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Archive for the ‘custom facial implants’ Category

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.
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.


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

OR Snapshots – Male Custom Jawline Implant

Friday, November 11th, 2016


The best way to change the shape of the jawline for many men is a custom jawline implant. Custom designed from the patient’s 3D CT scan, the implant is usually a wrap around style that augments the entire jawline. Changing the shape of the jaw angles and jawline in a continuous fashion around the arc of the jaw can create a dramatic change if the patient so desires.

While such a jawline implant is custom designed, how to create the exact look that the patient wants from such a designing process remains more of an art form rather than an exact science. Besides the implant design the exterior facial change that is achieved is affected by the overlying soft tissues as well.

male-custom-jawline-implant-dr-barry-eppley-indianapolisHaving designed and implanted many a custom jawline implant I am still always amazed when seeing the actual implant at the time of surgery. When designing such implants I may think they are big or small but seeing them in person is almost always a revelation. The size of all custom jawline implants fits into my relatively small hand.

Inserting such a facial implant always seems daunting given its size and how it compares to much smaller standard cheek and chin implants. But a three-incisional insertion technique allows a safe and effective placement method.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Natural Custom Jawline Implant Result

Monday, November 7th, 2016


Background: The lower third of the face is a very important component of the male face. Whether one choices to call it more attractive or masculine, a well defined jawline creates an essential aesthetic feature of the lower face in a man. While fashion and beauty ideals change across various cultures and periods of time, there has never been a time in history where a weak or short jawline in a man was viewed as desirous.

There are numerous methods of jawline augmentation, all of which have a role to play in male facial enhancement. Provided one has a stable and well interdigitated bite (occlusion), most augmentation methods involve some form of implant placement. There is a role for a sliding genioplasty in more severe underdevelopment of the jaw but it is far less frequently done than that of implants.

Jaw implant augmentation consists of either using standard implant shapes and sizes or having a custom jaw implant made. The decision between these two choices comes down to which approach can best create the desired aesthetic result. Or to put it another way…can standard chin and jaw angle implants suffice? Does one have to go as far as having a custom jaw implant made? That answer depends on two dimensional issues; 1) Do the desired chin and jaw angle changes fall within what standard implant shapes can achieve and 2) Does one want a smooth jawline connection between the chin and jaw angle area?

male-custom-jawline-implant-design-dr-barry-eppley-indianapolisCase Study: This 35 year-old male wanted a more defined jawline but he did not want it to look too big or unnatural. In essence he did not want it to be obvious that he had surgery. Thus a relatively modest custom jaw implant was designed to make his chin more square and provide some increased angularity to the jaw angles.

male-custom-jawline-implant-design-and-actual-implant-dr-barry-eppley-indianapolisUnder general anesthesia the custom jawline implant was placed through a three-incision technique. (anterior submental skin and posterior bilateral intraoral mucosal incisions) The implant was placed from front to back through a subperiosteal tunnel under the intervening mental nerves. The one-piece wrap around implant was secured at the chin and jaw angles by a single 1.5mm microscrew at each location.

custom-jawline-implant-results-oblioque-view-dr-barry-eppley-indianapoliscustom-jawline-implant-result-side-view-dr-barry-eppley-indianapolisSix weeks later all of his swelling had resolved and most of the final result could be appreciated. His jawline had a greater chin prominence and a stronger jaw angles. But it looks perfectly natural and still fits his face well.

A custom jawline implant does not have to be big to be effective. Small to modest sized jaw implants can produce a nice improvement to the lower face


1) Having a visible and more defined jawline is a frequent aesthetic request amongst men

2) A more stronger and more defined jawline does not always mean that it is substantially bigger, just more evident chin and jaw angle areas.

3) A custom jawline implant offers the only jawline augmentation procedure that creates a stronger chin and jaw angles with a smooth connection between them.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Split Custom Jawline Implant

Friday, October 28th, 2016

Augmentation of the jawline can be done by a variety of implanted materials. While recent trends in plastic surgery have focused on using injectable fillers and fat for many forms of facial augmentation, this is not a particularly successful treatment strategy for the jawline. Most jawline shape changes, particularly in men, call; for a more defined and angular definition which soft injected materials can not usually create. Such external changes require a firm push from the bone surface using firmer implanted materials.

While jawline augmentation has traditionally been done by preformed chin and jaw angle implants, some patients need greater dimensional changes than three separate implants can provide. This is where the expanding role of custom implants made from the patient’s 3D CT scan has become extremely useful. A one-piece wrap around jawline implant unites changes to the chin and jaw angles for a more complete and smooth jawline effect. Such custom jawline implants can be made into virtually any size and shape although great preoperative consideration must be given to its design for who it may affect the patient’s external appearance and desired facial aesthetic goals.

split-custom-jawline-implant-dr-barry-eplpey-indianapolisSurgically placing a one-piece wrap around jawline implant can be challenging. It requires a three incisional approach, one anterior and two posterior. The anterior incision may be either intraoral or external below the chin. Subperiosteal tunneling is done between the incisions to make a path for the implant to slide into place. I always try to place such  jawline implants in one piece but this is not always possible or advised. The size of the jaw angles on the implant determine whether it can be folded and safely passed under the mental nerve from the anterior incision or not. When the jaw angles are too big it is best to split the implant in half through the chin segment. Then it is passed from back to front so the smaller chin segment can go underneath the mental nerves without too much stretch on them. The implant is then reunited in the midline and secured together with small titanium microscrews as seen in this picture.

While a custom jawline implant may be made as a single piece, this does not mean that it needs it be placed that way. Screw fixation of the implant segments, like a bon fracture, allows it to become once again as a single unit. With only two pieces this is one puzzle that is easy to solve.

Dr. Barry Eppley

Indianapolis, Indiana

Recovery from Custom Facial Implants

Monday, October 24th, 2016


fig-11a-panfacial-implants-design-front-viewThe decision to undergo surgery with a custom facial implant for aesthetic facial augmentation is an exciting change. Like all elective surgeries, there is a recovery process before the patient will finally see the results of the implant design and surgical placement efforts. This is a predictable process that always involves more swelling than expected and a recovery period that is longer than one wants. In understanding the recovery process, here are five key points to know before surgery.

Most custom facial implants cause a great deal of swelling.What is unique about most custom facial implants is that they are usually larger in size and, as a result, involve more tissue dissection to be placed. While the entry incision(s) may be small, the internal area dissected is much larger.  This usually creates a significant amount of tissue swelling and facial distortion. It is almost always much more than any patient can anticipate. No matter how much you think it can swell and cause the image you see in the mirror to become almost unrecognizable, it will likely be even more so.

The swelling phase is both predictable and prolonged. Facial swelling after implant placement follows a predictable postoperative course. It will take at least two days for the peak of the swelling to occur. While you may feel as though you might not look too badly the day after surgery… more swelling is yet to come. Once the swelling has peaked, it will go down on a decreasing percent resolution over the next six to eight weeks. At ten days, 50% of the swelling will be gone, two-thirds to 75% by three weeks and about 90% by six weeks after surgery. This postoperative course indicates that it will take several months following surgery to truly see the final results of your custom facial implant procedure. Any judgment beforehand would be premature.

The recovery process can be very stressful. While the swelling and the course of its resolution is explained in detail before surgery, managing it can be very different from understanding it. Many patients go through a difficult and psychologically distressing period after surgery. Viewing your own face while it is distorted during recovery is very challenging versus what is revealed during the implant design process in the 3-D planning pictures prior to surgery. This can make some patients concerned that something has gone wrong or they have chosen an incorrect the implant design(s). It is very important to expect this period of adjustment and stress to happen after surgery, and to understand that recovery is a process.  What you see in the mirror just days or weeks after surgery is not the final result.

Evaluating the final results from custom facial implant surgery takes time. Because facial recovery can be very psychologically disturbing, some patients think about changing the implant design or even removing implants in the first month after surgery. Such decisions are completely premature and are emotionally based rather than logical. It is important that one persist through the full extent of the recovery process until the final results of surgery are visible three to six months following the procedure.

custom-midface-implant-design-dr-barry-eppley-indianapolisCustom facial implant results are as much an art form as a science. While the use of 3D CT scans and computer software to design these implants appears very scientific and exacting, it is only partially so. No one can predict with great accuracy how any implant design will look on you. How the soft tissues will drape over the implant and appear on the outside remains an unknown variable in every patient’s surgical outcome. While serious medical issues from this type of facial surgery are rare (e.g., infection), aesthetic adjustments to the implants are not. But before any such secondary surgery should be considered necessary one should wait until the full recovery process is complete.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Custom Jawline Implant

Sunday, October 16th, 2016


Background: While jawline augmentation is most commonly associated with men, it is gaining aesthetic significance in women as well. A strong jawline is historically associated with increased masculinity. Women are more associated with softer and more recessed chin positions and jawline shapes. But the contemporary female jawline is now desired to have a more definitive jawline with increased angularity particularly at the posterior jaw angle area.

The one jawline dimension that is the hardest to change in both men and women is that of its vertical dimension. Short of orthognathic surgery to correct a deep bite, vertical augmentation with implants is needed to lengthen the lower face. But no standard chin or jaw angle implant provides any substantial vertical elongation. And lengthening the entire jawline as a single unified structure by bony movement requires the chin wing osteotomy with its own set of aesthetic issues.

female-custom-jawline-implant-design-dr-barry-eppley-indianapolisCase Study: This 26 year-old female presented with a history of injectable fillers to her chin to correct a significant chin deficiency. Despite multiple ccs of filler she still had a horizontal chin deficiency. Equally pertinently is that her lower jaw was vertically short compared to the upper two-thirds of her face. A custom jawline implant was designed to both vertically lengthen her entire jawline from angle to chin as well as provide horizontal chin augmentation.

female-custom-jawline-implant-intraoperative-insertion-dr-barry-eppley-indianapolisUnder general anesthesia the custom jawline implant was inserted through an intraoral approach. Three intraoral mucosal incisions were used including an anterior one below the front teeth and two posterior ones behind the second molars. It was inserted as a single piece passing it under the mental nerves from the chin area back to the jaw angles.

female-custom-jawline-implant-fronjt-view-ddr-barry-eppley-indianapolisfemale-custom-jawline-implant-oblique-view-dr-barry-eppley-indianapolisHer immediate after surgery results showed a substantial improvement in the fullness of her lower face. Her chin has better projection and her jawline back to the angles was more visible and defined.

female-custom-jawline-implant-result-side-view-dr-barry-eppley-indianapolisCustom jawline implants in females can be done just as it is in men. The difference is that they are often smaller in overall size with less dimensional augmentation. Creating a sharper and more defined jawline, not necessarily a substantially bigger size, is their usual focus. The exception is in the vertically short jawline where the lower face is disproportionately smaller than the upper two-thirds. In these cases vertical jawline lengthening needs to be done and pull down and out the lower third of the face.


1) Custom jawline augmentation for women can be done as successfully as that in men.

2) For vertical lengthening of the jawline in women only a custom jawline implant will suffice.

3) Most women get smaller custom jawline implants which may allow for a complete intraoral placement approach.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Jawline Implant Replacement

Monday, October 10th, 2016


Background: Jawline augmentation has become a popular surgery today as patients seek a stronger and more well defined lower facial shape. Augmenting just the front of the jaw (chin augmentation), while still commonly done, often overlooks a more complete jawline change. The addition of jaw angle implants to that of the chin creates a total jawline change.

While an effective jawline augmentation approach for many patients, the use of three preformed chin and jaw angle implants has a relatively high potential for implant malposition. While any single facial implant always has its own risk of malpositioning, that risk increases three-fold when three implants are used. Most jawline augmentation malpositions occur back in the jaw angle area where implants are hard to place well and can suffer from visible asymmetry.

In cases where the three implant jawline approach has aesthetically ‘failed’ due to implant malpositions, a custom jawline approach should be considered. This changes three implants into a single wrap around implant that is predesigned using computer software. This lessens the likelihood of implant malposition considerably since it is a single implant that is made to fit the jawline precisely.

malpositioned-chin-and-jaw-angle-implantsCase Study: This 30 year-old male had a prior history of unsatisfactory jawline implant augmentation using three implants. The surgical outcome was unsatisfactory as the patient desired a strong angular jawline which he did not achieve. A 3D CT scan showed anteriorly displaced widening jaw angle implants and a cleft chin style implant that was positioned low on the chin bone.

custm-jawline-implant-dimensions-dr-barry-eppley-indianapoliscustom-jawline-implant-replacement-design-dr-barry-eppley-indianapolisA new one-piece jawline implant was created making the chin and jaw angle changes that would more effectively create a more defined and angular jawline. This required a significant vertical elongation at the jaw angles (15mms) and a more pronounced horizontal and vertical change change. The changes in the one-piece implant design were compared to his indwelling inplants in an overlay fashion.

custom-jawline-implant-replacement-surgeryDuring the surgical procedure where the original three implants were removed and replaced by the new custom jawline implant, they could be compared in a side by side fashion. The replacement operation required making a subperiosteal connection between the chin and jaw angles to properly seat the new implant.

While a custom jawline implant does cost more than three preformed implants, there is less control over their shape and position. Should a revision be necessary because of implant malposition the cost will then exceed that of a custom implant. In total jawline augmentation the potential benefits of a custom approach need to be strongly considered. initially.


1) Jawline augmentation using three preformed chin and jaw angle implants can be effective but also has an increased potential for implant malposition.

2) A 3D CT scan will reveal the location of chin and jaw angle implants which can help in the new custom jawline implant design.

3) A custom jawline implant has a lower risk of implant malposition since it is a one piece implant that is made precisely for the patient’s bone shape.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Orbitozygomatic Implant in Facial Asymmetry

Tuesday, September 27th, 2016


Facial asymmetry is common and it is often said that everyone has some degree of it. While this is true, more significant facial asymmetries are not common and are a source of frequent patient self-esteem issues. In significant facial asymmetries the entire face is affected from the brow down to the jawline. The affected side is almost always lower as if it is pulled downward. It is extremely rare to ever see a facial asymmetry where the affected side is higher rather than lower than the normal side

The most significant component of facial asymmetry is often around the eye area. This is usually manifest by a difference in the horizontal level of the pupils. The eyeball sits lower as the orbital floor is located more inferior than the opposite normal side. But the orbital floor is not the culprit but a symptom of the overall facial asymmetry. The entire orbitozygomatic bony complex is situated lower. This is seen by the presence of a smaller and less projected cheek and greater soft tissue fullness below the cheek.

In correcting the orbital or midfacial component of facial asymmetry, orbital floor and cheek augmentation are the two skeletal components of the problem that needs to be addressed. There are a variety of materials and methods to this type of skeletal augmentation and all can be successful when done well.

orbitozygomatic-implant-for-facial-asymmetry-dr-barry-eppley-indianapolisorbitozygomatic-implant-design-for-facial-asymmetry-dr-barry-eppley-indianapolisThe more recent availability and use of 3D CT scan imaging and computer designing, however, brings greater precision to the level of the surgical result obtainable for orbito-zygomatic reconstruction in facial asymmetry. Comparing the lower side to the higher normal side allows for an implant that can create a bony augmentation that matches to the other side with millimeter precision. In addition a total one-piece implant can be made that augments all outer areas of the bone including the infraorbital and lateral orbital rim. This would be the most accurate method of implant reconstruction available.

orbitozygomatic-implant-placement-for-facial-asymmetry-dr-barry-eppley-indianapoliscustom-orbitozygomatic-implant-placement-incision-closure-dr-barry-eppley-indianapolisA custom orbitozygomatic implant is placed through a lower blepharoplasty incision. This is a subciliary incision with a small lateral canthal extension. A skin-muscle flap is raised down to the bone where subperiosteal undermining is done to placed the implant. It is important on closure that the orbicularis muscle suspension is done as well as closing the deeper tissue layer over the lateral orbital rim.

It is important to recognize that a custom orbitozygomatic implant provides bone correction but the overlying soft tissues of the eye must often be addressed as well. These could include lateral canthoplasty for outer corner of the eye correction as well as potential upper eyelid ptosis repair. As the eyeball is lifted a ptosis may be created as the upper eyelid position will not have changed. This eyelid correction should be corrected secondarily three months later when all the swelling has resolved and the tissues have stabilized.

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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