205A. Erian and M.A. Shiffman (eds.), Advanced Surgical Facial Rejuvenation, DOI: 10.1007/978-3-642-17838-2_19, © Springer-Verlag Berlin Heidelberg 2012

19.1 Introduction

Over the past few decades, there has been a paradigm shift in the approach to the treatment of facial aging. This philosophical shift has consisted of a departure from older “subtractive” facial surgery techniques to newer “restorative” techniques and procedures to evoke more beautiful natural-looking results.

Older methods of facial rejuvenation consisted pri-marily of removing (subtracting) skin and fat and pull-ing tissues tight. In many instances, this led to a skeletonized and more aged, and operated-upon appearance. We now recognize that it is not only the skin that needs to be addressed to correct the signs of facial aging, but facial soft tissues, including subcuta-neous tissue, fat, and facial bones that lose volume and projection over time.

The major architectural promontories of the facial skeleton, including the malar-midface region, nose, and chin, provide the structural foundation for aes-thetic facial beauty. The overall harmony of the face is largely determined by the balance, size, shape, and position of these structural fundamentals. A cosmetic surgeon may be able to add facial implants to the facial skeleton to accentuate the areas of the cheekbone or chin. These skeletal augmentations re-drape and tighten the skin of the face as well as reorchestrate the elements of facial balance and proportion for an

improved cosmetic result. Depending on an individual’s specific aesthetic requirements, implant procedures can be performed solo or in combination with other facial plastic procedures to provide a more healthy and youthful appearance. Implant placement surgeries are performed with hidden or invisible incisions so there are no visible scars and the results are immediately evident [1].

Proper selection of implants requires a working knowledge of general size, thickness, and material composition of available implant types. Alloplastic facial implants offer the surgeon many advantages over autogenous tissue, including easy availability of mate-rial and simplicity of the operative procedure. Care must be taken to select the proper implant characteris-tics for the desired aesthetic result, as each synthetic material has unique properties. With all implant types and materials, careful surgical technique is essential to minimize the risks of complications [1].

In the past, a variety of substances have been used for soft tissue and bony augmentation, including autog-enous elements such as iliac and rib bone grafts and nasal cartilage. Varied alloplastic materials including ivory, acrylic, and precious metals remain solely of historical interest. Advancements in biomaterial sci-ence have promoted the use of novel, alloplastic implant materials for facial skeletal augmentation [2]. There are several general features that contribute to the biocompatibility of an implant. An ideal implant is comprised of materials that do not elicit a chronic inflammatory response or foreign body reaction, are non-immunogenic, inert in body fluids, and noncarci-nogenic. Implant materials must also be nondegrad-able, yet malleable, such that the shape and position are sustained over time.

Facial Implants

Benjamin A. Bassichis

B.A. Bassichis Department of Otolaryngology – Head and Neck Surgery, University of Texas – Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235, USA andAdvanced Facial Plastic Surgery Center, 14755 Preston Road, Suite 110, Dallas, TX 75254, USA e-mail: drbassichis@advancedfacialplastic.com

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There are many materials used for alloplastic implants including silicone elastomers, expanded polytetrafluoroethylene (e-PTFE), high-density porous polyethylenes, methylmethacrylate, nylon mesh mate-rial, bioglass and alumina ceramics, and hydroxyapa-tite-calcium phosphate material [2]. Currently, the most commonly used materials are solid silicone and expanded polytetrafluoroethylene. Both materials have performed well in terms of the incidence of infection and lack of bony resorption tendencies (when posi-tioned in the correct plane of dissection).

Improved understanding of tissue-implant interface biology has encouraged the development of bioactive implants which allow for biologic bonding of tissue to implant, which permits natural tissue regeneration as opposed to chronic foreign body or inflammatory reac-tion. Evolving material technologies have permitted the creation of better implants; however, the ideal allo-plastic material has yet to be formulated [3]. The most significant burden still remains in accurate facial anal-ysis, assessment, and planning to achieve a good surgi-cal outcome.

19.2 Technique

Surgical technique affects both the short-term and long lasting outcomes in facial skeletal augmentation. General surgical principles relating to implantation technique such as avoidance of contaminated fields, use of perioperative antibiotics, and meticulous intra-operative handling of the implant materials are vital to the success and safety of the operation. Careful preop-erative assessment of the recipient site should deter-mine whether adequate vascularity and soft tissue coverage are present.

19.2.1 Midface Implants

Prominent malar eminences are a canon of beauty in many cultures, conveying the youthful appearance of facial fullness. A hypoplastic flat malar area can make the face appear tired and contributes to a pre-maturely aged countenance. This tired, sunken look can be secondary to midface hypoplasia and/or atro-phy and ptosis of the soft tissues. It can also be

accentuated by an over-resected facelift procedure. The goal of midface augmentation is to restore the appearance of youth and beauty by enhancing struc-ture and facial contour.

The majority of patients are unaware of the contri-bution the midface provides in terms of overall facial harmony; instead, many patients focus on the nose, eyes, or lax facial skin. The facial plastic surgeon can educate patients by illustrating how malar augmenta-tion can restore a youthful and balanced facial contour. In patients lacking bony substructure, rhytidectomy alone does not provide sufficient rejuvenation. Volume restoration by means of midface augmentation in con-junction with facelift can provide the scaffolding for a more optimal redraping of facial tissues to achieve a more successful rejuvenation. Malar implantation enhances rhytidectomy or rhinoplasty results by fur-ther improving facial balance and harmony.

The majority of malar augmentations are per-formed on an elective basis. General indications for malar augmentation include posttraumatic and post-tumor resection deformities, congenital deformities, aged face with atrophy and ptosis of soft tissues, unbalanced aesthetic facial triangle, a very round full face or a very long narrow face, and midface hypopla-sia. Patients may present with changes associated with aging, such as hollowing of the cheeks and ptosis of the midfacial soft tissue. Malar implants can augment cheek hollows and grooves associated with inferior displacement of the malar fat pad and soft tissues sec-ondary to volume depletion of aging. Patients with midface hypoplasia gain aesthetic benefit from enhanced facial volume. Patients with mild hemifa-cial microsomia may also show improvement. Other patients may request facial augmentation to produce a dramatic high and sharp cheek contour. Flat, thin, and round faces all benefit from malar augmentation, as it balances the face to create a more aesthetically appeal-ing appearance.

Facial analysis, incorporating photographic docu-mentation, is a critical component of patient selection for malar augmentation. Several techniques of facial measurement analysis of the malar region exist; how-ever, the exact location for augmenting the malar emi-nence is not universally agreed upon, as the type of malar deficiency varies from patient to patient.

After the determination of appropriate implant size to be used, the patient can undergo the procedure.

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The most common technique used is via an intraoral route. No external incisions are made on the face. The initial step is to adequately mark the patient, determin-ing the planned placement of the implants. The precise anesthetic solution used is not as important, as long as it contains epinephrine. After infiltration on both sides, a 1.5 cm sublabial incision is made in the vertical direction through all layers down to the bone. Horizontal incisions for the approach are discouraged. Once this incision has been made, a periosteal elevator is used to dissect the periosteum off the bone. Many authors favor the use of fixation to help secure the implant. The author prefers to use precise subperiosteal pockets for implant placement. Therefore, wide under-mining is not required, but careful, deliberate creation of pockets allows for precise localization. The infraor-bital nerve is not compromised during the dissection. Depending on the implant, the lateral dissection may be extended to the zygomatic arch. Submalar implants or combined implants will necessitate a more inferior dissection from the arch over the masseter muscle. The correct plane of dissection is over the glistening white fibers of the muscle.

Prior to implant placement, an antibiotic solution is used to irrigate the cavity. A 4–0 chromic suture is passed through the lateral edge of the implant. Using an Aulfricht retractor, the lateral extent of the pocket is identified and the same suture is passed through to the skin surface. With a gentle amount of tension, the implant is inserted into the pocket. The assistant gently pulls on the suture, while the surgeon is guiding from medial to lateral direction. The suture is then gently tied over a bolster, which will be removed after 5 days.

The pocket will “shrink-wrap” around the implant over the next 24–48 h. The incisions are closed in two layers. Attention to detail during the closure cannot be overemphasized as any saliva that penetrates into the wound can lead to infection.

Besides the intraoral route, there are other approaches that may be preferred by other surgeons. The subciliary approach, through a lower blepharoplasty incision, may be used to place smaller implants, especially implants used to augment the nasojugal fold. During facelift sur-gery, penetration can be made through the subcutane-ous musculoaponeurotic system (SMAS) and then carried down to the bone. A subperiosteal pocket can be formed from lateral to medial. This technique limits the access for implant positioning.

19.2.2 Mandibular Implants

The chin has a prominent role in anchoring facial sym-metry and aesthetics. Along with the nose, it is a pri-mary determinant of facial balance, especially in consideration of the facial profile. The features of the chin can determine characteristics of the face and even perceptions of personality where a long chin implies strength and power, and a short, small chin portrays weakness.

Abnormalities of the chin are commonly present in patients pursuing cosmetic facial surgery. Chin defor-mities are the most common abnormality of the facial bones, with microgenia being the most common abnor-mality but with the lack of an associated functional deficit, microgenia often remains untreated. Most com-monly, patients present requesting rhinoplasty and are unaware of their associated chin deficit.

When a patient is considered for chin augmentation with an alloplastic implant, it is important to carefully select the proper implant size and shape. Some allo-plastic chin implants, particularly silicone, will heal with the formation of a fibrous capsule resulting in thickening of the overlying skin and soft tissues. This should be taken into account when calculating the size of the augmentation. Women are most judiciously treated with under correction, to avoid the necessity of removal of an implant that is perceived as too large. This is rarely the case in male patients, where a strong chin is viewed as a positive facial feature [4].

Severe microgenia is a contraindication to augmen-tation mentoplasty. Other contraindications include labial incompetence, lip protrusion, shortened man-dibular height, severe malocclusion, and periodontal disease.

As with all procedures in facial plastic surgery, thoughtful preoperative analysis is crucial to a suc-cessful outcome. This analysis involves careful three-dimensional evaluation of the face as a whole, with specific attention directed toward the chin, lips, and nose [5]. The patient is examined from all angles, accompanied by precise photo documentation in the standard views. Face shape and length and the rela-tionship of the chin and nose to the face are exam-ined. The chin is analyzed for its soft tissue components and its bony structure. Chin projection and width are noted as is the position and depth of the labiomental fold. Labial competence and lip position

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are evaluated. The lower lip should be located poste-rior as related to the upper lip. The lower lip should also be in alignment with the anterior-most projec-tion 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 exter-nal 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 dissec-tion. 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 dis-section 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 approxi-mately 1.5 cm. During this portion of the dissection, the attachment of the mentalis muscle is carefully dis-sected. At this point, a 15 blade is used to vertically incise the periosteum. Using a Freer elevator, the dis-section 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 remodel-ing. 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 polydi-axanone (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 men-talis muscle back to the periosteum, also performed using 5–0 PDS suture. The following two layers of clo-sure 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 aug-mentation 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 pock-ets. There should be no folding or spring in the implant after placement. Impaired nerve function, usually tem-porary, 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, con-tracture and scarring, or an abnormally draped menta-lis muscle. In the event of a failed implant, treatment is removal. This requires removal of the capsule or deb-ridement 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 analy-sis with appropriate patient expectations is vital in all patients undergoing cosmetic surgery. Alloplastic facial implants offer the facial plastic and reconstruc-tive surgeon many advantages over autogenous tissue, including availability of allograft materials and simpli-fication of the surgical procedure. With all implant types and materials, careful surgical technique is cru-cial 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).

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a

b

Fig. 19.1 (a) Postoperative and (b) preoperative chin implant

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19.5 Conclusions

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

References

1. Eppley BL. Alloplastic implantation. Plast Reconstr Surg. 1999;104(6):1761–83.

2. Friedman CD, Costantino PD. Alloplastic materials for facial skeletal augmentation. Facial Plast Surg Clin North Am. 2002;10(3):325–33.

3. Friedman CD. Future directions in alloplastic materials for facial skeletal augmentation. Facial Plast Surg Clin North Am. 2002;10(2):175–80.

4. Frodel JL. Evaluation and treatment of deformities of the chin. Facial Plast Surg Clin North Am. 2005;13(1):73–84.

5. Terino EO. Facial contouring with alloplastic implants: aes-thetic surgery that creates three dimensions. Facial Plast Surg Clin North Am. 1999;7:55–83.

a bFig. 19.2 Twenty-six-year-old male. (a) Preoperative and (b) postoperative chin implant and rhinoplasty