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Archive for the ‘facial implants’ Category

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

Custom Facial Implant Design And Fabrication From 3-D Facial Models

Thursday, March 24th, 2011

Synthetic implants are commonly used for augmentation of numerous facial bone sites for cosmetic augmentation or reconstruction of defects and asymmetries. Facial implants are available in a wide variety of styles and sizes for such areas as the cheek, orbit, chin and jaw angle, to name the most common. Most of these implants are composed of materials that allow for relatively easy shaping, trimming and otherwise custom adaptation.

But some facial cosmetic and reconstructive needs can not ideally be met by using off-the-shelf implants, no matter how they are shaped and modified. In some more uncommon cases, only a custom designed facial implant will suffice. As uncommon as the need for such implants are, they are more frequently used in reconstruction of facial defects and more rarely for cosmetic augmentation.

The fabrication of custom facial implants is a process that initially begins by getting a facial skeletal model of the patient. This is initially done by the patient obtaining a 3-D craniofacial CT scan done with high resolution 1mm cuts. Such a scan can be obtained at just about any CT facility today as 3-D software is commonplace. Once the scan is obtained, it is then sent to a model fabrication manufacturer. I use Medical Modeling (Golden, CO) but there are numerous other manufacturers that can create similar models. They can make a patient’s model in numerous ways including an Osteoview (radiopaque) or a Clearview (translucent) model. For custom implant fabrication, I usually use an Osteoview model as the view of underlying structures such as nerve and teeth are not usually necessary and it is less expensive.

Once the patient’s facial model is obtained, a mock-up of the implant is then made. This is done by sculpting it by hand on the model. At one time, I used acrylic as the modeling material but this requires grinding after being set and that makes it a more difficult fabrication process. Currently, soft modeling clay is used but it is of the type that does not dry out with extended use and can be cured by baking once the final shape is obtained. Such modern clays are much easier to use than older clay materials for this purpose.

The cured clay implant(s) is then sent to a silicone manufacturer (e.g., Implantech) for the manufacture and sterilization of the final implant(s). Currently, custom facial implants can only be made in silicone. Other implant materials, such as Medpor and Gore-Tex, have to be machined and not poured and cured into a mold made from a custom implant design. (this makes them considerably more expensive)

Contrary to popular perception, custom facial implants for cosmetic facial enhancement are not made magically by some computer technology. They are done by hand by traditional sculpting off of a model made by computed tomographic scanning. It is a total process that takes about 6 to 8 weeks from the time the CT scan is obtained until the actual sterile implants are in hand. I have found them to be particular useful for mandibular augmentation (e.g., vertical lengthening) which, due to its large surface area of bone, has contours that may not be able to be met by conventional preformed implant shapes.    

Dr. Barry Eppley

Indianapolis, Indiana

The Value of Facial Implants and Skeletal Augmentation in the Aging Face

Thursday, January 20th, 2011

Aging has an obvious effect on how the face looks from the outside with many recognized soft tissue changes. Wrinkles, deepening nasolabial folds,  crow’s feet and jowls are but a few of the effects that gravity and time cause. This understanding has led to the many well known plastic surgery procedures whose intent is to resuspend sagging skin as well as skin removal/reduction.

But much like beauty, aging goes the whole way down to the bone and is not spared. In many ways it is somewhat reflective of what has happened on the outside. Multiple studies in plastic surgery have looked at how the face ages beneath the skin. Volume loss, primarily of fat, creates an overall facial ‘deflation’ and this understanding has led to the widespread use of synthetic injectable fillers and injections of your own fat to help plump up the aging face. But loss of the deepest tissue, the bone, also makes a contribution to this volume.

Since the bone provides a scaffold onto which the overlying soft tissues drape onto, it is logical to assume that the facial skeleton changes as well. Recent studies using CT scans have looked at various areas of the facial bones and their aging changes. The width and size of the eye (orbit) increases with an almost sagging appearance to the outer lower orbital rim. The glabella (bone between the brows) and the upper rims of the eyes (brow bones) flatten. The maxilla is affected by loss of pyriform aperture and a decrease in the maxillary angle. The length and height of the lower jaw (mandible) shortens with resorption of the jaw angle. (enlarged mandibular angle)

All of these facial bony alterations with age can be correlated to associated outward soft tissue changes. The dropping of the brows and the piling of eyelid skin is a reflection of the loss of underlying bone support. The deepening nasolabial folds and the sagging cheeks are reflective of the maxillary resorption. A weaker chin, jowling and lax neck tissues are partially effected by the loss of lower jaw volume.

The facial skeletion does change with age, primarily with loss of volume of key bony support areas. This results in lessening areas of soft tissue adherence and sagging and deflated overlying soft tissues. This in addition to the loss of facial fat creates the appearance of the aging face.

Bone augmentation of the aging face with implants can be a useful surgical strategy for some patients. Reversing the age-related changes (atrophy) of certain facial bone areas can be done very simply with implants, adding volume to where it has been lost. Implants can do this in two ways, filling out concavities and bulking up weakened convexities. Tear troughs and paranasal deficiencies are examples of deepening concavities. Orbital rims, cheeks, chin and jaw angles are areas of weakened convexities.

Skeletal facial implants, while often thought of as just for younger patients seeking better facial highlights, can be useful for the aging face patient as well. They offer a permanent solution to specific aging facial areas that have ongoing resorption which contributes to loss of overlying soft tissue and skin support. They can be used in conjunction with any of the soft tissue redraping procedures to help create a better facial rejuvenative effect.

Dr. Barry Eppley

Indianapolis, Indiana   

3-D Implant Design and Engineering in Facial Reconstructive Surgery

Sunday, January 16th, 2011

Facial reconstruction patients can benefit today from custom-made bone replacements and bone fixation aids to optimize for the postoeprative form and function. High-resolution computed tomography (CT) modeling allows plastic surgeons to custom-design implants prior to reconstructive surgery. They are particularly useful for facial bone defects of the lower jaw (mandible), skull and the forehead and eye (orbital) areas.

Severe facial and eye (orbital) bone deformities and defects may be present at birth or can occur following facial trauma or, most commonly, facial tumor removal. Surgery to correct such defects aims to restore the original anatomy and the patient’s appearance by inserting an implant made either of the individual’s own bone and tissue or synthetic materials. The traditional use of implant materials in facial reconstructive surgery, which are shaped during surgery, often do not recreate ideal three-dimensional contours in the face and take a lot of time working with them as the patient is asleep. Designing synthetic implants beforehand improves theirprecision and contours and helps shorten the time of surgery.

I have looked at my series of ten facial reconstructive patients done over the previous nine years who received computer designed and generated custom implants and were more than one year after their surgery. The six men and four women were between the ages of 31 and 67 years, with an average age of 46.1 years. The defects were caused by either trauma (2), tumor resection (6), or a congenital deformity (2). Most of the patients (7) had a history of prior failed reconstructive efforts. The patients underwent three-dimensional high-resolution CT scanning of the face from which customized implants composed of either pure titanium (bone fixation device) or HTR (porous hard tissue replacement bone substitute) were made. All implants was surgically placed and fixed using titanium plates and screws.

Example #1

This 62 year-old female had a right mandibular angle bone resection secondary to an intraoral carcinoma. She never had any radiation treatments. The defect was only spanned by a reconstruction plate which had fractured three separate times over the past eight years. A 3-D CT scan showed the defect and the mandibular segment contraction. She did not want a fibular free flap reconstruction.

A custom titanium dual plate and mesh construct was designed to hold the bone segments apart in anatomic position and contain an iliac marrow graft. Through a neck incision approach, the old fractured plate was removed and the new 3-D engineered construct placed. The resultant mandibular form, occlusion and jaw opening was excellent.

Example #2

This 65 year-old male had a history of esthesioneuroblastoma with a resection by frontal craniotomy and removal of his left heminasal cavity and maxillectomy. He received radiation afterwards. Over the enduing ten years, he developedorbital floor bony resorption due to osteomyelitis and dropping of the eye downward. His orbital condition and eye position eventually stabilized as his osteomyelitis resolved. A 3-D CT scan shows the loss of orbital floor bone and the orbital dystopia.

A custom HTR orbital floor implant was manufactured to match the opposite orbital floor shape and volume. Through a lower eyelid incisional approach, the implant was placed and secured to the orbital rim with titanium plates and screws. He had much improved postoperative globe symmetry. He went on to have eye muscle surgery and a dermal fat graft to fill out the soft tissue atrophy of the lower eyelid and cheek region.

During an average of over four years of follow-up, none of the patients experienced any implant-related complications including infection, extrusion, or displacement of the implants. Healing around the implant sites was uneventful. All of the patients had sustained improvement of facial deformities including mouth opening in those that involved the lower jaw.

While numerous types of implant materials have been used for reconstructive facial surgery, one important aspect of their success is proper design and engineering. Time spent before surgery evaluating the exact dimensions of the bone defect and then custom designing the implant has numerous advantages. Having an implant that is not bigger or oversized for the defect lowers the risk of potential extrusion. A near perfect fit makes for good facial contour restoration. Oral function and occlusion is more assured if the lower jaw reconstruction is as precise as possible. Donor site pain and morbidity is eliminated or reduced with maximal use of synthetic replacement parts. Operative times can be reduced significantly, often cutting the length of an operation in half. Implants are also structurally stable and will not resorb or change their shape over time. Any synthetic implant no matter how well designed and engineered, however, has limitations. Good healthy soft tissue flaps over the synthetic reconstruction is extremely important to avoid potential infection and exposure problems.

Dr. Barry Eppley

Indianapolis Indiana

Common Questions about Facial Implants

Sunday, January 24th, 2010

1.      What are the different types of facial implants?

 

All facial implants are designed to highlight or augment weak facial bone structures. Most commonly, three specific areas are most commonly done including the cheeks, chin, and jaw angles. As a result, there are numerous sizes and styles for these frequently used implants.

 

But there are other areas of the face for which implants also exist including the nose, paranasal, maxilla, premaxillary, orbit, forehead and temple areas. Even if specifically shaped implants are not commercially available, carving blocks of various materials are available to ‘make your own’ for any specific facial need.

 

2.      What are facial implants made of? Is one material better than another?

 

There are several synthetic materials from which most facial implants are manufactured. These include silastic (silicone), Gore-tex (polytetrafluoroethylene, and Medpor. (polyethylene) Each has some different handling properties which affects the flexibility and stiffness of the implants. While they are all chemically and structurally different, the body sees them all the same way…as a foreign material which it tolerates by surrounding it with scar tissue. (capsule)

 

Each plastic surgeon may have their preference but that is not based on whether it is a ‘better’ implant material. It is a function of what they are familiar with and have had good experiences. For me, I am more interested in the shape of the implant that I need to treat the patient’s problem and the ease with which it can be placed in the correct anatomic position. The actual material composition is not that the most critical factor.

 

3.      How are facial implants placed?

 

The method of introduction, or incision, is most commonly done through the mouth. Short of farway places on the skull and orbit, all facial implants locations can be reached intraorally. This approach offers numerous advantages over an external skin approach. The one exception to this is for chin implants. They usually are best inserted through a skin incision under the chin which is associated with fewer potential complications.

4.      How do you select the right size of a facial implant?

 

The sizing of any specific implant has a lot to do with experience and an artistic judgment. Some facial areas, like the chin, can be measured and the exact amount of augmentation needed can be precisely determined.

 

But most facial augmented areas are not profile structures so they lack a silhouette or outline which can be easily measured. This is why many implants have intraoperative sizers. By initially placing a temporary implant to determine what effect it creates, a final sterile implant is not opened until one is certain the effect matches what the patient wants.

 

5.      What can go wrong with facial implants?

 

Like any synthetic material placed into the body, there is the risk that it can become infected. When infection occurs around an implant, it can be difficult to eradicate with antibiotics alone. Often the implant may need to be removed. Many people mistakenly think an infection is the body rejecting the implant but that is not so.

 

While infection is the worst complication of a facial implant, it is fortunately very uncommon. The more common problems are aesthetic…size and position issues. Implants can be too big or not big enough, creating too strong or too weak of an effect. The implant(s) can be off center (chin) or asymmetric. (cheeks and jaw angles)They can also shift for their desired position after surgery. This is why some plastic surgeons secure them into position with a screw.

 

6.      Can multiple implants be used in a single facial surgery?

 

Yes. Implants are often part of many combined facial procedures. Most commonly, chin implants are used in rhinoplasty and facelift surgery to improve the lower facial profile. A multiple implant strategy is part of sculpting the male face and may include cheek, chin and jaw angle implants all together. Cheek and maxillary implants can bring out a flat or recessed midface.

 

The use of facial implants is only limited by the imagination and artistic eye of the plastic surgeon. Computer imaging can help one understand what effect one or more facial implants may cause.

 

7.      When should facial implants not be used?

 

The long-term success of facial implants is primarily determined by the amount of healthy soft tissue around them. A good barrier or buffer of soft tissue is needed between the overlying skin and the inside of the mouth.

 

Implants have a much higher rate of complications in facial sites that have received radiation or been scarred by prior surgery or injury. Patients that are edentulous (without teeth) are also at risk as they have less bone and overlying soft tissue onto which to place and keep an implant adequately covered.

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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