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Archive for the ‘facial implants’ Category

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

Microscrew Fixation of Facial Implants

Monday, September 21st, 2015

 

Facial implants offer a permanent solution to many desired areas of skeletal augmentation such as the chin, jaw angles and cheeks. There are many factors that go into a successful facial implant augmentation outcome from the preoperative planning, style and size of the implant, implant placement and last, but not least, implant stability. Prevention of facial implant displacement is the last step in the surgical process but is by no means the least important.

Screw Fixation Tear Trough Implants Dr Barry Eppley IndianapolisMany a facial implant surgery has been marred by implant displacement and positional implant asymmetry. Surgeons have numerous techniques for stabilizing facial implants from pocket control, suture fixation and external facial bolsters or dressings. While all have their merits and advocates, there is only one fixation method that provides absolute assurance of implant stability…that of screw fixation. Screwing the implant to the bone with one or two screws (to prevent rotation in some cases) guarantees the implant’s position on the bone surface.

When screws are mentioned to patients for their facial implant(s) surgery they almost always have two concerns. First they think of screws as being large like those used in orthopedic surgery or woodworking. Secondly they are concerned that the screws may set off metal detectors due to their size and composition.

Microscrews in Facial Implant Fixation Dr Barry Eppley IndianapolisMIcroscrew Size in Facial Implant Fixation Dr Barry Eppley IndianapolisIn reality facial implant screws are very small and are better referred to as microscrews. They are of the dimensions of 1.5mm in diameter and are not greater than 7mms in length. I often refer to them as the size of the screws in eyeglasses. But to put that in better perspective it is helpful to see how they look on a penny or dime. On either Lincoln on the penny or Roosevelt on the dime, the microscrew takes up no more surface area than the length of either of the President’s jawline.

As for concerns about metal detection, it is important to realize that these microscrews are composed of titanium. Unlike an alloy like stainless steel, which all common screws are made of, titanium is nearly a pure metal. (atomic number 22 and Ti on the Periodic Table) It has a high strength, is corrosion resistance, and is non-ferromagnetic. It is the metal of choice for craniomaxillofacial bone fixation and for dental implants due to its superior properties over stainless steel. In short, titanium screws will not set off any alarms or metal detectors.

The use of titanium microscrews for facial implant fixation is both safe, effective and are so small that they are virtually undetectable.

Dr. Barry Eppley

Indianapolis, Indiana

The Infraorbital Rim Implant

Sunday, May 17th, 2015

 

Tear troughs and deep grooves under the eyes are often the result of underdeveloped or a weak skeletal structure. Specifically these would be the inferior orbital rims and the anterior cheek bones which sit at the bottom of the lower eyelid and supports the upper cheek soft tissues. Treatment of undereye hollows and grooves is most commonly done by injection techniques using either synthetic fillers or the patient’s own fat. While successful for some patients, not all experience the type of result they want or gets a result that is sustained.

Permanent and assured augmentation results in the face are achieved with preformed synthetic implants for select bony areas. While many styles and sizes exist for the commonly implanted areas of the chin, cheeks and nose, there are no implants that are commercially available for the inferior orbital rim. Given the new demand for augmentative treatments of this area, there exists a need for a preformed infraorbital rim implant for those patients who desire a permanent treatment method.

Infraorbital Rim Implant Designs Dr Barry Eppley IndianapolisAn infraorbital rim implant should provide superior and anterior projection along the bony rim from the naso-orbital junction out to the cheek. It only needs to be a few millimeters thick (2 to 4 mms) to make a noticeable difference. The naso-orbital junction is important as this represents the tear trough area which is a frequent aesthetic concern. How far out onto the cheek the implant should go can be debated but most infraorbital rim deficiences also involve a portion of the zygoma as well. However its lateral extent should be limited to the anterior aspect of the cheek.  (zygoma) If it extends out further a ‘bump’ will often appear in the side of the cheek.

Infraorbital Rim Implant Design Dr Barry Eppley IndianapolisInfraorbital Rim Implant Screw Fixation Dr Barry Eppley IndianapolisThe infraorbital implant is best placed through a lower blepharoplasty (eyelid) incision. While it can be placed through an intraoral approach, getting around the large infraorbital nerve is difficult and will create a postoperative period of lip and cheek numbness which hopefully is self-resolving. A lower eyelid skin-muscle flap provides direct access to the infraorbital rim and permits precise implant positioning and small screw fixation. This creates no more trauma than a lower blepharoplasty surgery. Like a lower blepharoplasty it is important to resuspend/reattach the orbicularis muscle  over the lateral orbital rim during closure, and use a lateral canthopexy if necessary, to prevent any postoperative lower eyelid contraction deformities. (ectropion)

The need for an infraorbital facial implant has been driven by the popularity of injection treatments for lower eyelid hollows and tear troughs. It offers a permanent treatment option for those who do not want injections or have failed previous injection treatments.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Fixation of Tear Trough Implants

Sunday, February 1st, 2015

 

Treatment of the tear trough has become quite common since it has been recognized as an aesthetic deformity. A sunken in appearance in the inner aspect of the lower eyelid creates an indentation or trough that creates a shadow and the appearance of being tired or older. Its treatment has become popularized due to the use of injectable fillers. They offer a simple and usually very effective solution for tear troughs by adding volume to the depressed afrea

But even very successful tear trough treatments with injectable fillers is not a permanent solution. While hyaluronic acid based fillers do persist for a year or longer along the orbital rim, they will eventually be resorbed. Fat injections to the tear troughs may offer the potential for longer and maybe even a permanent solution but their take and survival is never a sure thing.

Tear Trough Implants Dr Barry Eppley IndianapolisScrew Fixation Tear Trough Implants Dr Barry Eppley IndianapolisAnother approach that offers a permanent solution is that of tear trough implants. Designed to be a bony augmentation implant to fill in the suborbital groove, it is placed through a lower eyelid incision. This makes it a good solution if one is having a lower blepharoplasty or is having other facial augmentations such as cheek implants. While they can be placed as an onlay in a soft tissue pocket, I prefer to secure their position using a small self-tapping 1.5mm screw. It is important to set the the screw into the implant so there is no possibility that it can be felt through the thin lower eyelid tissues.

Tear trough or suborbital implants offer a permanent solution to a recessed orbital rim in the inner half of the lower eyelid. For now such implants need to be placed through a lower eyelid incision. Future developments may allow a tear trough implant to be placed through an intraoral approach

Dr. Barry Eppley

Indianapolis, Indiana

Implant Options for Deep Glabellar Wrinkles/Furrows

Sunday, November 16th, 2014

 

The most common cosmetic treatment of the glabellar region is that of Botox injections. By decreasing the effects of the procerus and corrugator muscles, the creation of vertical glabellar wrinkles or furrows is diminished. But Botox only treats dynamic dynamic wrinkling and will not change static wrinkles which represent the long term effects of unrestrained dynamic glabellar muscle action.

For static glabellar wrinkles/furrows, this is where the role of injectable fillers comes into play. But very deep furrows, which are more of an inverted V shape, respond poorly to the push of injectable fillers because of their contracted indented nature. There is also the risk, albeit rare, of the risk of blindness that has been associated with the use of fillers in this area. An alternative treatment option is that of an implant.

In the December 2014 issue of the Annals of Plastic Surgery, an article was published entitled ‘Correction of Deep Static Glabellar Lines With Acellular Dermal Matrix Insertion’. In this paper the authors inserted a strip of acellular dermal matrix (ADM) underneath deep glabellar wrinkle lines. Over a three year period, thirty patients were implanted and then evaluated using the Lemperle scale for wrinkle depth assessment as well as patient questionnaires. No infections or material complications were seen. They reported that the improvement in the reduction of the depth of the glabellar furrow was sustained for a long time. This clinical study shows that this type of glabellar implant is simple and easy to do as well as effective. For deep glabellar furrows that do not correct well with an injectable filler, implant insertion is another treatment option.

Glabellar Implants Dr Barry Eppley IndianapolisThere is no question that deep glabellar furrows treated with an injectable filler can be disappointing. I have tried over the years a variety of allogeneic, autogenous and alloplastic implants into the deep glabellar furrow. The use of human (e.g., Alloderm) or even animal-derived (e.g. Permacol) materials offer an easy approach since they have easy availability by just opening the package. Fat, particularly a small dermal-fat graft, can also be effectively used but does require a graft harvest site. Synthetic materials can also be used, having placed Advanta (Gore-tex) tube in the past and more recently soft silicone tubes. (Permalip)

Because the glabellar furrow is a straight line and short, it is easy to thread almost any material into it. Whether any of the mentioned materials is better than another can be debated but all offer some degree of sustained improvement in the deep and problematic glabellar furrow.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Widening Implants

Tuesday, September 9th, 2014

 

Facial implants are commonly used to augment various areas of the face. While historically this had been relegated to the cheeks and chin, their use has been widely extended to many other facial areas as well. One of the newer areas of facial implant use has been the temporal region for correction of excessive temporal hollowing or concavity.

Zone 1 temporal implant results Dr Barry Eppley IndianapolisTemporal implants are uniquely different from almost all other facial implants because they do not augment bone. Rather they are soft tissue implants that augment the amount of muscle volume that exists in the temporal region. What causes temporal hollowing is loss of fat volume and/or muscle, not a change in bone volume. While augmenting the anterior aspect of the temporal bone can be done, it would require a large implant placed very deep under the muscle to create that effect. It is far simpler and more effective to place a smaller implant right under the fascia on top of the muscle which is how newer temporal implants are done today.

High Temporal; Implant Design for Forehead Widening Dr Barry Eppley IndianapolisTraditional temporal hollowing involves the lower half of non-hair bearing aspect of the temporal region just to the side of the eye. (lateral orbit) This is referred to as the Zone 1 temporal region. But other temporal areas can be augmented as well for different aesthetic effects. One of these is the Zone 2 temporal region. This is the upper half of the non-hair bearing area (above Zone 1) which is more to the side of the forehead than it is the eye. It abuts right up against the anterior temporal line of the forehead. Thus augmenting the temporal zone 2 creates a forehead widening effect.

high temporal implant Dr Barry Eppley IndianapolisZone 2 temporal implants, like Zone 1, are placed under the fascia from a small incision in the temporal scalp area. While they are subfascial, the temporalis muscle gets very thin as it approaches the forehead. In addition, the underlying temporal bone no longer is concave but starts to become almost convex as it merges into the forehead. Thus a Zone 2 temporal implant is closer to being a bony augmentation technique rather than a purely muscle implant like Zone 1.

Widening the forehead has been traditionally very difficult. Extending bone cements from a forehead augmentation onto the temporalis fascia can result in a visible line of the material and discomfort. Fat injections can be done but their survival and smoothness if far from assured. Custom silicone implants can be made for forehead augmentation that extends onto the temporalis fascia to both augment projection and width of the forehead. But for those patients that just want a little more forehead widening only, there have been no options to date.

Forehead Widening Implant result Dr Barry Eppley IndianapolisForehead Widening Implant result 2 Dr Barry Eppley IndianapolisZone 2 temporal or forehead widening implants offer s a simple and effective solution to those patients that would like to see just a slight increase in their horizontal forehead width. By placing an implant just to the side of the anterior temporal line under the fascia,  the forehead can be made wider in appearance. This procedure, like Zone 1 temporal implants, has a very rapid recovery with little swelling and discomfort afterwards.

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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