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Archive for the ‘chin augmentation’ Category

Case Study – Mersilene Mesh Chin Implant Replacement

Saturday, May 20th, 2017

 

Background: Chin augmentation is one of the oldest facial reshaping procedures. It has been performed for over fifty years and just about every conceivable material has been used to perform it. But historically and currently silicone implants have been preferred due to the wide variety of styles and sizes that are commercially available as well as their ease of insertion and removal.

But silicone implants are not perfect as they do not permit tissue ingrowth into them or attach firmly to the surrounding tissues. (depending upon how you view it this can be an advantage as well as a disadvantage) This lack of tissue adherence has allowed the use of a few select biomaterials for chin augmentation that have tissue adherence by virtue of having surface porosity or actual intermaterial porosity

One of these porous materials is mersilene mesh. Mersilene mesh is a synthetic non-resorbable polyester fiber that looks and feels like a fine mesh screen.  This mesh structure allows for fibrovascular ingrowth. It comes in thin sheets that are easily cut and has been widely used in hernia repair. But it has been applied for many other medical applications from ptosis eyelid repair to vaginal and urethral slings. It can be folded into a multilayer shape and sutured together to create a ‘chin implant’.

Case Study: This 30 year female had a history of two prior chin implant surgeries. She originally had a small anatomic chin implant which she felt produced inadequate projection and not the desired v-shape to the chin. It was subsequently replaced by a mersilene mesh implant to improve its projection and shape. This second chin implant ended up looking more like a block on the end of the chin and was further removed form the desired chin look.

Under general anesthesia and through the existing submental incision, the mersilene mesh material was tediously removed due to ingrowth of the surrounding soft tissues. It not only was stuck to the overlying tissues but had left an imprint on the underlying bone. (passive underlying resorption) An anatomic silicone chin implant was used as a replacement and its sides was tapered into more of a v-shape with s scalpel technique. The new implant was placed more on the bottom edge of the chin bone to add some vertical projection as well.

Mersilene mesh chin implants can be successfully removed with careful technique. Patients should expect more postoperative swelling than the original placement surgery due to the increased tissue dissection needed.

Highlights:

  1. Despite tissue ingrowth mersilene mesh chin implants can be successfully removed.
  2. Mersilene mesh material leaves impressions in the bone like every other type of chin implant.
  3. The shape options in mesh style implants are limited and can be the reason for chin implant replacement.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Double Chin Correction

Tuesday, February 21st, 2017

 

Background: The shape of the chin has a major effect on facial appearance. Since the chin is a projecting facial structure, it highly influences the shape of the face and how defined the neck can look. The shorter the chin becomes the more convex the facial profile becomes and the neck looks increasingly ‘lost’.

A common aesthetic facial concern is that of the Double Chin. This is really an urban term that is a misnomer. It is not really a double chin per se, it is really a chin deficiency or lack of enough chin projection. When combined with even a small amount of excess neck fat, which occurs right under the chin (submental fat), the profile will show two humps or mounds. They may look like two projecting chins but the lower ‘chin’ ir excessive neck fat.

The treatment of the double chin is a classic diametric surgery. Each ‘chin’ change must be in opposite directions to create the best facial profile change. The upper ‘chin’ must be moved forward and requires some type of bony procedure. (implant vs sliding genioplasty) The lower ‘chin’ requires soft tissue reduction using liposuction fat removal. Together the entire lower face is improved as it becomes more ‘pulled out’ and defined.

Case Study: This 45 year-old female was bothered by the increasing size of her double chin as she aged. She has always had a shorter chin but as she had gotten older the ‘double chin’ appeared.

Under general anesthesia an initial small submental incision was made through which the neck was treated by liposuction removing about 12ccs of fat. The submental incision was extended to 1.5 cms and a 7mm thick curvilinear silicone chin implant was placed in a subperiosteal pocket on the bottom of the anterior chin bone. (the implant had no extended side wings)

Double Chin Correction result side view Dr Barry Eppley IndianapolisDouble Chin Correction result front view Dr Barry Eppley IndianapolisHer eight week postoperative result show elimination of the double chin and a much improved facial profile. Between the chin augmentation and the liposuction, it really takes at least six weeks after surgery to see the full benefits of the double chin correction procedures. Depending upon the degree of horizontal (and even vertical) chin deficiency, the chin deficiency may be better done using a sliding genioplasty for a more 3D chin augmentation effect. It also can have a more positive neck reshaping effect as it pulls the underlying neck muscles (roof of the neck) forward and up.

Highlights:

1) The double chin deformity is a combination of excess fat fullness under the chin and insufficient horizontal chin projection.

2) The combination of submental/neck liposuction and chin augmentation effectively treats the double chin deformity.

3) Whether the chin augmentation is best done by a chin implant or sliding genioplasty depends on the degree of horizontal chin deficiency.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Chin Implant Stacking

Sunday, February 5th, 2017

 

Chin implants come in a wide variety of sizes and shapes. They can be placed either from an intraoral degloving approach from inside the mouth or from an incision underneath the chin. Both can be successful chin augmentation techniques as long as the implant stays where it is placed, albeit with either suture or screw fixation.

In some cases of chin augmentation the amount of horizontal projection is better but may still be deficient from the patient’s perspective. This could be due to either an inadequately sized chin implant or that the patient’s chin deficiency exceeded what standard implants can achieve. More times than not it is the latter. In these situations it is always better to either choose a larger implant if it is available or have a custom one made.

Chin Implant Stacking in Chin Augmentation Dr Barry Eppley IndianapolisBut another technique exists for improving the chin augmentation effect without removing the indwelling implant. This is the technique of facial implant stacking. This is where a new implant is placed on top of the other one. This provides additional horizontal projection and possibly some width if the implant wings are kept. When stacking implants it is important to secure them to the underlying implant as well as to the bone. Double screw fixation is ideally needed to prevent rotation of the overlying stacked implant.

The stacking of chin implants should be reserved for the very rare situations when other more established alternatives do not exist due to either standard implant limitations or for cost reasons.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Intraoral Chin Implant Placement

Wednesday, February 1st, 2017

 

Chin augmentation through the use of an implant is an historic procedure that dates back over fifty years and is still commonly performed today. It is typically done with a silicone chin implant due to its wide variety of styles and sizes and its smooth surface which facilitates its insertion and placement.

A chin implant can be inserted from either above or below the chin, each with its own distinct advantages and disadvantages. The submental or under the chin technique uses a  skin incision to access the chin bone to make the subperiosteal pocket. It has the advantage of not disrupting the origin of the mentalis muscle attachments, has a lower risk of potential implant contamination and ensures a more desired lower implant position on the bone. Its lone disadvantage is the concern about the scar appearance which usually heals very well. It is the more commonly use chin augmentation technique.

The intraoral chin implant technique approaches the chin bone from above. Its lone advantage is that it is a scarless chin augmentation. It has to disrupt the mentalis muscle bone attachments to create the subperiosteal pocket down to the bottom of the chin bone. Without  screw fixation there is a risk of the implant sliding upward towards the direction from whence it was placed after wound closure. In theory it is the more contaminated approach although there are no studies that validate the intraoral approach is associated with a higher rate of infection than the submental route.

Intraoral Chin Implant placement Dr Barry Eppley IndianapolisOne technical strategy in using the intraoral route for implant placement is to use a vertical muscle splitting approach. Rather than disrupting the complete mentalis muscle attachments through a horizontal degloving incision, the muscle is split vertically below its attachment point and the subperiosteal pocket created in a more blind instrumented fashion. The implant can then be inserted and rotated into position and secured in the desired location.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Medpor Chin Implant Removal

Saturday, November 26th, 2016

 

The use of implants for chin augmentation is the most popular method to achieve enhanced projection of the lower face. Many materials have been used for chin implants and today it usually comes down to the use of either a silicone or Medpor material. There are surgical advocates for both types of chin implants and both can be successfully used under the right circumstances.

Where silicone and Medpor chin implants differ dramatically and unequivocally is if the patient wants the implant removed. The aggressive tissue ingrowth into the Medpor material makes its removal difficult and fairly traumatic to the surrounding tissues. I have read some surgeons who say the material can’t be removed. This is not true, it is just that it is much more difficult than the easy removal of silicone implants.

If a Medpor chin implant is removed, there is often the need to replace it. The question is what should that be. That depends on why the implant was originally placed, its size and shape, and what the patient’s aesthetic goals.

medpor-chin-implant-removal-and-sliding-genioplasty-replacement-intraop-dr-barry-eppley-indianapolisIn this example a small petite female with a very short chin and high jaw angles had a Medpor chin implant placed. The implant produced numerous adverse aesthetic sequelae including a wide and elongated chin. Through an intaoral approach the Medpor chin implant, which was secured by 6 screws, was able to be removed in many pieces. The tissue ingrowth of the wings of the implant had adhered to the mental nerves which required careful separation to avoid nerve avulsion. The chin augmentation replacement was a sliding genioplasty. This brought the chin forward, made it less wide and vertically shortened it as well.

While chin implants are made of different materials, their effectiveness is best determined by the selection of implant style and size. It is important that chin augmentation in females is seen as aesthetically different than that of men. The type of chin implant style that works well in men often does not in females.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Chin Implant after Sliding Genioplasty

Saturday, August 6th, 2016

 

Background: The sliding genioplasty is a well known chin augmentation procedure that is often viewed as a substitute for a chin implant. While this is certainly true in some patients, for other patients it is a better alternative as both an autologous operation and because it can offer some dimensional chin changes that an implant has historically not been able to do.

One dimensional limitation of this bony genioplasty operation is that the amount of horizontal augmentation obtainable is controlled by the thickness of the bone. To ensure bony healing as well as survival of the downfractured chin segment, bone contact must be maintained. This means that the maximal amount of horizontal bone movement is that the back cortex of the mobilized chin segment must stay in contact with the front cortex of the intact chin bone above it.

Because of this anatomic limitation not every sliding genioplasty can achieve ideal chin projection. This leaves the role of a chin implant to achieve an even better chin augmentation result.

Chin Deficiency after Sliding GenioplastyCase Study: This 25 year-old female had previously undergone a sagittal split mandibular advancement with a sliding genioplasty. Even with these two combined lower jaw movements, her chin projection remained aesthetically deficient.

Chin Implant after Sliding Genioplasty intraop Dr Barry Eppley IndianapolisUnder general anesthesia an intraoral approach was used to access her chin. A extended medium chin implant was placed below the existing metal plate from her prior sliding genioplasty. The implant was positioned lower on the chin bone to help create some vertical lengthening as well. (8mms forward and 3mm down) The implant was secured in its position with two 1.6mm screws at the superior aspect of the implant.

There is no reason that an implant can not be placed on top of a prior sliding genioplasty. This would be the simplest way to improve a prior bony chin augmentation procedure. With the many styles of chin implants now available many alloplastic options exist to change the shape of the prior remodeled chin bone.

Highlights:

1) A sliding genioplasty does not always create the ideal horizontal position of the chin particularly in significant lower jaw deficiences.

2) A chin implant can be a secondary addition to a prior sliding genioplasty.

3) The extended wings of a chin implant can help camouflage any bony irregularities along the jawline from the prior sliding genioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Volume Comparison of Chin Implants and Injectable Fillers

Sunday, May 29th, 2016

 

Chin Implant Augmentation Indianapolis Dr Barry EppleyChin augmentation is a common aesthetic facial reshaping procedure that is second only to rhinoplasty. It has been traditionally performed by the placement of a preformed implant. While many different chin implant styles have been used over the years, the basic concept of an alloplastic chin augmentation is the same.

The emergence of injectable methods for facial augmentation using a variety of injectable fillers and fat has now become an accepted treatment approach for chin augmentation. While no injectable material offers an assured and permanent outcome as that of an implant for chin augmentation, it does provide an opportunity for patients to non-surgically ‘wear’ the result for awhile to determine if it suits them.

An interesting but relevant issue when using injectable fillers for chin augmentation is how do they compare volumetrically. To create an injectable chin augmentation effect, what volume of injectable filler is needed to compare to what a chin implant does? It is not a fair comparison if one is ‘testing’ an injectable filler and the volume injected does not equal what that of the effect that a chin implant does.

Volume Displacement of Facial Implants Dr Barry Eppley Indianapolisextended-anatomical-chin-implantComparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would equal to the volume of the implant. (provided that they sink in water and all chin implants do) Using the most commonly used extended anatomic chin implants (Implantech) of small, medium, large and extra large, their weights in grams and volume displacement were as follows:

Small Chin Implant        2.1 grams     1.3cc

Medium Chin Implant   2.7 grams      1.7cc

Large Chin Implant      3.4 grams     2.2cc

X Large Chin Implant  4.0 grams     2.7cc

The volume displacement of all injectable fillers is on the syringe so the comparison to chin implants is straightforward. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be less than even a small chin implant. A small anatomic chin implant more favorably compares to 1.5cc of Radiesse. Larger chin augmentation effects requires up to 3ccs of injectable filler regardless of the type.

There are other variables that affect how any of these materials create an external facial augmentation effect. The most significant would be how well does the material push on the overlying soft tissues or push off of the bone to create their effect. This is known as G Prime Force or their elastic modulus. It is quite clear that implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) Therefore it is probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to that of chin implants.

Dr. Barry Eppley

Indianapolis, Indiana

The Vertical Lengthening Chin Implant

Sunday, January 24th, 2016

 

Chin augmentation is the most historic but still the most commonly performed facial augmentation procedure. While many other types of facial implants have been developed, increasing projection of a deficient lower face is still the most potentially dramatic facial augmentation change of them all.

Chin implants have evolved considerably over the past few decades with numerous new styles. The fundamental concept of these style changes has been to create a more natural chin augmentation look or augment different regions of the chin area. But the one constant of all the chin implant styles is that they create a straight horizontal dimensional increase. This is so because all of the implant remains on the front edge of the chin bone.

But some chin deficient patients have more than just a horizontal bone deficiency. Certain short chins are also vertically deficient as well. Historically the only surgical method to substantially increase chin height was an opening wedge sliding genioplasty.  While effective some patients would prefer to avoid a bone cutting surgery.

While it is true that a standard chin implant can be placed very low on the  bone(on its ledge so to speak), this is not how the implant is designed or made to be used. This makes it potentially unstable to sit on the lower end of the bone and, even in doing so, produces a a very limited vertical lengthening effect.

Vertical Lengthening Chin Implant vs Standard Chin Implant Dr Barry Eppley IndianapolisTo address the combined horizontal and vertically lacking chin with an implant, the vertical lengthening chin implant (Implantech) has been developed. What is unique about this chin implant style is that the projection of the implant goes down from the chin at 45 degrees. This creates a combined horizontal and vertical increase. The implant actually sits on the ledge of the chin by design and thus it is more stable. To ensure optimal stability and positioning, a single 2.0mm screw can be placed through the implant to the bone when done from a submental incision. When done intraorally, a 1.5mm screw can be placed through the top edge of the implant to prevent any risk of upward migration. (which actually should be done with all chin implants placed intraorally)

Vertical Lengthening Chin Implant result 1 Dr Barry Eppley IndianapolisVertical Lengthening Chin Implant result 2 Dr Barry Eppley IndianapolisProper patient selection for the vertical lengthening chin implant is critical. It should only be used in patients with a significant vertical deficiency of the chin that also has a horizontal shortness as well. Most of these patients with have an almost 45 degree backward slant between the lower lip and chin. In general, the shorter the horizontal chin deficiency the more likely there will chin height shortness as well. Because it is an implant the width of the chin will also get bigger as the chin gets longer with greater horizontal projection. (a key aesthetic consideration)

Vertical Lengthening Chin Implant result 3 Dr Barry Eppley IndianapolisIn some men with slight or even no real vertical deficiencies, the addition of chin height will create a stronger or more masculine lower facial appearance. While this may be effective for some men, this is not a good strategy for women.

Vertical Lengthening Chin Implant sizes Dr Barry Eppley IndianapolisDifferent sizes (angulations) of the vertical lengthening chin implant are available which can increase the vertical up to 7ms while increasing the horizontal up to 12mms. Such chin augmentation changes may allow some patients to avoid an osteotomy of the chin.

The vertical lengthening chin implant is truly the first 3D chin implant ever made as it increases all three chin dimensions.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Extended Chin Implant

Tuesday, October 6th, 2015

Background: Chin augmentation is the commonly performed facial bone augmentation site. Chin implants have been around for almost fifty years in a preformed fashion. A large number of different chin implant styles and sizes now exist that seemingly can treat just about every type of aesthetic chin deformity.

Chin Implant with lateral wings compared to a central button chin implant Dr Barry Eppley IndianapolisThe single greatest change/advance in chin implants over the past decade has been the concept of adding wings or lateral extensions. This makes sense for most chin augmentations to avoid a ‘bump-like’ appearance on the front edge of the chin and to have the implant flow more smoothly around the bony curvature of the chin. These wings can extend back onto the parasymphyseal area and front portion of the body of the mandible. The purpose of chin implant wings is not to add volume but to create a smooth transition between the implant and the jawline.

But not all aesthetic chin deformities truly stop at the front edge of the mandible. While the jaw behind the chin may not be especially short, the lower edge of the jawline is often not well defined. Adding volume or definition alone the jawline with a chin augmentation can be of benefit to some patients.

Case Study: This 50 year old female had numerous surgeries in the past to treat a medical problem that left her with multiple problems of the lip, chin and jawline. As part of her treatment strategy, an extended chin implant was planned to build up her chin as well as back along the jawline. The goal was to create a volumetric effect along the entire jawline.

Extended Chin Implant design and placement Dr Barry Eppley IndianapolisUnder general anesthesia she had multiple procedures done (e.g., fat grafting, lip resuspension) as well as an extended chin implant through an existing submental incision.

Custom Extended Chin Implant result oblique view Dr Barry Eppley IndianapolisCustom Extended Chin Implant result front view Dr Barry Eppley IndianapolisAt six months after surgery, it can be seen that the effect of the extended chin implant was beyond that of just horizontal chin augmentation. The entire jawline behind the chin just short of the jaw angles had augmentation to make it slightly wider and more defined.

The extended chin implant concept is a much longer extension than that of the traditional winged chin implant. It can provide true increased jawline definition behind the chin since it is designed to do so. Such an extended chin implant can have numerous applications to other patients who need/want jawline definition but not necessarily stronger jaw angles.

Highlights:

1) Augmentation of the jawline can be done beyond that of the chin using a specially designed preformed implant.

2) Creating a more defined jawline extending backwards from the chin can be done with an extended chin implant.

3) The wings of all preformed chin implant do not extend much beyond the sides of the chin.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Female Custom Chin Implant

Monday, September 7th, 2015

 

Background: Chin augmentation is the most commonly performed jawline enhancement procedure. It is also along with rhinoplasty the most common facial bone reshaping operation. Placing an implant over the end of the chin bone is conceptually simple. But the wide variety of chin implant styles and sizes demonstrates that the aesthetics of chin augmentation is not so simple.

Female Chin Augmentation Surgery Dr Barry EppleyWhile there are no gender specific chin implants made, it is clear that there are differences in the male and female chin. The ideal male chin is known to be stronger (greater horizontal projection), wider and have a more angular or square shape. Conversely the ideal female chin is more narrow, triangular in shape and can tolerate slightly less horizontal projection. The selection and use of chin implants is often done taking these aesthetic concepts into consideration. Unfortunately often they are not and this can create one reason for dissatisfaction from chin implant surgery.

For many female improvement in their chin shape comes best from an overall ‘cupping effect’ on the chin. The chin may need some modest horizontal augmentation but may need some vertical increase as well. The implant then needs to blend into the sides of the chin to maintain a more triangular shape. Such an implant shape does not come in any standard form and must be custom made.

Custom Chin Implant design front view Dr Barry Eppley IndianapolisCustom Chin Implant design side view Dr Barry Eppley IndianapolisCase Study: This 46 year old female wanted her chin shape improved but did not desire just a simple horizontal advancement. She wanted a modest change but one that had more of an overall chin shape augmentation but still keep a feminine look. She also had bony chin asymmetry as evidenced by a vertically longer genial tubercle on the right side. From her 3D CT scan a custom chin implant was designed and made. The implant design corrected her asymmetry but also keep a more triangular shape.

Custom Chin Implant placement intraop Dr Barry Eppley IndianapolisCustom Chin Implant design top view Dr Barry Eppley IndianapolisUnder general anesthesia the custom chin implant was placed through a small 2 cm incision in the submental skin crease. The implant as expected (and should) fit perfectly over the chin bone. It was secured into placed with a single 1.5mm titanium screw

Chin augmentation can be accomplished in the majority of cases by using preformed standard implant styles and sizes. From one manufacturer alone (Implantech) there are seven different styles of implants with three or four different sizes. For most people this assortment will be more than adequate. But not every chin augmentation patient fits the normal implant options and this is the role that a custom chin implant serves.

A custom chin implant is often thought of as being for extreme cases where the amounts of chin dimensional changes exceeds what the standard implant can do. While this is certainly one role that a custom chin implant can do well, they can also be used for more modest chin shape changes that are not served by performed standard styles.

Highlights:

1) Chin augmentation is most commonly performed by a variety of standard styles and sizes of implants.

2) Standard styles of chin implants can not add consistent vertical length and can not create a cupping effect over the chin bone.

3) A custom chin implant can be made in any shape and can be a better option for certain types of female chin deficiencies.

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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