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Archive for the ‘custom facial implants’ Category

Case Study – Correction of Custom Chin Implant Malposition with Lag Screw Fixation

Sunday, October 29th, 2017

 

Background: Chin augmentation with implants has a long successfully history. While standard chin implants work for many patients, significant chin deformities do not fare as well. The shape and size of off-the-shelf implants are made for more modest to moderate aesthetic deficiencies primarily in the horizontal direction.

In the more severe horizontally deficient chin, which in many cases is really a manifestation of a mandibular growth deformity, the chin often has a dimensional deficiency that is not just in the forward dimension. As the ramus of the mandible fails to grow vertically long enough the jaw angles remain high and the mandibular body tilts downward. This creates a short but vertically long chin. Placing a standard implant on the front part of the chin will bring its projection forward and downward…not an ideal aesthetic change.  While the implant can be placed higher up on the front edge of the chin, this can create an exposed lower edge of the chin bone. This is why a sliding genioplasty is usually favored in this type of chin deformity as it can vertically shorten the chin  as it is brought forward.

Very horizontally short chins in females poses a unique challenge for implants.  Large chin implants have long extended wings which end up widening the chin significantly in the front view…an aesthetic problem that most women will find unacceptable. Women prefer more narrow chin widths and there are not standard implants that can offer enough projection but with a narrow base width.

Case Study: This female had a chin implant history of five previous surgeries over the years to find an acceptable chin augmentations result. She had a very short lower jaw, a class II malocclusion, and previous standard chin implants which were modified to try and give enough horizontal projection but not be overly wide. Her fifth and last surgery involved a custom chin implant made from a 3D CT scan. It had an uncommon design with a lot of horizontal projection, a narrow base and an almost cone-like shape.

She reported that this custom implant produced a satisfactory aesthetic change right after surgery. But with the first week after its placement, the chin shape changed and her chin become vertically long and lost its horizontal projection. She had a CT scan which showed that the implant had become displaced, basically falling of the chin and rotating 90 degrees. This gave her a ‘pharoah’s chin or false beard look.

Under general anesthesia and through her existing submittal incision, the displaced implant was removed through a thin overlying soft tissue coverage. A capsulectomy was done on the bone and releasing capsulotomies were done on the surrounding soft tissue pocket lining. The implant was reinserted and positioned as it was designed and secured with two 2.0mm screws through the implant into the bone. A capsular flap was raised from the inferior side of the soft tissue pocket and added as another tissue layer over the implant prior to skin closure.

Her immediate result showed how the chin was designed to look from the custom implant design.

Screw fixation of facial implants in general, and chin implants in particular, has often been debated. But it is important to remember that an implant over the front edge of the chin is not particularly stable. This can become more so based on the implant’s dimensions. While a custom chin implant ensures that the desired shape and size is achieved, there is no assurance it will stay where it is designed to be placed. In implants that look less positionally secure, double lag screw fixation ensures this will not be a postoperative problem. Repositioning of any chin implant malposition probably merits screw fixation to prevent recurrence.

Highlights:

1) A custom chin implant is as prone to malposition as a standard chin implant.

2) Any form of a chin implant completely falling off the chin bone is rare but in a high horizontal:vertical base ratio implant that risk is accentuated.

3) Screw fixation of chin implants prevents postoperative malpositioning and should be used in ‘high risk’ facial implants.

Dr. Barry Eppley

Indianapolis, Indiana

The ‘Customizable’ Custom Jawline Implant

Saturday, September 16th, 2017

 

Bony augmentation of the face has been done by a variety of commonly used facial implants. While many of these implants work fine for standard aesthetic problems of the chin and cheeks, many other facial areas require a customized implant approach. This is particularly relevant when jawline augmentation is needed. Due to the amount of surface area coverage and the thickness and complex shape of the implant, total jawline  augmentation requires the creation of an implant design from a 3D CT scan.

Custom jawline implants are one of the most common types of 3D designed facial implants in my experience. Made from the patient’s 3D CT scan, its design can be planned employing chin and jaw angle measurements and how to make the connection between them. While the implant can be designed to any specifications, the question always is what should those exact dimensions be? The answer to that question for each patient is not precisely known. There is no software program that can tell us how to make the implant for the exact type of facial change the patient seeks. This remains the art form of any custom facial implant design.

As a result there are certainly circumstances where both the patient and the surgeon may question whether the final design chosen and the manufactured implant will best serve their aesthetic needs. Such questioning may exist right before surgery (on the part of the patient) or during surgery. (on the part of the surgeon) The good news is that any custom implant, even larger jawline implants, can be changed or modified during surgery. Using large scalpel blades and experience in doing it, the custom implant can be reduced in size and its shape modified prior to placement.

This customizable custom jawline implant approach allows for shape changes that either have become apparent during surgery or for modifications that the patient desires right before surgery. Such changes do not violate the integrity of the implant or makes it lifelong durability any less.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Linear Custom Jawline Implant

Wednesday, August 2nd, 2017

 

Background: Augmentation of the total lower third of the face is historically and most commonly done using standard implants. The combination of chin and jaw angle implants, a three implant approach, provides enhancement of the three corners of the lower face. While theoretically appealing and a good solution for many jawline needs, it can be unsuccessful for a variety of reasons. These include implant asymmetry, the inability of standard implants to provide the desired aesthetic result and the lack of connection between all three implants.

A custom jawline implant connects the chin and jaw angle regions in either a linear or non-linear fashion.The size or thickness of the connection between the chin and jaw angles of the implant determines whether there is a smooth or linear look going from the chin back to the jaw angles or whether the chin and jaw angles stand out more than what connects between them. (non-linear look)

Designing a custom jawline implant with existing indwelling implants is ‘easier’ and more helpful than if no implants were there at all. Knowing what the aesthetic effects of existing implants creates, even if undesired, helps guide a new implant design that may produce a better result. While the custom implant design process is greater from the standpoint of fit to the bone, symmetry of both sides of the implant and creating a unified look, the computer or surgeon has no way of knowing exactly what implant dimensions can exactly achieve the patient’s goals.

Case Study: This 45 year-old male had Medpor chin and jaw angle implants previously placed which did not produce the jawline look that he had hoped. Fundamentally it did not give the jawline angularity that he seemed and did not have a smooth connection between the chin and the jaw angles. In the implant design process his existing implants were digitally removed and a one-piece jawline implant designed.

Under general anesthesia and through a combined intraoral and submental existing incisions, his Medpor chin and jaw angle implants and their numerous large screws were removed.

His new custom jawline implant was placed using a split implant technique. Due to the size of the implant jaw angles and concerns about injury to the mental nerve when passing the implant from front to back as a single piece, the implant is first sectioned in the midline of the chin in a geometric interlocking pattern. This then permits the implant to be placed in two sections from back to front and then reconnected in the middle. This is safer for the mental nerve as the sizes of the implant that must pass underneath it is smaller.

His one day results show an immediate improvement in his jawline shape in a more connected fashion. (linear jawline look) There is also more angularity evident in the chin and jaw angle corners. While he will go on to have some tremendous swelling that will take up to month or more to fully resolve, his very early jawline result looks more favorable to his aesthetic goals.

Highlights:
1) Jawline augmentation by three separate preformed implants often does produce a satisfactory or desired shape of the lower third of the face.
2) With existing chin and jaw angle implants in place, a custom jawline implant can be designed for an improved facial outcome.
3) Contrary to popular perception, Medpor implants can be successfully removed although it is more traumatic to the tissues than that of silicone implant removal.

Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Custom Forehead-Temporal Implant Replacement

Wednesday, July 19th, 2017

 

Background: The size of the forehead has a major influence on the appearance of one’s face, occupying the entire upper third of it. Beyond its size the shape of the forehead is also important with many gender specific features. In general, males have stronger brows, a wider forehead and a gentle backward slope to it. In contrast female have no brow bone protrusion, a convex forehead shape that has a more vertical orientation.

\Of all the facial bones, the forehead is the least commonly augmented. Intraoperatively shaped bone cements and preoperatively shaped custom implants are the two most common methods of forehead augmentation. Given the advantages of a more thought out forehead shape design and the ability to place it through a small scalp incision, custom forehead implants are usually the superior treatment approach.

But the success of a custom forehead implants comes down to its design. While computer designing an implant has many advantages, what the best shape and dimensions are that can create the patient’s desired forehead shape  is not a mathematical calculation. It is an art form that is based on the surgeon’s understanding of the patient’s desires and experience in appreciating the effects of various designs on the outward aesthetic outcome.

Case Study: This 25 year-old male had a custom PMMA forehead implant placed through a full coronal scalp incision six months previously. While the implant provided some brow bone augmentative effect, it did not extend all the way top the forehead and created a line of demarcation at the mid-forehead level. He was interested in having an implant design that covered his entire forehead as well as extended outward further into the temporal areas.

A new custom forehead-temporal implant design was made that covered more than 100% greater surface area than his indwelling implant. It covered the entire forehead back behind the frontal hairline, extended over the entire anterior temporal region down to the zygomatic arches as well as added a few more millimeters of brow bone augmentation.

Under general anesthesia, his existing coronal incision was re-opened and his forehead implant exposed and removed. The difference in surface area coverage between the removed and new custom forehead-temporal implant was significant.

The new style of custom forehead implant was then inserted and secured with small microscrews to the bone and sutures of the temporal extensions to the temporal fascia.

When designing a forehead implant there are four surface areas or zones to consider. They are the brow bones, the mid- and upper forehead, the temporal lines and the temporal zones. (often referred to as the sides of the forehead) The coverage or lack oil coverage of these areas must first be considered before determining what thicknesses they should be.

Highlights:

  1. Subtotal forehead implants often leave the forehead inadequately augmented.
  2. Custom forehead implants must consider the impact on the entire forehead as well as the adding temporal regions.
  3. Complete frontal augmentation covers the entire forehead as well as the temporal areas.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Female Jawline Implant

Sunday, July 9th, 2017

 

Background: The shape of the lower face is defined primarily by the size and dimensions of the lower jaw. While a strong or more defined lower jaw shape has always been desired by men, it has also taken on more significance in women with contemporary aesthetic facial standards. The well defined female jaw shape can be seen today in models, actresses and many other celebrities.

The difference between a distinct male and female jawline is really a function of size in most cases. They share similarities of a linear smooth shape from angle to angle and a visible jaw angle shape. The female chin is less square and more tapered and the jaw angle has less lateral flare. But a visible uninterrupted jawline is the hallmark of a defined lower face in a female. It doesn’t have to be big but it has to be defined.

Case Study: This 35 year-old female wanted a better defined lower jawline. She had been receiving injectable fillers for a chin augmentation effect. but wanted a permanent result that improved the entire jawline. From a 3D CT scan of her a custom jawline implant was designed providing 7mms of horizontal chin projection with 3mms of vertical length and 7mms of jaw angle width with 5mms of vertical length.

Under general anesthesia the jawline implant was placed through three intraoral incisions. (one anterior and two posterior) The front and back jawline pockets were connected by a subperiosteal tunnel under the mental nerves exits on each side.

Her six months after surgery results showed an improved jawline shape that had better jaw angle definition and a linear jawline shape that came together into a tapered chin. One of the key features to her improved jawline shape was the increase on overall vertical length.

Most female jawline implants would be considered more modest in size in comparison to many men. This is, of course, due at least to a body size difference. But it is also relevant to overall implant size compared to that of the jaw size.

Highlights:

  1. Total jawline augmentation, from angle to angle, requires a custom jawline implant.
  2. A linear shape to the jawline requires a single piece implant.
  3. Female jawline augmentation is more about shape and definition than it is about size of the implant.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Cheek-Maxillary-Paranasal Implant

Sunday, June 25th, 2017

 

Cheek implants provide augmentation to the cheekbone or zygomatic major bony prominence. This produces an anterolateral midface effect that is useful for more common augmentations of isolated and mild to moderate aesthetic cheek deficiencies.

But the cheekbone is part of the overall midface skeleton with extensions onto the eye (infraorbital rim) and the upper jaw. (maxilla) As a result, when midface developmental deficiencies occur or in certain ethnicities the facial effects are more than just a lack of adequate cheek projection. The entire midface can be deficient as manifest with a flatter face appearance that lacks overall horizontal projection.

In midface deficiences standard cheek implants do not address the complete skeletal problem. Making custom implants to have broader coverage of the midface provides a more complete solution. Extending the implant down onto the face of the maxilla and over to the pyriform aperture provides a zygomatic-maxillary augmentation effect. Short of the central upper lip and teeth changes, this design creates a LeFort I advancement effect with cheek augmentation.

This custom cheek-maxillary-paranasal implant is placed through an incision inside the mouth like standard cheek implants are. It is easier to position than standard cheek implants due to its length and visible positioning up against the pyriform aperture. The risk of malposition is low as most of the implant is visible inside the mouth during placement.

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

Male Custom Brow Bone Implants

Monday, June 5th, 2017

 

The shape and appearance of the forehead is highly influenced by the appearance of the brow bones. While usually taken for granted when they are normal, the brow bones or supraorbital rims serve as the roof/overhang of the eye.  A strong or weak bony overhang influences the appearance of the eye as well as that of the overall face.

The appearance of the brow bones is very gender specific. Men naturally have stronger brow bones due to greater development of the frontal sinus cavity. This results in a brow protrusion and the creation of a suprabrow break above it into the forehead. This also results in a slight backward pseudoinclination to the forehead. Conversely women had flatter brow bones, no brow bone break and a more vertical and convex forehead shape.

For the male seeking stronger brow bones, the underlying bone usually has to be augmented. Injections methods using synthetic filler and fat can be very effective to create a temporary effect  or just some slight augmentation across the brow bone proper. But a permanent and more versatile augmentation approach requires a brow bone implant.

Traditionally augmenting the brow bones requires a coronal scalp incision for access. Once widely exposed the brow bones can be built up with a variety of bone cements or implant materials. Besides the obvious lack of appeal of creating a long scar in the scalp for most men it is difficult to intraoperatively shape bone cements or even adequately place implants at the lower end of the turned down scalp flap.

A more effective brow bone augmentation approach is that of a custom brow bone implant. Using a patient’s 3D CT scan the exact dimensions and brow bone coverage of the implant can be determined BEFORE surgery. This avoids any intraoperative shaping judgments and allows a 3D shaped implant that will fit the bone precisely and create the most symmetric result.

Equally importantly a custom brow bone implant can be place WITHOUT the need for a coronal scalp incision. It can be placed using an endoscopic approach with two small scalp incisions or a single scalp incision combined with two upper eyelid incisions. Which approach is best is determined by the shape and size of the implant. Brow bone implants that some down further along the lateral orbital rims require the eyelid incisions to ensure optimal placement and fixation.

A custom brow bone implant provides a contemporary method of lower forehead augmentation that better meets the aesthetic demands of the male who usually seeks it out. Such implants are apable of being placed without creating adverse scar trade-offs.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Jawline Defining Implant

Sunday, June 4th, 2017

Background: Augmenting the jawline today is more than just a chin or jaw angle implants. To change the entire jawline from angle to angle in a smooth united fashion, custom jawline implants offer aesthetic results not previously obtainable. Made from the patient’s 3D CT scan they provide a precise fit to the bone as well as smooth transitions into the surrounding bone.

Designing a custom jawline implant allows for any type of dimensions/thicknesses/shape provided that the soft tissue will permit it. What those implant dimensions should be for any specific patient depends on their goals. However, how to translate these aesthetic goals into dimensional numbers is not an exact science. The computer design process can only create what it is told, it does not know how to make anyone look exactly like they want. Such custom facial implants designs remain an art form based on the surgeon’s input at the present time.

Some patients prefer a more subtle or modest change to their jawlines. They want to provide some accents to their jawline not necessarily make it ‘big’ or have any extreme change. Creating more visible jaw angles and chin points and a smooth connection between them is their facial goal.

Case Study: This 35 year-old male wanted a jawline enhancement to create an overall more distinct jawline. He didn’t want it too big or too  noticeable. Using a 3D CT scan a custom wraparound jawline implant was designed with most changes at the chin (2mm forward and 3mms vertical elongation) and the jaw angles. (4mms vertical elongation and 4mms jaw angle width)

Under general anesthesia and through two intraoral incisions and one submental incision, the custom implant was inserted in a subperiosteal plane as a one-piece unit. It was secured with three small screws at the chin and jaw angles.

He had a full recovery at six weeks after surgery. When seen three years later he had a subtle but distinct change to his jawline as would have been expected given the modest size of the implant’s dimensions. A smooth connection existed between the front and back end of the jaw creating a smooth linear jawline effect.

Highlights:

  1. A custom jawline implant augments the entire jawline from angle to angle, hence the term ‘wraparound’ to describe it.
  2. Selecting the dimensions of the implant during its preoperative design is an art form for which there is not exact science.
  3. The implant’s dimensions can be modest to only create a jawline enhancing effect.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Splitting the Custom Jawline Implant

Tuesday, May 16th, 2017

 

A custom jawline implant has become the premiere method of total jawline augmentation. Being able to control the dimensions of the three corners of the jawline (chin and jaw angles) as well as its connections through the body of the mandible creates the opportunity for a complete lower facial skeletal makeover.

This type of facial implant is very powerful because it covers a broad surface area. This creates a naturally stronger effect than ‘spot’ augmentation alone of just the chin or jaw angles. (or even both) But with larger implants comes the challenge of how to insert it into the subperiosteal jawline pocket.

Just because a custom jawline implant is bigger, the size and location of the incisions toinsert it do not have to be. Like all silicone implants their flexibility permits insertion through still small incisions. But the real issue with their insertion is passing underneath the mental nerve on each side where the subperiosteal tunnel is the narrowest. While this can be accomplished in such implants with smaller jaw angle components, the risk of nerve injury is always present.

I have developed a two-piece approach to placing custom jawline implants that substantially reduces the risk of mental nerve injury. Rather than passing the jaw angle portions of the implant as a single piece in a front to back direction (which also makes for a bigger submental or intraoral incision) the implant is split in the midline and then passed in a back to front direction. This allows the smaller chin segment to pass through the subperiosteal tunnel under the nerve. The implant is then reunited in the midline once positioned. I usually use interlocking midline split design which helps ensure that segments are not rotated once reunited.

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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