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Archive for the ‘facial implants’ Category

Skeletal Augmentation of the Aging Face

Tuesday, October 2nd, 2012

 

Aging of the face has been historically perceived as being a soft tissue problem.  This has led to how the vast majority of anti-aging facial surgery has been done, employing lifting and redraping of the soft tissues back up from whence they came. There is a reason the term ‘facelift’ has persevered for nearly one hundred years as correction of sagging has been the standard approach.

More recently, it has been acknowledged and incorporated into contemporary facial rejuvenation approaches that correction of volumetric loss is important as well. This has largely been done by fat injection grafting, spurned by the relative simplicity of the procedure and its immediate effects. But aging affects all facial structures right down to the bone. Taking a variant from a well known phrase, ‘beauty may well need to be treated all the way down to the bone’.

Certain bones of the face are well known to be affected by aging, marked by bone resorption. Three areas that have the strongest areas of resorption from aging are the midface around the pyriform aperture, the lateral rim of the orbit and the prejowl area of the lower jaw. Bone resorption in these areas contribute to some of the classic signs of aging with the development of jowling, cheek tissue sag and midface retrusion. These primary resorption areas as well as others will be accelerated and more severe with early loss of one’s teeth.

The periorbital area is known to resorb on the upper and lower lateral rim of bone. This causes prominence of the inner fat pocket on the lower eyelid and contributes to a tear trough deformity. Elevation of the inner brow appears due to dropping of the outer brow and lengthening of the lid-cheek junction. In essence, the loss of skeletal support causes the cheek tissues to fall causing a cascade of periorbital and cheek findings. This serves as the basis for midface/cheek lifts, cheek and submalar implants and fat injections.

Resorption of the maxilla around the base of the nose involves the bone just above the teeth. This is a naturally concave area making it more susceptible to resorption with aging.  With resorption, the nasal base retrudes deepening the nasolabial fold areas and even helping close down the nasolabial angle a few degrees. Other than injectable fillers for the nasolabial folds, there few commonly employed augmentation options. They use of injectable hydroxyapatite granules and preformed paranasal and premaxillary implants can provide needed skeletal augmentation.

Resorption in the prejowl area of the lower jaw is the most vexing of all skeletal aging areas. Why this area resorbs is not clear as it is a naturally convex bone structure. But resorption causes a relative concavity in this area and contributes to the appearance of jowls. For those with weaker chins, jowls may appear earlier due to the increased lack of bone support. This area of resorption is the reason the prejowl implant exists which is most commonly used in conjunction with a facelift or combined with a chin implant.

Resorption of the facial bones is a contributing factor for many patients in an aging facial appearance. Strong facial skeletal features play a major role in why some people seem to age better than others. The next frontier in facial rejuvenation surgery is bone augmentation with or without soft tissue suspension.  Current technologies for facial skeletal augmentation  include hydroxyapatite and HTR granules and preformed facial implants.

Dr. Barry Eppley

Indianapolis, Indiana

The Role of Custom Facial Implants in Aesthetic Facial Surgery

Friday, August 17th, 2012

 

Implants provide a wide array of options for facial augmentation. While initially only a chin implant was available forty years ago, today there are over fifty different styles and shapes that are available in more than one material composition. From the chin to the forehead, the options for bony enhancement now cover such obscure areas as the tear trough, paranasal and geniomandibular  areas. Such facial implants play a very valuable role in aesthetic facial augmentation whether it is the younger patient seeking a structural facial change or the older patient  in which an implant complements soft tissue lifting procedures.

Despite the tremendous diversity of facial implants, off-the-shelf styles and sizes can not fill all patient aesthetic needs. There are certain types of aesthetic problems in which stock implants are inadequate such as facial asymmetries, congenital and traumatic deformities and failed results using commercially-available implants. While stock facial implants, particularly those composed of silicone, are easy to intraoperatively shape and ‘customize’, the judgment of how they are to be shaped is still a matter of artistic adaptation.

The use of custom facial implants offers real advantages in challenging cases of facial augmentation. I classify custom facial implants into four types; 1) intraoperative modification of stock implants, 2) preoperative stock implant modification on a standard anatomic model, 3) preoperative stock implant modification on a patient-specific anatomic model, and 4) fabrication of an implant on a patient-specific anatomic model. Type #1 and #2 custom facial implant approaches have been done for decades and may even be questionable as to whether they are truly custom implants. Types #3 and #4 are a truly custom implant approach.

The basis of a truly custom facial implant approach is a patient-specific anatomic model. This requires the patient to first receive a 3-D facial CT scan based on a 1mm slice-taken protocol. These images are then sent to a manufacturer of craniofacial models. The manufacturer that I use is  Medical Modeling (Golden, CO) although there are others. The model can be made in either an Osteoview style (opaque) or a Clearview style. (clear acrylic) In the Clearview style, teeth, nerves, plates and screws and other implants can be colorized (red) so they stand out from the clear bone structures. The Osteoview is satisfactory if a custom implant is needed and the patient has not had prior surgery. The Clearview model is preferred when prior bone or implant work has been done and the bony anatomy has been altered.

Off of these models, the custom facial implants are made. While most patients think that there is a computer program that makes the implants, and this certainly exists, the cost and availability of this technology makes it currently not practical in aesthetic facial surgery applications.  Custom implant designs and prototypes are made by hand. I mold, shape and carved them out of clay or silicone elastomer which air dries to a hard set. If needed, they are further shaped and contoured by diamond wheels on a small hand drill. Finally they are covered by a lacquer which dries to a clear coat.

As part of this process, I often share images with patients of their implants in the fabrication process by e-mail or they may come in to see and handle the implant prototypes. It is important in the custom implant fabrication process for patients to participate in the decision process about the design. Once the design is agreed upon, the implant(s) are sent to a manufacturer for fabrication. Most custom implants can only be made from silicone. For many custom facial implants this is the best material  because their differing shapes and sizes may make them difficult to place. Flexibility and lack of frictional resistance on insertion are important implant insertion properties in any facial implant but is of critical importance in many custom designs. Besides the obvious benefit of creating an implant design that is as accurately accurate and symmetric as possible, the custom design process can also add features that make them able to be more effectively secured to the bone by screw fixation.

From the time that a 3-D anatomic model is obtained, a three week period is usually needed from design until the sterilized implants are returned from the manufacturer and ready for surgery. Depending upon the number of implants, the cost of custom designed facial implants can be from $3500 to $7500 in addition to other surgical costs.

Dr. Barry Eppley

Indianapolis, Indiana

Injectable Fillers vs Synthetic Implants In Facial Sculpting

Monday, March 26th, 2012

Injectable fillers have come a long way since the approval of the first non-collagen based product in 2002. While once conceived as only a way to make lips bigger and nasolabial folds less deep, injectable fillers have evolved into an aesthetic technology that has a wide number of facial uses. Aiding the expanded uses has been helped by the large number of different filler compositions offering variability in viscosity and flow charactistics as well as in longevity and in how they create their effects.

 

Fundamentally, injectable fillers are used for two main aesthetic applications, spot filling and volumetric enhancement. It is the latter that is often coined as ‘non-surgical facial sculpting’. That term is probably more accurate than not as it definitely takes skill and a good eye to get pleasing facial volume results with fillers. There is more art to it than science.

 

When it comes to facial volumetric enhancement with fillers, they are often compared to and even viewed as a substitute for surgical solutions to the same problems. Some injectors view synthetic fillers as  a better treatment choice as they are easier to do and have less risk of complications than surgery. While that is true, that does not mean they always give better aesthetic results or offer the best value for the money invested to do them.  There are advantages and disadvantages with both approaches depending upon exactly what facial application to which one is referring.

 

For skeletal augmentation of the three facial highlights, chin, cheek and jaw angles, injectable fillers can be used to create a visible external effect. When placed down at the bone level, I prefer Radiesse. Its calcium hydroxyapatite composition makes it the most viscous filler which provides a better push of the overlying soft tissues per cc of volume.  But when comparing it to synthetic facial implants that have been used for decades, it has several disadvantages. It takes a fair amount of syringe volume to get a visible effect, often at least two or three syringes depending upon the area. (chin = 1 syringe, cheeks = 2 syringes, jaw angle angles = 3 to 4 syringes) This makes it relatively expensive. In addition, the effect will never be as significant as a surgical implant and the filler material will go away by about one year or so after injection. This makes using an injectable filler for facial skeletal augmentation very patient selective. Filler are best used for skeletal augmentation when one is uncertain about how a surgical implant may look (trial ‘implant’) or if the need/result is time dependent based on an upcoming event and one doesn’t want to recover from surgery.

 

Other injectable fillers can be used for a skeletal effect but are placed in the subcutaneous tissues and not down at the bone level. In these cases, a hyaluron-based filler like Juvederm or Perlane are preferred which have higher material concentrations and will last about a year also.

The face is made up of a lot of non-skeletal areas that are not supported by underlying bone. These include two large areas in the lateral face and the temples. In the triangular area between the cheeks, chin and jaw angles lies the lateral facial region whose shape is not dependent on any bony support. It can be concave, flat or convex depending upon the shape of one’s face and the thickness of the underlying soft  tissues. This area has garnered a lot of attention in facial aging as it becomes more concave in some people as they age due to fat atrophy. Plumping it up with fillers has become popular as a rejuvenative manuever. I prefer Sculptra for the lateral facial triangle because of the volume of material needed. Using an 8cc per bottle reconstitution of Sculptra creates an almost pure watery form. This makes it  easy to get a good amount of material over this large area and have a low risk of creating any lumps. Sculptra does not work immediately and it takes time and three total injection sessions to get the best result. But it will last for up to two years.

 

The temple area is another soft tissue supported area. Muscle and fat make up its shape and it is smaller than the lateral facial triangle but still has a sizeable surface area. Sculptra seems to work best in this area because of the volume needed. But the result and its persistence can not be compared to the relatively simple placement of a subfascial implant. Again, fillers here are more of a trial to determine if an implanted result is worth the effort.

 

Injectable fillers can also be used in the nose for limited amounts of reshaping. This has led to the concept of the ‘non-surgical rhinoplasty’. In truth, this moniker has a large marketing slant to it because fillers can not obviously replicate what a surgical rhinoplasty does.  But to temporarily mask an upper nasal bump, fill in some asymmetries or do a little tip lifting,  the judicious use of fillers can make some aesthetic nasal improvements.

 

Dr. Barry Eppley

Indianapolis, Indiana

The Psychological Aspects of Facial Structural Surgery

Wednesday, March 21st, 2012

There are many reasons that patients request surgical changes to their face. With over twenty different facial regions that can be altered, there are seemingly endless options and combinations. But when you break it down, there are two main reasons for making cosmetic changes to the face. I divide these into either facial anti-aging surgery and facial structural surgery. For the most part, this is the difference between soft vs hard tissue facial surgery.

Anti-aging facial surgery includes many of the most recognizeable procedures such as a facelift, blepharoplasty (eyelid tucks) and skin resurfacing. These are done to counteract the effects caused by time, age and sun exposure. Changes are made to the soft tissues of the face, largely the outer skin layer. Facial structural surgery goes much deeper and makes changes to the bone and cartilage. The most common structural procedure historically is rhinoplasty but today includes everything from forehead augmentation and brow reduction down the face to chin and jaw angle augmentation.

Besides the tissue levels which these two types of cosmetic facial surgeries affect, there are also very significant psychological differences between them. Anti-aging facial surgery is more psychologically comfortable for patients because the goal is to take them back to once how they looked, a place in which there is familiarity. The surgery and recovery may be scary but the end result is a look that the patient can recognize and has known in the past. In contrast, structural facial surgery is very different. The end result is one that is not familiar. It is a new look, an alteration of a face that one has known their whole life.

Having done many facial structural procedures in my practice from rhinoplasty to jawline enhancement, I have made several observations about these types of plastic surgery. Some of these are not new and have been known in plastic surgery for a long time. But new technologies and biomaterials have changed what is possible today and with that comes new psychological ramifications for patients.

Changing the structure of one’s face obviously requires an understanding as to what the patient’s goals are. Patients provide that information by descriptions of their concerns and often provide visual aids such as drawings, self-photographs and photographs of other people. These are all really helpful and collectively important. But one concerning issue is the overuse of model or celebrity facial photos. Seeing too many of these or having a patient show a whole notebook of other people’s or famous face may be a sign of unrealistic expectations after surgery. While everyone willingly acknowledges that they can not look like someone else, whether they believe that or not may be another story.

To aid presurgical discussions and goals, I consider computer imaging essential to any facial structural surgery. For the psychological reasons previously mentioned, I rarely do it for anti-aging facial surgery but consider it essential for structural changes. But computer imaging can be misinterpreted and often is. It is not a guarantee of results and such imaged results may never actually be achieved. It is a communication tool about surgical goals and what a patient wants changed and the degree of those changes. It is only as good as the person doing it and is really an integration of surgical experience and how well one knows computer imaging technology. This is why a plastic surgeon should be doing the imaging, for only they know what can really be achieved by different types of facial surgery. But even in the best of hands, a patient should not assume that is exactly the way they will look after surgery. It is an estimate or prediction but human tissues induce more variables than pixels on a computer screen.

When going through structural facial surgery, the recovery is going to be longer and more psychologically difficult that most patients envision. The swelling and bruising on the face can be quite shocking and no patient is ever really prepared for it. When the dressings, splints or sutures come out days or a week later, it is not a moment of celebration or expectation. It is just the first step in the recovery process. One is not looking at the final result and, depending upon the procedure(s) being done, full recovery is not just a few weeks away.

Facial areas will be puffy, swollen and distorted and usually far more than one anticipates. It may be significant or not all that bad, but this is not the time to judge the results. More importantly, and I have seen this many times, one should not assume that the changes are too big and need an immediate revisional surgery. What appears too big at two or three weeks after surgery may be just perfect at two or three months. My minimal time for judgment of facial structural surgery results is three months and I will not consider any revision before then unless they are compelling medical reasons. (e.g., infection) One should not attempt aesthetic revision on a moving target.

When three or more structural facial procedures are done at the same time, the appearance of the face the first few weeks after surgery can be very disturbing. Patients will often feel that they have made a mistake and even wish to return to how they looked before even though they obviously did not care for that appearance. Such after surgery appearances disrupt work and social interactions but are part of the process. If one thinks they will go back to work in two or three weeks after such surgery and will look perfectly normal…this is not realistic. Plan accordingly and I mean this from a psychological perspective. Living through the process of facial swelling resolution and tissue adapation around the bone or implant shape requires tolerance, explanations and even an openness about what has been done if necessary.

One of the most important considerations about structural facial surgery is an appreciation that the risk of needing revisional surgery is significant. At the least, it is much higher than that of a facelift or eyelid surgery. On the most simplistic level, let’s compare the risk of complications/revisional surgery of eyelid surgery (1 % to 2%) vs a chin implant (5% to 7%) in my experience. Both are fairly straightforward and relatively simple procedures. But the use of an implant introduces issues of infection, malposition and size and shape issues that do not exist as much in manipulating one’s natural skin. Now multiple that times the number of facial structure procedures being done, each with their own percent of risk, and it is easy to see why the risk of revisional surgery in facial structural surgery is significant.

For example, take a patient who is having rhinoplasty (5% revision risk), a chin implant (5% revision risk) and jaw angle implants (10% revision risk) done as a single procedure. On an additive risk basis, the real risk of revisional surgery in this case is 20% or higher, If you take more extreme cases of five or more facial structural procedures being done at the same time (a not uncommon collection of procedures in my practice), the potential risk of revisional surgery could be as high as 50%. This doesn’t mean that the complications are devastating or severe but are almost always about symmetry and the size of the changes done in the various areas. It is hard aesthetically to make so many facial changes and have them all look perfect afterwards…particularly when one is not precisely sure how they will interpret the changes.

Facial structural surgery can make significant aesthetic changes to either give the face a better shape, more definition and improved balance or to improve asymmetries between the two sides. But it is harder surgery to undergo both in planning and during recovery and has a higher risk of the need for revisional surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Aesthetic Principles Of Facial Implant Augmentation

Monday, January 30th, 2012

Implants have been an important part of aesthetic facial surgery for over fifty years. Starting originally as just small implants for chin augmentation, they have evolved into a large line of bone-based implant shapes and sizes. They are commercially available today for just about every conceivable area of facial bone augmentation from the skull down to every zone region of the mandible. While chin and cheek implants constitute the most widely used facial implants, many other augmentation areas are becoming more recognized as useful such as jaw angles, submalar, infraorbital and temporal implants.

With the emergence of synthetic injectable fillers and autogenous fat injections, many surgeons have chosen to use these less invasive techniques for facial augmentation. While their simplicity is very appealing, such injectable filling methods are best used for soft tissue augmentation of facial areas not supported by bone. While they can be effective for augmenting facial bony prominences, their cost and lack of guaranteed volume preservation ensures that synthetic implants will continue to play a valuable role in aesthetic facial augmentation.

Like any implant placed in the body, there are known complications with their use. While infection, implant malposition and implant exposure are the medical risks of facial implants and always require revisional surgery to sure, there are also aesthetic risks as well, These include implants that are too big, too small, or the creation of an undesired aesthetic effect. While good surgical technique and implant placement are extremely important keys to prevent the medical complications, the aesthetic complications can be more difficult to avoid as this remains the artistic side of the procedure.

Over the years, I have come to appreciate several aesthetic guidelines of using facial implants successfully. These relate to the more obscure principles of facial implants that have little to do with surgical technique. It is about how to select and place the best implant style and size.

The first aesthetic facial principle is that the biomaterial composition of the implant is not that important. Implant selection should first focus on the right style and design of the implant regardless of its material composition. While many different manufacturers and surgeons tout the benefits of different biomaterials, the reality is that none are perfect. All of them have different handling and placement characteristics but they all work equally well from a biologic standpoint. The body sees all implant materials as the essentially the same, not a natural part of the body. It will create a layer of scar around all implant materials known as a capsule. Implants with more porous or irregular surfaces will have this capsule become more adherent to it but this should not be confused with true integration into one’s own tissues.

The second aesthetic facial implant principle is that the effects of facial volume change from implants is not completely predictable. While both surgeons and sometimes even patients take measurements on x-rays, drawings and computer images in an attempt to select the right implant size, the overlying facial soft tissues will not necessarily respond in a 1:1 or direct linear fashion. Measurements taken on pictures and facial skeleytal models can not take into account the thickness of the soft tissues between the implant and the outer facial appearance. While it is important to have some method in choosing an implant’s size, patients should know that it is far from an exact science. The most common implant size problem is that it is too big, usually not because it is too small. This is particularly true as one moves up to facial bone areas above the mandible where the soft tissues become thinner. When in doubt, choose a smaller implant size. It can be surprising how much of a difference a small implant off of the operating table.

The third aesthetic facial principle is that implants may need be modified during surgery. Implants are made based on average dimensions and in a range of sizes to try and fit the most number of patients possible. But not every implant style and all sizes for any given facial area can be available for every procedure. The use of implant sizers, which are available from most manufacturers, is very helpful during surgery particularly in choosing implant size. But when in doubt shape or carve implants for custom adaptation if needed. All implant materials are fairly easy to shape with either a scalp, scissors or even a burr for more inelastic materials.

Applying these three aesthetic facial implant principles, best implant style regardless of material composition, conservative size selection and intraoperative implant modification if needed, will help improve aesthetic results and decrease the need for revisional surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Semi-Custom Facial Implants From 3-D Models

Sunday, December 11th, 2011

The use of implants makes it possible for many cosmetic facial procedures to be done. The mere existence of some of these implants has created new possibilities for facial augmentation. A wide variety of preformed implants of differing materials are available which allows the plastic surgeon to enhance structures as diverse as the temporal regions to the jaw angles. But despite the dozens of implants available, there still remains certain aesthetic facial problems which are not adequately treated by their existing dimensions and sizes.

The use of custom facial implants is ideal for the truly unique aesthetic case, whether it be because of altered anatomy or that existing preformed implants are not adequately sized or shaped. The traditional use of custom facial implants begins with obtaining a 3-D model of the patient from a high resolution CT scan. From that model, either the plastic surgeon or a manufacturer creates the desired implant design. In my practice, I hand carve all implant designs myself out of clay based on this model. The final facial implant is then manufactured out of silicone material and sterilized by one of several major implant manufacturers.

While this custom approach to unique facial implants is ideal, it adds considerable expense and time to the final cost of the surgery. There are cases where the custom facial implant process can be streamlined and expenses reduced. In this custom approach, a 3-D CT model is still needed and used as a template for implant fabrication. But instead of making a new implant design from scratch, existing preformed implants are used as the ‘templates.’ They are placed on the patient’s 3-D model and carved down to the desired shape before surgery. This then becomes the final implant which is then sterilized for the patient’s surgery.

This modified custom approach obviates the need to have a new implant fabricated, saving presurgical time and cost. In an elective aesthetic facial case, however, time is not as important as cost. This concept only works when the size of the preformed implant is adequate but its shape or adaptation to the desired bone site is insufficient. If the preformed implant is too small, then the custom implant will have to be made in the traditional manner from a clay or silicone elastomer prototype.

I have found that this modification of preformed implant approach is effective for a variety of aesthetic facial situations. For the patient who is just not comfortable with the  traditional but ‘blinded’ approach to facial implant augmentation, the 3-D model can help create confidence in the implant selection process. It also allows any minor modifications to the implants selected. Where it can be tremendously helpful is in revisional facial implant surgery where the positions of the existing implants are ill-placed, asymmetric or otherwise of inadequate shape.  

Dr. Barry Eppley

Indianapolis, Indiana

Facial Implants Instead of Orthognathic Surgery

Thursday, December 8th, 2011

While facial implants are commonly used to highlight the convex bony prominences of the cheeks, chin and jaw angle for purely cosmetic purposes, they have applications to other facial regions and problems as well. They can be very useful in bony deficiencies as well such as midface and mandibular hypoplasias as an orthognathic surgery alternative.

In these orthognathic deficiencies, the face is deficient in the cheek, paranasal and jawline regions but their occlusion is perfectly normal…or has already been orthodontically corrected. This obviates the use of maxillary and mandibular osteotomies to correct the facial appearance. But the use of implants can be used to simulate what would otherwise be achieved through bony movements.

Chin implants are the most well known example of  an orthognathic surgery alternative. Bringing the bony prominence of the chin forward can virtually replicate the identical lower facial change to that of mandibular advancement osteotomies. While a mandibular osteotomy can only bring the chin forward as far as the distance that makes the occlusion fit, implants are much more versatile. Not only differing in the horizontal thickness of the implants, they also can add width and different shapes to the central chin. (square to more angular) If custom implants are used, the chin can also be vertically lengthened as far back as to the jaw angles.   

Some elements of midface or central facial deficiencies are the result of a very concave pyriform aperture shape. This makes the nose undersupported making it appear flat with wide or even flared nostrils. This can also extend onto the base of the nose under the columella where it is supported by the projection of the anterior nasal spine. A short spine or near absent spine allows the columella to be recessed and one have a 90 degree or less nasolabial angle. Augmentation of the paranasal region (pyriform aperture) can simulate the effect of a LeFort I maxillary osteotomy using either paranasal, premaxillary or both implant types. This helps pull out the nose and its base with increased central projection and less flattening.

If one goes above the level of the maxilla, most people quickly think about flat or weak cheek bones. As a general rule, if the cheeks are flat the entire midface below it will also be. But cheek flatness usually also involves the infraorbital rim medial to it as well. This zone is one of the least appreciated areas of midfacial skeletal deficiency. A variety of midface implants are available for the cheek and infraorbital rim that create the visual effect of a LeFort III osteotomy. When the bony deficiency extends across the cheek to the nose, cheek implants alone may accentuate the existing infraorbital rim recession.

Implants can be used to simulate the appearance of facial skeletal osteotomies in patients with either normal or orthodontically corrected occlusions. Often a combination of facial implants is used, particularly in the midface, to create the overall effect of increased skeletal projection.   

Dr. Barry Eppley

Indianapolis, Indiana

Facial Implants As An Adjunct To Orthognathic Surgery

Saturday, November 26th, 2011

Facial skeletal imbalances present in many manifestations. Most commonly these are perceived from the profile view as maxillary and mandibular discrepancies in the mid- to lower face. Often they are reflected as changes in one’s occlusion when the bone deficiencies become significant enough. In these cases, orthognathic surgery is used for facial skeletal correction. Despite this surgery, all areas of facial bony deficiencies may not be aesthetically improved.

Facial osteotomies only change certain bony prominences and aesthetic facial highlights. It is important in orthognathic surgery, therefore, to recognize what will or will not be changed by maxilla-mandibular repositioning. A perfect occlusion is great but an opportunity to add to an improvement in one’s facial appearance can be missed if not diagnosed and treatment planned.

In combination with or after orthognathic surgery, several treatment areas exist. The level of the commonly-performed LeFort I osteotomy is below the cheek and orbital area. It only moves the tooth-bearing portion of the upper jaw. (maxilla) This leaves the cheek bones and the infraorbital rim unchanged. Cheek implants and newer styles of infraorbital rim implants can do what no osteotomy can. Ideally, the benefits of such implants are recognized before the orthognathic surgery so they can be done simultaneously. This is particularly convenient for cheek implants which are placed through the same incision as that of the maxillary osteotomy. Paranasal and premaxillary implants offer increased projection of the nasal base, the central portion of the midface above the teeth. They can be safely used at the same time as a LeFort osteotomy.

Mandibular osteotomies do a great job of changing horizontal position but no changes ever happen in width. This can leave the jaw angles deficient which often occurs after a sagittal split mandibular osteotomy. Implants can dramatically change the shape and width of the jaw angle but should not be used at the time of an osteotomy due to increased risks of infection and impairment of bony healing. They may be desired later, particularly if some bony resorption of the jaw angle has occurred which is not rare. The common chin implant has a role both during and after jaw repositioning surgery. While an osteoplastic genioplasty is often done for additional chin advancement at the time of an osteotomy, one can always substitute a chin implant if the main movement desired is solely horizontal in direction. Good preoperative treatment planning should avoid the need for chin implants later. But bony irregularities and asymmetries may be treated by extended or even custom chin and jawline implants.

  

For those patients who have residual facial bone deficiencies after orthognathic surgery or have bony deficiencies recognized as part of orthognathic surgery treatment planning, facial implants offer a viable option. The variety in size and shape of facial implants, whether off-the-shelf or from custom designs, today offers numerous safe and effective treatments as an adjunct to orthognathic surgery to create the visual illusion of actual bony movements.

   

Dr. Barry Eppley

Indianapolis, Indiana

The Process of Custom Jawline Implant Design and Fabrication

Thursday, September 1st, 2011

A well-defined jawline has become a recognized aesthetic facial skeletal feature, particularly amongst men. An appealing male jawline has a strong chin, jaw angles that are more square with a slight outward flare and a continuity between the front and back of the jaw, creating a wrap-around effect that flows smoothly around the arc of the jaw. While such a male jawline has probably always been desireable through the ages, it has acquired a lot more attention recently due to new techniques and implants that make it surgically possible to alter or create one.

While most male jawline augmentations can be done with conventional off-the-shelf implants, certain jawline deficiencies and aesthetic desires can not be ideally treated this way. Vertical lengthening of the jawline is a good example where standards implant can not create this dimensional change. Certain styles of jaw angle implants do provide some vertical lengthening but no chin implant does so. Traditional chin and jaw angle implants, which come in many different styles, do not connect across the body of the mandible which disrupts a smooth jawline look.

Custom jawline implants are designed off of a patient’s jaw or mandibular model. This is obtained by first getting a 3-D CT scan of their lower jaw. This can be done at almost any facility, hospital or free standing, that offers CT services. The CT scan is done with 1mm cuts which is standard for 3-D reconstructions. The scan data is then sent to a model manufacturer. I currently use Medical Modeling (Golden, Colorado) who makes great models with a rapid turnaround time. Such models can be made either opaque (osteoview) or with clear acrylic where the intrabony structures can be seen. (clearview) For implant designing, the opaque osteoview model is just fine and comes at a lower cost.

The jaw model is then used to make the chin and jaw angle implants. While it is often thought that such implants are made using a computer or CAD-CAM technology, such is not the case. No computer or technician can know what is the best design for the patient’s need or, more importantly, whether any implant design can actually be made to fit into the patient. Computer design works well in reconstruction when there is a facial deficiency on one side and it is normal on the other. Then the computer has a well-defined implant design goal to match. But in aesthetic implant designing, the end target is not as clear and requires the aesthetic judgment of the surgeon. This is why I custom design and fabricate them myself out of modeling clay. These shapes can be shared with the patient for their input as well. Once the final clay implant models are completed, they are allowed to cure and covered with a varnish finish.

The custom-designed jaw implants and the model are then sent to an implant manufacturer. The only material that can be used to make custom implants is silicone. This is because it is a liquid composite that can be poured into a mold and allowed to set. The clay implants are used to make a mold into which the silicone is poured. Other implant materials, such as medpor, would have to be machined which would not only would be a lot more expensive but its manufacturer does not currently offer that service. The final implants are sent back to me for surgical insertion.

Custom jawline implants can be designed and available for surgery in as little as three weeks after a patient acquires their 3-D CT scan. The cost of this custom facial implant process is $3500 to  $7500 depending upon how many implants are needed. Surgical placement costs are in addition to the implant fabrication process. While only a minority of male jawline enhancement need custom implants, the final aesthetic results are far superior to trying to use or modify existing off-the-shelf facial implants.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Implants: Avoiding and Managing Their Complications

Wednesday, July 6th, 2011

Facial implants are an effective method of creating specific areas of volume augmentation as well as providing bony highlights and improving facial symmetry. Over the past two decades, the available options in facial implants has expanded tremendously and more patients who undergo cosmetic facial surgery are receiving implants than ever before. With such widespread use of facial implantation, the number of postoperative complications have also increased.

Complications with facial implants generally fall into several categories including implant selection, placement technique, nerve injuries and infection. Almost all of these potential problems can be minimized by specific techniques, although not always completely avoidable.

IMPLANT SELECTION

With such a large number of different facial implant styles and sizes, it is no wonder that an incorrect implant choice can be made. This can occur in both the style and size of the implant. Despite knowing the exact measurements and shape of an implant, there is no way to guarantee what the final influence on the external shape of the face will be. This has a lot to do with the quality of the overlying tissues, the thickness of the skin, fat and muscle layers, as well as the shape of the underlying bone. In terms of facial predictability amongst the three most commonly used implants, chin implants are better than cheek and jaw angle implants.

Cheek and jaw angle implants have a significant rate of revision and dissatisfaction due to selection issues. The three-dimensional shape of the cheek area requires a very careful analysis and discussion with the patient as to exactly what they want to achieve. The adjoining shape of the orbit and maxilla also influences how cheek augmentation may look. The cheek is clearly the most ‘artsy’ of all facial implants as there is no precise measurement method of such a curved bony area. Jaw angle implants must consider the width and height of the angle area to avoid giving someone just a wider lower face. Many patients need vertical lengthening as well as increased width and not every jaw angle implant style is designed to make that change.

DISPLACEMENT AND ASYMMETRY

Implants can shift around after surgery as the pocket dissected to place them is always greater than the size of the implant itself. While certain implant materials do slide on the bone less than others due to increased frictional resistance, complete implant stability requires screw fixation. While most surgeons don’t use them as they feel suture or no fixation at all is sufficient, the extra time and cost to use them pays dividends with decreased complications. There are no risks with using screws so there is little reason not to use them.

With the exception of the chin, most facial implants are done on both sides. (bilateral) While it seems that it should be easy to do exactly the same thing to both sides, it is not. Symmetrical implant placement is as much an art as it is a science. The implant cavities are never open to unimpeded view and can not usually be seen at the same time. Landmarks from the surrounding anatomy must be used but not every patient has perfectly symmetric anatomy either. Surgeons are usually one-handed and often work from just one side of the patient. This can create unintentional distortions in the perception of implant positioning.

Cheek implants have the highest rate of implant asymmetry due to the thinner tissues of the cheek as opposed to the chin or jaw angles. Great attention must be paid to how the implants line up along the bone using landmarks of the adjoin nerve and the lower teeth.

NUMBNESS

While every patient will have some temporary numbness of the overlying skin under which it is placed, cheek and chin implant can cause nerve distribution problems. The infraorbital nerve of the cheek and the mental nerve of the chin can be injured during dissection (very uncommon) or from impingement of the implant on the nerve as it exits from the bone. (most common) Prolonged numbness, and more pertinently sharp pain, beyond a few weeks after surgery should raise suspicion of impingement. Early intervention and implant repositioning and/or trimming is needed to prevent permanent numbness and pain. The best way to avoid nerve impingement with an implant is to see the nerve and where the implant edges. Screwing the implant in will also prevent it from shifting over and touching the nerve as well.

INFECTION

While rare, infection with facial implants can occur. It does seem to occur more commonly with porous implant materials than smooth silicone in my experience. To decrease the risk of infection, the use of antibiotics is done intravenously, the implant soaked in a solution of it, and oral antibiotics are used afterwards. But I think the most important step is the use of sizers during surgery. These are used to judge the pocket and size of the implant, thus the final implant can go from package into the implant pocket directly with minimal handling. (one-time pass)

When infection occurs, the standard treatment is to remove the implant and let the infection resolve. But this is not always necessary and the implant procedure can sometimes be salvaged. The implant can be removed, the pocket irrigated and a new implant can be simultaneously placed. The risk for recurrent infection is higher with this approach but I have seen it work numerous times. The key is to get out the inoculated implant as that is the source of the infection.

BONE EROSION

I mention it as a complication but only as a sidebar. I have read about it for many years, and seen numerous patients, who had severe ‘bone erosion’. (always in the chin with very highly positioned implants which have been in a long time) Many facial implant patients ask beforehand about this risk. Largely, I think it is a non-entity. Implants, particularly chin implants, can settle into the bone a few millimeters which is a passive pressure-relief phenomenon. But implants eating into the bone is a myth not a reality.

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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