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Archive for the ‘facial implants’ Category

Case Study: Custom Wrap Around Implant for Male Jawline Enhancement

Monday, August 25th, 2014


Male Jawline Dr Barry Eppley IndianapolisBackground: The ideal male jawline is seen as strong and chiseled…at least by most men.  (some women may prefer a softer jawline which creates a more nurturing appeal) For those men that do not have it, implants can be used to create a stronger or more pronounced jawline. While once traditionally seen as simple chin augmentation, today’s facial implants now incorporate jaw angle implant designs to change the back part of the jaw as well for a more complete or total jawline enhancement.

For many men the use of standard chin and jaw angle implants, through a three-point augmentation approach, can create the desired jawline improvement. With a three implant approach, however, the sides of the jawline may remain deficient since there may not be a direct connection between the chin and jaw angle implants. Also three implants placed individually runs the risk of implant asymmetry since they are not connected and their position must be ‘eyeballed’ for placement as they relate to each other. There is also the limitations of jawline changes based on the sizes of existing chin and jaw angle implants.

All of the existing potential problems with standard jaw implants can be overcome by the use of a custom-designed jawline implant. By making a single piece wraparound implant, the entire jawline can be augmented in just about any dimensions that one wants and the overlying soft tissues can tolerate.

Custom Jawline Implant design Dr Barry Eppley IndianapolisCase Study: This 23 year old male wanted to have a more masculine jawline with a stronger chin and jaw angles. By using computer imaging, it could been seen that the look he wanted was more of a total wrap around effect that just augmentation of the chin and jaw angle areas. By using his 3D CT scan, a wrap around jawline implant design was done creating a more square chin, prominent jaw angle flare and a smooth connection between the front and back part of the jaw.

Custom Jawline Implant placement Dr Barry Eppley IndianapolisUnder general anesthesia, a small (2.5 cm) submental incision was made behind his existing skin crease. (accounting for a forward rollout of the incision which will always occur. Subperiosteal dissection was done over the entire chin and back along the jawline to the angle with special long-handed dissectors. This was combined with two posterior vestibular incisions to expose the jaw angle. The implant was folded and tunneled into position from the submental incision. The positioning of the jaw angle sections of the implants was checked through the intraoral incisions to ensure good seating over the jaw angles. A single microscrew was used anteriorly but the fit over the jaw angles was so good no screw fixation was felt necessary.

Custom Jawline Implant result front viewCustom Jawline Implant result oblique viewThis is his result just 10 days after surgery. While these is still some slight swelling and tissue ‘stiffness’, his face/jawline looks very acceptable at this early point that he could pass as not being obviously ‘surgical’. His jawline shows improved definition and now has more of a classic strong male jawline that has much more angularity to it without being too big or overdone.

Male jawline enhancement is optimally done by a custom wraparound implant if one wants a total change to the entire jawline that appears connected throughout the implant. It is also the only implant approach that will work if one has more extreme dimensional needs that standard implants can not achieve. While the cost of a custom jawline implant is more than that of standard implants, the difference is not as great as most would think. The custom aspect of the implant also lowers the risk of revisional surgery as the shape and location of it along the jaw is determined prior to to surgery in the computer designing process.

Case Highlights:

1) Complete jawline enhancement involves a total change to the entire horizontal portion of the lower jaw in a ‘wrap around’ fashion.

2)  A custom jawline implant is made from a patient’s 3D CT scan and incorporates changes to the chin, jaw angles and the jawline between them in the desired dimensional changes.

3) Due to the flexibility of even a large silicone one-piece jawline implant, it can be inserted through a small submental skin incision conbined with two intraoral mucosal incision to check for posterior positioning.

Dr. Barry Eppley

Indianapolis, Indiana

Five Things You May Not Know About Custom Facial Implants

Thursday, July 10th, 2014


The use of facial implants dates back to over fifty years ago when the first chin augmentation was done. With the expansion of facial implant styles and sizes over the years, there are many options today for nose, cheek, chin and jaw angle implants as the standard facial areas treated. In addition to these areas, there are expanding options available for other facial regions that are less commonly done. But despite a large number of available facial implants, some patients require or request a custom approach for their facial augmentation needs.

As custom facial implants are becoming more popular due to improved technology, there are numerous misconceptions about them. Here are some things you may not know about custom designed and fabricated facial implants.

Custom Facial Implants Are Not Really New. While the technology has dramatically improved and the internet has made their existence easily found, the use of custom implants for the face has historic precedence. Surgeons for years have used blocks of various materials to fashion implants during surgery. (although I would call this a semi-custom approach with a lot of guesswork in doing so) But the use of a patient’s model to create an exact fitting implant to the bone before surgery dates back to when higher resolution CT scanning and computer-generated models became available. I did my first such custom facial implant case back in 1997 where modeling clay was used to create a mockup of the implant from a resin-spun hand-held model.

A 3D CT Scan Is Needed To Make Custom Implants. Whether it is done by an actual model or on the computer screen, only a high resolution CT scan of the face with 3D reconstruction can be used. The scan has to be done using .1mm slices and not the standard 3mm or 1mm slices normally taken. An old or regular facial CT scan will not do nor will an MRI. These type of facial CT studies are quick and easy to do today at a very low cost at any CT scanning facility. The software to do them is now standard.

The Design May Be Done On The Computer But The Surgeon Creates It. While computers and their software can do incredible things, they do not yet know how to create a specific look for any patient. In designing facial implants, the computer has no innate knowledge or software algorithms to know what size or shape the implant(s) needs to be….unless they have a desired and exact target to mirror. This works for facial asymmetry (making an implant to match an opposite  normal side) but not for purely aesthetic facial augmentations. It is the doctor that must tell the computer (specifically the design engineer) the shape, thickness and orientation that they want the implants to be. The computer design process will make sure the implants fit the bone perfectly and compensate for any bony asymmetries.

Custom Implants Can Be Made For Any Craniofacial Area.  Implants can be designed from the end of the jaw to the back of the skull on any bone area. While most implants are made for bone augmentation, soft tissue implants can be similarly made. The outline and bulk of the muscles on the bone can be imaged and implants designed to fit under or on top of them. This is most useful for the temporal region where aesthetic width issues may exist.

The Cost of Custom Facial Implants Can Be Affordable. While the cost of custom implants does cost more than using preformed implants, the difference today is not as dramatic as it once was. If one has significant facial asymmetry or has extreme facial augmentation needs, the use of preformed implants may lead to disappointing results and revisional surgery. This can end up costing much more than using custom implants initially.

Dr. Barry Eppley

Indianapolis, Indiana

The Biocompatibility of Silicone Polymer Implants in Plastic Surgery

Thursday, May 1st, 2014


Short of metal implants used for fixation and repair in bone surgery, most implants used  in plastic surgery are composed of a silicone-based material. It may have varying states of being a solid, (soft to more firm) but silicone-containing implants have long been recognized as one of, if not the most, biocompatible synthetic material in existence. The breast implant fiasco in the early 1990s created a vast patient scare and its negative connotations still reverberate today. This is despite the fact that silicone breast implants received complete vindication as being harmful and were re-introduced for clinical use again in 2006.

Periodic Table of Elements Dr Barry Eppley IndianapolisBecause of its prevalence in implant surgery and various and often diverse opinions about its safety, it is time to review the basic science of silicone materials. To do so requires going to the periodic table and looking at the element called Silicon.

Silicon elementSilicon sits as a chemical element five vertical rows from the left and three horizontal rows from the top. It has the symbol Si and has an atomic weight of 14. It is what is called a tetravalent metalloid, which sounds like it is really a metal, although the term means that it has properties of both metals and non-metals. Joining Silicon as a metalloid are some familiar names from the very friendly Carbon (the basis of all organic life) to the very poisonous Arsenic. It is the second most common element available in the earth’s crust after oxygen, appearing in dust and sands usually in the form of silicon dioxide. (silica) It does not exist much in its purest form, but its use in that regard impacts all modern technologies as it serves as the basis of semiconductor electronics and integrated circuits.

Silicone Polymers in Plastic Surgery Dr Barry Eppley IndianapolisSilicon has long served as the backbone for silicon-based polymers known as silicones. One should not confuse, however, Silicon and Silicone. The polymer Silicone does contain Silicon but it is put together with other elements such as oxygen and hydrogen which give it very different physical and chemical properties than elemental Silicon.  These formulations create common products with a wide range of physical forms (soft to hard) such as silicone oils, rubber, caulk and a diverse number of medical implants. Silicone polymers have a large number of very favorable properties as an implanted material including remarkable stability (does not change over a temperature range of -100 to 250 degrees C), does not absorb water or other fluids, has little chemical reactivity, little known toxicity and does not support bacterial growth. Thus it is a structurally stable polymeric material that is not likely to degrade in any way over a patient’s lifetime.

The biocompatibility of a long-term implantable medical device refers to its ability to perform its intended function without creating any undesirable local or generalized effects. A silicone polymer fulfills that role well and, when combined with the wide availability and low cost of its base material, it is no wonder that most non-metal medical implants are made of some or all of it. Its easy moldability makes it able to be molded into almost any shape or size such as silicone gel breast implant, a soft solid pectoral or buttock implant and a soft but more firm facial implant.

But besides its unique physical properties when made into a polymer, is there anything else that makes it so biocompatible? It probably does not hurt that its closest vertical neighbor is Carbon. By its electronic composition, Carbon and Silicon are closely related event though they are distinct elements that form distinct compounds. But being next to the element that is responsible for all life on earth probably does not hurt how that life sees it.

Dr. Barry Eppley

Indianapolis, Indiana

Saline Injection Trials for Facial Implants

Saturday, January 11th, 2014


Facial augmentation can be done by either temporary injectable fillers into the soft tissues or permanent implants placed down on the bone. Such materials causing a change in the external shape of the face in the area treated but its exact change can not be precisely predicted. While computer imaging can try to create the change caused by these facial volumizing procedures, it is still an estimate.

When it comes to the placement of facial implants, there is much more of a commitment due to the surgical process. Some patients may feel more comfortable having a test or trial volumization procedure done prior to the actual surgery. While the most common method for a facial implant trial would be any of the commonly used injectable fillers, for a few select patients the length of their duration may be too long. (months)

Saline Solution for Facial Injection Dr Barry Eppley IndianapolisAnother type of injectable filler that can be used that is very short-term (hours) is that of saline. Saline injections, which are a mixture of water and salt, are used for variety of medical purposes. The most common use for a saline mixture is for intravenous infusions for hydration, mixing it with medicines to make an injectable solution and as over the  counter nasal sprays and contact lens cleaner. Additional but less common uses for saline injections are for spider vein treatments, acne scars and some very unusual types of body modifications.

Saline is often called Normal Saline (NS) or isotonic saline as a solution of 0.9% of sodium chloride (NaCL) created by dissolving 9 grams of NaCL in 1000ml of water. (for those who like a kitchen analogy that would be 1.6 teaspoons of salt) Normal saline contains 154mEqL of Na+ and Cl- and has only a slightly higher degree of osmolarity than blood. A 0.9% concentration is often presumed to be the sodium concentration in human blood which is inaccurate  since it is closer to 0.6%.

Saline can be injected very safely into the face in any location that would be typically augmented for increased volume. By using a microcannula technique it can be done painlessly. However, saline solutions have some degree of acidity (ph of 5) and may be associated with sight burning on injection. This can be remedied by adding a touch of sodium bicarbonate or using a more ph-balanced solution like Lactated Ringer’s. (LR)  The volumes adds to create a facial effect are greater than what one experience with traditional injectable fillers due to their higher viscosity. Saline or LR is absorbed quite quickly and will usually be completely gone in less than four hours.

Saline Facial Injections Dr Barry Eppley IndianapolisThe purpose of saline injections is to give the patient an immediate facial volumizing effect so they can see if augmentation of a facial area is aesthetically beneficial. When requested by a potential facial implant patient, it can make the patient feel more secure about a surgical decision for implants. This is particularly true in cheek and orbital rims implants where insecurity about that area of facial augmentation is often most uncertain.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Wisdom: 3D Custom Facial Implants

Wednesday, November 27th, 2013


Plastic Surgery Wisdom Dr Barry Eppley IndianapolisFacial implants are an invaluable aid in aesthetic facial rejuvenation and structural changes as well as less frequently in facial reconstruction. Facial implants are most commonly perceived as preformed implants of various styles and sizes to augment areas like the cheeks, chin, jaw angles and nose. (off-the-shelf implants) Less commonly, blocks or sheets of various implant materials are available to carve or shape during surgery to make the desired implant. (semi-custom implants) The use of true custom-designed facial implants done from a patient’s 3D CT scan before surgery has emerged today as another viable and reasonably economic implant method. While once rarely done due to imaging and software design limitations as well as cost, it is now emerged as a much easier and economic implant method to do.

The custom design method for facial implants is truly amazing when visualized on a computer screen. The ability to create any shape and thickness of an implant and match the symmetry between facial sides, if needed, is impressive. But one limitation of computer designing implants is that it is done on an inanimate facial skeletal computer image that does not take into account the soft tissue cover…nor how such designed implants may be capable of being placed. Given that placing facial implants must be done in an inconspicuous and visible scar-free manner, being able to get a custom designed implant through the limitations of intraoral or discrete external facial incisions can be problematic.

Custom designing facial implants often allows larger and more encompassing implants to be created. But part of their design must take into consideration how they can be inserted and whether the overlying soft tissue cover will be adequate and still get the incision closed in a tension-free manner over it.

‘Any Size and Dimension of Facial Implants Cane Be Computer Designed, But That Does Not Always Mean It Will Be Made To Surgically Fit’

This issue is an important one where the input from the plastic surgeon based on their experience can help modify a custom designed facial implant to ensure it can be successful.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Female Jawline Implant Augmentation

Friday, October 25th, 2013


Background: An underdeveloped jaw or mandible has been historically treated by chin and jaw angle implants. A chin implant enhances the front part of the jaw while jaw angle implants augment the posterior part of the jaw. While these types of facial implants are tremendously effective at augmenting the two obvious prominences of the jaw, they neglect the intervening part of the jawline between the two of them known as the body area.

The mandible is a unique facial bone to aesthetically augment because it is a long curved bone that wraps around the lower face. No off-the-shelf implant currently provides a wrap-around augmentative effect of the entire jawline. Such an aesthetic need exists to make the entire jawline more pronounced and would be of value to make jawlines larger from a side-to-side standpoint. Because silicone is a very flexible material, a wrap around jawline implant could be used for just about any jaw shape and could be inserted through a very small incision.

Case Study: This 33 year-old female was having a skull reshaping procedure and wanted to improve her mildly weak chin as well. She felt her overall jawline was weak and not just her chin area but she did not want her jaw angles to be any bigger or flared. Her horizontal chin deficiency measured only 3 to 4mms in projection.

A new uniquely designed jaw implant was selected for her known as a jawline implant. It is essentially a very long and thin extended chin implant that extended back to the jaw angle area creating a wrap around effect along the inferior border. While the chin projection of the implant was 4mms, it tapered back along the jawline to a 2mm feathered edge. Because of its thin and long design, the stiffness (durometer) of the silicone material was stiffer than that used in other facial implants. That extra stiffness prevents the back tail of the implant from folding onto itself on insertion.

Under general anesthesia, a small 2cm submental incision was made down to the bone. A long extended periosteal elevator was used to make a long and narrow tunnel for the implant back along the lower edge of the jaw (inferior border) to the jaw angles. The implant was folded in half and inserted through the incision with both ends of the implant directed into their respective sides of the tunnels. The implant was easily slide into place and the central chin part of the implant was sutured into place to prevent migration. (although with an implant this long there really could not be an migration or displacement.

The jawline implant offers a new type of jaw augmentation implant that is uniquely different from the chin and jaw angle styles. By making the jawline more distinct and adding some slight width, it makes a more prominent jawline in a subtle but aesthetically pleasing manner. It is not designed to create an overpowering jawline augmentation but a subtle enhancement.

Case Highlights:

1) A more defined and distinct jawline is a desireable feature for both men and women and is the result of a more defined inferior border of the mandible.

2) A jawline implant is different than other jaw implants such as a chin or jaw angle implants as it accentuates the mandibular inferior border from the chin back to the jaw angles.

3) Jawline implants can be used alone to enhance a mildly weak jawline or as an additive benefit to facelift surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Wisdom – Choosing Breast and Facial Implant Size

Saturday, September 21st, 2013


Aesthetic augmentation using implants is an important part of many cosmetic plastic surgery procedures. Whether it is the breast or different areas of the face, implants are used to make these areas bigger. While there are numerous factors that go into selecting the right implant for the need, the consideration of implant size is one of the most important. Plastic surgeons use numerous methods to try and determine implant sizing beyond just experience. Sizers exist for breast implants and various measurements can be made for the face. But in the end there is no guarantee that no matter how much thought goes into the implant selection that it will be exactly what the patient desires. Often during surgery, in which intraoperative sizers are initially placed, there may be a debate about one size versus the other. (smaller vs. bigger)  Since  breast augmentation is about large volumetric enhancement on the body and facial implants is about smaller changes measured in millimeters, I have learned to make that choice based on the margin for ‘error’ and which choice is most likely to lessen the potential need for revisional surgery due to unhappiness with the amount of aesthetic augmentation.

‘When In Doubt Choose The Larger Size in Breast Implants and The Smaller Size in Facial Implants’

This is said because more women who are unhappy with their breast augmentation size is because the implant was not big enough. Conversely facial implant surgery revision is much more likely to occur because the implant was too big.

Dr. Barry Eppley

Indianapolis, Indiana

Skeletal Augmentation of the Aging Face

Tuesday, October 2nd, 2012


Aging of the face has been historically perceived as being a soft tissue problem.  This has led to how the vast majority of anti-aging facial surgery has been done, employing lifting and redraping of the soft tissues back up from whence they came. There is a reason the term ‘facelift’ has persevered for nearly one hundred years as correction of sagging has been the standard approach.

More recently, it has been acknowledged and incorporated into contemporary facial rejuvenation approaches that correction of volumetric loss is important as well. This has largely been done by fat injection grafting, spurned by the relative simplicity of the procedure and its immediate effects. But aging affects all facial structures right down to the bone. Taking a variant from a well known phrase, ‘beauty may well need to be treated all the way down to the bone’.

Certain bones of the face are well known to be affected by aging, marked by bone resorption. Three areas that have the strongest areas of resorption from aging are the midface around the pyriform aperture, the lateral rim of the orbit and the prejowl area of the lower jaw. Bone resorption in these areas contribute to some of the classic signs of aging with the development of jowling, cheek tissue sag and midface retrusion. These primary resorption areas as well as others will be accelerated and more severe with early loss of one’s teeth.

The periorbital area is known to resorb on the upper and lower lateral rim of bone. This causes prominence of the inner fat pocket on the lower eyelid and contributes to a tear trough deformity. Elevation of the inner brow appears due to dropping of the outer brow and lengthening of the lid-cheek junction. In essence, the loss of skeletal support causes the cheek tissues to fall causing a cascade of periorbital and cheek findings. This serves as the basis for midface/cheek lifts, cheek and submalar implants and fat injections.

Resorption of the maxilla around the base of the nose involves the bone just above the teeth. This is a naturally concave area making it more susceptible to resorption with aging.  With resorption, the nasal base retrudes deepening the nasolabial fold areas and even helping close down the nasolabial angle a few degrees. Other than injectable fillers for the nasolabial folds, there few commonly employed augmentation options. They use of injectable hydroxyapatite granules and preformed paranasal and premaxillary implants can provide needed skeletal augmentation.

Resorption in the prejowl area of the lower jaw is the most vexing of all skeletal aging areas. Why this area resorbs is not clear as it is a naturally convex bone structure. But resorption causes a relative concavity in this area and contributes to the appearance of jowls. For those with weaker chins, jowls may appear earlier due to the increased lack of bone support. This area of resorption is the reason the prejowl implant exists which is most commonly used in conjunction with a facelift or combined with a chin implant.

Resorption of the facial bones is a contributing factor for many patients in an aging facial appearance. Strong facial skeletal features play a major role in why some people seem to age better than others. The next frontier in facial rejuvenation surgery is bone augmentation with or without soft tissue suspension.  Current technologies for facial skeletal augmentation  include hydroxyapatite and HTR granules and preformed facial implants.

Dr. Barry Eppley

Indianapolis, Indiana

The Role of Custom Facial Implants in Aesthetic Facial Surgery

Friday, August 17th, 2012


Implants provide a wide array of options for facial augmentation. While initially only a chin implant was available forty years ago, today there are over fifty different styles and shapes that are available in more than one material composition. From the chin to the forehead, the options for bony enhancement now cover such obscure areas as the tear trough, paranasal and geniomandibular  areas. Such facial implants play a very valuable role in aesthetic facial augmentation whether it is the younger patient seeking a structural facial change or the older patient  in which an implant complements soft tissue lifting procedures.

Despite the tremendous diversity of facial implants, off-the-shelf styles and sizes can not fill all patient aesthetic needs. There are certain types of aesthetic problems in which stock implants are inadequate such as facial asymmetries, congenital and traumatic deformities and failed results using commercially-available implants. While stock facial implants, particularly those composed of silicone, are easy to intraoperatively shape and ‘customize’, the judgment of how they are to be shaped is still a matter of artistic adaptation.

The use of custom facial implants offers real advantages in challenging cases of facial augmentation. I classify custom facial implants into four types; 1) intraoperative modification of stock implants, 2) preoperative stock implant modification on a standard anatomic model, 3) preoperative stock implant modification on a patient-specific anatomic model, and 4) fabrication of an implant on a patient-specific anatomic model. Type #1 and #2 custom facial implant approaches have been done for decades and may even be questionable as to whether they are truly custom implants. Types #3 and #4 are a truly custom implant approach.

The basis of a truly custom facial implant approach is a patient-specific anatomic model. This requires the patient to first receive a 3-D facial CT scan based on a 1mm slice-taken protocol. These images are then sent to a manufacturer of craniofacial models. The manufacturer that I use is  Medical Modeling (Golden, CO) although there are others. The model can be made in either an Osteoview style (opaque) or a Clearview style. (clear acrylic) In the Clearview style, teeth, nerves, plates and screws and other implants can be colorized (red) so they stand out from the clear bone structures. The Osteoview is satisfactory if a custom implant is needed and the patient has not had prior surgery. The Clearview model is preferred when prior bone or implant work has been done and the bony anatomy has been altered.

Off of these models, the custom facial implants are made. While most patients think that there is a computer program that makes the implants, and this certainly exists, the cost and availability of this technology makes it currently not practical in aesthetic facial surgery applications.  Custom implant designs and prototypes are made by hand. I mold, shape and carved them out of clay or silicone elastomer which air dries to a hard set. If needed, they are further shaped and contoured by diamond wheels on a small hand drill. Finally they are covered by a lacquer which dries to a clear coat.

As part of this process, I often share images with patients of their implants in the fabrication process by e-mail or they may come in to see and handle the implant prototypes. It is important in the custom implant fabrication process for patients to participate in the decision process about the design. Once the design is agreed upon, the implant(s) are sent to a manufacturer for fabrication. Most custom implants can only be made from silicone. For many custom facial implants this is the best material  because their differing shapes and sizes may make them difficult to place. Flexibility and lack of frictional resistance on insertion are important implant insertion properties in any facial implant but is of critical importance in many custom designs. Besides the obvious benefit of creating an implant design that is as accurately accurate and symmetric as possible, the custom design process can also add features that make them able to be more effectively secured to the bone by screw fixation.

From the time that a 3-D anatomic model is obtained, a three week period is usually needed from design until the sterilized implants are returned from the manufacturer and ready for surgery. Depending upon the number of implants, the cost of custom designed facial implants can be from $3500 to $7500 in addition to other surgical costs.

Dr. Barry Eppley

Indianapolis, Indiana

Injectable Fillers vs Synthetic Implants In Facial Sculpting

Monday, March 26th, 2012

Injectable fillers have come a long way since the approval of the first non-collagen based product in 2002. While once conceived as only a way to make lips bigger and nasolabial folds less deep, injectable fillers have evolved into an aesthetic technology that has a wide number of facial uses. Aiding the expanded uses has been helped by the large number of different filler compositions offering variability in viscosity and flow charactistics as well as in longevity and in how they create their effects.


Fundamentally, injectable fillers are used for two main aesthetic applications, spot filling and volumetric enhancement. It is the latter that is often coined as ‘non-surgical facial sculpting’. That term is probably more accurate than not as it definitely takes skill and a good eye to get pleasing facial volume results with fillers. There is more art to it than science.


When it comes to facial volumetric enhancement with fillers, they are often compared to and even viewed as a substitute for surgical solutions to the same problems. Some injectors view synthetic fillers as  a better treatment choice as they are easier to do and have less risk of complications than surgery. While that is true, that does not mean they always give better aesthetic results or offer the best value for the money invested to do them.  There are advantages and disadvantages with both approaches depending upon exactly what facial application to which one is referring.


For skeletal augmentation of the three facial highlights, chin, cheek and jaw angles, injectable fillers can be used to create a visible external effect. When placed down at the bone level, I prefer Radiesse. Its calcium hydroxyapatite composition makes it the most viscous filler which provides a better push of the overlying soft tissues per cc of volume.  But when comparing it to synthetic facial implants that have been used for decades, it has several disadvantages. It takes a fair amount of syringe volume to get a visible effect, often at least two or three syringes depending upon the area. (chin = 1 syringe, cheeks = 2 syringes, jaw angle angles = 3 to 4 syringes) This makes it relatively expensive. In addition, the effect will never be as significant as a surgical implant and the filler material will go away by about one year or so after injection. This makes using an injectable filler for facial skeletal augmentation very patient selective. Filler are best used for skeletal augmentation when one is uncertain about how a surgical implant may look (trial ‘implant’) or if the need/result is time dependent based on an upcoming event and one doesn’t want to recover from surgery.


Other injectable fillers can be used for a skeletal effect but are placed in the subcutaneous tissues and not down at the bone level. In these cases, a hyaluron-based filler like Juvederm or Perlane are preferred which have higher material concentrations and will last about a year also.

The face is made up of a lot of non-skeletal areas that are not supported by underlying bone. These include two large areas in the lateral face and the temples. In the triangular area between the cheeks, chin and jaw angles lies the lateral facial region whose shape is not dependent on any bony support. It can be concave, flat or convex depending upon the shape of one’s face and the thickness of the underlying soft  tissues. This area has garnered a lot of attention in facial aging as it becomes more concave in some people as they age due to fat atrophy. Plumping it up with fillers has become popular as a rejuvenative manuever. I prefer Sculptra for the lateral facial triangle because of the volume of material needed. Using an 8cc per bottle reconstitution of Sculptra creates an almost pure watery form. This makes it  easy to get a good amount of material over this large area and have a low risk of creating any lumps. Sculptra does not work immediately and it takes time and three total injection sessions to get the best result. But it will last for up to two years.


The temple area is another soft tissue supported area. Muscle and fat make up its shape and it is smaller than the lateral facial triangle but still has a sizeable surface area. Sculptra seems to work best in this area because of the volume needed. But the result and its persistence can not be compared to the relatively simple placement of a subfascial implant. Again, fillers here are more of a trial to determine if an implanted result is worth the effort.


Injectable fillers can also be used in the nose for limited amounts of reshaping. This has led to the concept of the ‘non-surgical rhinoplasty’. In truth, this moniker has a large marketing slant to it because fillers can not obviously replicate what a surgical rhinoplasty does.  But to temporarily mask an upper nasal bump, fill in some asymmetries or do a little tip lifting,  the judicious use of fillers can make some aesthetic nasal improvements.


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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