ORAL & MAXILLOFACIAL SURGERY

DENTAL IMPLANTS

Together with dentists/prosthetologists, our Clinic’s oral and maxillofacial surgeons initially place implants on jaws, along with bone grafts, where necessary, and subsequently the prosthetologists create the reconstructive prosthesis that will be placed on the implants.

Since our Hospital’s establishment, the Oral and Maxillofacial Surgery Clinic provides a high level of medical services in the field of Implantology, not only for containing intraoral prostheses, but also for applying extraoral implants (e.g. artificial nose, ears, etc.), particularly in cancer and traumatology patients, following related surgery or injury.

SPECIAL CARE FOR PERSONS WITH A HEAVY MEDICAL HISTORY

Our experienced and highly trained Oral and Maxillofacial Surgery Clinic medical and nursing staff provide full support for oral and maxillofacial surgery and dental treatment on patients with a heavy medical history (heart patients, people suffering from diabetes, oncological and immunosuppressed patients), as well as people with special needs (autistic children, mentally handicapped people etc.).

COSMETIC ORAL AND MAXILLOFACIAL SURGERY

Cosmetic facial surgery has long been the treatment of choice for the correction of natural malformations resulting from aging, disease, injury and congenital deformities. In recent years, all the more men and women of all ages have been choosing cosmetic facial surgery to improve their appearance and to reduce the signs of aging.

Thanks to the development of sophisticated medical devices and biomaterials, many of the modern cosmetic facial procedures are minimally invasive and can be performed within the Clinic, using local and/or intravenous anesthesia. However, certain surgical procedures may require a previous visit to the Outpatient Department or hospitalization in the One-Day Clinic, or even admission and hospitalization.

Cosmetic facial surgery can refine, improve and/or revive existing features used for facial expressions and external expressions of underlying anatomical facial units. In many cases, though, the uncontrolled and excessive desire for a new face or a new life is not an achievable goal. The extent to which the change is appreciated depends primarily on the patient, but also on the extent of each surgical intervention. Age, health condition, skin texture, bone substrate, healing ability and personal habits, such as smoking or alcohol consumption, are all factors which can affect the results of cosmetic surgery.

Thanks to surgical and dental training, our oral and maxillofacial surgeons are uniquely trained to perform cosmetic procedures relating to functional and aesthetic parameters of the face, mouth, teeth and jaw. Their extensive training and practice performing surgical procedures involving both the indulgent (skin and muscle) and the hard tissues (bones and joints), make oral and maxillofacial surgeons the ultimate surgeons, successfully transforming in practice the need to achieve harmony between facial appearance and functionality.

Common cosmetic maxillofacial surgical procedures

Zygomatic implants (cheek augmentation surgery): They contribute to creating high and more chiseled cheekbones that significantly affect the balance, harmony and aesthetic appearance of the face. Special silicone or ePTFE (expanded polytetrafluoroethylene) implants are placed under local or general anesthesia, after performing an intraoral or sub-brow incision, to achieve higher cheekbones (Image 1)

Genioplasty (Chin Surgery): It increases or decreases the length and projection of the chin. Its position and form plays an important role in the aesthetic balance and the overall harmony of a person. Depending on whether there is micro-or macrogenia, i.e. abnormal smallness or excessive projection of the chin in relation to the aesthetic line carried vertically from the rhinion, there is also corresponding disharmony of the face, which is often accompanied by dental occlusion disorders, i.e. the way the teeth of the upper and the lower jaw fit together.

In the case of microgenia, surgical treatment involves either placement of a special silicone or ePTFE implant under local or general anesthesia (Image 1 & 2), or chin osteotomy (lower anterior portion of the mandible) and movement of the implant outwards, down and forward. Access in both cases is performed either via a small intraocular incision in the mandibular junction or with an extraoral pituitary incision (i.e. a cut in the skin under the chin).

As far as macrogenia is concerned, surgical treatment involves performing chin osteotomy and moving inward, over and back, with intraoral or extraoral access.

Ear surgery (Otoplasty): Usually performed to reposition protruding/prominent ears back and closer to the head, to correct the shape, or to reduce the size of large ears. Otoplasty is usually performed on people over the age of 4, when the ear has completed 90% of its growth. It corrects the shape of the tracheal skeleton of the ear and restores its normal lumps and bumps, also correcting and restoring the normal angle between the head and the ear.

Blepharoplasty (Eyelid Surgery): It removes the fat and excess skin from the upper and lower lid (Image 3); it can be performed under local or general anesthesia, either on its own or in combination with other facial surgery interventions, such as facelift or browlift. Everyone knows that the eyes play an important and decisive role in communication between people. They are considered by many the mirror reflecting the inner soul of an individual. The appearance of the eyes is greatly influenced by excess skin, wrinkles and the typical bags that have a decisive effect on the overall physical and facial appearance of a person. There are various anatomical reasons for the basic underlying reason for this image, such as skin laxity, which is particularly evident in the upper eyelid folds; periorbital fat herniation, especially in the lower eyelids, with the typical bags giving the impression of permanently swollen eyelids; and formation of wrinkles in the lateral canthus area (crow's feet).

Facelift: It gives a more youthful appearance, by stretching the facial skin and muscles to restore all the anatomical elements of the face in their natural position, while removing any excess skin. Facelift surgery treats the results aging and gravity, which are characterized mainly by sagging facial skin, wrinkles around the lateral canthus area (crow's feet), descending facial fat resulting in stronger projection of the cheekbones, deepening of the nasolabial folds, jowling of the cheek skin, drooping mouth corners, and intense wrinkles under the mouth corners (marionette lines), the lower lip of the mandible body and the preauricular area. Five facelift techniques, performed under general or local anesthesia or a combination of local anesthesia and conscious sedation, are available: 1) conventional subcutaneous facelift, 2) SMAS facelift, whereby, after the skin is detached, the superficial muscular aponeurotic system (SMAS) is also detached to a certain extent - which essentially includes all the mimic muscles as well as a thin layer of connective tissue, the superficial fascia, which connects them - and lifted 3) advanced or invasive facelift (composite facelift), whereby the skin and the SMAS are simultaneously detached, 4) subperiosteal facelift, whereby detachment is performed at the level of the periosteum, and 5) mini facelift, a minimally invasive technique that only involves small incisions.

Forehead/Brow Lift: I is often performed in combination with eyelid surgery and/or facelift, with the objective to improve the position of the eyebrows, lifting them along with the rest of the forehead, to reduce frown wrinkles, and to limit or eliminate forehead wrinkles. It is divided into conventional and endoscopic. The conventional forehead facelift involves a horizontal incision performed inside the hair, between the two temple areas. The skin, subcutaneous fat and frontal muscles are sequentially detached from the underlying frontal bone to the tip of the eyebrows and pulled upwards. The fundamental advantage of a forehead lift is that, after the removal of excess skin, it is stapled deep into the scalp, leaving only a thin scar hidden inside the hair. During an endoscopic forehead lift, 3-5 small vertical incisions are performed behind the hairline. A suitable endoscope with the corresponding special tools (skids etc.) is inserted through the incisions and used to detach the skin, subcutaneous fat and the frontal muscles from the underlying frontal bone, up to eye orbit level.

Necklift: This is the method of choice for the treatment of laxity of the neck skin and platysma, a superficial muscle of the anterior surface of the neck, part of the SMAS. It contributes to the elimination of intense wrinkles in the area of the neck, limits the appearance of the typical double chin and corrects the intense vertical folds observed within the limits of platysma. Usually, a 3-4 cm incision is performed under the bottom lip of the anterior portion of the mandible body, removing any excess fat, and restoring and suturing the platysma to the midline.

Face and neck liposuction: It assists in reshaping the face by removing excess fat, usually called liposculpture. Neck liposuction is usually performed in combination with other procedures, such as chin augmentation and orthognathic surgery, aiming mainly to correct abnormalities of the neck, improving its appearance. Liposuction is usually performed under local anesthesia; initially, the suction area is macerated with a local anesthetic solution containing vasopressors, followed by a small skin incision, through which a special cannula which connects to the liposuction device is inserted.

Lip augmentation: It can reshape the lips, adding volume to the upper and lower lip and contributing to a more aesthetic or youthful appearance. Lip augmentation is performed using various biomaterials (collagen, hyaluronic acid, etc.), which inflate, adding volume and fullness to the lips, and reducing vertical wrinkles (Image 4).

Rhinoplasty: It usually reduces or increases the size of the nose, reshapes the rhinion or the back of the nose, limits (narrows) nostril width, or changes the angle between the nose and upper lip. In many cases the nose may be larger than normal or showing some asymmetry or deformity, either as a result of injury or even as a congenital defect, while some patients may experience functional problems that may cause difficulty breathing. Rhinoplasty can correct all of these problems and restore the nose both aesthetically and functionally, giving the patient greater self-confidence and decisively restoring their self-image. It is usually performed under local anesthesia, with a closed or open procedure.

Minimally invasive cosmetic maxillofacial surgical procedures

Currently there are several minimally invasive techniques available – both in terms of their underlying philosophy and their application - to treat various facial and neck skin problems, which are characterized by intense wrinkles, scarring or various deformities. The extent of the resulting improvement varies, and mainly depends on the initial state of the patient’s skin and the selected treatment.

Injections: They may limit the signs of aging by reducing muscle activity, as well as forehead and eyebrow wrinkles. They are particularly effective in limiting expression wrinkles (frowning etc.). They contains type A botulinum toxin in small doses. The action of this toxin is based on the botulism toxin, produced from the Clostridium botulinum. The substance has been approved by the US Food and Drug Administration (FDA) for use in the treatment of forehead and midbrow wrinkles since April 2002. It does not replace cosmetic surgery, but it improves a person’s appearance or offers a complementary effect to people who do not want to directly undergo extensive cosmetic surgery on the face and the neck. The action mechanism of type A botulinum toxin involves suspending the release of the acetylcholine neurotransmitter that causes muscle contraction from nerve cells. This weakens muscle activity and movement, preventing wrinkle creation for as long as the drug is active. The application of injections is indicated for the treatment of frontal wrinkles of the forehead (Image 5), mid-brow wrinkles (vertical wrinkles between the eyebrows), wrinkles on the side of the eyes (crow's feet), as well as – in selected cases – the upper and lower lip and the neck. This minimally invasive procedure is simple and brief (5-10'). It is safely performed by trained professionals within a clinical environment, and its effective action becomes evident after 48-72 hours, reaching the maximum point of effectiveness after 15 days. The results last for 4-6 months, with the possibility of a future re-injection.

Injectable skin implants (or Fillers): These are natural (autologous, heterologous) or synthetic (alloplastic) biomaterials, which are injected in the facial skin. They aim to restore the wrinkles or facial folds (fillers), but also completely configure the volume and shape of the perioral area (Image 4), the cheekbones, the forehead, the temporal and periocular area. In addition, they restore the loss of volume in the cheeks and ear lobes, even intraorally (volumizers).
The fillers mainly used are classified into four categories: 1) hyaluronic acid (non-animal origin) [Restylane®, Juvaderm®, Revanesse®, Captique®, etc.], 2) collagen (bovine, porcine and human) [Artefill ® (also contains PMMA and lidocaine), Cosmoplast/Cosmoderm®, Evolence®, Zyderm/Zyplast®], 3) synthetic [Silskin ® (silicone free), Radiesse  (hydroxylapatite), Sculptra® (Poly-L-lactic acid), Laresse ® (carboxymethyl cellulose and polyethylene oxide)], 4) autologous fat.

The filler application process is relatively simple, short and well tolerated by the patient. It can be performed in a clinic, often not requiring the use of local anesthesia, maceration or other local applications; it offers immediate results. A disadvantage is the fact that the result achieved by the use of most injectable fillers is not permanent, meaning that the process needs to be repeated after 3, 6, 12, or 24 and more months accordingly.

Chemical Peel: Application of a solution that causes peeling (flaking) of the wrinkled or damaged skin surface layers, revealing new and healthier skin after healing is complete. There are several types of chemical peels: light peel for the removal of surface wrinkles, medium-depth peel and deep peel to address more serious conditions. Usually, chemical peels are used to treat fine skin wrinkles of the face and neck, rough skin, superficial radial lesions and various spots, as well as decreases in skin turgor.

Dermabrasion, Skin Resurfacing: Using CO2 or Erbium YAG laser, superficial skin layers are removed using ablation, resulting in new, healthier, softer and smoother skin, which gives a more radiant and youthful appearance. This method is used to treat photo-aged skin and wrinkles due to aging, sun exposure, heredity or acne. The application of laser in cosmetic oral and maxillofacial surgery has been extremely beneficial, especially for the treatment of wrinkles, spots, radial lesions and scars (acne or traumatic), applied either to the entire face or on isolated areas. The key criteria for selecting a patient for treatment with laser dermabrasion are the thickness and texture of their skin. A feature of this treatment method is that the deeper the dermabrasion, the longer it takes for the skin to regain its normal color, but also the more impressive the results.

Face and neck rejuvenation using laser: This method is used to treat thin wrinkles, slight face laxity, brown spots, telangiectasias, hypermelachrosis etc. In the majority of cases, 3-5 sessions in 4 weeks are usually enough, with immediate return to daily activities, while treatment is repeated once a year.

 
Image 1: Woman, aged 44, before and after zygomatic implant placement and chin surgery (same case).

Image 2: Treatment of third molar hypoplasia and microgenia using ePTFE implant placement on the cheekbones and chin. Patient pictured in Image 1 (same case).

Image 3: Before and after upper and lower eyelid blepharoplasty.

Image 4: Before and after injection of non-animal hyaluronic (Restylane ®) in the upper and the lower lip, with a view to total volume configuration of the lips (Dr Joe Niamtu’s patient, III, Richmond, VA, USA).

Image 5: A) extensive horizontal wrinkles on the forehead B) successful outcome following an injection of type A botullinum toxin ( ®). (Dr Joe Niamtu’s patient, III, Richmond, VA, USA).

Dr. ANASTASIOS I. MYLONAS
Oral and Maxillofacial Surgeon
Associate Director