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Posts Tagged ‘facial implants’

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

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

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

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 – 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

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

The Psychological Aspects of Facial Structural Surgery

Wednesday, March 21st, 2012

There are many reasons that patients request surgical changes to their face. With over twenty different facial regions that can be altered, there are seemingly endless options and combinations. But when you break it down, there are two main reasons for making cosmetic changes to the face. I divide these into either facial anti-aging surgery and facial structural surgery. For the most part, this is the difference between soft vs hard tissue facial surgery.

Anti-aging facial surgery includes many of the most recognizeable procedures such as a facelift, blepharoplasty (eyelid tucks) and skin resurfacing. These are done to counteract the effects caused by time, age and sun exposure. Changes are made to the soft tissues of the face, largely the outer skin layer. Facial structural surgery goes much deeper and makes changes to the bone and cartilage. The most common structural procedure historically is rhinoplasty but today includes everything from forehead augmentation and brow reduction down the face to chin and jaw angle augmentation.

Besides the tissue levels which these two types of cosmetic facial surgeries affect, there are also very significant psychological differences between them. Anti-aging facial surgery is more psychologically comfortable for patients because the goal is to take them back to once how they looked, a place in which there is familiarity. The surgery and recovery may be scary but the end result is a look that the patient can recognize and has known in the past. In contrast, structural facial surgery is very different. The end result is one that is not familiar. It is a new look, an alteration of a face that one has known their whole life.

Having done many facial structural procedures in my practice from rhinoplasty to jawline enhancement, I have made several observations about these types of plastic surgery. Some of these are not new and have been known in plastic surgery for a long time. But new technologies and biomaterials have changed what is possible today and with that comes new psychological ramifications for patients.

Changing the structure of one’s face obviously requires an understanding as to what the patient’s goals are. Patients provide that information by descriptions of their concerns and often provide visual aids such as drawings, self-photographs and photographs of other people. These are all really helpful and collectively important. But one concerning issue is the overuse of model or celebrity facial photos. Seeing too many of these or having a patient show a whole notebook of other people’s or famous face may be a sign of unrealistic expectations after surgery. While everyone willingly acknowledges that they can not look like someone else, whether they believe that or not may be another story.

To aid presurgical discussions and goals, I consider computer imaging essential to any facial structural surgery. For the psychological reasons previously mentioned, I rarely do it for anti-aging facial surgery but consider it essential for structural changes. But computer imaging can be misinterpreted and often is. It is not a guarantee of results and such imaged results may never actually be achieved. It is a communication tool about surgical goals and what a patient wants changed and the degree of those changes. It is only as good as the person doing it and is really an integration of surgical experience and how well one knows computer imaging technology. This is why a plastic surgeon should be doing the imaging, for only they know what can really be achieved by different types of facial surgery. But even in the best of hands, a patient should not assume that is exactly the way they will look after surgery. It is an estimate or prediction but human tissues induce more variables than pixels on a computer screen.

When going through structural facial surgery, the recovery is going to be longer and more psychologically difficult that most patients envision. The swelling and bruising on the face can be quite shocking and no patient is ever really prepared for it. When the dressings, splints or sutures come out days or a week later, it is not a moment of celebration or expectation. It is just the first step in the recovery process. One is not looking at the final result and, depending upon the procedure(s) being done, full recovery is not just a few weeks away.

Facial areas will be puffy, swollen and distorted and usually far more than one anticipates. It may be significant or not all that bad, but this is not the time to judge the results. More importantly, and I have seen this many times, one should not assume that the changes are too big and need an immediate revisional surgery. What appears too big at two or three weeks after surgery may be just perfect at two or three months. My minimal time for judgment of facial structural surgery results is three months and I will not consider any revision before then unless they are compelling medical reasons. (e.g., infection) One should not attempt aesthetic revision on a moving target.

When three or more structural facial procedures are done at the same time, the appearance of the face the first few weeks after surgery can be very disturbing. Patients will often feel that they have made a mistake and even wish to return to how they looked before even though they obviously did not care for that appearance. Such after surgery appearances disrupt work and social interactions but are part of the process. If one thinks they will go back to work in two or three weeks after such surgery and will look perfectly normal…this is not realistic. Plan accordingly and I mean this from a psychological perspective. Living through the process of facial swelling resolution and tissue adapation around the bone or implant shape requires tolerance, explanations and even an openness about what has been done if necessary.

One of the most important considerations about structural facial surgery is an appreciation that the risk of needing revisional surgery is significant. At the least, it is much higher than that of a facelift or eyelid surgery. On the most simplistic level, let’s compare the risk of complications/revisional surgery of eyelid surgery (1 % to 2%) vs a chin implant (5% to 7%) in my experience. Both are fairly straightforward and relatively simple procedures. But the use of an implant introduces issues of infection, malposition and size and shape issues that do not exist as much in manipulating one’s natural skin. Now multiple that times the number of facial structure procedures being done, each with their own percent of risk, and it is easy to see why the risk of revisional surgery in facial structural surgery is significant.

For example, take a patient who is having rhinoplasty (5% revision risk), a chin implant (5% revision risk) and jaw angle implants (10% revision risk) done as a single procedure. On an additive risk basis, the real risk of revisional surgery in this case is 20% or higher, If you take more extreme cases of five or more facial structural procedures being done at the same time (a not uncommon collection of procedures in my practice), the potential risk of revisional surgery could be as high as 50%. This doesn’t mean that the complications are devastating or severe but are almost always about symmetry and the size of the changes done in the various areas. It is hard aesthetically to make so many facial changes and have them all look perfect afterwards…particularly when one is not precisely sure how they will interpret the changes.

Facial structural surgery can make significant aesthetic changes to either give the face a better shape, more definition and improved balance or to improve asymmetries between the two sides. But it is harder surgery to undergo both in planning and during recovery and has a higher risk of the need for revisional surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Aesthetic Principles Of Facial Implant Augmentation

Monday, January 30th, 2012

Implants have been an important part of aesthetic facial surgery for over fifty years. Starting originally as just small implants for chin augmentation, they have evolved into a large line of bone-based implant shapes and sizes. They are commercially available today for just about every conceivable area of facial bone augmentation from the skull down to every zone region of the mandible. While chin and cheek implants constitute the most widely used facial implants, many other augmentation areas are becoming more recognized as useful such as jaw angles, submalar, infraorbital and temporal implants.

With the emergence of synthetic injectable fillers and autogenous fat injections, many surgeons have chosen to use these less invasive techniques for facial augmentation. While their simplicity is very appealing, such injectable filling methods are best used for soft tissue augmentation of facial areas not supported by bone. While they can be effective for augmenting facial bony prominences, their cost and lack of guaranteed volume preservation ensures that synthetic implants will continue to play a valuable role in aesthetic facial augmentation.

Like any implant placed in the body, there are known complications with their use. While infection, implant malposition and implant exposure are the medical risks of facial implants and always require revisional surgery to sure, there are also aesthetic risks as well, These include implants that are too big, too small, or the creation of an undesired aesthetic effect. While good surgical technique and implant placement are extremely important keys to prevent the medical complications, the aesthetic complications can be more difficult to avoid as this remains the artistic side of the procedure.

Over the years, I have come to appreciate several aesthetic guidelines of using facial implants successfully. These relate to the more obscure principles of facial implants that have little to do with surgical technique. It is about how to select and place the best implant style and size.

The first aesthetic facial principle is that the biomaterial composition of the implant is not that important. Implant selection should first focus on the right style and design of the implant regardless of its material composition. While many different manufacturers and surgeons tout the benefits of different biomaterials, the reality is that none are perfect. All of them have different handling and placement characteristics but they all work equally well from a biologic standpoint. The body sees all implant materials as the essentially the same, not a natural part of the body. It will create a layer of scar around all implant materials known as a capsule. Implants with more porous or irregular surfaces will have this capsule become more adherent to it but this should not be confused with true integration into one’s own tissues.

The second aesthetic facial implant principle is that the effects of facial volume change from implants is not completely predictable. While both surgeons and sometimes even patients take measurements on x-rays, drawings and computer images in an attempt to select the right implant size, the overlying facial soft tissues will not necessarily respond in a 1:1 or direct linear fashion. Measurements taken on pictures and facial skeleytal models can not take into account the thickness of the soft tissues between the implant and the outer facial appearance. While it is important to have some method in choosing an implant’s size, patients should know that it is far from an exact science. The most common implant size problem is that it is too big, usually not because it is too small. This is particularly true as one moves up to facial bone areas above the mandible where the soft tissues become thinner. When in doubt, choose a smaller implant size. It can be surprising how much of a difference a small implant off of the operating table.

The third aesthetic facial principle is that implants may need be modified during surgery. Implants are made based on average dimensions and in a range of sizes to try and fit the most number of patients possible. But not every implant style and all sizes for any given facial area can be available for every procedure. The use of implant sizers, which are available from most manufacturers, is very helpful during surgery particularly in choosing implant size. But when in doubt shape or carve implants for custom adaptation if needed. All implant materials are fairly easy to shape with either a scalp, scissors or even a burr for more inelastic materials.

Applying these three aesthetic facial implant principles, best implant style regardless of material composition, conservative size selection and intraoperative implant modification if needed, will help improve aesthetic results and decrease the need for revisional surgery.

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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