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Archive for the ‘custom facial implants’ Category

Case Study – Custom Extended Square Vertical Lengthening Chin Implant

Friday, January 5th, 2018

 

Background: Chin implants come in a wide variety of styles and sizes. They have the greatest number of standard options available amongst all facial implants. This is because they have been clinically used for decades, longer than any other facial implant, and they are the most commonly performed facial implant augmentation.

But despite these options, standard chin implants do not work for everyone.  Certain aesthetic dimensional needs of the chin remain largely unserved by standard chin implants. This is most relevant for the vertical dimension. For those patients seeking vertical chin lengthening it almost always not a true vertical drop. It is more of a 45 degree downward angulation, a combination of both a vertical and horizontal increase. This type of chin implant is unique because it sits on the edge of the bone rather than completely on it.

While one style of a vertical lengthening chin implant does exist, it has a rounded or anatomic shape. For the male seeking a more square vertical lengthening chin implant a custom implant approach is needed. Such an approach allows for the degree of squareness to match that of the patient’s mouth width as well as allow long posterior extensions to augment the jawline in a tapering fashion backward.

Case Study: This male wanted to increase the vertical dimension of his lower face. He also wanted a more square chin as opposed to his current rounded one. With a 45 degree projection downward from the chin (7mms), it was necessary to extend the posterior wings of the implant back along the sides of the jawline for a natural flow of the implant into the bone. This also added some width to the center of the jawline which is important to prevent the chin from looking too square.

Under general anesthesia a small submental incision was made through which a subperiosteal pocket was made from the chin back to the attachment of the master muscle. Despite the long span of the implant, its flexibility allows it to be inserted through a smaller submental skin incision that most would believe possible.

Highlights:

1) Custom chin implants can be designed with long jawline extensions back to the anterior attachment of the masseter muscle.

2)  Most chin implants that require vertical lengthening ned to be custom designed so they flow smoothly back into the jawline behind it.

3)  The degree of squareness in a custom designed chin implant for a male can be designed based on the patient’s mouth width.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Male Custom Forehead Implant for Upper Facial Reshaping

Wednesday, December 20th, 2017

 

Background: The upper third of the face has well known gender differences. The shape of the male forehead is distinctly different than that of a female.  It is usually wider and vertically longer than in women, there is a slight backward slope to it as it ascends into the hairline and there is the presence of brow bone protrusions with a suprabrow break before heading upwards into the forehead.

Studies have shown that the angle of the curvature of the forehead is higher in women than in men which supports that the rounder forehead in the female and the more backward slope of the forehead in males. The acceptable aesthetic degree of backward angulation in the male forehead is not precisely established but what matters on a practical basis is whether the person finds it acceptable or not. One factor that has a major influence on the appearance of the slope of the male forehead is the vertical skin length. The further the hairline sits back, or even its complete absence, will affect how much of the forehead stands out.

Augmenting the male forehead is more challenging in men than women due to the frontal hairline location and the anterior scalp hair density. For most men the historic use of bone cements is often not practical since these require an almost full coronal scalp incision for proper placement and contouring. The best method today is the use of custom forehead implants made from the patient’s 3D CT scan. This allows their placement through a much smaller scalp incision and assure the smoothest forehead contour and desired shape due to preoperative designing.

Case Study: This young male was bothered by the shape of his forehead which was wider, flatter and sloped back more then he desired. A custom forehead implant was designed that, staying within the anterior temporal lines, gave his forehead a more rounder look and less of a backward slope into his hairline.

Under general anesthesia a 7 cm scalp incision placed behind the frontal hairline was used for implant placement. Endoscopic dissection permitted the subperiosteal elevation of the pocket across the brow area with preservation of the supraorbital neurovascular bundle. The implant wad folded, inserted through the scalp incision, unfold and positioned and secured into this position with two microscrews.

The immediate effects of the custom forehead implant could be seen intraoperatively. All patients will develop some temporary swelling and bruising around the eyes which can take up to a full month after surgery to completely resolve.

Highlights:

1) A excessively backward sloping forehead  is not an aesthetically desirable male forehead shape.

2) Forehead augmentation can be done while leaving the brow bone areas alone.

3)  A custom forehead implant can be placed through a relatively small scalp incision.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Remove and Replace Custom Jawline Implant

Sunday, December 17th, 2017

 

Background: The jawline for men and women is the key feature of the lower face. While once all focus was on the chin, this perspective is short-sighted today. While many patients will still benefit by chin augmentation alone, a growing number of patients want/need a total jawline approach to achieve their aesthetic facial goals.

Total jawline augmentation consist of changing the chin and the paired jaw angles, the three points of the jaw. There are numerous standard preformed chin and jaw angle implants that are available to do so and the ‘three corner’ jawline technique will work for many patients. But for those patients seeking a linear jawline effect that connects the three corners or who have dimensional needs that may exceed what standard implants can do, a custom jawline implant is the  other option for total jawline augmentation.

Designed and made from the patient’s 3D CT scan a one-piece implant is created from jaw angle to jaw angle. It has the advantage that as a connected piece it is less prone to implant positioning asymmetries than that of three implants. But like all other facial implants, jaw implants included, what the dimensions should be to achieve the patient’s goals is not an exact science.

Case Study: This young male had a prior history of a custom jawline implant. While providing improvement it was not dimensionally adequate and there was jaw angle implant asymmetry. A new 3D CT scan was used to determine the implant’s position and shape.

Having any jaw implants, custom or standard, is an enormous help in knowing how to design a custom jawline implant. Knowing the inadequacies of one implant design provides insight into how to make the next one better. From that information a new custom implant designed. Increased chin projection and vertical lengthening of the jaw angles were additional desk features.

Under general anesthesia and through a three incisional approach, the existing implant was removed and replaced with the newly designed implant. The improvements in the jawline shape were consistent with the implant design improvements.

The effects of a custom jawline implant are based on how it is designed and its position on the bone. Unfortunately there is no exact method to determine before surgery what external facial effect any implant design will create. When the first implant design ‘fails’ it still provides useful information as to how to make the next implant better.

Highlights:

1) A custom jawline implant has the best chance to create a more angular and well-defined jawline….provided the dimensions are correct.

2) Most custom jawline implant designs have to be ‘over exaggerated’ as their effect is blunted by the overling soft tissue cover.

3)  A second custom jawline implant can be done to replace a first one if the dimensions are not adequate.

Dr. Barry Eppley

Indianapolis, Indiana

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


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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