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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘custom facial implants’

3D PEKK Implants For Complex Craniofacial Reconstructions

Sunday, August 31st, 2014


The concept of 3D printing of human replacement parts has been all over the medical and scientific news over the past few years. While each news release seems like it is revolutionary and new, most are the natural evolution of the refinement of 3D CT scanning and the ability to manufacture custom replacement parts from these images from various synthetic materials. This is of specific relevance to the skull and face where their complex anatomy make shaping natural tissues to fit difficult and often lacking inadequate donor volume to do so.

I have performed custom skull and facial reconstructions made of either HTR polymer or titanium for over twenty years…and custom silicone skull and facial implants for aesthetic enhancements over the past three years. As good as these synthetic reconstructions have been, there is always room for improvements and further technical advancements.

OsteoFab PEKK Skull Implants Dr Barry Eppley IndianapolisOne of these has been in the evolution of improved materials for custom implant fabrication with the use of the polymeric material PEEK. (polyetheretherketone)  This is a colorless organic thermoplastic polymer from the polyaryletherketone (PAEK) family. This material has excellent mechanical properties with a Young’s modulus of 3.6 GPa and a tensile strength of around 90 to 100 MPa. It is resistant to breakdown (melting) up to temperatures as high as over 340 degrees C (650 degrees F) In addition to resistance to thermal degradation, it is also highly resistant to breakdown by a wet environment or organic enzymes.

OsteoFab PEKK Facial Implants Dr Barry Eppley IndianapolisCustom implants made from PEKK were first FDA-approved in 2013 for cranial reconstructions and just recently approved in 2014 for facial reconstructive parts. (OsteoFab, Oxford Performance Materials) Through their processes it is possible to print patient-specific implants from either 3D CT or MRI scans. The implants are 3D printed and combined with laser sintering manufacturing technology and proprietary OXPEKK powder formulation to print skull and facial implants. These implants are biocompatible, mechanically similar to bone, radiolucent, and osteoconductive.

PEKK craniofacial implants offer several advantages over the traditional use of metal materials such as titanium or stainless steel. They have reduced weight, do not ever corrode, can be tailored to meet complex shapes with great precision and differing biomechanical loading properties. They also have a density and stiffness similar to bone and are radiolucent. (do not cause scan scatter) Some evidence also indicates that it has osteoconductive properties.

PEKK craniofacial implants is just one example in a long line of 3D printed biomedical advances. This technology and material allows complex craniofacial cases to be treated in a more precise manner that is ultimately more cost effective. While the actual implant(s) is not inexpensive, the savings in operative time and expense, need for donor site harvest and the high likelihood of subsequent revisional surgeries justifies the up front fabrication costs.

Dr. Barry Eppley

Indianapolis, Indiana

Five Things You May Not Know About Custom Facial Implants

Thursday, July 10th, 2014


The use of facial implants dates back to over fifty years ago when the first chin augmentation was done. With the expansion of facial implant styles and sizes over the years, there are many options today for nose, cheek, chin and jaw angle implants as the standard facial areas treated. In addition to these areas, there are expanding options available for other facial regions that are less commonly done. But despite a large number of available facial implants, some patients require or request a custom approach for their facial augmentation needs.

As custom facial implants are becoming more popular due to improved technology, there are numerous misconceptions about them. Here are some things you may not know about custom designed and fabricated facial implants.

Custom Facial Implants Are Not Really New. While the technology has dramatically improved and the internet has made their existence easily found, the use of custom implants for the face has historic precedence. Surgeons for years have used blocks of various materials to fashion implants during surgery. (although I would call this a semi-custom approach with a lot of guesswork in doing so) But the use of a patient’s model to create an exact fitting implant to the bone before surgery dates back to when higher resolution CT scanning and computer-generated models became available. I did my first such custom facial implant case back in 1997 where modeling clay was used to create a mockup of the implant from a resin-spun hand-held model.

A 3D CT Scan Is Needed To Make Custom Implants. Whether it is done by an actual model or on the computer screen, only a high resolution CT scan of the face with 3D reconstruction can be used. The scan has to be done using .1mm slices and not the standard 3mm or 1mm slices normally taken. An old or regular facial CT scan will not do nor will an MRI. These type of facial CT studies are quick and easy to do today at a very low cost at any CT scanning facility. The software to do them is now standard.

The Design May Be Done On The Computer But The Surgeon Creates It. While computers and their software can do incredible things, they do not yet know how to create a specific look for any patient. In designing facial implants, the computer has no innate knowledge or software algorithms to know what size or shape the implant(s) needs to be….unless they have a desired and exact target to mirror. This works for facial asymmetry (making an implant to match an opposite  normal side) but not for purely aesthetic facial augmentations. It is the doctor that must tell the computer (specifically the design engineer) the shape, thickness and orientation that they want the implants to be. The computer design process will make sure the implants fit the bone perfectly and compensate for any bony asymmetries.

Custom Implants Can Be Made For Any Craniofacial Area.  Implants can be designed from the end of the jaw to the back of the skull on any bone area. While most implants are made for bone augmentation, soft tissue implants can be similarly made. The outline and bulk of the muscles on the bone can be imaged and implants designed to fit under or on top of them. This is most useful for the temporal region where aesthetic width issues may exist.

The Cost of Custom Facial Implants Can Be Affordable. While the cost of custom implants does cost more than using preformed implants, the difference today is not as dramatic as it once was. If one has significant facial asymmetry or has extreme facial augmentation needs, the use of preformed implants may lead to disappointing results and revisional surgery. This can end up costing much more than using custom implants initially.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Temporal Implants for Head Widening

Friday, February 21st, 2014


Background: The head has a wide variety of shapes and sizes. Like the face, there are  certain head shapes that are more pleasing than others. While one knows intuitively whether they like their head shape or not, there are certain measurements of height and width of the head that can help classify its beauty or conversely its degree of deformity.

Head Measurements Dr Barry Eppley IndianapolisHead and face measurements and their ratios have been studied for over 100 years in a field of scientific study known as anthropometry. Classic anthropometric measurements of the head are its length, width and cephalic index. The length of the head (front to back) is measured from the midpoint of the brow just above the nose back to maximal projecting point of the back of the head. The width of the head is from a point just above the ears from one side to the other. Taken together the cephalic index is derived which is obtained by taking dividing the width of the head by its length which creates a percent ratio. This number is almost always less than 1 since most normal human skulls are longer than they are wide. Based on their cephalic index, head shapes have been historically divided into three main types; long-headed (dolichocephalic, > 80%), medium-headed (mesocephalic, 75% to 80%) and round-headed (brachycephalic, < 80%)

The dolichocpehalic head is one that has a narrow head width. (which is compensated for by an increased head length) But there are certain head shapes that are narrow in their bitemporal width but do not have an increased cranial length. Their mid-temporal region slants inward as it ascends upward to the top of the skull rather than having a more aesthetically pleasing convex shape on the side of the head.

To date, there has not been any known method to safely and easily create aesthetic augmentation for increasing the width of one’s head should their bitemporal width be too narrow.

Case Study: This 35 year-old young man did not like the narrow width of his head. He felt his head was too narrow above the ears and it slanted inward rather than outward. This made his head ‘too small’ and disproportionate for the rest of his head and face shape. He wanted a wider head but did not want any visible scars in doing so given his close cropped hair.

Custom Temporal Implants for Head Widening Dr Barry Eppley IndianapolisWhile a 3D CT scan would have been ideal to make his custom temporal implants, he wanted to forego that extra expense. Using a standard male skull model, implant designs were done in silicone elastomer putty by hand with dimensions of 10 cms long, 8cms high and 7mms thick at its central location. The edges were made paper thin to have a smooth implant transition. The handmade temporal implants were converted into a medium durometer medical grade silicone implant and sterilized.

temporal implant size dr barry eppley indianapolisTemporal Widening Implants Surgical Placement Dr Barry Eppley IndianapolisUnder general anesthesia, skin incisions were made on the back of the ear in the depth of the postauricular sulcus. Dissection was carried down to the fascia and then superiorly under the lower edge of the temporalis muscle. Wide submuscular elevation was done over markings for the implant location that were made prior to surgery. The temporal implants were then rolled and inserted through the small incision and all edges unrolled once inside. The implants were then secured to the underlying bone at its lower edge with two 1.5mm titanium screws. The incision were closed in multiple layers, re-establishing the postauricular sulcus by dermal sutures to the fascia.

While he had some moderate temporal swelling after surgery, his pain was minimal. He had little recovery other than some swelling that resolved in a few weeks. His head width was instantly changed into a more convex shape which was very pleasing, adding 1.5 cms of bitemporal width. (Due to patient privacy, he did not want his before and after pictures published online. However he is willing to have them sent to anyone that wants to view them privately. You can request his before and afters by contacting me at info@eppleyplasticsurgery.com)

This type of temporal implants provide increased width and convexity for the narrow head. While custom temporal implants can be made from a  patient’s 3D CT scan, the relative flat bony surface of the mid- and posterior temporal region makes a semi-custom approach a good treatment option. This new type of skull implant design provides another option in skull reshaping/augmentation that provides a different type of temporal augmentation that smaller more anterior-based implants for the non-hair bearing temporal hollow.

Case Highlights:

1) A narrow head is usually due to a bitemporal width reduction of the skull and/or muscle.

2) Custom temporal implants can be made to increase the bitemporal width from 5mm to 7mms per side.

3) Large custom temporal implants can be discretely placed through incisions on the back of the ears.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Custom Vertical Lengthening Jawline Implant

Monday, February 17th, 2014


Background: One of the original facial implants ever made was for a short chin. Chin implants are the oldest facial implant used and can do a job of lengthening a wide variety of horizontal chin/jaw deficiences. Other jaw deficiences in the angle area on the back end of the jaw can also be augmented by differing jaw angle implant styles as well.

But the one type of jaw deficiency that can not be treated by any type of off-the-shelf preformed implant is that in the vertical dimension. The vertically short jaw is characterized by a lower third of the face that looks small and disproportionate. The chin may or may not be horizontally short and one may or may not have a large amount of overbite dental relationship. A vertically short lower jaw violates the classic canons of the facial thirds for a well proportioned face.

Correcting the vertically short jaw requires an unusual type of implant. It must be one that mostly sits on the lower edge of the bone and wraps around the entire jawline from angle to angle. This can only be obtained by making a custom implant from the patient’s own anatomy using a high resolution 3D CT scan.

Case Study: This 26 year-old young man wanted to have a stronger lower face/jaw appearance. He had always felt his jaw was short and, out of habit, he always held his jaw lower with an open bite relationship to make it look bigger. He had done this jaw repositioning habit almost all of his life. In obtaining his best jaw posiiton, the distance between his central upper and lower central incisors was 8mms.

Vertical Lengthening Jawline Implant Design Dr Barry Eppley IndianapolisA 3-D CT scan was obtained of his face and a custom vertical lengthening jawline implant designed. Based on experience with other jaw lengthening implants, the implant added 8mms of length at the chin which tapered back to 3mms at the jaw angle to keep a mandibular plane angle. A more square chin width was designed but only 3mms of width was added at the jaw angles. It was made as a single piece implant of firm durometer.

Under general anesthesia, a curved submental and bilateral ascending ramus incisions were made to create a subperiosteal tunnel around the jawline. The implant was sectioned in the midline and inserted from the submental position and properly seated on the bone. Screw fixation (2.0mms) was used on each side of the split chin implant for stabilization. Through the intraoral incisions, the correct position of the implants was confirmed and were stabilized by 1.5mm screws through a percutaneous technique.

Vertical Lengthenng Jawline Implant result oblique viewVertical Lengthening Jawline Implant result front viewHis early postoperative course showed a large amount of swelling as anticipated. By ten days after surgery enough swelling went down to be passable and at three weeks the majority of the swelling had resolved. However, the final result of the surgery is not judged until three months later when one can be assured all of the swelling was gone.

Vertical Lengthening Jawline Implant result side viewThe vertically lengthening wrap around jaw implant can effectively increase the height of the lower face to make it either proportionate to the upper two-thirds or even stronger. Its fabrication from a 3D CT scan assures the most symmetrical shape and other desired features of the jawline/chin area are incorporated into it. This new type of custom facial implant design is reflective of a what modern imaging and computer design processes can achieve.

Case Highlights:

1) The vertically short lower jaw is a completely different and more challenging problem than one that is horizontally short.

2) A wrap-around custom vertically lengthening implant made from a patient’s 3D CT scan equalize the height of the lower face to the upper two-thirds of the face.

3) While large, a wrap-around jaw implant can be inserted through a combined submental and intraoral approaches.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Wisdom: 3D Custom Facial Implants

Wednesday, November 27th, 2013


Plastic Surgery Wisdom Dr Barry Eppley IndianapolisFacial implants are an invaluable aid in aesthetic facial rejuvenation and structural changes as well as less frequently in facial reconstruction. Facial implants are most commonly perceived as preformed implants of various styles and sizes to augment areas like the cheeks, chin, jaw angles and nose. (off-the-shelf implants) Less commonly, blocks or sheets of various implant materials are available to carve or shape during surgery to make the desired implant. (semi-custom implants) The use of true custom-designed facial implants done from a patient’s 3D CT scan before surgery has emerged today as another viable and reasonably economic implant method. While once rarely done due to imaging and software design limitations as well as cost, it is now emerged as a much easier and economic implant method to do.

The custom design method for facial implants is truly amazing when visualized on a computer screen. The ability to create any shape and thickness of an implant and match the symmetry between facial sides, if needed, is impressive. But one limitation of computer designing implants is that it is done on an inanimate facial skeletal computer image that does not take into account the soft tissue cover…nor how such designed implants may be capable of being placed. Given that placing facial implants must be done in an inconspicuous and visible scar-free manner, being able to get a custom designed implant through the limitations of intraoral or discrete external facial incisions can be problematic.

Custom designing facial implants often allows larger and more encompassing implants to be created. But part of their design must take into consideration how they can be inserted and whether the overlying soft tissue cover will be adequate and still get the incision closed in a tension-free manner over it.

‘Any Size and Dimension of Facial Implants Cane Be Computer Designed, But That Does Not Always Mean It Will Be Made To Surgically Fit’

This issue is an important one where the input from the plastic surgeon based on their experience can help modify a custom designed facial implant to ensure it can be successful.

Dr. Barry Eppley

Indianapolis, Indiana

Computer-Designed Custom Facial Implants for Aesthetic Enhancement

Monday, June 3rd, 2013


Synthetic implants play a valuable role in the treatment of both aesthetic and reconstructive facial problems. While there are a large variety of preformed off-the-shelf facial implants which can be placed in their initial shape or modified during surgery, some patient’s bone and soft tissue volume deficiences are not ideally treated in this manner. While a plastic surgeon’s eye and experience goes a long way, standard implants may only result in facial improvement that may still be wanting in ideal volume and symmetry correction.

The use of computer technology to make custom facial implants has been around for over two decades. Using a 3D CT scan, an actual hand-held facial skeletal model is made out of a polymer material. Off of this model, an implant design can be fashioned by hand or one can be computer-designed. The most common implant materials used is that of either silicone or HTR (hard tissue replacement, Biomet Microfixation, Jacksonville, FL) I haved used this approach for the successful reconstruction of multiple craniofacial and maxillofacial deformities since 1991.

The application of such computer-generated implants has historically not been considered for purely aesthetic facial concerns. The cost of obtaining a 3D CT scan and the model/implant fabrication process was both expensive and time consuming. While the  reconstructive facial patient is having all or most of their surgery paid through insurance, the purely aesthetic patient is paying out of their pocket.

In my Indianapolis plastic surgery practice, I have made custom made facial implants for years. Using computer-generated facial skeletal models, a patient’s implant designs were made out of a clay or silicone elastomer material based on my experience, calipers for measurments and my own eyes. Those implant designs were then shared with the patient, any modifications subsequently done and then sent for implant fabrication. (Implantech, Ventura, CA)

But the concept of computer-generated custom facial implants has evolved due to several recent developments. The availability of 3D CT scanning technology, once reserved for large hospitals and university centers, is now readily available in any facility that offers CT scanning. The cost of obtaining a 3D CT scan has dropped dramatically over the past decade. A 3D CT scan that used to cost thousands of dollars can now be obtained for a few hundred dollars. This now makes it affordable for just about anyone anywhere.

In addition, computer software is now available where an implant design can be done exclusively on screen and communicated with the doctor online. The three-dimensional shape of the facial implant(s) and perfect symmetry (if two sides are being done) can be obtained. (Medical Modeling, Golden, CO) This can bypass the time-consuming need to hand make the implant designs. The computer-generated designs can then be sent to a facial implant manufacturer for fabrication. (3D Accuscan, Implantech, Ventura, CA)

Aesthetic facial implant patients have a better option today than in the past. For those patients that have aestheic facial needs for which standard facial implants do not have the right size or shape or have indwelling implants that are inadequate, the 3D Accuscan process now makes it possible and affordable to make truly custom computer-designed 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

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

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

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

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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