Complications of facial implants

The Biocompatibility and the Effect of Titanium and PEKK on the Osseointegration of Customized Facial Implants

The purpose of this study was to investigate the optimization of computer-aided design/computer-aided manufacturing (CAD/CAM) patient-specific implants for mandibular facial bone defects and compare the biocompatibility and osseointegration of machined titanium (Ma), Sandblasted/Large-grit/Acid-etched (SLA) titanium, and polyetherketoneketone (PEKK) facial implants. We hypothesized that the facial implants made of SLA titanium had superior osseointegration when applied to the gonial angle defect and prevented the senile atrophy of the bone. Histologic findings of the soft-tissue reaction, hard-tissue reaction, and bone-implant contact (BIC (%) of 24 Ma, SLA, and PEKK facial implants at 8 and 12 weeks were investigated. There was no statistical difference in the soft tissue reaction. Bone was formed below the periosteum in all facial implants at 12 weeks and the BIC values were significantly different at both 8 and 12 weeks (p < 0.05). Ma, SLA, and PEKK facial implants are biocompatible with osseointegration properties. SLA can enhance osseointegration and provoke minimal soft tissue reactions, making them the most suitable choice. They provide an excellent environment for bone regeneration and, over the long term, may prevent atrophy caused by an aging mandible. The bone formation between the lateral surface of the facial implant and periosteum may assist in osseointegration and stabilization.

Facial Implants in Male Rejuvenation

Many different methods achieve male facial augmentation. Arranged from shorter- to longer-term results, these methods include filler, fat/tissue grafting, fat/tissue transposition, and alloplastic implants. This study solely reviews allografts, which provide the most predictable hard-tissue augmentation. An array of alloplasts will be discussed in this study including chin, cheek, mandibular angle, frontal, and temporal implants. The most common and severe complications will also be explored with preventative and treatment algorithms.

Transoral endoscopic thyroid surgery via vestibular approach with silastic chin augmentation genioplasty

From July 2020 to March 2022, 3 patients with papillary thyroid cancer (PTC) and microgenia underwent transoral endoscopic thyroid surgery via a vestibular approach or a endoscopic lateral neck dissection via the breast and transoral approaches with chin silastic augmentation genioplasty performed concurrently. Image documentation, patient satisfaction, complications and other factors such as demographics and clinicopathologic details were recorded. None of the patients developed major complications and there were no complications such as infection or displacement of the implant. All patients were satisfied with the cosmetic outcomes. Despite the study being limited to these 3 selected patients with PTC and microgenia, the follow-up to our initial description of the new technique established its safety and efficacy.

Silicone Facial Implants, to Fixate or Not to Fixate: A Narrative Review

Silicone implants are one of the most widely used implants for facial augmentation, especially in the chin, mandibular angle, and malar area, utilizing different surgical approaches. Despite their various advantages, many complications have also been reported, including hematoma, infection, bone resorption, numbness, displacement, and asymmetry. This study aims to evaluate the need for facial-implant fixation and compare and contrast fixated and nonfixated facial silicone implants in different facial sites. A narrative review of the topic of facial-implant stabilization using the PubMed database inclusion criteria included articles that discussed the topic of facial implants, were published in English, and included critical information such as the location of the implant, type of stabilization, follow-up periods, and complications. A total of 11 studies were included. Of these, two were prospective clinical studies, three were case series, and the remaining six were retrospective clinical studies. The studies were published between 1995 and 2018. The sample size varied from 2 to 601 cases. Stabilization includes suturing, monocortical screws, or no stabilization. Complications were reported in most of these studies, including asymmetry, bone resorption or erosion, displacement, dissatisfaction, edema, hematoma, infection, mucosal irritation, pain, and paresthesia. The follow-up period ranged from one month to 17 years. Despite the varied settings of these studies, silicone facial implant complications were reported in both fixated and nonfixated implants, with a lack of significant differences between fixated and nonfixated facial silicone implants regarding the method of fixation.

Tear Trough Malar Implant Penetrating Lacrimal Sac Causing Lacrimal Obstruction and Epiphora: Case Report and Review

Tear trough implantation may be associated with a number of well-reported complications. To our knowledge, penetration of the lacrimal sac has never been reported as a complication of malar or tear trough implants. We report a case of lacrimal sac penetration discovered at the time of endoscopic dacryocystorhinostomy surgery in a patient who developed epiphora soon after the tear trough implant was placed.

Hyperbaric Oxygen Therapy: An Effective Auxiliary Treatment Method for Large Jaw Cysts

Background: To evaluate hyperbaric oxygen therapy (HBOT) on infection rates and repair rates during the treatment of large jaw cysts. Methods: A prospective randomized, non-blinded, controlled clinical trial included 90 patients with jaw cysts, randomly divided into three groups. Patients were treated with enucleations and bone substitute was used in the experimental and control groups. The experimental group received HBOT. The primary predictor variable was HBOT. The infection rate, repair rate, preoperative volume of the jaw cysts, age, and sex were statistically analyzed. The Fisher exact test was used to compare the infection rate and postoperative complications. The repair rate of the bone defects was analyzed using the repeated-measures analysis of variance and the least significant difference tests. The Kendall's coefficient of concordance and Kappa statistics were calculated to evaluate the consistency between the two investigators. Results: The infection rate was 3.4% in the experimental group, 14.3% in the blank group, and 32.1% in the control group (P<0.05). The repair rate in the experimental group was significantly higher than in the control and blank groups at 1, 3 and 6 months after surgery (P<0.05). Conclusion: The results showed that HBOT reduced the postoperative infection rate following the enucleation of large jaw cysts with bone substitute filling, and it also improved the bone repair rate.

Patient-specific Implant for Temporomandibular Joint Replacement in Juvenile Arthritis and Facial Asymmetry

The aim of this report is to present a patient with juvenile arthritis, condylar resorption, and residual facial asymmetry treated with orthognathic surgery and unilateral joint replacement with a full three-dimensional computer-aided design and computer-aided manufacture (CAD-CAM) temporomandibular joint (TMJ) prosthesis, including an increase in the left ramus and mandibular angle to achieve facial symmetry. The patient, a 30-year-old male, came to our department for orthosurgical treatment. The patient had been receiving treatment for juvenile arthritis for 15 years; at facial level, he had a chin deviation of 12 mm from the facial midline, maxillary retrusion, and Angle Class III. The computed tomography revealed a reduced height of the left condyle and a significant difference in the morphology of the mandibular ramus and angle. Using CAD-CAM technology and additive manufacturing, a TMJ prosthesis was produced, through the use of the mirror image, orthognathic surgery was realized using the right side as “esthetic side” with suitable shape and angulation. The prosthesis was created, and this was taken to the surgery. The surgery was performed without problems, a mouth opening of 35 mm and absence of pain were noted after 12 months of follow-up. The surgery remained stable, and facial symmetry was restored. In conclusion, it is viable to develop a TMJ prosthesis by CAD-CAM that includes esthetic modifications to the face; prospective and clinical studies must be conducted to confirm protocols. Level of Evidence: V.

Zygomaticomaxillary "lateral swing" osteotomy for augmentation of midface deficiency

Introduction:

Various surgical modalities have been proposed for the augmentation of midface deficiency without correction of the occlusal component. They include autogenous bone and cartilage grafts, alloplastic materials, and osteotomies. We propose an innovative osteotomy technique for augmentation of the midface including the infraorbital rims, the zygoma, the anterior maxillae, and the paranasal areas without advancing the dental-bearing segment.

Materials and Methods:

This procedure was carried out on a 21-year-old male patient who had a deficiency of the anterior maxillae including the infraorbital rims. His occlusion was in Class I molar relation. The surgical exposure was carried out through a midface degloving approach. This bilateral osteotomy encompasses the anterior maxillae and the zygoma; the osteotomy line running superiorly from the medial aspect of the infra-orbital rim to the root of the frontal process of maxilla. Inferiorly, the line runs above the apices of the maxillary teeth laterally underneath the zygomatic buttress, separating part of the zygomaticomaxillary suture posteriorly. Medially, the osteotomy line runs parallel to the piriform aperture. The osteotomy is pedicled on the zygomaticotemporal suture. A greenstick fracture at the zygomatic arch pedicled the osteotomized segment to the zygomatic process of the temporal bone. The entire segment was swung laterally outward, effectively separating part of the zygomaticomaxillary suture posteriorly. Fixation was achieved with a single 2-mm L-shaped, 4-hole plate with gap at the zygomatic buttress region.

Results:

This osteotomy technique resulted in fullness of the anterior maxillae and infraorbital rims, with increased anterior and lateral projection of the zygoma.

Conclusion:

The zygomaticomaxillary “lateral swing” osteotomy is a reliable and stable technique for total midface augmentation not requiring occlusion correction.

Alloplastic Facial Implants: A Systematic Review and Meta-Analysis on Outcomes and Uses in Aesthetic and Reconstructive Plastic Surgery

BACKGROUND

Alloplastic materials in facial surgery have been used successfully for various applications in the reconstructive restoration or aesthetic augmentation of the facial skeleton. The objective of this study was to conduct a comprehensive systematic review of alloplastic implant materials utilized to augment the facial skeleton stratified by anatomical distribution, indication, specific material used, and respective outcomes.

METHODS

A comprehensive systematic review on alloplastic facial implant data was conducted utilizing Medline/PubMed database. Articles were stratified by (1) anatomic localization in the face, as well as (2) alloplastic material.

RESULTS

A total of 17 studies (n = 2100 patients, follow-up range = 1 month-27 years) were included. Overall, mersilene mesh implants were associated with the highest risk of infection (3.38%). Methyl methacrylate implants were associated with the highest rate of hematoma (5.98%). Implants placed in the malar region (2.67%) and frontal bones (2.50%) were associated with the highest rates of infection. Implants placed in the periorbital region were associated with the highest rate of inflammation (8.0%), explantation (8.0%), and poor cosmetic outcome (17.0%). Porous implants were shown to be more likely to potentiate infection than non-porous implant types.

CONCLUSIONS

Alloplastic facial implants are a reliable means of restoring facial symmetry and achieving facial skeletal augmentation with a relatively low complication profile. It is important for plastic surgeons to understand the relative risks for each type of implant to develop postoperative complications or poor long-term cosmetic results. Interestingly, porous implants were shown to be more likely to potentiate infection than non-porous implant types.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The accuracy of virtual-surgical-planning-assisted treatment of hemifacial microsomia in adult patients: distraction osteogenesis vs. orthognathic surgery

Hemifacial microsomia (HFM) is a common congenital craniofacial deformity with a high prevalence. Orthognathic surgery and distraction osteogenesis are two conventionally used treatments of HFM. The main objective of this retrospective study was to evaluate the accuracy of two treatments with the help of virtual surgical planning in adult HFM patients. Sixty-eight adult patients with unilateral HFM were enrolled in this study. Preoperative surgical planning and simulation were performed on three-dimensional computed tomography models. Orthognathic surgery or distraction osteogenesis was performed under the guidance of three-dimensional surgical templates. Postoperative evaluation of the intervention was performed by comparison of the affected ramus height, chin deviation and the occlusal cant in surgical planning and actual result. Outcome and feedback information (an average of 14 months) showed that virtual surgical planning was accurately transferred to actual surgery in both surgical approaches. There were no statistical differences between the accuracy of affected ramus height and the occlusal cant in two surgical approaches. The orthognathic group showed significantly higher accuracy in chin deviation. In conclusion, virtual surgical planning and three-dimensional surgical templates were proved to facilitate treatment planning and offer an accurate surgical result in the treatment of adult HFM patients.

[Prosthetic genioplasty versus osseous genioplasty in aesthetic chin augmentation: Literature review and knowledge update]

Chin augmentation is commonly practiced, whether in microgenia treatment, in cases of orthognathic or cosmetic surgery. Located at the crossroads of many specialties, the technique choice still differs according to the surgeon specialiy. A large number of publications on the subject are available. A comparaison between different surgical methods is therefore possible concerning their indications and their complication. The purpose of this study was to carry out a literature review, with updating knowledge, as well as a synthesis indication regarding aesthetic osseous and alloplastic genioplasty. Despite the generalization of "modern" implants in France, prosthetic genioplasty remains more frequently the source of serious complications (infections, extrusions, bone erosions). Similarly, this technique has much more limited indications than osseous genioplasty, which has the advantage of a better longevity. In order to increase the aesthetic appearance of the chin, osseous genioplasty should be performed more easily and more frequently by surgeons on all sides.

A Review of Complications and Their Treatments in Facial Aesthetic Surgery

Aesthetic surgery has become increasingly popular in the last several decades, with facial aesthetic surgery accounting for a large percentage of the procedures performed. With this surge in popularity and the increase in the number of cosmetic surgeries and procedures completed, comes an inevitable increase in the number of complications encountered. This review elucidates common complications and effective management of frequently performed cosmetic facial surgeries. This article represents a general overview of the topic. For a more exhaustive review, the reader is encouraged to turn their attention to the facial plastics and additional surgical subspecialty literature. Aesthetic procedures discussed in this article include rhinoplasty, rhytidectomy, facial augmentation, otoplasty, brow lift, blepharoplasty, skin resurfacing and chemical peels, and facial injections.

The use of expanded polytetrafluoroethylene in depressed deformities of the face

Expanded polytetrafluoroethylene (ePTFE) has been extensively used for facial soft tissue augmentation procedures, and is regarded as safe and reliable and suitable as a permanent implant. This implant is generally used in the lower third of the face for lips filling, nasal augmentation, nasolabial folds and chin augmentation, and rarely for congenital or acquired depressed deformities of the face. The aim of the present study was to assess the effects of ePTFE in congenital or acquired depressed deformities of the face. From September, 2008 to January, 2014, 26 patients were implanted with the material ePTFE to correct depressed deformities of the face. The average age at operation was 23.2 years, with a range of 17-45 years. The depressed deformities were lateralized. The follow-up period was 6-18 months (average 9 months). The etiologies of the depressed deformities included stable hemifacial atrophy (3 cases), craniofacial microsomia (13 cases), bony depression after trauma (8 cases), and other unclear reasons (2 cases). The operations were performed under local anesthesia. ePTFE was inserted in different tissue planes that varied among the different subanatomical areas in the face: beneath the superficial temporal fascia in the temporal area, and on the surface of the superficial musculoaponeurotic system in the zygomatic area, cheek and mandibular area. All of the patients were followed up. Most of the patients [25 of 26 patients (96.2%)] were satisfied with the results, while 1 patient (3.8%) was not satisfied for incomplete correction of the depressed deformity. In conclusion, aside from lipofilling and a free flap transfer, the results showed that ePTFE was an alternative treatment for facial depressed deformity.

Aesthetic occiput augmentation using methylmethacrylate

Cranioplasty for only aesthetic reasons has not been commonly performed to date. However, recently there has been a new focus by the public on a more aesthetically pleasing head shape with frequent patient requests for purely aesthetic contouring of the occiput, an important definer of cosmetic head shape. For example, in Asia, where the normal cranial shape is mesocephalic or brachycephalic and often with a planar occiput, requests for its aesthetic correction are increasingly common. Accordingly, the author developed a minimally invasive occiput augmentation using methylmethacrylate. In this study, the indications for aesthetic occiput contouring were planar occiput, left-right asymmetric occiput, and grooved occiput. Under local anesthesia, soft methylmethacrylate is subperiosteally inserted through a small incision (about 5-cm length), manually and precisely contoured in situ through the scalp to the desired occipital shape. All is performed as an outpatient procedure, and a quick recovery is the case. Between March 2007 and October 2013, 959 patients received such aesthetic occiput augmentation. The mean follow-up period was 49 months (range, 3-84 months). Nearly all patients were satisfied with the outcome, and complications were very rare. Only 5 patients (0.5%) needed additional corrective procedures. The author has concluded that aesthetic occiput augmentation using methylmethacrylate yields consistent, predictable, and satisfactory results. Additional long-term follow-up is required for a final conclusion, however.

Computer-aided design and rapid prototyping-assisted contouring of costal cartilage graft for facial reconstructive surgery

Complex 3-D defects of the facial skeleton are difficult to reconstruct with freehand carving of autogenous bone grafts. Onlay bone grafts are hard to carve and are associated with imprecise graft-bone interface contact and bony resorption. Autologous cartilage is well established in ear reconstruction as it is easy to carve and is associated with minimal resorption. In the present study, we aimed to reconstruct the hypoplastic orbitozygomatic region in a patient with left hemifacial microsomia using computer-aided design and rapid prototyping to facilitate costal cartilage carving and grafting. A three-step process of (1) 3-D reconstruction of the computed tomographic image, (2) mirroring the facial skeleton, and (3) modeling and rapid prototyping of the left orbitozygomaticomalar region and reconstruction template was performed. The template aided in donor site selection and extracorporeal contouring of the rib cartilage graft to allow for an accurate fit of the graft to the bony model prior to final fixation in the patient. We are able to refine the existing computer-aided design and rapid prototyping methods to allow for extracorporeal contouring of grafts and present rib cartilage as a good alternative to bone for autologous reconstruction.

Biocompatibility comparison of novel soft tissue implants vs commonly used biomaterials in a pig model

OBJECTIVE

To develop a model to evaluate biocompatibility, integration, and substrate independence of novel porous bioscaffolds for maxillofacial and plastic reconstruction using sphere-templated angiogenic regeneration technology compared with currently available synthetic and biologic soft tissue implants.

STUDY DESIGN

A prospective pilot study using animals.

SETTING

Military medical center.

SUBJECTS AND METHODS

Five pigs underwent dorsal subcutaneous implantation of a polypropylene-based material coated with precision pore silicone granules (sphere-templated scaffold), expanded polytetrafluoroethylene, human dermis, and porcine dermis. Sham and undissected sites were also used as controls. Specimens were harvested 7, 21, 90, and 180 days after surgery and evaluated histologically for inflammation, neovascularization, and collagen deposition.

RESULTS

All materials and sham sites induced a mild to moderate inflammation that decreased over time, except for human dermis, which elicited a moderate to severe inflammatory response. The responses were varied and measurable using subjective scoring methods. The sphere-templated scaffold demonstrated numerous foreign body giant cells adjacent to the silicone granules, which were not seen in any of the other specimens.

CONCLUSION

Subjective scoring of pathology slides and measurement of capsule thickness appeared to show differences between the materials, but these differences require a larger number of subjects and proper statistical analysis to assess. The robust foreign body reaction elicited by the polypropylene/silicone-based scaffold argues against the use of this material in future studies. The authors advocate using inert biodegradable substances for future bioscaffold constructs.

Vertical incision intraoral silicone chin augmentation

OBJECTIVE

Solid silicone augmentation mentoplasty is a common procedure with consistent aesthetic results in properly selected patients. While many plastic surgeons employ the external approach, the intraoral method affords excellent aesthetic outcomes while avoiding an external scar. This is the largest series in the literature describing the midline intraoral incision approach with minimal disruption of soft tissues.

STUDY DESIGN

Case series.

SETTING

Academic medical center.

SUBJECTS AND METHODS

One hundred twenty-five patients underwent chin augmentation with solid silicone implants between 2004 and 2010. Among these implants, 105 were placed transorally. Eighty-five patients were followed for at least 1 year. Demographic information, indications, patient satisfaction questionnaire results, and complications were recorded.

RESULTS

All implants yielded satisfactory results with no displacement, infection, tissue reaction, lower lip incompetence, mental nerve injury, or intraoral implant contamination. Two cases of superficial mucosal irritation at the suture site were observed and resolved without consequence. Symmetry, projection, and overall balance of facial components were excellent. Although all patients were satisfied with the functional and aesthetic results, 20% stated they would like further augmentation. Patients were extremely satisfied with the lack of an external scar.

CONCLUSIONS

Based on our series, the intraoral technique with a midline incision avoiding disruption of the mentalis muscle is recommended for its ease, simplicity, patient satisfaction, low complication rate, and circumvention of an external scar. The external approach should be considered in cases that require a very large implant.