Facial Skeletal Augmentation Research Articles

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

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. 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. A total of 17 studies (n = 2100 patients, follow-up range = 1month-27years) 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. 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. 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 .

Commentary on: Alloplastic Augmentation of the Asian Face: A Review of 215 Patients.

It is human nature to avoid responsibility when faced with unfortunate outcomes. Blame the gun, not the perpetrator; blame the implant, not the surgeon. Hence, as the authors of this article point out, alloplastic facial implants have been demonized by many in the plastic surgery community. To their credit, the authors document that, with appropriate technique, facial implants can be safe and effective.1 Using the same basic principles as the authors, but with some different personal preferences, I too have found facial implants to be effective with few complications. This commentary provides the opportunity to emphasize the important commonalities in our use of facial implants and mentions variations and preferences that I have found useful. Implant materials used for facial skeletal augmentation in the United States have been approved as safe and biocompatible by the federal Food and Drug Administration. They have an acceptable reaction between the material and the host. In general, the host has little or no enzymatic ability to degrade the implant with the result that the implant tends to maintain its volume and shape. Likewise, the implant has a minimal and predictable effect on the host tissue that surrounds it. Hence, implant materials per se do not have toxic effects on the host. Implant materials differ in their surface characteristics. …

Utility of high density porous polyethylene implants in maxillofacial surgery.

The aim of this paper was to determine the utility of high density porous polyethylene implants (HDPE) in a variety of facial skeletal deformities. Sixteen patients (age range 14-28 years) with facial deformities requiring skeletal defect reconstruction or augmentation, treated between January 2008 and December 2010. The follow-up of the patients ranged from 6 months to 2 years.The types of deformities and defects treated include: one patient each with hemifacial microsomia and nasal tip correction, two patients each with malar deformities and orbital floor reconstruction, three patients with paranasal deformities and mandibular hypoplasia and four patients with chin augmentation. A total of 24 implants were placed. The complications included infection and wound dehiscence in one patient. The implants were palpable extraorally in two patients. It is concluded that HDPE is an excellent alternative to autogenous grafts for facial skeletal augmentation. Its porous nature, excellent soft tissue growth and coverage are the advantages and disadvantages include its rigidity and sometimes it is palpable extraorally.

Long-term results of high-density porous polyethylene implants in facial skeletal augmentation: An Indian perspective

ABSTRACT Context: With the increasing emphasis on well-sculpted facial features, today there is a growing need for tools to augment the facial skeleton; either for cosmetic reasons or to re-contour deformities—congenital, post-traumatic and post-ablative. The limitations of autogenous materials has lead to evolution of numerous ‘alloplasts’, of which, high-density porous polyethylene (HDPE) seems to be a promising alternative. Aims: To evaluate the long term results of HDPE in facial skeletal augmentation in terms of achieving desired facial contour, patient satisfaction and complications. Settings: A tertiary care referral centre in a metropolitan set-up. Design: Case Series Materials and Methods: All patients undergoing HDPE implant insertion for facial skeletal augmentation between July 2001 and November 2009 were included in the study. A total of 70 HDPE implants were inserted in 44 patients. All procedures were performed by a single surgeon following standardized pre, intra and post-operative protocols. The results were evaluated with respect to improvement in facial contour desired and achieved, overall patient satisfaction and complications encountered. Results: The study included 44 patients with a male:female ratio of 1:1, a mean age of 25.09 years (14 to 58 years) and a mean follow-up of 45.34 months (0.5 to 100 months). HDPE implants were used to augment the nasal dorsum, maxilla, malar eminence, chin, mandibular body and angle, orbital rim and frontal region. The overall recontouring afforded by the HDPE implants was good, with most patients reporting satisfactory results. There were seven complications (10%), including three cases of deviation (4.29%), three cases of exposure (4.29%) and one case of sub-clinical infection (1.43%). None however necessitated implant removal. Nasal dorsal HDPE implants, especially those involving secondary surgery, suffered a much higher complication rate compared to other implants. Conclusions: HDPE is an alternative to autogenous grafts for facial skeletal augmentation with good long-term results and a low incidence of complications, provided there is adequate vascular soft tissue cover.

Long-term results of high-density porous polyethylene implants in facial skeletal augmentation: An Indian perspective.

Context:With the increasing emphasis on well-sculpted facial features, today there is a growing need for tools to augment the facial skeleton; either for cosmetic reasons or to re-contour deformities-congenital, post-traumatic and post-ablative. The limitations of autogenous materials has lead to evolution of numerous 'alloplasts', of which, high-density porous polyethylene (HDPE) seems to be a promising alternative.Aims:To evaluate the long term results of HDPE in facial skeletal augmentation in terms of achieving desired facial contour, patient satisfaction and complications.Settings:A tertiary care referral centre in a metropolitan set-up.Design:Case SeriesMaterials and Methods:All patients undergoing HDPE implant insertion for facial skeletal augmentation between July 2001 and November 2009 were included in the study. A total of 70 HDPE implants were inserted in 44 patients. All procedures were performed by a single surgeon following standardized pre, intra and post-operative protocols. The results were evaluated with respect to improvement in facial contour desired and achieved, overall patient satisfaction and complications encountered.Results:The study included 44 patients with a male:female ratio of 1:1, a mean age of 25.09 years (14 to 58 years) and a mean follow-up of 45.34 months (0.5 to 100 months). HDPE implants were used to augment the nasal dorsum, maxilla, malar eminence, chin, mandibular body and angle, orbital rim and frontal region. The overall recontouring afforded by the HDPE implants was good, with most patients reporting satisfactory results. There were seven complications (10%), including three cases of deviation (4.29%), three cases of exposure (4.29%) and one case of sub-clinical infection (1.43%). None however necessitated implant removal. Nasal dorsal HDPE implants, especially those involving secondary surgery, suffered a much higher complication rate compared to other implants.Conclusions:HDPE is an alternative to autogenous grafts for facial skeletal augmentation with good long-term results and a low incidence of complications, provided there is adequate vascular soft tissue cover.

Use of HDPE implants in facial skeletal augmentation: Should we rush for it?

Use of HDPE implants in facial skeletal augmentation: Should we rush for it?

Skeletal volume enhancement: implants and osteotomies.

Facial plastic surgeons are concerned with improving or restoring function and form. Most surgeons perform primarily soft tissue procedures, which alone are often sufficient. However, deficiencies in the underlying craniomaxillofacial skeleton must also be addressed. Facial skeletal augmentation remains an essential aspect of cosmetic and reconstructive surgery. This article reviews the basic alloplastic biomaterials available for facial volume enhancement, discusses the zygomatic sandwich osteotomy for malar augmentation, and describes recent applications of distraction osteogenesis in the craniomaxillofacial region. An update in tissue engineering and computer modeling is also provided. High-porosity expanded polytetrafluoroethylene has been developed to provide a softer feel with less shrinkage and migration because of better biointegration and cellular ingrowth. Long-term results with porous polyethylene have demonstrated superior biocompatibility and minimal complications. Hydroxyapatite cement has been associated with an immunoguided delayed inflammatory reaction that leads to thinning of the overlying skin and exposure of the implant.Applications of distraction osteogenesis are rapidly expanding and include deformities of the mandible, midface, and cranium. There has been a trend toward the use of internal hardware, and internal devices are being developed to deliver a greater degree of vector control. Biodegradable devices have been developed to eliminate the second surgical procedure necessary for hardware removal. In the future, successful tissue engineering could eliminate many of the drawbacks associated with implants and osteotomies. The ability to stimulate stem cells to generate autogenous bone has been demonstrated in the laboratory. A novel application of computer technology that integrates laser surface scanning and digitizing with computer-aided design and manufacturing to produce facial prostheses has been described. An abundance of alternatives exist for skeletal volume enhancement including alloplastic implants, standard osteotomies, and distraction osteogenesis. The surgeon must evaluate the pros and cons of each technique in the context of each individual patient to determine the most appropriate option. Technologic advances in biomaterials, distraction hardware, computer modeling, and tissue engineering will continue to supply the surgeon's repertoire with improved methods to augment and restore the craniomaxillofacial skeleton.

Mesenchymal stem cells: Aesthetic applications

Adult stem cells may have significant aesthetic surgery applications. Their replicative capacity and plasticity may be useful in engineering autologous grafts for soft tissue and facial skeletal augmentation. Another possibility is that increasing the concentration of mesenchymal stem cells in the facial soft tissue at regular intervals during adulthood will maintain volume and elasticity. ( Aesthetic Surg J 2003;23:504-506.)

Facial skeletal reconstruction using porous polyethylene implants.

A retrospective review of clinical outcomes was performed to determine the clinical utility and morbidity associated with the use of porous polyethylene facial implants. Three hundred seventy implants were placed in 162 consecutive patients, in 178 operations performed in 11 years. The number of patients, the number of implants used, and the average follow-up period were categorized according to the cause of the deformity. The resultant distribution was as follows: acquired (tumor-related), 17 patients, 39 implants, and 30 months; congenital, eight patients, 31 implants, and 92 months; aesthetic, 39 patients, 97 implants, and 24 months; secondary posttraumatic, 48 patients, 139 implants, and 37 months; and acute trauma (internal orbit reconstruction), 50 patients, 64 implants, and 9 months. The distribution of implants according to location was as follows: frontal, 21; temporal, 30; internal orbit, 145; infraorbital rim, 28; malar, 58; paranasal, 29; nasal, 13; mandible, 24; and chin, 22. The combined average follow-up period per patient was 27 months (range, immediate postoperative period to 11 years). All implants were placed in the subperiosteal plane, and the majority were fixed with titanium screws. Antibiotics were administered perioperatively. No implants were extruded or migrated, formed clinically apparent capsules, or caused symptoms attributable to bioincompatibility. The overall reoperation rate was 10 percent (n = 16), which included operations to remove implants because of acute infections (2 percent, n = 3) or a late infection (1 percent, n = 1), to remove implants causing displeasing contours (2 percent, n = 3), and to improve contours (6 percent, n = 9). Porous polyethylene implants have biomaterial properties favorable for facial skeletal augmentation. Screw application of the implants to the skeleton allows precise predictable contouring, thus limiting the need for revisional surgical procedures.

The role of facial skeletal augmentation and dental restoration in facial rejuvenation

Facial aging is almost exclusively a result of soft tissue changes in patients with full dentition. Loss of teeth can hasten facial aging and make aging more pronounced as a result of bony erosion of the alveolar ridges. This article describes these changes and demonstrates that properly selected oral implants and precisely placed hydroxyapatite implants can integrate with facelifts to produce superior facial rejuvenation in edentulous patients.

Demineralized Bone: Implant Resorption With Long-term Follow-up

The osteoinductive properties of demineralized bone have stimulated its use in facial skeletal augmentation and reconstruction. Demineralized bone has been shown to induce phenotypic conversion of mesenchymal cells into osteoblasts, with bone formation within 29 days (osteoinduction). In this clinical study, 75 demineralized bone implants were followed up from 1 to 48 months (average follow-up, 14.3 months). There were 41 major dorsal implants, with an average degree of resorption of 50.7%. Eight dorsal implants were followed up for more than 24 months, with an 82.5% degree of resorption. Overall resorption for all implants was 49%. Major factors contributing to implant resorption included lack of surrounding mesenchymal cells and inadequate contact between host tissue and bone-inducing surface area. Other factors included infection, poor vascularity, and compression of the implant. Demineralized bone has an unacceptably high resorption rate and should only be used in highly selective cases where the implant can be positioned in a site rich in primitive mesenchymal or bone-forming cells.