jawsurgeryforums.com
General Category => Aesthetics => Topic started by: ppsk on January 11, 2017, 11:30:13 AM
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There are only two implant results I have ever seen on the internet that i would consider good. A handful i would consider adequate. The rest serve to either make you wonder what the patient payed for or even make them look worse, bloated and what not.
Ive been thinking about this, and while you should take my amateur opinion with a grain of salt, i have to conclude this: it is not complicated technically to install jaw angle implants. I.e Its a prosthetic jaw angle that must be positioned over the real jaw angle. Theres not a whole lot of grey area.
So why then do jaw augmentation results frequently look s**t? Ruling out obvious cases of misalignment/poor placement, it seems obvious to me that the results must be down to A) the design of the implant and/or B) the material.
The latter aspect is what i want to discuss. Has anyone inspected/handled facial implants? I cannot shake my suspicion that a large reason for the lackluster results is because the most widely used material - silicone - is nothing at all like bone. Surgeons frequently seem to describe their preference for being able to "mold" and "shape" silicone in the room - this strikes me as odd. Imagine trying to shape or mold real bone, it wouldnt happen without some heavy tools, certainly heavier than a scalpel.
I suspect this is why the aesthetic outcome is frequently poor. The suggestion from surgeons like Eppley is that the "sharp jaw" look is not possible when the patient has fatty tissues, and I agree, but I highly doubt it is THAT rare to have a male patient, especially young ones, who are lean before the surgery. There is one example of this, but bizarrely, you have to dig through the annals of Eppley's blog to find it, and here are the results:
http://exploreplasticsurgery.com/case-study-9/
to be quite fair to Eppley, it is a GOOD result. But if you notice, there is a lack of projection around the gonion/angle despite the pronounced flare on the 3d image design, which i suspect is because the silicone is being compressed or "squished" by the powerful masseter muscle. I suspect even a good implant design and operation is let down by the material properties of silicone. Something much closer to bone in density and hardness, like PEEK, would provide superior results i assume.
There is only one surgery/surgeon i know of that explicitly uses PEEK for facial implants, and that is profilosurgical in Australia. If it is being used in the nanny worry wort bureaucratic nightmare state of Australia its is for damn sure being used elsewhere, but i am having no luck finding out.
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1) Silicone is inferior to medpor in terms of aesthetic result, longevity etc
2) Everyone who goes in for aesthetic surgery has a different deficiency. Sometimes it projection, sometimes its width, sometimes its angle, and often its a combination. If someone who needs a bimax or a chin wing or a side wing and goes in to epply for a consult hes getting custome implants, and the results will be underwhelming
3) Most young men who have jaw augmentation with implants opt not to have their pictures on the internet. Ive seen them in surgeons offices, and theyre good (with medpor)
4) Australia is also one of the only places that uses hydroxyapatite facial implants which seem to have incredible results as seen:
https://www.realself.com/review/melbourne-au-cheek-augmentation-chubby-droopy-face-weak-facial-bones
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1) Silicone is inferior to medpor in terms of aesthetic result, longevity etc
2) Everyone who goes in for aesthetic surgery has a different deficiency. Sometimes it projection, sometimes its width, sometimes its angle, and often its a combination. If someone who needs a bimax or a chin wing or a side wing and goes in to epply for a consult hes getting custome implants, and the results will be underwhelming
3) Most young men who have jaw augmentation with implants opt not to have their pictures on the internet. Ive seen them in surgeons offices, and theyre good (with medpor)
4) Australia is also one of the only places that uses hydroxyapatite facial implants which seem to have incredible results as seen:
https://www.realself.com/review/melbourne-au-cheek-augmentation-chubby-droopy-face-weak-facial-bones
So on 1. you would agree with me that the density and hardness of the material is crucial to its aesthetic outcome? This seems obvious to me but some surgeons insist otherwise. Anything that is flexible/soft enough to be forced through a small incision seems obvious to me it is flexible and soft enough to be compressed by the tissues of the face, not least the powerful masseter muscle. PEEK is similar to medpor i believe? except PEEK does not have the porosity (or maybe it does) for tissue ingrowth, which is the only area I believe medpor is not preferable to silicone (i would rather have the implant fixed in place by titanium screws than by tissue ingrowth)
If you dont mind answering, which surgeons did you see in office?
hydroxyapatite is interesting but I assume would be quite brittle and easily damaged by a blow to the face.
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That's the best HA result I've seen by a country mile.
I agree with others on the board, it seems like a fake review
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Ive seen a few surgeons, but theyre all in canada so i doubt youd be familliar.
Id consider the tissue ingrowth to be one of the reasons medpor is superior to silicone. Titanium screws are used in securing medpor implants as well in most cases (as is the case with my surgeon). The ingrowth and vasculization of the implant takes a few months, so if the immediate outcome isnt as expected revision isnt extensively difficult. Once the implant is vascularized there is essentially zero percent infection rate, whereas silastic implants can get infected years in the future.
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That's the best HA result I've seen by a country mile.
I've heard Brian Mendelsohn is a HUGE quack and an asshole. I think because he's offering something different he's really cashing in on that by aggressively posting about it and ramping up he website --I've seen it change radically over the past few years but GIVE ZERO real looking before and afters --it's all either unnoticeable or f**king photoshopped.
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I've heard Brian Mendelsohn is a HUGE quack and an asshole. I think because he's offering something different he's really cashing in on that by aggressively posting about it and ramping up he website --I've seen it change radically over the past few years but GIVE ZERO real looking before and afters --it's all either unnoticeable or f**king photoshopped.
Thats my impression too.
Its a bit on the nose when he is saying HA turns into real bone while other doctors who have also used HA are saying that it is simply does not.
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i think the general consensus is that it does not. However, the material is some of the closest we have in practice to day to the properties of real bone.
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Ive seen a few surgeons, but theyre all in canada so i doubt youd be familliar.
Id consider the tissue ingrowth to be one of the reasons medpor is superior to silicone. Titanium screws are used in securing medpor implants as well in most cases (as is the case with my surgeon). The ingrowth and vasculization of the implant takes a few months, so if the immediate outcome isnt as expected revision isnt extensively difficult. Once the implant is vascularized there is essentially zero percent infection rate, whereas silastic implants can get infected years in the future.
thats really interesting lefortitude
I thought medpor was discontinued, is this not the case?
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Once the implant is vascularized there is essentially zero percent infection rate, whereas silastic implants can get infected years in the future.
That's nonsense. An infection can always occur. The infection rate with medpor implants is between 5-10%. I agree that bone erosion with medpor cheek implants does NOT happen if the implant is properly secured with titanium screws which prevents it from shifting.
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Thats my impression too.
Its a bit on the nose when he is saying HA turns into real bone while other doctors who have also used HA are saying that it is simply does not.
Granules (HA):
70% of bone is made up of HA.
It has the ability to integrate in bone structures & support bone ingrowth, without breaking down or dissolving it (i.e it is bioactive).
HA doesn't turn into bone but bone grows around it, it is like telling bone where to grow (it is scientifically proven!).
Please take a look at M.M. power point presentation (first link).
https://www.google.de/?gws_rd=ssl#q=hydroxyapatite+mommaerts+ppt
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That's nonsense. An infection can always occur. The infection rate with medpor implants is between 5-10%. I agree that bone erosion with medpor cheek implants does NOT happen if the implant is properly secured with titanium screws which prevents it from shifting.
can you source that or are you just bias against implants?
http://link.springer.com/article/10.1007/BF00437109
that article "clinical experience with medpor porous polyethalyene implants" cites <2%
http://journals.lww.com/jcraniofacialsurgery/Citation/1993/07000/Use_of_Medpor_Porous_Polyethylene_Implants_in_140.7.aspx
this source cites less than 1% for the reason i stated above, which you so quickly dismissed as bulls**t. there are dozens more like it.
produce a source or ur talking out of ur ass
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It can only boil down to the shape and material, silicone will always look like putty, medpore gives great results if the shape is right. I have never seen PEEK but I know that is what Zurich University uses now, they previously used medpor so they must see some advantage to it.
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produce a source or ur talking out of ur ass
https://www.ncbi.nlm.nih.gov/pubmed/26276064
(...) followed by infection rate (7.2%)(...).
Most Medpor implants were placed at the mandibular angle and the orbital floor.
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It can only boil down to the shape and material, silicone will always look like putty, medpore gives great results if the shape is right. I have never seen PEEK but I know that is what Zurich University uses now, they previously used medpor so they must see some advantage to it.
Medpor implants are meant to be carved unless you're talking strictly customs. Dr's like medpor because of the (scar??) tissue ingrowth, less chance of rotation or movement long term, can be shaped during surgery, and (falsely) it doesn't cause bone resorption or have a significantly lower infection rate vs silicone.
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Medpor implants are meant to be carved unless you're talking strictly customs. Dr's like medpor because of the (scar??) tissue ingrowth, less chance of rotation or movement long term, can be shaped during surgery, and (falsely) it doesn't cause bone resorption or have a significantly lower infection rate vs silicone.
Interesting, I meant that they must see an advantage of using PEEK over medpor. I don't know anything about PEEK apart from the fact that it also causes resorption of the underlying bone.
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Interesting, I meant that they must see an advantage of using PEEK over medpor. I don't know anything about PEEK apart from the fact that it also causes resorption of the underlying bone.
Maybe because Peek can be 3d printed. 3d printing is the future.
"In our article, we described a series of patients whose reconstruction included the use of PEEK PSIs. After a follow-up period of 16 to 20 months, none of the patients experienced implant-related complications such as infection, extrusion, or malposition, while all improved with respect to aesthetics or function."
- Nice result btw:
http://medcad.net/wp-content/uploads/2015/07/PEEK_case_study.pdf
https://cmf.stryker.com/products/peek-customized-implant
http://www.mkprecision.com/why-peek-implants/
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Maybe because Peek can be 3d printed. 3d printing is the future.
Ah yes that must be it, the only problem with 3D printing is that when the surgeon puts the implant in they may think that the amount of augmentation was misjudged, I mean what looked good on the computer didn't turn out to be enough to normalize the defect or desired result.
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Medpor implants are meant to be carved unless you're talking strictly customs. Dr's like medpor because of the (scar??) tissue ingrowth, less chance of rotation or movement long term, can be shaped during surgery, and (falsely) it doesn't cause bone resorption or have a significantly lower infection rate vs silicone.
Recent reports have shown that the bone resorption observed in the past were caused by surgeons who used the fiberous ingrowth or musculature (i.e masseter muscle) to hold the implant in place (as opposed to screwing them in). As such, micro movements from facial animation over time lead to friction between the surface of the implant and the bone, causing the resorption cited in previous literature.
Surgeons who are prudent nowadays with medpor implants always use titanium screws, and have reported that bone resorption is no longer an issue
ALSO @Lestat that PEEK result is amazing, but the sample size is quite small. i worry that since it hasnt been observed long term on a large scale that we dont really know as much as we do about medpor or silastic which have been used for decades
i could be wrong, ofcorse
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Recent reports have shown that the bone resorption observed in the past were caused by surgeons who used the fiberous ingrowth or musculature (i.e masseter muscle) to hold the implant in place (as opposed to screwing them in). As such, micro movements from facial animation over time lead to friction between the surface of the implant and the bone, causing the resorption cited in previous literature.
Surgeons who are prudent nowadays with medpor implants always use titanium screws, and have reported that bone resorption is no longer an issue
+1
(A world class surgeon confirmed me that in a personal consultation).
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It can only boil down to the shape and material, silicone will always look like putty, medpore gives great results if the shape is right. I have never seen PEEK but I know that is what Zurich University uses now, they previously used medpor so they must see some advantage to it.
you mentioned university, something I do not understand as ive encountered quite a few maxfacs with excellent CVs who are now staffed at universities.... do universities take on elective/private patients? or are they only doing studies?
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you mentioned university, something I do not understand as ive encountered quite a few maxfacs with excellent CVs who are now staffed at universities.... do universities take on elective/private patients? or are they only doing studies?
I was told that in Zurich university you can go as a private patient for facial implants, but I've never asked the university myself so can't confirm if that is true.
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You do realise those are essentially similar figures to silicone infection rates? (1-3% from memory)
It also depends where the implant is positioned; the closer to the sinus cavities the greater the chance of infection (~10% from memory)
Infection rates shouldn't be a deciding factor between the two, it's so close. They are both low single digit percentages for most cases.
That's not true. There are three components to the bone resorption issue:
1. Implant not being held sufficiently in place
2. Implant not exactly matching anterior surface of bone contour
3. Biological response to foreign body being pressed against bone in combination with facial musculature
So even if you had an implant held in place with loads of screws (1) and it was 3D printed to exactly match (2), you could still have (3). Eppley states (3) happens regardless of screws or not.
Thanks for the information! From my understanding the medpor implants are heated during the surgery, causing them to become malleable after which they are pressed against the bone such that they form to the anterior contour.
Most importantly i think is the vascularization and ingrowth into medpor implants. This is because during the dissection, surgeons scrape the bone surface clear of the overlying soft tissue. this soft tissue is responsible for bringing bloodflow to the bone surface, without which, resorption is more likely to occur. This is usually only an issue in older patients and patients who have had say multiple osteotomies like ZSO or chin wing or had several revisions to their implant where the soft tissue is repeatedly being dissected, resulting in scar tissue with impaired vascular capabilities.
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It also depends where the implant is positioned; the closer to the sinus cavities the greater the chance of infection (~10% from memory)
Great I have a damn medpor implant on my nose bridge, I will probably go to someone to replace it with cartilage.
I am the Lord of the cartilage said he.
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I am the Lord of the cartilage said he.
Hi! Who are you? The Lord of cartilage? I am Lestat! I have never seen you before, you seem to be an old member!
I would not use cartilage. I think the risk of resorption is very high.
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Noo Lestat it's MrFox I just changed my screen name from Tightrope to this, yes I hate that cartilage resorbs.
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Noo Lestat it's MrFox I just changed my screen name from Tightrope to this, yes I hate that cartilage resorbs.
Yes OF COURSE I knew but you are not really Mr.Fox. >:( I wish he could return, he is my friend!
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Yeah I know, MrFox is nice, I don't like Lord of the Cartilage... he keeps telling me to get more cartilage. :(
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Tell him my life would be perfect if cartilage would not resorb!
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Tell him my life would be perfect if cartilage would not resorb!
Same, have you noticed any resorption? I am sure mine have shrunk to some degree.
One night I had to sleep on this stupid concrete thing and lay on the side of my face and now that cheekbone looks less good I think.
What do you think is the best implant material that is available at the moment?
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Same, have you noticed any resorption? I am sure mine have shrunk to some degree.
One night I had to sleep on this stupid concrete thing and lay on the side of my face and now that cheekbone looks less good I think.
What do you think is the best implant material that is available at the moment?
A little bit maybe. It is hard to tell. Imo ha and bio oss are the best implant materials at the moment.
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Yes I agree that they should be safe options in terms of how the body handles those materials, I don't like that they can't give hard and severe shapes.
Do you think that drinking a substantial amount of alcohol, and my god I mean substantial, would increase resorption of the cartilage?
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Same, have you noticed any resorption? I am sure mine have shrunk to some degree.
One night I had to sleep on this stupid concrete thing and lay on the side of my face and now that cheekbone looks less good I think.
What do you think is the best implant material that is available at the moment?
Everything I've read on PEEK makes it seem pretty ideal in so far as having a material that is similar in density and hardness to bone, low rate of infection, not degraded by body fluids.
US surgeons dont seem to be saying boo about it, but I guarantee the moment the FDA approves it for facial implants they will start singing its praises. I'm guessing whatever regulatory bodies are in the EU and places like Australia already approved it a while ago, or don't differentiate between implants approved for the cranium vs the face.
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Everything I've read on PEEK makes it seem pretty ideal in so far as having a material that is similar in density and hardness to bone, low rate of infection, not degraded by body fluids.
US surgeons dont seem to be saying boo about it, but I guarantee the moment the FDA approves it for facial implants they will start singing its praises. I'm guessing whatever regulatory bodies are in the EU and places like Australia already approved it a while ago, or don't differentiate between implants approved for the cranium vs the face.
Good observation! Prof. S. recommend me a Peek implant for my jawline. One problem with Peek is that it is very expensive. S. told me that. He wanted to attach it with titanium screws.
I asked him about bone erosion, how many mm, "1mm in 5 years"?
S. said yesyes, only a very small amount of bone. It is not clinically significant.
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Good observation! Prof. S. recommend me a Peek implant for my jawline. One problem with Peek is that it is very expensive. S. told me that. He wanted to attach it with titanium screws.
I asked him about bone erosion, how many mm, "1mm in 5 years"?
S. said yesyes, only a very small amount of bone. It is not clinically significant.
Stay away from him Lestat, he is a criminal now, unfortunately he was one of the most skilled surgeons at one time... now he is just a con man with a scalpel. I have such deliciously destructive things to say about him but will save those for my autobiography.
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I believe rib is better. If it was me I would just leave it unless there's an aesthetic reason too.
I like how it looks even though it is asymmetric, (Sailer's favorite saying is "symmetry is overrated").
I am scared that it could get infected at any time, especially if someone hit me on the nose... which given my personality, seems quite imminent.
Also it will be resorbing the underlying bone, where as rib wouldn't.
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I'm skeptical that a harder jaw implant material will provide more angular results. I've seen a handful of silicone jaw implants that were excellent. I just think it's a hard task that takes artistic skill and luck.
I will pose this question to Eppley next time I talk with him.
Eppley on his blog pretty much already answered that question.
I think he is wrong, and he is saying any surgeon who says otherwise doesnt know what they are talking about. Well that's insulting to peoples intelligence, it is simply OBVIOUS that the hardness of the material will be a factor in how it supports the soft tissues! I do not think eppley is being sincere.
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I forget which part of the skull it is that doesn't resorb when grafted, but if surgeons can use cadaver ribs then why not cadaver skull bones for implants?
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Bumping with another Peek example (http://www.facialsculptureclinic.com/en/surgery/jaw-surgery/jaw-angle/). Looks promising. I wonder how quickly this will gain acceptance?
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Bumping with another Peek example (http://www.facialsculptureclinic.com/en/surgery/jaw-surgery/jaw-angle/). Looks promising. I wonder how quickly this will gain acceptance?
I think it is more widespread than we think. A lot of surgeons don't detail what materials they can or will use on their websites. For example when i talked to Coceancig, he described he's used just about everything there is including ceramics and PMMA. Without knowing that experience, you would think these materials are super rare but PMMA for example has actually been used in reconstructive surgery as early as WW2 afaik
Its also worth remembering that a large portion of the "internet" image of plastic surgery is largely shaped by American surgeons, who are regulated by the FDA. Not the case in Europe or Australia who have different regulatory bodies, so its not surprising that american surgeons don't know anything about PEEK because they cannot use it in facial augmentation (Despite being approved for cranial defects) so its of no interest to them.
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While the definition of a good vs a bad post operative surgical result is open to discussion there are various reasons most results publicly available online don't meet most patients' aesthetic needs.
One is that the vast majority of people getting such procedures are not very comfortable of sharing their post operative results online. While this fact indicates that there might be a lot more negative experience with this type of surgery than one can imagine, it can also mean that there might also be much more positive experience and therefore better results.
Another reason is poor implant selection -if we're talking about out of the shelf implants- or poor implant design -in the case of custom implants-.
The most important reason though is patient selection. This is a rather dissappointing reason but the truth is that the patients that would benefit the most from the implant procedures are the ones who don't have thick tissues around the jawline area. Keep in mind that this has not much to do with body weight since there are plenty of people who are overweight and still have a relatively lean and thin tissues facial appearance that would improve even more if they were to lose weight, but there are also patients that even if they went underweight their face would not lose a significant amount of fat.