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Posts Tagged ‘chin implant revision’

Case Study – Chin Implant Revision

Saturday, May 21st, 2016

 

Background: Chin augmentation is one of the original facial reshaping surgeries and has been performed for decades. Whether done through the mouth or done from an incision below the chin, the fundamental concept is that an implant is placed over the central aspect of the lower chin bone. (pogonion)

While the basic technique for chin augmentation has not changed over the years, the styles of chin implants has. Chin implant shapes have evolved to be large with long lateral wings. Known as anatomic chin implants, these lateral wings are added to the implant to allow it to transition more smoothly into the lower border of the jaw behind the chin.

While this lateral wing concept has its merits, it is also prone to creating chin implant asymmetry. Even slight amounts of chin implant rotation can cause the end of the wings to be asymmetric. The higher wing can even be felt inside the mouth as it encroaches into  the vestibule and may even put pressure on the mental nerve.

Chin Implant MalpositionCase Study: This 67 year-old female had two previous chin implants. An initial larger implant was placed two years ago and subsequently downsized due to dissatisfaction with its size. Once the swelling subsided the patient noticed an asymmetry of the chin with a higher wing on the right side.  The implant asymmetry was seen externally across her chin. She could feel it inside her mouth at the gumline on the right side which caused intermittent tingling and numbness sensations on the right side of her lip.

Chin Implant Malposition surgery Dr Barry Eppley IndianapolisChin Implant Repositioning surgery Dr Barry Epley IndianapolisUnder general anesthesia, her chin implant was approached through her existing submental incision. The chin implant was found to be located about 1 cm above the lower border of the chin bone and the midline shifted to the right with obvious canting of the implant. The implant was removed, the lateral wings reduced and the implant pocket adjusted. The chin implant was out back in a central position lower on the bone and secured with a single 1.5mm screw.

Chin implant malposition is especially prone when a large implant is replaced with a smaller one. The smooth surface of silicone implant makes it especially prone to sliding around on the smooth underlying capsular layer. This is where the value of placing a single screw ca be invaluable in its prevention and/or correction.

Highlights:

1) Chin implant malposition is not an uncommon complication of chin augmentation surgery.

2) With today’s winged chin implants, asymmetry of the lateral wings of the implants can easily occur.

3) Chin implant revision surgery creates a new pocket for the implant and secures it centrally with a screw placed in the midline.

Dr. Barry Eppley

Indianapolis, Indiana

The Removal Of Medpor Chin Implants

Sunday, May 15th, 2011

The most common method of chin augmentation is to use a synthetic implant. While there are a large number of chin implant sizes and styles, the compositions of them are more limited. The two most commonly used materials for chin implants are silicone elastomer and porous polyethylene. (Medpor) Each has their own merits and surgeon advocates but both can work well with good placement technique.

One of the highly touted advantages of Medpor implants is that they develop some degree of tissue ingrowth due to its semi-porous material property . This is opposed to the completely smooth surface of silicone implants which develop a surrounding scar capsule instead. While this tissue ingrowth is advantageous for long-term implant stability, it also makes the removal of Medpor facial implants difficult.

The difficulty with removing Medpor facial implants is well chronicled, particularly across the internet. Despite this purported difficulty, I have not had the same experience. Over the years, I have had the opportunity to remove or remove and replace numerous Medpor implants, most commonly those of the chin. While they are more difficult to remove than silicone implants, which literally slide right out, that difference in difficulty is only a comparative one. They are not impossible to remove nor are they ‘extensively destructive’ to the surrounding tissues to do so.

Many times in their removal it is easier to remove them in pieces as they fragment fairly easily. Here is a recent case I did where another surgeon secured a chin implant in with 8 screws! While I am a fan of screw fixation  for facial implants, the reason for 8 screws in a single chin implant is  unclear. With so many screws, the Medpor chin implant needed to be removed in pieces to access all of the screws.

A new Medpor chin implant, of a different size and style, was inserted and secured with two new screws. The underlying bone showed no resorption and the overlying soft tissues had but a thin capsule. There was nothing abnormal about the revised chin implant site.

Medpor facial implants should not be viewed as overly difficult or destructive to remove should they need be. The material easily fragments helping preserve the tissue quality of the recipient site.  

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Chin Augmentation Revision with Implant Exchange and Repositioning

Monday, January 10th, 2011

Background:  Chin augmentation is the original and the most common area of facial skeletal enhancement. As a projecting edge of bone that is fairly easy to access, placing a chin implant is understandably perceived as a very simple and near error-free facial implant procedure. Despite this commonly-held belief, however, chin implants do have problems and need to be revised, replaced, or even removed.  

There are two common chin implant problems, malpositioning and implant selection. Malpositioning of a chin implant can occur in two different ways. Superior or upward migration of the implant usually occurs if it is placed from inside the mouth. While the intraoral approach avoids an external incision, its path of dissection provides an avenue for the implant to slide up along the bone afterwards. Lateral or wing malpositioning is actually the most common problem and is a result of the newer styles having thin and more floppy wing extensions which can easily fold onto themselves. Chin implants can also have size (undersized, oversized) and style (too wide, too narrow) problems which is a preoperative diagnosis and selection issue.

Case Study: This 40 year-old male was unhappy with the result of his chin augmentation. He had two prior chin implant procedures. They were done from an intraoral incisional approach. He felt that his chin was still not defined and prominent enough. He wanted a more masculine chin appearance. He had a record of his indwelling chin implant which was silicone in composition,7mms in projection, with limited lateral wings.

To improve his chin result, two different approaches were discussed for a revisional surgery. First, use a submental skin incision to remove the existing implant and replace a new one at the lowest position on the bone. Secondly, a different implant style would be used that had greater lateral extensions to add more lateral chin fullness and width.

During surgery, the submental incision was done but no implant was found at the inferior border of the chin. Located 14mms above the chin border, an implant was found and removed. There was 2 to 3mms of bone resorption underneath the implant when it was removed. Pockets  were dissected out along the  lower border of the jaw from the midline about 4.5 cms per side. A new chin implant style, a chin-prejowl design, was then inserted. Pulled down to the lower edge of the bone, the implant was secured with a single 12mm long titanium screw.

The immediate results of this chin implant exchange and repositioning can be seen just one hour after surgery. The chin had more lateral fullness and better horizontal projection, particularly at the low edge of the chin bone which is the most important point of increasing its projection.  

Case Highlights:

1)      Chin augmentation requires proper placement of the implant on the bone. Intraoral chin augmentation is prone to superior implant migration and malpositioning.

 

2)      Replacement of a highly positioned chin implant is best done from a submental approach with screw fixation.

 

3)      In the male chin augmentation, consideration needs to be given to an implant design that provides more lateral fullness and extends back further towards the body of the mandible.

Dr. Barry Eppley

Indianapolis, Indiana

 

 

  

 

Secondary Correction of Chin Implant Complications

Thursday, March 25th, 2010

Chin augmentation using an implant is a very common and highly successful procedure.With easy access to the front of the lower jaw (mandible) and few anatomic structures in which to be concerned about injuring, changes in the chin are quick and predictable. As a stand alone procedure or in combination with numerous other facial changes, chin implants provide a great tool for structural facial enhancement.

But like all implants used anywhere on the body, they are not complication-free. Mishaps and untoward outcomes do occur and secondary surgery is occasionally needed. Most of these problems are eminently improveable by implant adjustment or replacement and/or soft tissue modification.

Unhappiness with chin projection or shape after augmentation is a function of implant selection. There are now over seven styles of chin implants that offer more than a set amount of horizontal advancement. How far the implant goes back along the jawline and how much fullness to the side of the chin that is created can be altered by chin implant options that are now currently available. By comparison to the original operation, replacement with a new chin implant is a relatively easy operation since a pocket already exists. In some cases, a chin implant may have been asked to do too much. If the amount of forward chin movement needed is greater than 10mms, one may consider an osteotomy instead for such large chin changes. It will be prone to less potential complications.

Chin implants can shift as they are placed along a curved bone surface. Such shifting can occur horizontally or vertically. Most commonly, an implant that has shifted to the right or left is easy to spot as the central chin point is off-center. The center of the chin and its underlying implant should be along a vertical line drawn down from the center of the lower lip and through the midline between the mandibular central incisors. To prevent shifting during initial placement, a centrally-placed screw through the implant to the bone can be used. Similarly, correcting a deviated implant uses the same approach.

Vertical malposition (up too high) is usually the result of the implant being placed through an intraoral (inside the mouth) approach. With an open path from which it was inserted, it can easily slide up from the inferior border of the chin. It is more important to use a screw with the intraoral approach than from an incision under the chin where upward migration is limited by the  superior extent of the pocket dissection during placement.

One of the newer complications of contemporary chin implants (anatomic designs) is lateral wing malposition. While it is usually a benefit to have the implant extend back further along the jawline, it is necessary to have these wings tapered to blend into the bone as the implant ends. This makes the wings very thin and extremely flexible. It is quite easy for them to fold or bend at the back end of the pocket during placement. This can be felt as a bend or fold along the jawline at the implant-bone transition. The implant must be removed, the pocket extended and the implant re-inserted.

One of the well known chin augmentation problems does not involve an implant at all. When a chin implant is removed for whatever reason, the expanded soft tissues may not shrink back down. If they do not, and the larger the original implant the less likely they will, the chin soft tissues fall creating the classic witch’s chin deformity. This can be corrected by refilling the collapsed space with a new implant or an advancement osteotomy.  Another option is to remove the lax tissues and tighten them from underneath the chin. (a submental tuck-up)

Dr. Barry Eppley

Indianapolis, Indiana

Revision of Problematic Chin Implants and Associated Soft Tissue Issues

Friday, December 12th, 2008

Chin augmentation with an implant is a common and relatively simple operation in most cases. However like all plastic surgery procedures that require an implant to create much of the result, implant-related complications can occur. These complications can include inadequate to oversizing of the implant, infection, and shifting and malposition of the implant. Many chin implant problems can be solved by simple revisions such as adjusting the implant’s position or changing the implant’s size or shape.

One chin implant problem that poses a more difficult problem is fixing an implant that is too big or one that has to be removed in its entirety. Or the appearance of the chin after an implant has already been removed, known as a ‘witch’s chin’ deformity. The expanded soft tissues of the chin will not simply shrink back down and be like they were before the implant was ever placed. Just like removing a breast implant, the overlying expanded skin will sag after the support of the implant is lost.

Management of the soft tissues of the chin from implant expansion can be dealt with in several ways. If the augmentation of the original chin implant is still desired (but an implant is not), then the bone of the chin can be moved forward in a procedure known as an osteoplastic genioplasty. The forward movement of the bone will serve the same purpose as the implant and will ‘re-expand’ the soft tissue envelope of the chin. The mentalis muscle can also be further tightened from the inside of the mouth where this operation is performed. If the implant is not going to be replaced or was removed previously (and no new implant is desired), then the skin and muscle must be retightened. This is done using the original incision underneath the chin (or a new one must be made if the the chin implant was put in from inside the mouth) The loose muscle and skin is removed and tightened from below. This technique will prevent chin tissue sag after a chin implant is removed or will correct the witch’s chin deformity that exists from a prior chin implant removal.

In some cases, it may be possible to lift and tighten the sagging chin tissues from inside the mouth. This technique requires special suture-bone anchors or screws placed into the bone onto which sutures can be used to hold the new position of the lifted chin muscle.

Revision of chin implants requires knowledge and skill at performing a variety of chin procedures including moving the bone and methods to resuspend and retighten loose chin tissues.

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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