Face Implants in Aesthetic Surgery

Key Points

•Midface volume loss is a consistent feature of facial aging.

•Cheek implants provide numerous advantages over other procedures which address midface volume loss.

•Cheek implants are available in numerous sizes and anatomic configurations.

•The intraoral route provides the best method for insertion of midface implants.

•The micro-screw system can be used to secure midface implants to the facial skeleton.

•Midface implants are easily and quickly inserted and can be removed or adjusted rapidly with minimal morbidity.

21.1Introduction

Midface augmentation with alloplastic implants is a powerful tool in modern facial rejuvenation [1–12]. It can significantly improve the outcome of facial cosmetic surgery, and if ignored can equally detract from the final result. Often times surgeons omit the midface evaluation and subsequent intervention, while routinely performing brow lifts, blepharoplasty, and rhytidectomy for facial and periorbital aesthetic surgery. After surgery, this omission leads to potentially glaring discrepancies in facial proportions to the trained eye. These patients look “different” or “done” and can demonstrate classic stigmata of plastic surgery. This concept is further magnified when a volume depleted midface is elevated over a face devoid of appropriate skeletal support. The results are less than ideal.

J. Niamtu III (*)

Cosmetic Facial Surgeon, Private Practice, Midlothian, VA, USA

e-mail: niamtu@niamtu.com

To achieve a more natural outcome, there must be an understanding of the importance of restoring facial volume, especially in the midface. No other region of the face contributes as much to youthfulness, as a rounded and volumized midface which is a hallmark of both youth and beauty [1]. Virtually all patients in their late 40s and 50s will become volume deficient in the midface. With this progression, what once was the midface now become the jowls (Fig. 21.1). As a result, midface augmentation must be discussed with all cosmetic facial surgery patients over 40 years of age [3, 4, 10]. Since, most patients are not aware of this aspect of facial aging, a hand-held mirror is used to allow careful inspection of the cheek region with the patient in repose, as well as smiling. The act of smiling simulates the addition of midface volume that usually imparts a youthful appearance. Supporting the elevated cheek with the thumb and forefinger, and asking the patient to relax their smile, then demonstrates how the midface volume retreats to the jowl region (Fig. 21.2).

Another means of showing a patient the importance of midface volume restoration is to recline the examination chair, placing the patient in a supine position. The patient then holds a mirror above them. The gravitational influence will fill the gaunt midface in a similar fashion to the results achieved with midface implants (Fig. 21.3). Finally, midface deficiency can be illustrated by simply holding a submalar implant over the patient’s cheeks. The implant usually is an exact match for the volume deficit and the patient can see firsthand how the implant can fill the midface hollow (Fig. 21.4).

By using one, or all, of these techniques for patient demonstration, the surgeon can increase patient awareness and acceptance for the placement of midface implants. Even the most conservative of patients will consider this option in their treatment plan, if they understand and visualize the mechanism of midface aging and volume restoration.

Fig. 21.2 To educate patients about midface volume loss, the cheek is elevated to show where the volume once existed, then released to show the gaunt midface as it exists. (Photo courtesy Joe Niamtu III)

21.2Midface Treatment Options

These are various options available for midface volume restoration including fillers, autologous fat grafting, endoscopic midface lifting, and alloplastic implants [1]. Fillers and fat

Fig. 21.3 Placing the patient in the recumbent position will enable gravity to fill the midface and give the patient an idea of how cheek implants may contribute to facial rejuvenation. (Photo courtesy Joe Niamtu III. Reprinted from Niamtu [13], with permission from Elsevier)

grafting do enhance midface volume; but the techniques are rarely permanent and typically require repeat treatments and maintenance. Fat grafting and fillers can also contribute to tissue ptosis. An endoscopic midface lift can be a powerful procedure in the hands of an appropriate surgeon. However, the surgery is intricate, requires experience with technical equipment, and the results are frequently short-lived, and often do not adequately restore volume to the region.

Table 21.1 Silicone midface advantages

Hidden incision

Simple to place

Permanent (when fixated)

Anatomic configurations

Numerous sizes and shapes

3D volume restoration

Reversible

Silicone cheek implants differ from filling or lifting in that they are permanent, three dimensional, reversible, and simple to place (Table 21.1). When they are placed and retained with a bone screw, migration is extremely rare. With time, they become encapsulated yet do not integrate into surrounding soft tissues, and are thus simple to remove.

21.3Diagnosis and Implant Selection

For the novice implant surgeon, appropriate facial analysis as well as implant selection can be intimidating and confusing. From a diagnostic standpoint, one must understand midfacial anatomy and aging to properly select the correct implant. Changes in the skin, muscle, fat, and bone contribute to the aging midface and can vary from patient to patient. The midface can be subdivided into an infraorbital, submalar, and malar region (Fig. 21.5).

Most individuals begin to lose submalar volume in their early 40s. There is usually a concomitant component of

infraorbital volume loss manifesting as a nasojugal groove or “tear trough” (Fig. 21.6a). These patients will benefit from a submalar implant which is the most commonly utilized midface implant in the author’s practice (approximately 95% of cases) (Fig. 21.7a). Other patients have volume loss in the zygomatic superolateral “malar” region but have adequate submalar volume (Fig. 21.6b). This population benefits from the placement of a malar shell type implant as this configuration adds more volume to the superiolateral zygomatic region and little to the submalar region (Fig. 21.7b). This is also the style of implant for patients who request a “high cheekbone” appearance. Finally, some patients manifest volume loss in the submalar and malar regions and require dual site augmentation (Fig. 21.6c). These patients respond well to the combined submalar shell implant that is an amalgamation of the two previously described implants (Fig. 21.7c).

The infraorbital region is a more challenging region to treat with implants only. Although “tear trough” silicone implants exist, they demonstrate variable degrees of success and are thus less commonly used. In the author’s experience, many patients will achieve some degree of infraorbital volume improvement from submalar implants, especially when performed with lower blepharoplasty and skin resurfacing.

It is also important to note that implants can also address issues other than midface aging. Some implants are placed to enhance midface features in youthful patients in the same manner that breast implants are used for augmentation. This is also true of youthful patients with genetic or developmental maxillary or malar hypoplasia.

As each patient has a different anatomic need, custommade three-dimensional implants would lead to a more optimal outcome. These implants, commonly used for reconstructive and asymmetric cases, are typically developed

Fig. 21.5 This image shows three regions of the midface that can be augmented. The red region is the tear trough (infraorbital region), the white region is the submalar area and the blue region is the malar area

from computerized tomographic scans (Fig. 21.8). The numerous sizes and shapes available of silicone implants enable “off the shelf” treatment for the vast majority of patients presenting for aging or augmentative treatment. The experienced surgeon can customize these implants by carving or trimming the edges to produce a more customized result.

After trying almost every implant material over the years, including silicone, ePTFE and porous polyethylene, silicone has become my primary implant preference. In theory, any bio-compatible implant will suffice if it maintains stability over time. Porous polyethylene implants have gained popularity, but in the author’s experience, are rigid, and do not conform to the underlying osseous anatomy. Their biggest drawback is that they are extremely difficult to remove as their porous structure leads to tissue integration. Removal of this type of implant is traumatic and results in adjacent tissue loss and severe implant fragmentation. Rigid plastic implants are hard, do not contour to bone well, and can be difficult to modify. Their utility is limited compared to silicone implants. Silicone rubber is soft and malleable. The implant curves around the cheek, from the surrounding weight of the soft tissues, without creating contour irregularities or obvious external signs of placement. Another advantage of silicone, over a rigid plastic implant, is that it does not fragment and is extremely easy to trim or carve. They also resist cracking or shattering if a screw is placed too tightly. Finally, these implants become well encapsulated, making removal or replacement easy if desired.

Fig. 21.6 (a) A patient with submalar volume loss and a candidate for simple submalar implants. (b) A patient with adequate submalar fill but with hypoplasia of the malar region who would be a good candidate for a malar shell implant. (c) A patient who lacks volume in both the

submalar and malar regions and is a good candidate for a combined submalar shell implant. (Photos courtesy Joe Niamtu III. Reprinted from Niamtu [13], with permission from Elsevier)