are evaluated. The lower lip should be located posterior as related to the upper lip. The lower lip should also be in alignment with the anterior-most projection of the chin.

The technique of implant placement for anterior mandible augmentation can be performed through an intraoral or an external route. Similar to the midface augmentation, a precise subperiosteal pocket will allow for minimal migration of the implant. The external approach is preferred by the author, through either a previous scar in the submental region, or through a 1.5 cm incision in the submental crease. The implant is placed along the inferior edge of the mandible. Preoperative marking delineate the midline, inferior edge of the mandible, and lateral extent of the dissection. The lateral dissection is usually carried out 5 cm on each side, but is dependent on the specific implant used. Once the area is infiltrated with local anesthetic, the submental crease incision is performed. The dissection is carried down through skin and subcutaneous tissue to the periosteum. The midline, inferior edge of the mandible is found and the dissection proceeds superiorly in a supra-periosteal plane for approximately 1.5 cm. During this portion of the dissection, the attachment of the mentalis muscle is carefully dissected. At this point, a 15 blade is used to vertically incise the periosteum. Using a Freer elevator, the dissection is extended 5 cm laterally on both sides. The mental nerve is not routinely identified, but caution is warranted if dissection is superior to the inferior edge of the mandible. The central cuff of periosteum will be used for fixation of the implant to provide a small amount of protection against anterior bone remodeling. After the pocket is created, an antibiotic solution is used to irrigate the cavity. The implant is carefully placed into the pocket on its side and then the opposite side is folded over onto itself to allow for placement.

Once the implant has been positioned, a 5–0 polydiaxanone (PDS) suture is used to fixate the implant to the periosteum in two places. The next layer of wound closure involves reattaching the cut edges of the mentalis muscle back to the periosteum, also performed using 5–0 PDS suture. The following two layers of closure involve the subcutaneous tissue and skin. With meticulous wound closure technique, the incision is very well tolerated by the patient.

19.3 Complications

The complications of using implants for facial augmentation include infection, extrusion, malposition, bleeding, persistent edema, abnormal prominence, seroma, displacement, and nerve damage. Most of the complications are due to technical error, not due to the implant material used. Extrusion of the implants should not occur if the implants were not forced into the pockets. There should be no folding or spring in the implant after placement. Impaired nerve function, usually temporary, is caused by trauma to the tissues overlying the dissection. Bone erosion beneath the implant can occur, and is more commonly seen in mandibular implants. As long as the implant is in correct position, there have been no reports of clinical significance.

Disfigurement is a risk following a failed implant. This can occur with the formation of a capsule, contracture and scarring, or an abnormally draped mentalis muscle. In the event of a failed implant, treatment is removal. This requires removal of the capsule or debridement of the wound in case of infection. Implant replacement is not recommended. Rather, the patient can be reevaluated and recommended for osteoplastic genioplasty.

19.4 Discussion

The role of skeletal changes in facial aging has brought to light the importance of volume restoration in facial rejuvenation. Many patients seek surgery to improve the appearance and balance of facial features to restore a youthful visage. Complete and detailed facial analysis with appropriate patient expectations is vital in all patients undergoing cosmetic surgery. Alloplastic facial implants offer the facial plastic and reconstructive surgeon many advantages over autogenous tissue, including availability of allograft materials and simplification of the surgical procedure. With all implant types and materials, careful surgical technique is crucial in minimizing the risks of extrusion and infection. Both cheek and chin implants can serve to replace lost volume with relative simplicity and low morbidity (Figs. 19.1 and 19.2).

19.5 Conclusions

In the properly selected patients, alloplastic facial implantation can yield highly satisfying results and may complement other facial plastic surgical procedures.

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