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Archive for the ‘chin implant’ Category

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

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

Case Study – Three Implant Jawline Augmentation

Thursday, October 27th, 2016

 

Background: Creating a stronger male jawline can be done by a variety of methods, most of which are done by permanent implants. While many plastic surgeons still think that the approach to a better jawline comes from chin implant augmentation alone, that approach excludes any consideration of the back of the jaw which makes up two-thirds of its structure. A more contemporary treatment approach takes the whole jawline into consideration.

The traditional jawline augmentation approach uses three standard styles and sizes of facial implants. This include a chin and two jaw angle implants. The choices for chin implants are either a more commonly used anatomic or convex implant shape and a more square formed shape style. Jaw angle implants can be either a widening or vertical lengthening style. Historically only the widening jaw angle style was available but newer vertical lengthening styles offers a better option for those patients with high jaw angles.

The advantage of a standard three implant jawline augmentation are economy and time efficiency. Unlike a custom implant which requires a 3D CT scan and a month to design and manufacture, standard facial implants are available off the shelf and at a lower implant cost. The one aesthetic disadvantage is that the implants are not connected so there will be an indentation along the jawline between the chin and the jaw angles. For some patients this may not be an aesthetic detraction and may even be a desired effect.

Case Study: This 25 year-old male wanted a stronger jawline with a more square chin and wider jaw angles.

standard-chin-and-jaw-angle-implants-result-front-view-dr-barry-eppley-indianapolisUnder general anesthesia, a medium square chin implant was placed through a submental skin incision. Widening jaw angles of 7mms were placed through bilateral intraoral incisions.

three-piece-chin-and-jaw-angle-implants-result-oblique-view-dr-barry-eppley-indianapolisthree-piece-chin-and-jaw-angle-implants-result-side-vuew-dr-barry-eppley-indianapolisHis postoperative result showed a satisfied patient with a more defined jawline. The chin was more square and the jaw angles wider. The jaw angles even had a slightly more increased vertical length to them by a few millimeters.

As long as the patient can accept a non-connected jawline look through chin and jaw angle implant augmentation, the use of standard implants can be an effective total jawline augmentation approach.

Highlights:

1) Total jawline augmentation consists of increasing the dimensions of the its three main points, the chin and the two jaw angles.

2) A three implant approach to total jawline augmentation includes the use of a square chin implant and two jaw angle implants.

3) A three implant jawline procedure creates a three point augmentation with an intervening concavity of the body of the mandible.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Vertical Lengthening Genioplasty

Wednesday, October 19th, 2016

 

Chin augmentation is traditionally thought as a choice between a chin implant and a sliding genioplasty. While seen as the two procedure choices for chin reshaping they are not really interchangeable. Besides the difference between synthetically augmenting the bone vs actually cutting and moving the bone, they can achieve different dimensional chin changes.

The one movement that a sliding or bony genioplasty can do much better than an implant is changing the vertical dimension of the chin.  While it is obvious that an implant can not shorten the chin, it historically could not lengthen it very well either. That has changed more recently with vertical lengthening chin implant styles. But the intraoral genioplasty remains an historic mainstay for increasing the vertical length of the lower face. (chin)

vertical-lengthening-genioplasty-intraop-dr-barry-eppley-indianapolisDone through an intraoral mucosal incision, the chin bone is cut well below the level of the lower tooth roots. An opening wedge is performed by dropping down the chin bone to the desired vertical distance that is needed to create the aesthetic result. In most cases the vertical gap that needs to be created is at least 7mms. Much less does not produce a very obvious vertical lengthening. The amount the vertical gap can be opened is only limited by the length of the fixation plate used and what other chin dimensions need to be changed if any.

A debatable issue with vertical chin lengthening is whether the bone ago created between the two chin segments needs to be filled in. In small gaps in the range of 5mms or less grafting of the defect is probably not needed. The body will fill it in on its own. But larger bone gaps should be grafted. I prefer to use allogeneic cadaveric bone grafts which conveniently come in wedge forms that can fit nicely as an interpositional bone graft.

Case Study – Chin Implant Revision

Monday, July 25th, 2016

 

Background: The most common facial augmentation procedure is the chin implant. It has been done for over fifty years with the silicone implant as the most common device used for most of this time. It is often combined with a rhinoplasty but can also be done along or in conjunction with anti-aging procedures like a facelift or other face and jawline procedures like jaw angle implants.

Chin implant designs have evolved over the years with the standard style now used being an extended or anatomic shape. These longer wings that go back along the jawline from the central area of projection allow a smoother transition into the jawline without an obvious ‘bump’ sitting on the chin. This creates a more natural chin augmentation result.

But these extended wings on a chin implant have some potential disadvantages as well. They require a longer dissection along the jawline for the wings to fit. And great attention has to be paid to their symmetrical pocket development and placement. A slight degree of tilt to the implant can have the back end of the wings more significantly displaced up or down. In fact the number one complication of such chin implants today is wing asymmetry.

Chin Implant Malposition Dr Barry Eppley IndianapolisCase Study: This 60 year-old female had a prior history of a chin implant placed several years ago. She developed problems with chin asymmetry, a bulge in the right intraoral mandibular vestibule at the gumline and stiffness in moving the lower lip which also had some asymmetry.

Chin Implant Revision with Screw Fixation Dr Barry Eppley IndianapolisUnder general anesthesia through her existing submental scar, the chin implant pocket was opened and the implant removed. The implant had its right high up on the right side and low on the left side creating  a clockwise tilt. The right implant pocket was opened up and lowered while the left implant pocket was opened and raised. The wings on the implant were shortened 7mms per side and placed in the midline and secured with a single 2.0 x 10mm screw. Closure was done in three layers.

Chin Implant Revision Surgery results Dr Barry Eppley IndianapolisThe improvement in the appearance of the chin became evident as the swelling subsided over the first postoperative month. The chin was more symmetric as was the lip. The lip also moved more naturally. The chin will take several months to feel more soft and to have normal mentalis muscle function. There may also be some chin pad indentations develops as the part of the implant pocket that is no longer used needs to shrink back down to the bone. These chin pad soft tissue irregularities should eventually subside.

Many chin implant revision cases s are due to an asymmetry caused by a tilt of the implant (yaw) or a side to side shift. While the best way to prevent this from occurring is to secure it firmly when initially placed, this becomes doubly important when repositioning the implant during a chin implant revision.

Highlights:

1) Extended style chin implants can develop asymmetry by malposition of their long wings.

2) Repositioning an asymmetric chin implant (chin implant revision) is best stabilized by screw fixation in its new position to prevent relapse.

3) The extended chin implant can have its wings shortened if that is aesthetically advantageous at the time of repositioning.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Chin Implant Revision

Saturday, May 21st, 2016

 

Background: Chin augmentation is one of the original facial reshaping surgeries and has been performed for decades. Whether done through the mouth or done from an incision below the chin, the fundamental concept is that an implant is placed over the central aspect of the lower chin bone. (pogonion)

While the basic technique for chin augmentation has not changed over the years, the styles of chin implants has. Chin implant shapes have evolved to be large with long lateral wings. Known as anatomic chin implants, these lateral wings are added to the implant to allow it to transition more smoothly into the lower border of the jaw behind the chin.

While this lateral wing concept has its merits, it is also prone to creating chin implant asymmetry. Even slight amounts of chin implant rotation can cause the end of the wings to be asymmetric. The higher wing can even be felt inside the mouth as it encroaches into  the vestibule and may even put pressure on the mental nerve.

Chin Implant MalpositionCase Study: This 67 year-old female had two previous chin implants. An initial larger implant was placed two years ago and subsequently downsized due to dissatisfaction with its size. Once the swelling subsided the patient noticed an asymmetry of the chin with a higher wing on the right side.  The implant asymmetry was seen externally across her chin. She could feel it inside her mouth at the gumline on the right side which caused intermittent tingling and numbness sensations on the right side of her lip.

Chin Implant Malposition surgery Dr Barry Eppley IndianapolisChin Implant Repositioning surgery Dr Barry Epley IndianapolisUnder general anesthesia, her chin implant was approached through her existing submental incision. The chin implant was found to be located about 1 cm above the lower border of the chin bone and the midline shifted to the right with obvious canting of the implant. The implant was removed, the lateral wings reduced and the implant pocket adjusted. The chin implant was out back in a central position lower on the bone and secured with a single 1.5mm screw.

Chin implant malposition is especially prone when a large implant is replaced with a smaller one. The smooth surface of silicone implant makes it especially prone to sliding around on the smooth underlying capsular layer. This is where the value of placing a single screw ca be invaluable in its prevention and/or correction.

Highlights:

1) Chin implant malposition is not an uncommon complication of chin augmentation surgery.

2) With today’s winged chin implants, asymmetry of the lateral wings of the implants can easily occur.

3) Chin implant revision surgery creates a new pocket for the implant and secures it centrally with a screw placed in the midline.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Square Chin Implant

Saturday, May 14th, 2016

 

Background:  Chin augmentation is one of the most popular lower facial reshaping procedures and has been so for many decades. Its benefits are most commonly perceived in the side profile demonstrating increased horizontal projection of the chin. While changes in how far the chin projects forward is one of the most important benefits of a chin implant, that view alone is an inadequate perception of the overall chin augmentation  effect.

Chin augmentation should be seen as a 3D procedure and not just a 2D one. This takes into account the frontal view as well, assessing the vertical and transverse dimensions. The frontal view of the chin includes its width which is highly gender specific. The female chin ideally has a amore narrow and tapered shape. Conversely the male chin is wider, more angular  and can even have a square shape.

While there are numerous styles of chin implants, they have only two basic frontal shapes…convex and square. The square chin implant is unique in that it maintains a square shape when applied to the front edge of the chin bone which is usually convex. It does so because it is thicker on the sides of the chin so when pressed against the bone it maintains a square shape.

Case Study: This 45 year-old male had a chin implant placed several years previously through an intraoral approach. While it did improve his profile, he had been unhappy with how his chin looked straight on and he also felt it was sitting too high. He wanted more of a masculine square chin shape.

Chin Implant Removal Dr Barry Eppley IndianapolisChin Implant Replacement Dr Barry Eppley IndianapolisUnder general anesthesia, his existing chin implant was removed through a submental skin incision. The implant was positioned high and was asymmetric in position. It was a central style of chin implant that was curved with no lateral wings. It was replaced with a style 1 square chin implant of similar anterior projection thickness. (7mms) A centrally placed 2 x9mm screw was inserted to ensure its central position low on the chin bone.

Square Chin Implant replacement result Dr Barry Eppley IndianapolisA square chin implant is uniquely made for men who desire a wider and more angular chin shape. It comes in two widths known as a style 1 and style 2 chin. In the style 1 the square chin width is 45mms and in the style 2 the square chin width is 55mms. Which style of square chin width is best for each patient depends on the horizontal width of their mouth and how strong they want the square chin to appear.

Highlights:

1) Chin implants come in both different styles as well as sizes.

2) When considering chin augmentation how the chin will look in the frontal view is often overlooked.

3)  For men who seek a more angular and wider chin look, the square chin implant can help achieve this type of frontal chin shape.

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 data-lazy-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


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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