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Archive for the ‘custom facial implants’ Category

Technical Strategies – Intraoperative Positioning Guides for Custom Jawline Implants

Sunday, February 18th, 2018

 

Custom jawline implants offer an unparalleled ability to reshape the entire jawline and the lower face. Combining chin and jaw angle augmentation in a connected fashion can have a powerful effect given the surface area of the lower jaw that it covers. Because of this surface area coverage even small amounts of implant thickness create an external shape change that is more than I would think.

While the appeal of such a lower jaw implant is obvious, it is not a perfect technology. The design process remains subjective since the software can not yet tell us how to design the implant to achieve any patient’s specific desired look. The surgeon must provide that information to the best of his/her ability and hope the implant’s shape and various thicknesses throughout achieve what the patient wants.

In addition to design considerations, just because an implant is custom designed for the face does not mean that its surgical positioning will match exactly how it was designed to fit on the bone. While this is one of the obvious surgical goals, there is always the chance of implant malposition. Custom facial implants are not like Lego blocks, they do not snap fit together. (I wish they did as it would make the surgery a lot easier) The surgeon still has to place a smooth slippery implant on a smooth bone surface under indirect vision.Through small incisions and pockets that are not fully visualized, the surgeon must position the implant. This is a lot harder to do than how the implant design appears on the 3D skeletal model.

In some patients who have had prior osteotomies (sagittal split ramus osteotomy and sliding genioplasty), the indwelling hardware is actually very helpful. The implant can be designed around or over the hardware which serves as an intraoperative guide for its surgical placement as this hardware is always seen through the incisions.

But most patients don’t have these handy intraoperative guides. As a result it is very helpful to incorporate some intraoperative positioning guides on the implant’s design. I do this by making an extended tab of material that goes up to the ascending ramus opposite the 2nd/3rd molar teeth. Since this can easily be seen through the posterior vestibular incision, it provides a guide as to how the posterior and inferior aspects of the angle portion of the implant is positioned in the bone. (since this part of the implant can not be seen)

Once the custom jawline implant is positioned and secured his tab of material can be removed. It is always best to have any implant material as far removed from being directly under the incision as possible.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Custom Chin Implant

Saturday, February 17th, 2018

 

Background: Chin implant augmentation is the most commonly performed of all facial implants. The procedure has been done for over fifty years and, as a result, a wide variety of chin implant styles have been developed. While often named after the surgeon who developed them (which is not particularly helpful in understanding what they are intended to do), just about every aspect of every external chin change can be accomplished.

It is important to remember that most chin implants have been developed for the ‘average’ facial bones they augment and are based on anatomical skeletal models. As a result they will not fit everyone’s face well and create the exact intended aesthetic result. This becomes particularly evident in cases where the anatomy is abnormal such as in bony chin asymmetry, vertical chin deficiencies, gender specific needs and when the aesthetic demands are ‘extraordinary’.

Surgeons often try to make standard chin implants work in these non-standard augmentation situations through modification of the implant or in its bony position. And while it may work some of the time, there are many instances when it does not. These aesthetic failures create the need for a custom chin implant approach. And also illustrate why a custom implant approach may have been done initially.

Case Study: This female wanted a chin augmentation that was very specific for her small feminine face. She had existing chin asymmetry with the one side of the chin longer than the other. (or one side shorter than the other?)

Her goal was a chin augmentation result that corrected the asymmetry, kept the chin narrow and provided a forward and slightly vertically longer chin. A custom chin implant was designed to create this specific type of changes. While it was a petite chin implant it had very specific dimensional criteria.

Under general anesthesia and through a submental incision, the chin implant was placed and secured with a single microscrew. Chin implants that have some vertical design to them sit more on the edge of the bone, and even though they are custom made, are best secured with small screw fixation.

Just because the area of chin coverage may be relatively small does not mean that there does need to be an exacting design to it. Like the nose the projection nature of the chin makes its shape erasely apparent and scrutinized.

Highlights:

1)  Not all standard chin implants work well for everyone.

2) The most common reasons a standard chin implant is inadequate is when there is bony chin asymmetry, a need for vertical lengthening, dimensions beyond what standard sizes can do or when extensions are needed far back along the jawline.

3) A custom chin implant is most commonly used when a standard chin implant has ‘failed’, unless the surgeon first recognizes how likely a standard implant can work.

Dr. Barry Eppley

Indianapolis, Indiana

The Contemporary Use of Custom Forehead Implants

Sunday, February 11th, 2018

 

Augmentation of the forehead is done for a variety for reasons which differ based on gender and ethnicity. In women it is usually to create a rounder and more vertically inclined forehead which often does not include the brow bones. In men it is either for brow bone augmentation alone, correction of a backward forehead inclination or for a combined forehead-brow augmentation effect.

Historically forehead augmentation was done using bone cements. While this method can be effective for some more modest aesthetic forehead improvements, its use requires a full or nearly full coronal scalp incision as well as the need to intraoperaively shape the material. While intraoperative material shaping may seem appealing, it relies entirely on the surgeon’s ability to do so and is more limited for complex shapes particularly if it involves the brow bones.

Custom forehead implants have become the contemporary method for an type of augmentation of the upper facial third. While its solid silicone material can appear to be a disadvantage due to lack of tissue ingrowth/adherence, its many other advantages far outweigh this one biologic ‘disadvantage’. First and foremost, custom forehead implants are made before surgery through the use of computer design. This means that any shape and thickness of the forehead augmentation can be created provided the surgeon believes the overlying scalp/forehead tissue can accommodate it. This is of tremendous relevance when the augmentation involves the brow bones since this area is very hard to adequately augment with bone cements.

The second advantage of custom forehead implants is that they can be placed through a much smaller scalp incision. Because the implant is flexible it can pass through an incision that has less of a length than the widest part of the implant. At the very least the scalp incision does not have to extend beyond the lateral temporal lines…and keeping the incision away from the side of the head (temples) helps tremendously with incision camouflage.

The third advantage of custom forehead implants, which on the surface may not seem so, is that it is easily reversible. Should a revision of the forehead implant be necessary, it can be removed and reinserted in the straightforward manner in which it was inserted.

Most forehead augmentations do not usually need large amounts of augmentation in terms of thickness or forehead expansion. Conversely, however, their shape demands are often very specific and the outline (footprint) of the implant is critical. The surface of the forehead may seem fairly flat but it is more complex than usually perceived and changing that surface into a more desirable outer contour is best done with preoperative computer designing.

Dr. Barry Eppley

Indianapolis, Indiana

The Anatomic Basis for Custom Infraorbital-Malar Implants

Sunday, February 11th, 2018

 

The cheeks occupy a prominent aesthetic position in the midface. They create some amount of facial prominence/angularity as they curve around between the eye and the side of the face. While the cheek is often perceived as an isolated circular area by the side of the eye, as is commonly seen in the shape of most standard cheek implants, this is not how this facial area is anatomically constructed.

The cheek or malar region is an aesthetic term of which its bony anatomy is more extensive than the name implies. The zygomatico-maxillary-orbital bone complex is the bony foundation of the cheek. It is not an isolated bony area but a long stretch of bone that runs from the temples posteriorly to the infraorbital rim. This can be appreciated by those people who have or seek the ‘high cheekbone’ look.

It should be not surprise, therefore, that undereye hollows are associated with flatter cheeks as well given that they are part of the same bony region. When treating undereye hollows by implant augmentation it would be very uncommon that infraorbital augmentation is done alone. It is always best done by more of a wraparound implant design that provides a continuous and blended stretch of augmentation which is the anatomic basis for custom infraorbital-malar implants.

Custom infraorbital-malar implants are placed through subciliary lower eyelid incisions. This provides the most direct access for the linear dissection that is needed from the nasal bones medially to the posterior end of the zygomatic arch. It is interesting how long or large such an implant can look when placed on the face compared to how it looks on the bone in a 3D design.

Saddling on the infraorbital rim rather than just sitting in front of the bone is part of the smooth continuous design and is an important design feature than provides the best improvement in undereye hollows. This part of the implant is secured to the infraorbital rim with small microscrews. Assuring a good fit along the infraorbital rim is critical as this determines how the long hidden wings of the implant over the zygomatic body and arch will be positioned.

Dr. Barry Eppley

Indianapolis, Indiana

Square Custom Jawline Implant Design Principles

Tuesday, February 6th, 2018

 

The well defined jawline has become a desirable facial feature. Actually I do not think that a weaker or poorly defined jawline has ever been a desired facial trait. But with today’s aesthetic facial trends highlighted by strong social media exposure has brought this desirous lower facial shape into high focus. While most commonly pursued by men, it is not uncommonly requested by some women as well.

For many patients the only way to really change the shape of their jawline in a reliable manner is with a custom made jawline implant. With a wrap around shape and the ability to set its angles and dimensional thickness, it is no surprise that it can be very effective. In the right face, that is not overly round or has very thick tissues, a more angular or squared jawline shape can be obtained.

But the key in any jawline implant design is what should that shape be? While every person is different and there is no set shape that will work for everyone, there are some basic guidelines I have learned from doing hundreds of these implant designs. (and then seeing their actual effects after being implanted)

For a square jawline implant the first step is to set the angles. From the frontal view the chin should be squared off at the vertical line of the canines. The jaw angles should be squared off at the desired width as well as at the horizontal level of how one wants t set the new jaw angle projection position. (width only, primarily vertical or some combination thereof) This is the hardest angle point to set but one of the most important.

In the side view the jaw angle shape is determined. Here it is important to not make it too square. But doing so it runs the risks of having the back part of the angle end up behind where the masseter muscle can cover it. So it must not be 90 degrees but more open at 110 degrees of so.

The width of the jaw angle should not exceed a vertical line dropped down from the widest part of the zygomatic arch. As you don’t want the width of the lower face to exceed the midface. (unless that is the patient’s desired aesthetic goal)

With this as a general guideline for the jawline implant shape its dimensions (thicknesses) must be determined. For this there are no exact guidelines but the setting of the chin and jaw angle shapes and positions will serve as a good guide.

Despite the fact that wrap around jawline implants are custom designed, it is not an exact science nor is there any guarantee that the patient’s desired result will be obtained. But by following certain design guidelines the chance for a satisfactory jawline augmentation change is more likely.

Dr. Barry Eppley

Indianapolis, Indiana

The Role of Custom Chin Implants

Saturday, February 3rd, 2018

 

Chin implants are the original and most frequently performed facial implant augmentation procedure. With an over fifty year history of clinical use it is no surprise that a wide variety of implant styles and sizes of each have become available. Despite the relatively small size of the bony chin, many different implant shapes have evolved to change its shape. While all of these implant styles create some degree of horizontal projection, they differ primarily in how far back along the jawline they go and augment it as well.

But despite the variety of off-the-shelf options, standard chin implants will not achieve the aesthetic objectives of every patient. The chin being a central projecting facial feature should be viewed as a 3D structure. As such when considering its augmentation all dimensions need to be considered including horizontal projection, vertical length, and its width. Technically its 4th dimension is how it connects to the jawline behind it. (lateral wings of the implant)

This is where the role of custom implant fabrication for the chin comes into play. Such chin shape/objectives where custom chin implants are of value include the following: 1) various amounts of vertical lengthening with or without horizontal projection (and not desiring bony chin lengthening), 2) significant chin asymmetries, 3) desire for amounts of squareness or roundness not obtainable by standard implants, 4) the need for long extended wings back along the jawline, 5) high central implant height close to the intraoral vestibule and 6) any combinations of #1 thought #5 which makes it a truly patient-specific chin implant.

While custom designing allows for any chin implant shape and size to be made, it is important to consider how the soft tissue pad of the chin will adapt over it. The tightness of the soft tissue chin pad does provide a limit as to how much implant volume can be placed under it. This is reflected in the potential inability to get the soft tissue pad pulled sufficiently over it which can result in a ‘double bubble’ chin deformity. This is the one cautionary note in larger custom chin implants, indicating that just because you can make it does not always mean it will fit into teh soft tissue cover.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Jawline Implant Replacement for Displaced Chin and Jaw Angle Implants

Saturday, February 3rd, 2018

 

Background: A stronger and more defined jawline is a frequent aesthetic facial request for both men and women today. While jawline augmentation used to exclusively refer to the chin (front part of the jaw), today a more comprehensive approach is usually done for an entire lower facial effect from the chin back to the jaw angles.

Augmentation of the jawline can be successfully done by a variety of standard preformed chin and jaw angle implants. With almost ten chin implant and three jaw angle implant styles, there are a large number of possible implant combinations to satisfy most patient’s aesthetic needs. While putting together these various implants for each patient needs is an art form that requires an understanding of their external facial effects, their surgical placement is more straightforward with much less variability.

But what makes jawline augmentation unique is that it requires three implants to achieve a total lower facial effect. As every single implant has its own inherent risks (infection, malposition and undesired aesthetic effect) this makes such risks three times greater for a total jawline augmentation. Such risks are commonly recognized  for any other paired or bilateral implants (e.g., cheeks, temples) but no other place on the face (or body) has a three-fold implant complication risk.

Case Study: This male desired a more defined jawline with a square chin and stronger jaw angles. He had undergone a three implant jawline augmentation with standard chin and jaw angle implants. While he was happy with the chin and right jaw angle implant result, his left jaw angle was asymmetric. A 3D CT scan sows that the asymmetry was caused by malpositon of the left jaw angle implant.

He decided to have a one-piece total jawline implant made based on the dimensions of his existing implants rather than just reposition the left jaw angle implant. This also gave him the opportunity to add a little more width to the chin and some width to the sides of the jawline to the connections between the chin and jaw angles.

Under general anesthesia his existing chin and jaw angle implants were removed through existing submental skin and intraoral vestibular incisions. Through the same incisions the custom jawline implant was inserted and fixed into position.

A custom jawline implant, besides allowing for chosen dimensions before surgery, lessons the risk of malposition that does naturally exists the using three separated and not connected implants along the jawline.

Highlights:

1) A three piece total jawline implant approach has three times the chance of implant malpositions.

2) A custom jawline implant because it is one single implant has a much lower chance of a malposition problem.

3) Having existing standard implants is an enormous aid in designing a custom jawline implant.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The High Cheekbone Look with Custom Infraorbital-Malar Implants

Monday, January 29th, 2018

 

Background: There are a wide variety of cheek looks that patients want from cheek augmentation surgery, most commonly achieved used implants. While typically done in patients that have flat or weak cheek bone prominences, contemporary cheek augmentation patients often seek improvements in their midfacial shapes that do not have any really inherent structural deficiencies.

One of the desires for some cheek enhancement patients is the ‘high cheekbone look’. While this is an aesthetic term that is well known, it has variable interpretations amongst patients and surgeons. What some patients say they want a high cheekbone look, that is often not exactly what they mean.

Technically such a look really refers to having the upper part of the cheekbone augmented throughout its length. Given the natural anatomy of the cheekbone (zygomatico-orbital-maxillary complex) this refers to a linear augmentation from the zygomatic arch across the upper half of the main body of the cheekbone which continues across the infraorbital rim. Such an augmentation must be more modest in most cases to not look unnatural.

Case Study: This young male wanted to enhance his infraorbital rim out across his cheeks, cresting the high cheekbone look. In the spirit of enhancing his natural bony anatomy a custom implant design was done that stayed within the shape of the bone adding a few millimeters of augmentation across the infraorbital rim and cheek.

Under general anesthesia subciliary lower eyelid skin incisions were made with a skin-muscle flap raised down to the bone. A long subperiosteal pocket was made from the nasal bones out past the mid-zygomatic arch suture back to the temporal bone. The implants were inserted and positioned up onto the infraorbital rims and secured with two microscrews per side. The eyelid incisions were closed with lateral canthopexies and orbicularius muscle resuspension sutures.

The high cheekbone look may be open to individual patient interpretation but its actual meaning is a linear augmentation along the cheekbone ‘line’ from the side of the nose to the back of the zygomatic arch.

Highlights:

1) The high cheek look really means a linear infraorbital-malar augmentation.

2) A custom implant can be made that creates a subtle but linear augmentation from the side of the nose back along the zygomatic arch.

3) A custom infraorbital-malar implant is placed through a lower eyelid incision for optimal positioning and fixation.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Implants for Jawline Asymmetry after Mandibular Osteotomies

Tuesday, January 23rd, 2018

Background: Jaw asymmetry is one of the most common forms of perceived facial asymmetry. Whether it is localized to the chin or extends back along the jawline to involve the two jaw angles as well affects the magnitude of the deformity. The long length of the body of the mandible and the size of the jaw angles, compared to that of the much smaller chin, usually makes the facial asymmetry more obvious.

Patients undergoing orthognathic surgery frequently have bony asymmetry. When recognized before surgery it is usually built into the surgical plan and some adjustment accounted for by the osteotomy cuts. But such preoperative jawline asymmetries often persist after surgery and others can inadvertently be created by the surgery, particularly when sagittal split osteotomies of the ramus (SSRO) are done. How the bone cuts are made on each side, how the segments are put back together once the occlusion is set in the oral splint and the potential for some postoperative bony resorption due to the tissue stripped off of the bone all create the potential for the postsurgical occurrence or the magnification of presurgical asymmetry.

The treatment of jawline asymmetry, if augmentation is the corrective approach (which it almost always is), is best done with a custom jawline implant. The only relevant preoperative question is whether one or both sides should be treated.

Case Study: This young male had a prior bimaxillary orthognathic surgical procedure. He  acknowledged that facial asymmetry existed prior and was unclear if it was the same or worse than before that surgery. A 3D CT scam showed a tilt to the face with the left side being smaller than that of the right. From the chin back to the jaw angle the left side ws vertically shorter and less wide. His interest was to correct the left-sided facial asymmetry as well as enhance the overall jawline any a modest amount.

From this scan a two implant approach was designed to augment the whole jawline, factoring in the smaller left side, as well as a small cheek implant to augment the more subtle left cheek flatness. Both implants were relatively small as the goal was not to create some dramatic facial change.

Under general anesthesia the custom jawline implant was placed through a completely intraoral approach using three internal incisions. These were used to tread the jawline implant into place. The left cheek implant was placed through a standard intraoral upper lip vestibular incision.

The complete correction of any facial asymmetry is difficult and a perfect result should probably be considered unrealistic. There is always the variable of the surgical placement of the implants whose perfect positioning is never assured. (it is not as easy as the implat designs make it appear)  But custom designed facial implants adds one symmetric variable to an otherwise asymmetric situation and gives the best chance to improve the facial asymmetry as much as possible.

Highlights:

1) Jawline asymmetry is not uncommon after orthographic surgery and may or may reflect presurgical asymmetry.

2) A 3D CT facial scan is the best method to accurately diagnosis the location and extent of the jaw asymmetry.

3) A custom jawline implant can be designed to treat the entire jawline and is always best to create an overall jaw enhancement as well.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Jawline Implant Replacement for Malpositioned Chin and Jaw Angle Implants

Sunday, January 7th, 2018

 

Background: Jawline augmentation today usually refers to enhancement of its three primary aesthetic points, the chin and two jaw angles. There are a variety of standard preformed chin and jaw angle implants to achieve this effect and, with proper implant style and size, satisfactory results can be achieved.

But beyond the challenge of selecting the right implant style and size for three different bony jaw areas, there is the need to place them in the proper bony location to exert their desired external effects. The latter is often taken for granted by the patient but not by the surgeon. Placing three implants at different locations on the jawline without being able to reference one to the other due to the limitations of incisional access makes this part of the operation more difficult than it seems. This is far more challenging than placing a single chin implant or even paired cheek implants.

As a result the incidence of implant malposition and asymmetry is not all that uncommon in a three implant approach to jawline augmentation. This risk is magnified when the patient has pre-existing jaw angle bony asymmtetry which may or may not have been recognized before surgery.

Case Study: This middle-aged male had total jaw augmentation previously with a standard anatomic chin and widening jaw angle implants. While the patient recognized that his jaw was asymmetric after the surgery, his surgeon assured him the implants were in good position. A 3 D CT scan showed that the chin implant was positioned too high and to the left and the jaw angle implants were in completely different positions, neither of which was in ideal position.

Using this 3D CT scan a one-piece jawline implant was designed to correct his asymmetries. The dimensions of his existing implants (projections) served as a good guideline as to the size of the various ‘corners’ of the jawline implant.

Under general anesthesia and using an external submental skin incision combined with bilateral posterior vestibular incisions, his chin and jaw angle implants were removed. The new one-piece jawline implant was able to be inserted as the intact piece by which it was designed. His results with pictures taken years later showed good jawline/lower facial asymmetry and better chin and jaw angle projections.

There are many patients in whom standard chin and jaw angle implants work well. But it is not easy to successfully place three independent jaw implants in a perfectly symmetric fashion. Even with a lot of surgical experience it can still happen. When a three-piece jaw implant approach has not been successful, a custom jawline implant will offer improved results by its ‘one implant’ design.

Highlights:

1) Total jawline augmentation done with standard implants has a relaltively high risk of malposition/asymmetry of at least one of the implants since there are three implants used.

2)  A 3D CT scan can confirm standard jawline implant positions as well as be used for a one-piece total jawline implant.

3) Indwelling implants provide dimensional guidelines in designing a custom jawline implant.

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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