Bone Resorption and Sliding Genioplasty Hardware
Q: Dr. Eppley, my surgeon told me that when he degloved the chin and removed the titanium screws and plates from the sliding genioplasty (which was performed last year by another surgeon) he found granulomatous tissue in the area of the screws and plates. Where the screws were attached there was now diseased bone which he removed. According to the surgeon, he removed all dead tissue and cleaned up the area with an antiseptic solution. It seems as if I have had a major infection/inflammation around the screws which has killed off the surrounding bone.The strange thing is that I never noticed any puss, swelling, redness of the skin or even any real sensation in this area. Many months after the sliding genioplasty when I pressed on this area, I felt only a slight tingling sensation and absolutely nothing that would have alerted me to the gravity of what was happening. Furthermore, the sliding genioplasty was only performed 11 months before this latest implant surgery so the process seems to have been quite aggressive. Due to the nature of the placement of the plates and screws, the problem was restricted to the middle of the chin. At the epicenter of the problem, there is a wide hole in the middle of the chin where most screws were placed which according to the surgeon may surpass the cortical bone in depth.
What worries me is that it took almost four weeks for the sutures inside the front of the mouth to fully close from this last surgery. This observation is of course only based on what I noticed inside the mouth, which means that the incision may have closed up further down leaving only the top part unhealed for a longer period of time. I did not poke inside the incision to see if it was unclosed all the way. Since he put in an implant, there are new screws attached to the remaining chin bone, which may serve as a foundation for a further infection that may have taken hold if indeed the sutures did not close up quickly enough. Luckily, I did take antibiotics in a moderate dose for 3 weeks after the operation. Since I did not notice anything unusual after the sliding genioplasty, I do not expect to see any clear signs of problems now either. Still, it may be worth mentioning, that there is no redness or puss in this area. The chin is somewhat swollen though, especially the top part where the problem area is, even after more than 2 months and 1 week since surgery. I do have some shooting pain coming from the area a few times a day, otherwise, I mostly feel a faint tingling sensation. If I press the area, I get kind of a mild cold sensation but no immediate pain. The thing is that the implant used by the surgeon had about twice the projection I asked for, subsequently, my chin is very tight and I am still numb in most of my chin and lower part of the lip area. There is also an overall burning sensation in the whole chin area. I suspect that all of this is masking some of the sensations from the problem area in the chin.
I have decided that I will not seek a revision by the surgeon and will most likely ask you to replace the jaw implant and possibly the cheek implants also. The surgeon also agreed that he was not the right person to deal with either the problem in the chin or the implant revision for numerous reasons. The insertion of a new jaw implant is, of course, complicated by the state of my chin. Assuming that you want to take on this case, what do you think is the appropriate action?
1. To wait 4 more months and hope that new bone has formed to fill out the holes and then replace the jaw implant? My main problem with this is that I do not know what is going on in my chin and I do not trust that the surgeon did a good enough job cleaning up and thus I might have a new infection brewing which is impairing any healing process of the bone or even worse, extending the holes in my chin. The surgeon himself said that he was unsure if he did enough. Up until the last surgery, the problem was confined to the middle of the chin, leaving me with an intact outer border. But if bone starts breaking down around the new screws, maybe I will end up with a hole extending all the way to the border of the chin. Another problem with this approach is that the soft tissues will adapt even more to the faulty design of the current jaw implant, which I would like to avoid if possible.
2. To deglove the area and fill out the holes with a bone graft (I assume that you do bone grafts) and maybe remove the current jaw implant and then put in a new jaw implant further down the road? My main problem with this is the blood supply from the soft tissues to the problem area. If this is interrupted again so close to the recent degloving, may I then face the risk of avascular necrosis of the chin? Or is the internal blood supply from the inferior alveolar sufficient. Also, if there still is an infection in the area, a bone graft may not be possible to perform, or am I wrong? Maybe, if you clean out any infection before inserting the bone graft?
3. Do the same thing as in 2. but also replace the implant with one of your customized silicone implants at the same time. The problems I see are the same as in 2., I guess. This seems to be the most desirable option for me, but maybe not the most prudent or even a possible option.
4. Replace the jaw implant after maybe cleaning out the area again if necessary but without any bone graft. Problems are the same as in 2.
I am really shocked that this has happened. The surgeon could not give an explanation what went wrong with the sliding genioplasty. I have not been able to reach the surgeon who performed the genioplasty yet. I am otherwise a very healthy individual with a great immune system which means that I am almost never sick. I also had great results on my recent blood tests and I eat very well, including lots of natural supplements, and have absolutely no deficiency in micro- or macronutrients.
A: Thank you for sending all of your pictures and detailing your most recent surgical chin history. Bone loss/instability around the plate and screw fixation from a sliding genioplasty is very rare. However I have seen it twice before. It most likely occurs, not from infection, but from some localized bone necrosis from the drilling of the screw holes. Remember that a high speed drill is used to make the holes in the bone and this generates heat. If overheated the bone around the screw heads dies and micro motion of the screw develops. This can result is sequestrum of bone around the site which is usually on the downfractured or inferior plate and screw segment. This does not create enough instability to lose projection of the chin but does cause a localized area of osteonecrosis and granulation tissue. This is what I believe has occurred in your case.
I would allow this area to fully heal over a period of six months before ever reopening the area to place any type of a jawline implant.
Dr. Barry Eppley