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Archive for the ‘facial implants’ Category

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

Facial Implants and Biofilms

Saturday, August 13th, 2016

 

Synthetic implants are widely used and important for many types of facial augmentation. Without them many aesthetic facial procedures would not be possible or would be far more difficult to perform and have higher risks. The risk of infection with facial implants is acknowledged by surgeons and patients alike. Fortunately facial implant infections are very low due to the highly vascularized tissues of the face with a risk probability of 1% to 2%. The cause of facial implant infections, like implants infections anywhere else on the body, is the development of a biofilm layer on the implant.

What is a biofilm? In a wet environment bacteria can organize and attach to a solid surface. Once attached they can multiple and create a biofilm layer. The bacteria excrete  a material known as an extracellular polymer substance (EPS) which encases the bacteria and helps protect it. It also offers an increased resistance to antibiotics as well as to the bodies own immune responses. This resistance makes it frequently necessary to remove the implant for resolution of the infection.

biofilm layer on implantsIn the July/August 2016 issue of the JAMA Facial Plastic Surgery journal, a paper entitled ‘Analysis of Facial Implants for Bacterial Biofilm Formation Using Scanning Electron Microscopy’ was published. In this clinical study an analysis was done on seven (7) facial implants that were extracted. This included four (4) silicone and (3) porous polyethylene (Medpor) Implants, most of which were from the nose. (6 out of 7). Scanning electron microscopy images was done to assess for the presence or absence of biofilm formation. All porous polyethylene implants showed biofilm formation to various degrees, some areas were classified as severe. The only 2 implants without any evidence of biofilm were silicone implants. Of the other 2 silicone implants,  they had varying degrees of moderate to severe biofilm formation.

This study suggests that smoother surfaced facial implants are less inclined to develop biofilm layers than non-smooth surfaces…and the layer may be less severe. This is well known and undoubtably accounts for the very low of silicone facial implant infections. It should be noted that these are very small numbers of implants evaluated and were almost exclusively from the nose.

It also speaks to the fact that once a facial implant develops, antibiotics alone are not likely to solve it because of the persistent biofilm layer. Either the implant has to be removed or it needs to be removed, cleaned/re-sterilized and then immediately re-inserted for a successful infection resolution.

Dr. Barry Eppley

Indianapolis, Indiana

Volume Comparison Between Nasal Implants and Injectable Fillers

Thursday, June 16th, 2016

 

Augmentation of the nose is a frequent element in many rhinoplasty procedures. While the use of locally harvested cartilage grafts works in may cases, more significant augmentations of the dorsum require different volume addition techniques. The choices for major dorsal augmentation rhinoplasty for Asian and African-American patients, for examples, is either that of a nasal implant or a rib cartilage graft. But any patient that needs more than a few millimeters of dorsal augmentation faces the same choices.

The emergence of injectable fillers has now allowed for a non-surgical rhinoplasty. The basic concept of a non-surgical rhinoplasty is that it can only add volume. Noses can become bigger with an injection technique but they can never become smaller. An injectable rhinoplasty can be used to trial what the augmented nose will look like but it will not be a permanent result. While there are some long lasting injectable fillers, placement of them into the nose carries some significant risk. But at the least injectable filler provides an instantaneous result and the opportunity for the patient to determine if this type of nasal enhancement is right for them.

Nasal implants offer a permanent method for dorsal nasal augmentation that does not require a harvest site. But it is an invasive procedure and requires the commitment to having a synthetic material in the nose. For this reason some patients may want tio have an injectable filler placed first.

An interesting questions is how does an injectable filler in the nose compared to a nasal implant? How does the volume of an injectable filler compared to the displacement effect caused by a solid implant?

Nasal Implants Dr Barry Eppley IndianapolisComparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would equal to the volume of the implant. (provided that they sink in water and nasal implants do) Using the most commonly used style of nasal implants for total dorsal augymentation (Rizzo nasal implants from Implantech) of all available sizes, their weights in grams and volume displacement were as follows:

NASAL IMPLANTS

Extra Small    0.96 grams    .7 ml

Small             1.14 grams     .8 ml

Medium         1.37 grams    1.1ml

Large             1.71 grams    1.5ml

Extra Large   1.95 grams    1.7 ml

Nasal Implant vs Radiesse Filler Dr Barry Eppley IndianapolisThe volume displacement of all injectable fillers is on the syringe so the comparison to nasal implants can be directly compared. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be equal to small and medium sized styles of nasal implants. Larger nasal implants more directly compare to a 1.5cc syringe of Radiesse. (which weighs 1.7 grams)

Volume alone, however, is not the complete story of any material’s external facial augmentation effect. Besides volume there is the issue of how well the material pushes on the overlying soft tissues to create their effect. This is known as G Prime Force or the elastic modulus. By feel it is obvious that implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) It is therefore probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to implants. This may be particularly relevant in the nose where the nasal skin is less elastic and more firmly attached than other facial areas.

The use of 1 to 1.5cc of an injectable filler can compare volumetrically to that of an implant in the nose for more significant dorsal augmentations.

Dr. Barry Eppley

Indianapolis, Indiana

The Composite Nasal Implant in Asian Rhinoplasty

Sunday, May 29th, 2016

 

In Asian rhinoplasty, one of the principle elements of its treatment is dorsal augmentation. This can be done using a silicone nasal implant or the autologous option can be done using a rib graft. Because of its ease of use and that it spares the patient a donor site, silicone nasal implants are widely used around the world particularly in many Asian countries.

Despite the effectiveness of its use, silicone nasal implants are a synthetic material. As a result, they do have a well known potential for complications including infection and migration. The very feature that makes them easy to use (smooth and non-adherent surface) is exactly what can lead to its potential complications.

Composite ePTFE coated Nasal Implant Dr Barry Eppley IndianapolisIn the Published-Ahead-Of Print section of the May 2016 issue of the Annals of Plastic Surgery, an article appeared entitled ‘Silicone-Polytetrafluoroethylene Composite Implants for Asian Rhinoplasty’. In this paper the authors used this composite nasal implant in 177 patients over a three-year period. One-third (63) of these were placed in primary rhinoplasties while roughly two-thirds (114) were placed in secondary rhinoplasty surgery. The majority of the rhinoplasty patients were women. The composite nasal implants were 1.5 to 5 mm thick and 3.8 to 4.5 cm long. The implants did not extend onto the nasal tip which was treated in every case with cartilage grafts.

Over the three year study period, there was a 10% incidence of complications including deviation, persistent redness, infection (1%) and  dissatisfaction with the height of the dorsal augmentation. This lead to a 9% revision rate for corrections. No significant differences in these complications occurred between primary and secondary rhinoplasty.

A composite nasal implant places a 0.3mm layer of PTFE (Gore-Tex) on the silicone surface. Given that Gore-Tex implants have a history of tissue ingrowth into their surface,  this would theoretically make them more biocompatible and less prone to complications. To date the theoretical benefits to composite nasal implants have not been substantiated in a large clinical study until this report.

While no synthetic material implanted in the face will ever be free of complications, the addition of a PTFE coating onto a nasal implant appears to offer some clinical advantages over non-coated silicone nasal implants. Whether their long-term results will be more favorable than uncoated implants in rhinoplasty can not be determined from this study.

Dr. Barry Eppley

Indianapolis, Indiana

The Extended Tear Trough Implant

Sunday, May 15th, 2016

 

Volume loss is a well recognized aspect of facial aging. This has led to a now popular and widespread use of facial volume augmentation techniques. Synthetic injectable fillers and fat are most commonly used since most of volume loss occurs in soft tissue compartments and these materials are easily placed by injection.  The re-establishment of volume loss in the cheeks is often done as part of a facelift, for example, for an improved rejuvenative effect.

While injected fat or fillers can virtually be placed anywhere in the face, it is not always appreciated as to what the external effect may be. Since the face has well known soft tissue compartments, located in the deeper layers, it will have surface topographic effects based on the anatomic compartment boundaries.

medial cheek augmentation zoneIn the May 2016 issue of Plastic and Reconstructive Surgery, an article was published entitled ‘Three-Dimensional Topographic Surface Changes in Response to Compartmental Voluminization of the Medial Cheek: Defining a Malar Augmentation Zone’. In this cadaveric study the authors injected a fat analogue into the deep medial cheek compartment. 3D analysis was done to assess the external volume changes on the face. They found that voluminization of this medial cheek region had distinct boundaries with the superior edge at the level of the arcus marginalis of the inferior orbital rim. When the arcus marginalis was released the upper edge of the augmentation zone was no longer restricted.

arcus margnalisIn this paper the authors have identified a very specific medial cheek zone that is often overlooked in facial volume augmentation. Its location is often part of a large area of volume loss that involves the tear trough region as well. Given its location over the medial orbital region and nasomaxillary skeleton, it is also an area that can be treated by facial implants as well. This requires a special type of facial implant design that I refer to as the extended tear trough implant.

The extended tear trough implant has one of its effects along the medial orbital rim for the classic tear troughs that many people develop or even have congenitally. But because the implant is designed to be placed intraorally, it has an inferior extension down over the medial maxillary wall. This puts it right under the medial cheek zone as described in this paper. Since an arcus marginalis release is needed to place the implant, its augmentation effect can cover two facial augmentation zones.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Screw Fixation of the Premaxillary-Paranasal Implant

Monday, March 28th, 2016

 

paranasal implant anatomy pyriform aperture dr barry eppley indianapolisAugmentation of the central midface can be done by placing an implant along the base and sides of the nose. Known as the pyriform aperture, it is the bony outline of the nasal cavity which makes a hole in the facial skeleton to the back of the throat. The soft tissue and cartilage structure of the nose sits on top or in front of it.

Peri-Pyriform Implant Dr Barry Eppley IndianapolsParanasal Implant placement Dr Barry Eppley IndianapolisThe pyriform aperture area can be augmented by a standard preformed implant known as the peri-pyriform implant. It has bilateral wings that augment the paranasal or sides of the pyriform aperture and a connecting center piece which crosses the premaxillary region along the bottom of the nose. Technically this implant should be called a premaxillary-paranasal implant. It is a versatile implant since it can be sectioned to just do paranasal augmentation or its wings can be removed to create just a premaxillary implant.

Paranasal Implant Placement Dr Barry Eppley IndianapolisThe premaxllary-paranasal implant is placed through a low anterior vestibular incision up under the upper lip. It is important to place the incision above the fixed mucoperiosteal to leave a cuff of tissue to create a good closure. Sunperiosteal dissection is done up to the anterior nasal spine and around the sides of the pyriform aperture. It is important to stay close to the edge of the bone but to not violate the nasal mucosal lining. The implant is placed snug up against the anterior nasal spine and along the sides of the pyriform aperture. Two 1.5mm screws are placed through the wings of the implant to secure it to the bone.

The premaxillary-paranasal implant is the only implant that can provide central face augmentation. It has a LeFort 1-like effect on the base and sides of the nose. Firm fixation to the bone by microcrews is a simple and effective method to ensure its postoperative placement and long-term stability

Dr. Barry Eppley

Indianapolis, Indiana

Outcome Study of Asian Facial Implants

Sunday, March 20th, 2016

 

facial implants dr barry eppley indianapolisFacial implants are having a resurgence in popularity and use over the past decade. This is due to a variety of reasons including the widespread use of injectable fillers, new facial implant styles and patient demand for permanent facial volume enhancement methods. With increased use large volume facial implant clinical studies that describe the outcomes is helpful to both surgeons and patient alike.

In the advanced online edition of the March 2015 issue of the Aesthetic Surgery Journal, an article appeared entitled ‘Alloplastic Augmentation of the Asian face: A Review of 215  Patients’. This was a retrospective review of Asian patients over a four year period that underwent facial implant augmentation of the forehead, nose, midface and chin. Complications consisting of infection, malposition, extrusion and revision for aesthetic reasons were evaluated. This included 243 implants of which 141 were done in the nose. (58%) In the nose the infection rate was 1.5%, extrusion 1%, malpositions almost 10% and aesthetic revision of 11%. This makes for an overall nasal implant complication rate of 18%. Chin implants (40) had a 2.5% incidence of malposition and 15% rate of aesthetic revisions. Midface (31) and forehead (31) implants were associated with the lowest rates of revisional surgery with just one patient. (3%) Overall infection and extrusion rates were less than 1% each.

Based on their experience with facial implants in Asian patients, the authors conclude that when used properly, facial implants have a low complication rates and satisfying aesthetic outcomes.

There are several of this paper’s conclusions of which I would agree. In properly selected patients facial implants can create aesthetic changes that can be very pleasing and relatively easily achieved. No other plastic surgery techniques can create facial augmentation results so directly and immediately. To keep complications rates low, facial implants should be placed in subperiosteal pockets right next to the bone with as much tissue thickness over the implants as possible. Facial implants should be placed as far away from the incision as can be done to avoid implant exposure should wound dehiscence occur.

While one of the main conclusions of this paper is that facial implants have a low complication rate, that is both a true but inaccurate statement. Major medical complication rates are indeed low as shown by a 1% or less occurrence of infection and extrusion. This proves that in the face implants are incredibly well tolerated when properly placed. But the aesthetic revision rate by comparison is high although normal in my experience. The nose and chin implant revision rates, which accounted for two-thirds of their patients, was 10% to 15%.  This may seem high to patients but compares very favorably to many other implants placed in the body. (actually body implant revision rates are usually higher than that of facial implants)

While this was a clinical study of Asian patients, its findings really apply to patients of all races. The only unique implant experience in this study is the high rate of nasal implants which is always highest in this patient population.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Nasal Implant

Sunday, February 28th, 2016

 

Background: Augmentation of the nose is a frequently needed maneuver in rhinoplasty surgery. This is particularly needed in many ethnic patients who are genetically prone to low and wide nasal bones and lack of an elevated straight dorsal line. Dorsal augmentation requires some form of material which can be either synthetic or harvested from the patient. This has lead to an historic and controversial debate between nasal implants vs. cartilage grafts.

While the use of nasal implants may be controversial and prone to a higher long-term rate of complications, they are the most widely performed method for nasal augmentation. The most common material used is silicone and they are manufactured in a wide range of styles and sizes. The benefits of silicone in the nose, like the rest of the face and body, is that they are easily inserted and also easily removed.

Nasal Implants Dr Barry Eppley IndianapolisImplant materials are most safely used in the dorsum or bridge of the nose. Keeping an implant material off the tip of the nose from just under the skin is the surest method to avoid complications. The dorsal skin can tolerate implant materials fairly well as the skin can be stretched more easily and it has an uninterrupted blood supply when an open rhinoplasty is used to place it.

The size of the most commonly used nasal implants has a thickness ranging from 2mm to 5mms for most styles of implants. For some patients with very low nasal bridges/nasal dorsal concavities, a custom nasal implant design may be needed for optimal dorsal line elevation.

Case Study: This 30 year-old male had a history of a prior rhinoplasty that used a standard sized silicone implant of 5mms thickness. While he clearly was improved over his natural nasal shape, he desired further nasal height as it approached the radix and glabellar areas. He also wanted the bridge area to be wider to have a more masculine appearance. The tip had a downward inclination and also needed to be elevated. A custom nasal implant was designed that provided 8mms of dorsal height and 12mms of width that tapered downward to the tip. The nasal implant length was 40mms.

Custom Nasal Implant Replacement result side view Dr Barry Eppley IndianapolisCustom Nasal Implant result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, an open rhinoplasty was performed and his existing silicone nasal implant was removed. The new custom nasal implant was placed and one end of it was placed and secured under the dome cartilages. The tip of the nose was built up with ear cartilage grafts to increase tip projection.

Custom Nasal Implant result front view Dr Barry Eppley IndianapolisA custom nasal implant can be used to create dorsal nasal dimensional changes that can not be achieved by standard implant designs. This approach is usually done when the patient already has an dwelling nasal implant that has proved inadequate for their aesthetic nasal needs. It is important in a nasal implant design that its size not stress the overlying thin nasal skin excessively.

Highlights:

1) A dorsal augmentation rhinoplasty builds up the bridge or dorsal line of the nose.

2) Nasal implants are frequently used because of their simplicity and reliable amount of smooth augmentation.

3) A custom nasal implant can be used when the traditional sizes of nasal implants are inadequate.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Asian Nasal Implant Rhinoplasty

Wednesday, November 18th, 2015

 

Background: The need for augmentation of the nose can be due to congenital, traumatic or iatrogenic saddle nose deformities or for elective ethnic rhinoplasty surgery. Ethnic rhinoplasty indications are usually for the Asian or African-American patient in my practice and are dorsal line augmentations that usually involve the tip as well. The debate is such nasal augmentation is always one of using the patient’s own tissues (cartilage) or that of the a nasal implant.

The debate of an autogenous vs. alloplastic rhinoplasty is not new and the advantages and disadvantages of both are well known. An implant rhinoplasty simplifies the operation, provides and assured shape and saves the patients any extranasal graft harvest site. But it is an implant and with that comes an increased risk of infection and the potential for ong-term tissue thinning and exposure. Conversely the need for a substantative cartilage graft requires a rib graft harvest with an uncomfortable donor site and scar and the potential for  warping of the dorsal graft. But a rib graft has a very minimal risk of infection and no danger of long-term tissue thinning or extrusion.

Nasal implants often have a bad reputation in the mind. of many plastic surgeons. There are certainly easily findable major complications from them that can be located on the internet. But like all surgical implants of any type, how and when they are used plays a major role in their ultimate success and failure. Large nasal implants, dorsocolumellar implant styles that cross the tip area, and noses with thin tissues all increase the risk profile of what is really a subcutaneous synthetic implant.

Case Study: This 24 year Asian female was undergoing numerous facial reshaping procedures of which one was that of a rhinoplasty. She desired a higher bridge from the radix down to the tip. A nasal implant vs a rib graft was discussed thoroughly and she opted for the nasal implant.

dorsal nasal implant dr barry eppley, indianapolisUnder general anesthesia she had an open rhinoplasty through which a silicone implant was used for the bridge and a septal cartilage graft for the tip. The bridge was built up with a medium Implantech dorsal nasal implant that had 3.5mms at the radix and 4mms at its lower end which was placed under the dome. The nasal tip had increased projection through a septal columellar strut graft and tip suturing techniques.

Asian Implant Rhinoplasty result front view Dr Barry Eppley IndianapolisAsian Female Implant Rhinoplasty Dr Barry Eppley IndianapolisAt six months after her implant rhinoplasty she had a nice straight nose with a higher dorsal projection. Smoothness and straightness of the dorsum are the aesthetic advantages offer by an implant. This style of dorsal nasal implant is fairly narrow in width and is best used in women and not men for this shape reason. A pencil thin nose in men is usually not an ideal nasal look.

Asian Female Implant Rhinoplasty oblique view Dr Barry Eppley IndianapolisNasal implants can be used very successfully if they are not asked to do too much augmentation and in the carefully selected patient. Limiting the augmentation to the dorsum and not the nasal tip and avoiding excessively high amounts of augmentation will help diminish the risk of complications with their use to very low levels.

Highlights:

  1. Nasal implants often have a bad reputation when their success is tied more to their use and the patient’s nasal augmentation needs
  2. Dorsal nasal implants have a high rate of success when the amount of augmentation needed is not excessive.
  3. Nasal implants avoid the need for a rib graft harvest and offer a more assured straight nose that permanently stays so.

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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