Fig. 21.16 A simple 4–0 gut suture is used to close the mucosal incision after implant placement. (Photo courtesy Joe Niamtu III. Reprinted from Niamtu [13], with permission from Elsevier)

21.5Postoperative Care and Healing

As stated above, a dressing is not placed after cheek implant surgery. All patients receive antibiotic coverage beginning the day before surgery and continuing for 6 days after. An analgesic suitable for moderate discomfort is prescribed, as well as a steroid regimen if excessive swelling is anticipated. Patients are asked to refrain from excessive facial animation for 72 hours and are placed on a liquid or soft diet for the first 48 hours. Ice is applied to the midface intermittently for 48 hours, followed by warm compresses for the next several days.

Patients are told that the recovery period is typically 1–2 weeks with a qualification that most people will typically miss only one work week. Swelling is the primary complaint after surgery. Although this can take several weeks to resolve, most patients are presentable in a week or sooner. Ecchymosis is rare. Most patients will experience transient numbness of

the infraorbital region which will spontaneously resolve over 1–2 weeks. Patients are also informed that their smile and/or pucker will appear unnatural for the first 7–10 days after surgery. This results facial edema, and disruption of the lip elevator musculature from the subperiosteal dissection.

Patients must be aware that the implants may look unnatural and large in the initial phase of recovery. They are encouraged to wait at least 6 weeks before deciding to remove the implant, as it takes time for subtle swelling to settle and for the patient to accommodate to the augmented midface.

21.6Implant Complications

Significant complications have been rare in my practice but can include the following:

•Bleeding

•Hematoma/seroma

•Acute infection

•Late or chronic infection

•Implant migration

•Implant extrusion

•Permanent dysesthesia

•Overcorrection

•Undercorrection

•Asymmetry

•Facial pain

Many complications can be prevented by judicious preop-

erative screening [12]. Patients should be questioned for possible sources of infection such as dental or sinus disease. Oral hygiene should also be evaluated to assure there is no active dental or periodontal disease. Smokers may have problems with wound dehiscence, implant migration associated with puckering, and infection.

Subjective postoperative dissatisfaction can be avoided by appropriate patient selection. Various “red flags” can

signal potential problematic patients. Caution should be employed when considering surgery on patients under 30 years of age who have had multiple cosmetic procedures. These patients often have components of body dysmorphic disorder and can be impossible to please. In addition, patients (especially males) who at consult requesting a “chiseled” face, or those who bring in numerous pictures of celebrities or models (who they want to look like) are very concerning. The best candidates for cheek implants, in my opinion, are those patients with midface aging or hypoplasia who will be happy with moderate improvement after surgery.

Overor under-correction should be treated by exchanging the prostheses with a more appropriate implant. Again, waiting 6 weeks after placement may reduce the revision rate. Asymmetries are not unusual, given that many patients have preexisting facial asymmetries. Gross asymmetry should be recognized preoperatively and pointed out to the patient. In these cases, the surgeon may elect to place different size implants on either side of the face. For more subtle asymmetry, trimming or shaving the implants may be sufficient.

In the author’s experience, infections after surgery are rare. This is most likely related to the stabilization technique described which reduces the risk of seroma formation and foreign body reaction. Fixation also allows the retained implants to better respond to “salvage” procedure if infection occurs. Implant infections, when present, typically occur in the first several days after placement. An infection must be considered if a patient develops unilateral pain, discharge, and/or periorbital swelling (Fig. 21.17). If an infection is present in an implant not secured with a screw, my preference is removal and replacement 4–6 weeks later. For screw

Fig. 21.18 This patient had a chronic recurrent subclinical infection that was treated with antibiotics numerous times. An oro-facial fistula finally formed requiring implant removal. Chronic infections of this nature are quite rare. (Photo courtesy Joe Niamtu III)

retained implants, incision and drainage, antibiotic lavage, and oral antibiotics may salvage the implant.

Some patients may present with recurrent swelling that is consistent with infection but clears with oral antibiotics. If this cycle recurs, the surgeon should remain suspicious that a chronic infection or implant inflammatory reaction is present. Figure 21.18 shows a patient with an external perforating fistula from a chronically infected left cheek implant

that continued with a subclinical course. In these instances the implant should be removed.

Persistent facial pain, especially shooting pain into the lip or teeth, can signify implant compression on the infraorbital nerve. If these symptoms continue after several weeks, exploration with implant modification for relief of impingement should be considered.

resultant contour irregularities and depressions (tear trough, nasolabial fold). It is important for the cosmetic surgeon to identify these deficits and plan accordingly to address them in surgery. Silicone midface implants are an effective tool in attaining this goal. They are easy to place, reversible, and have few postoperative complications. As with any procedure, expertise comes with time and experience. The results to surgery are excellent and patient satisfaction high.

21.7Conclusion

Midface aging leads to significant facial changes that must be considered in the evaluation of the aesthetic patient. These changes include tissue deflation, descent, flattening, and

Fig. 21.19 This 45-year-old female desired a very subtle cosmetic change and underwent placement of medium submalar implants as a stand-alone procedure. (Photos courtesy Joe Niamtu III)

Fig. 21.20 This patient underwent upper blepharoplasty, facelift, and medium submalar cheek implants. The addition of midface volume is dramatically apparent in this case. (Photos courtesy Joe Niamtu III. Reprinted from Niamtu [13], with permission from Elsevier)

21.8Case Presentations

Figures 21.19–21.25 show before and after images of various facial rejuvenation cases employing facial implants.