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Archive for the ‘chin implants’ Category

OR Snapshots – Double Stacking Chin Implants

Wednesday, September 27th, 2017

 

Chin implants are the original and still today the most common form of facial skeletal augmentation. Having been around for over fifty years in various forms, chin implants have undergone many evolutionary changes in their shapes to satisfy a wide variety of aesthetic chin needs. Because of its history and frequent use, they have the greatest number of different styles and sizes off any type of facial implant.

But even with such a diversity of standard options, not every patient will do well with an off-the-shelf implant shape. This is where the role of custom implants comes into play where any dimensional need can be addressed through patient specific designing for unique chin dimensional augmentations. While extremely effective custom facial implants come at an increased cost over standard ones that may be a limiting factor for some patients.

While chin implants can be modified by hand carving them during surgery, adding to them is a different matter. There is no recognized method for increasing the size or shape of a standard chin implant. In some situations I have found it effective to marry together two different implant styles to get the desired effect. This is an example where a prejowl implant is added to an anatomic implant to get wider wings for more prejowl augmentation. By suturing the implants together in multiple locations, shifting or one implant sliding off of the other is prevented.

It is acknowledged that the use of 3D imaging and implant designing is best for most unique chin augmentation needs. But in the right circumstances it is possible to create a ‘semi-custom’ chin implant using standard implants in a stacking technique with suture fixation.

Dr. Barry Eppley

Indianapolis, Indiana

The Mentalis Muscle and Chin Augmentation

Monday, September 18th, 2017

 

The mentalis is a well known muscle of the chin. Any chin surgery procedure involves manipulation of this muscle no matter what type of dimensional chin change is being done or how it is being done. (implant vs. osteotomy vs osteotomy) Since it is the only muscle that has attachments to the anterior surface of the chin bone, postoperative problems with its function can occur. While many chin procedures are done successfully with the return of normal muscle function, mentalis muscle dysfunction is not rare and is a frequent source of after surgery chin problems. Given the frequent misunderstanding of the mentalis muscle anatomy and function amongst patients and even some surgeons, its role and relevance in chin augmentation surgery merits review.

The mentalis is a paired central muscle of the chin that runs vertically over the chin bone. It actually has two halves and is separated by a fat pad that is most prominent near its bony origin underneath the labiomental fold below the lower lip. The relevance of this central fat pad in the muscle is not clear. The muscle is attached to the bone at the depth of the internal vestibule superiorly and runs down vertically to insert into the soft tissues of the lower submental chin pad. It is important to appreciate that the point of firm fixation is at its origin to the bone but its insertion is into the soft tissue inferiorly. The primary function of the muscle is contraction of the chin pad superiorly and inward (towards the lower lip) which will concurrently raise the lower lip creating a pout type facial expression. It is innervated by the marginal mandibular branch of the facial nerve which crosses over the jawline laterally to reach the muscle’s surface.

In chin augmentation surgery incisional access is either intraoral through the mucosa or submental through the skin. In sliding genioplasty the only choice is intraoral. But implant placement can be done both ways. Both incisional approaches cut through the mentalis muscle but they do so through different areas of the muscle. (origin or insertion. This is more than just an anatomic distinction, it can have a significant influence on muscle tension and function after surgery.

Cutting through the insertion of the muscle with an intraoral approach does so at the point of its maximal muscle thickness and tension. It is extremely important to leave an adequate cuff of muscle attached to the bone with this maneuver, otherwise there will be nowhere to attach the released inferior bulk of the muscle bellies. Without a reattachment the muscle will contract down, the labiomental fold will get deeper and the chin pad will pull down off of the bone. (chin ptosis)

With a retained muscle cuff onto which the released muscle can be reattached, one is essentially re-establishing muscle length at the thickest part of the muscle. But it is easy to see how the muscle length is changed when the soft tissue chin pad is stretched out by an implant or an advanced bony chin segment. The larger the chin pad displacement the tighter the muscle closure will be. This accounts for many a patient’s complaints of prolonged chin tightness and stiffness after a sliding genioplasty, particularly in large advancements. It can also occur with chin implants and is most commonly seen when the implant rides up high and pressures the resutured muscle origin.

In the submental approach for chin implants, it is the insertion of the muscle that must be cut and lifted up to reach the bone. Since this is not a firm bony attachment, muscle elevation and closure is done at the thinner lower portion of the muscle and has a much lower risk of adversely affecting muscle tension and postoperative function. This is why there are far fewer complaints of chin stiffness and tightness from submentally placed chin implants as re-establishing muscle length is much easier as opposed to pulling the muscle back up to its original bony attachment.

Mentalis muscle anatomy and its function is just one issue to consider in chin augmentation and is most relevant with implants where both incisional options are in play. When the patient prefers an intraoral approach for a standard chin implant I use the muscle splitting approach through its septum rather than cutting the muscle’s bony attachment.

Dr. Barry Eppley

Indianapolis, Indiana

The Role of Custom Chin Implants

Sunday, June 18th, 2017

 

Alloplastic chin augmentation is the oldest facial implantation procedure. As a result, many different styles and sizes of chin implants have been used over the five decades of the procedure being performed. While in the vast majority of patients standard preformed chin implants work just fine, they do not always achieve the patient’s aesthetic lower facial reshaping goals. It is important to remember that current chin implants styles are based on historic patient’s aesthetic needs and surgeon experiences as well as what is economically feasible for the manufacturer. (they can’t produce endless styles of chin implants that end up having few commercial sales)

It is also relevant that today’s patients may have different aesthetic goals than that of what was popular ten or twenty tears ago. Patients are also becoming increasingly sophisticated as to the nuances of their facial aesthetics and, in some ways, are becoming more ‘3D’ in the desire for their facial changes. There is also the patient who has had a standard chin implant and is dissatisfied with the result due to shape issues.

As a result, there is an increasing role for custom chin implants. Even though the chin implant is the ‘simplest’ of all facial augmentation procedures that does not mean it is always easy to get a pleasing chin augmentation outcome. Contrary to popular perception the revision rates of chin implant surgery is not as low as most patients and surgeons believe. I have seen many patients who are on their second or third chin implant seeking an improved result.

Customizing a chin implant design can achieve several shape improvements over standard chin implants. First and foremost it can provide a horizontal projection versus width ratio that is not available in standard styles. Secondly, it can create a vertical lengthening increase with horizontal and transverse widths that is not currently available. Third, the wings of the implant can be designed to blend in better along the inferolateral borders of the lower jaw. Lastly, features such as a vertical chin cleft can be added.

Dr. Barry Eppley

Indianapolis, Indiana

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

Square Chin Implants

Sunday, April 2nd, 2017

 

While chin implants has historically been viewed as a critical component of profile enhancement for some patients, this is a limited view of what it can aesthetically do. A more complete assessment of chin implants, 3D chin augmentation, takes into account what changes are needed or will occur in the frontal and three quarter views as well. Such changes take on great gender significance as what men and women want in the frontal view of their chin can be very different.

Some men prefer a more square shape to their chin and this can be one of the desirous changes of placing a chin implant. Increasing the angularity creates a stronger and more defined shape to the lower face at the front edge of the jaw. This is well illustrated in many male celebrities and model who have very defined jawlines and are often referred by men seeing chin and jaw augmentation.

The desire for a more square chin look is probably represented by those men that wear goatees that are specifically cut to create a square chin look. Underneath the facial hair may lie a rounder less angular chin.

The one style of facial implant that is designed to create more angularity is that of the square chin implant style. Its obvious more square shape is in contrast to every other chin implant style which is rounder and is designed to augment the natural curve of the front edge of the chin. It is available in several different styles. What separates the two basic square chin implants is the width that is created. A style 1 is 45mm wide while a style 2 is 55 wide from corner to corner.

Careful inspection of naturally square chins shows that the chin width should not exceed a vertical line dropped down from the corner of the mouth or not much beyond that line. This should be the guide as to whether a style 1 or style 2 square chin implant is used. Going significantly beyond the corners of the mouth with chin squareness can take on a cartoon-like appearance and make the overall face too square.

The other square chin implant style is the extended version. This has long wings that go way back along the jawline. This would be a good square chin implant style to use if one is also getting jaw angle implants for a total jawline augmentation. Such an approach may avoid the need for a custom wrap around jawline implant in some cases that do not involve any vertical jawline increase.

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

Technical Strategies – Sliding Genioplasty and Chin Implants

Tuesday, November 24th, 2015

 

A sliding genioplasty is a very versatile chin reshaping procedure that has been used for decades. In elective chin augmentations it is the alternative option to the use of a chin implant. Although chin implants are by far more commonly done in a ratio of at least 20:1 if not greater. While chin implants are a simpler procedure they are not appealing to everyone nor are they always the best choice for every type of chin deficiency.

A sliding genioplasty is usually best done for younger patients who have significant chin deficiencies. There also is a much higher tendency to  them at the time of orthognathic surgery when other facial bones are being manipulated as well. In larger chin deficiences moving of the bone has less potential for any long-term problems than does an implant.

The limits of how far forward a sliding genioplasty can move the chin horizontally is a function of the thickness of the chin bone. It is important to maintain some bone contact between the upper and lower chin segments, meaning the back edge of the downfractured chin segment should at least touch the front edge of the chin bone above it. (and be stabilized by plate fixation)

Sliding Genioplasty Chin Implant Combination Dr Barry Eppley IndianapolisBut in some larger chin deficiencies even maximal forward chin bone movement may still leave one with less than an ideal profile change. In these circumstances, whether recognized during the initial sliding genioplasty or afterwards, the solution can be a chin implant. A chin implant can be placed on the front edge of the sliding genioplasty to gain an additional 3 to 5mms of horizontal chin projection. An extended anatomic chin implant is used so that its wings cover the step off area on the back side of the osteotome line. It is critically important that the chin implant is secured by screw fixation to the sliding genioplasty segment.

While chin implants and sliding genioplasties are traditionally thought of as being mutually exclusive, they do not have to be. In need of extreme amounts of chin projection, the combination of a sliding genioplasty with a chin implant overlay can be a useful chin augmentation strategy.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Recycled Medpor Chin Implant in Sliding Genioplasty

Saturday, June 13th, 2015

 

When a chin implant ‘fails’ it may be replaced or revised by a sliding genioplasty. Chin implant failure can usually be defined as an implant that had not met the patient’s aesthetic desires due to design, size or positioning issues. This is most commonly seen when a chin implant is used for larger chin deficiencies whose horizontal and vertical dimensional needs are at the fringe or beyond what a standard performed implant can achieve. Recurrent chin implant problems such as asymmetry and visible or palpable edges are another indication to consider moving from a synthetic to an autogenous or more natural chin augmentation solution.

Medpor Chin Implant Removal Dr Barry Eppley IndianapolisMedpor is a chin implant material, which while used far less than that of silicone chin implants, is a favorite among some patients and surgeons. While it is a biomaterial that does offer good tissue adherence and fixation it can suffer the same chin implant problems that silicone implants do. The material composition does not make it immune to similar aesthetic issues. While many surgeons state that Medpor facial implants are impossible to very difficult to remove that perception is a relative one when they are compared to silicone. I have removed many Medpor facial implants and they all can be removed in their entirety with careful surgical technique. They rarely come out as one piece by rather in multiple smaller sections.

Medpor Chin Implant Removal and Sliding Genioplasty Dr Barry Eppley IndianapolisMedpor Implant in Sliding Genioplasty Dr Barry Eppley IndianapolisWhen a sliding genioplasty is used to replace a chin implant, it is sometimes more prone to having a ‘step’deformity’ than that of an implant. The aesthetic consequence of this step and the merits of filling it in can be debated. But should the surgeon choose to do so, it can be filled in with a wide variety of materials. A cost effective approach of filling in the step deformity of a sliding genioplasty is to ‘recycle’ the removed chin implant material. With a Medpor chin implant this would be placing the multiple pieces of the implant material that became that way from removal. Since this implant material already has tissue ingrowth on it it can be come quickly ingrown with further tissue, thus serving as an ‘autoalloplast’ so to speak.

Having used recycled Medpor chin implants in over a dozen sliding genioplasties no infections have occurred and the step has been aesthetically covered eliminating the risk of a much deeper labiomental fold.

Dr. Barry Eppley

Indianapolis, Indiana

Minimal Incision Chin Augmentation

Thursday, March 12th, 2015

 

Chin Implant Styles Dr Barry Eppley IndianapolisChin augmentation using synthetic materials is both the most historic facial implant procedure and still the most commonly done. This is evidenced in that chin implants have the largest number of styles and sizes commercially available of any facial implant manufactured today. Chin implants are inserted by incisions either from the inside of the mouth mucosa or through the skin under the chin. There are advocates for either approach but successful chin augmentation results can be obtained either way with good attention to their unique technical details.

The placement of chin implants is most commonly done from a submental skin incision. It has the advantages of more limited disruption of the mentalis muscle of the chin, less risk of lower lip numbness and a more assured and sustained placement of the implant on the lowest portion of the chin bone. (where it belongs for its maximal effect) Understandably some patients are concerned about the final appearance of the submental scar. This concern is most significant in patients of intermediate skin pigments.

I have seen many submental chin implant scars and there are often much larger (longer) than they need to be. The use of silicone chin implants, even the longer anatomic or winged ones, allows for the implant to be inserted in a folded fashion, one half at a time. This enables a remarkably small incision to be used despite the length of the chin implant.

Small Chin Implant Incision Dr Barry Eppley IndianapolisThe key is to develop the subperiosteal tunnels along the sides of the chin bone in largely a blinded fashion. Once the incision is made down to the bone, small elevators are used to  made the subperiosteal tunnels along the inferior border of the mandible. It is important to make these tunnels longer than the wings of the implant on each side. By so doing half of the implant can be inserted and slide past its midline to one side. This will allow the opposite wing to be folded and inserted easily and then slide back to the midline.

Small Incision for Chin Implant Dr Barry Eppley IndianapolisOnce the implant is in the tunnels it can be slide back into the midline and secured by whatever fixation method one desires. (in this case of a vertical lengthening chin implant a 1.5mm screw was used)

Minimal incision chin augmentation can be very effectively done through a submental skin incision using preformed silicone implants.

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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