The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

The caudal dissection along the anterior temporal line (temporal crest) encounters
the temporal ligament, better known as the fusion line; this is where the periosteum
meets the deep temporal fascia.
Careful tissue elevation with the endoscope will minimize trauma to the infraorbital
nerve and avoid paresthesias in the midface. Creation of a limited medial area of dis-
section in the transition between zones 1 and 3 will prevent harm to the temporal
branch of the facial nerve by avoiding the two lateral thirds of the zygomatic arch.
These branches extend from the superior pole of the parotid gland, cross the zygo-
matic arch under the SMAS, and then become more superficial. They perforate the
superficial temporal fascia and follow an anterosuperior direction, approximately
1 cm lateral to the tail of the brow, until they reach the frontal area.
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Part VII  Midfacial Rejuvenation
Masseteric fascia
(over masseter muscle)
Zygomatic
minor muscle
Zygomatic
major muscle
Area of
dissection
Zygomatic
facial nerve
Medial temporal
zygomatic vein
Medial temporal
zygomatic nerve
Lateral temporal
zygomatic nerve
Frontal
bone
Supraorbital
periosteum
divided
Deep
temporal
fascia
Fusion
line
Supraorbital rim
periosteum
Fusion
line

Area of
dissection
Corrugator
muscle
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Chapter 38  Endoscopic Rejuvenation of the Midface
If the brow is also being treated (zone 2), the supraorbital dissection continues me-
dially until the corrugator muscle is seen. The corrugators are completely avulsed
with an endoscopic grasper; the branches of the supratrochlear nerve are preserved.
The assistant keeps finger pressure over the glabella to assist in the removal of the
corrugator fibers and to minimize trauma to the underlying skin and the develop-
ment of possible future indentations in this area.
Limited undermining into zone 2 reaches the suborbicularis ocular fat (SOOF). The
SOOF is a fatty sheath located below the suborbicularis oculi muscle in the lower
eyelid and is firmly attached to muscle fascia.
The next step is the dissection and release of the fusion line that continues with the
release of the supraorbital rim periosteum to allow release of the brow and permit
entry to zone 3 in the midface. The supraorbital nerve is identified and preserved.

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Part VII  Midfacial Rejuvenation
Area of
dissection
Plane of dissection
Temporalis muscle
Superficial temporal fascia
Cranial nerve VII
Periosteum
Zygomatic bone
Deep temporal fascia
Intermediate temporal fascia
Temporal fat pad
The endoscopic temporal subperiosteal approach down
to zone 3 does not interfere with the muscle innervation
of the lower eyelid and thereby avoids the risk of ectro-
pion and scleral show that can sometimes be seen with
the subperiosteal approach through the inferior eyelid.
This complete subperiosteal undermining of zones 1 and
3 allows an en bloc suspension of the midface tissues,
permitting repositioning and restoring midface volume.
The subperiosteal dissection at the level of the lateral or-
bital rim extends laterally to the malar bone and medi-
ally along the infraorbital rim.
If the brow is not being treated and only zones 1 and 3 are to be dissected, the next
step is to extend the subperiosteal dissection down into the lateral orbital rim. Care-
ful attention to this narrow and often delicate area is needed to maximize endoscopic
vision and minimize trauma to the neurovascular structures present in this transi-
tion zone.

1175
Chapter 38  Endoscopic Rejuvenation of the Midface
The Bichat ball or buccal fat pad is located inferiorly and deeper to the malar bag
and medial to the masseter muscle and superficial to the buccinator muscle. The
branches of the facial nerve pass superficial to the Bichat ball.
Dissection continues down to the gingival groove after complete release of the or-
bital retaining ligament. At the gingival groove, the periosteum is thin and easily dis-
rupted during dissection. In this region the nasolabial fold can be treated, if it is too
deep, by undermining of the subcutaneous tissue around it.
The masseter muscle inserts into the zygomatic bone. It is often necessary to release
some of its fibers to allow an easier dissection to facilitate insertion of the scope
through the lateral orbital rim down into the midface. These fibers should be care-
fully avulsed or transected with the endoscopic scissors. A wider dissection in this
very narrow tunnel allows better visualization of the midface cavity, more secure fix-
ations, and decreased incidence of relapse after midface lifting with the potential for
better long-term results. However, a wide midface dissection can also cause more
pronounced and prolonged edema.
Once the lateral orbit rim periosteum is elevated, the endoscope can be advanced
with a downward movement. Subperiosteal undermining with a hockey-stick eleva-
tor allows dissection of the inferior orbital region in a safe plane. The objective is to
elevate the whole periosteum and lower eyelid and its structures to allow correction
Area of
dissection

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Part VII  Midfacial Rejuvenation
of depressions in this area. The dissection lifts and redrapes the skin and underlying
tissues. The inferior eyelid can be treated separately through a transconjunctival ap-
proach to ameliorate the herniated fat pockets. If there is skin excess, it can be treated
by very conservative skin removal or laser therapy. This safe approach protects the
integrity of the lower eyelid innervation. The dissection extends medially to the nasal
bones. At this point the premaxilla is completely released and ready for fixation.
Fixation
Long-lasting results often depend on adequate dissection, extensive periosteal re-
lease, and appropriate fixation. Two different techniques of fixation will be presented:
the direct needle fixation technique and the device fixation technique.
Direct Needle Fixation
Fixation begins after undermining is complete. With this technique, a straight, thin
needle (Casagrande needle) is used, based on the principles of the Reverdin needle.
The needle is introduced through the skin at points that are marked for skin elevation.
After the needle is inserted, endoscopic visualization allows direct observation of the
needle penetrating the optical cavity. The needle is carefully drawn out through the
temporal incision, and a nonabsorbable suture is introduced through the eye of the

needle. The needle is then passed back under the skin, and after a small trajectory
through the soft tissues, is brought out again externally through the temporal inci-
sion and secured to the deep temporal fascia. At this point the suture material is re-
moved from the needle’s eye and kept attached to the soft tissues, promoting elevation
and fixation. Outlining of the nerves in this region helps the surgeon to avoid any
damage during this maneuver. The soft tissues are secured first. In extended endo-
scopic frontal lifting, there is only one point of fixation at the level of the SOOF. In
endoscopic midface lifting, two, three, or more points of fixation are used: the first at
the level of the malar fat pad, the second to the SOOF, and another one at the infra -
orbital area. In the frontal region the fixation points are applied through the parame -
dian incisions. Usually the first fixation point is applied in the direction of the lateral
canthus, the second at the level of the lateral brow, and the third at the hairline. Prox-
imally, the fixation is as close as possible to the hairline and deep temporal fascia.
This fixation technique permits precise repositioning and fixation of soft tissues, with
predictable outcomes. The subperiosteal dissection provides an adequate blood sup-
ply to the skin flaps and allows the simultaneous use of skin resurfacing modalities,
such as lasers and chemical peels. The limitations of this technique are that it relies
on suture suspension only, may result in minor asymmetry because of different vec-
tors for fixation, and involves a long learning curve.
1177
Chapter 38  Endoscopic Rejuvenation of the Midface
This 50-year-old patient requested full facial rejuvenation. She underwent endoscopic
suspension of the frontal region and midface with a Casagrande needle and suture
technique, with fixation to the temporal fascia. She also had a cervical lift, treatment
of zones 1 and 3, and a SMASectomy, as described by Baker.

Device Fixation Technique
Since 2003 I have been using the Endotine midface device (Coapt Systems, Palo Alto,
CA). It is now my preferred method of suspension and fixation for malar fat pad el-
evation. The surgical technique for dissection is the same as previously described.
The Endotine midface device has five prongs or tines that will engage the soft tissues
and suspend and secure them in position.
1178
Part VII  Midfacial Rejuvenation
A deployment system protects the implant during insertion, and deployment is
achieved with a simple trigger release to engage tines to soft tissue. Digital pressure
engages the tines.

Once the soft tissue is engaged, the insertion tool is removed through the temporal in-
cision.
1179
Chapter 38  Endoscopic Rejuvenation of the Midface
Tension is applied to the anchoring leash to achieve the desired elevation. The leash
is then sutured to the temporal fascia and the excess leash is trimmed.

This easy, step-by-step midface suspension-fixation device enhances soft tissue fixa-
tion, provides simple adjustability for optimal elevation and projection, and main-
tains mechanical fixation until biologic fixation is adequate. The five tines provide
multiple points of contact for secure soft tissue fixation. The elevation forces are
evenly distributed over a wide area, eliminating skin irregularities. Insertion and de-
ployment are readily accomplished through the temporal incision. Implant palpa-
bility is minimal, and reabsorption starts at 6 months. The Endotine midface fixa-
tion technique offers several advantages:
 It avoids an intraoral incision.
 It eliminates sutures.
 The deployment is simple, secure, and offers multipoint fixation.
 The device is bioabsorbable.
 The leash fixation mechanism provides fast and simple adjustability for opti-
mal control of the elevation and volume of the midface.
Tissue glue is sprayed in the dissected pocket to decrease swelling and bruising by
acting as a sealant on the lymphatic drainage system.
Closure
The scalp is closed in the temporal area in two planes: one reattaching the scalp to
the temporal fascia and the other closing the dermis and the skin, both using ab-
sorbable sutures. The hair and scalp are shampooed, then the patient is extubated
and taken to the recovery room.
Postoperative Care
During the immediate postoperative period, the position of the patient’s head should
be watched carefully to maintain the airway. In the anesthetic recovery room, the
headboard should remain elevated to 30 degrees to avoid excessive facial edema. The
patient’s blood pressure must be carefully monitored to avoid bleeding and
hematomas. Ice bags can be used on the surgical areas. We also supply a splint on
the undermined areas for 5 days. The patient is allowed to shower from the first post-
operative day. Analgesia is accomplished with the use of an oral analgesic. Antibi-
otics are used for only 24 hours. Lymphatic drainage massage (48 to 72 hours post-
operatively) promotes opening of the lymphatic channels with decreased swelling,
less discomfort, and improved appearance in the early postoperative period.
1180
Part VII  Midfacial Rejuvenation

1181
Chapter 38  Endoscopic Rejuvenation of the Midface
Results
This 49-year-old patient underwent endoscopic lifting of the frontal region and mid-
face with fixation, using the Casagrande technique. She also had a cervicoplasty com-
bined with a SMASectomy, superficial and deep chemical peels, and a combined
rhinoplasty. She is shown 1 year postoperatively.

This 45-year-old woman was seen in consultation for midface rejuvenation. She was
treated with an endoscopic brow and midface lift using the temporal incision only
and Endotine devices for fixation. Fibrin glue was sprayed in the midface pocket to
minimize swelling and bruising. Lateral and oblique views at 1 year after surgery
show rejuvenation of the midface area with elevation of the malar fat pad, im-
provement of the tear trough, and softening of the nasolabial folds.
1182
Part VII  Midfacial Rejuvenation

This 39-year-old woman requested forehead and midface rejuvenation. She under-
went a brow and midface lift in which the endoscopic technique was used, with a
temporal incision only. The fixation of the brow lift was completed using permanent
sutures from dermis to deep temporal fascia under the temporal incisions and En-
dotine fixation devices for the paramedian incisions. The midface elevation was ob-
tained by using Endotines. Fibrin glue was sprayed in both dissected pockets to seal
the tissues, minimize bleeding, and decrease early postoperative swelling.
1183
Chapter 38  Endoscopic Rejuvenation of the Midface

This 52-year-old woman requested facial rejuvenation. She was a candidate for full-
face and forehead rejuvenation with a brow and face lift. However, she did not want
to have a face lift at this time to avoid the preauricular scars. She underwent a fore-
head and midface rejuvenation with an endoscopic technique through a temporal
incision, avoiding any visible scars. The 1-year postoperative views demonstrate im-
provement in the forehead wrinkles, brow position and symmetry, and periocular
and midface rejuvenation. Midface suspension also softened the nasolabial folds and
decreased obvious jowling. Although a face lift would have provided a better solu-
tion for the lower face, this procedure employed a combination of minimally inva-
sive procedures to meet the patient’s expectations.
1184
Part VII  Midfacial Rejuvenation

This 49-year-old patient wished to improve her facial appearance, especially her mid-
face and neck. She underwent surgical rejuvenation of the entire face, with endo-
scopic frontal and midface suspension with fixation to the deep temporal fascia with
the use of 3-0 and 4-0 nylon sutures. She also had treatment of the cervical region
and a SMASectomy.
1185
Chapter 38  Endoscopic Rejuvenation of the Midface

1186
Part VII  Midfacial Rejuvenation
Complications
The most common complications are temporary supraorbital and supratrochlear
nerve paresthesia caused by pocket dissection and stretching of the tissues. They usu-
ally last 2 to 3 weeks, are manifested frequently as numbness or local itching, and
recover spontaneously.
This 45-year-old woman was seen in consultation for forehead rejuvenation. She
underwent endoscopic forehead rejuvenation and experienced temporary paralysis
of the right temporal branch of the facial nerve. She recovered completely after
120 days. Paresthesias resulting from a lesion of the temporal branch of the facial
nerve are extremely rare. The treatment is observation and reassurance for 3 to
6 months, time required for spontaneous resolution.
Persistent edema and ecchymosis can also occur, and patients should be instructed
to avoid sun exposure during this period. Hematomas can be avoided with good sur-
gical technique, careful hemostasis, control of blood pressure during surgery, and a
smooth recovery. Treatment for expansive hematomas consists of immediate surgi-
cal evacuation and drainage.
Brow and midface asymmetries can occur. They can be related to dissecting pockets
differently, asymmetrical or inadequate lifting in one or both sides, and/or excess of
facial muscular action immediately after surgery. Sometimes surgical revision is nec-
essary to correct the resulting asymmetry.

Clinical Caveats
 In an endoscopic midface lift, during the dissection from the temporal region to
the lateral orbital rim and midface (the zone of transition), it is critically impor-
tant to preserve the nerve structures to avoid numbness in the cheek area.
 If necessary, the sentinel veins can be cauterized for better dissection and easier in-
strument manipulation in the transition zone between the temporal region and
the midface.
 Subperiosteal elevation at the level of the lateral orbital rim is the key to facilitat-
ing safe undermining of the midface.
 Release of masseter attachments to the malar bone facilitates dissection and im-
proves the surgeon’s ability to slide the scope along the narrow tunnel in the lat-
eral orbital rim to visualize the midface structures.
 Fixation with an Endotine device is quick, safe, and reliable and does not produce
the asymmetry seen with some suture fixation.
 Fibrin glue can decrease the amount of swelling, discomfort, and bruising when
sprayed in the midface pocket before fixation.
 Intraoral incisions can be used to reinforce the fixation if necessary.
 It is important to preserve the integrity of and avoid trauma to the inferior orbital
nerve to prevent paresthesias.
 Patients should be informed that swelling may be present for 3 to 4 weeks and
numbness for 6 to 8 weeks.
 Endoscopic midface lifting does not treat jowling and aging of the neck—it does
not replace a face lift.
1187
Chapter 38  Endoscopic Rejuvenation of the Midface
Annotated Bibliography
Casagrande C, Saltz R, Chem R, et al. Direct needle fixation in endoscopic facial rejuvenation.
Aesthet Surg J 20:361-367, 2000.
This study examines the efficacy of endoscopic facial rejuvenation with direct transcu-
taneous needle fixation. In a series of 50 patients, the authors found that subperiosteal
lifting with direct needle fixation allows more precise repositioning of the inferior, peri -
orbital, and frontal regions. In 30 patients undergoing additional treatment for the mid-
face, this technique eliminated the need for midface intraoral and/or infraciliary inci-
sions. The authors conclude that endoscopic facial rejuvenation through the use of direct
needle fixation provides safe and aesthetically pleasing results with a high level of pa-
tient satisfaction at 24 months’ postoperative follow-up.

de la Fuente A, Santamaria AB. Facial rejuvenation: a combined conventional and endoscopic
assisted lift. Aesthetic Plast Surg 20:471-479, 1996.
This article describes the authors’ personal approach for facial rejuvenation combining
conventional and endoscopic procedures. For a forehead lift, the authors use an endo-
scopic assisted technique, as they find this minimally invasive technique less traumatic
and time consuming; it allows a greater range of possibilities for individual needs be-
cause it limits the incision and dissection to the required areas and has a higher level of
acceptance by the patients. It is also a good complement to a conventional face lift.
Saltz R. Endoscopic temporal incision only midface lift is enhanced by Endotine technique.
Aesthetic Surg J 25:80-83, 2005.
The Endotine midface technique, through an endoscopic temporal incision only ap-
proach, is the author’s preferred method of malar fat pad suspension and fixation. The
bioabsorbable Endotine device avoids an intraoral incision, eliminates sutures, offers
multipoint fixation, and the leash fixation mechanism provides fast and simple ad-
justability for optimal control of midface elevation and volume.
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follow-up. Plast Reconstr Surg 123:1025-1033, 2009.
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lift incision on lower facial rejuvenation. Facial Plast Surg 21:33-37, 2005.
Bonnefon A. [Subperiosteal midface lifting] Ann Chir Plast Esthet 51:170-177, 2006.
Chajchir A. Endoscopic subperiosteal forehead lift. Aesthetic Plast Surg 18:269-274, 1994.
Chasan PE, Kupfer DM. Direct K-wire fixation during endoscopic brow lift. Aesthetic Plast
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Clayton HM, Food PF, Mandeville D, et al. Atlas Colorido de Anatomia Aplicada dos
Grandes Animais. São Paulo: Manole, 1997.
Core GB, Vasconez LO, Askren C, et al. Coronal facelift with endoscopic techniques. Plast
Surg Forum 15:227-228, 1992.
Cornette de Saint-Cyr B, Garey LJ, Maillard GF, et al. The vertical midface lift. An improved
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Daniel RK, Tirkanits B. Endoscopic forehead lift. Aesthetics and analysis. Clin Plast Surg
22:605-618, 1995.
Daniel RK, Tirkanits B. Endoscopic forehead lift: an operative technique. Plast Reconstr Surg
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Eppley BL, Sadove AM. A comparison of resorbable and metallic fixation of calvarial bone
grafts. Plast Reconstr Surg 96:316-322, 1995.
Eppley BL, Coleman JJ, Sood R, et al. Resorbable screw fixation technique for endoscopic
brow and midfacial lifts. Plast Reconstr Surg 102:241-243, 1998.
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Part VII  Midfacial Rejuvenation

de la Fuente A, Franz Hönig J. Transtemporal endoscopic multiplanar upper midface lift
(MUM lift). Aesthet Surg J 25:471-480, 2005.
de la Fuente A, Hönig JF. Video-assisted endoscopic transtemporal multilayer upper midface
lift (MUM lift). J Craniofac Surg 16:267-276, 2005.
Graham HD. Methods of soft-tissue fixation in endoscopic surgery. Facial Plast Surg Clin
North Am 5:145-154, 1997.
Guyuron B, Michelow BJ. Refinements in endoscopic forehead rejuvenation. Plast Reconstr
Surg 100:154-160, 1997.
Hoening JF. Rigid anchoring of the forehead to the frontal bone in endoscopic facelifting: a
new technique. Aesthetic Plast Surg 20:213-215, 1996.
Isse NG. Endoscopic facial rejuvenation. Clin Plast Surg 24:213-231, 1997.
Kim SK. Endoscopic forehead scalp flap fixation with K-wire. Aesthetic Plast Surg 20:217-
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Kobienia BJ, Beek AV. Calvarial fixation during endoscopic brow lift. Plast Reconstr Surg
102:238-240, 1998.
Loomis MG. Endoscopic brow fixation without bolsters or miniscrews. Plast Reconstr Surg
98:373-374, 1996.
Marchac D, Ascherman J, Arnaud E. Fibrin glue fixation in forehead endoscopy: evaluation
of our experience with 206 cases. Plast Reconstr Surg 100:701-712; discussion 713-714,
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Marotta JC, Quatela VC. Lower eyelid aesthetics after endoscopic forehead midface-lift. Arch
Facial Plast Surg 10:267-262, 2008.
McKinney P, Celetti S, Sweis I. An accurate technique for fixation in endoscopic brow lift.
Plast Reconstr Surg 97:824-827, 1996.
Metzner DM. The role of canthopexy in midface rejuvenation. Aesthet Surg J 26:601-602,
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Newman J. Safety and efficacy of midface-lifts with an absorbable soft tissue suspension de-
vice. Arch Facial Plast Surg 8:245-251, 2006.
Paul MD, Calvert JW, Evans GR. The evolution of the midface lift in aesthetic plastic sur-
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Quatela VC, Marotta JC. Pitfalls of midface surgery. Facial Plast Surg Clin North Am 13:401-
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cussion 1004-1006, 1995.
Romo T III, Sclafani AP, Yung RT, et al. Endoscopic foreheadplasty: a histologic comparison
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Saltz R. Advances in Endoscopic and Minimally Invasive Plastic Surgery. University of Utah
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Saltz R. Endoscopic temporal-incision only midface lift is enhanced by endotine technique.
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Saltz R. Tissue sealants in plastic surgery. Aesthet Surg J 17:203, 1997.
1189
Chapter 38  Endoscopic Rejuvenation of the Midface

Saltz R, Sierra D, Feldman D, et al. Experimental and clinical applications of fibrin glue. Plast
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1190
Part VII  Midfacial Rejuvenation

Alloplastic Facial Contouring

EDWARD O. TERINO
CHAPTER 39

T
hrough the ages, mankind has acknowledged that perceived beauty bestows ad-
miration and power to its possessor. Although standards of beauty change from
century to century and generation to generation, the effects that beauty has on those
who both perceive it as well as on those who possess it are profound. Facial beauty
represents an even more desirable goal, because all communication with others is di-
rected from the eyes and face. The rest of the body, while it may be eloquent in its
movements, is camouflaged with clothing most of the time.
Standards of facial beauty have always been associated with the face’s anatomic con-
tours. These contours exist as a result of the location, volume, and size of the facial
soft tissues and their relationship to the three-dimensional architecture of the un-
derlying facial skeleton. During some eras, roundness and fullness of facial soft tissues
were the aesthetic ideal of artists, whereas in other periods more defined and dra-
matic skeletal contours in the malar and jawline regions were considered most at-
tractive.
During the Renaissance, many artists depicted the ideal female face as heart shaped,
with a weak lower face, chin, and mandibular contours. In contrast, contemporary
standards of female beauty embody stronger structural contours. Today’s women
seeking aesthetic plastic surgery request jawlines with more anterior projection, a
wider midlateral region, and stronger definition of the posterolateral angle. Malar-
midface cheek contours cited as ideal are also strong and defined.
Facial aesthetics is important to today’s patients, for whom the idea of surgical al-
terations to improve attractiveness has become almost a commonplace. The sculp-
tural shape of faces has been known by artists from time immemorial; when plastic
surgeons describe a face as sculptural, we are referring to its three-dimensional form,
including its many integral parts, whose volumes and masses interrelate through jux-
taposition. The location of these elements and their relative size and shape consti-
tute what plastic surgeons call facial contours. Therefore facial contouring surgery
refers to the art of manipulating specific anatomic features in specific locations by
working with the skeletal foundation and soft tissues to alter facial topography to
either create or enhance facial attractiveness. The skeletal foundation lends defini-
tion and structure to the face. Our culture considers such definition attractive or
beautiful in youth and even more so during the aging process. The shape of the fa-
cial skeleton determines the contours of the overlying soft tissues. Thus skeletal aug-
mentation with alloplastic materials allows plastic surgeons to sculpture faces three-
dimensionally.
1192
Part VII  Midfacial Rejuvenation

Autologous soft tissue manipulations and injectable fillers add versatility to the ar-
senal of aesthetic plastic surgeons; however, I think the results with these materials are
less predictable and less precise than with alloplastic contouring. Structural fat graft-
ing techniques are discussed in Chapter 13.
The Future Interrelationship Between Alloplastic
Facial Implant Volumization and Injectable Fillers
To the knowledgeable surgeon who is experienced in enhancing facial volume and
who has become comfortable with creating attractive facial contours by using im-
plants, the mention of temporary injectable fillers may engender a response equivalent
to the negative attitude of trained craniofacial and oromaxillary surgeons toward us-
ing alloplastic facial implants. The time-honored tradition in plastic reconstructive
surgery has been to use autologous materials for reconstructing facial skeletal in-
juries, deformities, deficiencies, and disfigurements.
My development of alloplastic skeletal alterations for both aesthetic and recon-
structive purposes, which began 35 years ago, has taken many years to gain accep -
tance by traditional orthognathic, craniofacial, and oromaxillary surgeons, who prefer
bone, bone substitutes, and rigidly fixed materials such as Medpor and hydroxyap-
atite in the face. However, such materials have had a persistent history of causing in-
fection, palpable and visible deformities, and difficulties with removal and exchange -
ability. Silicone rubber implants have enjoyed the true test of time and have persisted
for more than 40 years because of their significant advantages.
Alloplastic facial contouring surgeons fully appreciate the inherent necessity of cre-
ating skeletal structural integrity that provides the foundation for either minor or
quite dramatic and significant improvements in facial balance to create aesthetic at-
tractiveness or beauty. They also appreciate the value of the permanent, precise di-
mensional qualities of these implants, which can be easily removed, modified, ex-
changed, or eliminated according to the patient’s and the doctor’s desires.
The technical simplicity with which facial implants can be routinely inserted can be
thought of as equivalent to surgical interns learning their first hernia, hemorrhoid,
or varicose vein operations. The only difference is that the surgeon requires an artis-
tic perception and precise understanding of patients’ anatomic needs and must know
how to provide them alloplastically.
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Chapter 39  Alloplastic Facial Contouring

These procedures are far simpler than a rhytidectomy, SMAS dissection, deep plane
dissection, or midface suspension. They require only the willingness and interest of the
surgeon to learn this advanced unique, to master this valuable technology and to pay
great attention to detail regarding patients’ descriptions of their needs and endeavor
to translate them into reality. The anatomic and technical concepts presented in this
chapter are intended to provide a basis for learning these techniques.
In my experience, alloplastic facial structuring and volumization of faces are the
most creative forms of facial aesthetic surgery. The role of today’s injectable fillers
can also be very valuable. Along with autologous fat transplantation to the face, in-
jectable fillers have enjoyed much interest and extensive use. The role of fat grafting
and injectable fillers in facial rejuvenation is more valuable than originally thought,
because their results have become more predictable and longer lasting. The benefi-
cial effects of a hyaluronic acid filler used in nonanimated areas of the face, such as
the suborbital, malar, or midface region or the nasolabial sulcus area, can last 1 to
2 years. Moreover, there may even be some permanence to these fillers, because there
have been some reports that their results persist for an extended period.
However, this remains an underresearched enigma. Although there are experts in fat
contouring who show excellent permanent results, the process is very technique de-
pendent: a number of plastic surgeons have found that the fat may partially or
totally resorb, depending on circumstances. When transplanted fat persists, it some-
times results in unnatural-looking contours, bumps, and swellings that may be dif-
ficult to correct. When one also considers that an increase in weight produces an ex-
pansion of the transplanted fat in the face, it seems that the indications for fat
transplantation should be carefully defined, and it should be used sparingly when
surgeons are trying to provide long-term or permanent volume changes for their
patients.
However, injectable fillers provide an exciting adjunct when combined with allo-
plastic facial structuring and volumization. They can be used to modify and improve
the areas over, around, and near the basic foundation structure of the implants, en-
abling the surgeon to refine the desired aesthetic contours.
1194
Part VII  Midfacial Rejuvenation

This 62-year-old woman had marked midfacial atrophy 20 years after inappropri-
ately shaped implants were inserted by another surgeon (left). We replaced the im-
plants with implants of the correct size and shape (right) and used injectable HA
fillers to soften the contours around the implants and to fill the lower submalar mid-
face region. The patient is seen 3 years postoperatively.
1195
Chapter 39  Alloplastic Facial Contouring

This 54-year-old woman had acne that had caused midfacial subcutaneous atrophy,
and incorrectly shaped malar implants had been placed by another surgeon 12 years
earlier (left). She is seen (right) 1 year after soft tissue volumization in the submalar
midface to soften contours, and the malar implants were replaced to improve her
cheek shape.
When HA fillers are used, the surgeon is able to reverse, alter, or modify unsatisfac-
tory contours with hyaluronidase, adding another beneficial dimension to the use of
semipermanent fillers. When permanent alloplastic implant facial foundations have
already been built by the alloplastic surgeon, these fillers are used to augment and
refine contours with greater precision.
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Part VII  Midfacial Rejuvenation

Advantages and Disadvantages
The advantages of alloplastic augmentation of the facial skeleton are many:
 Such procedures provide volume, mass, and shape to the various natural
promontories of the face. The most important of these are the malar-midface
and jawline-premandibular regions. The nose is a third major promontory.
Great aesthetic advantage derives from augmenting or diminishing its volume.
However, alloplastic augmentation of the nose is still very controversial.
 Alloplastic materials do not require harvesting operations on other areas of
the body.
 The operations tend to be relatively rapid.
 Placement under the periosteum and directly on bone produces rapid immo-
bilization by surrounding fibrotic capsule formation.
 Depending on the material used, the biologic compatibility of the host to resist
rejection and infection is very high.
I favor silicone rubber, because any surrounding infections can be resolved in nearly
all cases without the need to remove the implant. Administering antibiotics and plac-
ing drains will abolish infection around such implants as long as they are nonporous.
If infection occurs, porous materials such as Gore-Tex, hydroxyapatite, and Medpor
(Porex Surgical Group, Atlanta, GA) may have to be removed, because infectious
processes can lodge within the interstices of these nonsmooth materials and chal-
lenge the body’s defenses.
Another major advantage of alloplastic facial augmentation, especially when using
a smooth, flexible material such as silicone rubber, is that it is easily removable, re-
versible, and changeable. Silicone rubber implants are very flexible and can be in-
troduced and removed through small incisions.
Although it is true that removal of large implants from the central chin region may
produce soft tissue ptosis of the central chin mound, this problem is much less likely
to happen when introduction of the implant does not transect the mentalis muscle
in a horizontal fashion and the dissection is performed vertically through the mid-
line pillars of the muscle. In a rare case, a patient may request removal of a mandibu-
lar angle implant or malar-midface implant. In my series, no cosmetic or functional
problem has ever resulted from removal.
The major disadvantages of the use of alloplastic materials are several:
 Severe infection is possible, especially with porous materials, which become
infiltrated with fibrotic ingrowth that complicates ready removal.
 Contour abnormalities of an unattractive or even disfiguring nature can occur
when implants do not have the proper shape, size, and positioning.
 Damage to facial nerves and musculature is possible from excessive and inap-
propriate trauma during dissections to introduce or remove the implant.
1197
Chapter 39  Alloplastic Facial Contouring

1198
Part VII  Midfacial Rejuvenation
Indications and Contraindications
Good indications for alloplastic facial augmentation are determined by relative or
absolute deficiencies of contour volumes in various anatomic regions resulting from
heredity, aging, or trauma from accidents, surgeries, or ablation. Contraindications
exist when the overlying soft tissue coverage is severely deficient (as in severe HIV
subcutaneous atrophy) or in volume deficiencies in areas of the face that do not have
a stable skeletal base, such as the orbital and oral apertures.
I think that any area of the facial skeleton can be successfully contoured with allo-
plastic implants if they have an anatomically correct design and are placed appro-
priately.
1
2
4
3
3
Infraorbital
nerve foramen
1
2
4
Optimal implant designs must include a posterior surface that contours to the facial
skeleton to provide secure contact and fibrotic immobilization. The margins of the
implants must be finely tapered to eliminate palpability. There should be no fenes-
trations in the implant to allow penetration or fixation with fibrotic scar tissue dur-
ing the healing process; this makes implants difficult and dangerous to remove. In
the vast majority of cases, skeletal fixation using hardware is not necessary and may
make removal complicated and risky for a novice surgeon. When desired or indi-
cated in a specific patient situation, customized implants can be manufactured rap-
idly by extracting data from CT scans and skeletal radiographs (Accuscan, Implantech
Corporation, Ventura, CA).

1199
Chapter 39  Alloplastic Facial Contouring
Basic Concepts of Facial Aesthetic Contouring
Indications for alloplastic facial contouring arise from considerations of facial aes-
thetics. An artist is one who perceives natural beauty and develops techniques to imi -
tate it. Artistic perception varies from artist to artist, patient to patient, and surgeon to
surgeon. However, there are common denominators in facial form and structure that
are perceived by the majority and dictate what is ultimately highly desirable today.
Even the casual observer easily notices the progressive, shrinking, atrophic quality
of soft tissue substance in the faces of both men and women. This quality has often
been described as the older, tired look of aging rather than the beauty of youthful
maturity. This deterioration of the more ample and youthful quality of a face may
be observed as early as a person’s mid to late twenties and may rapidly proceed into
the thirties and early forties.
It is also commonly acknowledged that in individuals with an excellent underlying
skeletal foundation, as aging progresses the soft tissues shrink, and the bony promi-
nences show more definition in the face. For some individuals, this definition actu-
ally enhances their beauty, whereas in others it unattractively emphasizes the atro-
phy of the overlying soft tissue. This frequently produces a negative effect that
emphasizes the loss of youthful beauty.
Facial beauty relates fundamentally to a harmony and balance of various parts of
facial anatomy. Therefore soft tissue substance as well as skeletal structure consti-
tute the common denominators that determine the three-dimensional aesthetic form
and shape of faces culturally recognized as attractive or beautiful.

This 58-year-old patient’s face lacked balance. To correct this problem, she under-
went an upper midface suspension (suborbital mimetic muscle elevation, or SOMME
lift), malar augmentation in zone 1 and submalar zone 5 (SM5) with medium 3 mm
malar shells. She also had palpebral shape contouring with a lateral canthal sling
and revision rhinoplasty. Her lips were augmented with AlloDerm and her chin was
augmented with a Terino extended anatomic large implant (Implantech). She is shown
12 months postoperatively.
1200
Part VII  Midfacial Rejuvenation

The major elements of facial volume and mass are four promontories: the chin and
jawline, the nose, the malar-zygomatic cheek prominence, and the forehead and
supraorbital volumes. Secondary considerations are the temple contours, the pre-
maxilla, and the suborbital region. These areas contribute more subtly but are im-
portant nuances to overall aesthetic facial balance. Tertiary contour considerations in-
volve small increases or decreases in soft tissue volumes of the face. These exist:
 Along the jawline as jowls
 Within the perioral nasolabial region as creases and folds
 In the suborbital tear trough valley as hollowness
 Around the central perinasal premaxilla as a retrusion or protrusion
Contours in these areas also have major relevance to facial form and balance. It is
the interplay between the topographic soft tissue collections and the underlying skele-
tal promontories that architecturally determine the contours that are perceived as
facial harmony, balance, and beauty.
1201
Chapter 39  Alloplastic Facial Contouring
Brow
Malar-midface (cheek)
Nose
Mandible (chin and jawline)

There are three major architectural aesthetic facial segments: upper, midface, and
lower. The fundamental principle of facial balance is that a diminution or enhance-
ment of volume (size) in one facial segment directly and inversely affects the aesthetic
impact on the others. This principle applies equally to all of the primary, secondary,
and tertiary volume/mass contour subunits.
Although large volume/mass changes are the most significant in matters of facial bal-
ance, even minor alterations of the subunits are equally important to observe and
understand. Augmenting the nasolabial sulcus, the suborbital regions, the glabella,
and other more minor subcutaneous contours has a major visual impact on facial
aesthetic balance and attractiveness.
Significant aesthetic improvement is possible only when all three facial segments are
evaluated precisely and comprehensively for possible simultaneous alteration. Allo-
plastic augmentation permits the surgeon to adjust both the major and minor
promontories with equal ease and predictability, subtly or dramatically. Modifying fa-
cial contours involves three-dimensional change, whereas traditional face-lifting pro-
cedures are severely limited because of their more two-dimensional nature.
Recent suspension techniques of the upper facial segment (brow and forehead) as
well as the malar-midface segment significantly complement the three-dimensional
changes that provide alloplastic regional volume enhancement when performed alone.
Nonetheless, only with alloplastic techniques can permanent, precise, and aestheti-
cally pleasing changes in facial contour be produced.
1202
Part VII  Midfacial Rejuvenation
Upper
two thirds
Lower
third
NEW
CONCEPT
OLD
CONCEPT
Lower
third
Middle
third
Upper
third
AESTHETIC UNITS

Twenty years earlier, this 46-year-old woman underwent orthognathic surgery for
prognathism. Fifteen years ago, she underwent malar augmentation in zone 1 and
SM5 with large malar shells; she also had rhinoplasty. She is shown 1 year after un-
dergoing upper midface suspension, a lateral canthal sling, palpebral contouring, lip
augmentation with AlloDerm, and chin augmentation with extended anatomic
medium and mandibular angle implants, 8 mm on the left and 10 mm on the right.
Patients with round, full, fleshy facial contours, an abundance of subcutaneous fat,
and substantial muscle bulk are limited in their options when they desire a lean face
that is well defined in the malar and chin-jawline regions. However, with alloplastic
augmentation, full-faced patients can enjoy modest but often significant improve-
ments to help them achieve their goal of a more sculpted face.
1203
Chapter 39  Alloplastic Facial Contouring

This 44-year-old man underwent revision rhinoplasty with conchal cartilage dorsal
augmentation, as well as malar augmentation with extra-large malar shells and a
large square I chin implant (8 mm projection). He is shown 2 years postoperatively
with more definition to his chin-jawline and malar regions.
At equal disadvantage are extremely lean-faced individuals with a vertically long and
horizontally narrow skeletal architecture and who may have extreme volume-shape
weakness of the malar-maxillary or chin-mandible skeleton. These patients frequently
have extremely prominent nasal contours. Although miracles cannot be accomplished,
modest and often significant improvements can be achieved by rearranging adjacent
proportions within their facial aesthetic segments by employing alloplastic onlay
techniques in the midface or mandibular regions, with or without rhinoplasty.
1204
Part VII  Midfacial Rejuvenation

Pertinent Anatomy
Understanding the fundamentals of aesthetic facial form and balance is critical for
applying technical alterations to the facial skeleton successfully and predictably, with-
out complications. Thus it is essential that surgeons adopt a specific method for an-
alyzing faces that defines anatomic zones as well as any aesthetic segmental defi-
ciencies of volume and mass. Relating this data about a patient’s anatomy to specific
goals in facial form permits surgeons to execute alloplastic contouring with excel-
lence and precision.
Conceptualizing the anatomy of facial form into aesthetic units and anatomic zones
enables surgeons to determine which areas of the premandibular, malar, and mid-
face region will respond well to augmentation and produce contour changes that
have visual impact, as well as emotional impact for the patient. These anatomic zones
are few, but when augmented properly, each produces a different appearance.
Although the three major aesthetic segmental units of the face—upper, middle, and
lower—have been described as equal thirds, the lower third jawline aesthetic unit is
often smaller, both horizontally and vertically. This deficiency of the entire lower
third of the face can make the nose appear too strong and overbearing. True aesthetic
deficiencies in the malar-midface region often go undetected when there is a weak
lower jawline segment.
1205
Chapter 39  Alloplastic Facial Contouring
This 37-year-old man with a weak lower jawline underwent rhinoplasty, chin aug-
mentation with a square I extended extra-large anatomic implant (9 mm projection),
submental-submandibular liposuction, and platysma plication to correct the defi-
ciency and improve his profile. He is shown 13 months postoperatively.

1206
Part VII  Midfacial Rejuvenation
This 65-year-old woman underwent a standard rhytidectomy, SMAS plication,
platysma plication, and insertion of an extended anatomic implant with a 6 mm pro-
jection. Seen 9 months postoperatively, she has a more balanced face.
When the lower facial segment is equal to the other two aesthetic units of the face,
a malar-midface deficiency is more obvious, and many noses do not seem prominent
but instead appear to be in balance with the rest of the face.
Examples of aesthetic balancing: increasing a weak lower jawline segment reduces
the prominent appearance of the nose. This 39-year-old man had a malar-midface
deficiency. He did not wish to have nasal contouring surgery. He underwent chin
augmentation with insertion of a large square I implant (6 mm projection) to cor-
rect his deficit. He is shown 11 months postoperatively.

Anatomic Zonal Analysis of the Malar-Midface Region
1207
Chapter 39  Alloplastic Facial Contouring
The midface aesthetic segment comprises the entire zygomatic-maxillary complex.
The malar space is therefore the region on the facial skeleton that when augmented
appropriately produces a beneficial aesthetic change in the contour of the midface-
cheek segment.
The malar space can be seen as containing five distinct anatomic zones. Zone 1 is
the largest subspace and includes the major portion of the malar bone. It extends
from the infraorbital foramen to include the first third of the zygomatic arch and
continues inferiorly to the lower border of the malar bone. A volume expansion of
4 to 5 mm in this zone increases the contour only in the upper portion of the cheek;
this effect is often not suited to creating the desired softness of feminine facial form.
An implant in zone 1 may appear too strong and skeletal. A 3 mm volume expan-
sion is considerably more subtle, especially when combined with midface suspen-
sion techniques. However, augmentation of zone 1 by 4 to 5 mm is frequently use-
ful in men to create a strong, masculine, sculptured appearance.
CM
Central mentum
ML
Midlateral
PL
Posterolateral
PM
Premaxilla
SM
Submandibular
SM5
Submalar zone 5
CM
SM
PM
SM5
PL
ML
1
1
Malar
zones
Premaxilla
zone
Mandibular
zones
2
2
3
3
4
4

1208
Part VII  Midfacial Rejuvenation
This 33-year-old woman presented with previously placed malar augmentation that
she felt was too prominent. To correct this problem, she had secondary malar aug-
mentation with large malar shells in a submalar SMS location. She is shown 10
months postoperatively.
Zone 2 has less aesthetic significance. It comprises the middle third of the zygomatic
arch. Volume enhancement in this zone, especially in combination with zone 1, accents
the cheekbone laterally, creating a broader dimension to the upper third of the face.
It is therefore useful in improving the appearance of patients with a narrow upper
face or a long-face syndrome. This 36-year-old woman demonstrates how a malar
implant extending into zone 2 of the zygomatic arch will broaden the upper midface.

1209
Chapter 39  Alloplastic Facial Contouring
Zone 3, the paranasal region, is medial to the infraorbital foramen and nerve. A de-
ficiency in this suborbital region can create a hollow “valley” appearance called a
jugal-malar sulcus or tear trough. Alloplastic implants have been specifically designed
for this anatomic zone. Releasing the origins of the orbicularis oculi muscle from the
medial orbit is necessary to specifically improve this suborbital hollow appearance.
Because of the thin nature of the skin and subcutaneous tissues over zone 3, any al-
loplastic implant or transplanted tissue must be perfectly shaped and tapered to en-
sure invisibility.
This 37-year-old man presented with maxillary suborbital deficiency and brow pto-
sis. He underwent an upper midface suspension (SOMME lift), a lateral canthal sling,
and palpebral shape contouring. He also had large extended malar mandibular im-
plants (12 mm) inserted bilaterally and a medium square I chin implant (6 mm pro-
jection) placed. He is shown 1 year postoperatively.
The infraorbital nerve is more sensitive to trauma than the mental nerve is; dissec-
tion around it must be gentle to prevent prolonged, disabling symptoms. Extended
malar suborbital implants that comprehensively augment zones 1, 2, and 3 are use-
ful for treating people with a hereditary infraorbital maxillary bone deficiency called
negative-vector polar bear syndrome.
Zone 4 overlies the posterior third of the zygomatic arch. Volume enhancement in
this area is never necessary and would produce an unnatural appearance. Inappro-
priate dissection in this zone as well as in zone 2 could injure either the capsule of
the temporomandibular joint or the zygomaticotemporal branches of the facial nerve.
Such injuries can produce edema, pain, temporary dysfunction of the temporo-
mandibular joint, and/or weakness of eyebrow elevation. These conditions are rare
and usually temporary.

1210
Part VII  Midfacial Rejuvenation
Zone 5 consists of the submalar zonal triangle. This region of the midface is the most
significant for augmentation, requiring the most frequent use of midface implants in
both older and younger patients. Augmentation in this area extends midfacial full-
ness down from the malar bone itself, creating a rounder, fuller, “apple cheek” con-
tour. Submalar zone 5 (SM5) is defined anatomically as follows. The masseter mus-
cle and its overlying tendinous fascia are posterior; more medially, the border of the
masseter muscle is adjacent to the canine fossa of the maxilla. These structures serve
as the floor on which implants are placed. Its anterior soft tissue roof consists of the
overlying zygomaticus muscle groups, their origins and innervations, and the sub-
muscular aponeurotic system (SMAS). The medial limit of the submalar triangle is
adjacent to the nasolabial mound.
Effective alterations in this zone may often need to be extended up and into zone 1
to create the illusion of a larger malar bone and to imitate soft tissue volume. Some-
times an implant is indicated to augment only the submalar space. The superior
boundary of submalar zone 5 is also the lower border of zone 1 and constitutes the
inferior bony margin of the malar eminence.
The inferior limit of SM5 is a sulcus created below the malar zone that can be ex-
tended downward through a natural dissection plane that exists between the mas-
seter muscle and the overlying zygomatic muscle complex. As the submalar midface
dissection and augmentation are extended lower, the fullness of the midface contour
created by an implant in this location is also extended downward. However, no im-
plant can extend below the mucosa of the gingival buccal sulcus adjacent to the lat-
eral commissure of the mouth.
Correction: malar implant in submalar zone
and possibly in lower zone 1
Zone SM5
and lower
zone 1
SM5
1
Type II aesthetic deficiency:
submalar zone 5

This 28-year-old woman presented with facial type II submalar aesthetic volume de-
ficiency. She had submalar augmentation with insertion of 4 mm large malar shells.
She is shown 2 years postoperatively with a softened, more youthful cheek.
1211
Chapter 39  Alloplastic Facial Contouring
This 49-year-old patient had a similar aesthetic submalar deficiency. To correct her
deficit she underwent rhytidectomy, nasal contouring, and had 4 mm extra-large
malar shells placed in SM5. She is shown 6 months postoperatively with a rounder,
fuller cheek contour.

1212
Part VII  Midfacial Rejuvenation
Soft tissue volume deficiencies in the submalar-midface region are very common.
These can be inherited, or, more frequently, are the result of the natural aging process.
Atrophy of submalar facial fat removes the soft, full contour of youth.
Correction: large malar shell implant placed into the
canine fossa and submalar triangle
Type III
deep
submalar
recession
Type III aesthetic deficiency:
prominent malar eminences plus deep submalar
recession in submalar zone 5

Preoperatively this 61-year-old man displayed prominent malar eminences with deep
submalar recessions, a type III submalar volume deficiency; 4 mm extra-large malar
shells were inserted to augment SM5. He is shown 6 months postoperatively.
In many people, midface atrophy creates a tired, drawn, haggard appearance early
in the third and fourth decades of life. Restoration of soft tissue fullness in the sub-
malar region is the most significant function of midface alloplastic augmentation to
restore youthful contour.
1213
Chapter 39  Alloplastic Facial Contouring

1214
Part VII  Midfacial Rejuvenation
This 47-year-old woman complained of submalar atrophy and facial laxity; she un-
derwent a rhytidectomy and upper and lower blepharoplasties. Her chin was aug-
mented with a large 4 mm malar shell. She is shown 10 months postoperatively with
more youthful contours.
The second most frequent need for midface contouring is comprehensive augmen-
tation of the malar-midface region, which involves both zone 1 and SM5. A large
shell that augments both zonal regions mimics both midfacial soft tissue volume in
the lower aspect and bony augmentation in the more superior zone 1 area. The de-
sign concept of a large midface shell is to augment a generous midface area with an
implant that is thinly tapered at the margins to produce volume changes without be-
ing visible or palpable and without the unnatural appearance of a localized protu-
berance that can be produced by smaller, traditional oval implants.

This 54-year-old woman had a relative midface volume deficiency resulting from the
natural aging process. An upper midface suspension (SOMME lift) with palpebral
aperture shaping, lateral temple brow contouring, submandibular liposuction, and
platysma plication were performed. She also had submalar augmentation with large
4 mm malar shells and an AlloDerm lip augmentation. The result, seen 10 months
postoperatively, shows natural contours and a more youthful appearance.
1215
Chapter 39  Alloplastic Facial Contouring

Zonal Anatomy of the Premandibular Jawline
Aesthetic Facial Segment
Assessment of the lower third facial aesthetic segment is also necessary to compre-
hensively evaluate facial aesthetic balance that improves appearance. The pre-
mandibular space, when variously augmented, produces attractive changes to the
shape and volume characteristics of the lower third of the face and jawline.
1216
Part VII  Midfacial Rejuvenation
CM
Central mentum
ML
Midlateral
PL
Posterolateral
PM
Premaxilla
SM
Submandibular
PL
ML
CM
SM
PM
PL
ML
CM
SM
PM
Within the premandibular space, four anatomic zones can be defined. These zones
enable the surgeon to assess the relative volume correction needed for deficiencies in
the premandibular region. Correction of such deficiencies by alloplastic implants can
create specific contours for the lower face, depending on patients’ individual needs
and preferences.

The central mentum is the area between the mental foramina where traditional chin
implants have been placed for more than 45 years. As seen in these four patients, im-
plants placed under this central segment alone without lateral extension will pro-
duce an unattractive contour with an abnormal rounded central protuberance that ac-
centuates the appearance of a prejowl sulcus or a valley in the area of the anterior
mandibular ligament just below the mental foramen.
1217
Chapter 39  Alloplastic Facial Contouring
The floor of the central mentum zone is the surface of the central mandible, which
includes the midline mental tubercle. Recent anatomic implants are contoured poste -
riorly to securely fit this bony contour like a glove. They provide an entirely natural-
looking augmented jawline.
Contemporary anatomic implant
Traditional central implant

The midlateral zone of the mandible extends from the mental foramen posterior to the
oblique line of the horizontal ramus. The anterior limit of this zone is at the mental
nerve and foramen; the posterior limit is the oblique ridge of the mandible. Its su-
perior boundary is the upper border of the horizontal mandible. The lower extent is
the inferior border of the mandible. The mandibular branch of the facial nerve exits
through the mental foramen 8 to 10 mm above the inferior border of the mandible.
The roof of overlying soft tissues in the mid-jawline contains the platysma, SMAS,
anterior facial vein and artery, and the marginal branch of the facial nerve as it crosses
the mandible to enter the depressor muscles of the lower lip. Implants can augment
the midlateral zone, widening the appearance of the lower jawline segment while in-
creasing the anterior-posterior dimension of the central mentum.
1218
Part VII  Midfacial Rejuvenation
I have designed a variety of implants that have differing shapes and volumes to al-
ter the central projection and vertical length of the mandible as well as the midlat-
eral region (midlateral zone) of the horizontal ramus.
Men are requesting jawline changes with increasing frequency. Their main area of
concern is the posterolateral zone of the mandible, which includes the posterior third
of the horizontal ramus extending back from the oblique line and includes the go-
nion of the mandible and the lower 4 cm of the ascending ramus. Its boundaries are
as follows: the floor is the mandible itself; the roof is the overlying masseter muscle;
the superior border is limited by the sigmoid notch of the mandible; and the poste-
rior and inferior borders are limited by strong, fibrofascial insertions of the masseter
muscle. These must be completely released to expand the space around the bony bor-
ders of the mandible. This release is necessary to allow the curved borders of the an-
gle implants to extend around the inferior and ascending posterior mandible mar-
gins to secure these implants into position.

1219
Chapter 39  Alloplastic Facial Contouring
A mandibular angle augmentation is shown on the left, with a 3 cm intraoral inci-
sion. The illustration on the right shows degloving of the ascending ramus and in-
ferior border of mandible.
The surgeon must avoid a traumatic dissection when releasing the masseter muscle
from the bone so that neither the mandibular branch of the facial nerve (VII) nor
the fragile posterior jugular veins or anterior facial vein and artery are harmed. When
damaged, these vessels can bleed profusely.
The angle can be augmented to produce a strong posterior jawline contour with ex-
cellent angle definition. Implants are available that either widen this posterolateral
segment in a lateral direction or extend it downward in an inferior direction. Ex-
tending it down creates a less obtuse, more acute posterior mandibular angle that
gives the lower mandibular border more horizontal definition.

Exhibiting posterolateral zone deficiency of the premandibular region, this 38-year-
old man requested mandibular augmentation. A 12 mm implant was inserted on the
right side and a 10 mm implant on the left to correct his facial asymmetry. He is
shown 1 year postoperatively with a strong posterior jawline and excellent angle
definition.
1220
Part VII  Midfacial Rejuvenation