jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: PloskoPlus on February 22, 2014, 09:18:55 PM
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My surgeon mentioned augmenting my chin to make it less pointy (the length is fine). He said that in the past it was hard to control (would get mushy and not set properly upon contact with water), but that now days it works a lot better. I am also considering orbital augmentation. I hear all sorts of contradictory stuff regarding this stuff (mainly on this forum):
* Waste of time?
* Get reabsorbed?
* Erodes the bones underneath?
* Hard to control?
* Only good for gaps?
* Good as a filler orbital, paranasal augmentation, etc., but not the "edges" - chin, lower, jaw, gonial angles, etc..
So what's the deal? Can HA paste augmentation be done sometime after the main surgery? Or is it too much of a hassle (cutting gums open again).
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Studies show that it does not get reabsorbed, and half those other complaints I really don't know where they come from.
I would love for some members to go through and systematically document the evidence for each of those claims as I've not seen any to date. I'm not taking any side, I just want to see proof for these claims to I can make the best decision possible.
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People often confuse temporary fillers like Radiesse with the porous form of hydroxyapatite that surgeons like Arnett and Gunson use. I've tried finding out why so few plastic surgeons use it but I've never really found a good answer.
I assume you're having surgery with Mommaerts despite everything people here have written about him?
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Even when I saw MM, he did not mention using HA even though I told him that I wanted more jaw definition and so am an obvious candidate for it, which seems strange if it so easily brings about good results. Some could say that implies a reluctance to use it. The next time I saw him, I specifically mentioned it to him, and he did say that it could be used, and I asked him whether there's a chance of infection, and he said that it has only ever happened to one person that he has treated with it, who experienced trauma to the jaw while playing soccer and so had to have it removed.
I've spoken to two other surgeons who said it won't give me any definition, although that may be because they don't have the expertise to apply it.
I've spoken to another surgeon who says he does not use it 'from experience' but without elaborating on this remark.
It is also true that not many surgeons use it (which may imply something) but then again, I've never seen a post on a jaw surgery forum saying that they had a bad experience with it so who knows.
It could simply be that its use extends the length of surgery considerably and so many surgeons don't like using it for marginal benefits or it could be that it is unsafe. I think the former is probably closer to the mark since dangers about its use would be recorded in the academic literature but the only way to find out is to actually use it. Reading studies is only going to tell you so much. At some point, you are actually going to have to find out for yourself.
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I asked MM about HA paste. He said it was OK for small augmentations but for anything else, custom titanium implants were the way forward - if you could afford it.
I think HA paste is OK for smoothing any mandible notches and for minor augmentation of malar region in class 3s. But for those with really weak mandibles or who want defined angles, only custom implants are going to give the desired look. I've never seen it achieved with HA.
I did find one surgeon who appears to routinely combine implants with jaw surgery. No idea how good he is as a jaw surgeon, just wanted to share the pictures as examples. Some of the results look great (e.g. the 5th pair of pics in the malar gallery, first and second pairs in the ramal gallery) and some look...meh. I presume the implants are silicone (rare is the surgeon who does titanium implants :()
Malar implants -
http://www.drwittenberg.com/photo-gallery/checkbone-malars-gallery.html (http://www.drwittenberg.com/photo-gallery/checkbone-malars-gallery.html)
Mandible Angle implants -
http://www.drwittenberg.com/photo-gallery/ramal-gallery.html (http://www.drwittenberg.com/photo-gallery/ramal-gallery.html)
(warning, annoying music on site)
It's a shame it's so difficult to get titanium implants.
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Would you get titanium implants for stuff like paranasal or infraorbital rim augmentation? I'm having a hard time imagining how that would work out.
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I'm just asking anyone with more knowledge about this than me. I don't like the idea of hardware in the face which is why I prefer HA over silicone implants. It would of course be better not to need any of this to begin with but many of us aren't so lucky and have quite serious deficiencies in the face.
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Why say this then not offer any proof? Just like everyone else who says this I can not find a single source for it.
In fact studies were done which showed it didn't reabsorb.
So please, I'm not even attacking you here, can you show me some examples of this actually happening?
Why do you give such credence to the idea, that not having studies to show a particular substance causes problems, therefore automatically makes it a safe and useful technique? Is word of mouth information of no value to you? Before you say "no, it is not", remember that people used to believe in extraction orthodontics being the best form of treatment for malocclusions, or that asbestos was a safe and harmless material.
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Really, we are thinking that it potentially reabsorbs randomly? It's one thing if it just doesn't work, but it's a completely different animal if it reabsorbs randomly all over your face. What if, say, 5 years after surgery, one under eye area is all perky and the other is, um...not?
Anyway, thanks for this post; I was going to ask this same question.
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This jaw surgery stuff just keeps getting better and better.
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My take on HA paste, is that it is unpredictable and it DOES re-absorb and there is no knowing how much or how little of it will stick around. I've heard of surgeons putting in a bit more than you need as some of it gets re-absorbed, but its tricky. I agree if its something very very minute a little bit of HA paste wont hurt or change too much, its when its utilized solely for major bone deficiencies- than you will probably run into problems down the line.
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My take on HA paste, is that it is unpredictable and it DOES re-absorb and there is no knowing how much or how little of it will stick around. I've heard of surgeons putting in a bit more than you need as some of it gets re-absorbed, but its tricky. I agree if its something very very minute a little bit of HA paste wont hurt or change too much, its when its utilized solely for major bone deficiencies- than you will probably run into problems down the line.
Ok, that's cool. How about instead of this thread become a six page long echo chamber without proof someone posts photos?
Can nobody provide a single example of verifiable HA reabsorption?
I just want to see photos of this!!!
>:( >:( >:( >:(
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Ok, that's cool. How about instead of this thread become a six page long echo chamber without proof someone posts photos?
Can nobody provide a single example of verifiable HA reabsorption?
I just want to see photos of this!!!
>:( >:( >:( >:(
Maybe reabsorption can only be felt, not seen. i.e. HA paste effects are minimal to begin with. So the upside is the reabsorbed part does not look much different from the non-reabsorbed part. The downside is... the same as the upside.
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Ok, that's cool. How about instead of this thread become a six page long echo chamber without proof someone posts photos?
Can nobody provide a single example of verifiable HA reabsorption?
I just want to see photos of this!!!
>:( >:( >:( >:(
Given that there are precious little clear photographic examples of before/after augmentations done with HA paste, I think we are going to be hard pressed to find pictures of absorption. Most pictures are published by surgeons and no surgeon is going to publicise this kind of picture are they?!
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I had paranasal augmentation with HA and two months after the surgery I see no signs of reabsorption. Maybe it's too early?
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Given that there are precious little clear photographic examples of before/after augmentations done with HA paste, I think we are going to be hard pressed to find pictures of absorption. Most pictures are published by surgeons and no surgeon is going to publicise this kind of picture are they?!
So we can't talk to people who've had it because they aren't here, and everyone who in recent times got it has had no problems.
There are no photos to demonstrate this.
No studies.
Yet people on here talk about this like it's an undisputed fact.
Where are people getting this information from?
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IMO, photos can be deceiving. People could be imagining things. The best solution would be CT scans for those who suspect reabsorption. A study like that would be good.
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IMO, photos can be deceiving. People could be imagining things. The best solution would be CT scans for those who suspect reabsorption. A study like that would be good.
Scans and studies have been done on reabsorption and have shown it didn't occur, others seem to indicate it was replaced by bone. Here are some I've found:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628530/ (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628530/)
http://www.ncbi.nlm.nih.gov/pubmed/11845356 (http://www.ncbi.nlm.nih.gov/pubmed/11845356)
http://boneandjoint.org.uk/highwire/filestream/16123/field_highwire_article_pdf/0/654.full-text.pdf (http://boneandjoint.org.uk/highwire/filestream/16123/field_highwire_article_pdf/0/654.full-text.pdf)
http://books.google.com/books?id=8yu0OZpAYSgC&pg=PA83&lpg=PA83&dq=hydroxyapatite+resorption&source=bl&ots=UPuKdlxB3P&sig=wBM91uNgFRdRg5pcpS0-cPdZLaY&hl=en&sa=X&ei=9tsNU43cH8fAkgWY3YDYDQ&redir_esc=y#v=onepage&q=hydroxyapatite%20resorption&f=false (http://books.google.com/books?id=8yu0OZpAYSgC&pg=PA83&lpg=PA83&dq=hydroxyapatite+resorption&source=bl&ots=UPuKdlxB3P&sig=wBM91uNgFRdRg5pcpS0-cPdZLaY&hl=en&sa=X&ei=9tsNU43cH8fAkgWY3YDYDQ&redir_esc=y#v=onepage&q=hydroxyapatite%20resorption&f=false)
http://ispub.com/IJOS/18/2/6058 (http://ispub.com/IJOS/18/2/6058)
Interestingly enough MM claims that the outcomes with HA are largely a result of surgeon skill, and not necessarily the material. At least that's the impression I got from a quote out of pastebin.
"2. What is the advantage of using a bone graft? I only ask because another surgeon I consulted with wanted to take a graft from my hip. You said you do this operation without a graft, so I am curious what the difference is.
Experience"
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I would like to hear what Arnett and Gunson have to say about this since they use HA extensively. If I consult with them then I'll make sure to ask them.
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People get their information straight from the horses mouth- people who went through the surgery. HA does get re-absorbed, I myself had HA put on my cheekbones and now have one cheek that is larger than the other, and I know of two other people experiencing the same thing. Not all of us are comfortable sharing pictures (I might once I get it corrected). There is no absolutes in this thing, just because it absorbed for me, doesnt mean it will happen to you (if you end up using HA), its not as predictable as using your own bone or lets say an implant of a specific size and shape.
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How long did it take before you noticed the reabsorption? What did Gunson say about it?
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I have HA and have not noticed it reabsorbing at all.
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I have HA and have not noticed it reabsorbing at all.
Me neither but if it affected everyone then they probably wouldn't be using it. The important detail to know is what percentage of patients it affects.
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I've spoken to a few patients who had it done. In one case, one side ossified and the other completely resorbed. Two other cases said it made no difference. Last case said he liked them but has chronic inflammation around one two years later. Plastic surgeon I spoke to said they don't like it because it doesn't deliver good results and really still is a foreign body.
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Oh two I spoke to said they solidified asymmetrically but they still recommended the surgeons because overall they saved their lives. You cant see soft tissue until it's too late to change them. It's a cool invention, not sure it can be used anywhere but laterally though. Yes I've heard they use it elsewhere and their patent also mentions drooping.
The nice thing about it is they're using materials that are fillers anyway so have the same safety profile as those. Some bony in growth occurs and hopefully the rest resorbs. That's a good thing! Foreign body reactions and infection still possible but safety profile better than implants since it's vascular but that also means hard to remove. What doesn't respob, well bone is constantly changing, especially after 40. Who knows where it will migrate to, if it'll stay in one piece as the bone underneath changes shape. Would suck to have lose fragments stuck under there, never clean all those up. Might not look good once fat pads thin but I think it's ok in that respect. I'm told best to wait until midlife to think about this stuff so you don't have to live with it too long with the problems, if any.
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Scans and studies have been done on reabsorption and have shown it didn't occur, others seem to indicate it was replaced by bone. Here are some I've found:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628530/ (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628530/)
http://www.ncbi.nlm.nih.gov/pubmed/11845356 (http://www.ncbi.nlm.nih.gov/pubmed/11845356)
http://boneandjoint.org.uk/highwire/filestream/16123/field_highwire_article_pdf/0/654.full-text.pdf (http://boneandjoint.org.uk/highwire/filestream/16123/field_highwire_article_pdf/0/654.full-text.pdf)
http://books.google.com/books?id=8yu0OZpAYSgC&pg=PA83&lpg=PA83&dq=hydroxyapatite+resorption&source=bl&ots=UPuKdlxB3P&sig=wBM91uNgFRdRg5pcpS0-cPdZLaY&hl=en&sa=X&ei=9tsNU43cH8fAkgWY3YDYDQ&redir_esc=y#v=onepage&q=hydroxyapatite%20resorption&f=false (http://books.google.com/books?id=8yu0OZpAYSgC&pg=PA83&lpg=PA83&dq=hydroxyapatite+resorption&source=bl&ots=UPuKdlxB3P&sig=wBM91uNgFRdRg5pcpS0-cPdZLaY&hl=en&sa=X&ei=9tsNU43cH8fAkgWY3YDYDQ&redir_esc=y#v=onepage&q=hydroxyapatite%20resorption&f=false)
http://ispub.com/IJOS/18/2/6058 (http://ispub.com/IJOS/18/2/6058)
Interestingly enough MM claims that the outcomes with HA are largely a result of surgeon skill, and not necessarily the material. At least that's the impression I got from a quote out of pastebin.
"2. What is the advantage of using a bone graft? I only ask because another surgeon I consulted with wanted to take a graft from my hip. You said you do this operation without a graft, so I am curious what the difference is.
Experience"
Experience may be a major portion of the issue. There is a report by Ousterhout of a series of about 200 patients over a period of 25 years for which he used it in sliding genioplasties. Zero infections or other significant complications. Apparently about 9% of those were re-works of earlier surgeries by other surgeons that did not work out well. Often used to support gaps until natural bone fills in.
Apparently it quickly gets very hard and supports the gaps in the bones until nature does her thing. In that case, re-absorption over time would not really be a problem. When used as surface filler to modify the contour, it also appears to work and last well with very few complications and the noted very low infection rate.
I gather that, as noted above, and as is often the case, there is some experience and technique involved in how it is used to get the optimum results.
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One prominent surgeon told me HA is very weak. Plus, it's not very osteoconductive. That's why A/G mix it with bovine and cadaver bone. I think they also vacuum your bone shards as they cut and add it to the mix. Super sexy technology.
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I've heard different things.
Arnett told me it fuses and even turns eventually into bone. That said I don't think it actually produces a hugely augmented effect.
What's his name, the butcher from amsterdam, uses it for jaw angles and all sorts of rim and malar augmentation --many of his patients are assymetrical as a result and it can't be fixed. Horrible situation.
A/G do mix it with you own blood and stem cells and s**t --they really know what they're doing.
Honestly, I don't only use it for minor filling in gaps. I think it's totally safe etc. but I'd wanna se before and afters from a surgeon to actually gauge their skill level. Like Mommaerts no way, I know patients who were lopsided after he used too much HA paste to augment their ramus or whatever.
And I bet he doesn't mix it with stem cells and stuff the way A/G do.
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Dr G told me the bone grows into it but doesn't replace it. The patent says the same but that sometimes it gets replaced by bone. I didn't see anything about stem cells there, just mixing it with PRP which is just to speed healing along. That why I say, the asymmetry and inability to produce desired results tend to be more of the problem, especially long term. They seem to be round balls in x-rays and that soft tissue masks it well now, later I don't know but the moldability of it probably still makes it better than implants.
My sample size is limited but it seems the odds are about 20% of giving a good result, 40% of giving a neutral result, and 40% of giving a bad result but because it wasn't significant to begin with, didn't matter that much. Despite what people say, it's not too expensive so I don't think it's padding their pockets or anything. It may be a market differentiator. Like I'm not really sure about this facial balance stuff since so many other things need to change too, however in many cases we do have growth deficiencies and it can help there. Many times patients don't go back to surgeon or don't voice their opinions so the surgeons may have less feedback about results than you'd think. Seems that other professionals in the industry have no idea what this product is.
What I like about it is there's no fixation required so it's probably the least foreign augmentation that you can get right now. People I've spoken to have said they're very hardy once cured. There's still is no way to know the long term prognosis for these things. Like, just look at the guy on this forum who had a fracture there and it's compressing a facial nerve causing him lots of pain. I'd say if you really want it, then absolutely these are the guys to deliver and, even if it resorbs, I think you could always augment on top of them later to correct things. It's not like they're doing extra incisions to get there. It seems to me they could be using BMP2 for those now too, I guess they won't want to mess with what works. They could also graft with BioOSS or HA blocks and use this stuff as a binder for more significant results but less moldability post-op. That would give the extra augmentation people may want but again, with unpredictable soft tissue changes might not be a great idea to do too much anyway. Who knows, maybe they're experimenting with it now already. Or maybe Dr G will read this post and it will give him some ideas :P
I would also add that while it's primarily an aesthetic issue, it's not fair to say that's the only reason to fix your cheekbone projection. Flat cheekbones can cause problems down the line. Poorly supported skin pulls on the lower lid more, resulting in extra work for those muscles to support them. In extreme cases, those lids can even flip inside out and a skin lift is needed, which we know doesn't have a great prognosis. The eyelids can also not close properly, a problem I've had before and I can tell you that's one of the most miserable conditions one can suffer. The eyes will tend to dry out poorly supported too I think. These are common problems, since deficiencies here are common even in people with normal jaws. And these are problems we nearly all experience at some point but those who are deficient will experience them sooner. Fixing it or again in your 50s isn't a terrible idea and, hopefully by then we'll have better options on the market for augmentations. As for aesthetic effects, those procedures may be worse and at some point the aesthetic effects can be so demoralizing that the risks of this particular procedure may outweigh the risks of not fixing it. Don't neglect mental health!
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^Am I part of the 20%? lol
I reeeeeally hope it doesn't change for the negative down the line.
yknow I had out of normal range swelling probably due to HA (although Dr. G never admitted that), I wonder if there is a correlation between the stuff giving a prominent "good" result and how much trauma it causes the soft tissue to induce extreme prolonged swelling.
Of course there's nothing to support that and doesn't really make sense but part of me still wants to justify that god awful f**king swelling that tortured me. And it's still some left on my right cheek after 2 years! f**k you HA paste... :D
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I forget but I think I spoke to you a while back, right? Whether HA paste would cause swelling... very individual. You'd have gotten it from fillers too, very routine. I wouldn't blame Dr G from that. I've met people without fancy work who had cheek swelling too. BMP may be responsible, that stuff swells like mad but lots of surgeons using it now. I've listed my gripes with HA paste here and it's not all that bad. But you may be in a bit of a bind now cause if you don't like the way it looks, I don't know whether it's a good idea to layer over that fancy new product on top of it. I know it's ossified but does that mean bone can grow on top of it? One of the biggest risks with surgery is that you can't get the fancy new surgery that comes along in a few years. We're all gonna feel like s**t when these awesome silk based resorbable plates come around and we're still having problems with this crap. Of course, it might not pan out but probably mid-2020s before people start feeling comfortable with it. I don't know about you but I don't want to wait 10 years to fix my bite, plus the risks and recovery gets worse with age. Just a reality of things I guess.
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I forget but I think I spoke to you a while back, right? Whether HA paste would cause swelling... very individual. You'd have gotten it from fillers too, very routine. I wouldn't blame Dr G from that. I've met people without fancy work who had cheek swelling too. BMP may be responsible, that stuff swells like mad but lots of surgeons using it now. I've listed my gripes with HA paste here and it's not all that bad. But you may be in a bit of a bind now cause if you don't like the way it looks, I don't know whether it's a good idea to layer over that fancy new product on top of it. I know it's ossified but does that mean bone can grow on top of it? One of the biggest risks with surgery is that you can't get the fancy new surgery that comes along in a few years. We're all gonna feel like s**t when these awesome silk based resorbable plates come around and we're still having problems with this crap. Of course, it might not pan out but probably mid-2020s before people start feeling comfortable with it. I don't know about you but I don't want to wait 10 years to fix my bite, plus the risks and recovery gets worse with age. Just a reality of things I guess.
Agreed about individual response to swelling.
don't get me wrong, I'm happy with my cheekbones now, don't ever plan on touching them or having any other facial procedure except alar base reduction.
It's just the residual swelling. From the little I've found there isn't much one can't do about it except hope it eventually subsides. Have you read or head about the elimination of residual swelling after several years post-op?
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Depends on the cause. If it's a foreign body reaction, then I suspect it will stop when the foreign body is removed. Should the augmentation ever start to degrade, you'd get scattered pockets of inflammation. It happens with fillers too sometimes I hear. I think there's a treatment for breaking it down when that happens, you might look into that? But then you might lose some of your augmentation too. Personally, I wouldn't want a chronic inflammatory condition in my body since it can have systemic effects but it's also to some extent a reality of life.