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Archive for the ‘facial implants’ Category

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

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


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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