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Archive for the ‘facial implants’ Category

OR Snapshots – ePTFE Premaxillary-Paranasal Implant

Monday, December 4th, 2017

 

Increasing the projection of the central midface at the base of the nose and upper lip involves augmenting the bony perimeter of the pyriform aperture. This anterior bony opening in the maxilla leads into the nose. At its more narrow end superiorly are the nasal bones. At its larger lower end the bone curves down and inward and meets in the middle to create the anterior nasal spine.

From an implant augmentation standpoint the pyriform aperture region has two distinct zones, the lateral paired paranasal regions and the central premaxillary region over the anterior nasal spine. The paranasal region has a flat or slightly concave surface while the premaxillary region is distinctly convex with a more V-shape projection to it. These anatomic central middle regions can be a augmented by three different styles of implants, paranasal, premaxillary and a combined premaxillary-paranasal implant.

Because of the tree different zones of potential augmentation and the very limited implant styles available, this is a very confusing area for surgeons and patients alike. The only preformed facial implant available is the peri-pyriform silicone implant. By its name and shape it is a premaxillary-paranasal implant since it covers all three zones. But it can be sectioned in the middle and turned into just paranasal implants if desired.

Another option to make a complete premaxillary-paranasal implant is to carve it out of an ePTFE block. Shaped almost like a moustache, the adaptability of this material allows it to be molded into placed over the central projecting spine and around the more concave sides into the maxilla. It may look large when positioned on the outside of the patient but it needs a lot of material to properly cover this central midface area.

The premaxillary-paranasal implant is placed through an intraoral incision under the upper lip. The key is to make the incision high enough on the lip side of the vestibule to maintain a good musculomucosavl cuff of tissue to close over the implant with a two layers of suture.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Vertical Heightening Infraorbital Rim Implants

Friday, November 24th, 2017

 

Background: Aesthetic deficiencies of the lower eye/eyelid have a variety of presentations. Dark circles, teat tear troughing, negative vectors and a flat midface describe some of the common terms used to describe the external appearance of a skeletal deficiency of the infraorbital rim or lower eye bone. As a companion to the supraorbital rim or brow bone above it, the infraorbital rim is either at or slightly less forward projecting. When it is less far less horizontally positioned, it is usually associated with other midface hypoplasias of at least the cheek to which it has a common embryologic origin. (zygomatico-orbital complex)

The only standard facial implant that has ever been developed to treat an infraorbital bony deficiency is that of the tear trough implant. Having been around for decades, it is an implant that is designed to fit on the front of the infraorbital rim providing anterior projection and displacing the lower eyelid tissues forward. While effective for the right patient, it is not adequate to treat many other infraorbital deficiencies. It is in fact a one-dimensional trick pony so to speak.

Some lower eyelid bony deficiencies have a vertical component as well. The vertical inter orbital rim distance may be increased as well creating such issues as lack of lower eyelid support, excessive scleral show, fat pseudoherniation and a prominent eye appearance. There are no standard orbital implants that can adequately correct this type of skeletal hypoplasia.

Case Study: This male patient was bothered by his very dark circles and flat area under his eyes. He had a negative vector, flatter cheeks and some false herniation of his lower eyelid fat pads. Custom infraorbital implants were designed to create both horizontal and vertical augmentation of the entire infraorbital rim from side to side. He did not have any concerns about his cheeks so the implant design did not incorporate that skeletal area.

A vertical infraorbital implant has a very unique design feature over that of traditional tear trough implants. The vertical augmentation requires that the implant have a saddle effect across the rim. Thus the implant literally looks like a saddle particularly from the inferior view of it.

Under general anesthesia a subsidiary lower eyelid incision was made with a small lateral cantonal extension. A skin-muscle flap  was raised down to the infraorbital rim with wide subperiosteal undermining with inside and outside of the rim s well as from the nose out to the cheek. The custom infraorbital plants as carved to fit and secured into place with two microscrews per side. Lower eyelid closure consisted of a lateral canthopexy and lateral orbiculares muscle suspension for ectropion prevention.

The vertical or heightening infraorbital implant requires a custom design and creates a higher level of the natural bony infraorbital rim. In some patients with deep tear troughs, dark circles and infraorbital rim deficiency it is more effective than the traditional tear trough implant.

Highlights:

1) Most orbital rim augmentations provide horizontal projection but not increases in its vertical height of the bone.

2) Some lower eye skeletal deficiencies require increases in the height of the orbital rim wth or without an increase in anterior projection.

3) Only a custom made inferior orbital rim implant can create a decrease in the vertical inter orbital distance.

Dr. Barry Eppley

Indianapolis, Indiana

The Three Types of Infraorbital Rim Implants

Monday, August 28th, 2017

 

The undereye area has become a focus of aesthetic attention for the management of tear troughs and hollows. Some of these occur as a result of aging and others have a more congenital origin which then becomes more apparent with aging. Treatment for aesthetic under eye issues is fundamentally about adding volume. Injectable fillers and fat are the mainstays of this volume addition with the adjunctive use of lower blepharoplasty skin removal if needed.

While the injectable management of undereye contour issues cam be very effective, it does not work well for some patients. It is particularly ineffective for true infraorbital bone underdevelopment which is associated with a negative orbital vector. In these cases an infraorbital rim bone augmentation using an implant would be best. While a surgical procedure it provides permanent smooth rim augmentation whose volume retention is assured.

Infraorbital implants is an uncommon facial implant and, as a result, the differences in the style options is rarely appreciated. They come in three styles, one performed and the other custom made. Most surgeons are aware of tear trough implants or what I call type 1 infraorbital rim implants. These are preformed implants that comes in three basic sizes, differing largely in their  These are designed to fit on the front edge of the infraorbital rim and provide horizontal projection. The do effectively improve the classic tear trough deformity at the medial orbital rim by a release of the arcus marginalis and the addition of volume. But they do not provide any vertical rim augmentation and do not extend out into the malar region. Attempts at trying put their upper edge above the level of the existing infraorbital rim bone will result in a palpable and potential visible edge in the thin tissues of the lower eyelid.

The type 2 infraorbital rim implant covers both the infraorbital rim and extends out onto the cheek. It provides a vertical as well as a horizontal rim augmentation effect and extends from close to the nasal bones medially out onto differing locations in the cheek laterally. It is custom made so a wide range of dimensions and surface area coverage are possible based on the aesthetic needs of the patient. It is the ideal design for augmenting an infraorbital rim bony deficiency as there is always associated cheek flatness as well. As a result it creates a smooth and harmonious flow of augmentation across this very visible facial region.

Custom infraorbital rim implants can also be made to just cover the infraorbital rim area only, providing vertical rim augmentation. (type 3 infraorbital rim implant) This is the least commonly used type of infraorbital rim implant. Such isolated vertical augmentation could only be effectively done in a custom made process.

Augmentation of the infraorbital rim area can not be accomplished with a single implant style for the range of anatomic deformities that occur and to achieve satisfactory aesthetic outcomes. Understanding the differing options of this unique facial implant can be a good complement to injectable treatment strategies.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Chin-Jawline Implant

Saturday, April 29th, 2017

 

Chin augmentation has been done for a long time and many different implant materials and shapes have been used. The most common chin implant used today is that of an extended or anatomic design. Rather than just sitting on the front edge of the chin this contemporary chin implant is anatomic as its side wings blend along and into the lateral jawline to the sides of the chin.

But as useful as the anatomic chin implant is, it does not augment much of the jawline behind it. It remains a front of the lower jaw augmentation method only.

An extension of the anatomic chin implant is what I call a chin-jawline implant. It is a chin implant that has winged extensions that go back all the way along the jawline…stopping just short of the jaw angle area. This creates greater definition of the jawline although not much width due to the thinness of the extensions.

It is inserted just like any chin implant through either a submental or intraoral incision. A submental incision, however, is preferred as it allows a direct line dissection with long instruments back along the jawline. Despite their aesthetic advantages in properly selected patients, the long extensions offer an opportunity for displacement and asymmetry. Small intraoral incisions can be made to check the most posterior portion of the wings go ensure their smooth positioning along the jawline if desired.

The chin-jawline implant offers enhanced bone definition of the lower lateral border of the jawline. It is useful with jaw angle implants to create a total jawline augmentation effect, to improve jawline definition of a lower facelift and to extend the benefits of chin augmentation. It is available in male and female versions that differ in the shape of the chin with the male being more square and the female being rounded,.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – ePTFE Orbital Implants

Monday, April 24th, 2017

 

Surgery for vertical orbital dystopia always includes augmentation of the orbital floor. Most of the time the inferior orbital rim is lower as well and needs to be concurrently augmented. Various materials have been used for orbital implants from bone grafts to numerous synthetic implants. In the ‘aesthetic’ orbital dystopia patient (4mms or less of horizontal pupillary  discrepancy) the use of bone grafts is not very appealing.

The ideal method to augment the orbital floor and lower rim is to make custom implants from a 3D CT scan of the orbits. With this technology the exact amount and location of orbital floor and rim augmentation can be determined and made before surgery. This obviates any need for intraoperative fabrication of the implants.

Beyond the use of preoperatively fabricated implants, various materials offer intraoperative workability. One of my favorite implant materials for the orbit is that of ePTFE. Originally known as Goretex, it comes in sheets of various thicknesses that are easily cut and molded to any surface. Composed of a fluorine-based material that is both very smooth and non-reactive, its flexibility and adaptability make it ideal for the complex contours of the orbit.

ePTFE sheets of 2mm thickness can be layered and adapted to the orbital floor and inferior orbital rim as needed. It is a good idea to secure the material to the orbital rim with several micro screws to make sure it lays flat and is as non-palpable as possible through the thin tissues of the lower eyelid.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Undereye Hollows Implant (Infraorbital-Malar Design)

Thursday, April 20th, 2017

 

The most common method of permanent midface augmentation is that of the cheek implant.  Cheek implants have been around for decades and have evolved into a wide variety of styles and sizes. Their fundamental designs have been to augment the prominence of the cheek bone (malar region), the underside of the cheek bone (submalar region) or both. (combined malar-submalar shell or midface implant).

Despite being an adjoining anatomic region to the cheeks and having a smooth skeletal connection, the infraorbital region (undereye area) has been relatively neglected. While there are tear trough implants that can augment the front of the lower eyelid rim, they do not create a smooth and seamless flow into the cheeks nor do they sit on top of the infraorbital rim and increase its vertical height.

The combined infraorbital rim-malar implant augments the anterior cheek (malar region) and the infraorbital rim. For those patients that have a tired look due to an infraorbital-malar skeleta) deficiency (undereye hollows), a unified one-piece implant can be a good solution. It provides a smooth connection along the lower orbital rim into the cheek and provides a more complete correction of the undereye hollow problem. It is best placed through a lower eyelid incision to get optimal fit along the infraorbital rim which is best done from a superior approach.

While there are numerous injectable materials to fill in undereye hollows, which can be very effective for many patients, an implant can provide an alternative treatment option. But not just any implant design will do and there are no standard undereye hollows implant designs currently available. This special design of mine, technically known as the infraorbital-malar design or undereye hollows implant, can provide an effective and permanent option in the properly selected patient. It provides a more complete correction of the underlying skeletal cause of undereye hollows.

Dr. Barry Eppley

Indianapolis, Indiana

ePTFE-Coated Silicone Nasal Implants

Monday, February 6th, 2017

 

ePTFE (expanded polytetrafluoroethylene) offers a facial implant material that is very biocompatible and also induces some tissue adherence. Due to the microfibrillar nature of its surface, ePTFE has some surface porosity where fibroblasts can attach and induce collagen attachments. ePTFE, however, does not come in any solid preformed facial implants and they have to be hand carved during surgery out of a block of the material.

For nasal implants, ePTFE offers a fairly easily and quick carving to get the desired length and shape. But it would still be preferable if a performed version of an ePTFE nasal implant existed.

ePTFE Composite Nasal Implant Dr Barry Eppley IndianapolisIn the February 2016 issue of the Annals of Plastic Surgery, a paper was printed on this very topic entitled ‘Silicone-Polytetrafluoroethylene Composite Implants for Asian Rhinoplasty’. Over a four year period, 177 Asian patients underwent rhinoplasty using a dorsal composite nasal implant.  (about 2/3s primary rhinoplasty and 1/3 secondary rhinoplasty) The average dimenions of the ePTFE coated silicone nasal implants was 1.5 to 5 mm thick and 3.8 to 4.5 cm long. Autologous cartilage was used for tip coverage in every case. Glabellar augmentation was also performed in 11% of the  patients.

There was an 11% complication rate which included implant malposition/deviation (5%), persistent redness (2%) and actual infection. (1%) There were no cases of extrusion. There was a 9% revision rate either due to malposition or inadequate dorsal height from the patient’s perspective. There were no complication differences between use of the implant in primary or secondary rhinoplasty.

The use of an implant, whether it is solid silicone or solid ePTFE, are mainstays of Asian rhinoplasty. They both havge their own distinct advantages and disadvantages…silicone offers a performed shape while ePTFE offers some tissue adherence. Silicone-polytetrafluoroethylene (PTFE) composites have a silicone core and a thin ePTFE coating. They appear to offer the advantages of silicone and ePTFE in a single implant. Despite that they have been around now for several years, there have been no published reports in them.d alternatives for rhinoplasty because of a lack of relevant reports. This clinical study shows that the short-term ouotcome is similar to that of ePTFE alone and can be effectively used for both primary and secondary augmentation rhinoplasty in Asians.

One of the keys to the use of any nasal implant is to keep it from putting too much pressure on the nasal tip skin. Thus the use of a cartilage graft over the tip area.

Dr. Barry Eppley

Indianapolis, Indiana

ePTFE Facial Implants

Saturday, February 4th, 2017

 

There have been a wide variety of materials used for facial implants over the past fifty years. But as today there are really only three basic biomaterials that have proven consistently effective and easily manufactured with a relatively low incidence of complications in human facial implantation use. These biomaterials are silicone, polyethylene (Medpor) and polytetrafluoroethylene. (PTFE) None of them are perfect and each have their own distinct advantages and disadvantages. By far silicone is the most widely used facial implant material around the world followed by Medpor at a very distant second.

MELTZER_Chapter-23 619..640The least well known facial biomaterial is that of PTFE even though it has been used in the face for over thirty years in various forms, most commonly for soft tissue augmentation. PTFE implants are made of carbon and fluorine molecular chains (CF2-CF2) that create a synthetic polymer that is completely inert and non-resorbable. (there is no known enzyme capable of cleaving the carbon-fluorine bond) It simply can degrade or breakdown under any circumstances.

MELTZER_Chapter-23 619..640The original PTFE was known as Teflon® and was made from a paste into many forms including strands, sheets and tubes. But innovations in its manufacture led to its most current form known as expanded polytetrafluoethylene or ePTFE. This is made through a manufacturing process where PTFE is extruded through a dye which creates a microporous framework of PTFE nodules interconnected with PTFE fibrils. This makes a woven form of the material and creates a mesh-like surface structure. It is the expanded fibrils of the materials that allows this microfibrillar surface texture to be achieved. Such a surface structure allows for some tissue ingrowth and attachment into it. In addition it has the chemical property of having a highly electronegative surface due to the fluorine molecules. The exact biologic benefit to this material property is unclear although bacteria may be less like to stick to it. At the implant level, ePTFE has the handling properties of being soft and flexible but yet very strong.

What is most relevant about ePTFE is that host cells around the implant site can adhere directly to the material. This is done through a substrate formed by extracellular proteins and proteoglycans onto which fibroblasts lay down collagen into the interstices of the microfibrillar surface of the implant.

The ePTFE polymer has pore sizes ranging of 10 to 30 microns. It is well known that implants with pore sizes greater than 1 micron can harbor bacteria. Since macrophages can not enter a pore size smaller than about 50 microns, it is not an infection proof material. (but no materials are)The ideal infection-proof implant would have no pores (i.e., silicone) to prevent bacterial invasion or pores greater than 50 ?m to allow tissue ingrowth and cellular antimicrobial activity. That being said, there is no clinical evidence that infections rate are higher with ePTFE implants than those of either silicone or Medpor.

ePTFE Composite Chin Implant Dr Barry Eppley IndianapolisePTFE Composite Cheek Implant Dr Barry Eppley IndianapolisePTFE Composite Nasal Implant Dr Barry Eppley IndianapolisePTFE facial implants are available in two forms. Certain styles of performed silicone facial implants have been coated with a thin layer of ePTFE, known as Composite Facial Implants. This has the advantage of using known and popular silicone implant styles but giving them the added bonus of a coating that can allow for some actual tissue adhesion. They are available in basic designs for the cheek, chin and nose.

ePTFE Blocks and Sheets for Facial Implant Fabrtication Dr Barry Eppley IndianapolisThe second form are ePTFE facial implants come in sheets and blocks. These allow the surgeon to cut and carve their own implant designs at the time of surgery. This material is very easily carved with a scalpel somewhat similar (although easier) than a bar of soap. A #10 scalpel blade works quite well.

Solid and coated ePTFE facial implants offer the patient another well known biomaterial that develops a soft tissue reaction to the material somewhere between that of silicone (which has none) and that of Medpor. (which develops a significant soft tissue ingrowth) But unlike Medpor it is very easily shaped during surgery and subsequently removed if needed.
Dr. Barry Eppley
Indianapolis, Indiana

Pyriform Aperture Implant for Excess Gingival Show

Wednesday, November 30th, 2016

 

A gummy smile or excess gingival exposure is well known to be the result of vertical maxillary bony excess. Corrective methods include a maxillary impaction procedure or soft tissue lowering gummy smile procedures. Both approaches have their indications and are most commonly used in Caucasian patients.

In the December 2016 issue of the Annals of Plastic Surgery an article entitled ‘Correction of Midface Depression Using An Inverted M-Shaped Expanded Polytetrafluoroetylene Implant Improves Gingival Exposure’. The authors have previously observed a correlation between gingival excess and midfacial depression in Asian patients. Over an eight year period they treated 42 patients with excessive gingival exposure with varying degrees of midface depression with an inverted M-shaped ePTFE implant placed at the base of the pyriform aperture at the bone level.

Based on before and after pictures as well as measurements of upper lip length, nasolabial angle, and facial convexity angle, the results of the midface implant was assessed. The average maximum gingival exposure was around 5.5mms (± 1.5 mm) before surgery which was significantly decreased to less than 2mms at 6 months after surgery. The nasolabial angle was improved from 85° to 95° in some patients. Most patients rated their postoperative results as highly improved. Temporary and typical postoperative findings were upper lip numbness, foreign body sensation, and a stiff smiling. These symptoms resolved after three months. No infections or implant extrusions were seen.

This paper shows that in cases of midface depression excessive gingival exposure can be reduced by pyriform aperture implant augmentation. This approach appears to offer a safe and effective treatment option with a high level of patient satisfaction.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapsots – Tear Trough Implants

Monday, November 21st, 2016

 

The tear trough deformity has become well recognized today and is a natural consequence of the attachments of the lower eyelids and infraorbital rim bone. Originally called the nasojugal fold, it is a sulcus that runs downward and outward from the inner corner of the eye. It is formed by the fascial attachments to the periosteum at the orbital rim between that of the orbicularus oculi and upper lip muscles. This creates a hollow area under the eye that often appears as a dark circle.

Tear troughs become magnified with age and particulalry with poor underlying skeletal support. Recessed orbital rim bone makes tear troughs look deeper and allows lower orbital fat to appear as if it is prolapsed or herniated.

The most popular treatments for tear troughs are injectable fillers and, as an isolated procedure, can be very effective. Surgical treatments for tears trough come into play usually because a lower blepharoplasty procedure is being done for an overall periorbital improveent.These include a variety of fat grafting techniques as well as implants.

tear-trough-implants-screw-fixationThe well known silicone tear trough implant was developed over two decades ago to avoid the problems with free and pedicled fat grafts. They are most commonly placed through eyelid or intraoral incisions. Available in differing sizes they are placed along the infraorbital rim staying above the infraorbital nerve foramen. Their placement requires a full arcus marginalis release. The best method to ensure permanent implant placement is small microsrew fixation to the bone. (only the subciliary eyelid incision allows this to be done)

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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