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

Implants in the submalar zone improve or correct a witch’s-chin deformity and the
anterior mandibular prejowl sulcus, as is seen in this 62-year-old woman. She had
facial laxity resulting from aging, suborbital hollowing, and prejowl sulcus and platys-
mal laxity. To correct these problems, she underwent an upper midface suspension
with fat transposition and palpebral aperture shaping. In addition, medium malar
shell implants were inserted in lower zone 1, and extended anatomic implants with
4 mm projection were inserted in the upper SM5. A rhytidectomy with SMAS pli-
cation and platysma plication were performed during the same operation. She is
shown 7 months postoperatively.
Augmentation of the submalar zone involves complete disinsertion of muscle origins
along the lower mandibular border. At present submandibular implants afford only
4 mm of projection. There are times when additional projection necessitates place-
ment of a second implant on the anterior surface of the central mentum.
Just as volume augmentation changes are specific for each zonal area of the malar-
midface middle third facial segment, contour changes can be differentially produced
in the lower third of the premandibular jawline.
1222
Part VII  Midfacial Rejuvenation

Nasal size alterations are also frequently requested. These procedures also contribute
greatly to overall aesthetic facial balance.
The correct choice of implant size and shape as well as positioning it properly are
the key steps to achieving specific, predictable results.
1223
Chapter 39  Alloplastic Facial Contouring
This 27-year-old man presented with nasal deformity, lower third facial aesthetic seg-
ment deficiency, submental and submandibular lipodystrophy, and a defuse neck. He
is shown 1 year after cosmetic rhinoplasty, submental-submandibular liposuction,
and platysma sculpture. Submandibular augmentation with a medium vertical ex-
tension implant was also performed.

1224
Part VII  Midfacial Rejuvenation
This 22-year-old patient demonstrates dramatic improvement in facial balance from
malar, chin, and mandibular angle implant augmentation combined with rhinoplasty.
He is shown 2 years postoperatively.
Anatomic Danger Zones
Midface
Midface problems and complications arise from too vigorous a dissection over the
middle third of the zygomatic arch when the surgeon places a malar implant into
zone 2 to create a broader face. The overlying facial nerve branch to the frontalis
muscle may be damaged temporarily or permanently. Branches of the zygomaticus
muscle groups, as well as those that extend up into the inferior lateral orbicularis
muscle can be traumatized during dissection into malar zone 1 and SM5. This may
result in transient or permanent lagophthalmos and an impaired ability to elevate
the nasolabial area during smiling and facial animation.
Dissection in the zone 3 medial suborbital maxilla area exposes the infraorbital nerve
to damage when alloplastic tear trough implants are introduced or during midface
suspension techniques.
When a subperiosteal malar space is created over the lateral aspect of the orbital rim,
but the dissection space is not opened inferior enough on the maxilla to permit a
malar shell to be placed approximately 4 mm below the orbital rim, the implant can
ride high enough to overlap the lateral rim, encroach on the orbit, and produce ver-
tical descent of the lower eyelid or ectropion. This is particularly common when im-
plants are introduced through the subcilial lower eyelid approach.

Premandible
1225
Chapter 39  Alloplastic Facial Contouring
During premandibular dissections, trauma to the mental nerve is common, but symp-
toms are usually transient. Dissecting gently along the inferior border of the mandible
and sweeping upward lightly to observe and protect the mental nerve helps to avoid
these symptoms.
The surgeon is able to visualize the mental nerve using a retractor and insert an im-
plant submentally.
Dissecting and degloving the muscles along the inferior mandibular border are an
absolute necessity for midlateral zone augmentation. However, during this dissec-
tion the marginal mandibular branch of the facial nerve can be injured, producing
lower lateral lip dysfunction.
Unless great care is exercised during dissection in the posterolateral mandibular zone
by degloving the entire posterior region of the inferior border and ascending ramus
of the mandible, the jugular vessels posterior to the ascending ramus can be injured.
This could create profuse, dangerous bleeding.
A forceful upward dissection into the sigmoid notch and coronoid process of the
mandible can produce troublesome temporomandibular joint symptoms. These are
usually transitory—less than a week in duration. Trismus is an uncommon sequela
of posterior angle augmentation. In my experience, this has always been extremely
short lived.

Regional Midfacial Volume Deficiencies
To determine which elements are necessary to achieve facial balance in a specific pa-
tient, the surgeon must recognize malar-midface zonal deficiencies. Although there
are infinite variations in facial size, shape, and contour, there are several common
midfacial types that can easily be identified for determining specific implant sizes
and positioning. Several of these will be described.
1226
Part VII  Midfacial Rejuvenation
Selection of Implants
Facial
Anatomic
Type
Augmentation Zone
Size (depends on skull size)
I
1 and 2
3 or 4 mm (occasionally 5 or 6 mm)
II
Submalar 5
4 or 5 mm (possibly a combined shell)
III
Submalar 5
5 or 6 mm (large or extra-large)
IV
1, 2, submalar 5
5 or 6 mm malar shell (large or extra-large)
V
3
Tear trough implant (small, medium, or large)
VI
Premaxilla
Various premaxilla implants
Brink implant*
*Manufactured by Implantech Corp., Ventura, CA.
Surgical Treatment Plan for Premandibular Augmentation of Regional
(Zonal) Volume/Mass Deficiencies
Zone
Implant* (depends on face size)
Central mentum
Anatomic or styles I and II
4-9 mm
Posterolateral
Mandibular angle implants
8-12 mm
Lateral projection
Midlateral
Lateral bars
4-6 mm
Widens lateral jawline
Submandibular
Vertical extension implant
4 mm
Inferior and anterior projection
*Manufactured by Implantech Corp., Ventura, CA.

Type I Deficiency
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Chapter 39  Alloplastic Facial Contouring
A facial type I deficiency consists of a relative contour weakness in the upper seg-
ment of the malar-midface region. It encompasses zones 1 and 2 over the malar bone
and the medial third of the zygomatic arch. This involves either a bony or soft tissue
deficiency, or both. Augmentation in these zones creates upper cheek fullness that
simulates both bony and soft tissue contour.
This 39-year-old woman had a type I regional volume deficiency. She is shown 1 year
after malar augmentation with 4 mm large malar shell implants in zones 1 and 2.
Correction: malar implant on zones 1 and 2
Zones
1 and 2
Type I aesthetic deficiency:
malar hypoplasia

1228
Part VII  Midfacial Rejuvenation
When a large implant is used to augment zone 2 as well as zone 1, the upper mid-
face becomes broader, shortening the appearance of a long, narrow face, as seen in
this patient. This 34-year-old woman desired more definition in malar zones 1 and
2 as well as in her mandibular angle. She also wanted aesthetic segment enhance-
ment of the lower third of the central mentum. She had 4 mm medium malar im-
plants inserted to augment zones 1 and 2. Her mandibular angle was augmented
with 8 mm per side, and 4 mm small extended anatomic implants were placed to
augment the central mentum. She is seen 1 year postoperatively.

Type II Deficiency
A type 2 regional aesthetic deficiency consists of a relative decreased volume in SM5.
An implant placed here produces volume filling that imitates bone and soft tissues.
Use of a large malar shell over the inferior aspect of the malar bone in zone 1 and
extending down into the submalar space creates the illusion of a round, full, apple
cheek. The fat atrophy that occurs with aging is corrected by placing implants in SM5.
1229
Chapter 39  Alloplastic Facial Contouring
This 55-year-old woman had facial laxity and submalar atrophy from aging. She un-
derwent a rhytidectomy, upper and lower blepharoplasties, and SM5 augmentation
with medium Terino 4 mm malar shells. She is seen 2 years postoperatively.
This 37-year-old woman had malar facial deficiency in zones 1 and 2. She underwent
malar augmentation with medium Terino 4 mm malar shells. She is seen 1 year post-
operatively.

This patient, 55 years old, had a type II midface volume deficiency and relative prog-
nathism. She had adequate malar bone prominence but was specifically deficient in
submalar soft tissue volume. This can create a tired, haggard look. The submalar
zone ends just lateral to the nasolabial smile mound. Volume filling of this space
deemphasizes the appearance of the nasolabial mound and corrects the sunken ap-
pearance in the midface to restore a fuller, more youthful appearance. Her proce-
dures included midfacial implants, upper and lower blepharoplasties, rhytidectomy,
rhinoplasty, and SM5 augmentation with medium Terino 4 mm malar shells. She is
seen 6 months postoperatively.
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Part VII  Midfacial Rejuvenation
Aging changes in this 62-year-old patient included brow ptosis, lateral face and neck
laxity, and type II malar deficiency. She underwent an upper midface suspension with
palpebral aperture shaping, malar augmentation of zones 1 and SM5 with a large
Terino 4 mm malar shell, lower face and neck rhytidectomy, SMAS and platysma
plication, and cosmetic rhinoplasty. She is seen 1 year postoperatively.

Type III Deficiency
A type III regional volume deficiency consists of a strong malar-zygomatic super-
structure accompanied by an extremely deficient submalar infrastructure. When this
condition is accompanied by thin skin and subcutaneum, the patient appears ema-
ciated and sick. Fortunately, unless a person has an actual physical debility, this facial
type is uncommon in the general population. Correction requires generous submalar
augmentation with a large surface area midface shell with a projection thickness of
5 to 7 mm.
1231
Chapter 39  Alloplastic Facial Contouring
This 67-year-old woman had an emaciated appearance, facial atrophy, and extreme
laxity of the facial skin. She desired only augmentation of the malar-midface region.
A malar-midface SM5 and zone 1 augmentation was done with an extra-large Terino
5 mm malar shell. She is seen 1 year postoperatively.
Extreme type III submalar atrophy and prominent malar bones were present in this
43-year-old woman. She underwent SM5 augmentation with large Terino 4 mm
malar shells. Her cheeks have a more youthful fullness 6 months after surgery.

Type IV Deficiency
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Part VII  Midfacial Rejuvenation
A type IV face consists of extreme volume deficiency throughout the anterior max-
illary region. This includes malar zones 1 and 2, the SM5 regions, and the entire or-
bital and paranasal zone 3 area. This deficiency seems to be more common in men
than in women. It is identified by a flat-face or dish-face appearance. It has been de-
scribed as the polar bear syndrome because of the deficiency recession of the infe-
rior orbital rim, which contributes to a proptotic bulging appearance of the ocular
globe. This is called a negative-vector bony deficiency of the inferior orbital rim. It
may be associated with a downward or vertical descent of the lower eyelid causing
sclera show.
Significant improvement in this type IV aesthetic imbalance can be achieved through
placement of a comprehensive shell implant that contributes volume in all of these
midface zones, including the infraorbital region. This implant also adds support to
the lower eyelid and elevates it to a more attractive horizontal position.
Correction: jumbo malar shell implant; combined shell implants
are necessary when paranasal zone 3 “tear trough”
suborbital volume deficiency is also significant
Zone SM5
and lower
zone 1
Type IV aesthetic deficiency:
combined volume deficiency (malar hypoplasia
plus submalar deficiency)

1233
Chapter 39  Alloplastic Facial Contouring
This 35-year-old man had a negative-vector suborbital hollowness deficiency, type
IV aesthetic regional volume deficiency, malar hyperplasia, and submalar maxillary
deficiency. An extra-large Terino 5 mm malar shell was placed in zone 1 and SM5.
He is seen 1 year postoperatively.
Lateral canthopexy techniques are often necessary to correct the descent of the lower
eyelid that is common with this facial type and to prevent its worsening after malar
surgery. This represents both an aesthetic and a functional correction.

A type V aesthetic regional deficiency involves a specific weakness of skeletal struc-
ture in the inferior orbital and medial tear trough region. This contributes to a tired,
hollow appearance around the eyes following the deflation and atrophy of the peri-
orbital tissues as the individual ages.
A uniquely designed tear trough implant is placed that extends from the medial can-
thus to the lateral orbital malar rim; this considerably improves the previously hollow
appearance. Autologous tissue transplants of fat, muscle, galea, and temporalis fas-
cia placed into this area have provided good results, but their success and the asso-
ciated complication rate are still controversial. Fat grafting along the inferior orbital
rim is considered by some to be advantageous. My own experience has been that au-
tologous soft tissue grafting results in unpredictable shrinkage and may produce ir-
regularities or yield negligible improvement.
Type V Deficiency
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Part VII  Midfacial Rejuvenation
Correction: tear trough implant; tissue transplants
or midface lift possibly indicated
Tear
trough
deformity
Type V aesthetic deficiency:
suborbital zone 3 and upper zone 1 deficiencies

1235
Chapter 39  Alloplastic Facial Contouring
This 42-year-old man presented with an extreme suborbital volume deficiency. This
deficiency was corrected with large tear-trough implants of 5 mm projection, placed
through a transconjunctival approach. He is seen 1 year postoperatively.
Over the past 5 years there has been strong interest in a subperiosteal elevation of
all soft tissue layers from the maxilla followed by a suspension of them in an upward
direction to provide greater volume filling in the inferior orbital rim area. This mid-
face suspension can be accompanied by inferior orbital fat rearrangement over the
inferior orbital rim. This is done after severing the origins of the orbicularis muscle
and disrupting the arcus marginalis and underlying SOOF tissues in the medial tear
trough area.

Subperiosteal midfacial suspension alone without the addition of alloplastic implants
is a technique that is still new enough to require the test of time to evaluate long-
term persistence of volume correction and three-dimensional improvement of the
suborbital hollow appearance and malar-submalar shape.
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Part VII  Midfacial Rejuvenation
SOMME MIDFACE SUSPENSION LIFT
The subperiosteal dissection in the SOMME midface suspension lift extends 3 to 4 cm
below the lower border of the malar bone and over the masseter tendon down to the
area of the buccal fat pad. This also extends to the buccal sulcus just superior to the
canine tooth. The entire soft tissue mass of the cheek, which includes the zygomati-
cus muscles, is secured to the deep temporal fascia via a subperiosteal tunnel made
along the lateral orbital rim. This elevation automatically includes the orbicularis,
which adds an additional layer of support over the infraorbital bony rim, obliterat-
ing the hollow lid-cheek junction.
A midfacial implant can be chosen to fit (1) on the malar bone, (2) on the submalar
zone over the masseter tendon, or (3) to be an extended tear trough implant in the
midface when placed during a midface suspension procedure.

Type VI Deficiency
1237
Chapter 39  Alloplastic Facial Contouring
A type VI midface deficiency occurs in the perinasal premaxillary region. Volume de-
ficiency or the appearance of retrusiveness in this aspect of the skeleton is common
in certain ethnic groups, especially in Asians and Indians in the Americas. It also ex-
ists as a congenital hereditary trait, which can be mild or severe and may require
complicated orthognathic surgery using maxillary LeForte bony advancement tech-
niques.
Alloplastic augmentation can improve mild to moderate premaxillary deficiency to
produce significant aesthetic changes. There are several designs and sizes of silicone
rubber implants that have been used successfully over the years to alter nasolabial
and premaxillary relationships. Although other materials such as AlloDerm, autol-
ogous fat, Gore-Tex, collagen, and other injectable materials are used in the na-
solabial and perialar sulcus, these have only resulted in temporary augmentations.
Alloplastic augmentation is permanent. Type VI peripiriform and premaxillary vol-
ume deficiencies are common. They are frequently overlooked by aesthetic surgeons.
They are usually of lesser magnitude than the greater volume/mass interrelationships
of the malar-midface area, jawline, and nose. Therefore they do not warrant as much
attention during an initial aesthetic facial contour consultation unless the patient is
focused on such a deficiency.
Correction: premaxillary implant
Type VI
perinasal
premaxillary
recession
Type VI aesthetic deficiency:
recession in perinasal premaxillary region

1238
Part VII  Midfacial Rejuvenation
Left: A local anesthetic is injected over the intended bed of the implant and at the
preferred incision site, which is at the junction of the columella and floor of the right
nostril. Center: The orbicularis oris muscle is split and the dissection plane estab-
lished directly on bone. Right: The pocket is easily developed with a periosteal ele-
vator. The edges of the piriform aperture are visualized, and the nasal vestibule is
avoided.
Left: External palpation can facilitate dissection in the upper reaches of the pocket.
Right: With an Aufricht retractor and curbed hooks, the implant is inserted with a
rotary motion first to the side opposite the incision.

Left: The implant can be gently overinserted on the first side to facilitate introduc-
ing its trailing edge into the incision. Center: The Aufricht retractor and hooks are
repositioned to assist insertion through the incision. The implant is advanced back
to midline. Right: The symmetrical position of the implant can be confirmed by di-
rect visualization of its central notch at the nasal spine and by external and intra -
oral palpation.
1239
Chapter 39  Alloplastic Facial Contouring
This 38-year-old Asian woman had a type VI regional facial deficiency with a retru-
sive maxilla RY volume deficiency. Correction was accomplished by the addition of a
Brink small premaxillary peripiriform implant. She is seen 6 months postoperatively.

This patient, 33 years old, had a type VI severe retrusive peripiriform volume defi-
ciency. A Brink peripiriform medium premaxillary implant was placed. One year
postoperatively, the patient shows significant improvement.
Preoperative Assessment
Physical Examination
I use computer imaging as an integral part of the physical examination/consultation
to provide more objective analysis of the patient’s anatomic contours. The patient
holds a mirror during the examination. One of the most important objectives of the
consultation is to precisely identify the various asymmetries of bone and soft tissues
in the patient’s face; it is imperative that the patient understand the significant limi-
tations in correcting these asymmetries.
A fundamental and critical element in a consultation is to accurately define a pa-
tient’s desires and goals by asking the patient to precisely describe changes he or she
hopes to achieve and in which anatomic regions. The surgeon must then be able to
relate the patient’s remarks to the anatomic zonal analysis data previously described.
I require patients to bring two sets of standard medical facial photos and, just as im-
portant, examples from magazines of contour ideals they want to emulate. It cannot
be overemphasized that the selection and placement of implants is determined by di-
rectly comparing the anatomic zonal contours from their choice of images to the pa-
tient’s own face. It is important to discuss with the patient in precise terms whether
or not it is possible to achieve his or her goals, and to what degree.
1240
Part VII  Midfacial Rejuvenation

Patient Education
The Consultation Process
In my practice, patient education begins with the requirement that patients who de-
sire facial contour alterations must describe verbally, as well as in writing, the spe-
cific details of their desired contour changes. This must include their perception of
their contour deficiencies. This written statement must be accompanied by standard
professional photographs of the patient in five views: one frontal, left and right pro-
file, and left and right oblique views. These facilitate analysis of their perceived con-
tour deficiencies and are used along with photographs they choose from magazines
and other sources to demonstrate the ideal they would like surgery to create. Photos
of the patient at an earlier age are also requested.
1241
Chapter 39  Alloplastic Facial Contouring
This patient provided photos of herself at age 41 (left) and at age 50 (right). She was
seen for consultation at age 59 with relative midfacial atrophy from aging. She de-
sired a return of youthful fullness as well as contouring of her lower face, neck, and
jowls.

1242
Part VII  Midfacial Rejuvenation
An upper midface suspension was performed, with lateral temple–brow contouring.
Submalar midface augmentation was also done in lower zone 1 and SM5 using a
large Terino 4 mm malar shell. A lower face and neck rhytidectomy with SMAS and
platysma plication was also performed. She is seen 1 year postoperatively.
The patient benefits from the use of educational tools before a face-to-face consul-
tation with the surgeon. The Confirm Program CD on facial implants, which I pre-
pared for the American Society of Plastic Surgery, serves as an excellent instructional
tool to explain concepts of facial balance as they relate to the basic interrelationship
of the three major promontories: the malar-midface, the nose and the chin-jawline.
I also use other videos and photos in which I draw the malar zygomatic and pre-
mandibular zones of the facial skeleton on the patient’s face and demonstrate how
specific positioning of various sizes and shapes of implant alters the third dimension
of the midface in different ways.

Computer Imaging as a Teaching Tool
Computer imaging is an invaluable tool to assist the surgeon in explaining the pos-
sible outcomes of augmentation. It must be emphasized to the patient that while it
is useful to view a simulated potential result, there is no guarantee that the result will
be identical to the simulation.
1243
Chapter 39  Alloplastic Facial Contouring
In this series, the patient is shown preoperatively on the left, and a computer simu-
lation of possible alterations is shown on the right. The lateral views demonstrate
volume augmentation of the chin and diminished volume of the nose. The oblique
views show the effect of augmentation of the cheeks, chin, and angle of the mandible
without rhinoplasty. The frontal views demonstrate the effect of using rhinoplasty
in addition to malar and chin augmentation, and angle of mandible augmentation.

1244
Part VII  Midfacial Rejuvenation
Not only can changes be shown that simulate desired volume and shape alterations,
but these can later be compared using side-by-side preoperative, computer-generated,
and postoperative images. When this tool is used cautiously and conservatively, the
surgeon can demonstrate that the final results of surgery (in the case of these two
patients, 1 year postoperatively) are photographically superior to the image simula-
tions made during the consultation.
Markings
Final planning is done on the morning of surgery before the patient is taken to the
operating room or given any form of preoperative medication. The surgeon sits with
the patient before the image computer and with the selected magazine photographs
brought by the patient. Markings are made on the patient’s face to outline the bor-
ders of the bony architecture and to designate the facial zones of the midface and
premandibular regions. Similar markings can be made on the magazine photographs.
The patient is then asked to identify which specific zones he or she wants altered by
looking at the marked magazine photos and their own facial markings in a mirror.
Preoperative
Computer simulation
Postoperative result

1245
Chapter 39  Alloplastic Facial Contouring
These are typical markings made before augmentation surgery. The red markings in-
dicate the supraorbital, infraorbital, and mental nerves in the malar, submalar, and
chin region. The outline of the chosen implants is circumscribed as well.
Then the implant size, surface area, and projection are discussed with the patient by
placing implant sizers on the patient’s cheek over the skin markings of the anatomic
zone or zones the patient has selected. In this way the patient assists in the decision
about the zones and implant sizes most suitable for an ideal result. The implications
of various sizes and thicknesses of implants and how they could be used to achieve
a subtle, conservative result or a more dramatic appearance are discussed.
For this patient, malar-midface augmentation was planned. Outlining of the malar
zygomatic bone and infraorbital nerve is shown, as well as measurement of the sub-
malar zygomatic space. Measurements are used to help select the proper size implant
to fit the patient’s anatomy. The red marks demonstrate the planned augmentation,
which in this patient will extend below the malar bone and into the top of the sub-
malar zone to create fullness in that area.

A similar patient-doctor communication session with the computer and magazine
images is used when augmenting the lower third of the face, chin, and jawline.
PREOPERATIVE PLANNING
Implant Considerations
Choice of Implant
Detailed discussions with the patient always reveal the subtleties and nuances of the
specific contour results he or she anticipates. It remains for the surgeon to evaluate
whether the patient’s desires can be fulfilled by means of up-to-date implant aug-
mentation techniques.
The following guidelines are suggested:
1. Implant enhancement of the upper malar/zygomatic bony region (zone 1) pro-
duces a sharp, high, angular appearance.
2. Placing the implant or choosing one that extends laterally into zone 2 widens
the upper aspect of the midfacial segment.
3. Augmenting the submalar region to correct a hereditary defect or the ap-
pearance of aging (type 2 midface deficiency) produces a fuller midface in the
lower aspect of the cheek below the bone.
4. Deciding whether to augment the upper malar bone aspect of the middle third
aesthetic facial unit or the lower submalar soft tissue segment is the most im-
portant factor in creating a specific cheek-midface contour that meets the pa-
tient’s goals.
Implant Size
The size of an implant relates to surface area and thickness. Standard 4 mm com-
mercial shells of large or jumbo sizes are suitable to produce natural, pleasing aug-
mentations in more than 90% of patients. Occasionally, when the patient wants a
more subtle effect, 3 mm medium shells can be used. When a more dramatic effect
is desired, 5 or 6 mm shells are most advisable. Large shells of 20 cm2 and jumbo
shells of 30 cm2 are always preferable to small implants of 15 cm2 or medium im-
plants of 18 cm2. A broader surface area creates subtle, invisible, and nonpalpable
contours rather than a prominent, localized lump.
1246
Part VII  Midfacial Rejuvenation

Implant Positioning
A subperiosteal location has proved the most desirable one because of rapid fixation
of implants to the bone or underlying structures, such as the masseter muscle. Sub-
cutaneous placement frequently results in implant mobility, because circumferential
encapsulation occurs within elastic soft tissues, permitting ready movement when
manually manipulated.
Fibrous ingrowth into porous materials or through implant fenestrations is com-
pletely unnecessary. When smooth implants are used, correction of a malposition
simply requires that a new, accurately located space be created directly on the bone
level and beneath all anatomic tissue planes, including scar tissue and previous cap-
sules. Dissection of the space of slightly larger capacity facilitates placement of an
implant without buckling, infolding of the edges, or abnormal bulging.
Facial Asymmetry
Natural facial asymmetry is universal. A form of hemifacial microsomia occurs in
more than 90% of patients. On careful examination, the left and right sides of the
face are usually quite different in size, shape, or volume. One side may be wider and
have a greater volume of bone and soft tissue. One orbit, eyebrow, or eye complex
is usually lower than the other.
Patients can be very particular and obsessed with asymmetries. Such asymmetries
frequently go unnoticed before facial implant contouring. Therefore it is imperative
to evaluate facial asymmetry meticulously in the preoperative consultation, noting
them in the medical record, and explaining them in detail to the patient. It is also
necessary to warn the patient that asymmetries will still be present to some degree
following surgery, even when implants of different sizes are chosen and positioned
to compensate for the variations in volume and shape that already exist.
1247
Chapter 39  Alloplastic Facial Contouring

This 42-year-old man had subtle asymmetry of his mandible-jawline for which
he requested improvement. Different sizes of mandibular angle implants were used,
12 mm thick on his smaller right side and 10 mm thick on his larger left side. Malar
implants were also requested. He is shown 2 years postoperatively.
In my practice, asymmetries are documented in the patient’s chart by computer im-
aging or photographic modalities. Documentation helps to counter any postopera-
tive criticism if the asymmetry is still apparent in the least degree to the patient.
1248
Part VII  Midfacial Rejuvenation

This 28-year-old man had significant hereditary facial asymmetry, as demonstrated
by computer imaging technology. The computer-generated images dramatically show
that the right side of his face was proportionally narrow compared with the left side.
The patient is shown 1 year after mandibular augmentation.
1249
Chapter 39  Alloplastic Facial Contouring
Preoperative
Computer-generated
right-sided mirror image
Computer-generated
left-sided mirror image

Although CT-generated computer-aided design/computer-aided manufacturing
(CAD/CAM) technology can be used to create implants from customized models
with asymmetrical skull anatomy, at present such an advanced method is used only
for correction of the most complicated and sophisticated problems. CAD/CAM cus-
tomized modeling has been used mostly for correction of posttraumatic and con-
genital birth defects and deformities. Such customization is time consuming and ex-
pensive, and the results are at best only moderately more successful than those
obtained with standard, universally designed anatomic implants. In the past 3 years,
however, approximately 1 out of 12 of my patients who consulted exclusively for fa-
cial implant contouring felt comfortable purchasing implants derived from CT
CAD/CAM technology; these are molded on their posterior aspect to custom-fit a
personalized skull model.
Advancements in this area of computer technology are rapidly evolving and will soon
enable aesthetic plastic surgeons to correlate implant sizes and shapes with desired
changes in facial form and contour.
Choosing implants to correct asymmetries is presently a matter of intuitive artistic
judgment rather than of technical precision. Obviously, a thicker implant with a
larger surface area is indicated for the side of the face that lacks bone and soft tis-
sue volume. Similarly, for jawline asymmetries in the posterior mandibular and mid-
lateral zones, implants that provide additional thickness of 1, 2, or 3 mm at the an-
gles and along the horizontal ramus can be used on the deficient side of the mandible.
Perhaps the most important principle for the surgeon to remember is that minor
asymmetries tend to become less noticeable within a 6-month postoperative healing
period, during which relaxation of the collagenous capsular matrix around the im-
plants allows the contours to appear softer.
Custom Designing Implants Using Three-Dimensional
Computer Modeling
Any chapter on facial volumization with implants would be incomplete without a
brief discussion of the latest unique and innovative techniques for custom-designed
facial implants. I have been responsible for the major advances to date regarding the
development of anatomic alloplastic designs for the chin, jaw, malar midface, sub-
orbital maxillary area, and other regional volume deficiencies in the face. I first used
these designs in 1977. My patented implant designs represent a decade of evolution-
ary alterations to evaluate the final contours produced by observing the resolution
of the final swelling at the end of the first postoperative year.
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Part VII  Midfacial Rejuvenation

Through years of experience, I found that the need for certain small modifications
was obvious for a number of patients. With the growing popular interest in facial
contour modification by means of implant volumization, current patients have be-
come very specific and particular about the details of the contours they believe can
be achieved through the modern miraculous work of aesthetic plastic surgeons.
Some patients develop unachievable expectations from having pored over glamor-
ized articles, photographs, comments, and various media reports that indicate that
many of the most attractive models and actors have achieved their structural beauty
through prosthetic plastic surgery.
Thus present patient demands have stimulated sophisticated alloplastic facial sur-
geons to accept the challenge to meet such expectations. Custom-designed facial im-
plants are now possible through modern CAD/CAM methods that perfectly dupli-
cate anatomic topographic contours to form-fit implants individually to the skeleton
in these more sophisticated and demanding cases.
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Chapter 39  Alloplastic Facial Contouring
These CAD/CAM models were generated from CT scans that precisely duplicate
anatomic topographic facial skeletal contours.
Over the past 20 years, three-dimensional CAD/CAM implants have been used suc-
cessfully for facial reconstructions by craniofacial and oromaxillary surgeons. Over
the past 8 years, I have found good reasons to also apply this technology for regional
aesthetic facial volume deficiency problems.

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Part VII  Midfacial Rejuvenation
Although asymmetries of the face are present 100% of the time in varying degrees,
when they are minor, they may go unnoticed by patients before their cosmetic sur-
gery consultation, and if these are not brought to their attention before surgery and
documented, the surgeon will surely be plagued by patient complaints after surgery
about perceived malpositions, asymmetries, and postoperative deformities.
When asymmetries are more obvious, many patients come to the consultation with a
specific goal to have their asymmetries corrected. Many have somehow come to be-
lieve implicitly that the aesthetic facial surgeon, especially one who performs facial im-
plant procedures, can succeed in achieving a near-perfect result. All experienced sur-
geons know that nothing can be farther from the truth. In trying to accomplish
symmetry over a 35-year period, I have discovered that this is rarely possible, al-
though considerable improvements can be made through the use of different sizes
and shapes of implants positioned slightly differently on the facial skeleton. Even so,
today’s patients demand still more precision. Therefore custom-designed fitted im-
plants that are accurately matched to the external surface nuances of the bony facial
skeleton can often provide more ideal positioning and attachment of the implants to
the underlying bony prominences.
These CT scans show accurate positioning and form-fitting of multiple custom im-
plants for a particular patient’s skull (see patient on p. 1254).
L
H
A
P
F
A
H
R
L
F

This silicone rubber preliminary custom-made implant has been form-fitted based
on a patient’s CAD/CAM-generated mandible model.
I have also discovered that facial asymmetries are never exclusively skeletal in ori-
gin. In cases in which by good fortune surgery has resulted in perfect bony symme-
try, soft tissue deficiencies of the muscle, fascia, and fat layers still persist, demon-
strating that they also contribute to the asymmetries in every instance. This reality
must also be emphasized to patients preoperatively.
It is not within the scope of this chapter to discuss the detailed techniques for using
custom-designed facial implants. My purpose is to acquaint readers with this sub-
ject and to indicate the marvelous technologic progress in aesthetic facial contour-
ing that exists and will continue to be developed.
All facial aesthetic surgeons are waiting for the historical moment when computer
image modification of the patient’s photographic image in their office can be suc-
cessfully combined with a three-dimensional CT scan to provide instant individual-
ized patient information regarding the dimensions of implants and specifics for po-
sitioning them, which will provide optimal precision results. Indeed, if equipment
were available for office use that could readily manufacture such personalized im-
plants, the ultimate dreams of an alloplastic aesthetic surgeon would be realized. Pa-
tients as well as surgeons would be grateful for the emotional security and enhanced
confidence in both the surgeon and the procedures.
The details of this customized methodology can be found in the references section.
For aesthetic custom design implants to be used for facial skeletal volumization, bio-
compatible alloplastic implant materials such as Silastic (silicone rubber) are more
predictable and durable than autologous grafts. Experience as well as research with
bone or cartilage autografts has confirmed that unpredictable and variable amounts
of resorption occur, and harvesting the grafts carries a risk of donor site morbidity.
1253
Chapter 39  Alloplastic Facial Contouring

This 41-year-old man required multiple malar-midface and chin–mandibular angle
custom-made form-fit implants, as seen on his CT scans on p. 1252.
It has also been established that it is easier to predict soft tissue displacement after
direct augmentation with grafts or implants than with orthognathic procedures such
as osteotomies and segmental bone repositioning. Therefore custom-designed onlay
implants are a more desirable option than more extensive traditional orthognathic
reconstructive surgery.
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Part VII  Midfacial Rejuvenation

A custom-made hemimandible silicone implant is shown.
1255
Chapter 39  Alloplastic Facial Contouring
This 27-year-old woman had a congenital right hemimandibular deficiency. The mark-
ings for the surgery are shown, and she is seen 6 months after a right hemimandibular
implant was placed.

Operative Technique
Patient Positioning
In all facial contouring surgery the patient is positioned supine on the operating
table. General anesthesia is indicated to control the blood pressure adequately. Cloni-
dine (0.2 mg) is given preoperatively for vagosympathetic stabilization. The systolic
blood pressure is maintained by the anesthesiologist at a level of 90 to 100 mm Hg.
A local anesthetic is also generously infiltrated into the tissues. The ideal anesthesia
for alloplastic facial contouring is shown in the box.
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Part VII  Midfacial Rejuvenation
A volume of 20 ml is injected into each malar and premandibular region. The anes-
thesia solution should be placed beneath the periosteum. This protocol enables the
surgeon to execute facial implant surgery in a nearly bloodless field.
Incision Placement
Incisions to approach the malar-midface and premandibular regions are as follows:
 Intraoral
 Lower blepharoplasty (subcilial)
 Rhytidectomy
 Transcoronal
 Transconjunctival
Anesthesia Protocol
General Anesthesia
 Maintain systolic blood pressure at 90 to 100 mm Hg
 Clonidine 0.2 mg given orally preoperatively
Local Anesthesia
 Lidocaine solution 0.2%
 Epinephrine 1:800,000
 Generous tissue infiltration into malar or premandibular space (20 to 30 ml each)

There are several surgical approaches for augmenting the malar-midface space. The
most traditional and commonly used approach for midface augmentation is the in-
traoral route. A 1.5 cm incision is made only through the mucosa. The excision is ex-
tended obliquely upward over the anterior buttress of the maxilla just above the ca-
nine tooth. It is connected with another 1.5 cm horizontal incision made 1 cm above
the gingival buccal sulcus that is extended posterior to the premolar tooth. The dis-
section is initiated onto the bone only through the lower border of the incision and
always remains on the bone.
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Chapter 39  Alloplastic Facial Contouring
A lower blepharoplasty incision can also be used by dissecting beneath a skin mus-
cle flap onto the lower orbital bony margin and penetrating the suborbicularis oculi
fat (SOOF) layer in the lateral aspect of the orbit down to the bone. The midface
zone 1 area can be dissected subperiosteally from that location.
If a rhytidectomy insertion is intended, a small penetration is made through the soft
tissues over the lateral aspect of the malar bone at the junction with the zygomatic
arch. This facilitates entrance into the subperiosteal malar space in an area where no
major facial nerve branches are endangered.

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Part VII  Midfacial Rejuvenation
Premandibular augmentation involves two types of incisions to:
 Augment the angle of mandible
 Create the central mentum space for insertion of a central implant with lat-
eral anatomic extensions
The central mentum space can be approached from the intraoral route or with an
incision in the submental crease. The submental crease incision is preferred when
there is to be dissection into the neck, either to remove fat or to manipulate and
tighten the platysma muscle, or both. This incision is approximately 2.5 cm in trans-
verse length and penetrates directly down onto the lower border of the mandible.
From that location a subperiosteal dissection is done laterally in both directions. The
intraoral incision is a transverse mucosal incision of 2 cm only, placed 1 cm supe-
rior to the gingival labial sulcus. Next a vertical penetration is then made between
the two pillars of the mentalis muscle. The mentalis muscle should never be tran-
sected, because this would produce weakening and ptosis of the central chin mound.
By dissecting vertically between the muscles and then developing the subperiosteal
space inferior to them, the muscular support of the soft tissues of the chin mound
is maintained.
In either dissection, the mental nerve should be located and identified. It is usually
situated 8 to 12 mm above the inferior border of the mandible and 2.5 to 3.5 cm
from the midline of the central mandible. Extreme variations of distances are re-
ported, although these are rare.

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Chapter 39  Alloplastic Facial Contouring
The posterior mandibular angle space is created by an incision made 1 cm anterior
to the molars in the gingival buccal sulcus and extending it laterally 4 cm. A sturdy
1 cm layer of mucosa and muscle must be preserved to ensure a secure closure. The
dissection is then immediately directed onto the bone. The soft tissues elevate very
easily from the inferior border and ascending ramus of the mandible. At the angle
itself, there may be tendinous attachments of the masseter muscle, especially in men.
These may need lysis with an electrocautery needle to enable the muscles to be disin-
serted from the angle and posterior border of the mandible. It is critical, however,
to disinsert the fibrous attachments at the angle and the posterior border completely
so that the implant will seat correctly. The masseter muscle itself is quite thick and
strong and will hold it in proper position without fixation. Malpositions and extru-
sions are rare when the posterolateral space is dissected properly.

A long, curved clamp is placed on the implant to facilitate the posterior and upwards
placement of the implant.
A peripiriform premaxillary implant is inserted through a single 4 to 5 mm nasal
floor incision, although one on each side may be used if necessary. An intraoral in-
cision in the superior labial sulcus should be avoided, because it may predispose to
implant erosion through that area. The plane of dissection is developed deep to the
orbicularis oris muscle to create a subperiosteal pocket for the implant.
Tear trough implants can be placed through an external subcilial blepharoplasty in-
cision, a transconjunctival incision, or an intraoral route. The most important con-
sideration is to carefully dissect around the infraorbital nerve under direct visuali-
zation to prevent nerve trauma and subsequent disabling symptoms. The tear trough
implant is placed after cutting out a segment that allows it to surround the main
trunk of the infraorbital nerve. If desired, it can be secured by one or two stitches to
the medial orbicularis muscles or to the inferior orbital rim.
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Part VII  Midfacial Rejuvenation

Postoperative Care
Postoperative care for facial implants is straightforward and uncomplicated. Oral
antibiotics are used perioperatively; at present cephalosporins are favored. Before the
procedure begins, the anesthesiologist administers cephazolin (Ancef) 1 g intra-
venously; 10 mg of dexamethasone (Decadron) is also administered intravenously
during the surgery to control postoperative edema. During the postoperative period,
a 5-day diminishing course of a steroid (methylprednisone; Medrol Dose-Pak) is
taken orally. For the first 12 hours cold compresses are applied intermittently to the
operative site either in the midface or premandibular region. No bandages are used.
Removal of intraoral mucosal and external subcuticular sutures is unnecessary. A
soft diet is maintained for 10 days. It is highly recommended that the patient recline
at a 45-degree angle, supine, for at least 1 week. Vigorous physical activity is not per-
mitted for 4 weeks, after which patients may engage in any and all types of exercise.
Problems and Complications
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Chapter 39  Alloplastic Facial Contouring
Cellulitis and inflammation developed in this 38-year-old woman after she under-
went malar augmentation surgery. Left and center: She is seen 10 days after surgery.
Right: At 3 weeks after surgery, the cellulitis has resolved after treatment with an-
tibiotics and drainage.

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Part VII  Midfacial Rejuvenation
Percutaneous suction drainage can be combined with intensive antibiotic therapy to
manage a midface suppurative infection.
Extrusion of a central mandibular chin implant is rare but can be caused by exces-
sive trauma or internal pressures created by an inadequate space for the implant.
Intraoral extrusion of a midface implant can
follow inferior placement of the implant with
overlying pressure erosion caused by a dental
prosthesis, hematoma and infection, or inade-
quate midface anatomic dissection.

A three-dimensional CT scan was used to diagnose the extrusion of this anatomic
extended chin implant from the lower internal buccal sulcus mucosa.
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Chapter 39  Alloplastic Facial Contouring
The chin implant in this 48-year-old man was adjusted through the previous sub-
mental incision and the internal extrusion site was repaired to achieve a successful
resolution.

A hematoma that developed during the first 24 hours after surgery caused pain and
swelling in this 61-year-old woman. With the patient under local anesthesia, the clots
were easily evacuated and the cavity irrigated copiously with antibiotic solution
(1 g Ancef in 1 L of Ringer’s lactate solution) after the implant was removed. It was
immediately replaced and resutured, to heal uneventfully.
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Part VII  Midfacial Rejuvenation
This 35-year-old patient sustained damage to the upper lip segment of the orbicu-
laris oris muscle as a result of implant surgery. After 8 weeks, the injury had fully
resolved.

Facial nerve injuries are rare following facial implant surgery and are usually tem-
porary. These are examples of temporary damage to the frontalis and orbicularis
branches of the left facial nerve after malar augmentation.
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Chapter 39  Alloplastic Facial Contouring

Avoiding Unfavorable Results and Complications
In 1991 and 1998, I conducted a survey of ASPRS and ASAPS members regarding
their experiences in aesthetic surgery with alloplastic implants. In 2008, a similar
survey was done with ASFPS and ASOMS surgeons. The most statistically significant
categories for “unfavorable results” with facial implantation reported in all these
surveys over the last 20 years were as follows:
1. Patient or doctor dissatisfaction
2. Lack of correction of asymmetries or asymmetries resulting from surgery
3. Inappropriate shape and/or malposition
4. Hematoma, seroma, and inflammation
5. Infection necessitating removal
6. Nerve dysfunction
Notably, in the 1998 survey more than 90% of the surgeons considered their “un-
favorable results” to be relatively insignificant, both emotionally and physically. Per-
haps this is because the majority of untoward sequelae were either temporary asym-
metries and inappropriate shapes associated with the healing phase, reversible
problems requiring implant removal, or nerve dysfunctions that in the vast major-
ity were temporary and partial rather than permanent.
More than half of the responding surgeons in the 2008 survey had practices with
over 80% cosmetic cases and approximately 10% reconstructive cases. Ninety per-
cent of the surgeons surveyed use alloplastic materials. Silicone rubber implants
scored 3 to 1 over the next contender, Medpor. Gore-Tex was used by 25% of the
surgeons.
Further evaluation revealed silicone rubber to be the most desirable, as cited by two
thirds of the surgeons, Medpor by 20%, and Gore-Tex by 16%. Nearly half of the
surgeons stated that silicone (Silastic) was the only material that they used. It was
cited for its low infectability; easy insertion, removal, or exchangeability; confor-
mation to the bony skeleton; and stable, long-term, predictable volume. Two thirds of
the reporting surgeons use silicone implants for the cheek-midface submalar region
and 80% for the chin-mandibular facial aesthetic segment.
For chin implants, twice as many surgeons rated silicone rubber as exceptional or
excellent by twice than those who rated the material as fair, good, or useful. In the
malar region, Silastic implants were rated six times more successful in achieving ex-
ceptional or excellent results than those producing fair, good, or useful results. No
one rated facial implants as poor.
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Part VII  Midfacial Rejuvenation

Ninety percent of the surgeons surveyed rated facial implant surgeries as useful from
10% to 50% of the time, and 45% of the surgeons felt they would use them in 20%
to 50% of cases. Forty percent of the surgeons considered facial volumization with
alloplastic materials indispensable or mostly necessary; 60% rated them as desirable
or useful at times. Only 0.5% considered them to have too many problems to be
used. Although these numbers come from the latest 2008 survey, there has been a
significantly increasing endorsement of facial implant technology since my first sur-
vey in 1999.
Concluding Thoughts
Clearly, the use of alloplastic facial augmentation has gained tremendous momen-
tum in respectability and success over the past 20 years and apparently is considered
one of the leading tools for a plastic surgeon’s aesthetic armamentarium for faces.
Clinical Caveats
 Always perform the anatomic space dissection directly on the bone and beneath
the periosteum.
 Maintain the dissecting elevator on the bone at all times.
 Never push the tip of an elevator into adjacent soft tissues. This can create severe
trauma to the facial nerve, infraorbital nerve and/or zygomaticus muscles disturbing
facial expression in the malar-midface region. In the perioral and mandibular re-
gions traumatic dissection into the soft tissues can produce mental nerve or mar-
ginal mandibular nerve damage, and even mimetic muscle dysfunction. Potential
dangers in posterior angle dissections involve trauma to a large retromandibular
vein behind the posterior border of the mandible or to the anterior facial artery
just adjacent to the inferior border of the mandible. Disruption of these would
produce profuse hemorrhaging.
 External palpation of the lower mandibular border with the index finger facili-
tates an accurate and controlled dissection beneath the mental nerve as well as
protecting the inferior soft tissues and marginal branch of the seventh nerve.
 Manual palpation externally over the malar region facilitates a precise dissection
of the malar space beneath the external preoperative ink markings on the midface
skin. A small hockey stick incision with 1.5 cm limbs will facilitate a wide midfa-
cial premaxillary and submalar dissection. Once again, the entry point should be
beneath the muscles and onto the bone of the anterior maxillary buttress.
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Chapter 39  Alloplastic Facial Contouring
Continued

Clinical Caveats—cont’d
 The intraoral chin space dissection should be done vertically between the men-
talis muscle pillars to go beneath the muscle and onto the bone without transect-
ing or damaging the mentalis muscle which can produce central chin ptosis.
 All intraoral incisions should have a secure muscle and mucosal closure to prevent
entrance of bacteria or wound dehiscence.
 Intermittent irrigations with copious amounts of antibiotic solution should be per-
formed inside the anatomic zonal spaces during the surgery.
 A “no-touch” technique should be meticulously enforced when inserting implants.
This is done by placing a clamp on the implant and immersing it in a Betadine
and antibiotic solution before inserting it gently into the soft tissue anatomic space
aperture.
 Implants should be inserted as gently and atraumatically as possible. Finger ma-
nipulations are to be avoided. Silicone rubber implants have the advantage of be-
ing extremely flexible and therefore easily insertable or removable.
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Part VII  Midfacial Rejuvenation
Annotated Bibliography
Binder WJ. Custom-designed facial implants. Facial Plast Surg Clin North Am 16:133-146,
2008.
The author presents a comprehensive, detailed, and up-to-date description of this sub-
ject, including references to the earliest articles first utilizing these techniques.
Hinderer UT. Malar Implants for improvement of the facial appearance. Plast Reconstr Surg
56:157-165, 1975.
This report is one of the earliest to cite the aesthetic value of alloplastic malar augmen-
tation.
Pitanguy I. Augmentation mentoplasty. Plast Reconstr Surg 42:460-464, 1968.
This study is one of the earliest to report the value of using chin implants in conjunc-
tion with rhinoplasty to accomplish dramatic profileplasty changes.
Ramirez OM. The subperiosteal rhytidectomy: the third-generation face-lift. Ann Plast Surg
28:218-232, 1992.
The author describes the use of techniques from craniofacial surgery to achieve exten-
sive subperiosteal elevation of midfacial soft tissues so that they may assume a more el-
evated position with internal suspension sutures.

Terino EO. Alloplastic facial contouring. In Goldwyn RM, Cohen MN, eds. The Unfavor-
able Result in Plastic Surgery—Avoidance and Treatment, 3rd ed. Philadelphia: Lippin-
cott Williams & Wilkins, 2001.
This chapter discusses prevention and treatment of all significant facial implant com-
plications. It also reviews results of two major surveys of members of the American So-
ciety of Plastic and Reconstructive Surgery in 1991 and members of the American So-
ciety for Aesthetic Plastic Surgery in 1998.
Terino EO. Alloplastic facial contouring: surgery of the fourth plane. Aesthetic Plast Surg
16:195-212, 1992.
Techniques based on the concepts of zonal anatomy are used to describe alloplastic im-
plants. These implants significantly improve facial contours to correct inherited defi-
ciencies and changes resulting from aging.
Terino EO. Unique mandibular implants including lateral and posterior angle implants. Fa-
cial Plast Surg Clin North Am 2:311-328, 1994.
This early report emphasizes the versatility of alloplastic premandibular augmentation
in achieving a variety of jawline-chin shapes, using several types of implants in the
anatomic zones.
Terino EO, Edwards MC. The magic of mid-face three-dimensional contour alterations com-
bining alloplastic and soft tissue suspension technologies. Clin Plast Surg 35:419-450;
discussion 417, 2008.
The authors present a brief history of facial aesthetic surgery, with references to the
source articles.
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