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Archive for the ‘custom facial implants’ Category

Case Study – Custom Jawline Implant Replacement

Monday, January 23rd, 2017

 

Background: A more complete jawline augmentation is most commonly done using standard chin and jaw angle implants. With good implant selection and ideal placement on the jawbone, an enhanced and satisfying jawline can be achieved. While numerous options in both silicone and Medpor facial implants exist, the material used is of no biologic or long-term consequence. What matters is the shape and size of the implants used.

While more successful than not, a three implant jawline implant approach is associated with a higher rate of complications than any one single facial implant. With three implants the associated risks of infection, implant malposition and undesired aesthetic effects are…three times higher than that of a single implant. By far, implant malposition (asymmetry) of the jaw angles and undesired aesthetic results make up the vast majority of jawline implant complications and the need for revisional surgery.

When the aesthetic results of standard chin and jaw angle implants are inadequate the most effective approach is to make a new implant using a custom approach. This is particularly relevant if the standard implants were very inadequate for the patient’s desired aesthetic needs.

Before Custom Jawline Implant Dr Barry Eppley IndianapolisMedpor Chin and Jaw Angle Implant Jawline Augmentation Dr Barry Eppley IndianapolisCase Study: This 42 year-old male previously had Medpor chin and jaw angle implants to try and create a more masculine and well defined jawline. While he had no medical complications from his implants and they were placed fairly symmetrically, they did not come close to the desired jawline effect. A custom one-piece wrap around jawline implant was designed from a 3D CT scan and a stone jaw model as a replacement.

Medpor Jaw Implant Removals Dr Barry Eppley IndianapolisCustom Jawline Implant design on model Dr Batrry Eppley IndianapolisUnder general anesthesia, his Medpor chin and jaw angle implants were removed through his existing external submental and intraoral posterior incisions. The jaw angle implants were particularly difficult to remove due to tissue adherence and being wrapped around the bony jaw angles. The implants and their fixation screws were removed in many pieces.

Custom Jawline Implant Replacement of Medpor Implant result front view Dr Barry Eppley IndianapolisCustom Jawline Implant Replacement of Medpor Implants result oblique view Dr Barry Eppley IndianapolisCusytom Jawline Implant Replacement for Medpor Implants result side view Dr Barry Eppley IndianapolisHis new custom jawline implant was inserted and fit perfectly to the bone as designed on the 3D CT scan. His immediate surgery results showed a dramatically different aesthetic outcome from his standard implants with a much more defined jawline appearance.

Highlights:

1) Replacement of inadequate standard chin and jaw angle implants is best done with a custom jawline implant design.

2) Removing Medpor facial implants can be very challenging particularly over the jaw angle region.

3) Placement of a total custom wrap around jawline implant can be done through the same incisions as the original chin and jaw angle implants were placed.

Dr. Barry Eppley

Indianapolis, Indiana

The LeFort Custom Midface Implant

Sunday, January 22nd, 2017

 

LeFort 1 osteotomyThe LeFort osteotomy is the well known of all facial osteotomies and is used to correct midface retrusion. In its most commonly used form, the  LeFort I osteotomy, it is named after the fracture pattern originally described by Rene LeFort over one hundred years ago in that cuts are made across the maxilla above the tooth roots as well as through the pterygomaxillary junction. Although less commonly performed, higher levels of the LeFort osteotomy (II and III) are used for more complete midface deficiencies that are associated with craniofacial deformities.

Aesthetic midface deficiences are common in certain ethnic faces (e.g., Asian), traumatic midface fractures as well as general developmental patterns in some people. Many of these patients, however, can not be treated by LeFort osteotomies as they have a normal Class I or orthodontically corrected occlusion. Without the simultaneous correction of a malocclusion, the bone can not be brought forward otherwise it would create one. In addition, most aesthetic midface deficiencies do not justify skeletal correction due to the magnitude of the surgery and its associated risks.

Custom Midface Mask Implant Dr Barry Eppley IndianapolisThe custom midface implant offers an effective aesthetic operation that can have much of the same midface augmentation effect as many of the Lefort osteotomies. (minus the potential aesthetic benefit of forward teeth movement on the upper lip) It can cover the anterior face of the maxilla up onto the orbital rims and the cheeks. This can effectively pull the entire midface soft tissues forward including the base of the nose. It appears much like a mask in its design.

Total Custom Midface Implant Dr Barry Eppley IndianapolisThe design of the custom midface implant can done in variable amounts of dimensional changes across the face of the implant. The greatest fullness can be around the base of the nose and anterior nasal spine or it can be the exact opposite where it is thicker over the cheeks and infraorbital rim. It all depends on each patient’s aesthetic facial needs.

The custom midface implant is usually completely inserted from inside the mouth. In some cases where the implant comes ups around the infraorbital rims a lower eyelid incision may be needed to ensure its accurate positioning. The implant is inserted around the infraorbital nerve by making a slit in the implant above the nerve hole so it may safely wrap around it during insertion.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Total Jawline Enhancement with Custom Implant

Friday, January 20th, 2017

 

Background:  The approach to improving the shape of the lower face has evolved beyond just chin augmentation. While the projection of the chin still has a valuable role to play in lower facial reshaping, it is not a comprehensive approach to lower facial aesthetics. The shape and size of the entire jawline must be considered.

The single most effective complete jawline augmentation method is by using a custom jawline implant design. While it is made from a 3D CT scan and fits the bone as designed, its effect comes from expanding the entire bony borders of the lower jaw.  Because it covers a broad surface area, its effect can range from a subtle to a dramatic type of facial change.

In some male (and most female) jawline augmentations the patient is seeking a more conservative change. This means that one wants the jawline to be sharper and more angular with modest chin and jaw angle size changes. This is the classic definition of a jawline enhancement as opposed to a major jawline augmentation. To do so the custom jawline implant is often smaller with thin connections between the chin and jaw angles.

male custom jawline implant design Dr Barry Eppley IndianapolisCase Study: This 35 year-old male wanted a stronger jawline but one that was not ‘too big’. He always wore a closely trimmed beard which helped to create the appearance of  stronger jawline. He stated that he would continue to have such a beard after and this had to be factored into the implant’s design and size.

male custom jawline implant design and actual implant Dr Barry Eppley IndianapolisUnder general anesthesia and through a three incisional method (extraoral submental chin and intraoral vestibular incisions), a custom jawline implant was placed. To prevent mental nerve injury it was placed in a midline split two-piece fashion.

Custom Jawline Implant results oblioque view Dr Barry Eppley IndianapolisCustom Jawline Implant result side view Dr Barry Eppley IndianapolisHis after surgery results show a subtle but evident change in the appearance of his lower face. Increased chin prominence was evident as was a more defined jawline heading back to the jaw angles on both sides.

Custom Jawline Implant result front view Dr Barry Eppley IndianapolisTotal jawline enhancement can be done using a custom jawline implant. Keeping the projections at the chin and jaw angle areas more modest with thin connections between these three jawline points can keep the jawline augmentation effect more limited and create a more angular jawline.

Highlights:

1) A custom jawline implant affects the entire jawline in a wrap around implant fabrication.

2) Creating three points of augmentation (chin and jaw angles) that are connected can have a powerful effect on the shape of the lower face.

3) A small custom jaw implant provides an increased angularity to the lower face witout making it too big.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Interlocking the Custom Wrap Around Jawline Implant

Monday, January 16th, 2017

 

A custom wrap around jawline implant offers an unparalled approach to jawline augmentation. Made from a 3D CT scan it is designed to provide varying amounts of chin and jaw angle dimensional changes that are connected as a single piece implant. Because it is one larger implant it usually has to be placed through a three-incisional technique, one around the chin and the other two intraorally back by the jaw angles.

Because each incision is much smaller than the length of the implant, the sides of the implant must be initially introduced through the chin incision. The sides of the implant are then fed through the side tunnels back into the jaw angle area. The flexibility of the implant permits such a placement technique through the comparatively small incisions.

The ability to thread a custom wrap around jawline implant from front to back depends the size of the jaw angle portions. If the back portion of the implant is fairly big, trying to pass it through a subperiosteal tunnel below the mental nerve risks a stretch or tear injury to it. In these implant sizes it is better to split it in the middle and thread it from back to front. The smaller chin portion is safer to pass under the mental nerves.

Custom Jawline Implant modification Dr Barry Eppley IndianapolisReuniting the split custom wrap around jawline implant in the midline once positioned can be done with sutures or screws. Getting two vertically split midline implant sections perfectly together can be challenging. An alternative strategy is to create an interlocking connection down the midline when the implant is sectioned.

Custom Jawline Implant Re-assembly Dr Barry Eppley IndianapolisWhen reuniting these interlocking midline segments, like lenticular puzzle pieces, the precision of the implant design is re-established over the chin.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Custom Forehead Implant

Sunday, January 15th, 2017

 

The aesthetic correction of a retroclined or sloped forehead can be done by a variety of surgical techniques. Fat has become popular as an ‘easy’ injectable method of augmentation but it is important to remember that it is best used for soft tissue augmentation. In most cases forehead augmentation is a bony deficiency not a soft tissue one. Fat injections into the forehead can be unpredictable in terms of volume retention and smoothness so it is not a primary forehead augmentation procedure.

A variety of implant materials can be used in the forehead. Bone cements have a long history as a skull augmentation material including in the forehead. While effective their use requires a near coronal scalp incision for placement and is prone to irregularities and edge deformities. Their shape also depends on the surgeon’s artistic skills and being able to translate the patient’s aesthetic desires into a moldable shape.

Custom Forehead Implant Dr Barry Eppley IndianapolisAll of the potential negative aspects of bone cements for forehead augmentation are eliminated by the use of a 3D custom forehead implant. The exact shape and edging of the implant are determined and made before surgery. The insertion of the implant is done through a much smaller scalp incision due to its flexible nature. Tissue ingrowth into the implant is fostered by the placement of numerous perfusion holes. The outer smoothness of the augmented shape is assured by its preoperative design.

A custom forehead implant offers a superior method of aesthetic forehead contouring in my experience. While it still requires accurate placement of its predetermined design, the number of variables that can lead to undesired effects is reduced by its basic concept.

Dr. Barry Eppley

Indianapolis, Indiana

The Custom Midface Implant

Tuesday, January 10th, 2017

 

When most people (and many surgeons) think of midface augmentation, the use of cheek implants comes to mind. While cheek implants certainly do augment one area of the midface, they only cover one specific of the midface…the upper and outer corner of it.

Most of the midface lies between the cheeks and consists of the maxilla (upper jaw) and nasal base bones. From a bone standpoint midface augmentation is usually perceived as either a Lefort I or maxillary advancement (low midface) or a LeFort III osteotomy for a total midface advancement.

total-custom-midface-implant-dr-barry-eppley-indianapolisBut the midface can be augmented with implants just as effectively, or even more effectively, as moving the bone and way beyond what simple cheek implants can do. The use of a custom midface implant from a 3D CT scan can cover the entire midface from the pyriform aperture up to the cheeks. Such an implant can be inserted completely through an intraoral approach.

A custom midface implant is designed to increase central facial projection. It is an effective approach for patients with flat or concave facial profiles or for patients with negative orbital vectors. The point of maximum projection can be altered to either a low maxillary-anterior nasal spine point or higher up along the cheeks and infraorbital rims.

The typical ranges of increased midface projection for these custom implants is between 3mm to 7mms in most cases. Because it covers a broad surface area (the entire midface), its effect is greater than one would initially think.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Jawline Implant Replacement

Monday, December 26th, 2016

 

Background: Augmentation of the jawline by today’s standards usually means chin and jaw angle increases. This three-point approach typically uses performed chin and jaw angle implants. With the many different types of facial implants available today, most male and female demands for jaw augmentation can be met.

When using the three implant technique for jaw augmentation, there is a need for accurate placement of each implant. Implant malposition is the number one complication of facial implant surgery. Bilateral facial augmentations, such as the cheek and jaw angles for example, are prone to a unique risk of implant malposition…asymmetry. Even very slight differences in jaw angle implant positions can create visible external asymmetries that can be bothersome to the patient.

If you add up the general risks of implant malposition and size concerns with a single facial implant (around 10%), it is easy to see what the revisional surgery risks are in a three piece jaw augmentation procedure. Since surgical risks are additive for each implant, a total jawline augmentation with standard implants has risks of 30% or greater for issues that may merit revisional surgery. While it is true that some patients are more particular than others about ‘perfection’ or a result that meets their ideal aesthetic goals, my experience has been that most patients seek a result that is more than just close.

malpositioned-jaw-angle-implants-2malpositioned-jaw-angle-implantsCase Study: This 21 year-old female previously had chin and jaw angle implants palced for a complete jaw augmentation effect. While she liked the over all augmentation effect, she as bothered by the jaw angle asymmetry and the lack of a smooth jawline from front to back. A 3D CT scan showed a good chin implant position but obvious jaw angle implant asymmetry with standard widening angle implants. (She also had cheek implants which were asymmetric but that is not relevant to this case study)

custom-jawline-implant-replacement-for-malpositioned-jaw-angle-implants-front-view-dr-barry-eppley-indianapoliscustom-jawline-implant-replacement-for-mapositioned-jaw-angle-implants-side-view-dr-barry-eppley-indianapolisA custom jawline implant was created using the dimensions from her prior implants with some small changes. (9.5mm horizontal chin augmentation, 12mm wide jaw angle) Equally importantly the chin and jaw angles were connected by a smooth implant bar on each side.

custom-jawline-implant-replacement-for-malpositioned-jaw-angle-implants-overlay-dr-barry-eppley-indianapolisThis is a great example of how the custom jawline implant may keep many of the sizes of the standard implants but makes the entire jawline augmentation smooth and connected…like one’s natural jawline. This can be appreciated in the overlay of the existing implants (in green) with the new implant design (in light blue) on the implant planning pictures.

custom-jawline-implant-replacement-dr-barry-eppley-indianapolisUnder general anesthesia her existing submental and intraoral incisions were used to remove her indwelling implants and replace them with the one piece jawline implant.

A three-piece jawline implant augmentation can be prone to less than ideal implant positions and external aesthetic effects. A custom jawline implant can be used for a replacement. The existing implants serve as an invaluable guide in how to design the new one-piece implant.

Highlights:

1) A three-piece jaw augmentation approach using standard implants is prone to implant malpositions.

2) A custom jawline implant can replicate what standard jaw implants can do but in a single implant that is less prone to jaw angle malpositions.

3) A one-piece jaw implant permits a smooth linear connection between the chin and the jaw angles.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Custom Jawline Implant Placement

Monday, December 5th, 2016

 

The use of a custom jawline implant is the most effective technique to reshaping the lower face. Its one-piece design allows the changes in the front of the jaw (chin) and the back of the jaw (jaw angles) to be connected in a smooth linear fashion.

While the one-piece design of the implant has numerous aesthetic advantages, it does pose a unique intraoperative challenge. How does such a jawline implant get inserted? The sheer size of the implant is completely different than much smaller chin and jaw angle implants which are placed through single incisions.

The custom jawline implant is usually placed through a three incisional approach. There is the two intraoral posterior vestibular incisions and the anterior chin incision. The chin incision can be done either through the skin under the chin or from inside the mouth. Through these three incisions a subperiosteal tunnel is made that connects them going under the exit of the mental nerve from the bone. The custom jawline implant is positioned into place by passing the back parts of the implant through the chin incision

The size of the jaw angle part of the implant determines how easy or hard the custom jawline implant placement technique is. If the jaw angle implant part is very large it may be impossible to pass it under the tunnel that connects the chin and the jaw angle without significant risk of injuring or even tearing the mental nerve.

bg-custom-jawline-implant-reunited-in-midlineIn these cases the custom jawline implant is split in the middle and each half passed from back to front. Since the chin segment is smaller it passes easier through the subcutaneous tunnel and poses less risk of injury to the mental nerve. The implant halves are then reunited in the midline using either sutures or screws.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Cheek and Jaw Angle Implant Replacements

Sunday, December 4th, 2016

 

Background: Facial reshaping surgery is a broad collection of bone augmentation and reduction procedures. Almost all of the facial bone augmentation procedures are done by some form of onlay augmentation, most commonly preformed by preformed implant styles. Of all available facial implants the four most common areas augmented are the chin, nose, cheek and jaw angles. All of these represent facial projection points where augmentation can make a big difference on the perception of the face.
Of all available facial implants the hardest ones to choose a proper style and then surgical place are the cheeks and jaw angle locations. Cheek implants are technically easier to place but getting the right style of implant can be difficult as they are major gender aesthetic differences in this part of the midface. Jaw angle implants have less style choices but is very hard to place and position on the bone properly and are highly prone to malposition.
The success of facial implants is most fundamentally controlled by the style and size of the implant chosen. A perfectly performed facial implant placement that heals without complications may be viewed as a surgical success. But if it fails to meet the patient’s facial change goals it is still an aesthetic failure.
wrong-cheek-and-jaw-angle-implants-dr-barry-eppley-indianapoliswrong-cheek-and-jaw-angle-implants-2-dr-barry-eppley-indianapolisCase Study: This 36 year-old male had a prior history of standard cheek and jaw angle implants placed one year previously. The implant creased undesired facial shape changes. The submalar cheek implants created a more feminine ‘apple cheek’ look rather than the high cheekbone look he desired. He had high jaw angles but widening jaw angle implants were used. This made his face look look wide and fat. A 3D CT scan showed that the implants were well placed but they simply were the wrong style and size.
cheek-and-jaw-angle-implant-exchange-dr-barry-eppley-indianapolischeek-and-jaw-angle-implant-exchange-2-dr-barry-eppley-indianapolisNew custom cheek and jaw angle implants were made that were designed to create a high cheekbone look and vertical lengthening of the jaw angles. The differences between the old and the new custom implants can be seen in the 3D overlay.
custom-cheek-and-jaw-angle-implant-designs-dr-barry-eppley-indianapoliscustom-cheek-and-jaw-angle-implant-designs-2-dr-barry-eppley-indianapolisUnder general anesthesia a complete intraoral approach was used to remove the old implants, perform capsulectomies, extend the pockets and place the new implants. The horizontal portion of the chin part of the jawline was removed as that the chin ended up more square but did not additional horizontal projection.
How to choose proper facial implant style and size is not only not an exact science, it is really not something that any plastic surgeon learns to do in their training. It is still a judgment by the surgeon who tries to understand the patient’s facial goals and then makes an aesthetic judgment about implant selection.
Highlights:
1) Facial reshaping surgery often includes cheek and jaw implants.
2) Incorrect styles of cheek and jaw angle implants can lead to undesired facial shape changes.
3) Certain types of facial reshaping changes requires custom cheek and jaw implants to achieve the patient’s desired aesthetic result.
Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Custom Temporal Implants

Sunday, November 20th, 2016

 

Background: Contour deformities in the temporal region can be caused by either bone or muscle deficiencies. They often develop from prior surgeries such as craniotomies for tumors and infantile cranial vault surgeries for craniosynostoses. Elevating the temporalis  muscle at any age often results in muscle retraction and/or muscle atrophy. Even though the surgeon may resuspend the temporalis muscle at the end of the operation some degree of temporal contour deformity often still occurs.

Recontouring of many temporal deficiencies can be done by either fat injections or implants. Fat injections have their merit but they can be unpredictable in terms of both survival and contour shape. Implants of various materials have been used for decades for many forms of skull contouring. While many cranioplasty materials have been used in the temporal region, they have less than ideal properties because they are intended for bone contouring not that of muscle augmentation.

The temporal region is comprised of a thick layer of muscle in its anterior region beside the eye. When the muscle retracts or atrophies a pronounced indentation will occur. Filling in the indentation with a satisfactory aesthetic result can be difficult as this is a soft skull area and not a hard one.

medpor-temporal-implants-dr-barry-eppley-indianapolisCase Study: This 36 year-old male wanted to improve the appearance and feel of his tenporal regions. He had a history of a congenital skull deformity which underwent early surgery as an infant. As an adult the resultant temporal hollowing was treated by unknown temporal implants which he did not like because they were very hard and had visible irregularities and edges. A 3D CT scan showed multiple regular circular indentations in the upper temporal region which was consistent with Medpor style temporal implants.

custom-temporal-implants-design-dr-barry-eppley-indianapolisNew custom temporal implants were designed from the 3D CT scan by initially adding on the missing bone since the the scan cut off the upper temporal bone.

medpor-temporal-implant-removal-dr-barry-eppley-indianapoliscustom-temporal-implamnt-replacement-dr-barry-eppley-indianapolisUnder general anesthesia the temporal region was approached using his existing incisions from prior surgeries. The existing Medpor implants were removed in their entirety. Their underside revealed the multiple pegs of material for which they are recognized. The new custom temporal implants were put in as replacements with some trimming of its bottom thicker edge. Multiple 3mm perfusion holes were placed through the implants prior to their placement.

Highlights:

1) Temporal augmentation can be done using either standard or custom temporal implants.

2) Medpor temporal implants can be hard to shape and avoid palpable or visible edges.

3) Custom temporal implants are made from a 3D CT scan whose design can be based on how to improve the failures of indwelling temporal implant materials.

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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