J6

TtrtC

tmmcSOtwormpm

m7tpfrpi

tdtrttiepnt

N

a

2

©

0

d

Oral Maxillofac Surg8:1420-1429, 2010

Essentials of Cheek and Midface Implants

Joe Niamtu III, DMD*

mcqspdtd

ap

2cu

s

D

aslptoyfiCdcttpm

uyufst

cit

his author has placed cheek implants sporadically forhe past 25 years. Previous to 2004, expanded polytet-afluoroethylene cheek implants were used, but sincehat time, only Silastic implants (ImplanTech, Ventura,A) have been placed.Since 2004, the author’s practice has been limited

o cosmetic facial surgery and with this focus manyore implants were placed as a solitary procedure orore commonly with facelift or other cosmetic pro-

edures. From January 2004 to December 2007, 204ilastic cheek implants were placed in 102 patients.f these 204 implants, 3 implants were removed due

o infection for an infection rate of 1.5%. All 3 of theseere replaced after resolution of the infection. Threether patients had implants electively removed andeplaced with different size implants for a replace-ent rate of 3%. A single patient electively had im-lants removed and not replaced for an elective re-oval rate of 1%.In the author’s experience, most implant infectionsanifest early in the recovery period, usually within

2 hours. The clinical manifestations are very similaro maxillary dentoalveolar infections and present withain, swelling, erythema, purulence, and drainage

rom the incision site. Delayed infections have beenare and could be associated with a mobile implantroducing a foreign body reaction or a sinus or dental

nfection whose spread can involve the implant.When a patient presents with a suspected infec-

ion, he or she is placed on antibiotics and, if there israinage, the incision is opened. Salvage may be at-empted for implants that have been secured withigid fixation screws and are not mobile. Any infec-ion associated with a mobile implant requires explan-ation. For the secured infected implant, the incisions opened and the purulence is expressed and thentire surgical site is copiously irrigated with an ap-ropriate antibiotic irrigation solution. The incision isot resutured and the patient is seen daily for irriga-ion. The author has salvaged several implants by this

*Private Practice, Richmond, VA.

Address correspondence and reprint requests to Dr Niamtu, III:

iamtu Alexander Keeney Harris and Associates, Oral/Maxillofacial

nd Cosmetic Facial Surgery, 10230 Cherokee, Richmond, VA

3235; e-mail: niamtu@niamtu.com

2010 American Association of Oral and Maxillofacial Surgeons

278-2391/6806-0035$36.00/0

boi:10.1016/j.joms.2009.12.004

1420

ethod and the incision will granulate and healingan be uneventful. If the infected implant does notuickly respond to this conservative therapy, ithould be removed. Cultures and gram stains areerformed before any surgical therapy. The authoroes not attempt salvage procedures on smokers, ashe continual perioral movement and fresh smokeecrease the chance of success.Reimplantation is always an option after infection

nd the author usually waits about 6 weeks for reim-lantation.Over the 48-month period, the author performed

27 facelifts and 27% of these patients (62/227) hadoncomitant cheek implants placed, underlining thetility and popularity of this procedure (Table 1).Table 1 shows the number of midface implants

imultaneously used in facelift patients.

iscussion

THE AGING MIDFACE

The aging midface is one of the most overlookedreas in cosmetic facial surgery. Many well-knownurgeons perform extensive surgery on the upper andower face and overlook the midface. One of theroblems associated with cosmetic facial surgery overhe past 30 years was the fact that after surgery weften made the patient’s face look tighter, but notounger. One of the primary advances in cosmeticacial surgery has been the realization of volume lossn aging and volume replacement in cosmetic surgery.ontemporary cosmetic facial surgeons routinely ad-ress midface issues in many ways; by making smallorrections in the midface, big changes are realized inhe final result. Synergy results in the situation whenhe total is greater than the sum of the parts; thishenomenon is common with simple midfacial aug-entation.Beauty equals youth and youth equals facial vol-

me. One of the main reasons that a person looksoung or beautiful is the abundance of midfacial vol-me. It short, it involves having the right amount ofat in the right areas of the face. It is the loss orenescent repositioning of this fat that is a main con-ributor to facial aging.1

The youthful midface is discernable as a singleonvexity in harmony with the lower eyelid esthet-cs, as shown in Figure 1A. In the younger patient,he lower eyelid periorbital fat is not visualized

ecause it lies tight behind the orbital septum.

Aolata

ras(

allam

r

acvotacctctaicttniwufBtritp

Fwf

J2

J2

Fi

J2

JOE NIAMTU 1421

ging changes cause weakening of the lower eyelidrbital septum, resulting in pseudoherniation of the

ower orbital fat pads; this change is coupled withging changes to the overlying skin. The sum ofhese changes produces a double convexity profile,s shown in Figure 1B.

The youthful midface has voluminous and supe-iorly positioned malar fat pads. The malar fat pad istriangular structure with its base against the na-

olabial fold and its apex over the malar regionFig 2).

Due to actinic and senescent skin changes as wells gravity, fat atrophy, and deep connective tissueaxity, the malar fat pads lose volume and descendower into the face with age (Fig 3). The sum of theseging changes frequently yields a hollow or gauntidface.

TREATMENT OPTIONS

A plethora of treatment options for midfacialejuvenation include lifting procedures,1-7 inject-

IGURE 1. The youthful midface (A) consists of a single convexity,hile periorbital and midface changes produce a double convexity

acial curvature (B).

Table 1. SILASTIC CHEEK IMPLANTS WITHFACELIFT SURGERY

YearNumber of

FaceliftsNumber of CheekImplants (pairs) Percentage

2004 35 12 342005 47 13 282006 67 18 262007 78 20 26

Total 227 62 27

oe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg010.

moe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg010.

ble synthetic fillers,8-12 autologous fat,13-16 and fa-ial implants.17-21 Each treatment option carries ad-antages and disadvantages but, in this the author’spinion, midface implants are an optimum choice inhe average patient for multiple reasons. The maindvantage is that they are a permanent option whenompared with fillers and lifting procedures. Theheek midface implants lie in the subperiosteal plane,ight to the bone, and are not subject to the soft tissuehanges of the more superficial planes. In addition,hey are available in a vast array of anatomical sizesnd shapes to customize augmentation. They are eas-ly placed; the recovery is minimal, and the compli-ation rate is low. The silicone structure rendershem very biocompatible and they are not subjecto degradation seen with fillers and fat grafts. Fi-ally, and very importantly, they are very revers-

ble. Should the surgeon or patient be unhappyith the result, the implants are easily removednder local anesthesia, or they can be exchangedor larger or smaller sizes with minimal dissection.ecause silicone forms a well-developed capsule,he implants are much more easily removed oreplaced with no tissue damage compared withmplant materials that encourage tissue ingrowthhat complicates removal. The aforementionedoints make the placement of midface implants for

IGURE 2. The youthful malar fat pad has volume and lies superiorn the midface.

oe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg010.

idfacial rejuvenation a very attractive procedure.

ftocuapa

iihntaatctiae

cogas

pitmt

plripsctrttwTca

csaifitt

t

Fwm

J 2010.

1422 CHEEK AND MIDFACE IMPLANTS

FACIAL IMPLANTS

Cheek implants have existed for decades and haveallen in and out of favor for various reasons. One ofhe biggest problems with early implants was the lackf anatomical form. The early implants and the advo-ated positioning of them produced “blocky” andnnatural results that were very apparent. They werelso usually placed high in the zygomatico malar com-lex, giving patients an exaggerated and unnaturalppearance.

The last decade has brought a refinement of bothmplant form and placement. Contemporary midfacemplants are available in many sizes and shapes andave different indications dependent on the estheticeed. These anatomical implants have also given wayo more conservative surgical approaches that againre designed to provide targeted, precise, and natural-ppearing augmentation specific to various regions ofhe midface. Finally, with computer-assisted design/omputer-assisted manufacturing technology, cus-omized facial implants can be fabricated to personal-ze the augmentation as well as to correct defects andsymmetries or to accommodate personal prefer-nces on the part of the patient or surgeon.

IMPLANT SELECTION

Implants can be placed in most patients. Smokersan be problematic from the effects of heat and nic-tine on the incision line as well as the fact that theyenerally resume smoking immediately after surgerynd the continual perioral movement can disrupt un-

IGURE 3. The youthful midface is volumized and aging produceell as skin aging. The author’s 8-year-old son pictured in (A), theidfacial aging over 3 generations of males.

oe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg

ecured implants. The author has placed many im- f

lants in smokers without problems and all of thesemplants have been secured with a single rigid fixa-ion screw. Other contraindications to implant place-ent include active dental periodontal or sinus infec-

ions.Common implant materials have included ex-

anded polytetrafluoroethylene, methyl methacry-ate, porous polyethylene, and silicone rubber. Cur-ently, porous polyethylene and silicone rubbermplants are the most commonly used. The authorrefers silicone rubber implants for numerous rea-ons. They can be easily trimmed and, being flexible,onform well to underlying anatomy. Additionally,hey become well encapsulated and hence are easilyemoved or replaced if desired. Although the struc-ure of porous polyethylene implants allows betterissue integration, this can be extremely problematichen attempting to remove or replace an implant.he porosity encourages tissue ingrowth and signifi-ant tissue injury and defects can occur with removal,s well as implant fragmentation.

Which implant to use and where to place it can beonfusing. The greatest pitfall for the novice implanturgeon is the understanding of which implant isppropriate for a given aging indication. Although thiss related to personal preference, this author has re-ned the choices to 3 broad categories that are effec-ive for almost all cosmetic (or reconstructive) pa-ients.

The basis of implant selection lies in the recogni-ion of where the aging changes have occurred in the

nt or hollow appearance from atrophy and decent of malar fat asr-old author in (B), and the author’s 83-year-old father (C) illustrate

s a gau56-yea

ace and if they are single or multiple in nature. Most

prhrpvep

utapTthasvfftwyashddptalt

ppm

cs“salt(o

cdmtctvpowTrmam

utt

Fm

J

JOE NIAMTU 1423

atients, as they age, lose volume in the submalaregion. In this article the submalar area includes theollow area of the infraorbital, anterolateral maxillaryegion, and canine fossa regions. If the astute surgeonays close attention, he will notice that loss of facialolume represents early aging changes (late third andarly fourth decade) that are apparent in virtually allatients regardless of gender.Many esthetic practitioners and most patients are

naware of this phenomenon unless it is pointed outo them. If the surgeon hands the patient a mirror andsks him or her to smile, the lip elevators lift thetotic malar fat and produce a more youthful look.his simulation will cause many patients to comment

hat “this is how I looked when I was younger.” If youold the elevated tissues in place with your thumbnd index finger and ask the patient to relax his or hermile, the surgeon and patient will notice the midfaceolume quickly drops to its aged position lower in theace once the finger is released. In essence, the youth-ul cheek fat becomes the jowls later in life. Havinghe patient recline during the examination changeill also “reposition” the ptotic cheeks to a more

outhful position and can be used to illustrate agingnd predictive correction. Close observation will alsohow that although most of these patients have aollow submalar region, they have adequate and well-efined zygomatico malar esthetics. That is to say thatespite having lost submalar fat, they have adequatelyrojected cheekbones. This type of patient is bestreated with only submalar fill, as his or her problemnd solution are not malar deficiency, but rather theoss of submalar volume. This type of patient is illus-rated in Figure 4A. Figure 5A shows the approximate

IGURE 4. (A) shows a patient in need of submalar augmentation,alar augmentation, and (C) shows a patient in need of both zyg

oe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg 2010.

ositioning of the submalar implant. In the author’sractice, the submalar implant is used in approxi-ately 95% of midface implant patients.The second type of common facial esthetic defi-

iency found is in patients who have adequateubmalar and anterior maxillary fill but deficientcheekbones” (Fig 4B). Such patients have hypopla-ia of the zygomatico malar regions or simply desiremore defined, or “chiselled,” appearance, or in

ayman’s terms, “higher cheekbones.” The authorreats these patients with the malar shell implantFig 5B), which is used in approximately 1% to 2%f patients.The third type of common midfacial aging

hange is shown in the patient who has submalareficiency but in addition is in need of more zygo-atico malar augmentation. In essence, these pa-

ients need both anterior maxillary (submalar) filloupled with malar (“high cheekbone”) augmenta-ion (Fig 4C). These can be patients who have lostolume as a result of aging in both areas, or thoseatients who have underdeveloped skeletal anat-my. These patients are well suited for treatmentith the combined submalar shell implant (Fig 5C).his implant is designed to augment the submalaregion as well as a portion of the actual zygomaticoalar region. This implant is indicated for males

nd females and probably constitutes approxi-ately 4% to 5% of the author’s implant cases.As stated earlier, these 3 implant configurations are

sed for the described aging changes and satisfy allhe author’s esthetic midfacial enhancement indica-ions.

ws a patient with adequate submalar fill but in need of zygomaticoo malar and submalar augmentation.

(B) shoomatic

swtmp

irir

escepcw

lodmAtc

vtcc6ftoibmacdildt

todibibmaoctsda

Fss

J2

1424 CHEEK AND MIDFACE IMPLANTS

SURGICAL PLACEMENT

The placement of midfacial implants is a simple andtraightforward surgical procedure for those surgeonsith maxillofacial experience. With experience, ac-

ual placement can be performed in less than 10inutes. The implants are always placed in the sub-

IGURE 5. This image shows the approximate positioning of theubmalar implant (A), the malar shell implant (B), and the combinedubmalar shell implant (C).

oe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg010.

eriosteal plane and this must remain an axiom of z

nsertion. With the exception of the infraorbital neu-ovascular bundle, there is little vulnerable anatomyn the midface region, when dissecting in the subpe-iosteal plane.

Midface implants can be placed under local an-sthesia, although this author almost always uses IVedation. The implants can be placed as a solitaryosmetic procedure or concomitantly with othersthetic or orthognathic surgical procedures. Mostatients are unaware or ignorant of midface aginghanges and their contemporary treatments andhen educated frequently accept midface implants.The procedure is begun by injecting about 5 mL 2%

idocaine with 1:100,000 epinephrine transcutane-usly in the subperiosteal plane along the region to beissected. This usually includes the anterior maxilla,alar region, and the anterior zygomatic arch region.dditionally, approximately 3 mL of the same anes-

hetic is infiltrated in the soft tissue planes above theanine tooth.A 1-cm incision is made just below the maxillary

estibule, approximately 1 cm above the canineooth. The author usually uses a radiofrequency mi-roneedle and incises mucosa and soft tissues in theanine fossa region and through the periosteum (FigA). At this point, subperiosteal dissection is per-ormed for the remainder of the procedure. The ex-ent of the dissection is dictated by the shape and sizef the intended implant. Small or medium submalar

mplants require smaller dissections than do com-ined submalar or malar shell implants. The larger orore superolaterally placed implants require more

ggressive dissection to accommodate them. Theombined submalar and shell implants require moreissection over the malar and zygomatic regions. It is

mportant to not overdissect the implant pocket, as aarge pocket can contribute to implant mobility. Theissected pocket should be just slightly larger thanhe actual implant.

When beginning the dissection, it is not necessaryo dissect medially to the piriform aperture, as no partf the implant lies in this region. As the subperiostealissection is begun in the anterior maxillary region, it

s important to protect the infraorbital neurovascularundle. The described implants rarely impinge on the

nfraorbital nerve, and therefore aggressive infraor-ital dissection is not necessary. After the anterioraxilla is dissected, the periosteal elevator is angled

nd the remainder of the dissection is primarily in anblique vector. This oblique vector of dissection isarried out over the malar region and extends overhe anterior portion of the zygomatic arch. For themall or medium submalar implants minor zygomaticissection is required, but for the combined submalarnd malar shell implants, more aggressive malar and

ygomatic dissection is necessary. These larger im-

psodtlas

cpimipfcoa

ptfta

pufitsmtmit

FSi

J 2010.

JOE NIAMTU 1425

lants also require more aggressive inferolateral dis-ection, and it is not uncommon to encounter therigin of the masseteric tendon (or muscle) whileissecting in the area. There is no need to violate theendon or muscle, as the silicone implant can safelyie over these soft tissue structures without problem,nd frequently do. Figure 6B shows the typical dis-ected implant pocket.

After the implant pocket is dissected, the area ishecked for hemostasis, which is imperative torevent hematoma formation. The pocket is then

rrigated with antibiotic solution (300 mg of clinda-ycin mixed with 30 mL of sterile water) and the

mplant placed. A long, thin tonsil clamp facilitateslacement in the narrow pocket (Fig 6C). An Au-

richt nasal retractor (Miltex Inc, York, PA) is alsoonvenient to assist in visualization and placementf the implant in the pocket. Due to the customized

IGURE 6. (A) Shows the small initial incision required for implanhows the dissected maxillary and malar regions. (C) Shows the immplant in its intended position.

oe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg

natomical shape, the implants frequently seek the i

roper position. When inserting the implant, cau-ion is exercised to prevent the thin implant tailrom folding over on itself. Implants can be easilyrimmed with scissors to further control positionnd augmentation.

After implant placement, the surgeon thenushes on the external cheeks and manipulates thepper lip. If these maneuvers displace the implantrom the pocket or cause it to protrude out of thencision, the pocket is enlarged or the implant isrimmed. It is important that the implant lies pas-ively and does not have macro movement whenanipulating the surrounding soft tissues. When

he implant is successfully placed, a decision isade in reference to fixation. A well-conforming

mplant in a tight pocket is generally not fixated byhe author, as personal experience has shown the

ment. The tissues in this area are very elastic and will stretch. (B)eing inserted into the pocket with a tonsil clamp and (D) shows the

t placeplant b

mplants to remain stable (Fig 6D). If the pocket is

cdist

Fisd

J2

FuIig

1426 CHEEK AND MIDFACE IMPLANTS

onsiderably larger than the implant, if the implantoes not stay in the desired position, or if there is

ncreased mobility of the implant, a single fixationcrew can be placed. It is important not to place

IGURE 7. This patient developed an immediate post implantnfection on the left cheek. It began to swell at 24 hours and ishown at 72 hours (A) and 24 hours later (B) after incision andrainage and implant removal.

oe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg010.

he fixation in the thin bone of the anterior sinusJ2

IGURE 8. This 45-year-old female underwent a mini facelift,pper blepharoplasty, and concomitant placement of medium typeI submalar implants. The before (A) and after (B) midface changesllustrate the need and utility of cheek augmentation when treatinglobal facial aging changes.

oe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg010.

wfitmtd

coc5

FcrI

J2

Fdb

JOE NIAMTU 1427

all, as it is vulnerable to perforation or loss ofxation. The fixation screw is best placed in thehicker bone of the buttress area. An alternateeans of fixation is to place a 4-0 Vicryl suture from

he anterior medial portion of the implant to the

IGURE 9. This 66-year-old patient exhibited typical aginghanges (A) and was treated with comprehensive facelift, 4-quad-ant blepharoplasty, full face CO2 laser resurfacing, and large typeI submalar implants (B).

oe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg010.

eep tissues in that area. Finally, the incision isJ2

losed with interrupted 4-0 gut suture. At the endf the procedure, several layers of 4 � 4 gauze areompressed on the external cheeks and held in place forminutes to compress the surgical pocket.

IGURE 10. A, This 24-year-old male model requested moreistinct midface and cheeks. B, He was treated with large com-ined submalar shell implants.

oe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg010.

crfhts

tmpetntiitTsimm

mtcwtptafbvr

ts

R

Fllc

J2

1428 CHEEK AND MIDFACE IMPLANTS

POSTOPERATIVE CARE

No dressings are required and the postoperativeare includes analgesics, antibiotics, and tapering ste-oids if desired. The patient is instructed to refrainrom significant talking and animation for the first 48ours and is asked to follow a liquid or soft diet forhe same period. Ice packs are used for the first

IGURE 11. A, This 57-year-old patient shows extreme mid andower facial ptosis. B, She was treated with comprehensive facelift,ower blepharoplasty, full face CO2 laser resurfacing, and largeombined submalar shell implants.

oe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg010.

everal days.

SEQUELAE AND COMPLICATIONS

The patient must be warned that during the first 1o 2 weeks he or she will experience abnormal ani-ation when smiling and puckering. The initial im-lant dissection violates the orbicularis oris and liplevator musculature, which heals uneventfully withhe return of normal animation. Significant edema isot uncommon, especially with larger implants and inhe early postoperative period. Cold packs and taper-ng steroids are routinely used. Severe swelling mayndicate hematoma formation and, if the surgeon feelshat there is significant hematoma, it must be drained.his can usually be done by opening the incision anductioning the blood or clot from under or around themplant without compromising the result. Minor he-

atomas will usually heal uneventfully without treat-ent.Although numerous complications of implant place-ent have been described,22-28 they have been rare in

he author’s experience. Infection has been an un-ommon experience and usually manifests in the firsteek or 2. It is generally manifested by 1 side failing

o heal with complaints of pain, increased swelling,eriorbital edema, and drainage (Fig 7). It is possibleo salvage a minor infection with open incision, drain-ge, irrigation, and systemic antibiotics. Resistant in-ections warrant implant removal and the implant cane replaced after healing. Occasionally, subconjuncti-al or periorbital ecchymosis is seen but remains aare occurrence.

CASE PRESENTATIONS

Figures 8 through 11 illustrate cases performed byhe author using the implants and technique de-cribed within.

eferences1. Niamtu J: The adjustable vector deep plane midface lift. Atlas

Oral Maxillofac Surg Clin North Am 12:199, 20042. Niamtu J, Chisholm B: The adjustable vector deep plane mid-

face lift. J Oral Maxillofac Surg 62:630, 20043. Watson S, Niamtu J, Cunningham L: Endoscopic midface lift, in

Atlas of Oral and Maxillofacial Surgery Clinics of North Amer-ica. Philadelphia, PA, WB Saunders, 2003, pp 145-155

4. Niamtu J: Rejuvenation of the lip and perioral areas, in BellWH, Guerroro CA (eds): Distraction Osteogenesis of the FacialSkeleton. Ontario, Canada, BC Decker, 2007, p 629-650

5. Niamtu J: Advanta: ePTFE facial implants in cosmetic facialsurgery. J Oral Maxillofac Surg 64:543, 2006

6. Niamtu J: Minimally invasive cosmetic surgery, in Oral andMaxillofacial Surgery Clinics of North America. Vol 17. Phila-delphia, PA, Saunders, 2005, pp 29-39

7. Le Louarn C, Buthiau D, Buis J: The face recurve concept:Medical and surgical applications. Aesthet Plast Surg 31:219,2007; discussion, 232

8. Niamtu J: The use of Restylane in cosmetic facial surgery. J OralMaxillofac Surg 64:317, 2006

9. Niamtu J: Minimally invasive cosmetic surgery, in Oral and

Maxillofacial Surgery Clinics of North America. Vol 17. Phila-delphia, PA, Saunders, 2005, pp 17-27

1

1

1

1

1

1

1

11

1

2

2

2

2

2

2

2

2

2

JOE NIAMTU 1429

0. Steinsapir KD, Steinsapir SM: Deep-fill hyaluronic acid for thetemporary treatment of the Naso-jugal groove: A report of 303consecutive treatments. Ophthal Plast Reconstr Surg 22:344,2006

1. Niamtu J: Accurate and anatomic midface filler injection byusing cheek implants as an injection template. Dermatol Surg33:1, 2007

2. Graivier MH, Bass LS, Busso M, et al: Calcium hydroxylapatite(Radiesse) for correction of the mid- and lower face: Consensusrecommendations. Plast Reconstr Surg 120(Suppl):55S, 2007

3. Little JW: Applications of the classic dermal fat graft in primaryand secondary facial rejuvenation. Plast Reconstr Surg 109:788,2002

4. Obagi S: Autologous fat augmentation for addressing facialvolume loss. Oral Maxillofac Surg Clin North Am 17:99, 2005

5. Obagi S: Autologous fat augmentation: A perfect fit in new andemerging technologies. Facial Plast Surg Clin North Am 15:221,vii, 2007

6. Burgess CM: Principles of soft tissue augmentation for theaging face. Clin Interv Aging 1:349, 2006

7. Roy D, Mangat DS: Facial implants. Dermatol Clin 23:541, 20058. Burres S: Midface volume replacement with a transmaxillary

implant. Aesthet Plast Surg 29:1, 20059. Binder WJ, Azizzadeh B, Binder WJ: Malar and submalar aug-

mentation. Facial Plast Surg Clin North Am 16:11, 2008

0. Terino E, Edwards MC: Alloplastic contouring for suborbital,maxillary, zygomatic deficiencies. Facial Plast Surg Clin NorthAm 16:33, 2008

1. Constantinides MS, Galli SK, Miller PJ, et al: Malar, submalar,and midfacial implants. Facial Plast Surg 16:35, 2000 [Review]

2. Brody HJ: Complications of expanded polytetrafluoroethylene(e-PTFE) facial implant. Dermatol Surg 27:792, 2001

3. Adams JR, Kawamoto HK: Late infection following aestheticmalar augmentation with proplast implants. Plast ReconstrSurg 95:382, 1995

4. Dodson TB: Infection of proplast malar implants and dentalinjections. Plast Reconstr Surg 91:195, 1993

5. Wilkinson TS: Complications in aesthetic malar augmentation.Plast Reconstr Surg 71:643, 1983

6. Logani SC, Conn H, Logani S, et al: Paralytic ectropion: Acomplication of malar implant surgery. Ophthal Plast ReconstrSurg 14:89, 1998

7. Lypka M, Yamashita DD: Exuberant foreign body giant cellreaction to a Teflon/proplast temporomandibular joint im-plant: Report of a case. J Oral Maxillofac Surg 65:1680,2007

8. Mercuri LG, Giobbie-Hurder A: Long-term outcomes after totalalloplastic temporomandibular joint reconstruction followingexposure to failed materials. J Oral Maxillofac Surg 62:1088,

2004