Archive for the ‘Craniofacial’ Category

The Problem With Chin Implants

October 18, 2017

Chin implants may be a popular choice for chin surgery but removing them is also one of the most popular revision surgeries that we perform.

Chin implants are typically used in chin surgery (genioplasty) to improve a “weak” or nonexistent chin, or within the context of Asian V-Line surgery. The popularity of chin implants has grown over the last few years and has become one of the fastest growing procedures in plastic surgery. Unfortunately, chin revision surgery (revision genioplasty) is also one of the most popular revision surgeries we perform due to the often unsatisfactory results or resultant medical complications of using chin implants.

Chin implants are problematic and often cause complications.

Although chin implants are an option in some cases, and occasionally used, we believe that placing a foreign object (an implant) into your own body is counterintuitive and often problematic when there are much better ways to reshape and augment the chin.

Often chin implants are placed by inexperienced or unskilled surgeons and sold to the patient as an “inexpensive” or simple solution. This, of course, is so often untrue, due to the frequency of need for chin surgery revision procedures! Instead of one operation, the patient needs another one — often at an increased cost because a secondary procedure is always more complex than a primary one — not to mention the suffering, stress and mental anguish over the first, failed procedure.

Chin implants often cause complications, with the most common being:

  • The implant shifting from its original location,
  • The implant eroding into the roots of the anterior teeth,
  • And, most commonly a squaring of the chin which in females, in particular, can have an undesired masculinizing effect that is altogether unsatisfactory.

It is our belief, that a far better option in our experience, is to reshape the underlying skeleton or foundation of the chin by altering or repositioning the bone. In fact, there are several non-implant options for genioplasty surgery: the chin may be moved forward, down, centered, widened, or narrowed — depending on the desired outcome. In these cases, outcomes are improved because there are more “degrees of freedom” for the surgeon to reshape the chin into an aesthetically pleasing shape that is in harmony with other facial features.

The risks, complications and side effects of chin implants.

Apart from the obvious risk of choosing an unskilled or inexperienced surgeon to insert a chin implant – that the aesthetic result will not be a satisfactory one – there are several other serious medical complications and side effects to be aware of:

  • Damage to the marginal mandibular nerve — leading to permanent loss of movement in the lower lip
  • Damage to the mental nerve (a sensory nerve which provides sensation to the front of the chin and lower lip as well as the buccal gingivae of the mandibular anterior teeth and the premolars)
  • Implant is placed in the superficial tissues — not under the periosteum (the dense layer of vascular connective tissue enveloping the bones) leading to implant movement under the skin
  • The wrong sized chin implant is used resulting in a chin looks out of sync or inharmonious with other facial features
  • Injury or damage to the teeth, gums, or surrounding nerves
  • Permanent loss of sensation, and/or scarring.
  • Slow healing, infection, or internal bleeding leading to removal of implant
  • Inadvertent masculinization of the female chin
  • Unsightly deepening of the labiomental crease (the deep groove underneath the lower lip)

It is critical that when you choose a surgeon for your chin surgery, that you choose a U.S. Board Certified surgeon. The risks of choosing an uncertified, unskilled or inexperienced surgeon are too great and must be avoided at all costs.

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Is Long Format Plastic and Craniofacial Surgery Safe?

August 28, 2016


Long format surgery may take 6-12 hours, is it safe to be “under” for this long?

Sometimes it is recommended to undertake several plastic surgery procedures during one session. This is known as a long format surgery, which may take anywhere from 6-12 hours in duration. Most often we recommend long format plastic surgeries for either Pan Facial Rejuvenation, Facial Masculinization, or Facial Feminization.

These are complex surgeries that involve several procedures that need to be performed together to ensure a successful result. For example, if you need Forehead Feminization, it is ideal to combine this procedure with Hairline Lowering, a Brow Lift, and possibly even a Feminizing Rhinoplasty.

How safe is long format surgery?

One of the great concerns often expressed by our patients is:

How safe is it for me to be under anesthesia for this long?

This is a valid concern, and one we wish to address to dispel any myths or fears around long format plastic and craniofacial surgery.

Two elements are critical to understand:

First, it’s critical that your doctor is board certified, and that the procedure is performed in a hospital or certified ambulatory surgery center setting with a board certified physician anesthesiologist in attendance.

Dr. Deschamps-Braly has a stellar professional reputation and is cross-trained in both general plastic surgery, orthognathic (jaw) surgery, and craniofacial surgery. He works with highly qualified board certified anesthesiologists and has admitting privileges at various hospitals in the Bay Area in the event extended postoperative monitoring is necessary.

Second, the duration of long format surgeries can range from a couple of hours for a single procedure, to 10-12 hours for a multi-procedural surgery. This is why we carefully screen our patient’s health before surgery with lab and other tests to assess their suitability for long surgery. We may require additional input from other healthcare professionals prior to long surgery should anything be irregular on your health screening.

However, while a long format surgery can be safely be done in a single stage, it can also be broken up into parts—typically an ‘upper face’ and ‘lower face’ phase that would encompass a few procedures that closely relate to each other. Phases can be performed as close as two days or as long as several years apart.

Because long format surgery involves general anesthesia for an extended period of time, certain precautions must be taken. While undergoing 6-12 hours of surgery is typically safe, it is best to minimize the amount of anesthesia that is required–to also minimize postoperative sequelae.

Although delirium and confusion are rare after long format surgery, we require admission to the hospital for observation for any cases lasting longer than 5-6 hours. We work with anesthesiologists to tailor your anesthesia in such a way as to minimize any post operative confusion.

What type of anesthesia is needed for long format surgery?

Long format surgery is performed under a very light general anesthesia. We typically limit the amount of narcotics and other agents that circulate in the body for extended periods which also improves the recovery process.

Although staging surgeries into two smaller surgeries is possible, it rarely is necessary to do this way, and often increases costs by creating two separate trips to San Francisco.

Your surgeon will explain to you how much and what level of anesthesia is required for your specific series of surgical procedures.

During preoperative testing and evaluation, Dr. Deschamps-Braly will determine how safe general anesthesia will be for your particular situation, particularly if you have any other medical problems or conditions to consider. Local anesthesia is always combined with general to decrease the amount of general anesthesia medications that are necessary.

Your general health and lifestyle habits are also important predictors of outcome:

  • You should also have clearance from your family doctor to make sure you are healthy enough for a long surgery.
  • You should be put under anesthesia only by a board certified anesthesiologist and plan to spend the night of your surgery in the hospital.
  • You will be observed in the hospital overnight to make sure that you recover as planned.
  • Additionally, you should make sure that your surgeon does everything to ensure you have good circulation throughout long format surgery and during initial recovery time.

Have any major studies been undertaken in terms of long format surgery and patient safety?

Several studies validate that long hours for surgeries are not a higher risk to patient safety. In fact, one study noted considerable improvements in patient safety.

A 1999 study on the complications of long operations determined that reconstructive surgical procedures often take a long time to perform and duration of surgery is frequently cited as a major risk factor for postoperative complications. Yet, the study suggests that duration of surgery alone is not a major determinant of postoperative complications, and that the type of surgery performed and the patient’s general health are more important predictors of outcome.

A new national study published in the New England Journal of Medicine and presented at the Academic Surgical Congress in February of 2016 showed that allowing surgical residents the flexibility to work longer hours did not pose a greater risk to patients. The highly anticipated seminal study was led by Northwestern Medicine.

In addition, we have performed over 1,700 long format cases without a single serious health related complication. We maintain a successful track record through very thoughtful patient selection and screening.

What precautions do you take to ensure patient safety?

Dr. Deschamps-Braly and his team are highly regarded for their surgical expertise and exemplary patient care. Your pre-op planning consultation with Dr. Deschamps-Braly is an ideal time to discuss all the practical and important ways you can prepare yourself for a safe surgery and an optimized recovery, both initially and in the long term.

There are preliminary protections to take well in advance of surgery, the day of, and post-operation which include:

  • Follow all recommended pre-operative recommendations for optimal emotional, psychological, and physical well-being prior to surgery.
  • Specifically, your surgeon will discuss what level of sedation is needed, and will aim to keep the anesthesia as light as possible.
  • Per your surgeon’s instructions, discontinue any medications before and after surgery that could further alter brain activity.
  • Be well hydrated and nourished before surgery, to improve blood flow to the brain. Ensure you drink plenty of water and even electrolytes if you feel dehydrated.

Your safety is always our highest priority and primary concern.

Dr. Deschamps-Braly and his team take every step to ensure your utmost safety so that your entire patient experience is a positive one–that yields you the desired aesthetic outcomes as well as the best postoperative recovery experience possible. If you have any further questions, please don’t hesitate to ask Dr. Deschamps-Braly during your initial consultation.

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