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Archive for the ‘chin implants’ Category

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

Physiologic Tissue Adaptation to Face and Body Implants

Saturday, January 24th, 2015

 

Synthetic implants  are involved in some of the most common procedures performed in plastic surgery. From the skull down to the calfs, implants allow an instantaneous augmentation effect to be achieved of a variety of sizes and shapes. While rivaled more recently in some procedures by fat injection grafting, implants offers a permanent volume/augmentation effect that is simpler to achieve. (out of a box so to speak)

While implants offer many benefits, they also have their own set of potential complications. Infections, malposition and size issues are amongst the most common no matter where in the face and body an implant may be placed. These are obvious complications that occur in the short-term, within weeks or months after surgery.

But longer term changes which sometimes lead to complications with implants come about from a less obvious source. When a synthetic implant is placed in the body, the implant itself can never change as they are made of materials that do not degrade or change. (e.g., silicone) Rather the body must adapt to it and respond based on the pressure caused by the implant’s volume. Thus tissues change around the implant and these changes are almost always that atrophy. Surrounding tissues thin to varying degrees based on implant size and body location.

Chin Implant Settling Dr Barry Eppley IndianapolisOne of the classic examples of this response is that of the chin implant. Often erroneously referred to as ‘erosion’ (which suggests an inflammatory reaction which it is not) some chin implants can be seen on x-rays of being partially inside the bone. This is a benign but natural process of implant settling. As a response to the pressure of the chin implant, which causes its aesthetic effect by pushing off the underly bone on the soft tissues of the chin, the bone responds to this pressure over time by resorbing under the implant. This allows the chin implant to imprint into the bone. Once a ‘pressure release’ is obtained no further settling into the bone occurs. Interestingly it does not occur in all chin implants and rarely if ever occurs in any other type of facial implant.

Breast Implant Chest Wall Deformity Dr Barry Eppley IndianapolisAn often recognized example but one that is far more common is that of breast implants. The pressure release phenomenon occurs through the dual effect of overlying breast tissue thinning and underlying rib deformation. Every plastic surgeon has seen it in some women who undergo breast implant replacements. When the existing breast implant is removed, the remaining breast mound will look sunken in and deformed. This is one reason some women over time feel that their breast implants no longer look as big. The breast implant has never changed in volume but the surrounding breast tissue has become less and the implant may have settled down into the ribs more.

While this tissue response to chin and breast implants rarely causes any problems, such a response on the nose can be very problematic. Rhinoplasty that uses large implants for nasal augmentation is well known to cause thinning of the overlying soft tissues which is very thin. This can lead to implant exposure and infection.

Tissue atrophy and thinning occurs to some degree around every augmentative implant placed in the body. It usually does not cause any long-term problems but is one compelling reason to avoid very large implants at any face or body location.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies in Plastic Surgery – Combining Chin Implant and Sliding Genioplasty for Large Chin Augmentations

Friday, October 10th, 2014

 

Chin augmentation can be done by a variety of surgical methods including a chin implant and a sliding genioplasty. Each of these aesthetic chin techniques has a role to play and they have their own advantages and disadvantages. But both have the same limitation…a limit to how much the chin can be horizontally projected. Chin implants are not made with standard thicknesses that are greater than 10 to 12mms. A sliding genioplasty can only be moved as far as the thickness of the bone will allow which can vary between 10mm to 16mms.

The horizontal movements provided by standard chin implants and sliding genioplasties are sufficient for the vast majority of patients with chin/jaw deficiencies. But they can be inadequate for the few patients that have horizontal chin projection deficiencies that exceed 15mm and may be as significant as 25mms.

Sliding Genioplasty and Chin Implant Dr Barry Eppley IndianapolisChin Implant and Sliding Geniplasty in Large Chin Augmentations Dr Barry Eppley IndianapolisCombining a sliding genioplasty with an implant is a novel method to achieve larger amounts of chin projection that I have done for years. Through an intraoral approach, which is needed for a sliding genioplasty, the implant is placed on the chin bone just one would normally do. It does need to be secured into placed by screw fixation otherwise it would easily become displaced. A chin implant with long wings also has the advantage of covering over the bony step-off that often occurs at  the back end of the osteotomy.

Very large chin deficiences can be managed by the creation of a custom implant but combining an implant and a sliding geniplasty may be sufficient in some of these cases. In my experience there has been no higher infection risk when placing an implant on top of a sliding genioplasty than when using a chin implant alone.

Dr. Barry Eppley

Indianapolis, Indiana

Five Things You Didn’t Know About Chin Augmentation

Wednesday, December 18th, 2013

 

Chin Implant Augmentation Indianapolis Dr Barry EppleyChin augmentation is one of the most commonly performed aesthetic facial surgeries and has a long history in plastic surgery. Other than rhinoplasty, in which it is often concurrently performed, it is the most frequently changed facial skeletal structure for cosmetic enhancement. While historically done with bone and cartilage, it is almost always done today by a large collection of preformed synthetic implants that offer a wide range of three-dimensional changes  of horizontal projection, width and vertical length.

While chin augmentation is often perceived as a simple and straightforward procedure, both by surgeons and patients alike, there are numerous issues that must be considered for a successful result.

Chin Augmentation is a Three-Dimensional Facial Enhancement. While the historic assessment of chin deficiency, and the success of chin augmentation, has been based on the amount of horizontal augmentation, this dimensional consideration alone is inadequate. Adequate chin augmentation should take into consideration its width as well as its height or vertical length. These dimensions can be almost as important as horizontal projection when one is viewed or seeing themselves in the frontal and oblique facial views. Many of these dimensions can be changed by contemporary chin implant designs.

The Shape of the Chin Is Different in Men and Women. The shape of the face has some very gender specific differences and the chin is no exception. Men want a stronger chin that can aesthetically have more projection and width. (squareness) Conversely, a woman’s chin can be a little bit weaker (less projection) and should have more of a triangular shape, it should also not be too vertically long. The most frequent aesthetic chin augmentation ‘complication‘  is a chin augmentation result in a women that looks too big, often being too wide.

The Chin Is Connected to the Rest of the Jawline. Deficiencies in the chin almost always reflect other jawline issues since the chin is just an extension of the total mandibular bone and its growth and development. For these reason, short chins will almost always have a high jaw angle. For men this may mean that they may aesthetically benefit by the placement of jaw angle implants with their chin augmentation to really given them a much better shaped overall jawline.

The Path of Chin Implant Insertion Can Affect The Results. Chin implants can be inserted through either inside the mouth or from under the chin. While patients understandably are focused on avoiding a scar under the chin, the intraoral route is associated with a far greater risk of complications and poor implant positioning not to mention recovery…all due to disruption of the insertion of the mentalis muscle. It actually takes much greater technical skill to get a good chin augmentation result when done from the ‘scarless’ method of chin implant placement.

Not All Chin Implants Come Preformed Out Of A Box. While there is a wide variety of styles and sizes of chin implant available today, a performed implant may still not be the most ideal for some patients. If the jawline/chin has asymmetry or the amount of chin augmentation is extreme and may require an extended chin implant, a custom designed chin implant can be the much better way to go. While it does add cost, an unhappy result or revisional surgery may end up costing more later.

Dr. Barry Eppley

Indianapolis, Indiana

The Myth of Silicone Chin Implant Erosion

Monday, October 14th, 2013

 

One of the most commonly performed facial augmentation procedures is the placement of a chin implant. Whether it is done for significant microgenia (short chin) or as a complement in rhinoplasty and facelifts for less severe chin deficiencies, chin implants represent an historic and usually straightforward aesthetic facial procedure. Chin implants date back as far as the 1950s and were the first type of synthetic implant placed in the face. While other materials had been used both before that and since, the use of silicone is by far what makes up the vast majority of chin implants that have ever been placed.

Chin implants have a history and a much talked about issue of potential ‘erosion’ into the underlying chin (mandibular symphyseal) bone. This issue has raised all sorts of concerns from patients considering chin augmentation, fearing that it is a destructive process that eats the bone and ultimately poses other problems. For some potential patients, this is issue is so dissuasive that they will either not have an implant for their chin augmentation or will choose a sliding genioplasty or another implant material because they feel it is safer.

After over 30 years of doing chin augmentation in every way possible and seeing every conceivable implant material used for it, I have never seen what one would consider to be a pathologic or destructive bony process of the chin. This does not mean I have not seen many chin implant indentations and impressions on the bone but this should not be confused with an erosive process.

The  biology of any implant that is placed in the body under pressure is that it will cause some surrounding natural tissue absorption. The implant itself is chemically inert so when it pushes on the overlying tissues, as all augmentation implants do, the body adapts to the pressure of the implant by some natural tissue resorption to relieve the pressure or push of the implant. This is well known, for example, in breast augmentation. Over time, the thickness of the breast tissue between the implant and the overlying skin thins due to the pressure of the implant on it. This is why saline breast implants develop more visible rippling over time and women with any type of implant feels that their breasts are a bit smaller. This is a passive tissue remodeling process not an active inflammatory erosive reaction in response to the composition of the material.

Many, but not all, chin implants will develop a minor amount of adaption of the underlying bone which is best called ‘implant settling’. Usually it is not more than a millimeter or two. It is not uncommon to see the the implant sizing number or other markings of the implant on the bone as part of the settling process. When the implant is properly positioned over the thicker bony cortex of the lower chin, this is about the implant settling one will see. In very large chin implants in very short chins, the amount of implant settling may be a few millimeters more.

However, if the implant is placed too high up on the chin bone (which often happens with an intraoral approach), it sits over the much thinner alveolar bone adjacent to or over the incisor tooth roots. This bone is less thick than the lower cortical bone and is more prone to see deeper implant settling. This can look very dramatic and ominous in x-rays and there probably have been a handful of such chin implant cases where lower tooth sensitivity resulted. It is these type of x-rays that has undoubtably led to many of the descriptions of  ‘chin implant erosion’ and such poor implant positioning was common decades ago.

But the number of true chin problems (tooth root exposure, infection) that have resulted from such radiographically seen cases of implant settling is extremely rare and very few cases have ever been reported in the medical literature. (I actually know of none…but I will assume that there have had to be several in the past fifty years)

In conclusion, the phenomenon of chin implant erosion is a myth. Rather it is the mislabeling of a natural process of tissue adaptation to the presence of an implant. It is neither active, inflammatory or a progressive process. Rather it is a passive tissue remodeling process that is self-limiting and of no aesthetic or biologic concern. It is not exclusive to silicone chin implants and can occur with all chin implant materials. With proper chin implant positioning below the apices of the incisor tooth roots, even this remote possibility of potential impingement is eliminated. Interestingly, such tissue remodeling is not seen on any other facial implantation site other than that of the chin.

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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