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Archive for the ‘custom facial implants’ Category

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

Case Study – Custom Infraorbital Rim Implants

Wednesday, March 29th, 2017

 

Background: The infraorbital rim is the lower eye socket bone that accounts for the bottom half of the bone that encircles the globe. It is formed by the union of the zygomatic bone laterally and the maxillary bone medially. Between the two bones is a suture line that may or may be present in adults. The location of this inferior orbital rim suture line lies just above the infraorbital nerve foramen.

Augmenting the infraorbital rim can be done in several ways depending upon what one is trying to achieve. The rim can be augmented on its anterior edge to give greater horizontal projection. It can also be augmented vertically to raise up the level of the bony rim for increased lower eyelid support. Or both horizontal and vertical infraorbital rim augmentation can be done if needed.

The only effective method of infraorbital rim augmentation is with implants. One type of infraorbital implant is that of tear trough implants. Designed originally to fill in the classic soft tissue indentation along the medial half of the bony rim, they can be used to augment the entire anterior rim across its entire length. But there are no preformed implants that are actually designed to sit along the rim to built it up vertically.

Bilateral Orbital Rim Fractures 3D CT scan Dr Barry Eppley IndianapolisOld Infraorbital Rim Fractures Dr Barry Eppley IndianapolisCase Study: This 24 year-old female had an uncommon history of having had bilateral infraorbital rim fractures during birth due to a forcep delivery. She never had any fracture repair surgery as could have been predicted as an infant. Now as an adult she had a palpable stepff along the infraorbital rim at the old fracture site at the suture line. (this was undoubtably an original bend in the rim at the location of the suture line from the forceps) Her 3D CT scan shows the lateral orbital rim displacement.

Custom Infraorbital Rim implants design for fracture treatment Dr Barry Eppley IndianapolisCustom Infraorbital Implants design Dr Barry Eppley IndianapolisCustom infraorbital rim implants were fabricated to create a more elevated lower rim out to and around the lateral orbital rim to create a more natural contour.

Under general anesthesia the custom infraorbital rim implants were placed and secured through a lower blepharoplasty incision.

Recreating the height of the infraorbital rim, or at any location of the orbital rim, requires a custom implant approach. Getting the vertical dimension of the orbital rim can be done very effectively or securely with any other type of standard implant design.

Highlights:

  1. There is no true preformed infraorbital rim implants that actually sir or cup the rim itself.
  2. Custom infraorbital rim implants are design to sit along the rim and increase its vertical height.
  3. An infraorbital rim fracture can displace the normal smooth and horizontal shape of the lower bony rim.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Jawline Implant Designs

Friday, March 24th, 2017

 

Custom jawline implants provide a powerful tool for lower facial change. Covering the entire jawline from angle to angle provides a lot of surface area coverage to create significant augmentation effects.

These powerful implant changes have a double edge sword effect. With the right implant design and dimensions many desired patient jawline effects can be seen. What the right implant design and dimensions are, however, is never exactly clear before surgery in the designing process. There is no formula or design method that is available that can predict what the implant design to final effect result will be. This remains an artistic process that lacks complete clinical predictability.

Custom Jawline Implant Angle Widths Dr Barry Eppley IndianapolisHaving done many custom jawline implant designs there are three components of the process to consider. They are the chin, the jaw angle area and the connecting body portion. I find that the chin and the connecting body portions are usually straightforward and create few design quandries.

Custom Jawline Implant Angle design and dimensions Dr Barry Eppley IndianapolisCustom Jawline Implant Flare Design Dr Barry Eppley IndianapolisDesigning the jaw angle areas of the implant, however, is a different story. The 3D effects  of its vertical, horizontal and transverse dimensions creates challenging design considerations. Because much of the jaw angle dimensions are off the bone and ‘out into space’ it is hard to precisely predict its effects. How the soft tissue will respond and redrape over expanded hard tissue boundaries is one issue. What aesthetic effect will a larger prominence create at the back of the jaw on both sides is another. The larger the change in the jaw angle area the more unpredictable these effects become.

I have done many custom jawline implants with very satisfying aesthetic outcomes. But I have also seen many other such implants where its effects were unpredicted and had to be revised. In almost every instance it was the jaw angle component that posed the problem. In most instances its appearance not its position on the bone was the issue.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Implant for Vertical Orbital Dystopia

Wednesday, March 15th, 2017

 

Background: Few faces are perfectly symmetric and most of us have some noticeable differences between the right and left sides. Such facial side differences are usually well tolerated or may not even be known. We all recognize that ‘no one is perfect’ and everyone has a little bit of facial asymmetry which is seen within the range of normal.

But asymmetry of the eyes is often different because it is so easily recognized and almost impossible to visually ignore. While there are different types of eye asymmetry, many of which are related to the eyelids, one of the most recognized causes of is that of orbital dystopia. Orbital dystopia is bone-based with the orbital bony box being at different levels between the two sides. The most common type of orbital dystopia is vertical and the affected side is almost always lower than the normal side.

In vertical orbital dystopia, the affected eye sits lower which can be seen and measured by the horizontal positioning of the pupil of the eye.  The eye sits lower because the orbital floor, including the circumferential orbital rims and cheek bone, sit lower. In more minor cases the orbital dystopia is isolated to the eye area. But in more significant cases the entire side of the face from the eyebrows down to the jawline is lower.

Right Orbital Dystopia 3D CT scan Dr Barry Eppley IndianapolisCase Study: This 43 year-old male presented for cheek augmentation for which a custom designed approach was chosen. He had always been by a mild degree of eye asymmetry as well which was most apparent in pictures. A 3D CT scan shows that the affected eye had a vertical dystopia of around 3mms. The lower infraorbital rim and malar eminence as well as more inferiorly positioned orbital floor could be seen as the bony origin of the vertical dystopia.

Orbital Dystopia Orbital Floor Implanty with Custom Cheek Implants design Ddr Barry Eppley IndianapolisCustyom Cheek Implants with Orbital Floor Implant design Dr Barry Eppley IndianapolisHis custom cheek implants designs included a component on the affected side that wrapped over the infraorbital rim and onto the orbital floor to create the needed amount of globe elevation.

Orbitozygomatic Implant placement for Facial Asymmetry Dr Barry Eppley IndianapolisCustom Orbitozygomatic Implant Placement incision closure Dr Barry Eppley IndianapolisUnder general anesthesia and through a subciliary eyelid incision, the custom orbital floor-rim-cheek implant was placed and secured to the orbital rim with two microscrews. An orbicularis muscle rsuspension and lateral canthopexy was performed at closure.

Orbital Floor Augmentation result front view Dr Barry Eppley IndianapolisHis one year after surgery results showed improvement in the symmetry between the eyes. As is often the case in vertical orbital dystopia raising up the eye reveals the other components of the dystopia including the more inferiorly positioned upper eyelid and eyebrow. These are planned for adjustment in the future. (right upper blepharoplasty with ptosis repair and transpalpebral browlift.

Highlights:

  1. One cause of eye asymmetry is a malpositioned orbital box which causes the eye to sit at a lower horizontal level than the normal side.
  2. Orbital floor and infraorbital rim augmentation is one technique in the treatment of vertical orbital dystopia but it will not correct every aspect of the eye asymmetry.
  3. The orbital floor-rim augmentation implant is best made from a 3D CT scan in a custom implant fashion.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Jaw Angle Implants and Sliding Genioplasty

Thursday, March 2nd, 2017

 

Background: Jaw angle implants are enjoying a surge in popularity as patients are seeking improved shapes to their jawlines. Filling in the back part of the jaw offers a good complement to well established chin implants to create a more complete jawline augmentation effect.

Like just about every other facial implant, no one size or style fits all. This applies equally well to jaw angle implants. While the widening version has been around for over twenty years, a newer vertical lengthening style now exists. The key to which jaw implant style to use is the natural anatomy of the mandibular ramus. A highly positioned jaw angle and a steep mandibular plane angle are the indications for extending the jaw angle down through the vertical lengthening style.

While the use of three implants (one chin and two jaw angles) is one method of total jawline augmentation, some patients may not prefer their chin augmentation to be done with an implant. A sliding genioplasty can be combined with jaw implants if that is more favorable for the chin. (severe horizontal chin deficiency, lower lip incompetence, mentalis muscle strain) The consideration must then be given to the smoothness of the jawline since the front end of the jaw implant will not cover the back end of the sliding genioplasty bone cut.

Malpositioned Jaw Angle ImplantCase Study: This 43 year-old female previously had a chin implant and two jaw angle implants placed for a total jawline makeover by another surgeon. Unfortunately the right jaw implant became infected and the left jaw implant was severely malpositioned. The chin implant was fairly well placed but she did not like it because it made her chin too wide and did not improve her presurgical lower lip incompetence, mentalis muscle strain and chin dimpling.

Custom Extended Vertical Jaw Angle Imlpants design Dr Barry Eppley IndianapolisCustom Vertical Jaw Angles vs Standard Widening Jaw Angle Implants Dr Barry Eppley IndianapolisIt was decided to remove her chin implant and replace it with a sliding genioplasty which would better address the functional aspects of her chin deficiency. (as well as making her chin less wide) The style of jaw angle implants would also be changed to be more vertical lengthening and to come far enough forward to cover the notch at the back end of the proposed sliding genioplasty. These jaw implants would need to be custom made using a 3D CT scan.

Under general anesthesia and through an intraoral approach, the chin implant was removed and a sliding genioplasty done in its place. The chin was brought forward 8mms and vertically shortened 3mms. The custom jaw angle implants were also placed intraorally and their anterior ends were positioned over the ends of the sliding genioplasty  to create a smooth and unbroken jawline effect.

A sliding genioplasty can be combined with jaw angle implants. In many cases standard jaw implants may suffice. But for a more assured seamless transition from the jaw implants to the bone of the chin advancement, custom jaw angle implants work best.

Highlights:

1) The wrong jaw angle implant style will still be a failure even if it is well placed.

2) Many women need a vertical lengthening jaw angle implant style and not a widening jaw angle implant style.

3) When combining jaw angle implants with a siding genioplasty, a custom implant design approach is often best.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – V-Line Jaw Reduction Reversal

Wednesday, February 22nd, 2017

 

Background: One of the most popular jawline surgeries around the world, particularly in Asian people, is jaw reduction. Know more commonly as V-Line jaw reduction surgery, it involves removal of wide or flared jaw angle (amputation) and chin reshaping. (narrow and shortening through am intraoral T-shaped ostectomy) For those patients that have a wide jaw and and a lower facial prominence as a result, it can be an effective lower facial reshaping procedure. It is easy to see why this would be of aesthetic predominantly in Asian patients given their natural facial bone shape.

Because the procedure is performed exclusively through an intraoral approach, it can be very difficult to have even and symmetric bone cut lines. There is also the issue of how the bone heals and the smoothness that may or may not result. For this reason, it is really the norm to expect some bone asymmetries between the two sides of the jaw and even at the chin. Fortunately the overlying soft tissues are thick and can help mask such bony asymmetries/irregularities should they result from the procedure.

But like reduction surgery anywhere on the face and body, losing bone support can also cause adverse soft tissue issues. This is an issue primarily in the jaw angle areas in V-line jaw reduction surgery. It is not rare that I hear from a patient who has had jawline reduction surgery that they do not like the subsequent flattening/weakness of the back of their jaw and that they feel the soft tissues now sag along the jawline.

Jawline Deformity after Jaw Angle AmputationJawline Deformity after Jaw Angle Reduction fronkt viewCase Study: This 45 year-old Caucasian female had V-line jaw reduction surgery three years previously. She did not like the subsequent loss of her jaw angles, lack of jawline definition and how it made her lower face too narrow and more aged in appearance. She wanted more defined jaw angles vertically and a smoother and more linear jawline coming forward. A 3D CT scan shows the loss of jaw angles, higher positioned jaw angles, severely increased mandibular plane angle and inferior border jawline asymmetry.

Custom Jawline Implant foir Jawline Reconstruction after Jawline Reduction side view Dr Barry Eppley IndianapolisCustom Jawline Implanty after Jawline Reduction Surgery design front view Dr Barry Eppley IndianapolisA custom jawline implant was designed with the main purpose of re-establishing the jaw angles in a much lower position but without adding any significant jaw angle width. It also established a more symmetric and smooth jawline coming forward to the chin. A little anterior chin projection was added but creating very minimal chin width. Under general anesthesia and through an exclusive intraoral approach, the custom jawline implant was placed.

Custom Jawline Implant design for Jaw Angle Reconstruction Dr Barry Eppley IndianapolisV-line jaw reduction reversal has to be done using some form of implants. Custom jawline implants are best as the multidimensional jaw augmentation needs are very difficult, if not impossible, to adequately address with any standard jaw angle implant shapes.

Highlights:

1) Unfavorable aesthetic results can occur from jawline reduction (V-line jaw surgery) with loss of jawline definition and tissue support.

2) ‘Reconstruction’ of lost jaw angle and chin from V-line surgery requires a vertical lengthening of the shortened jaw angles and widening of the chin.

3) A custom jawline implant is the best approach to V-line jaw surgery reversal.

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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