentation of the upper arm is a combination of development of the biceps and triceps muscles. The biceps is the most recognized of the two upper arm muscles and the most pursued in terms of exercise development and arm flexing. The biceps muscle is a two-headed muscle that extends on the anterior surface of the upper arm from the shoulder down to the elbow. The muscle originates on the scapular bone and inserts across the elbow on the upper forearm bones. Its main function is to flex and rotate the forearm

While weight training and other forms of exercise are the best way to develop a larger and more prominent biceps muscle, there are biceps implant surgeries to bypass the natural augmentation methods. Biceps implants can be placed in the subfascial location over the muscle to enhance its muscular profile.

Biceps Implants Markings and Incision Dr Barry Eppley IndianapolisThe location of biceps implants is placed over the length of the muscle. But it is very important when making the implant location markings that it takes into account the shortening or contraction of the muscle. The distal length of the muscle should be marked when the muscle is maximally contracted when the elbow is bent at 90 degrees and the forearm is supinated.

Biceps Implants Incision and Pocket Dissection Dr Barry Eppley IndianapolisBiceps implants surgery is done in the supine position through an incision placed high in the armpit. This is the identical incision used for the placement of pectoral implants. Iyt does not need to be more than 3.5 to 4cms in length. This iincision is up under the lateral edge of the pectoralis muscle so it will be fairly hidden when it heals.

Biceps Implants Incision and Closure Dr Barry Eppley IndianapolisThe biceps muscle fascia can be identified under the fat underneath the incision down towards the arm. The fascia is incised and the subfascial pocket is dissected with a long smooth instrument down to just above elbow. A silicone contoured carving block (Implantech) is used and carved to length as needed. The implant is easily inserted along the full length of the subfascial pocket.

The fascia is closed and the overlying skin closed in two layers. An ace wrap along the full length of the arm is used as the only dressing.

Biceps implant surgery produces an instant muscle enhancement effect.The subfascial pocket approached from an axillary incision avoids any major neurovascular structures and enters the fascia where the two heads of the biceps muscle become unified.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Screw Fixation of Jaw Angle Implants

Sunday, May 10th, 2015

 

Width only Jaw Angle Implants Dr Barry Eppley IndianapolisThe placement of jaw angle implants has many unique aspects from other facial implants. It requires dissection in the most posterior part of the face done from inside the mouth making access and visibility challenging. It requires the largest muscle on the face to be lifted off the bone (masseter muscle) to place and position the implant. And certain types of jaw angle implants (vertical lengthening types) require that about half of the implant is not situated on the ramus portion of the mandible.

Because of these unique characteristics the success (and failure) of jaw angle implants are related to proper positioning and stabilization of them. Unlike many facial implants where fixation of the implant to the bone may be viewed as a ‘luxury’, I view fixation of jaw angle implants as a virtual necessity. They can become so easily displaced right after wound closure (push back of the masseter muscle causing them to slide forward) that the only postoperative assurance of implant positioning is to screw them into place.

Jaw Angle Screw Fixation Dr Barry Eppley IndianapolisThere are multiple methods of screw fixation but the simplest and most effective is a percutaneous technique using 1.5mm self-tapping screws. Screws are optimally placed from a perpendicular orientation to the bone and this is of paramount importance when the screw is self-tapping. (not requiring a drill to place a hole in the bone) Using a small 3mm skin incision from the side of the face over the implant allows the screw driver to be inserted through the skin and masseter muscle down to the implant’s surface. The screw is then placed on the screw driver and inserted through the implant to the bone. Usually only a single screw is needed that is no more than 5mms in length. (thus avoiding hitting any tooth or nerve structures that lie deeper)

Percutaneous Screw Fixation Technique for Jaw Angle Implant Fixation Dr Barry Eppley IndianapolisPatients are understandably nervous about a facial ‘scar’. But this nick incision is so small that it heals in a scarless fashion. The initial incision is closed with a single 6-0 plain gut suture.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Square Chin Implant and Vertical Cleft Creation

Friday, February 27th, 2015

square chin implant dr barry eppley indianapolisChin augmentation is most commonly done by placement of a synthetic silicone implant. Chin implants today come in a wide variety of dimensions, historically providing only horizontal projection, but now available in vertical lengthening styles as well. For men chin implants are even available to provide an increase in width, also known as a square chin look, to provide a more masculine chin/jawline appearance.

One other chin feature that is often desired in men is that of a chin cleft. Certain chin implants have a central cleft in them in an effort to create a midline cleft with the chin augmentation. While it looks good on the implant, it does not translate to creating that effect on the outside after implant placement. It simply is not that easy to create a vertical chin as it does not come exclusively from a defect or notch in the bone, contributions also come from a muscular diastasis as well.

square chin split implant technique dr barry eppley indianapolisvertical chin cleft creation technique dr barry eppley indianapolisTo effectively create a vertical chin cleft at the same time as placing a chin implant, it requires a concerted effort to make it appear. The chin implant is first split down the midline and separated. A 5 to 7mm gap is made between the implant. Because the implant is now in two pieces it is necessary to secure each implant half by screw fixation. Then a bone hole is made through the bottom of the chin in the midline. This allows a permament suture to be placed that is used to pul the mentalis muscle down into the implant gap. A stronger effect can be created by removing some soft tissue under the skin as well before passing the suture. How tight the suture is tied down will impact the degree of cleft creation. The shape of the cleft (its width) is also influenced by the size of the midline implant gap.

Square Chin Implant with Cleft result Dr Barry Eppley IndianapoliisA vertical chin cleft can be done at the same time as a square chin implant augmentation in men. Breaking up the wider square chin with a cleft helps add a visual feature of interest and disrupts a completely flat horizontal line across the bottom of the chin.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Fat Injections for Lower Eyelid Ectropion

Sunday, February 15th, 2015

 

Lower eyelid retraction, known as ectropion, occurs for a variety of reasons. The most common reasons are after an elective aesthetic lower blepharoplasty and/or midface lift or after repair of an orbital floor or cheek bone fracture. The lower eyelid retracts downward due to loss of support in one or several of its layers (lamellae) and the pulling effects of scar contracture. Its effects are greatest at the outer corner of the eye and less so medially.

In many milder cases, the lower lid ectropion can be self solving within a few weeks or months after the procedure. More severe cases or those that fail to improve after three to six months require surgical treatment. A variety of lower eyelid ectropion repair procedures exist, most which focus on an eyelid release and either a lateral canthopexy or lateral cantoplasty. While these can be effective, not all work because a portion of the lower eyelid lacks volume and the tissues are stiff and scarred.

Fat Injections for Lower Eyelid Ectropion Dr Barry Eppley IndianapolisOne technique that can be used in lower eyelid ectropion repair, and which has no morbidity and can be done without an open incision, is that of injectable fat grafting. Placing fat grafts into a scarred eyelid adds both volume and suppleness back into the tissues. It can be used as a preparatory procedure for more invasive ectropion repairs later or can be used in conjunction with more limited ones. The push of the added fat volume helps drive up and support the lower eyelid.

The amount of fat needed for each lower eyelid can be as small as 0.5cc up to 2ccs. It is always better to inject as much fat as possible since not all of the fat will survive. When done alone, the diluted fat liquid (nanofat) extract left behind after concentration can be injected directly into the skin using a 30 gauge needle. This adds an additional treatment to the thinner eyelid skin as well.

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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