Your Questions

Q: Dr. Eppley, I got my medpor jaw angle implant procedure over 2 years ago.  One year ago I had one side of the implant shaved down to make my face look more symmetrical.  But, the second procedure caused a mandibular nerve injury, which has impacted my smile and caused a dimple in my chin.  My smile and chin are improving, but very slowly.  I’m confident that my smile and chin will heal eventually on its own. 

If I go ahead and get these implants removed by Dr. Eppley, what are the chances of getting another nerve injury?  I was planning to get a 3D CT scan soon, which would probably help Dr. Eppley see where my nerves are and if it’s possible to safely remove my implants?

A: You  are referring to an injury to the marginal mandibular branch of the facial nerve. A nerve that is not seen on a bone scan unlike the inferior alveolar nerve that runs through the bone which is a sensory nerve not a motor nerve. It is not clear to me how that nerve got injured if the jaw angle implants were placed intraorally. It could have occurred if they were placed externally through a skin incision near the jaw angle but not intraorally.

There is a good motto to remember about recurrent surgical risks….past history predicts future behavior.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,I got my Medpor jaw angle implant procedure over 2 years ago.  One year ago I had one side of the implant shaved down to make my face look more symmetrical.  But, the second procedure caused a mandibular nerve injury, which has impacted my smile and caused a dimple in my chin.  My smile and chin are improving, but very slowly.  I’m confident that my smile and chin will heal eventually on its own. 

If I go ahead and get these implants removed by Dr. Eppley, what are the chances of getting another nerve injury?  I was planning to get a 3D CT scan soon, which would probably help Dr. Eppley see where my nerves are and if it’s possible to safely remove my implants?

A: You  are referring to an injury to the marginal mandibular branch of the facial nerve. A nerve that is not seen on a bone scan unlike the inferior alveolar nerve that runs through the bone which is a sensory nerve not a motor nerve. It is not clear to me how that nerve got injured if the jaw angle implants were placed intraorally. It could have occurred if they were placed externally through a skin incision near the jaw angle but not intraorally.

There is a good motto to remember about recurrent surgical risks….past history predicts future behavior.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a question regarding capsule formation that I was hoping you could clarify. I have heard what I believe is misinformation that the material of Medpor facial implants produces a different aesthetic outcome than silicone facial implants in terms of chin/jaw implants . The reasoning this individual used was that silicone implants form a capsule and therefore the appearance of such an implant will always appear “off”, and that Medpor implants will not result in such a capsule.

Correct me if I’m wrong, but I believe that Medpor also forms a scar capsule (albeit a smaller one) and that while silicone forms a capsule, it is not one that has any significant or noticeable aesthetic impact. Capsular contracture can form aesthetic complications, but that is a actually rare complication not common to chin or jaw implants. 

Is my understanding correct? If one were to make a custom silicone implant the exact same size and shape as a Medpor implant, wouldn’t the aesthetic outcome be identical?

I would appreciate any clarification you could provide on this topic.

A: All implants placed in the body produce a surrounding scar, whether it is a facial implant or a breast implant, regardless of the material. This is a natural protective reaction of the body. (self vs non-self) Thus both silicone and Medpor facial implants produce a surrounding scar (capsule) with the only difference being is that the capsule  produced around a Medpor implant will be more adherent or stuck due to the irregular semiporous surface of the implant. The scar capsule will also be slightly thicker as a result.The internal surface of a silicone implant capsule will be very smooth (and thinner) since the implant surface is smooth. But beyond that, the biology and make-up of both implant material’s capsules are similar.

From the outside and its aesthetic results, identically shaped and sizes of Medpor and Silicone facial implants will look the same.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering more about the chin implant and appreciate the computer imaging that you have done. My question is do I really need to enlarge my chin so much? Actually as far as I know the largest chin implant by Medpor enlarges chin by 7mm. Actually it looks better from the side view, but I am also was worried about asymmetry of the face from the front view. So I thought  to put the Geniomandibular Groove implant to right side only to correct it. But while would it correct the asymmetry, I would not look better from the side view. By using the Medpor RZ chin implant, is it possible to trim in operation or I would need to order jaw model by CT for custom implant because of the asymmetry?( http://eppleyplasticsurgery.com//blog/tag/custom-chin-implant/  ) How long would it take to get and much would it cost? Do you think I need a custom chin implant?

A: The imaging shown is just a point to begin the discussion of the changes you would like. Certainly the amount of horizontal chin projection can be less. But I would not go less than 7mms because anything less than that would not make much of a noticeable change.

Geniomandibular groove implants will not provide much horizontal projection, maybe 1 to 2mms. They are used primarily for vertical lengthening of 3 to 5mms and to fill out a notch at the lower mandibular border.

Your best off-the-shelf chin implant option would be the Medpor RZ extended square implant of 7mm projection. The wings of the implant could be intraoperatively modified  to try and compensate for your facial asymmetry along the jawline. I would expect improvement in the asymmetry but not ideal correction as this is a stock implant not a custom one…and your problem is obviously unique to your anatomy and not a ‘stock’ problem.

While custom implants are ideal for any patient, it is always a question of whether the cost is necessary for the amount of aesthetic improvement. That will always depend on the patient’s problem and how asymmetrical or unique the bone problem is. At $3500 extra costs to get it made, one does have to give that good thought. I think it depends on what one is prepared to live with when it comes to the result. In your case, if you can live with improvement but not ideal symmetry than I would go with  an off-the-shelf implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a chin implant and think I want the Medpor type. I have read about them and what there advantages and disadvantages are.  They say their advantages are that tissue ingrowth decreases movement which prevents erosion of the underlying bone and permits access of the implant to the immune system, reducing the long-term risk of implant infection and rejection. They can also be carved better to solve asymmetries. Their disadvantages are that they are harder to remove, higher risk of infection in the first few weeks and are more difficult to place. Are these accurate?

A:While there are material differences between Medpor and silicone rubber (silastic) for facial implants, choosing an implant based on its material composition is findamentally flawed. What is most important are the following issues in facial implants: 1) What is the correct implant style and size for the facial skeletal problem and 2) How easy is it to place, secure and subsequently remove if need be. If you fail to achieve these first two goals in using facial implants, then it really doesn’t matter what the material composition is.

Neither implant material type and their style and size selections is right for every patient and every facial aesthetic need.  The advantages and disadvantages of each material must be considered on an individual patient basis. Some of your listed advantages and disadvantages of  Medpor facial implants are inaccurate such as being easy to carve and adapt to the bone site, they are actually much harder to shape and place. Medpor has no proven advantage over silicone when it comes to infection/rejection. Medpor also has many less styles and sizes of available facial implants compared to silastic facial implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, five years ago I got Medpor malar implants. I am very happy with my cheek implants that provide me with very high and prominent cheek bones – a look that I have always wanted. I also like the fact that they integrate with my own tissue. But recently I have read this on the internet:

“Explantation of nonsilicone facial implants that have integrated into the surrounding tissues can be very difficult to remove, and in some cases it can contribute to nerve injuries. Any implant, regardless of material, can produce nerve injuries if a portion of the implant is in direct contact with a main branch of the sensory nerve.”

I know that one wing of the malar implants is directly below the foramen infraorbitale, where the infraorbitalis nerve comes out of the bone. Now I am worried that I could get serious nerve damage if the implant should have to be removed for a medical indication in future. What is your experience with explantation of Medpor malar implants and the risk of permanent nerve damage? Does this nerve stick to the Medpor implants?

A: While your concerns are understandable, you are worrying about a problem that you do not have and are very unlikely to ever get. Unless you now have infraorbital nerve symptoms (pain and/or numbness), your implants are not impinging on the infraorbital nerves and are not even that close to them. Thus, if you ever should need the implants removed, they should be able to be explanted without nerve injury. While Medpor facial implants are frequently stated to be very difficult and destructive to remove, that has not been my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  you have mentioned your experiences with porex facial implant removals. I am looking to get my pair of porex cheek implants removed that were placed about a year ago. I am 26 years old and hoping my face will be able to return to its pre-surgical state, but given the scar tissue must be removed am I setting my expectations too high? I am worried that if they are removed my cheeks could be even more depressed than before my original surgery.

A: I have heard and read about the ‘scar tissue’ that must be taken with Medpor facial implant removals numerous times. From my perspective, it is largely a myth and not reality. It is very similar to them being hard to remove as well. Both those issues stem from a comparative experience with that of silicone facial implants. Compared to the very easy removal of any silicone-based implant (it is very smooth so it slides in and out easily), the porous outer surface of Medpor does make it more ‘difficult’ but then anything would be hard compared to silicone. Medpor implants can be removed with just a little more effort and there is no reason to be taking out any scar tissue (known as the surrounding capsule) with them.

Therefore, when it comes to removing your Medpor cheek implants, a potential loss of volume in the cheeks will not come from having had scar tissue removed. But it is likely that it will occur due to a common implant sequelae known as tissue expansion. Depending upon the size of the implants you have in, there will likely be some cheek volume loss and/or sagging due to the stretching of the overlying tissues and the separation of the attachments of the tissues to the bone. Once the implants are removed, these tissues may not stick back down just the way they were before surgery. This potential problem can be countered by either inserting a smaller replacement implant, performing soft tissue resuspension, or inserting a dermal graft into the implant space to act as a ‘natural’ implant volume replacement. Whether any of these are appropriate for you is impossible me to tell based on the information that you have provided.

Dr. Barry Eppley

Indianapolis, Indiana