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Posts Tagged ‘technical strategies in plastic surgery’

Technical Strategies – Head Widening Implants

Monday, February 15th, 2016

 

The width of the side of the head  is controlled by the shape of the temporal bone and the thickness of the temporalis muscle, all located above the ear. While many think the bone is the main contributing factor, the thickness of the temporalis muscle should not be underestimated. By CT scan measurements it can be seen that the temporalis muscle usually makes a bigger contribution than that of the bone to the width of the side of the heasd.

Regardless of the anatomic makeup of the width of the head, widening the narrow head must be done by either onlay augmentation of the bone (submuscular) or onlay augmentation of the muscle. (subfascial) Which implant location is best depends on whether the augmentation involve just the posterior temporal region (above the ears) or also the anterior temporal region as well. (by the side of the eye)

Head Widening Implants (anterior and posterior temporal implants Dr Barry Eppley IndianapolisHead Widening Implants (incision and subfascial dissection) Dr Barry Eppley IndianapolisMost head widening implants augmentation include both the anterior and posterior temporal regions. This can be accessed through a single 4cm incision placed in an intermediate location in the temporal hairline. Using a subfascial incision and pocket dissection, extended anterior and larger posterior temporal implants can be placed through the same point of temporal incisional access.

Head Widening Implants (implant placement and subafscial closure) Dr Barry Eppley IndianapolisHead Widening Implants (incision closure) Dr Barry Eppley IndianapolisAfter the placement of both anterior and posterior temporal implants in the subfascial pockets, the fascia os closed over the them. The skin closure is done in a two layer fashion with resorbable sutures.

Head widening or complete temporal augmentation can be done through a single small temporal incision. Two implants are needed to increase the volume of both the anterior and posterior temporal regions.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Extended Temporal Implants

Sunday, February 14th, 2016

 

Temporal implants have become the surgical approach to the treatment of temporal hollowing.  They offer a rapidly performed permanent solution that eclipses the temporary and inconsistent effects of synthetic fillers and fat injections. These implants are placed in the subfascial location on top of the temporalis muscle through a small vertical or obliquely oriented incision back in the temporal hairline.

As the use of temporal implants has increased, new styles have emerged. The initial temporal implant design was designed to treat the deepest part of the temporal hollows by the side of the eye. These implants only went up about as high as the lateral brow bone.

Extended Anterior Temporal Implant Dr Barry Eppley IndianapolisBut as more experience with temporal implants has evolved, it become clear that the extent of bothersome temporal hollowing can extend all the way up to the side of the forehead. (anterior temporal line) This has led to an extended style of temporal implants that provides some augmentation much higher than the standard style. (up to 6.5 cm vertical height from the zygomatic arch)

Temporal Implants Incision and Insertion Dr Barry Eppley IndianapolisWith such a larger temporal implant, the concern would be that a much larger incision would be needed for its placement. To avoid more than a 3 cm to 3.5 cm incision, the key is to make the subfascial pocket through a small incision. This is easy to do with instruments in a blind fashion. Then the implant can be inserted lengthwise in a rolled fashion. Once making its way through the small incision, the implant is unfurled and rotated into the proper position.

Larger styles of temporal implants can still be inserted through relatively small temporal hairline incisions. This makes the appeal of temporal implants for larger areas of temporal hollowing equally appealing as smaller amounts of temporal hollowing.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Fat Grafting Chin Dimples

Tuesday, December 29th, 2015

 

Chin dimples are a not uncommon but anatomically perplexing facial feature. Sitting as a round central depression on the soft tissue chin pad, it serves no functional purpose other than a distinctive facial adornment. Like all facial dimples the cause has been shown to be caused by an underlying muscle deformity, specifically that of the mentalis muscle. Unlike its close cousin, the vertical or Y-shaped chin cleft, there is not an associated underlying bony deformity. Chin dimples and clefts are known to be an inherited trait on a dominant gene with variable penetrance.

The most common treatment to reduce or eliminate a chin dimple is by using an injectable filler. All of the commercially available injectable fillers can be used although their results will not be permanent. The use of silicone oil offers a permanent injection method although it is not FDA-approved for any facial augmentation procedure. Before placing any injectable filler a saline injection test should first be done to ensure that the dimple will be pushed out rather remaining indented and creating a ‘doughnut’ deformity.

Chin Dimple Release Dr Barry Eppley IndianapolisOne potentially permanent injection treatment option is that of fat grafting. Since injected fat is far more viscous than any injectable filler and does not have good linear flow, the bed into which it is injected should first be released. This can be done by using an 18 gauge needle placed in the center of the dimple and then rotating it around 360 degrees. The beveled edge of the needle will act like a small scalpel blade releasing the skin from its deeper attachments.

Chin Dimple Fat Injections Dr Barry Eppley IndianapolisOnce the chin dimple is released, a small amount of fat can be injected into the released subcutaneous space. This usually takes anywhere from .2ml to .5ml of concentrated fat. No one can predict with certainty how well injected fat takes so it is possible a second injection treatment may be needed. Three months should be allowed to pass to judge the retained injected fat volume.

There are alternative approaches to treating the chin dimple indentation done through an intraoral approach with muscle repair, but injection fat grafting offers a minimally invasive technique that has a high rate of success.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Male Direct Brow Bone Reduction

Thursday, November 26th, 2015

 

Brow bone reduction can be done by two basic techniques. A burring reduction of the outer table of the frontal sinus wall is one option. The amount of reduction achieved will be limited by the thickness of the outer table bone which can be anywhere from 2 to 5mms. The other method of brow bone reduction is removal of the entire outer table of the frontal sinus, reshaping it and putting it back in place. This method of brow bone reduction produces a more dramatic result with further setback than what can be achieved  by more simple burring methods.

But regardless of the method of brow bone reduction used, an open approach is always needed for the best result. While more limited incision approaches using an endocope have been described, they produce a very minimal reduction in brow bone prominence at best. While this open incisional access is less of an issue for women it is of major consideration in men…who coincidentally make up more than half of patients seeking brow bone reduction.

Male Direct Brow Bone Reduction markings Dr Barry Eppley IndianapolisOne option for male brow bone reduction is the mid-forehead incision. Using a prominent  horizontal wrinkle line identified by raising of the eyebrows preoperatively, a central forehead incision can be used. It is important to keep the location of the incision limited to the central third of the forehead between lines drawn up vertically between the pupils. By so doing the major branch of the supraorbital nerve is preserved so much of forehead sensation is saved.

Male Direct Brow Bone Exposure and Bone Flap Removal intraop Dr Barry Eppley IndianapolisMale Direct Brow Bone Reduction Bone Flap Fixation Dr Barry Eppley IndianapolisThrough this limited incision, the anterior table of the frontal sinus can be successfully removed by a combination of a reciprocating saw and osteotome technique. The frontal bone flap can be removed, reshaped and replaced by small plate and screw fixation. Once the incision is closed in layers with small resorbable skin sutures, an imperceptible scar results.

Male Direct Brow Bone Reduction Skin Closure Dr Barry Eppley IndianapolisMale brow bone reduction can be successfully done through a limited forehead incision. The result achieved is comparable to what can be done through a longer pretrichial or full coronal scalp incision. Given the state of many men’s hairlines and their potential regression with aging, a well healed mid-forehead incision can be considered a good option for brow bone reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Brow Bone Fixation with Microplates and Screws

Saturday, September 26th, 2015

 

Brow bone reduction surgery is often done either for men with extreme prominences or as part of facial feminization surgery. The brow bones can be reduced by two basic methods, bone burring or an osteotomized bone flap. The thickness of the anterior frontal sinus wall and how much brow bone reduction is needed will determine what is the best technique for the patient.

Brow Bone Thockness X-Ray Dr Barry Eppley IndianapolisBut for very prominent brow bones a frontal sinus wall setback technique is needed. Known as an osteoplastic bone flap method, it is done by removing the entire frontal sinus wall by sawing it off flush with the surrounding forehead bone. This exposes some or all of the underlying frontal sinus cavities. Sometimes the mucosal lining can be kept intact if it is carefully peeled off the cut bone segment. The removed bone segments are rehaping, usually thinning them out so a flat piece is obtained, and then put back.

Putting the frontal sinus bone flap back requires that it be fixed to the underlying and surrounding bone. A stable bone segment will permit a good seal over the frontal sinuses (to prevent a postoperative air leak) and will allow for bone consolidation/healing. Multiple methods of brow bone fixation have been used from resorbable sutures, wire ligature and various sizes of metal plates and screws. Depending on the shape of the repositioned bone segment and how it fits into the surrounding bone, any of these bone fixation methods can work. The most stable method is always going to be plate and screw fixation as it is anywhere else on the craniomaxillofacial skeleton. But the plates and screws need ti be fairly small so that their profile does not eventually show through the forehead skin.

Microplate Fixation Brow Bone Reduction Dr Barry Eppley IndianapolisMicroplate Fixation Brow Bone Reduction Indianapolis Dr Barry EppleyMicroplate and screw fixation is ideal for the brow bones. With screws that are just 1mm in size and plate profiles that also sit no higher than 1mm, they provide firm fixation with negligible prominence. They can be used to piece together small bone fragments to securely cover the exposed frontal sinus. The length of the screws need to be no longer than 4mms to just enter the outer cortex of the forehead bone.

Brow bone fixation with microplates and screws works well but has only one minor drawback…cost. Such fixation will always be more expensive than that of sutures or even large plates and screws.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Shaped Silicone Breast Implants Funnel Insertion Technique

Wednesday, September 16th, 2015

Shaped Breast Implants Dr Barry Eppley IndianapolisOne of the newer types of silicone gel breast implants is that of the shaped implant style. Often called the tear drop or anatomic breast implant, it is designed to distribute the gel volume differentially with about 2/3s of the volume in the lower half of the implant. This is done by having an implant shell which is so designed to do so.

The shaped silicone breast implant offers several advantages for certain women, most notably creating a greater likelihood that the breast will look more natural and not so round. This can be particularly useful in breasts that have a small amount of ptosis (sagging) where the additional volume can help fill out the bottom half of the breasts better. Because of its shape it will not look so high initially and settles into a more natural breast shape sooner after surgery.

Because a shaped silicone breast implant has a specific form that will only look right in one position, its outer shell has a textured or irregular surface. The purpose of this shell lining is to allow the body (scar tissue) to grab onto it and hold it into its exact position so that it does not rotate after surgery. This is unlike a smooth round silicone breast implant which can rotate around without causing any external breast deformation.

The textured surface of a silicone shaped breast implant has one disadvantage, it is stiffer and has a more firm structure. This can make it harder to insert through small inframammary skin incisions. Usually larger skin incisions are needed to permit it to be inserted and oriented properly. This feature can be circumvented by using a funnel insertion technique.

Textured Shaped Silicone Breast Implants Funnel Insertion Technique 1 Dr Barry Eppley IndianapolisTextured Shaped Silicone Breast Implants Funnel Insertion Technique 2 Dr Barry Eppley IndianapolisUsing a breast funnel, the textured shaped implant is placed into it after activating its internal lining by saline fluid. The shaped breast implant needs to placed into the funnel with the smaller upper pole towards the smaller tapered end. The vertical orientation line on the implant (Sientra shaped breast implants) should be placed upward so it is easily seen.

Textured Shaped Silicone Breast Implants Funnel Insertion Technique 3 Dr Barry Eppley IndianapolisTextured Shaped Silicone Breast Implants Funnel Insertion Technique 4 Dr Barry Eppley IndianapolisWith a prepared funnel insertion device, it is inserted into the small inframammary incision and squeezed into the breast pocket. Due to the placement of the shaped implant in the funnel, it will end up in the proper vertical orientation without having to even touch the implant.

The need for larger skin incisions and manipulation of the shaped silicone breast implant inside the submuscular pocket for proper orientation can be completely overcome by a funnel insertion technique.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Tracheal Shave by Burring Reduction

Wednesday, August 12th, 2015

 

A tracheal shave or Adam’s Apple reduction (technically a thyrochondroplasty) is a well known neck contouring procedure to reduce a thyroid cartilage prominence. While it is most commonly perceived to be a male to female transgender procedure, it is actually done just as commonly for men or women who have a prominent thyroid bulge and are not undergoing a facial feminization procedure.

The tracheal shave is one of those plastic surgery operations that is not really misnamed. In its name is exactly how it is done. The usually soft nature of the thyroid cartilage is exposed and shaved down with a scalpel reducing the laryngeal prominence at the thyroid notch and the anterior rim of the paired lamina. With the scalpel the reduction is shaved down in layers until the desired level is obtained.

Tracheal Reduction by Burring Dr Barry Eppley IndianapolisBut as patients get older the thyroid cartilages become stiffer and partially ossified. Around the age of 50 and older a scalpel will usually not cut into the cartilage and a true tracheal shave is not possible. It becomes necessary to change from the reduction method from a scalpel to a burring technique using a handpiece and drill. This mechanical rotary reduction method allows for a very precise laryngeal prominence reduction and also makes the cartilage edges very smooth.

Tracheal Shave by Burring Reduction Dr Barry Eppley IndianapolisIn older patients a tracheal shave becomes a tracheal burring reduction. The result with mechanical burring is just as effective. Given the need for a handpiece the tracheal reduction is best done through a small overlying skin incision rather than a more distant submental incision higher up under the chin.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Asian Love Band Surgery

Sunday, August 2nd, 2015

 

The Asian eyelid is very different from that of Caucasians both in anatomy and in aesthetic appearance. For the upper eyelid the ‘double eyelid’ blepharoplasty procedure is well known to create a crease which does not naturally exist. But for the lower eyelid aesthetic enhancements are less well known or requested.

Asian love band surgery indianapolisOne newer lower blepharoplasty aesthetic enhancement procedure is that known as Asian Love Band surgery. In this procedure a fullness is added to the lower eyelid just below the lashes. This is intended to enhance the underlying orbicularis muscle which in youth is fuller and more developed. (orbicularis roll) With aging the orbicularis muscle stretched and thins losing its fullness. To illustrate cultural differences in facial aesthetics,   an orbicularis roll in Caucasians would be considered undesireable and often requested to be removed. The Love Band operation is also perceived to make the eye look larger and more open, an optical illusion created by dividing the lower eyelid into two visible parts which is similar to what  “double eyelid” surgery does for the upper eyelids.

The Love Band lower eyelid surgery is done by placing small strips of grafts or implants under the skin through two small incisions at the inner and outer edges of the lid just below the lash line. Traditional materials used include allogeneic dermis (Alloderm) or Gore-Tex. The procedure can also be done non-surgically (albeit temporarily) by using hyaluronic-based injectable fillers.

Lower Eyelid Love Bands Surgical Technique 1 Dr Barry Eppley IndianapolisLower Eyelid Love Bands Surgical Technique 2 Dr Barry Eppley IndianapolisLower Eyelid Love Bands Surgical Technique 3 Dr Barry Eppley IndianapolisThe surgical technique that I have developed for Asian Love Band surgery uses temporalis fascia. This is a natural material that is harvested from small incisions in the temporal area. (although Alloderm can also be used) A small fat injection cannula is passed from one side of the eyelid to the other. The strips of temporalis fascia have a suture pass through them of which the ends are passed into the length of the cannula. The cannula is then removed leaving the suture on the other side of the eyelid. The suture is then used to pull the fascial graft through the lower eyelid tunnel, trimmed and closed with a tiny dissolveable suture.

The Asian Love Band procedure requires a method to pass a graft or implant right under the lash line through the tiniest of incisions. This cannula passing method provides a simple and effective method to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Hydroxyapatite Block Grafting in Sliding Genioplasty

Sunday, May 24th, 2015

 

A sliding genioplasty is the autologous alternative to using a chin implant. It is done far less frequently than using implants for chin augmentation, and it should be, but it does have a defined role for lower facial augmentation. It is indicated for large chin movements which standard implants can not achieve, for young patients who need large amounts of chin augmentation and for existing chin implants that have developed complications.

Labiomental Fold Dr Barry EppleyA sliding genioplasty involves a bone cut below the anterior tooth roots and mental foramen which is done at various angles depending on the type of dimensional bone movement needed. As the bone moves forward it is important to appreciate that the labiomental fold will not move with it. The labiomental fold or groove, which is situated about 1/3 the distance from the lower lip to the bottom of the chin, is a fixed structure that is reflective of the attachment of the mentalis muscle to the chin bone over the incisor tooth roots. Its deepest part correlates to the depth of the vestibule on the inside of the lower lip.

Hydroxyapatite Block in Maxillofacial Surgery Dr Barry Eppley IndianapolisHydroxyapatite Prorosity Dr Barry Eppley IndianapolisAs the chin bone comes forward with a sliding genioplasty, the labiomental fold ‘stays behind’. Thus it will get deeper with horizontal chin bone movements. This is due to the now ‘step’ shape of the chin which allows the lower part of the labiomental fold to stay where it is but the chin tissue beneath moves forward.  One historic effort to deal with the deepening labiomental fold effect in a sliding genioplasty is to graft the step of the osteotomy. Many materials have been advocated and used but the hydroxyapatite block graft is one of the most historic. They have long been used in maxillofacial surgery as an interpositional or onlay graft which offers excellent biocompatibility due to its inorganic mineral content and interconnected material porosity.

Hydroxyapatite Block Sliding Genioplasty intraoperative view Dr Barry Eppley IndianapolisHYdroxyapatite Onlay Block in Large Sliding Genioplasty Dr Barry Eppley IndianapolisA carved hydroxyapatite block to fill the step of a sliding genioplasty is an excellent graft choice. Its benefits are when the sliding genioplasty movement is significant, usually 10mms or greater where a large bone step is created. Part of the bone is covered in the midline by the fixation plate but the hydroxyapatite block is placed on top of it regardless. Bone will grow around the fixation plate and into the block.

Grafting the bone step of the sliding genioplasty is not the complete cure for preventing the deepening or for the treatment of the deep labiomental fold. It does, however, have some benefit and is a simple and uncomplicated adjunct to the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Postauricular Approach for Head Widening Implants

Thursday, May 21st, 2015

 

Augmentation of the face through a variety of implants has been around for along time. Implant augmentation above the face on the skull bones is almost unheard of. Skull augmentations are much less commonly done, not only because they are less frequently requested, but because they are no implants made for them and surgical techniques taught to do them.

Some people have abnornally narrow skull shapes with the temporal region above the ears (what I call the posterior temporal zone) being non-convex. The typical aesthetics of the posterior temporal zone is to have some convexity due to the shape of the bone and the thickness of the muscle. When the temporalis muscle is thin or the shape of the posterior temporal bone is more linear than convex, the side of the head can look very narrow. This becomes most manifest in men with short cropped hair or who shave their heads. Although I have seen patients who have substantial hair cover who are equally bothered by it.

A head widening or posterior temporal implant is a very effective implant augmentation of this area. The implant can be placed either in the subfascial or submuscular location depending upon the incisional access. A vertical incision directly in the side of the head provides direct and easy access to subfascial placement of the implant. However such an incisional approach introduces potential scar concerns particularly with little to no hair color.

Head Widenng Implant Surgical Technique Dr Barry Eppley IndianapolisHead Widening (Temporal) Implants Surgical Technique Incision and Pocket Dissection Dr Barry Eppley IndianapolisA postauricular approach is the ‘scarless‘ method for a head widening implant. With an incision in the crease of the back of the ear a submuscular pocket can be easily created. The pocket can be made from the very back of the posterior temporal region anteriorly to the front edge of the hair bearing temporal scalp. (anterior temporal zone) A posterior temporal implant can seem too large to fit through this small incision but the flexibility of a low durometer silicone implant makes it possible.

Head Widening (Temporal) Implants Surgical Technique Implant Placement Dr Barry Eppley IndianapolisThe posterior temporal implant must be folded onto itself, inserted and then unfolded once in the submuscular pocket. The pocket is fairly tight and the size of the implant makes it very unlikely that implant migration or displacement can occur. But I usually still place a single small titanium screw into the bottom of the implant for absolute security. It is critically important the closure of the postauricular approach re-estsblishes the muscle and fascia layers so the ear do not become protruding due to loss of its posterior attachments.

Posterior or head widening temporal implants can be placed through a postauricular incision into a submuscuar pocket. The implant usually does not need to be greater than 5mm to 7mms to great a substantial head width change when done on both sides of the head.

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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