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SECOND EDITION
Atlas of
FACIAL IMPLANTS
LEAD EDITOR
Michael J. Yaremchuk, MD
Clinical Professor of Surgery
Harvard Medical School
Chief of Craniofacial Surgery
Massachusetts General Hospital
Boston, MA, USA
ASSOCIATE EDITORS
Catherine S. Chang, MD
Beverley Hills, CA
Former Fellow, Adult Reconstructive & Aesthetic
Craniomaxillofacial Surgery
Division of Plastic & Reconstructive Surgery
Massachusetts General Hospital
Boston, MA, USA
Erez Dayan, MD
Reno, Nevada
Former Chief Resident
Harvard Plastic Surgery
Boston, MA, USA
Mohamed Amir Mrad, MD, FRCSC, MBA,
FACS
King Faisal Specialist Hospital and Research Centre
Department of Surgery
Plastic Surgery Section
Riyadh, Saudi Arabia
Alan Yan, MD
Fellow, Chang Gung Memorial Hospital, Taiwan
Former Fellow, Adult Reconstructive & Aesthetic
Craniomaxillofacial Surgery
Division of Plastic & Reconstructive Surgery
Massachusetts General Hospital
Boston, MA, USA
For additional online content visit ExpertConsult.com
© 2020, Elsevier Inc. All rights reserved.
First edition 2007
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verication of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in
the material herein.
ISBN: 978-0-323-62476-3
Content Strategist: Belinda Kuhn
Content Development Specialist: Sharon Nash
Project Manager: Julie Taylor
Design: Renee Duenow
Illustration Manager: Paula Catalano
Illustrator: Kip Carter
Marketing Manager: Claire McKenzie
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Preface
This atlas presents the use of alloplastic implants utilized for aesthetic and reconstructive applications of the
craniofacial skeleton. In the decade since I wrote the first
edition of the Atlas of Facial Implants much has transpired
in related technology, clinical applications and implant
design. For example, Computer Aided Design (CAD)/
Computer Aided Manufacture (CAM) of implants is
rapidly evolving not only for cranial reconstruction, but
also for aesthetic applications. Cranial implants are now
designed not only for protective or aesthetic indications,
but also with functional components (implantable neurotechnology - e.g. pressure monitoring, drug delivery…).
Recent studies have shown that critical areas of the
facial skeleton resorb with aging and hence, facial implants
have shown to be an important adjunct in rejuvenative
aesthetic surgery. Implants now have an accepted role in
refining orthognathic surgical procedures and surgically
treating Graves’ ophthalmopathy. These innovations are
included in this second edition.
In addition, the 10-year clinical experience has afforded
many new insights into this surgery providing improved
results and avoiding as well as treating complications.
This edition includes chapters arranged in five sections.
As before, the first section, Background, includes chapters
addressing implant fundamentals. It is followed by sections addressing implant applications for each anatomic
facial third - Upper, Middle and Lower Face. A fifth section, Developing Applications, now includes chapters
addressing implant use in facial rejuvenation, CAD/CAM
aesthetic surgery and postorthognathic surgery refinement. Videos of the implant procedure appropriate to each
anatomic area are now included.
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Acknowledgments
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My co-authors, Doctors Catherine Chang, Erez Dayan, Amir Mrad and Alan
Yan, were indispensable in the preparation of this book. They are all previous
trainees at the Massachusetts General Hospital and the Boston Center and are
now practitioners spread throughout the world.
Kip Carter, Chief of Medical Illustration Services at the College of Veterinary
Medicine at the University of Georgia, once again added his artistic precision
and nuance to the Atlas of Facial Implants. His illustrations are obviously key to
the visual presentation of this work.
Finally, Elsevier’s Sharon Nash, Belinda Kuhn and Julie Taylor coordinated
our efforts with great skill and professionalism.
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to
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MARILYNN
and KAIT
as well as
CHARLES and DEUCE (CHARLES II)
Chapter 1
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Indications for facial implants
The shape of the human face is composed of a skeletal bony framework that is covered
by a soft tissue envelope. Overall, skeletal proportions are probably the most important
component of facial attractiveness.
Fritz E. Barton Jr., 2009
Since the skeletal infrastructure of the human face is
fundamental to its appearance, its surgical change can
be powerful. Conceptually, autogenous bone would be
the best material to restore or augment the craniofacial
skeleton because it has the potential to be vascularized
and, then, incorporated into the facial skeleton. In time,
it can be biologically indistinguishable from the adjacent
native skeleton. Practically, the use of autogenous bone
to augment facial skeletal contours is limited. Donor
site morbidity as well as the time and operative costs
associated with autogenous bone graft harvest can be
significant. Furthermore, the inevitable resorption and
the poor handling characteristics of autogenous bone
grafts limit the quality and predictability of the aesthetic
result. With the exception of interposition grafts used to
reconstruct segmental load-bearing defects of the maxilla and mandible, the majority of craniofacial skeleton
replacements and, particularly, facial skeleton augmentation is done with alloplastic implants. A diagrammatic
survey of the alloplastic implants used for facial skeletal
reconstruction and enhancement is presented in Fig. 1.1.
Subsequent chapters will address each anatomic area.
Patients with normal, deficient, and surgically altered
or traumatically deformed anatomy may all benefit from
implant augmentation of their craniofacial skeleton.
1
Fig. 1.1 A diagrammatic survey of the alloplastic implants used for
facial skeletal reconstruction and enhancement.
3
Chapter 1 Indications for facial implants
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FACIAL BALANCE AND DEFINITION
Most often, facial skeletal augmentation is done to enhance facial appearance in
patients whose skeletal relationships are considered within the normal range.
They want more definition and angularity to their appearance. Other patients
desire to “balance” their facial dimensions. The woman in Fig. 1.2 underwent
chin and mandible angle augmentation at the time of rhytidectomy to provide
angularity and balance between her upper and narrower lower face.
Fig. 1.2 A 52-year-old woman underwent
mandible augmentation, chin augmentation,
and rhytidectomy. (A) Preoperative frontal
and (B) preoperative lateral view. (C)
Diagrammatic representation of implant
augmentation. (D) Postoperative frontal and
(E) postoperative lateral view.
A
C
B
4
D
E
SKELETAL DEFICIENCY
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Craniofacial deformities that are disfiguring and are of functional consequence
to vision, breathing, and mastication usually require skeletal osteotomies and
rearrangement as treatment. Less severe midface and mandibular hypoplasia are common facial skeletal variants. In patients with these morphologies,
occlusion is normal or has been compensated by orthodontics. These patients
have neither respiratory nor ocular compromise. In skeletally deficient patients
whose occlusion is normal or has been previously normalized by orthodontics,
skeletal repositioning would necessitate additional orthodontic tooth movement. Such a treatment plan is time-consuming, costly, and potentially morbid. It is, therefore, appealing to few patients. In these patients, the appearance
of skeletal osteotomies and rearrangements can be simulated through the use
of facial implants. Diagrammatic representations of how implant surgery can
mimic the appearance of skeletal osteotomies are shown in Figs. 1.3 and 1.4.
Skeletal deciency
Fig. 1.3 Diagrams show how multiple
implant augmentation of the midface
skeleton can simulate the visual
appearance of Le Fort III osteotomy and
advancement without altering dental
occlusion. (A) Illustration of midface
concavity and class III malocclusion. Dotted
line shows potential lines of osteotomy.
Arrow shows anticipated advancement.
(B) Osteotomy and advancement at the Le
Fort III level provides midface projection
and class I occlusion. Note change in soft
tissue prole. (C) Illustration of corrected
class I skeletal occlusion after orthodontic
tooth movement. (D) Multiple implants
augmented the midface skeleton whose
occlusion was corrected by orthodontia as
shown in (C). The implants project the soft
tissue envelope to mimic the contour of the
soft tissue envelope of Le Fort III skeletal
osteotomy and advancement.
A
C
B
5
D
Chapter 1 Indications for facial implants
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A
Fig. 1.4 Diagrams show how implant
augmentation of the mandible can
simulate the visual appearance of
sagittal and horizontal osteotomy with
advancement without altering dental
occlusion. (A) Mandibular deciency
with class II occlusion. Dotted line shows
potential lines of osteotomy. Arrows show
anticipated advancement. (B) After sagittal
split osteotomy with horizontal osteotomy
advancement of the chin to increase chin
projection. Note that the occlusion has
been corrected from class II to class I. Note
change in soft tissue prole. (C) Mandibular
deciency after corrected class I occlusion.
(D) The skeletal deciency of mandibular
deciency has been augmented with
implants. Note that the class I occlusion is
unchanged. Also note the change in soft
tissue prole. Notice the absence of border
regularities that are inherent with skeletal
osteotomies.
B
C
6
D
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