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Evaluation and planning for facial implant surgery
Physical examination is the most important element of preoperative assessment and planning for both reconstructive and cosmetic procedures. Reviewing photographic images with the patient can be helpful when discussing aesthetic concerns and goals.
All faces are asymmetric. Asymmetries are usually subtle but, with sufficient scrutiny, detectable ( Fig. 2.1 ).
To demonstrate the asymmetry in a “normal” face, a photograph has been manipulated to create three separate images. ( A ) Frontal view of 20-year-old woman presenting for rhinoplasty. ( B ) Composite created by joining right side of face with its mirror image. ( C ) Composite created by joining left side of face with its mirror image.
Their recognition preoperatively is important to both the surgeon and the patient. The patient’s asymmetry should be pointed out during the preoperative consultation so that the patient can anticipate asymmetry in the postoperative result. Preoperatively, the asymmetries belong to the patient. Postoperatively, if not identified before the surgery, they are attributed to the surgeon.
As asymmetries become more severe, it is important to recognize that they are more complex than relative skeletal deficiencies or excesses. Rather, they reflect three-dimensional differences that are most easily conceptualized as twists of the facial skeleton.
Pearl
Always describe a patient’s asymmetry during preoperative consultation.
Radiologic Examination
Most aesthetic procedures are done without preoperative radiologic assessment. In general, the size and position of the implant are largely aesthetic judgments. Cephalometric X-rays are most often used for planning chin and mandibular augmentation surgery. These studies define skeletal dimensions and asymmetries as well as the thickness of the chin pad.
While preoperative radiologic examination is uncommon for purely aesthetic surgery, computed tomographic (CT) evaluation is almost routine for reconstructive procedures. CT scans provide the ability to view the skeleton in different planes and, through computer manipulation, in three dimensions. CT imaging provides digitized information that can be transferred to design software. CAD/CAM implants provide an increased level of refinement in both reconstructive and aesthetic applications. This modality has been used since the 1990s to reconstruct cranial defects. Computer-aided design (CAD) and computer-aided manufacture (CAM) can be used to create life-sized models for surgical planning ( Fig. 2.2 ) and implants customized for the needs of the patient ( Fig. 2.3 ).
The design process can also be conducted virtually as demonstrated in Fig. 2.4 . The CAD/CAM process is the focus of Chapter 14, Chapter 15 .
Cone beam CT scans are available in many dental offices. They have the advantages of less expense and less radiation exposure to the patient. They can provide three-dimensional images of the facial skeleton and are therefore valuable in planning. Because their field is limited and head-positioning devices distort the soft tissue envelope, cone beam CT has a limited role in the CAD/CAM implant process.
Magnetic resonance imaging, invaluable for soft tissue assessment, does not have a role in skeletal evaluation and implant surgery planning.
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