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Archive for the ‘chin implant’ Category

Case Study – Chin Implant Asymmetry Correction

Sunday, May 21st, 2017

 

Background: Chin implants are well known to induce a variety of tissue reactions around the implant site. A surrounding encapsulation of scar tissue is always seen as occurs in every synthetic implant placed in the body. ‘Bone resorption‘ is often cited as an adverse reaction to chin implants but this is a misinterpretation of the actual biologic response that has occurred. It is more accurately described as a limited and passive bone remodeling as a response to the recoil of the expanded tight chin pad tissues now overlying the implant. It is, in effect, a pressure relief.

Some limited bone overgrowth around the edges of the implant is also not uncommonly seen. This occurs because the implant is placed in a subperiosteal location from which a limited osteogenic response is seen from the disturbed periosteal layer. It is actually rather remarkable that bone would grow up over portions of the implant given that it is a synthetic material. But this speaks to the osteogenic potential of the periosteum. But when such a bony overgrowth is seen it is limited to just the edge of the implant, usually the lower edge.

Case Study: This 35 year female had an anatomic chin implant placed eight years previously. While she liked the general chin augmentation effect, there were several aesthetic issues that developed from it that she didn’t like. The implant had some asymmetry to it with the left wing higher than that of the right. There were also multiple indentations that had developed over the soft tissue chin pad that were present at rest and became magnified when she smiled.

Under general anesthesia and through her existing submental incision, dissection was carried down to the chin bone. Initially the chin implant could not be found as only bone could be seen.Tapping on the chin bone had a hollow sound to it. It was suspected that bone had overgrown the bottom edge of the implant and its outer layer was chipped off with an osteotome over a small area to reveal the implant underneath. Continuing to remove the bone overgrowth eventually revealed that the entire implant was completely encased in bone including over the small lateral wings of the implant. The total bony ovegrowth was removed and the implant extracted. All edges of the bony overgrowth down to normal bone was removed. The implant was re-inserted and position in a midline neutral position and secured with double microscrew fixation to prevent implant rotation and recurrent asymmetry.

Complete bony overgrowth of an extended chin implant is a tissue reaction that I have not seen occur. Partial bony overgrowth occasionally occurs  but never complete bony encasement. Such a bony reaction to the implant could be the source of the overlying soft tissue chin pad indentations due to tethering into the tissues. It remains to be seen if removal of the bone improves these indentations.

It is important in treating chin implant asymmetry that any impedance to the wings of the implant be released/removed to allow the total implant to have achieve a completely horizontal orientation. Usually this involves a release of the surrounding scar capsule. In this case it involved all raised bony edges.

Highlights:

  1. Chin implants often induce local tissue reactions including bone overgrowth.
  2. Complete bony encasement of a silicone chin implant is not an implant reaction that I have seen previously.
  3. Chin implant asymmetry correction requires that all surrounding bony overgrowth must be removed.

Dr. Barry Eppley

Indianapolis, Indiana

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

Square Chin Implant in Men

Monday, May 8th, 2017

 

As the chin is usually the most protrusive part of  the lower face, its shape is clearly evident. While the shape of the human chin is highly variable there are some general trends based on gender. The male chin is known to usually be bigger than that of females in both projection but almost always in width. The male chin width can be round or more square-like based on genetics and growth.

The square chin has been for some time and remains currently a desired male facial trait. There has always been a lot of conjecture that it is an appealing facial feature to women due to the evolutionary need for procreation and furtherance of the species. It implies strength and virility and the appearance of a ‘high testosterone’ level. At the least its angular appearance adds facial highlights and makes the face more interesting.

In chin augmentation the only way to make a chin wider and more square is with an implant to do so. Of all the styles of jaw implants that are available, a square chin implant style does exist. It differs from most chin implants in that rather than having a round comfigurarion, it has more of a U shape. This broad U-shape makes for a more square chin appearance by adding thickness between the transition between the chin and the side of the jawline.

The square chin implant is usually placed through a submental incision since it is used exclusively in men who can easily tolerate this incisional approach. The additional width of the implant requires that a good pocket is created along the sides of the jawline to accommodate the long winds of this chin implant style.

There are two square chin implant styles, style 1 and style 2. Style 1 is more narrow (45mms) than Style 2. (55mms) The key to selection of which chin implant style is the width of the mouth. As  a general rule the width of a square chin implant should be no greater than a vertical line dropped down from the corners of the mouth on each side. When the chin width exceeds the width off the mouth it can look unnatural.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Chin-Jawline Implant

Saturday, April 29th, 2017

 

Chin augmentation has been done for a long time and many different implant materials and shapes have been used. The most common chin implant used today is that of an extended or anatomic design. Rather than just sitting on the front edge of the chin this contemporary chin implant is anatomic as its side wings blend along and into the lateral jawline to the sides of the chin.

But as useful as the anatomic chin implant is, it does not augment much of the jawline behind it. It remains a front of the lower jaw augmentation method only.

An extension of the anatomic chin implant is what I call a chin-jawline implant. It is a chin implant that has winged extensions that go back all the way along the jawline…stopping just short of the jaw angle area. This creates greater definition of the jawline although not much width due to the thinness of the extensions.

It is inserted just like any chin implant through either a submental or intraoral incision. A submental incision, however, is preferred as it allows a direct line dissection with long instruments back along the jawline. Despite their aesthetic advantages in properly selected patients, the long extensions offer an opportunity for displacement and asymmetry. Small intraoral incisions can be made to check the most posterior portion of the wings go ensure their smooth positioning along the jawline if desired.

The chin-jawline implant offers enhanced bone definition of the lower lateral border of the jawline. It is useful with jaw angle implants to create a total jawline augmentation effect, to improve jawline definition of a lower facelift and to extend the benefits of chin augmentation. It is available in male and female versions that differ in the shape of the chin with the male being more square and the female being rounded,.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Sliding Genioplasty with Chin Implant

Thursday, March 16th, 2017

 

Chin augmentation can be done through either placing an implant on top of the bone or moving the actual bone forward. Both are valid chin enhancement techniques and each has their own unique advantages and disadvantages. While there are strong surgeon advocates for both techniques, it is important to remember that not every patient is appropriate for either one and what matters for good results is matching the solution to the problem and not surgeon preference or familiarity with either surgical method.

There are rare instances where a sliding genioplasty and a chin implant can be combined. There are two indications for this composite chin augmentation approach. The first one is when the amount of horizontal chin augmentation desired is more than what a sliding genioplasty alone can produce. This would occur when the thickness of the chin bone is less than what the amount of horizontal bone movement that is needed to create the desired effect can be done. The additional horizontal projection is achieved by placing the  needed implant size in front of the moved chin bone.

The second indication for the composite chin augmentation approach is when one desires a different chin shape than that of the natural bone of the sliding genioplasty. This almost is always when one wants a more square chin shape and the natural chin bone is more round. A more square shaped chin implant, even if it is small, is placed in front of the sliding genioplasty. It is vey difficult, if not impossible in many cases, to make the chin bone more square in external appearance.

Sliding Genioplasty with Chin Implant Dr Barry Eppley IndianapolisWhen placing an implant in front of the sliding genioplasty, it is important to realize up front, that there will be some eventual implant settling into the bone. This is not bone erosion but simply the body seeking to relieve the pressure from the pushback of the stretched chin soft tissue pad. It is a natural and self-limiting biologic process.

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

Case Study – Sliding Genioplasty for Chin Implant Replacement

Monday, February 13th, 2017

 

Background: Chin implants in females is a common lower facial reshaping procedure. While they add desired amounts of horizontal projection and improve the facial profile, the extended wing designs of today’s chin implant designs can have adverse effects on they look in the front view. While the extensions on the implants are designed to create a natural transition into the jawline bone without a visible stepoff, they add chin width to do so. While this is rarely an issue in men, it can be more frequent aesthetic problem in women.

Women seeking an improved jawline have a different aesthetic goal than men. They do not necessarily seek an angular jawline with visible corners.  (some women may bit not the majority) Rather they usually desire a V-shape to their jawline with a smooth linear line from front to back. As part of that aesthetic goal the chin must be narrow and may even have a more pointy chin or smaller V-shape appearance. This is in contradiction to the look that many chin implant styles give to the augmented chin.

Case Study: This 35 year-old female had a prior history of having chin augmentation done using a Medpor chin implant of 6mm projection placed through an intraoral approach. She never liked the result as it gave her a wide and boxy chin. This did not fit her small petite face well. While it provided adequate horizontal projection, it made her chin too wide and too vertically long. She also developed some lower lip sag and excess tooth show.

Medpor Chin Implant Removal and Sliding Genioplasty Replacement intraop Dr Barry Eppley IndianapolisChin and Jaw Angle Reshaping result front view Dr Barry Eppley IndianapolisChin and Jaw Angle Reshaping result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia her indwelling Medpor chin implant was removed intraorally. To do so it had to be sectioned into multiple pieces and required the removal of 6 titanium screws. It was replaced by a sliding genioplasty that was brought forward 6mm and vertically shortened 3mms. A mentalis muscle resuspension and vestibuloplasty were performed to help with her lower lip sag. Concurrently, vertical lengthening jaw angle implants were placed through posterior vestibular intraoral incisions. The implants added 7mm of vertical length and 3mms of width.

Any form of chin or jawline augmentation must take into consideration the differences be tween male and female jawline shapes as well as the patient’s aesthetic goals. Even a ‘simple’ chin augmentation must take this into consideration as the operation may be a technical success but an aesthetic failure. (as this case illustrates) The entire jawline from front to back must also be considered in an effort to create an improved jawline that fits the patient’s face.

Highlights:

1) Chin implants in females create horizontal projection but often at the expense of too much chin width.

2) A sliding genioplasty can replace a chin implant by providing horizontal projection but with a more narrow chin width.

3) Jaw angle implants can create vertical lengthening with a sliding genioplasty to give a more defined jawline in females.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Implant Mental Nerve Compression

Friday, February 10th, 2017

 

Contemporary chin implants, often called anatomic chin implants, have extended wings of material that go back along the jawline. This change in the shape of chin implant was done decades ago to overcome the aesthetic shortcomings of the old style button chin implants which often looked like a round circle sitting on the front end of the chin.

While these extended wings on the chin implant have their aesthetic value, they also create other potential problems. Should the chin implant end up having a tilt to its alignment along the lower edge of the bone, the chin will develop asymmetry. While such chin asymmetry is an aesthetic complication, the more significant complication can come from mental nerve compression.

If the wing of the chin implant from an asymmetrical placement or shift of the implant gets close to the exit of the mental nerve, nerve impingement symptoms may develop. These can include numbness of the nerve’s distribution (lip and chin) but, more importantly, pain. The pain can be constant or can mainly occur only pressing on the nerve area. While some temporary numbness can occur from any chin implant procedure, it is the symptom of pain that alerts to the possibility of mental nerve compression.

Chin Implant Mental Nerve ImpingementWhile the symptoms alone may be sufficient to make the diagnosis, a 3D CT scan will show clearly the implant’s exact location relative to the mental nerve foramen. In today’s facial implant surgery, there is no reason to guess or presume one knows where the implant actually is. A 3D CT scan ends all that debate.

If a chin implant wing is compressing against the mental nerve, the sooner it is relieved by implant repositioning the better. Prolonged compression can cause axonal death and result in permanent nerve injury.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Chin Implant

Wednesday, February 8th, 2017

 

Background: Chin augmentation has been around for a very long time and many implant materials and sizes have been used to do it. From this experience has come standard implant sizes that work for the vast majority of people seeking chin enhancement surgery.

But some patients seek changes that exceed what these standard size can create or have discovered through prior surgery that their expectations have not been met. In these cases only a custom designed implant may suffice.

Custom Square Chin Implant Design Dr Barry Eppley IndianapolisCase Study: This 35 year-old male had a prior history of multiple chin procedures including a square chin implant and a sliding genioplasty. While all of these procedure produced a better chin, they fell short of his ideal chin shape and size goal. Therefore a custom chin implant was designed that brought the chin forward 25mm and gave it a very square shape without having any lateral wings.

Custom Square Chin Implant placement Dr Barry Eppley IndianapolisUnder general anesthesia and through a existing submental incision the custom chin implant was placed over the end of the chin bone after removal of the indwelling implant. It was secured with a single 2.0mm titanium screw.

Custom Square Chin Implant front view Dr Barry Eppley IndianapolisCustom Square Chin Implant result oblique view Dr Barry Eppley IndianapolisAt six months after surgery his chin shape was more square with some increased projection. He was pleased and had finally reached his aesthetic chin shape goal.

While custom chin implants can be made to any size and shape, it is important to consider how the soft tissue chin pad will drape over it. (or whether it will) While not all custom chin implants are of large dimensions, many are. The chin soft tissues will not adapt well with large amounts of spontaneous horizontal projection. This often causes tight tissues, lower lip stiffness and an abnormal appearance. It helps to have the chin soft tissues stretched out from prior chin augmentation procedures which is often the case before many patients seek a custom chin implant solution.

Highlights:

1) A custom chin implant is needed when the dimensions of standard chin implants can not create the desired effect.

2) An implant that provides significant horizontal projection with limited width requires a  custom design.

3) Very large chin implants require previous soft tissue expansion from prior chin augmentation procedures.

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


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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