Cosmetic Facial Surgery

Chapter 10  •  Facial Implants
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A
B
FIGURE 10-27.  Hematoma is a rare complication with cheek implants, and ensuring a blood-free field before wound closure is
generally preventive. If a hematoma is suspected or documented, the incision can be opened, and a small liposuction cannula
can be used to evacuate the collection under the implant without removing the implant. A, Major hematoma from cheek implant
24 hours after surgery. B, Evacuation with a small liposuction cannula.
FIGURE 10-26.  Significant ecchymosis is an uncommon finding but like any
surgery can happen. This patient is shown 1 week after bilateral cheek
implant placement and lower lid laser skin resurfacing.
unnoticeable. I have taken out a single implant and not replaced
it, without any noticeable cosmetic deficit. In other cases, the
deficient side is noticeable and must be reimplanted.
The patient must be warned that during the first 1 to 2
weeks, they will experience abnormal animation when smiling
and puckering and possibly have difficulty pronouncing some
words (Figure 10-31). The initial implant dissection violates the
orbicularis oris and lip elevator musculature, which heals
uneventfully with the return of normal animation. Patients
must be made aware of this in the consent process. Occasionally,
return of normal animation can take longer.
Perhaps the most commonly encountered problems relate to
implant position and symmetry and are usually operator depen-
dent. There is no exact science to placing cheek implants; the
exact position is a guess at best. Preoperative marking can assist,
as well as careful attention to reproducing each step of the
procedure in a similar manner. This includes similar dissection,
similar implant position, and similar alignment. Even in the
most carefully planned cases, it is possible to have a preexisting
asymmetry in the patient’s anatomy that can cause a disharmony
from one side to the other. All of this must be covered in the
informed consent process. It is not uncommon for one side to
look considerably different from the other, and the patient must
understand that many or most of the initial asymmetries will
disappear with edema resolution. I have had numerous patients
who felt that the augmentation was too drastic and wanted the
implants removed in the first several weeks of placement. My

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Chapter 10  •  Facial Implants
FIGURE 10-28.  Although seromas are rare, serous collections can happen
and can be aspirated intraorally or percutaneously.
staff and I were able to reassure them and wait out the edema
instead of removing the implants. Most often these patients
were very happy when the swelling resolved and the true effect
of the implants was apparent.
In the case of malpositioned implants, the patient must
decide which implant needs repositioned, because the problem
is usually unilateral. It is possible for an implant or implants to
migrate from the initial position, especially if they are not
fixated. If a single fixation screw is used, it is still possible for
the implant to rotate around the screw if the screw is in the
periphery of the implant. Making the smallest dissection pos-
sible to corral the implant will assist in maintaining original
position. If a given implant is prone to rotating, a second sta-
bilizing screw can be placed to prevent rotational forces. Limit-
ing postsurgical activities that require oral function can assist in
A
B
C
FIGURE 10-29.  A, This patient is shown 2 days post cheek implant placement, with a significant developing left-sided infection.
B, The patient on postop day 3 just before incision, drainage, and implant removal. C, The patient on postop day 5 with
complete resolution. The implant was uneventfully replaced 6 weeks later.
A
B
FIGURE 10-30.  A, Infected incision site in a smoker. B, Because of the amount of purulence, the smoking, and the delayed
infection (3 weeks), the implant was removed.

Chapter 10  •  Facial Implants
385
maintaining placement position. Talking, eating, and smoking
are all activities that should be minimized for the first several
postoperative days.
Figure 10-32 shows a patient with her right cheek implant
placed more inferiorly than the left. The right side was reposi-
tioned superiorly, and the patient was happy. Figure 10-33
shows a patient who had a springy palpable prominence over
the zygomatic arch region; the implant tail had folded under
the implant body during placement. The implant was removed
and the tail successfully repositioned. Figure 10-34 shows a
patient whose implant has migrated superiorly, and the implant
border is palpable at the orbital rim. The implant was removed,
trimmed, and successfully repositioned.
Occasionally an asymmetric case is obvious from the start
and requires that treatment planning proceed with symmetric
compensation in mind (Figure 10-35). In these cases, the
surgeon can place a larger or smaller implant to compensate
for the affected side. Alternatively, custom implants can be
fabricated.
Although not a complication, it is worth mentioning that
during the placement of cheek implants, the operator can
encounter unforeseen situations from previous surgeries or
trauma. I have placed numerous implants over antral perfora-
tions from trauma or sinus surgery and have also placed implants
over bone plates from previous corrective or trauma surgeries
(Figure 10-36). I have never encountered a healing or aesthetic
problem in the 10 or 12 implants I have placed over sinus open-
A
B
FIGURE 10-31.  This patient was unhappy with her symmetry; the right cheek implant was in a lower position compared to the
normally placed left side. The implant was removed and superiorly repositioned.
FIGURE 10-32.  Patient shows a postimplant asymmetry in which the right
side implant was lower than the left. This was later corrected by reposition-
ing the implant.

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Excessive nose blowing or sneezing has been known to cause
air emphysema in the soft tissues through a sinus perforation. I
have seen a patient experience this from nose blowing that
forced air through a screw hole in the anterior sinus. During
implant placement, a screw was placed and removed. The
1.5-mm screw hole was enough to admit air from the sinus into
the soft tissues.
Case Presentations
Figures 10-37 through 10-44 show various cases of cheek
implant augmentation.
Chin Implants
There are very few small procedures that can produce the dra-
matic profile changes that chin implants do. The chin, like the
nose, is a very important aesthetic pillar and is frequently sati-
rized in caricatures: a strong chin is synonymous with macho,
bravado, and masculinity, whereas a recessive chin is more syn-
onymous with a repressed, wimpy, or introverted person. It is
pretty amazing how several millimeters of augmentation can
truly change the look of a person. Like cheek implants, chin
implants are easy to place and are permanent but can be removed
if desired.
Like all surgeries, an accurate diagnosis is paramount to
proper treatment. Although many individuals have a recessive
chin profile, there are frequently other considerations besides
merely augmenting the chin. The occlusion must be checked,
and if a patient has a deficient chin due to retrognathia, they
should be referred to an orthodontist or oral and maxillofacial
surgeon to consider orthognathic surgery. By moving the maxilla
and/or mandible, the entire lower jaw is frequently anteriorly
positioned, which will many times normalize the profile while
at the same time correct the malocclusion. Patients with severe
malocclusions must be given the option for functional correc-
tion. Without treatment, they can experience future problems
with oral function, temporomandibular joint (TMJ) disease,
and restorative dentistry. Although orthognathic surgery was
very common in the 1980s and 1990s, insurance coverage has
dwindled, making the procedure much less frequent. For this
reason, even patients with malocclusions are more frequently
opting for isolated chin augmentation.
One of the main diagnostic pitfalls involved with chin
implants is the failure to diagnose deficiency of the lower third
of the face. The face is classically divided into three relatively
equal vertical thirds. The upper third is measured from the
hairline (trichion) to the glabella, the middle third is measured
from glabella to subnasion, and the lower third is measured
from subnasion to menton (Figure 10-45). Many patients
exhibit a shortened lower facial third, and this is sometimes
called short face syndrome. The manifestations of a foreshortened
lower facial third include a recessive chin and an exaggerated
mentolabial fold. The normal S curve that exists below the lower
lip and above the chin becomes collapsed in such patients
(Figure 10-46). A chin implant is not the solution for this type
of problem, because it would accentuate the mentolabial fold
and make the problem worse. For patients with lower-third
ings or hardware and personally do not consider them a contra-
indication to surgery.
From time to time, post cheek-implant patients will com-
plain of pain. This generally resolves by 90 days. Shooting pain
or radiating pain with oral function or when pushing on the
implant may indicate nerve impingement. It is possible for the
implant to abut the infraorbital neurovascular bundle and stim-
ulate the nerve. If this is suspected, the implant should be
explored to confirm that there is no impingement. If the implant
does abut the nerve, a notch of the implant should be removed
to free the impingement.
FIGURE 10-33.  A, Palpable and visible prominence from a folded implant
tail. B, The problem is associated with the implant folding over on itself.
Text continued on page 394.

Chapter 10  •  Facial Implants
387
A
B
C
FIGURE 10-34.  A, Outline of an implant that was too superiorly placed and impinged on the orbital rim. B, Implant outline when
the surrounding skin is stretched. C, Representation of the implant edge protruding over the inferior orbital rim.
A
B
FIGURE 10-35.  This patient with a facial developmental syndrome has severe midface asymmetry. To correct this, a medium
submalar implant was placed on her right side, and a large submalar implant was placed on her left. This is occasionally
necessary to compensate for significant asymmetry.

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A
B
FIGURE 10-36.  Implants placed over sinus perforations or existing hardware generally do fine, and these situations are not a
contraindication to placement.
A
B
FIGURE 10-37.  This 45-year-old female underwent minifacelift, upper blepharoplasty, and concomitant placement of medium
type II submalar implants. The before (A) and after (B) midface changes illustrate the need and utility of cheek augmentation
when treating global facial aging changes.

Chapter 10  •  Facial Implants
389
A
B
FIGURE 10-38.  This 66-year-old patient exhibited typical aging changes and was treated with comprehensive facelift, four-
quadrant blepharoplasty, full-face CO2 laser resurfacing, and large type II submalar implants.
A
B
FIGURE 10-39.  This 26-year-old male model requested more distinct midface and cheeks. He was treated with large combined
submalar shell implants.

390
Chapter 10  •  Facial Implants
A
B
FIGURE 10-40.  This 57-year-old patient shows extreme midfacial and lower facial ptosis. She was treated with comprehensive
facelift, lower blepharoplasty, full-face CO2 laser resurfacing, and large combined submalar shell implants.

Chapter 10  •  Facial Implants
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A
B
FIGURE 10-41.  This 44-year-old female was treated with minilift, upper blepharoplasty, and large submalar implants.
A
B
FIGURE 10-42.  This 56-year-old male was treated with four-quadrant blepharoplasty, facelift, and medium combined submalar
implants.

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Chapter 10  •  Facial Implants
A
B
FIGURE 10-43.  This 52-year-old female was treated with minifacelift, CO2 laser skin resurfacing, and large submalar cheek
implants.
A
B
FIGURE 10-44.  This 58-year-old female was treated with facelift, upper blepharoplasty, CO2 laser resurfacing, and large submalar
cheek implants.

Chapter 10  •  Facial Implants
393
FIGURE 10-45.  The average face is divided into vertical thirds, and this can be used to assist treatment planning.
A
B
FIGURE 10-46.  This patient illustrates a foreshortened lower facial third and an accentuated mentolabial fold. Placing an implant
in such a patient would worsen the problem.

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Chapter 10  •  Facial Implants
placement if I am not performing any open surgery in the
submental region (e.g., platysmaplasty), because it prevents a
visible scar. If I am performing platysmaplasty and already have
a submental incision, it makes sense to place the implant
through this route. In placing hundreds of implants over the
past 25 years, I have seen no greater incidence of infection
from the intraoral route. The intraoral route does provide more
disruption of the mentalis muscle and probably has a slightly
longer recovery.
When performing submental placement, the procedure is
performed in the following manner. With the patient standing,
the submental incision is marked before surgery. After the skin
is prepped, 5 mL of 2% lidocaine with 1 : 100,000 epinephrine
is injected in multiple planes to the periosteal level. A 3-cm
incision is made through the skin with a scalpel, and the remain-
ing dissection is performed with radiowave microneedle or
cautery to the bone level of the mandibular symphysis at inferior
vertical height deficiency, the proper treatment is to lengthen
the lower face. Most of these patients also have a recessive chin,
so the actual augmentation requires increase in the vertical and
horizontal dimensions. In some cases, a chin implant can be
used to increase the lower facial height. To do this, the implant
must be placed below the mandibular border, which in effect
will lengthen the chin. The problem with this treatment is that
there will be a palpable ridge under the chin that represents the
bottom of the extended implant and is bothersome to the
patient. Again, in most cases, a chin implant is not the appropri-
ate treatment for a short lower facial third.
This situation is best treated by a sliding genioplasty (some-
times called horizontal genioplasty). In this procedure, intraoral
access to the chin is utilized, and with a reciprocating, saggital,
or oscillating saw, an osteotomy is made in the mid-chin, taking
care not to injure the tooth roots. Once the osteotomy is made,
the inferior segment is separated and segment vitality is from
the attached posterior muscles and periosteum (Figure 10-47).
The osteotomized segment is advanced anteriorly (or posteriorly
if the chin is to be reduced) and vertically lengthened. Conve-
nient prebent rigid fixation plates are utilized to maintain the
advancement and lengthening. The average lengthening is about
5 to 10 mm, and the segment can be advanced 5 to 15 mm. I
personally do not utilize any bone grafts when the vertical gap
is 10 mm or less. The excellent stabilization of the plate allows
bony regrowth in the gap and prevents movement of the
advanced segment (Figure 10-48).
Patient examples of lengthening and advancement genio-
plasty are shown in Figures 10-49 and 10-50. Although osseous
genioplasty may seem out of place in a facial implant chapter,
it is important to understand the complete diagnosis and
expanded treatment options of aesthetic chin surgery.
Chin Implant Surgery
Chin implants can be inserted from an intraoral route through
the mouth or extraorally from the submental area. Arguments
exist between various practitioners regarding which route is best,
and it boils down to surgeon preference. I use intraoral
A
B
FIGURE 10-47.  A, Horizontal osteotomy being cut with a reciprocating saw. B, The osteotomized segment.
FIGURE 10-48.  A horizontal osteotomy with a rigid fixation plate in place.
The vertical advancement is about 8 mm (white arrow) and horizontal
advancement about 1 cm (yellow arrow).

Chapter 10  •  Facial Implants
395
lies approximately 15 mm above the inferior border of the
mandible, and its presence must be anticipated. A Molt number
9 periosteal elevator is an excellent instrument to use. It is
efficient, and the width of the spoon tip is narrow enough
to allow dissection under the mental foramen without disrupt-
ing the nerve (see Figure 10-51, E and F). If the operator keeps
the dissecting edge of the periosteal elevator on the inferior
border of the mandible, the mental nerve is generally well
protected.
The dissection is made posteriorly as far as necessary to
accommodate the implant tails of the specific style used. This is
usually in the area of the first molar tooth. The dissection pocket
border. The midline of the submental region is a very safe
region, and no major nerves or vessels are endangered. After the
skin incision, the subcutaneous tissue and fibers of the platysma
are encountered and transected (Figure 10-51, A and B). The
inferior border of the mandible is identified in the midline; it
is imperative to make sure that the incision is through the peri-
osteum. Using a periosteal elevator, the subperiosteal dissection
is continued laterally on both sides (see Figure 10-51, C and
D). The mental nerve is intimate to this region and must be
avoided. I prefer to dissect to the mental foramen and actually
visualize the neurovascular bundle, whereas other surgeons don’t
want to see the nerve at all, just protect it. The mental nerve
A
B
FIGURE 10-49.  Before (A) and after (B) images of a patient with a vertical and horizontal chin deficiency. Note the improved
aesthetics from both vertical and horizontal augmentation. The deep mentolabial fold is also improved.
A
B
FIGURE 10-50.  This patient underwent horizontal osteotomy for vertical and horizontal chin augmentation.

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Chapter 10  •  Facial Implants
A
B
F
C
D
E
FIGURE 10-51.  A, A 3-cm incision is placed just below the submental crease, and a scalpel is used to incise the skin. B, The
subcutaneous tissues and platysma are incised over the mandibular inferior border midline. C, The mandible after the periosteum
has been incised and dissection begun. D, With the periosteal elevator staying subperiosteal and on the bone, dissection is
performed posteriorly on both sides. E, By keeping the inferior edge of a Molt Number 9 periosteal elevator on the mandibular
border, the pocket can be dissected without impinging on the mental nerve. F, The mental foramen is approximately 15 mm
superior to the mandibular border, and the implant tails must not impinge on the nerve. G–H, The implant is inserted into the
small incision one side at a time (G). Fixation sutures can be placed through the implant and secured to the periosteum of
the inferior mandibular border (H). I–J, A self-drilling screw is placed through the implant for fixation. The deep tissues closed
with 4-0 gut suture (K), the subcutaneous tissue closed with 5-0 gut (L), and the skin closed in this case with 5-0 gut
suture (M).

Chapter 10  •  Facial Implants
397
I
J
G
H
K
M
L
FIGURE 10-51, cont’d.

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Chapter 10  •  Facial Implants
should be only slightly larger than the implant to prevent move-
ment. After the pocket is dissected, an implant “try-in” sizer can
be utilized if desired. These sizers are available for most common
implant configurations through the manufacturer. Most experi-
enced surgeons do not utilize sizers and are able to estimate the
result. Once the desired implant is chosen, the tails may be
trimmed depending upon the size of the implant and patient.
The dissection pocket is irrigated with antibiotic solution, and
one side of the implant is inserted into the incision. Since sili-
cone implants are very flexible, it is not difficult to fold the
implant in the center to insert the other side (see Figure 10-51,
G). Once the implant is in the proper position, it is important
to make sure that the implant tails are not folded under the
implant body. Many implants have a midline mark in the center,
and this should be aligned with the mandibular midline. Since
the dental midline may not be in alignment with the soft-tissue
midline, care should be taken to properly align the implant. In
addition, the inferior edge of the implant should generally lie
flush with the inferior border of the mandible. It is also impor-
tant to make sure that the tails do not lie below the inferior
border of the mandible, because they will be palpable. In some
cases, the inferior implant border may be intentionally extended
above or below the inferior border of the mandible, but this is
reserved for experienced surgeons.
Most surgeons agree that chin implants should be fixated in
some manner. In the vast majority of problem implants that I
have removed (placed by other surgeons), implant mobility was
a factor in the failure. Many surgeons utilize suture fixation by
placing a suture or sutures through the inferior border of the
implant and engaging the periosteum at the inferior border of
the mandible. This “semirigid” fixation is shown in Figure
10-51, H.
I perform screw fixation on all implants. A single self-drilling
screw (see Figure 10-24, A) is used to stabilize the implant in
the midline. If the screw is placed through the center of the
implant, a very long screw will be required, but by placing
the fixation screw closer to the superior margin, a smaller screw
can be used, which is easier to place. If the implant has a
tendency to rotate, a second screw can be placed to further
stabilize the implant. Figure 10-51, I and J illustrate implant
screw fixation.
After the implant is placed and fixated, the incision is closed.
No closure is necessary for the periosteum. The deep tissues are
closed with 4-0 gut suture, the subcutaneous tissues with 5-0
gut suture, and the skin with 5-0 gut or 6-0 nylon suture (see
Figure 10-51, K to M ).
Intraoral Placement of Chin Implants
As stated earlier, there are numerous advantages to intraoral
placement of chin implants, the biggest being a hidden scar, and
I do not believe there is any increased incidence of infection
when placing implants from inside the mouth. For the novice
surgeon, I also believe that the intraoral route provides a better
view of the mental nerve and foramen. The surgeon is looking
down on it as opposed to looking from the underside of a very
small submental incision. One relative drawback of the intraoral
incision is that the mentalis muscles are transected with the
intraoral approach and initially can have a temporary effect on
perioral animation. Also, mostly in the case of novice surgeons,
failure to rejoin the incised mentalis muscle can contribute to
lower lip incompetence. A gingival sulcular incision can also be
utilized. In this approach, the gingival sulci are incised and the
entire gingiva and papillae are elevated as a unit with release
incisions laterally. Proponents of this approach cite less post
postoperative discomfort and less mentalis muscle disruption as
advantages.
I perform simultaneous liposuction on almost all my chin
implant patients. This step is performed before placing the
implant so the tissue manipulation will not disturb the surgical
site.
The intraoral mucosal incision is made in a trapdoor configu-
ration about 15-20 mm anterior to the mandibular sulcus
(Figure 10-52, A). It is important to keep the incision anterior
on the lower lip and not too close to the sulcus, because the
incision scar will contract and can form a bothersome depres-
sion and food trap (Figure 10-52, B).
The incision is made with a radiowave microneedle, other
coagulative modality, or scalpel and is made just through the
mucosa. This is facilitated by stretching the lip with the nonop-
erating hand. The initial 3-cm wide incision is made directly
vertical through the oral mucosa and orbicularis oris muscles
(Figure 10-53). It is important to then redirect the incisional
vector to obliquely incise the mentalis musculature and related
soft tissue to the subperiosteal or bone level (see Figure 10-53).
If care is not used and the incision not redirected, the incision
can perforate the skin of the lower lip. To avoid this, the incision
must be angled on its way to the bone. Figure 10-54, A shows
the mucosal incision with the underlying orbicularis oris muscle,
and one of the labial branches of the mental nerve is shown in
Figure 10-54, B. This peripheral sensory branch of the mental
nerve is commonly transected but will generally not produce a
significant or lasting sensory deficit. The nerve is easy to view
and isolate, and I protect it by lateral retraction and never
intentionally sever the nerve; I believe that nerve preservation
is important at all levels of surgery.
Next, the mentalis muscles and central fat pad are incised,
and the incision is carried through the periosteum (Figure
10-55). To facilitate identification of the various tissue planes,
blunt dissection with a dry gauze pad is used.
After the bone level is exposed, the dissection continues to
create a dissection pocket to accommodate the implant. It is
important dissect to (or just slightly beyond) the inferior border
of the mandible to ensure that the implant can be placed flush
with the mandibular inferior border (Figure 10-56). The dissec-
tion is then continued posteriorly to the needed level
to accommodate the implant. The same tenets are used with
dissection and nerve protection, as shown in Figures 10-51, C
to F.
In cases of extreme retrognathia or microgenia, the patient
may not have adequate skin to accommodate the implant. It is
possible to release some neck skin to accommodate the implant
by using facelift scissors to dissect inferiorly in the neck in the
subcutaneous plane, which can be done by advancing and
spreading with facelift scissors (Figure 10-57).

Chapter 10  •  Facial Implants
399
A
B
C
FIGURE 10-52.  The incision is made about 10–20 mm anterior to the mandibular sulcus (A). If the incision is made too close
to or in the sulcus, a bothersome depression and food trap can occur (B) or increased scar formation from incising over a
concave region (C).
A
B
FIGURE 10-53.  The initial vector of the intraoral incision is vertical through the lip mucosa and orbicularis oris muscle. The inci-
sion is then angled obliquely toward the mid-mandibular symphysis as it cuts across the mentalis muscles and associated soft
tissues.

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Chapter 10  •  Facial Implants
A
B
FIGURE 10-54.  A, The mucosal incision with the underlying orbicularis oris muscle. B, One of the labial branches of the mental
nerve running at the lateral incision.
A
B
FIGURE 10-55.  A, The mentalis muscles are separated by a central fat pad in most patients. B, The mentalis muscles
isolated.
A
B
FIGURE 10-56.  The Ellman radiowave microneedle is used to dissect through periosteum to bone. It is important to incise and
dissect all the way to the inferior mandibular border.

Chapter 10  •  Facial Implants
401
FIGURE 10-57.  In cases of extreme chin deficiency, freeing some neck skin
through the intraoral or extraoral incision can provide skin drape to accom-
modate the implant.
FIGURE 10-58.  An implant sizer can be used to observe an estimation of
the final result. Shown here is an implant sizer in place, with another sizer
shown to illustrate the actual size.
Once the pocket is completely dissected, the area is irrigated
with antibiotic solution, and an implant try-in sizer can be used
if desired (Figure 10-58). It is not uncommon to trim or cus-
tomize the implant tails or the implant body. The soft silicone
implants are easily recontoured with a scalpel or scissors. The
desired implant is then placed in the pocket by placing one side
first, then folding the implant in the middle and inserting the
second side. The flexibility of silicone implants allows insertion
of a big implant through a small incision (Figure 10-59). It is
imperative to observe the midline of the implant and align it
with the patient’s true midline.
Although the inferior surface of the implant should sit flush
with the inferior surface of the mandible, advanced surgeons
may change this relationship. In most cases, the implant and
mandible should remain flush. Failure to observe this can cause
a palpable ridge or an unaesthetic result.
The same instrumentation shown in Figure 10-24, A is used
to secure the implant in the midline with a single rigid fixation
self-drilling screw (Figure 10-60).
The final closure is then completed. Wound closure is a criti-
cal step with the intraoral approach. It is absolutely imperative
to reapproximate the mentalis muscles, or serious lip dysfunc-
tion can occur. The mentalis muscles originate at the mandibu-
lar symphysis (Figure 10-61) and insert in the dermis of the
chin (Figure 10-62). If the incision is closed without proper
mentalis approximation, serious lip incompetence can result
(Figure 10-63). Figures 10-64 and 10-65 show the mentalis
muscle stumps approximated with 4-0 Vicryl suture and the
mucosa closed with interrupted 4-0 gut sutures. Using an inter-
rupted closure allows drainage, should any residual bleeding
occur, whereas a running suture can lead to hematoma by pre-
venting drainage.
The intraoral route can also be utilized with a less invasive
approach to implant insertion. Instead of the larger traditional
horizontal incision, a smaller vertical incision can be made. This
incision is designed to spare the transection of the mentalis
muscles by allowing the implant to be placed between the
implants. A small vertical incision is made in the exact man-
dibular midline that transects the fat pocket lying between the
paired mentalis muscles (Figure 10-66, A). The muscles are
spread with a hemostat to the subperiosteal level, and the
normal dissection proceeds as previously described. The implant
is then bent in half and inserted one side at a time through the
smaller incision (see Figure 10-66, B). This step is more difficult;
visualization is much less than with other approaches. Figure
10-66, C shows an implant in place between the mentalis
muscles, and Figure 10-66, D shows several holding sutures that
join the medial borders of the paired mentalis muscles. Although
this approach is more difficult due to decreased visibility, it
spares mentalis dysfunction when compared to intraoral tech-
niques that transect the mentalis muscles.
Although most patients require augmentation of the entire
symphysis and parasymphysis, some patients may require
contour improvement of the parasymphysis (jowl) regions
without horizontally augmenting the symphysis. Although a
prejowl implant exists, I do not favor this configuration; it is
nonrigid and harder to insert than a rigid implant. In addition,
not every patient needs augmentation in the exact same region,
and the off-the-shelf prejowl implant can limit usefulness. I
prefer to insert a normal implant and then excise the unneeded
anterior region of the implant. To do this, the implant is

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Chapter 10  •  Facial Implants
A
B
FIGURE 10-59.  The implant is inserted through one side at a time (A) and is positioned to the patient’s midline (B).
A
B
FIGURE 10-60.  Some implants are designed with holes for fixation screws (A) and others are not, but the fixation screw is simply
placed through the soft silicone (B).

Chapter 10  •  Facial Implants
403
A
B
FIGURE 10-61.  The paired mentalis muscles originate on the mandibular symphysis. (B Courtesy Primal Pictures Ltd., London,
)
FIGURE 10-62.  The mentalis muscle has its origin on the dermal surface of the chin.
A
B
FIGURE 10-63.  The mentalis muscles are extremely important in maintaining normal lip posture. Failure to attach the incised
mentalis can produce a significant aesthetic and functional deformity, as shown in the pictured patients from other offices.

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Chapter 10  •  Facial Implants
A
B
FIGURE 10-64.  A, Transected mentalis muscle stumps secured with 4-0 Vicryl suture. B, Repaired muscle approximated.
A
B
FIGURE 10-65.  The deep layers of the intraoral incision are closed with 4-0 gut suture (A) before mucosal closure (B).

Chapter 10  •  Facial Implants
405
A
B
C
D
FIGURE 10-66.  A, A minimally invasive vertical intraoral approach for chin implant placement. B, An implant being inserted in
the smaller incision one side at a time. C, An implant in place between the mentalis muscles. D, The medial borders of the
mentalis muscles secured with sutures.
inserted in the normal manner (Figure 10-67, A), but instead
of a single midline fixation screw, a lateral screw is used on each
side, and the center of the implant is removed (see Figure
10-67, B). Figure 10-68 shows a patient treated with lateral
implant wings to only augment parasymphyseal notching
(prejowl notch).
Figures 10-69 to 10-76 show before and after pictures of
selected chin implant cases.
Chin Implant Complications
Chin implant placement is a predictable procedure, and many
of the “complications” are proximal to the scalpel—in other
words, the fault of the surgeon. These most commonly include
overcorrection, undercorrection, and asymmetric placement.22-28
Normally the chin implant should be flush with the inferior
border of the mandible. In selected cases, the implant may
intentionally lie below the mandibular border to lengthen the
lower facial height, but the patient must be made aware that the
edge of the implant will be palpable and possibly annoying.
Occasionally the implant may be inadvertently placed too far
below or too far above the mandibular border and lead to aes-
thetic problems (Figure 10-77, A). Problems can also arise when
the implant is placed superiorly to the inferior border (see Figure
10-77, B). Minor superior positional problems may include a
palpable ridge or cosmetic deformity, but severe problems can
exist when the implant is placed too superiorly. The bone over
the lower anterior mandible (menton) is dense cortical in nature.
The bone overlying and around the tooth roots is much thinner.
The science of orthodontics involves moving teeth through this
thinner bone. Consequently, a mobile implant placed over this
thin bone can easily cause bone resorption and a significant
defect, possibly injuring the teeth. Figure 10-78, A shows
improper placement over the thin alveolar bone, and Figure
Text continued on page 411.

406
Chapter 10  •  Facial Implants
A
B
FIGURE 10-67.  For patients that require lateral mandibular augmentation without augmenting the symphysis, a standard implant
is placed and secured with screws on both sides (A). The center portion is then removed, leaving only the lateral wings of the
implant for augmentation (B) and thus not affecting the anterior mandibular size.
A
B
C
FIGURE 10-68.  A, A patient with prejowl notching (arrows). B, A rendition of the area augmented by using the implant tails only.
C, Actual postaugmentation result.

Chapter 10  •  Facial Implants
407
A
B
FIGURE 10-70.  This 9-year-old child was treated for Pierre-Robin Syndrome and underwent ribgrafts to the temporomandibular
joint (TMJ), with a medium chin implant placed—my youngest chin patient ever!
A
B
FIGURE 10-69.  Patient was treated with a large EAC (extended anatomic chin) silicone implant.

408
Chapter 10  •  Facial Implants
A
B
FIGURE 10-71.  Patient treated with a medium silicone chin implant.
A
B
FIGURE 10-72.  Patient was treated with a large silicone mandibular glove implant.

Chapter 10  •  Facial Implants
409
A
B
FIGURE 10-73.  This 62-year-old male patient was treated with a large Extended Anatomic Chin (EAC) silicone chin implant.
A
B
FIGURE 10-74.  Patient treated with a large silicone mandibular glove implant.

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Chapter 10  •  Facial Implants
A
B
FIGURE 10-75.  Patient was treated with submental liposuction and a large silicone chin implant.
A
B
FIGURE 10-76.  This 38-year-old female was treated with a medium silicone chin implant.

Chapter 10  •  Facial Implants
411
A
B
FIGURE 10-77.  A, The inferior portion of the silicone implant placed too
inferiorly below the mandibular border. B, The implant improperly placed
superiorly to the inferior border.
A
B
FIGURE 10-78.  A, Improper placement of the implant over the thin alveolar bone. B, Proper placement over the dense cortical
bone of the anterior, inferior mandible.
10-78, B shows proper positioning. Figure 10-79 shows actual
cases from other surgeons that presented with bone resorption
from improperly placed, mobile implants.
I have seen numerous chin implant complications from other
surgeons in the United States and internationally. In numerous
cases of anterior mandibular bone resorption, I have never seen
this occur from an implant secured with fixation screws. It is
impossible to guarantee that securing an implant will totally
prevent resorption, but it is a good bet that an improperly
placed, mobile implant will be problematic. Figure 10-80 shows
radiographs of a patient who presented with discomfort from
his chin implant. The radiographs looked normal (with the
exception of the implant riding too superiorly), but exploration
revealed a significant resorptive defect (Figure 10-81, A to D).
This illustrates the insidious nature of the slow resorptive
process.
Some degree of settling can be seen with any implant, and
it is not unusual to see 1 to 2 mm of erosion under a healthy
implant that has been in place for years. However, gross bone
loss is pathologic and must be treated by removing the implant
and dealing with the defect (see Figure 10-81, E to G).
Although any type and configuration of implant can lead to
bone loss, the nonanatomic “button” implants that are not
secured are among the worst offenders for implant failure
(Figure 10-82). If this type of small implant is placed without
fixation in the anterior mandible, it can become a virtual foreign
body. With all the mobility of the chin and lip musculature, a
small nonfixated implant is a prescription for disaster.
Figure 10-77 illustrates superior/inferior implant displace-
ment, and Figure 10-83 shows a similar problem with rotational
malposition. Problematic rotation can occur in a horizontal
direction (see Figure 10-83, A) or a vertical direction (see Figure
10-83, B). These types of implant malposition generally mani-
fest as a visible and palpable asymmetry (Figure 10-84).
As anatomic implants have evolved along with a better
understanding of correct implant placement, compatible bio-
materials, and rigid fixation, implant complications have become
infrequent occurrences. Some patients will naturally be more
prone to infections and are poor candidates to begin with. This
includes those patients with active dental or periodontal infec-
tion and heavy smokers (Figure 10-85; also see Figure 10-9).
Placing implants in patients with diseased intraoral tissues is an
invitation for failure. It is a good idea for all prospective implant
patients to have a complete dental exam and panoramic x-ray
to rule out any pathology that could affect the implant (see
Figure 10-85, C). A major surgical problem related to smoking
is that tissues do not heal as well. In addition, there are
direct negative effects of heat and nicotine on oral tissues and
incisions. Smokers are also continually puckering their lips,

412
Chapter 10  •  Facial Implants
A
B
FIGURE 10-79.  A, Radiograph of an actual case in which the chin implant (highlighted in blue) was placed over the tooth roots.
B, A similar case that resulted in severe mandibular bone resorption.
A
B
FIGURE 10-80.  This radiograph is from a patient with discomfort from an implant placed sometime previously. Neither the pan-
oramic radiograph (A) or the lateral radiograph (B) hint of any significant pathology. It is obvious that the implant is placed too
superiorly.

Chapter 10  •  Facial Implants
413
FIGURE 10-81.  A, An implant with significant resorption. Half of the implant is removed to show the depth of the bone defect.
B, A close-up of the defect. Note the negative impression of the M from the posterior surface of the (medium) implant that has
slowly become imprinted on the bone during the resorptive process. C, The depth of the resorption. D, The explanted silicone
device. Note the midline notch on the posterior surface of the implant is seen as a positive protrusion on the bony defect.
A
B
D
C
Continued

414
Chapter 10  •  Facial Implants
F
E
G
The defect is débrided (E), packed with cadaveric particulate bone (F), and covered with a membrane
to contain the graft and facilitate healing (G).
FIGURE 10-81, cont’d
A
B
FIGURE 10-82.  The small button-type implants are frequently implicated in implant failure, especially when they are not fixated
to stable structures.

Chapter 10  •  Facial Implants
415
A
B
FIGURE 10-83.  A, Horizontal implant malposition. B, Vertical rotation. Care must be taken at all stages of implant placement to
ensure that the implant body and tails are in the correct position.
A
B
C
FIGURE 10-84.  A, This patient had two palpable prominent areas due to displaced implant tails below the inferior border of the
mandible. B, A representation overlay of the malpositioned implant. C, The actual explanted prosthesis with the bent-under
implant tails.

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Chapter 10  •  Facial Implants
A
B
C
FIGURE 10-85.  A, A patient with right-sided chin swelling several months
after implant placement by another surgeon. B, An intraoral periodontal
abscess. C, A large radiolucent abscess at the base of the teeth.
which recruits numerous facial muscles and can disrupt or dis-
place implants. My experience is that most smokers will be
puckering around a cigarette within several hours of their
surgery. Figure 10-86 shows wound dehiscence in cheek implant
incisions in a heavy smoker. All of my patients who smoke must
sign a smoker’s consent and are made fully aware of the increased
problems associated with intraoral implant placement and
smoking. I shy away from recommending cheek or chin implants
in heavy smokers.
Chin implant infections are frequently slow growing and
can persist for weeks or months before manifesting significant
clinical signs or symptoms. Pain and swelling are the most fre-
quent indicators that something is awry. In the early stages of
infection, there may be no visible abscess or fistula, but clinical
signs will soon develop (Figures 10-87 to 10-89). These infec-
tions most often are very localized and do not cause fever or
sepsis. The surgeon must inspect the intraoral and extraoral
tissues for evidence of fistula or abscess. The question of whether
to attempt salvage or remove the implant often arises. Much
of this depends upon the actual implant and the chronicity
of the infection. Silicone implants with their smooth surfaces
may respond well to débridement, antibiotic lavage, and sys-
temic antibiotics. Implants made from porous materials will,
in the author’s experience, respond poorly. In addition, if
there is any mobility in the implant, it should be immediately
removed because it will only act as a foreign body in a pool of
sepsis. Implants that are smooth and fixated, however, may
respond to salvage procedures. When an incipient infection is
encountered with a silicone chin implant that has been fixated
with a screw, the granulation tissue can be débrided and the
infected site irrigated with hydrogen peroxide and topical
antibiotic solution. The patient is also treated with systemic
antibiotics. If the healing progresses, the implant may survive.
Again, attempts to salvage mobile or porous implants are most
frequently futile.
In some cases, longstanding infections can result in an osteo-
myelitis. Figure 10-90, A shows an intraoperative image of an
infected chin implant placed in another country. The fixation
screw evidently became infected, and severe bone erosion is
evident. Figure 10-90, B shows the explanted implant with the
fixation screw and the associated necrotic bone fragments.
Longstanding infections such as this can result in significant
hard- and soft-tissue destruction and illustrate the need for rapid
diagnosis and treatment with any implant where infection is
suspected.
Other chin implant–related complications include problems
from improper incision placement. which can be an annoyance
and inconvenience to the patient. If the intraoral incision is
placed too close to the sulcus, wound contraction can cause
thickened scar tissue and a depression. Astute surgeons realize
that incising over a concave area anywhere on the body can lead
to scar problems, and this region is no exception. Figure 10-91
shows a thickened scar band from improper incision placement,
which also served as a food trap. Every time the patient ate, food
debris accumulated in the trough and was annoying. The scar
band was excised, and the tissue was undermined and closed
primarily. The patient was asked to keep dental cotton rolls in
the vestibule as much as possible during the initial healing

Chapter 10  •  Facial Implants
417
A
B
C
FIGURE 10-86.  A, Dehiscence of a cheek implant incision in a smoker. B, The granulation tissue incised. C, The healthy tissue
resutured. This can only be performed in the absence of active infection.
A
B
FIGURE 10-87.  Chin implant infections may manifest at the incision site (A) or in some cases can develop an external fistula
(B) on a patient who had the implant placed by a surgeon elsewhere.

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Chapter 10  •  Facial Implants
A
B
FIGURE 10-88.  This patient had an implant placed by another surgeon. It was not fixated and became displaced in the soft
tissues of the chin and neck (A) and caused a fistula in the neck (B), necessitating removal and reconstruction.
A
B
C
FIGURE 10-89.  This patient had an ePTFE implant placed and complained of pain without early clinical symptoms of infection.
The patient was lost to follow-up and several months later presented with an active abscess and fistula of the neck (A).
B, Computed tomography scan showing the infection. C, The explanted infected prosthesis.
A
B
FIGURE 10-90.  A, Osteomyelitis secondary to longstanding implant infection in a patient that was treated outside the United
States. The notched, “moth-eaten” necrotic bone is evident. B, The removed implant with the fixation screw and necrotic bone
fragments.

Chapter 10  •  Facial Implants
419
A
B
FIGURE 10-91.  A, A thickened scar band that was formed as a result of the intraoral incision being placed too close to the lower sulcus. B, Same patient
after scar revision to release the thickened tissues.
period. This problem can be avoided by placing the incision
adequately anterior to the sulcus 15-20 mm.
Custom Chin Implants
Technically, custom CAD-CAM technology can be applied to
any facial implants and can be essential for patients with signifi-
cant asymmetries or reconstructive conundrums. Some patients
present with very specific augmentation requests that may be
beyond stock implants, and with custom fabricated implants,
precise implant construction is possible. I have employed this
technology for cheek, chin, and mandibular angle implants for
aesthetic and reconstructive purposes. This process begins with
a standardized computed tomography (CT) scan. Scans are
acquired at a high spatial resolution. Series should be acquired
with thin, contiguous image slices (<2 mm; 0.75 to 1.25 mm
is ideal) and as small a field of view (FOV) as possible while
still including the patient’s external contour. The patient
must remain completely still through the entire scan. If patient
motion occurs, the scan must be restarted. The entire study is
archived, preferably in DICOM format, to a removable medium
such as Sony/MaxOptix optical disk, Pioneer optical disk, 4- or
8-mm DAT, or CD-R. Many of the older proprietary image
formats (e.g., GE Advantage, Picker, Philips) can be supported,
but the most reliable method of image transfer is DICOM
format on CD-R. It is also possible to transfer image data
via computer network. These scans were in the past most fre-
quently obtained at a hospital or outpatient facility, but today
affordable office CT scan machines are becoming commonplace
(Figure 10-92).
Once a scan is taken, the data is used to fabricate a custom
model of the patient’s anatomy (Figure 10-93). This model is
very specific and accurate and serves as the basis for custom
implant fabrication. Because CT scanner software can add or
subtract layers, it is possible to scan a patient with a previous
implant and make a model with or without the actual implant
(see Figure 10-93).
After the implant model is made, the surgeon (or implant
company) can use polymer modeling clay to fabricate a totally
custom implant based on the desires of the surgeon and patient
(Figure 10-94).
The implant polymer and model are then sent back to the
company, and a preliminary custom silicone implant is fabri-
cated. This is then resent to the surgeon for final approval before
the actual patient implant is made (Figure 10-95). If the surgeon
and patient approve of the final preliminary model, the actual
implant is then fabricated and delivered to the surgeon (see
Figure 10-95, C).
Mandibular Angle Implants
In the normal aesthetic face, patients have volume and structure
in the posterior mandibular region, as well as a defined and
angular mandibular border. Sculpted mandibular features are
desirable in both genders (Figure 10-96). In female models, a
distinct angular jaw line is advantageous. In males, a well-
defined mandibular border and angle provide a “chiseled”
contour associated with a masculine appearance or “male-
model” features.
These desirable features are largely a result of heredity
and development. The specific anatomic components that
constitute posterior mandibular aesthetics are the size and shape
of the bony mandibular ramus and angle (Figure 10-97).
The facial soft tissues and especially the masseter muscle
volume also play an important part in mandibular aesthetics
(Figure 10-98).
Numerous types of mandibular angle implants are available,
including porous polyethylene and silicone. I prefer the Taylor
mandibular angle implant (ImplanTech Inc.). These implants
come in various sizes and shapes, with and without an inferior
and posterior ridge. I prefer the models with the inferior and
posterior ridge, which assist in seating and positioning during
placement and can also assist in the prevention of implant rota-
tion (Figure 10-99). When placing the implant on the man-
dibular ramus, the ridge overlaps the inferior mandibular border
and posterior ramus (see Figure 10-99, B).
When considering mandibular placement, the patient must
be examined to determine the deficient regions, and the implant
selected must augment these areas without distorting the sur-
rounding anatomy. These implants can be more challenging in
terms of diagnosis and treatment when compared to routine
cheek and chin implants; this area is more difficult to precisely

420
Chapter 10  •  Facial Implants
B
A
C
FIGURE 10-92.  In-office computed tomography (CT) scan machines are becoming commonplace in many surgeons’ offices and
are used for a myriad of reconstructive applications. A, An office-based CT scanner. B–C, A three-dimensional CT scan.
(Courtesy Imaging Sciences International, Hartfield, PA.)
FIGURE 10-93.  The lower computer-generated model shows the mandible of a patient who was unhappy with her previous
implant. The upper model shows the mandible with the implant subtracted by the software, which can now be used to fabricate
a new custom implant.

Chapter 10  •  Facial Implants
421
A
B
FIGURE 10-94.  After receiving the custom computer-generated model, the surgeon can use polymer clay to fabricate a facsimile
of the desired custom implant. Shown here is a newly fabricated and trimmed implant ready for transformation into the actual
custom silicone implant.
A
B
C
FIGURE 10-95.  The final preliminary silicone implant is fabricated on the model and sent back to the surgeon for surgeon and
patient approval. The final preliminary silicone custom implant is shown with the computed tomography model (A–B) and the
final custom implant (C).
A
B
FIGURE 10-96.  Full and angular posterior mandibular aes-
thetics are desirable.

422
Chapter 10  •  Facial Implants
A
B
FIGURE 10-97.  A, The gonial angle on a panoramic radiograph. B, Well-developed and flared gonial angles on a mandible.
A
B
FIGURE 10-98.  The aesthetic posterior mandible is a result of adequate bony support (A) as well as masseter muscle size and
volume (B).

Chapter 10  •  Facial Implants
423
A
B
FIGURE 10-99.  The mandibular angle implant with inferior and posterior ridges assists in positioning and placement as it “hugs”
the mandibular contour.
change. Generally, most patients who are candidates for man-
dibular angle implants require increased volume of the lateral
mandible as well as increased definition of the mandibular
border and angle (Figure 10-100).
When placing silicone implants, there are two basic configu-
rations. The Taylor mandibular angle implant provides the
contour for those patients who need actual definition of the
angle region but without significant lateral augmentation. These
are primarily used for patients who developmentally have little
or no angle prominence or patients who may have undergone
mandibular osteotomies or similar surgeries and have lost pos-
terior mandibular angle definition. More commonly, patients
require the Taylor lateral mandibular angle implant. This pro-
vides the same angular augmentation as the previously men-
tioned implant but also adds 8 to 12 mm of lateral mandibular
(masseter region) augmentation. This implant is available in
8-mm, 10-mm, and 12-mm thicknesses; in my opinion, most
patients require the 10- to 12-mm implants. For significantly
larger or smaller applications, custom mandibular implants may
be indicated and will be discussed later in this chapter.
Surgical Placement
These implants are placed subperiosteally over the lateral man-
dibular ramus through a mucosal incision over the inferior
ramus region. The implants lie in the space between the perios-
teum of the masseter muscle and the bone of the lateral man-
dibular ramus (Figure 10-101).
A 1.5-cm incision is made over the lateral mandible about
1 cm lateral to the posterior sulcus through the mucosa to the
subperiosteal level (Figure 10-102, A). This is very mobile tissue
and does not require an excessive incision. Next, a periosteal
elevator is used to dissect the lateral ramus under the periosteum
(see Figure 10-102, B). The superior aspect of the dissection
pocket is around the level of the sigmoid notch or less, depend-
ing upon the size of the implant. Figure 10-102, C shows
another view of the completed incision and dissection.
Posteriorly, the dissection must go to the posterior border
of the ramus if the implants without the retention ridge are
used or further if the ridged implants are used. Inferiorly,
the dissection will go to the level of the mandibular inferior
border, but additional dissection is required if a ridged implant
is used.
If ridged implants are used, I believe it is important to dissect
beyond the posterior ramus and the inferior border of the man-
dible to allow for the overlap of the retention ridge (shown in
Figure 10-99). A tight sling is formed over the inferior man-
dibular border by the masseter muscle laterally and the medial
pterygoid muscle medially and is adherent to the inferior border
by a thickened band of periosteum (Figure 10-103). In order to
violate this connection to make room for the overlapping ridged
implant, this dissection is facilitated by J-shaped periosteal strip-
pers (Figure 10-104).
The J-stripper is used to hook under the periosteum of the
inferior border of the mandible, and when brought around, the

424
Chapter 10  •  Facial Implants
A
B
C
FIGURE 10-100.  Most patients requesting mandibular angle implants are interested in increasing lateral facial volume as well as
definition of the mandibular inferior border and angle regions.

Chapter 10  •  Facial Implants
425
A
B
FIGURE 10-101.  A, A cadaver with the masseter muscle dissected from the lateral mandibular ramus. B, The placement of a
silicone implant (in this case, the implant sizer) over the lateral mandible.

426
Chapter 10  •  Facial Implants
A
C
B
FIGURE 10-102.  A, A 1.5-cm incision made lateral to the mandibular sulcus. B, The subperiosteal dissection over the lateral
mandibular ramus. C, The subperiosteal dissection on the lateral mandible and ramus in preparation for mandibular angle
implant placement.

Chapter 10  •  Facial Implants
427
FIGURE 10-103.  The mandibular sling is formed around the inferior border
by the masseter (M) and medial pterygoid muscles (P).
A
B
C
FIGURE 10-104.  J-stripper elevators are used to dissect the tenacious periosteum at the inferior border (A), the angle region
(B), and the posterior ramus area (C).
mandibular angle will also dissect the sling of the posterior
ramus.
After the dissection pocket is made, the area is irrigated with
antibiotic solution and the implant is placed. Due to the
L-shaped configuration of the implant, the superior vertical
portion is inserted first, then the implant is rotated to accom-
modate the horizontal portion of the implant into the smaller
incision. When the implant is in place, the surgeon must decide
the optimum area of projection of the lateral implant surface.
Since the implant has an 8- to 12-mm prominence, this must
be correlated with the correct desired soft-tissue prominence on
the cheek. In some cases, the implant will fit nicely on the lateral
ramus, but the intended prominence may not be in the proper
position for the soft tissues. I like to mark a region of the desired
prominence on the patient preoperatively and verify the correct
location of the most lateral prominence. I will place a

428
Chapter 10  •  Facial Implants
A
B
FIGURE 10-105.  To line up the lateral prominence of the implant with the proper soft-tissue position, the desired area of the
cheek is marked (green X in A). A needle is passed through this mark and should correspond with the most laterally prominent
region of the implant (B).
FIGURE 10-106.  Pulling the skin taut after implant placement and fixation
can verify proper placement and contour.
transcutaneous needle into the prominence of the implant to
make sure the desired augmentation is in the proper position
(Figure 10-105). It is sometimes difficult to discern whether the
implant is properly seated on the inferior border of the man-
dible. The skin can be pulled taut to verify the correct border
and angle contour (Figure 10-106). If the surgeon is concerned
that the implant is riding too far inferiorly below the inferior
mandibular border, a transcutaneous needle can be placed to
sound the bone and/or implant.
Once the desired position is achieved, the implant is secured
with a single fixation screw (Figure 10-107). This can be done
transcutaneously, which is easier because the screw can be placed
perpendicular to the ramus, but it requires a cheek incision
and a trocar/cannula system and is more invasive and time
consuming. If this route is taken, the surgeon must place the
screw in the ramus in a position to avoid the inferior alveolar
nerve. The fixation screw can also be placed through the implant
incision but will be placed at an angle—more difficult but more
practical. The most accessible region is on the thin bone of the
ascending ramus under the coronoid process, and there are no
underlying structures to damage. Since this screw will have to
be placed at an angle, a 7- to 8-cm long drill bit must be used.
This extended-length drill allows the surgeon to negotiate the
proper angle to secure the implant to the thin anterior ramus
with a 2-mm diameter fixation screw, 5 to 7 mm in length.
Alternately, a right angled drill handpiece can make access to
the lateral ramus easier. Some surgeons will extend the incision
so that a screw can be placed in the angle region in the body of
the mandible. If this route is taken, the surgeon must again be
cognizant of the position of the inferior alveolar nerve or tooth
roots.
As I have stated many times in this chapter, I believe that
screw fixation is an extreme advantage with all facial implants
and a requisite with mandibular angle implants, because the
heavy masticatory muscles can quickly displace a mobile
implant. The L-shaped configuration of these implants mean
they can not only be displaced in a vertical and horizontal
direction but can also have a rotational component of displace-
ment; the precise position must be determined and stabilized
(Figure 10-108).

Chapter 10  •  Facial Implants
429
A
B
FIGURE 10-107.  Two cases of implant screw fixation are illustrated. The screw is placed in the anterior ramus region through
the open incision.
A
B
FIGURE 10-108.  A, Mandibular angle implants are subject to rotational displacement as well as vertical and horizontal displace-
ment. B, Computed tomography scan of a rotated mandibular angle implant.
After the implant is fixated, the wound is again irrigated with
antibiotic solution and the incision closed with several inter-
rupted sutures. Running closure or numerous sutures are unnec-
essary: (1) the muscle action of the cheek will keep the wound
from gaping, and (2) it is preferable to allow any drainage to
flow through the loosely closed incision. Figure 10-109 shows
the incision being closed with 4-0 gut sutures.
Custom Implants
Like the other facial areas, mandibular angle implants can be
fashioned in a custom manner as previously described and in
many cases may be the preferred route. Although the stock,
off-the-shelf cheek and chin implants fit most patients, there
appears to be more variability with angle implants. The custom

430
Chapter 10  •  Facial Implants
FIGURE 10-109.  The implant incision is closed with 4-0 gut sutures.
A
B
FIGURE 10-110.  A, Preliminary custom-fabricated implant. B, Actual final implants in place on the custom three-dimensional
model. The visible screws are from another surgery and illustrate the precision of the CAD-CAM model.
application is as previously described, and a model is fabricated
from a CT scan (Figure 10-110).
Figure 10-111 shows a reconstructive case for which custom
implants were made on a CT-generated model for a patient who
had idiopathic mandibular osteolysis after saggital osteotomy.
Figure 10-111, A shows the large facial angular defect after the
mandibular bone loss. Figure 10-111, B and C show the custom
CT-generated model and custom implant fabricated on the
model. The patient’s 5-year postop images are shown in Figure
10-111, D to F.
Complications With Mandibular Angle Implants
Like all other implants, mandibular angle implants are
subject to problems or failure. Overcorrection, undercorrection,
and malposition are the most commonly seen problems.
Care in placement and screw fixation can prevent drift or
malposition.
Wound dehiscence is seen commensurate with other implants
and is more common in smokers or patients who begin oral
function and hard-consistency food too early. Similar to the
other implants, if the implant is fixated, most dehiscence or
minor infection can be regularly irrigated until secondary-inten-
tion wound closure occurs. Figure 10-112, A and B show a
patient with bilaterally dehisced wounds 5 days after implant
placement. The open incisions were débrided with antibiotic
solution and hydrogen peroxide, and the patient was placed on
an antibiotic mouthwash and oral antibiotic. Figure 10-112, C
and D show both incisions completely closed 4 weeks after
surgery. The implants remained stable.
As mentioned earlier in this chapter, silicone implants are
easy to remove if problematic. Porous implants are much more
difficult, as readily apparent in Figure 10-1, which shows a
removed implant with attached muscle and other soft tissues
that have integrated into the implant. Again, I have no com-
mercial bias regarding any implant material. When implants are
problem free, any material is great, but if the implant must be
removed, the surgeon and patient must be aware of the increased
chance of surrounding tissue damage when dealing with porous
materials.
Conclusion
Facial implants are an important and often overlooked part of
cosmetic facial surgery. They offer a three-dimensional, perma-
nent (when fixated) solution to volume restoration in the middle
and lower face and can be serviced or removed without maxi-
mally invasive surgery. Volume depletion has become well
appreciated in the aging process, and volume restoration is
imperative for natural-appearing cosmetic facial procedures.
Although there are many means of restoring volume and
enhancing the facial structures and profile, none of these carry
the advantages of solid silicone facial implants in ease of place-
ment, permanency, cost effectiveness, and ability to reverse the
procedure.

Chapter 10  •  Facial Implants
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B
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D
E
F
G
FIGURE 10-111.  A, This patient sustained mandibular osteolysis after osteotomy and was left with significant bilateral defects.
B–C, A custom computed tomography model was fabricated illustrating the significant defect in the posterior mandible and
the custom implants as they fit on the model. D–F, The patient is shown 5 years after custom implant reconstruction of the
mandibular defects.