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Posts Tagged ‘technical strategies’

Technical Strategies – The Versatile Temporal Implant

Sunday, May 8th, 2016

 

Augmentation of temporal hollowing has become a popular aesthetic procedure. While synthetic fillers and fat offer simplicity, they do not create a permanent treatment solution. Temporal implants fill that need and can be placed through a relatively minor surgical procedure.

Temporal Implant Design Dr Barry Eppley IndianapolisThe first generation standard temporal implants are of a soft flexible silicone material that is designed to simulate muscle tissue. It has a shape that simulates the lateral orbital rim anteriorly, the zygomatic arch inferiorly and then tapes superiorly and laterally into a tapered edge. It is longer horizontally than vertically and is designed to treat the deepest part of temporal hollowing which is at the lower half of the anterior temporal region between the eye and the temporal hairline.

Temporal Implants modifed use Dr Barry Eppley IndianapolisBut some patients have temporal hollowing that extends up higher and desire a temporal augmentation effect that is vertically longer. In these cases the standard temporal implant can be rotated 90 degrees so that it is placed with the longer horizontal part vertically and the vertical part horizontal. It is also important that the right and left temporal implants be switched when making this implant re-orientation. In other words, a right temporal implant is used on the patient’s left side that is rotated 90 degrees in orientation n the left temporal hollow.

The standard temporal implant offers some versatility in how it can be used to create its temporal augmentation effect. In the subfascial location, it offers two options for the extent of its effect based on how the implant is oriented.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Diced Rib Graft Injection in Rhinoplasty

Tuesday, April 12th, 2016

 

Primary or secondary correction of nasal bridge deformities is now well known to be corrected by injectable fillers. The use of hyaluronic acid-based (HA) injectable fillers provides a quick and very directed approach to a wide variety of nasal contour deformities. While effective, no HA filler to the nose provides a permanent contour correction in the vast majority of patients.

I have run across a handful of patients that stated they had gotten one HA injection to the nose years ago and the result was sustained. But it is hard to know whether this is merely cosmetic accommodation or was indeed a ‘permanent’ result. I suspect that of the nasal contour issue was significant, such a permanent result would not have been seen. I know from injecting a lot of dorsal hump patients with HA fillers to camouflage it (placing filler above the hump to create a straight dorsal line) that such filler volumes are not sustained in the nose.

Diced Rib Graft Injection Preparation Dr Barry Eppley IndianapolisAn alternative and permanent options for larger primary or secondary dorsal line defects is that of a diced cartilage graft injection. This is a concept that, while injected, must be differentiated from that of HA filler injections. This is where cartilage grafts from either the septum, ear or rib are processed to make them injectable. This is done by cutting (dicing) them into small 1 x 1mm cubes (or smaller) and placing them into an open barrel 1ml syringe.

Diced Rib Graft Injection Preparation 2 Dr Barry Eppley IndianapolisThrough an intranasal (intercartilaginous) incision, a tunnel is made on the dorsum up onto the upper dorsal defect area. (frontonasal junction, radix, nasal sidewall) The syringe is introduced and the compressed cartilage grafts are injected in the desired amount and shaped externally. The grafted area is taped to hold the desired shape for 7 to 10 days.

While many diced cartilage are traditionally wrapped in surgical or fascia, there is a role in smaller nasal dorsal defects for direct injection of the cartilage. The small nasal tunnel and confinement of the syringe allow the cartilage particles to be precisely delivered.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Screw Fixation of the Premaxillary-Paranasal Implant

Monday, March 28th, 2016

 

paranasal implant anatomy pyriform aperture dr barry eppley indianapolisAugmentation of the central midface can be done by placing an implant along the base and sides of the nose. Known as the pyriform aperture, it is the bony outline of the nasal cavity which makes a hole in the facial skeleton to the back of the throat. The soft tissue and cartilage structure of the nose sits on top or in front of it.

Peri-Pyriform Implant Dr Barry Eppley IndianapolsParanasal Implant placement Dr Barry Eppley IndianapolisThe pyriform aperture area can be augmented by a standard preformed implant known as the peri-pyriform implant. It has bilateral wings that augment the paranasal or sides of the pyriform aperture and a connecting center piece which crosses the premaxillary region along the bottom of the nose. Technically this implant should be called a premaxillary-paranasal implant. It is a versatile implant since it can be sectioned to just do paranasal augmentation or its wings can be removed to create just a premaxillary implant.

Paranasal Implant Placement Dr Barry Eppley IndianapolisThe premaxllary-paranasal implant is placed through a low anterior vestibular incision up under the upper lip. It is important to place the incision above the fixed mucoperiosteal to leave a cuff of tissue to create a good closure. Sunperiosteal dissection is done up to the anterior nasal spine and around the sides of the pyriform aperture. It is important to stay close to the edge of the bone but to not violate the nasal mucosal lining. The implant is placed snug up against the anterior nasal spine and along the sides of the pyriform aperture. Two 1.5mm screws are placed through the wings of the implant to secure it to the bone.

The premaxillary-paranasal implant is the only implant that can provide central face augmentation. It has a LeFort 1-like effect on the base and sides of the nose. Firm fixation to the bone by microcrews is a simple and effective method to ensure its postoperative placement and long-term stability

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Endoscopic Browlift Fixation with LactoSorb Screws

Friday, January 1st, 2016

 

Endoscopic Browlift Supraorbital Nerve Dissection Dr Barry Eppley IndianapolisThe most common surgical treatment today for sagging brows is the endoscopic browlift. As opposed to browlifts that involve long incisions and remove forehead or scalp tissue to create the lifting effect, the endoscopic technique uses minimal incisions and removes no tissue. It achieves a browlifting effect through a deep subperiosteal brow tissue release and a superior forehead and scalp backward tissue shift.

This relocation of the entire soft tissue of the forehead up and back, known as an epicranial shift, must be initially held in place to create the brow lift. A wide variety of endoscopic browlift fixation methods have been described since this browlifting technique was introduced about twenty years ago. Fixations methods including metal pins, metal screws, transosseous bone tunnels and resorbable grids or platforms. Each of these devices and methods have their advantages and disadvantages and the fact that so many endobrow fixation methods exist indicates that there is no perfect way to do it.

LactoSorb Endoscopic Browlift Screw Dr Barry Eppley IndianapolisHaving used all of these endobrow fixation methods, there is one that I found to be my favorite over the twenty years of performing the procedure. The use of LactoSorb resorbable screws offers a simple and very reliable soft tissue fixation method. This is a low profile 2.0mm screw made out of PLLA-PGA material which is naturally resorbed after 6 months of placement. It is a special resorbable screw that has a hole placed though its head and a pushpin design rather than that of a threaded shaft.

LactoSorb Endoscopic Browlift Drilled Screwhole Dr Barry Eppley IndianapolisLactoSorb Endoscopic Browlift Screw Suture and Lift Dr Barry Eppley IndianapolisThis fixation method issued by initially placing an outer cortical bone hole at the back end of the endo scalp incision. A suture is initially passed through the screwhead and then the screw is pushed into the bone hole. A snug fit allows the introducer for the screw to be removed. With the screw in place holding the suture, the uplifted scalp and forehead tissues are grasped with a bite of the suture and tied down. The overlying scalp incision is then closed.

Between the temporal lines of the skull, LactoSorb Endobrow resorbable screws can be used for central brow fixation. They are slightly palpable for a few months but their profile eventually flattens as they resorb over time. The time needed for natural fixation by healing of the elevated periosteum back down to the bone is reported to be a but a few weeks. So the months of fixation provided by the resorbable screw is more than adequate.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Intraoperative Shaping of Calf Implants

Sunday, December 27th, 2015

 

The use of calf implants to achieve improved fullness of the lower legs is the most reliable body contouring procedure of the lower legs. Calf augmentation is done for men that want to improve the overall size of their calf muscles. Women are often trying to put their calfs in better aesthetic balance to their thighs. The most common reconstructive use of calf implants is in the congenital club foot deformity to improve calf symmetry (unilateral) or have some semblence of calf muscle mass. (bilateral)

indianapolis calf implants dr barry eppleyCalf implants are made of a pliable and shapeable solid silicone material that feels a lot like muscle tissue. The implants come in three standard sizes which is defined by their length and volume of augmentation. (Implantech calf implants – 15 cms/75cc, 20cms/135cc and 24cm/185cc) The selection of calf implant size is affected by both of these considerations but one of the most important is the length of the patient’s gastrocnemius muscle.

lower leg musclesSince calf implants are placed in a subfascial location, they can not extend below the most inferior level of the gastrocnemius fascia where it meets with the soleus fascia/muscle and achilles tendon. The fascia overlying the junction of these two muscles and tendon is very tight and is easily disrupted. Trying to subfascially dissect and place calf implants that are too long will result in disruption of their fascial covering and a lower end of the implant that is in the subcutaneous location. This will result in a calf deformity and pain.

Intraoperative Calf Implant Sizing Dr Barry Eppley IndianapolisCalf Implant Size Adjustments Dr Barry Eppley IndianapolisWhen the size of the calf implant chosen is too long for the patient’s gastrocnemius muscle length, the implant can be intraoperatively trimmed. The silicone material can be easily and quickly reduced and shaped by scissors. Calf implants can be shorted and the lower end retapered. With the implant in the subfascial location, any small irregularities on the implant’s outer surface will not be seen.

I have yet to see a circumstance where the width of a calf implant needed to be reduced. But it is not rare to have to reduce the standard lengths of the medium and large calf implants to optimize the amount of calf augmentation effect.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Endoscopic Custom Forehead Implant Placement

Monday, November 30th, 2015

 

Forehead Implant Design Dr Barry Eppley IndianapolisAesthetic forehead augmentation to correct a sloped, irregular or deficient frontal bone can be done by a variety of materials placed on top of the bone. Having used every one of them, they each have their merits and each material type can be successfully used in experienced hands. But the forehead augmentation method that has the best results is that of a custom forehead implant.

Endoscopic Custom Forehead Implant incision Dr Barry Eppley IndianapolisBesides being able to create the exact shape and thickness desired before surgery, a preformed custom forehead implant can also be inserted through the smallest scalp incision. While the use of bone cements require a full coronal incision to be placed in most cases, a custom forehead implant can be inserted through an incision that is limited to between the bony temporal lines. This avoids extending the incision onto the temporal area on the sides of the head where the scar can be more easily detected and always gets wider than that across the top of the head.

Endoscopic Custom Forehead Implant positioning Dr Barry Eppley IndianapolisThe biggest concern about placing a custom forehead implant is to get it low enough over the brow bones if that is the way it was designed. Placing a forehead implant that does not involve the brow bones is far easier and adequate positioning is almost never an issue.   But placing a complete custom forehead implant that must go over the brow bones first requires a subperiosteal release and supraorbital nerve dissection. This must be done with an endoscope given the limited size of the scalp incision. Once the forehead implant is inserted checking its placement with an endoscope can also be done.

The use of the endoscopic technique in a custom forehead implant is to ensure as best as possible the extent of the subperiosteal pocket and protection of the supraorbital nerves. It is not used because it can limit the extent of the scalp incision like is done is more traditional endoscopic browlift surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Intraoral Chin Implant Placement

Sunday, November 22nd, 2015

 

Chin implants are the most common permanent method of facial augmentation. Chin implants of various materials have been used for almost fifty years. Whatever the material composition of the implant is and its shape and size, chin implants can be introduced from either a superior approach (intraoral mucosal incision) or from below. (submental skin incision) There are advantages and disadvantages of either incisonal approach as well as surgeon advocates for either chin implant introduction technique.

The submental incision for chin implants offers the most direct access to the bottom of the chin bone where the implant should be properly placed. It also provides a pocket which eliminates the risk of any upward migration of the implant provided the pocket is not made too high. Firm fixation of the implant can also be done to the bottom edge of the bone to ensure its midline positioning. Because of a sterile skin prep, it also has a very low risk of infection. From a recovery and potential complication standpoint it also does not disrupt the superior attachment of the mentalis muscle. Its only real downside is that it does create a scar under the chin which can be objectionable to some patients.

The intraoral approach offers a scarless method for chin implant augmentation as its main advantage. Because of going through the mouth (although this is not exactly true because the lower lip is pulled out and away from the oral cavity) and detachment of the superior mentalis muscle, many surgeons feel that it is associated with a higher rate of complications. Superior malposition of the chin implant is actually the most common problem with the intraoral approach.

Intraoral Chin Implant Placement Technique Dr Barry Eppley IndianapolisIntraoral Chin Implant Placement Technique 2 Dr Barry Eppley IndianapolisSeveral modifications of the intraoral approach can avoid most of the potential chin implant problems. First the intraoral incision should be vertical in orientation, paralleling the fibers of the mentalis muscle. This splits the mentalis muscle but does not separate the mentalis muscle attachments. With the lip pulled away from the teeth, it provides the angle to develop the subperiosteal pocket along the inferior edge of the anterior mandible.  Secondly, implant sizers are used to ensure that the pocket has been properly developed prior to inserting the formal chin implant. Lastly, the implant is inserted, positioned and then secured in its midline position with a single 1.5mm microscrew to prevent superior implant migration.

The intraoral approach for chin implants is sometimes preferred by patients with more pigment in their skin, females and any patient that wants to avoid an external skin scar. The incisional technique should be different than that needed for a sliding genioplasty and other chin surgeries with a more limited and less dissected approach By so doing all of the potential disadvantages of the intraoral chin implant approach can be avoided.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Minimal Incision Temporal Reduction Technique

Tuesday, November 3rd, 2015

 

Reduction of an undesired temporal convexity is becoming increasingly requested as it becomes aware that a procedure exists to do it. For a head that is too wide or convex above the ears, a technique has been developed to help narrow it. While such a temporal convexity is often perceived as being due to bone, the anatomy of the area indicates that the posterior belly of the temporalis muscle makes the greater contribution.

Resection of the posterior temporalis muscle can make a dramatic change in the shape of the side of the head. It can alter a convexity to a straight line as the thickness of the muscle is greater than one would think. In men the posterior belly of the temporalis muscle can be 7mm or more in thickness. Reduction of both sides of the head can thus result in a total width change of the head of up to 1.5 cms. Interestingly loss of the posterior temporalis muscle does not result in any loss of mouth opening.

Limited Incision Posterior Temporal Reduction technique Dr Barry Eppley IndianapolisLimited Incision POsterior Temporal Reduction technique 2 Dr Barry Eppley IndianapolisThe traditional method of posterior temporal reduction is done through a vertical scalp incision above the ears. Initially I made a 4.5 cm incisional length to remove the muscle. Having done the procedure many times I have been able to shorten the length of the incision down to 3 cms. This allows a subfascial approach to the head width in this area, reducing it by taking it out as a single piece of muscle.

left posterior temporal reduction result intraop dr barry eppley indianapolisTo demonstrate how effective posterior temporal reduction can be, here is an intraoperative view of the left side having been compared to the right side where the muscle still remains.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Custom Jawline Implants

Monday, October 26th, 2015

 

Custom Jawline Implant Dr Barry Eppley IndianapolisWhile individual chin and jaw angle implants make up the majority of lower facial augmentations, the use of custom jawline implants is steadily growing in use. Offering a total jawline approach, these wrap around implants cover the entire lower jaw from angle to angle crossing the chin anteriorly. No other implant approach can rival the changes that  an implant that covers this much skeletal surface area can do.

Custom Jawline Implant insertion Dr Barry Eppley IndianapolisBut a custom jawline implant by virtue of its size can make its placement challenging. When placed onto the face it can seem daunting as to how it should be surgically placed as a single piece unit. It seems too big to be introduced through just a single submental or intraoral incision. So how does one place a custom wrap around jawline implant as a single piece unit?

The proper placement of a custom jawline implant is through a three incisional approach. The anterior incision can be either a submental or an anterior intraoral vestibular incision.  But two or bilateral posterior intraoral vestibular incisions are needed to properly place the jaw angle portion of the implant. It is extremely important to check the position of the jaw angle portion to be certain it is properly seated against the bone. Only direct inspection can assure that it is.

Custom Jawline Implant submental approach Dr Barry Eppley IndianapolisBecause a silicone custom jawline implant is flexible when not on the bone, it can be folded and threaded through a soft tissue tunnel below the exit of the mental nerve. Whether this will he successful or not depends on the size and thickness of the jaw angle portion of the custom jawline implant design. Very thick and large jaw angle portions may necessitate a split of the implant into two pieces threaded in from back to front and the joined in the middle. But if the jaw angle portions are not to big, they can be folded in front the front and kept as a single one piece wrap around implant which can be fixed at the chin with a single screw.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Abdominal Etching Techniques

Saturday, October 10th, 2015

 

Liposuction of the abdomen is the single most common body site in which fat is surgically extracted. Most people are happy with some reduction of their abdominal fullness with the hope of being as flat as they can possibly be. An overall better abdominal shape is the goal and most patients would define abdominal shaping as seeing a more defined waistline.

But more extreme types of abdominal liposuction do exist and they are predicated on achieving a ‘supernormal’ abdominal result. The best illustration of that concept is abdominal etching. Designed to create a six or eight pack look, horizontal and vertical lines are created through a linear liposuction technique. Mimicking the abdominal wall inscriptions and the inner and outer edges of the rectus abdominus muscle, a properly selected patient can look like that have extremely fit and well toned abs. Some may call it cheating but surgical six pack and eight pack abdominal surgery does exist.

Abdominal Etching pattern Dr Barry Eppley IndianapolisAbdominal etching employs a technique that is the antithesis of what is normally done in liposuction surgery. In order to avoid irregularities and dimpling in traditional liposuction (regardless the type of device used) some thickness of fat needs to be left on the underside of the skin. Abdominal etching is based on doing the opposite…creating a specific linear line of maximal fat removal to create an indentation.

Abdominal Etching Basket Cannula Dr Barry Eppley IndianapolisTo help remove maximal fat on the underside of the skin in abdominal etching, I have found that a small basket cannula to be very effective. A basket cannula is usually used to break up fat and fibrous tissue. It is a very aggressive cannula tip and is not used for fat extraction. But is aggressive capability due to the basket tip not only removes fat but is used to scrape the underside of the skin. This helps contribute to skin adhesions down to the abdominal fascia to help create well-defined abdominal etch lines.

Abdominal Etching dressing intraop front view Dr Barry Eppley IndianapolisAbdominal Etching dressing intraop side view Dr Barry Eppley IndianapolisAnother useful abdominal etching technique is compression foam placed at the end of the procedure. Placed in a herring bone pattern with linear strips of foam placed along the etch lines, it helps the skin to stick down along the created indentation lines.

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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