The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

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secting in a suprachondrial submucosal plane also is a
risk for flap tear, because the perichondrial layer is the
strongest tissue plane of the entire flap. If left on the
septal cartilage, the resultant mucosal flap is signifi­
cantly weakened and can tear more easily, potentially
resulting in septal perforation. Reorienting to a submu­
coperichondrial plane can help prevent this complica­
tion. If red hue is left on the septal cartilage, the surgeon
should gently incise over the cartilage to identify the
perichondrial layer and then proceed with elevation of
the flap (Fig. 26D.1).
If it is in the correct plane, the mucosa is usually
thinnest at the apex of a spur. Raising the mucosa over
the apex of a spur often results in a tear in the flap. The
risk of a tear can be moderated by hydrodissection be­
fore flap elevation by directly injecting superiorly and
inferiorly and over the spur. In any event, if there is a
small tear on one side of the submucoperichondrial
flap during dissection that is opposed by an intact con­
tralateral flap, it usually will heal uneventfully. Many
surgeons even treat these as opportune drainage holes
to prevent a septal hematoma postoperatively. Larger
rents in the flap can be reapproximated with absorbable
suture in a simple, interrupted fashion to aid mucosal
healing. If there are opposed tears with or without carti­
lage, the risk of a septal perforation or cartilage necrosis
with subsequent perforation is exponentially increased.
Hemorrhage intraoperatively or immediately post­
operatively is a common complication of septoplasty,
with rates reported at 6 to 13.4%.1,2,3,5 Slow oozing in the
first 24 to 48 hours postoperatively is expected, and pa­
tients should be educated before surgery and discharge
The key step in septoplasty is raising an appropri­
ate submucoperichondrial flap. Inadvertent dissection in
the supraperichondrial or submucosal plane is common
and lends to both a more difficult procedure and po­
tential postoperative complications. The surgeon should
feel the “sandpaper” or granular texture of bare cartilage
when dissecting the submucoperichondrial flap with a
blunt instrument such as a Freer or Cottle elevator. Al­
though septoplasty is a fairly nonmorbid procedure,
common complications such as septal perforation, he­
matomas, and adhesions are reported to be 0.7 to 3.8%
in the literature.1,2,3,5
Intraoperative Complications
Anticipation of and preparation for intraoperative com­
plications before beginning the procedure helps im­
mensely decrease the morbidity of any procedure. With
regards to a septoplasty, in which major complications
are rare, this begins before the patient ever reaches the
operating room suite. A detailed history and physical is
performed to stratify patient risk:
•• Type of obstruction
•• Medical comorbidities (such as epistaxis of known
or unknown cause)
•• Transnasal drug use (such as cocaine, oxymetazoline,
etc.)
•• Hypertension
•• Obesity
•• Significant postanesthetic nausea or vomiting
Documenting nasal airway complaints, sidedness, cur­
rent medications, and prior medical treatment of nasal
airway obstruction help the surgeon determine appro­
priate surgical candidates. Endoscopic examination of
the nasal passageway and photographing (endoscopic
digital capture) potentially obstructive spurs help sup­
port a patient’s complaints. Often, a spur is significantly
obstructing one nasal passageway, but the patient
does not have any concerns. Further investigation of
the patient’s complaints may therefore be warranted.
Commonly mucosal edema, rather than structural
deviation, contributes more to a patient’s complaints
and can be managed medically rather than surgically,
preventing a dissatisfied patient postoperatively. Re­
versible forms of nasal obstruction can be identified by
using a nasal decongestant preoperatively by applying
oxymetazoline on cotton pledgets then assessing the
degree of nasal obstruction.
Knowledge of the status of the nasal mucosa can
help surgeons anticipate tears in the flap. As mentioned,
patients with altered nasal mucosa (e.g., cocaine use,
systemic mucocutaneous inflammatory disorders, au­
toimmune disorders) are at high risk for tears because
of brittle and poorly vascularized mucosal tissue. Dis­
Fig. 26D.1 Perichondrium on septal cartilage. (a) Red hue left
on septal cartilage with initiation of elevation of the septal flap.
(b) After the perichondrium is incised, the perichondrial layer
is elevated.
a
b

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Chapter 25 Postoperative Nasal Airway Obstruction
regarding this event. The use of total intravenous anes­
thesia does decrease intraoperative and postoperative
hemorrhage; however, we do not routinely request this
during procedures, because the expected benefit is mar­
ginal. An injection of 1% lidocaine with 1:100,000 epi­
nephrine should be made on both sides of the septum.
A period of 10 to 15 minutes allows for the hemostatic
effects of the epinephrine to work and provide a blood-
free field for the surgeon. Typically, 3 to 6 mL is injected
in a submucoperichondrial plane. Injecting in areas of
vessel confluence such as Killian’s plexus helps provide
superior hemostasis. This also achieves hydrodissection
of the submucoperichondrial plane and facilitates the
flap elevation during the actual procedure. If adequate
precautionary steps are taken to ensure hemostasis and
disruptive oozing is encountered while raising the sub­
mucoperichondrial flap, the surgeon should again deter­
mine whether dissection is in the correct plane. More
commonly, hemorrhage during and immediately after
surgery occurs from mucosal disruption, specifically a
tear in the septal flap or turbinectomy or turbinoplasty.
Aerosolized or colloid hemostatic agents can be used
at the end of the procedure to assist with hemostasis.
We do not recommend intranasal packing, particularly
prophylactically. Patient comfort, risk of toxic shock
syndrome, sleep disturbance, and hindrance of muco­
sal healing are all elevated with nasal packing without
an obvious decrease in hemorrhage rates.6–9
Cerebrospinal fluid (CSF) leak is a rare complication
of septoplasty. The usual cause is manipulation of the
ethmoid lamella resulting in disruption of the cribriform
plate. CSF rhinorrhea is the usual presenting symptom,
if not recognized intraoperatively.2,3 Dissecting postero­
superiorly on the cartilaginous and bony septum places
the patient at higher risk for this complication. Preven­
tion involves avoiding rocking or excessively manipu­
lating the posterior superior septum (ethmoid bone).
Management of a CSF leak during septoplasty involves
immediate repair of the area where the leak is identi­
fied, usually through an endoscopic approach with fat
or fascial grafting. Neurosurgical consultation is recom­
mended in larger, complicated leaks that may require an
external or multilayered approach, especially if there is
intracranial content herniation. All patients should im­
mediately start broad-spectrum antibiotics with good
meningitis bacterial coverage.
Early Postoperative Complications
Septoplasty is a well-tolerated procedure. Pain is lim­
ited because of the noninvasive nature of the procedure.
Surgical pain is well managed with limited and mild
narcotic use in the first days to week after the procedure.
Surgical pain after this period is rare, barring any fur­
ther complications. Gentle nasal saline rinses, upright
head positioning, and cold compresses are conservative
measures to improve patient comfort in the immediate
postoperative period. The placing of nasal splints and
packing is highly associated with pain in the first 48
hours of the procedure.3,7,9,10 It is common for patients
to feel significant relief after these are taken out.
Disruption of the normal mucosal lining of the nasal
cavity during septoplasty leads to transient bacteremia.
Temporary ciliary stasis also promotes a probacterial en­
vironment in the early stages of wound healing and in
the immediate postoperative period. Both these factors
are transitory and in most healthy patients do not result
in further complications. Postoperative infection can oc­
cur but is usually limited to the nasal septum. Rates of
infection reported in the literature are usually less than
3%.9 Rare infections that have been reported in the lit­
erature include osteomyelitis, meningitis, endocarditis,
toxic shock syndrome, and cavernous sinus thrombosis.
The use of perioperative antibiotics during septoplasty
is surgeon dependent and may be dictated by training
experiences and local trends. A survey of the American
Rhinological Society revealed that nearly 67% of sur­
geons used preoperative and postoperative antibiotics
during septoplasty.9 Despite this, there is no convincing
evidence that perioperative antibiotics decreases the
risk of postoperative infection after septoplasty.
A review of the literature and meta-analyses by
Gioacchini et al in 20149 did not show significant dif­
ferences in postoperative infection (and other compli­
cations) among groups that received a preoperative
antibiotic, preoperative and postoperative antibiotic,
or placebo. Many surgeons use antibiotics when sep­
tal splints or packs are placed. If removed within 48
hours, there is no convincing evidence that there is an
increased risk of postoperative infection without antibi­
otic prophylaxis. We recommend careful consideration
of patient comorbidities and postoperative course when
considering antibiotics for septoplasty. A septal infection
is a surgical emergency; the patient should be exam­
ined and if a fluid collection is seen the patient should
be taken back to surgery to have the fluid drained and a
drain placed to prevent reaccumulation of fluid.
Intermediate and Late Postoperative
Complications
A septal hematoma occurs when blood accumulates in
the dead space beneath the perichondrium, resulting
in cartilaginous and mucosal pressure edema. If not
treated, this can progress to a septal abscess and even­
tually a septal perforation. Dissection in an incorrect
plane increases the risk that postoperative intraflap
blood accumulation occurs. Symptoms of a hematoma
include persistent or worsening nasal obstruction after
removal of any intranasal splinting or packing. In many

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368
cases, hematoma occurs after the removal of intrana­
sal pressure packs. On physical examination, a bulge
is usually visible on the septum. Avascular cartilage is
viable up to 3 days; therefore prompt management is
required. This includes immediate needle aspiration
and incision over the hematoma. A small drain can be
left in place to prevent accumulation of fluid. Placing
nasal packing afterward to prevent reaccumulation has
not been supported in the literature. If an abscess is en­
countered, prompt drainage and a course of antibiotic
treatment with staphylococcus coverage is warranted.
Measures to prevent septal hematoma include nasal
packing, nasal splinting, and transseptal suture. There is
strong evidence to suggest transseptal suturing is equiv­
alent in preventing postoperative hematomas, abscesses,
and perforations with the added benefit of increased
patient comfort. In a prospective study of 150 patients
randomized to either receive transseptal suturing only,
nasal splinting only, or nasal packing only, there was
no statistical difference or trend toward increased risk
of septal hematoma, perforation, or abscess between
groups.7 Operative time was increased by a mean of 5
minutes in the suture group, but postoperative head­
ache, pain, airway obstruction, and general discomfort
was significantly improved.
Certal et al11 performed a systematic review and
meta-analyses of more than 800 patients in randomized
controlled trials and did not find any increased risk or
statistical difference in postoperative complications be­
tween those who had transseptal suturing versus pack­
ing. Predictably, subjective patient measures as men­
tioned previously all were improved in those that were
not packed. We prefer to perform transseptal suturing
with a 4–0 plain gut on a straight SC-1 needle in a cir­
cular fashion with absorbable suture without intrana­
sal packing. We reserve the use of intranasal splinting if
there is concern for postoperative synechiae formation.
Septoplasty is the second most common reason for
septal perforation behind nasal trauma. The literature
reports rates of perforation to be 2 to 7% after septo­
plasty.2,3,5 Perforations can occur for multiple reasons,
but compromise of the perichondrial layer of the mu­
coperichondrial flap is the underlying cause for most
perforations. Septal perforation can occur when there
are two opposed tears in the mucoperichondrial flap,
usually without intervening cartilage. Larger tears, with
cartilage in between, can lead to necrosis of cartilage
tissue because of lack of perichondrium and the nutri­
ents it passively brings. Overzealous cautery can cause
irreversible damage to the mucosa or cartilage. Septal
hematomas, if left untreated, can lead to pressure ne­
crosis of the intervening cartilage and mucosa, causing
a perforation. If hematomas progress to abscess, this can
lead to chondritis and necrosis of cartilage as well. Signs
and symptoms of a perforation include the following:
•• Persistent crusting
•• Epistaxis
•• Pain out of context to the postoperative date
•• Subjective nasal obstruction
•• Whistling sound during inhalation
•• Headache
Small (less than 1 cm) and posterior perforations of­
ten are asymptomatic and left alone. If large, a septal
perforation may compromise the structural integrity
of the nose and result in cosmetic deformities such as
a saddle nose.
The key is prevention. Studies show that the peri­
chondrium of the septum has the strongest tensile
strength among all layers of the overlying cartilaginous
septum. In fact, the perichondrium has nearly double
the tensile strength of the mucosal layer.12 Therefore
keeping the perichondrium intact during flap raising is
of critical importance. This is why nasal surgeon train­
ees are taught to keep dissection in a submucoperichon­
drial plane. It is also critical to remember that once the
bony septum is reached, keeping in a subperiosteal
plane is of equal importance to avoid ostotic complica­
tions. If perichondrium is violated or removed, opposing
mucosal flaps without cartilage lose tensile strength and
are more apt to perforate. If bare cartilage is exposed
without perichondrium, necrosis can occur because of a
lack of nutrients and lack of mucosalization of the inter­
vening cartilage. As emphasized, dissection in a submu­
coperichondrial plane and preserving perichondrium,
especially when intervening cartilage is to be resected,
are preventive factors that decrease septal perforation
rates and overall complication rates after septoplasty.
Randomized trials have not shown any benefit of septal
splints or packing in preventing septal perforations.7,10,11
Often septal perforations, especially small ones, can
be managed conservatively with good nasal hygiene. Sa­
line nasal sprays, humidified air, and saline irrigations
can help keep remaining mucosa healthy in an asymp­
tomatic perforation.3 A septal button can be placed if
whistling or subjective nasal obstruction is perceived,
and often no further intervention is needed. Smaller
perforations less than 2 cm can be repaired surgically
with a variety of local flaps, including septal advance­
ment flaps, rotational flaps, or pedicled intranasal flaps.
Placement of an interpositional graft is critical to maxi­
mizing the success rate when closing septal perforations.
I (D.M.T.) prefer using costal perichondrium as the in­
terpositional graft, because it is thicker than temporalis
fascia and also promotes vascular ingrowth. Allograft
or xenograft materials (acellular dermis) may also be
used, although the risk of foreign body reaction with
subsequent worsening of the perforation must be con­
sidered. The external rhinoplasty approach should be
used when repairing septal perforations to allow precise

369
Chapter 25 Postoperative Nasal Airway Obstruction
flap elevation and control of flap approximation. The use
of free tissue flaps has been reported but they are rarely
used in the clinical setting.
Adhesions or synechiae are a common complication
after septoplasty; reported rates are around 7%.2,3,5 These
can occur when damaged or denuded mucosa heals in­
appropriately, often to opposing denuded or damaged
mucosa and is most likely to occur when septal and tur­
binate procedures are performed in combination. Syn­
echiae are most commonly found between the septum
and inferior or middle turbinate postoperatively. Posteri­
orly based adhesions are often asymptomatic and can be
observed. Symptomatic patients will usually complain of
persistent nasal obstruction. Prevention includes careful
manipulation of mucosa of the septum and the rest of
the nasal cavity during topical injection and deconges­
tant packing. Tears that are opposed should be carefully
reapproximated.
Nasal splinting, most commonly with thin plastic
splints or silastic sheeting, are a common postopera­
tive measure for preventing adhesions by providing a
physical barrier between the septal mucosa and the rest
of the nasal cavity during the acute and subacute heal­
ing phases. Most surgeons keep splints in place for 1
week. However, the evidence does not strongly support
placing splints to prevent adhesions. In a meta-analysis
of more than 600 patients in six randomized trials, no
significant difference in postoperative adhesions were
found in those who had nasal splinting versus no splint­
ing (which included patients who had nasal packing
placed and removed on the first postoperative day and
patients with transseptal sutures placed). Postoperative
pain scores were higher in patients who had splints, es­
pecially after 1 week.10
Patients who underwent lateral nasal wall surgery
concurrently with septal surgery were at higher risk of
adhesions at the 6-week interval. We prefer placing sep­
tal splints if there are opposing mucosal tears or septal
and lateral nasal wall procedures were performed. If se­
vere adhesions do occur, division of scar bands under
local or general anesthesia is an option, provided me­
ticulous postoperative nasal hygiene is done. After the
synechiae are divided, septal splints should be placed
for at least 1 week to allow the mucosal surfaces to heal
and mucosalize.
Cosmetic changes to the external nose can be subtle
but when pronounced are a devastating complication of
septoplasty surgery. Changes to the nasal tip, tip pro­
jection, dorsum, supratip, and columella often are the
result of overaggressive bony-cartilaginous resection.
Minor aesthetic changes have been estimated to occur
in up to 33% of patients. Pronounced changes occur in 1
to 5% of patients.6 Preserving a 1 to 2 cm dorsal and cau­
dal strut maintains the structural integrity of the nasal
framework and prevents complications such as a saddle
nose deformity (Fig. 26D.2).
Careful dissection in an appropriate plane in the
K-area (convergence of dorsal septum, perpendicular
plate of the ethmoid, upper lateral cartilages and nasal
bones) is advised to prevent alar base widening. Cos­
metic changes often can occur late in the postopera­
tive period, sometimes several months later, because of
scarring and retraction of healing mucosa and cartilage.
Again, adequate L-strut preservation prevents changes
such as columellar retraction, saddle nose deformity
(Fig. 26D.3), unfavorable rotation and projection of the
tip, and nasolabial angle changes.
Palpation of the nasal tip and dorsum after resection
of cartilage can help the surgeon to gauge the structural
integrity of the nasal framework. If noticeable changes
or poor support is suspected, various grafts (mainly car­
tilaginous autografts harvested from resected septal car­
tilage, auricular cartilage, or rib cartilage) can be used to
reconstruct the nasal framework. High dorsal deviations
and anterior deflections may require an open approach
to properly address and then reconstruct the septum.
Spreader grafts and caudal septal replacement grafts are
helpful after resection of deviated portions of the sep­
Fig. 26D.2 An L-shaped dorsal caudal strut is critical to preserve
septal support. Ideally a 1.5-cm strut of cartilage should be left
intact and in continuity from ethmoid bone to nasal spine.
Fig. 26D.3 A saddle nose deformity and retracted columella
with an acute nasolabial angle caused by severe septal defor­
mity.

SECTION IV AESTHETIC SURGERY
370
tum. The ability to alter the nasal spine or insertion of
the septum is another advantage of an open septoplasty
to help adequately correct nasal airway obstruction. In
severe cases the entire caudal septum is removed and
replaced with a new caudal septum (caudal septal re­
placement graft) that can be sutured to a notch in the
nasal spine (Fig. 26D.4).
Sensory changes are extremely rare. Anosmia or
dysosmia occur in less than 2 percent of patients. Of­
ten scarring in the ethmoid or high septum can disrupt
Fig. 26D.4 (a,c,e,g) This patient had saddle nose, nasal tip, and nasal dorsum deformities. (b,d,f,h) Results after open septorhi­
noplasty.
g
h
a
c
e
b
d
f

371
Chapter 25 Postoperative Nasal Airway Obstruction
the fibers originating from the olfactory nerve at the
cribriform plate. Prevention is difficult, but knowing
the risk and proper counseling of the patient preopera­
tively and postoperatively are key. Disruption of sensa­
tion to the maxillary incisors can occur with excessive
cauterization of low septal bleeders. Injury to the ca­
nine fossae contents is believed to be the cause. Some
amount of temporary anesthesia is expected and should
be disclosed to the patient. Visual acuity changes are
extremely rare, but case reports exist in the literature.
Causes vary from local injection toxicity to physical in­
jury to the optic nerve with high dissection.2,3,5 Knowl­
edge of these risks and disclosing them to the patient
during preoperative counseling are imperative.
Inferior Turbinectomy
Inferior turbinectomy is a common adjunct procedure
to septoplasty. However, if performed well, an inferior
turbinectomy can be equally efficacious in providing a
patent postoperative airway. Our preferred method is a
submucosal resection (SMR) of tissue and bone with tur­
binate lateralization, which effectively reduces turbinate
size and increases the postoperative airway. This tech­
nique is better characterized as a turbinoplasty rather
than turbinectomy. SMR minimizes mucosal disturbance
and helps preserve turbinate function. We preferentially
perform SMR on a turbinate with compensatory hyper­
trophy contralateral to a spur or deviation. Powered in­
strumentation and cautery are two common methods
to perform SMR. Other than acute crusting, postopera­
tive complications are nonsignificant between the two
methods.13 Regardless of technique, evidence suggests
that SMR results in higher postoperative patency and a
reduction in complications versus turbinectomy or ra­
diofrequency ablation.14
Preservation of turbinate mucosa is key to prevent­
ing complications. Common complications of turbinec­
tomy include postoperative pain, hemorrhage, and na­
sal crusting. As discussed, intact mucosa with minimal
trauma will reduce these complications. Synechiae are
much more likely to occur when septoplasty and lateral
nasal wall surgery is performed, because the opportu­
nity for opposing disturbed mucosa is high. Therefore
we place silastic septal splints when SMR of the inferior
turbinate is performed. A rare but debilitating complica­
tion is secondary atrophic rhinitis, or empty nose syn­
drome (EMS). Described by Kern and Stenkvist in 1994,
this refers to the sensation of nasal obstruction despite
an adequate nasal airway.15 Loss of mucosa, such as with
turbinectomy, reduces the surface area of mucosa that
interacts with incoming air. It is the lack of airway resis­
tance that gives the feeling that no air is flowing through
the nasal cavity even though significant airflow may be
ongoing. Histologic changes to the mucosa postopera­
tively, such as decreased ciliary motion, hypoesthesia
to temperature, altered flow rate (more laminar), and
inability to cool incoming air also contribute to EMS.15
Gentle manipulation and minimal disturbance of tur­
binate mucosa during SMR help to limit complications
after turbinoplasty and retain a patent airway.
Conclusion
Septoplasty with or without SMR of the inferior tur­
binate is a well-tolerated procedure that is low risk.
The key step is raising a submucoperichondrial flap
that remains intact to prevent downstream complica­
tions. Transseptal sutures add minimal operative time
and are equivalent to packing and splints in prevent­
ing adhesions, hematomas, and perforations while de­
creasing postoperative discomfort. Understanding the
bony-cartilaginous framework and opting for an open
approach when indicated can improve nasal airway ob­
struction postoperatively while decreasing the risk for
major cosmetic deformities.
References
1. Palmer J. Septoplasty. Philadelphia, PA: Saunders/El­
sevier; 2013
2. Bloom JD, Kaplan SE, Bleier BS, Goldstein SA. Septo­
plasty complications: avoidance and management.
Otolaryngol Clin North Am 2009;42(3):463–481
3. Quinn JG, Bonaparte JP, Kilty SJ. Postoperative man­
agement in the prevention of complications after sep­
toplasty: a systematic review. Laryngoscope 2013;
123(6):1328–1333
4. Cottle MH, Loring RM. Surgery of the nasal septum;
new operative procedures and indications. Ann Otol
Rhinol Laryngol 1948;57(3):705–713
5. Ketcham AS, Han JK. Complications and management
of septoplasty. Otolaryngol Clin North Am 2010;43(4):
897–904
6. Dobratz EJ, Park SS. Septoplasty pearls. Otolaryngol
Clin North Am 2009;42(3):527–537
7. Özkırış M, Kapusuz Z, Saydam L. Comparison of na­
sal packs with transseptal suturing after nasal septal
surgery. Am J Otolaryngol 2013;34(4):308–311
8. Banglawala SM, Gill MS, Dhillion N, et al. Nasal pack­
ing after septoplasty: cardiopulmonary impact.
JAMA Otolaryngol Head Neck Surg 2014;140(3):
253–258

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9. Gioacchini FM, Alicandri-Ciufelli M, Kaleci S, Magli­
ulo G, Re M. The role of antibiotic therapy and nasal
packing in septoplasty. Eur Arch Otorhinolaryngol
2014;271(5):879–886
10. Tang S, Kacker A. Should intranasal splints be used af­
ter nasal septal surgery? Laryngoscope 2012;122(8):
1647–1648
11. Certal V, Silva H, Santos T, Correia A, Carvalho C. Trans-
septal suturing technique in septoplasty: a systemat­
ic review and meta-analysis. Rhinology 2012;50(3):
236–245
12. Kim DW, Egan KK, O’Grady K, Toriumi DM. Biomechan­
ical strength of human nasal septal lining: ­comparison
of the constituent layers. Laryngoscope 2005;
115(8):1451–1453
13. Joniau S, Wong I, Rajapaksa S, Carney SA, Wormald PJ.
Long-term comparison between submucosal cauter­
ization and powered reduction of the inferior turbi­
nates. Laryngoscope 2006;116(9):1612–1616
14. Bhandarkar ND, Smith TL. Outcomes of surgery for
inferior turbinate hypertrophy. Curr Opin Otolaryn­
gol Head Neck Surg 2010;18(1):49–53
15. Sozansky J, Houser SM. Pathophysiology of empty
nose syndrome. Laryngoscope 2015;125(1):70–74

373
CHAPTER
26

Alloplastic Implants for Facial Contouring
Alan Yan and Michael J. Yaremchuk
The use of alloplastic implants to restore or improve con­
tour of the facial skeleton was introduced in the 1960s
and 1970s when surgeons used alloplastic materials such
as silastic sponges and solid polyethylene to reconstruct
posttraumatic, postablative, and congenital defects. Be­
cause they were often used in compromised soft tissue
environments, visibility, extrusion, and infection were not
uncommon. At the same time, craniofacial techniques that
advocated extensive osteotomies and the liberal use of
autogenous bone as both interpositional and onlay grafts
were being developed and popularized. In the 1970s and
1980s, Terino, Flowers, and Whitaker saw the potential of
skeletal augmentation with alloplastic materials as an im­
portant element of aesthetic facial enhancement. Using
remote incisions to place biocompatible materials under
well-vascularized soft tissues, they developed techniques
to alter the contours of the facial skeleton reliably. In the
1990s, I (A.Y.), with a background in craniofacial surgery,
used the concepts of wide exposure and rigid fixation for
alloplastic implants to enhance the facial skeleton.
Although alloplastic facial skeletal augmentation can be
a powerful tool to reconstruct or rejuvenate the facial skel­
eton, it is not without risks and complications. A thorough
understanding of the facial anatomy and surgical concepts
will help to minimize and eliminate these unfavorable out­
comes.
Avoiding Unfavorable Results
and Complications Associated
with Alloplastic Facial Skeletal
Augmentation
Summary Box
Problems and Complications Associated with
Alloplastic Facial Skeletal Augmentation
•• Skin asymmetry, malposition of implant
•• Contour deformity
•• Visibility of implant
•• Implant extrusion
•• Nerve injury
•• Soft tissue injury
•• Postoperative hematoma
•• Postoperative infection
The problems and complications associated with alloplas­
tic facial skeletal augmentation are listed. As in any other
surgical procedure, avoidance of unfavorable outcomes
starts with thorough patient assessment, selection, and
careful preoperative planning.

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374
Adjunct to Orthognathic Surgery
Alloplastic implants can enhance the results of certain or­
thognathic surgery procedures, including the LeFort I max­
illary advancement, the sagittal split mandibular osteotomy,
and the sliding genioplasty.2
The Le Fort I advancement may fulfill its functional role
by creating an appropriate occlusal relationship but inad­
equately treats midface hypoplasia since only the lower half
of the midface is advanced. Patients in whom the infraorbital
and malar region were also deficient before Le Fort I osteot­
omy will continue to have these deficiencies postoperatively.
The rim deficiency in the parasagittal plane may be accentu­
ated by the more advanced position of the tooth-bearing Le
Fort segment. This may result in a convexity confined to the
lower half of the midface. Alloplastic augmentation of the
infraorbital rim with or without malar implants can create
the more aesthetic, convex midface.
Posterior mandible implants can camouflage osteotomy-
induced irregularities along the mandibular border as well
as malpositions of the mandibular angles after bilateral sag­
ittal split osteotomy. Chin implants with lateral extensions
or specially designed and strategically placed implants can
correct mandible border contour irregularities after sliding
genioplasty1 (Fig. 26.3).
Patient Selection
Patients with normal, deficient, surgically altered, or trau­
matically deformed anatomy may all benefit from implant
augmentation of their craniofacial skeleton.
Skeletal Enhancement
Most often, facial skeletal augmentation is performed to
enhance facial appearance in patients whose skeletal rela­
tionships are considered within the normal range but prefer
more definition and angularity to their appearance. Other
patients desire to “balance” their facial dimensions.
Alternative to Orthognathic Surgery
Midface and mandibular hypoplasia are common facial skel­
etal variants. These patients have normal occlusion or have
been compensated by orthodontics, with no respiratory or
ocular compromise. Skeletal repositioning would necessi­
tate additional orthodontic tooth movement. Such a time-
consuming, costly, and potentially morbid treatment plan
appeals to few patients. In these patients, the appearance of
skeletal osteotomies and rearrangements can be simulated
through the use of facial implants1 (Figs. 26.1 and 26.2).
Fig. 26.1 (a) Midface concavity and compensated occlusion. (b) Multiple
midface implants provide the same visual effect as a Le Fort III osteotomy
and advancement but do not alter occlusion.
a
b
a
b
Fig. 26.2 (a) Mandibular deficiency with compensated occlusion.
(b) The visual effect of sagittal split osteotomy and horizontal osteot­
omy of the chin with advancement has been simulated with mandible
and chin implants. Note that the class I occlusion is unchanged. The bor­
der irregularities inherent with skeletal osteotomies are avoided when
implants are used.

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Chapter 26 Alloplastic Implants for Facial Contouring
tor), which prove to be of substantial symptomatic relief
and improved periorbital aesthetics.3
Rejuvenation
Traditional concepts of periorbital and midface aging and
rejuvenation focus on the soft tissues. Recently, senescent
changes in the supporting facial skeleton have been inves­
tigated. Findings in these studies revealed retrusion of the
midface skeleton and mandible. This diminution in projec­
tion would hasten the gravitational-induced descent of
their overlying and now less-supported soft tissue enve­
lope.4 Alloplastic skeletal augmentation can both restore
skeletal contours and support the overlying soft tissue en­
velope5 (Fig. 26.4). Provision of these functions supports
the concept of selective alloplastic augmentation of the fa­
cial skeleton as part of the algorithm for facial rejuvenation
and enhancement. Selective augmentation of the infraor­
bital rim and malar and piriform aperture of the aging mid­
face skeleton can mimic the contours of its youthful coun­
Graves’ Ophthalmopathy
Graves’ ophthalmopathy is a chronic autoimmune condi­
tion that usually affects both orbits and involves all orbital
tissue compartments, including the extraocular muscles,
periorbital connective fatty tissue, and lacrimal gland. The
clinical signs and symptoms of Graves’ ophthalmopathy
reflect the mechanical consequences of increased orbital
tissue volume and pressure within the orbit. These conse­
quences lead to an abnormal and symptomatic protrusion
of the globes from the orbits. Clinical findings are proptosis,
impaired ocular motility, diplopia, lid retraction, and im­
paired visual acuity up to optic neuropathy, with menacing
blindness. In cases of moderate to severe proptosis, favor­
ing severity (when the relationship of the anteriormost
point of the cornea to the malar eminence is of a significant
negative vector), augmentation of the craniofacial skeleton
with an infraorbital rim implant and a subperiosteal mid­
face lift at the malar eminence effectively increase orbital
volume and globe lid coverage (reversing the negative vec­
Fig. 26.3 Infraorbital rim implants create upper midface con­
vexity to compensate for lower midface advancement. Poste­
rior mandible implants can camouflage osteotomy-induced ir­
regularities along the mandibular border as well as malpositions
of the mandibular angles. Chin implants can correct mandible
border contour irregularities after sliding genioplasty.
Fig. 26.4 The placement of infraorbital rim implant on an aged orbit creates contours that mimic a youthful orbit. (a) Computed tomog­
raphy of a youthful face and orbit. (b) Computed tomography of an aged orbit. (c) Implant augmentation of the infraorbital rim restores
a youthful orbital contour. (Reproduced from Yaremchuk MJ, Kahn DM. Periorbital skeletal augmentation to improve blepharoplasty and
midfacial results. Plast Reconstr Surg 2009;124(6):2151–2160.)
a
b
c

SECTION IV AESTHETIC SURGERY
376
Neoclassical Canons and Facial
Anthropometries
For the purposes of painting and sculpture, Renaissance
scholars and artists formulated ideal proportions and rela­
tions of the head and face based largely on classical Greek
canons. Although frequently referenced in discussion of
facial skeletal augmentation, these idealized neoclassical
canons have a limited role in surgical evaluation and plan­
ning. When the dimensions of normal males and females
were evaluated and compared with these artistic ideals, it
was found that some theoretic proportions are never found,
and others are one of many variations found in healthy
normal people, or those determined more attractive than
normal.6 The neoclassical canons do not account for facial
dimensions that are known to differ with sex and age. Most
of these canons of proportion (e.g., the width of the upper
face is equal to five eye-widths) are interesting but hold
for few individuals and cannot be obtained surgically or, if
obtainable, only with extremely sophisticated craniofacial
procedures. For these reasons, we have found it more useful
to use the anthropometric measurements of normal indi­
viduals to guide our selection of implants for facial skeletal
augmentation. Normal-dimensioned faces are intrinsically
balanced; that is, the relations between the various areas of
the face relate to one another in a way that is not distracting
to the observer. By comparing a patient’s dimensions to the
average, the surgeon has some objective basis as to what
anatomic areas may be amenable to augmentation, and by
how much.
Radiology
In general, the decision as to the size and position of the
implant are largely aesthetic judgments, and most aesthetic
procedures are done without preoperative radiology as­
sessment. Cephalometric radiographs are most often used
for planning chin and mandible augmentation surgery.
These studies define skeletal dimensions and asymmetries
as well as the thickness of the chin pad. With the advent of
patient-specific custom implants using computer-assisted
design (CAD) and computer-assisted manufacturing (CAM)
technology, preoperative medical computed tomography
(CT) or office-based cone beam CT (CBCT) is obtained for
each patient to reconstruct a virtual three-dimensional
model of the facial skeleton. This allows for millimeter
assessment of the contour deformity: symmetry, height,
width, projection, and its relationship to the entire facial
skeleton. By applying knowledge of the normal skeletal re­
lationship and aesthetic criteria, virtual surgery can be per­
formed, and patient-specific custom implants are designed
to provide the optimal surgical result.
terpart. Selective augmentation of the chin and mandible
can restore youthful contours of the lower jaw.
Skeletal Versus Soft Tissue Augmentation
Both the soft tissues and the facial skeleton contribute to
facial contour and are affected by the aging process; there­
fore soft tissue augmentation (free fat grafting, fillers) and
alloplastic skeletal augmentation can be used to restore
youthful facial contours. However, these two modalities
are not equivalent in their impact on facial appearance.
Free fat grafting and the injection of various fillers are in­
tuitive for the restoration of soft tissue volume from senile
atrophy. They have a limited role in simulating the effect
of an increase in skeletal projection. Whereas augmenting
the facial skeleton results in an increase in the projection of
the skeleton, augmenting the soft tissue volume results in
an inflation of the soft tissue envelope and blunting of the
contours of the skeleton. Overly aggressive augmentation of
either component makes this point obvious: If excessively
large implants were placed on the skeleton, the appearance
would be too defined and, ultimately, skeletal. If too much
fat were placed in the soft tissue envelope, an increasingly
spherical and otherwise undefined shape would result.
Preoperative Assessment and
Planning
For patients who present with reconstructive problems,
implant surgery is performed to return the involved area
to its original appearance, or, if that is not possible, to cre­
ate a face that is symmetrical and accepted as normal. For
patients presenting for aesthetic enhancement, the surgi­
cal goal is more arbitrary. Because implant augmentation
of the facial skeleton results in measurable changes in facial
dimensions and proportions, it is intuitively advisable and
appropriate to use facial measurement and proportion to
evaluate the face and to help guide surgery.
Physical Examination
Physical examination remains the most important element
of preoperative assessment and planning. Reviewing life-
size photographs with the patient can be helpful when
discussing aesthetic concerns and goals as well as demon­
strating the asymmetries common to all faces. The recogni­
tion of facial asymmetries is important to the surgeon in
preoperative planning and to the patient in anticipating the
postoperative result. Facial asymmetries are more complex
than relative skeletal deficiencies or excess; rather, they
reflect three-dimensional differences that are most easily
conceptualized as “twists” of the facial skeleton that can
only be partially compensated for with surgery.

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Chapter 26 Alloplastic Implants for Facial Contouring
lows fibrous tissue growth into the surface of the implant.
This porous characteristic has both advantages and disad­
vantages. Soft tissue ingrowth decreases the tendency for
the implant to migrate and to erode underlying bone. Po­
rosity also allows some flexibility and adaptability of the
implant. However, porosity causes soft tissue to adhere to
the implant, making placement more difficult and requir­
ing a larger pocket to be made than with smooth implants.
The soft tissue ingrowth also makes implant removal more
difficult. The firm consistency of porous polyethylene al­
lows it to be easily fixed with screws and contoured with a
scalpel or power equipment without fragmenting.
Requisites of Implant Shape,
Positioning, and Immobilization
Shape
The external shape of the implant should mimic the de­
sired shape of the bone it is augmenting. Its posterior sur­
face should mold to the bone to which it is applied. The
implant margins must taper imperceptibly into the native
skeleton so that they are neither visible nor palpable.
Positioning
Although some surgeons prefer to place implants in a soft
tissue pocket, clinical experience has led us to adopt a sub­
periosteal approach. Placement in a subperiosteal pocket
involves a dissection that is safe to peripheral nerves and
is relatively bloodless. It allows visualization and, therefore,
more precise augmentation of the skeletal contour. The size
of the pocket will be determined by the type of implant
used and its method of immobilization. The long-standing
teaching for using smooth silicone implants is to make a
pocket just large enough to accommodate the implant and,
therefore, guarantee its position. Porous implants require
a larger pocket because they adhere to the soft tissues
during their placement. Whether using smooth or porous
implants, I (A.Y.) dissect widely to visualize the complex
three-dimensional topography of the skeletal anatomy be­
ing augmented. This panoramic exposure allows more pre­
cise, symmetrical implant positioning.
Immobilization
Facial implants should be immobilized. Although it is com­
mon practice to stabilize the implant by suturing it to sur­
rounding soft tissues or by using temporary transcutane­
ous pull-out sutures, screw fixation of the implant to the
facial skeleton is preferred. Screw fixation prevents any
movement of the implant and also ensures application of
the implant to the surface of the bone. Because each facial
skeleton has a unique and varying surface topography, a
nonconforming implant will leave gaps between the im­
Implant Materials
Implant materials used for facial skeletal augmentation are
biocompatible—that is, there is an acceptable reaction be­
tween the material and the host. In general, the host has
little or no enzymatic ability to degrade the implant, with
the result that the implant tends to maintain its volume
and shape. Likewise, the implant has a small and predict­
able effect on the host tissues that surround it. This type
of relationship has an advantage over the use of autog­
enous bone or cartilage, which, when revascularized, will
be remodeled to varying degrees, thereby changing volume
and shape. The alloplastic implants presently used for fa­
cial reconstruction have not been shown to have any toxic
effects on the host.7 The host responds to these materials
by isolating the implant in the form of a fibrous capsule
around the implant. The most important implant charac­
teristic that determines the nature of the encapsulation
is the implant’s surface characteristics. Smooth implants
result in the formation of smooth-walled capsules. Porous
implants allow varying degrees of soft tissue ingrowth that
result in a less-dense and less-defined capsule. It is a clini­
cal impression that porous implants, as a result of fibrous
incorporation rather than encapsulation, have a lower ten­
dency to erode underlying bone or migrate due to soft tis­
sue mechanical forces and, perhaps, are less susceptible to
infection when challenged with an inoculum of bacteria.
The most commonly used, commercially available materi­
als for facial skeletal augmentation are solid silicone, which
has a smooth surface, and porous polyethylene (MEDPOR,
Stryker: Kalamazoo, MI; OMNIPORE, Matrix Surgical: At­
lanta, GA).
Silicone
Solid silicone and the silicone rubber used for facial im­
plants are a vulcanized form of polysiloxane, a polymer
created from interlinking silicone and oxygen with methyl
side groups. Silicone implants have several advantages:
they are easily sterilized by steam or irradiation; they can
be carved with either scissors or scalpel; and they can be
stabilized with a screw or suture. There are no known clini­
cal or allergic reactions to silicone implants. Because they
have a smooth surface, there is no soft tissue ingrowth, al­
lowing them to be easily removed. Disadvantages to sili­
cone implants include the tendency to cause resorption of
underlying bone, the potential to migrate if not fixed to the
underlying skeleton, and the likelihood of visibility of the
fibrous capsule when placed under a thin soft tissue en­
velope.
Polyethylene
Polyethylene is a simple carbon chain of ethylene mono­
mer. Polyethylene used for facial implants is porous, with
intramaterial porosity between 125 and 250 µm, which al­

SECTION IV AESTHETIC SURGERY
378
bital rim, the malar area, and the piriform aperture. Each
zone is amenable to augmentation alone or in combination.
Infraorbital Rim
Indications for infraorbital rim implants include patients
who are “morphologically prone”8 to lower lid malposition
because of a retrusive upper midface skeleton and patients
with a negative vector relationship between the globe and
infraorbital rim as described by Jelks and Jelks.9 Infraor­
bital rim augmentation can “reverse the negative vector”
(Fig. 26.5) and is part of the strategy for normalizing the
appearance in morphologically prone patients who are
first seeking improvement in their periorbital appearance
or for those whose lid malposition and round-eye appear­
ance have been exaggerated by previous lower blepharo­
plasty.10,11
plants and the skeleton. Gaps are problematic for two rea­
sons. The space between the implant and the skeleton is
equivalent to an additional augmentation. This can lead
to unanticipated increased augmentation and asymmetry.
Gaps are also potential dead space for hematoma and se­
roma formation. Screw fixation allows for final contouring
with the implant in position. This final contouring is par­
ticularly important where the implant interfaces with the
skeleton. Any step-off between the implant and the skel­
eton will be palpable and visible in patients with thin soft
tissue cover.
Midface Skeletal Augmentation
Virtually all aesthetic augmentation is performed on the
middle and lower thirds of the facial skeleton. The midface
is best conceptualized as having three zones: the infraor­
Fig. 26.6 Overview of operation to increase projection of infraorbital rim
and “reverse the negative vector” in patients with upper midface skel­
etal deficiency. A transconjunctival retroseptal incision (broken red line)
and, if necessary, the lateral extent of a lower lid blepharoplasty incision
(solid line) are preferred to expose the infraorbital rim. This approach
preserves the integrity of the lateral canthus and hence the palpebral
fissure. Transcutaneous blepharoplasty or transconjunctival blepharo­
plasty with lateral canthotomy incisions are alternative approaches that
provide greater exposure but are accompanied by a greater risk of pal­
pebral fissure distortion. An intraoral incision is used to access the lower
midface skeleton and to identify and protect the infraorbital nerve. The
lower lid and midface soft tissues are freed by subperiosteal dissection.
The implant is immobilized with titanium screws.
Infraorbital
nerve
Subperiosteal
dissection
Incision in
buccal mucosa
Fig. 26.5 Jelks categorized globe–orbital rim relationships by placing a line or “vector” between the most anterior projection of the globe
and the malar eminence and lid margin. (a) In the youthful face with normal globe-to-skeletal rim relations, the cheek mass supported
by the infraorbital rim lies anterior to the surface of the cornea. The position of the cheek prominence beyond the anterior surface of the
cornea is termed a positive vector. (b) In patients with maxillary hypoplasia, the cheek mass lies posterior to the surface of the cornea. The
position of the cheek prominence beyond the anterior surface of the cornea is termed a negative vector. (c) Alloplastic augmentation of the
infraorbital rim can “reverse” the negative vector.
Positive
vector line
Negative
vector line
Reversed
negative vector line
Implant
a
b
c

379
Chapter 26 Alloplastic Implants for Facial Contouring
Malar Area
Malar implant augmentation is often performed because
full cheeks are associated with a youthful look and promi­
nent malar bones are considered attractive. Patients with
malar hypoplasia may also benefit from malar augmenta­
tion. However, the lack of anthropometric and cephalo­
metric landmarks precludes the availability of normative
data, making analysis and augmentation of the malar area
largely subjective. Malar deficiency is often part of a gen­
eralized midface deficiency for which malar augmentation
alone may be inadequate or even inappropriate treatment.
Clinical experience has shown that when malar projection
is deemed inadequate, malar augmentation is most effec­
tive when it re-creates the contours of a normal skeleton
with prominent anterior projection.
Surgical Technique
The infraorbital rim and adjacent anatomy must be exposed
sufficiently to ensure ideal implant placement, impercep­
tible implant–facial skeleton transition, and screw fixation.
We prefer to use a transconjunctival incision together with
an intraoral sulcus incision to expose the entire midface
skeleton in the subperiosteal plane. The infraorbital nerve
is identified as it exits from the infraorbital foramen, which
is located about 1 cm below the margin of the orbit in
the midpupillary line.12 The implants are carved to fit the
specific needs of the patient and are fixed with titanium
screws. The cheek soft tissue mass is often resuspended by
sutures tied to the rim implant (subperiosteal midface lift).
This technique is summarized in1 Fig. 26.6. A clinical ex­
ample is shown in Fig. 26.7.5
Fig. 26.7 (a,b) This 52-year-old woman had undergone previous browlift, rhytidectomy, and upper and lower lid blepharoplasty. Lower lid
retraction was treated by multiple canthopexies, spacer grafts, and full-thickness skin grafts. Dry eye symptoms persisted. Infraorbital rim
augmentation, midface lift, and lateral canthopexy resolved her symptoms. Her brows and hairline were repositioned. (c,d) The procedure
transformed the preoperative negative vector to a positive vector globe–rim relationship. The vertical lines define the globe–rim relation­
ship. (Reproduced from Yaremchuk MJ, Kahn DM. Periorbital skeletal augmentation to improve blepharoplasty and midfacial results. Plast
Reconstr Surg 2009;124(6):2151–2160.)
a
b
c
d

SECTION IV AESTHETIC SURGERY
380
underlying skeleton (Fig. 26.8). A clinical example is shown
in Fig. 26.9.1
Piriform Aperture
The face of individuals of Western European descent is typ­
ically convex. A relative deficiency in lower midface projec­
tion may be congenital or acquired, particularly after cleft
surgery and trauma. Patients with satisfactory occlusion
but lower midface concavity can have their aesthetic look
improved with piriform aperture augmentation, which
simulates the visual effect of Le Fort I advancement and
other skeletal manipulations. Piriform aperture augmenta­
Surgical Technique
Malar augmentation can be performed through intraoral,
coronal, or eyelid incisions or combinations thereof. I (A.Y.)
prefer to access the malar midface through an intraoral ap­
proach (an upper sulcus incision). Transconjunctival and
crow’s-feet incisions are often performed to ensure proper
placement of the superior aspect of the implant. Care is
taken to identify the infraorbital nerve. Subperiosteal dis­
section is carried over the malar eminence and onto the zy­
gomatic arch almost up to the zygomaticotemporal suture.
The pocket size should allow precise insertion of the im­
plant to the area of the skeleton desired for augmentation.
The implants can be stabilized with screw fixation to the
Fig. 26.8 Overview of the operative technique for malar augmentation. The upper sulcus incision is at least 1 cm above the apex so that
sufficient tissue is available for closure. Transconjunctival and crow’s-feet incisions ensure proper placement of the superior aspect of the
implant. The infraorbital nerve is identified, and the subperiosteal dissection is carried over the malar eminence and on to the zygomatic
arch just beyond the zygomaticotemporal suture. Registration tabs on the implant rest on the lateral aspect of the infraorbital rim and su­
perior aspect of the zygomatic arch and decrease the likelihood of asymmetrical implant placement. Implants are fixed with titanium screws
for immobilization and for obliteration of the dead space between the posterior surface of the implant and the anterior surface of the facial
skeleton. The implants are contoured so that they are identical in size and shape, are appropriate for the area to be augmented, and merge
imperceptibly with the native skeleton. A trochar-attached suction drain is placed. It exits through the temporal hair-bearing scalp or the
postauricular area. The colored area denotes the area of subperiosteal dissection. The implant usually extends from the temporozygomatic
suture on the zygomatic arch to just below the foramen of the infraorbital nerve.

381
Chapter 26 Alloplastic Implants for Facial Contouring
Fig. 26.9 This 48-year-old woman underwent an infraorbital rim, malar, chin, and mandible implant augmentation, together with a
browlift reversal and midface lift. (a) Preoperatively, the patient had already undergone a browlift, blepharoplasty, and rhytidectomy.
(b) Result at 1 year postoperatively. (Reproduced from Yaremchuk MJ. Skeletal augmentation. In: Neligan P, ed. Plastic Surgery, Vol 2. 3rd
ed. London: Elsevier; 2012.)
a
b
Fig. 26.10 The effects of piriform aperture implant on the profile
and nasolabial angle.
tion also increases the projection of the nasal base, thereby
opening the nasolabial angle.13 Finally, it lessens the depth
of the nasolabial fold by effacing it from below (Fig. 26.10).1
Surgical Technique
An intraoral incision is made approximately 1 cm above
the sulcus, the medial extent of which is made just lateral
to the piriform aperture to avoid placing incisions directly
over the implant. Subperiosteal dissection exposes the
area to be augmented, and the infraorbital nerve is identi­
fied and preserved. The patient’s anatomy will determine
whether the entire crescent, or just the horizontal or verti­
cal limb of the crescent-shaped implant, will be used. The
root of the canine should be avoided if the implant is im­
mobilized with screws. The implant may compromise the
nasal airway if positioned over the piriform aperture. The
technique is illustrated in Fig. 26.11.1 A patient who under­
went aesthetic rhinoplasty and augmentation of the piri­
form aperture area is shown in Fig. 26.12.1

SECTION IV AESTHETIC SURGERY
382
Fig. 26.11 Overview of paranasal implant surgery. The purple area indicates the area of subperiosteal dissection. Note proximity of infra­
orbital nerve. Note that the root of the canine tooth lies below the area to be augmented. It must be avoided during screw immobilization
of the implant.
Subperiosteal
dissection
Canine root
Incision in
buccal mucosa
Fig. 26.12 (a,b) This 20-year-old woman underwent rhinoplasty and paranasal augmentation. (c,d) The skeletal augmentation increased
the nasolabial angle. Because midface concavity tends to increase the relative projection of the nose, creating midface convexity tends to
lessen the relative projection of the nose. (Reproduced from Yaremchuk MJ. Skeletal augmentation. In: Neligan P, ed. Plastic Surgery. Vol
2. 3rd ed. London: Elsevier; 2012.)
a
b
c
d

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Chapter 26 Alloplastic Implants for Facial Contouring
Visibility of Implant
Visibility of malar implants results from an improper im­
plant size or encapsulation of a smooth-surface implant by
the host’s foreign body response. Although implants with
greater projection are available, we rarely use malar im­
plants with more than 4 mm of augmentation at the point
of maximum projection. Larger implants may become obvi­
ous with time as the overlying soft tissues atrophy and sag.
The capsule formation that accompanies smooth-surface
implants further exaggerates the tendency toward implant
visibility. In my (A.Y.) experience, implants with large sur­
face areas do not mimic natural skeletal topography and
cause unnatural implant-dictated contours.
The operative strategy for visible malar implants is largely
determined by the patient’s concerns and the interval be­
tween implant placement and patient presentation. If revision
surgery is pursued within weeks to months of the original
surgery, implant removal, repositioning, or replacement alone
may be appropriate.18 When implants have been in place long
enough to be visually encapsulated, revision surgery becomes
more complex. The capsule, scar tissue mimicking the con­
tours of the implant, permanently distorts the soft tissue en­
velope. Its impact on the appearance of the cheek will depend
on the size and projection of the implant, and the thickness of
the overlying cheek soft tissue will become thinner. Moreover,
Unfavorable Outcomes and Complications
of Midface Skeletal Augmentation
Asymmetry or Malposition of the Implant
A review of the literature shows that there is a high inci­
dence of revision surgery after alloplastic malar augmen­
tation.14–16 Asymmetry is the most common complaint
after malar implant augmentation (Fig. 26.13), followed
by malposition of the implants where they are placed too
low.17 Although treatment consists of secondary surgery to
replace or reposition the malar implants, such unfavorable
results can be minimized by obtaining adequate skeletal
site exposure during primary surgery to ensure accurate
implant placement and screw fixation. More recently, im­
plant designs include registration tabs that rest on the lat­
eral aspect of the infraorbital rim and superior aspect of the
zygomatic arch (see Fig. 26.8). Placement of the implants
on fixed anatomic landmarks decreases the likelihood of
asymmetrical implant placement.
Patients with midface hypoplasia often require augmen­
tation of both the infraorbital rim and malar eminence. The
advent of custom implants using CAD–CAM technology al­
low precise preoperative planning, better fit, and more pre­
dictable postoperative facial contour than stock implants. A
clinical example is shown in Fig. 26.14.
Fig. 26.13 The most common complication after malar
augmentation is asymmetry, as shown here on comput­
ed tomography. Treatment consists of revision surgery
to replace or reposition the implants.
Fig. 26.14 Midface hypoplasia. (a,b) Preoperative three-dimensional image of the facial skeleton. (c,d) The design of a custom malar–
infraorbital rim implant using computer-assisted design and manufacturing technology.
a
b
c
d

SECTION IV AESTHETIC SURGERY
384
the infraorbital nerve travel supraperiosteally before they
pass into a superficial plane20 (Fig. 26.16). Postoperative
paresthesia in the infraorbital nerve distribution is often
transient and requires no further surgical intervention. Im­
pingement of the nerve because of improper implant place­
ment, however, requires surgical exploration and removal
or repositioning of the implant.
The zygomaticofacial nerve exits through its foramen on
the lateral aspect of the zygoma at 8 to 10 mm beneath the
infraorbital rim and in line with the lateral orbital rim. It sup­
plies a small portion of the skin of the upper cheek. Whereas
the infraorbital nerve must be protected during a subperios­
teal midface lift, the zygomaticofacial nerve can be sacrificed,
with the ensuing sensory loss rarely noted by the patient.
Extrusion
Extrusion of midface implants is rare. Piriform aperture im­
plants do have a higher chance of extrusion than malar or
infraorbital rim implants. This complication can be mini­
mized by placing the medial extent of the upper buccal sul­
the contour distortion may be exaggerated implant-induced
bone erosion, with subsequent loss of skeletal projection. In
these cases, after removing the offending malar implants and
replacing them with ones of appropriate size and shape, the
soft tissue distortion is then treated by repositioning of the
midface soft tissues via a subperiosteal midface lift.17,19 A clin­
ical example is shown in Fig. 26.15.
Nerve Injury in Midface Skeletal
Augmentation
Injury to the infraorbital nerve from midface skeletal aug­
mentation can happen, but it is transient in most cases. It
is imperative to identify the infraorbital foramen and nerve
during surgical exposure and after implant placement to
ensure no nerve impingement has occurred. The infraor­
bital nerve exits the infraorbital foramen approximately 9.4
(±1.8) mm below the infraorbital rim.20 It then divides into
an average of 5.2 branches: lower eyelid, alar, medial upper
lip, lateral upper lip, and lateral cheek, with a second alar
branch present 14% of the time. The terminal branches of
Fig. 26.15 (a,b) This 64-year-old woman was displeased
with her midface appearance after malar implant surgery
performed 15 years previously. The implants were placed
too far laterally, they were uneven, and they showed
through the skin. The patient had also had upper and lower
lid blepharoplasty and rhytidectomy in the past. Her lower
lid retraction was symptomatic. The combination of capsule
formation around a large, smooth-surface implant and soft
tissue atrophy with aging resulted in an overly prominent,
unnatural contour. Corrective surgery included implant re­
moval; onlay augmentation of the areas of bone resorption
with custom-carved, screw-fixed, porous polyethylene im­
plants; subperiosteal midface elevation; and lateral cantho­
pexy. (c,d) Results 2 years postoperatively.
a
b
c
d

385
Chapter 26 Alloplastic Implants for Facial Contouring
Technique
The midline of the chin is marked as a reference point. The
chin is accessed through either a submental or intraoral
incision; we prefer the submental approach. Subperiosteal
dissection should extend approximately 1 cm beyond the
area of augmentation to provide a panoramic view of the
complex and varying contours of the mandible, thereby
allowing precise implant placement. Porous polyethylene
implants consisting of two half pieces connected by a tab
insert allow the inferior border of the implant to mimic the
inclination of the inferior border of the mandible. In certain
implant designs, symmetrical placement is aided by reg­
istration tabs to the inferior border of the mandible. The
implant is immobilized with titanium screws1 (Fig. 26.17,
Videos 26.1 and 26.2). Clinical examples of alloplastic aug­
mentation of the chin are shown in Fig. 26.18.1
cus incision lateral to the piriform aperture to avoid having
the implant lie directly underneath the incision.
Mandible Implants
Each of the anatomic areas of the mandible—chin, body,
angle, and ramus—may be deficient and is amenable to
augmentation with alloplastic materials.
Chin
There is consensus that the ideal profile relation portrays
a convex face with the upper lip projecting approximately
2 mm beyond the lower lip, and the lower lip projecting
approximately 2 mm beyond the chin.21 On average, men
tend to have larger, more projecting chins than women.22
In addition, the male chin tends to have a more square ap­
pearance than that of the female.
Fig. 26.16 The infraorbital nerve fascicles run on
the anterior maxillary periosteum after exiting
the infraorbital foramen (a), and the fascicles are
shown entering the subcutaneous tissues (b).
The arrows indicate the point of elevation from
the periosteum. (Reproduced from Doumit G,
Gharb BB, Rampazzo A, et al. Surgical anatomy
relevant to the transpalpebral subperiosteal ele­
vation of the midface. Aesthet Surg J 2015;35(4):
353–358.)
a
b
Fig. 26.17 Screw fixation of the implant to the mandible prevents implant movement and obliterates gaps between the implant and ante­
rior surface of the mandible. Screw fixation also allows in-place contouring of the implant to ensure desired contour and an imperceptible
implant–skeleton transition. (a) “In-place” contouring of the implant fixed to the mandible with titanium screws. (b) A screw-fixed two-
piece porous polyethylene chin implant exposed through a submental incision. (b Reproduced from Yaremchuk MJ. Skeletal augmentation.
In: Neligan P, ed. Plastic Surgery. Vol 2. 3rd ed. London: Elsevier; 2012.)
b
Contouring
distal transition
Screw fixation
a

SECTION IV AESTHETIC SURGERY
386
Patients with mandibular deficiency who have had their
malocclusion treated with orthodontics may benefit from
mandible implants to correct the obtuse mandibular angle
and steep mandibular plane, as well as the decreased verti­
cal and transverse ramus dimensions1 (Fig. 26.19). The addi­
tion of an extended chin implant will camouflage the poorly
projecting chin.
Patients who have undergone orthognathic surgery of­
ten have contour irregularities after skeletal osteotomy and
rearrangement. Posterior mandible implants can camouflage
osteotomy-induced irregularities and malposition. Implants
are also available to correct border irregularities after slid­
Ramus, Angle, and Body
Aside from chin augmentation, three patient populations
may benefit from other mandibular augmentation proce­
dures. One group has mandibular dimensions that relate
poorly to the upper and middle thirds of the face but are
within normal range. These patients perceive a wider lower
face as an enhancement to their appearance and often pre­
sent with a desire to have a defined, angular lower face.
They benefit from implants designed to augment the ra­
mus and posterior body of the mandible and, in so doing,
increase the bigonial distance or lower facial width.
Fig. 26.18 (a,b) This 35-year-old woman with mi­
crogenia underwent chin augmentation with an allo­
plastic implant. (c,d) Results 1 year postoperatively.
(Reproduced from Yaremchuk MJ. Skeletal augmen­
tation. In: Neligan P, ed. Plastic Surgery. Vol 2. 3rd
ed. London: Elsevier; 2012.)
a
b
c
d
A
B
B
C
D F
E
Fig. 26.19 Configuration of an implant used to augment a deficient mandible. Because
it extends beyond the posterior border of the ramus and inferior edge of the ramus
and body, it closes the mandibular angle and levels the plane of the mandibular border.
Screw fixation guarantees the position and ensures application of the implant to the
skeleton. Typical implant dimensions are as follows: A = 10 mm; B = 32 mm; C = 5 or
10 mm; D = 7 mm; E = 10 mm.

387
Chapter 26 Alloplastic Implants for Facial Contouring
augmented, a submental incision is made for access and ex­
posure of the anterior mandible. The mental nerve is visual­
ized as it exits its foramen to avoid injury. It is important to
free both the inferior and posterior borders of the mandible
off soft tissue attachments to allow implant placement. To
ensure proper placement of the implant and its application
to the surface of the mandible, the implant is fixed to the
mandible with titanium screws placed intraorally or trans­
cutaneously. Screw fixation of the implants also allows fi­
nal contouring with a scalpel or mechanical burr with the
implants in place. A small suction drain is placed at the op­
ing genioplasty. Significant orthognathic surgery–induced
asymmetries are best managed with CAD–CAM implants
(Fig. 26.20).
Technique
An intraoral incision is made to expose the ramus and body
of the mandible. It is made at least 1 cm above the sulcus on
its labial side. The anterior ramus and body of the mandible
are freed in the subperiosteal plane from their overlying
soft tissues1 (Fig. 26.21). If the mental area is also being
Fig. 26.20 (a,b) This 36-year-old man with a history
of micrognathia presented with contour deformity
of the mandible after Le Fort I advancement, bilat­
eral sagittal split osteotomy, and sliding genioplasty.
A computer-assisted design, computer-assisted
manufacturing (CAD–CAM) custom chin–mandible
implant was designed to correct the mandibular
contour deformity and to improve the projection
of his chin. (c) Preoperative three-dimensional im­
age of the facial skeleton. (d) Design of the custom
chin–mandible implant using CAD–CAM technol­
ogy. (e,f) Postoperative result.
a
b
e
f
c
d
Fig. 26.21 An intraoral mucosal incision is made along the ramus and
posterior body of the mandible. It is made approximately 1 cm above the
sulcus on its labial side. A subperiosteal pocket is created for placement
of the mandible implant.

SECTION IV AESTHETIC SURGERY
388
ated a stuck-on appearance because of failure of the lateral
aspect of the implant to merge with the anterior aspect of
the mandibular body1 (Fig. 26.23). “Extended” chin im­
plants with tapered lateral extensions were later designed
to allow the chin implant to merge better with more lateral
mandibular contours.24 However, as implants become larger
with more complex three-dimensional configurations, they
are often less likely to fit the needs of a given patient. A one-
piece chin implant with lateral extensions is unlikely to have
an arc, projection, and inclination appropriate for every man­
dible. Furthermore, with one-piece implants, asymmetry in
horizontal positioning increases as one proceeds laterally. It
erative site and exits through the skin behind the ear. The
incision is closed in two layers with absorbable sutures.23 A
clinical example is shown in Fig. 26.22.1
Unfavorable Results and Complications
from Mandible Implants
Contour Deformity or Asymmetry
An unaesthetic outcome from alloplastic chin augmentation
is typically a result of improper choice or design of implant.
Early implants that augmented only the mentum often cre­
Fig. 26.22 (a,b) This 28-year-old woman with micro­
gnathia underwent horizontal osteotomy of the chin
with lengthening as well as placement of chin and
mandible implants. (c,d) Postoperative result. (Repro­
duced from Yaremchuk MJ. Skeletal augmentation. In:
Neligan P, ed. Plastic Surgery. Vol 2. 3rd ed. London:
Elsevier; 2012.)
a
b
c
d
Fig. 26.23 (a) A large button chin implant resulting in (b) a poor implant–mandible transition with a stuck-on appearance. (b Reproduced
from Yaremchuk MJ. Skeletal augmentation. In: Neligan P, ed. Plastic Surgery. Vol 2. 3rd ed. London: Elsevier.; 2012)
b
Button implant
a

389
Chapter 26 Alloplastic Implants for Facial Contouring
malposition of implants and lower lip dysfunction result­
ing from mentalis muscle division or detachment.21 After
reviewing his series of more than 100 cases of postopera­
tive chin problems, Zide25 noted that almost all chin implant
problems that he had encountered were caused by implants
that were placed intraorally. These patients often present
with increased lower incisor show, a deep sulcus, and chin
pad ptosis (Fig. 26.26). The submental approach, coupled
with an extended dissection, avoids damage to the mentalis
muscle and allows better visualization of the mental nerve.
When correcting chin ptosis and lip descent related to
mentalis disruption, I (A.Y.) prefer to access the chin via
an intraoral approach and free up the soft tissue around
is not uncommon to find one end of an extended silicone
implant impinging on the mental nerve, while the other end
extends beyond the edge of the mandibular border1 (Fig.
26.24). A two-piece chin implant allows adaptation of each
of these parameters for a given mandible1,21 (Fig. 26.25).
Injury to the Lower Lip Elevator and
Retractors
Placement of chin implants via the intraoral approach avoids
a cutaneous scar but provides limited exposure to the men­
ton while compromising the mentalis muscle. As a result,
the intraoral approach can be associated with superior
Fig. 26.24 A malpositioned one-piece extended implant. (a) When placed through an intraoral approach, it is common for one end to ex­
tend beyond the mandibular border while the other end impinges upon the mental nerve. (b) The extended one-piece implant protrudes
beyond the mandibular border (arrow).
b
Ill-adapting and mobile
one-piece implant
a
Fig. 26.25 Two-piece chin implant placed in a subperiosteal pocket. Note
the two-piece design, which allows the lateral extension of the implant to
follow the inclination of the mandibular border. Because the contour of the
posterior surface of the implant does not mimic the contour of the ante­
rior surface of the mandible, there is a gap between the mandible and the
implant.
Two-piece implant
Gap before
fixation

SECTION IV AESTHETIC SURGERY
390
lip. The platysma muscle sends fibers that originate from the
mandible beneath the oblique line and merge with the lip
depressors. Subperiosteal dissection separates these muscles
as a continuum from the bone. However, failure to do so may
cause damage, usually short-lived, to these muscles. Clini­
cally this injury mimics that of marginal mandibular branch
palsy because the marginal branch of the facial nerve inner­
vates the lower lip depressors. Transient palsy to this mus­
culature may last 1 to 2 weeks after primary surgery and 2
to 3 months after revision surgeries (Fig. 26.27).
the lowered sulcus. An anchored suture placed between
the tooth roots is used to reattach the mentalis muscle to
its origin. A submental incision is often required to ade­
quately mobilize the adherent soft tissues and to reposi­
tion the chin pad.
The depressor anguli oris (triangularis), the depressor
labii inferioris (quadratus), and the platysma are all depres­
sors of the lower lip. The depressor labii inferioris and de­
pressor anguli oris arise from the oblique line of the mandi­
ble and merge with the orbicularis oris and skin of the lower
Fig. 26.26 This patient’s mentalis muscle was di­
vided or stripped and not properly reapproximated
during an intraoral approach for chin augmentation.
(a) Lower lip malposition at rest. (b) Deepened sul­
cus.
a
b
Fig. 26.27 (a) Palsy of right lower lip depressors
2 weeks after third-degree chin implant surgery.
(b) Resolution of symptoms 10 weeks postopera­
tively.
a
b
Fig. 26.28 The pterygomasseteric sling and the effects of its disruption. (a) At the inferior border of the mandible, both the masseter and
medial pterygoid muscles have strong tendinous insertions that form the pterygomasseteric sling. (b) The pterygomasseteric sling has
been disrupted during exposure of the inferior border of the mandible for placement of a mandibular angle implant. (c) Contraction of
the masseter elevates the disinserted edge of the muscle, resulting in a skeletonized area over the implant and a soft tissue bulge above it.
Periosteal tear
Masseter
Medial pterygoid
Periosteum
Mandibular
implant
Contracted
masseter
a
b
c

391
Chapter 26 Alloplastic Implants for Facial Contouring
average of 4.5 mm under the mental foramen, advances 5
mm anteriorly, loops, and ends at the foramen. Knowledge
of the course and location of the inferior alveolar nerve
is important when placing screws in the mandible. They
should be placed at least 6 mm beneath the foramen. Af­
ter exiting the foramen, the mental nerve divides into two
or three branches to supply sensation to the mucosa and
the skin of the lower lip and chin. During alloplastic chin
augmentation, a wide dissection will allow clear identifi­
cation and protection of the mental nerve. Postoperative
paresthesia in the mental nerve distribution is most likely
caused by neuropraxia and is usually transient; impinge­
ment of the nerve, however, requires surgical exploration
and removal or repositioning of the implant.
Injury to the Pterygomasseteric Sling
The masseter muscle originates from the inferior border
and medial surface of the zygomatic arch. It inserts broadly
onto the lateral surface of the ramus of the mandible and
the coronoid process. The medial pterygoid originates from
the region of the lateral pterygoid plate and inserts onto
the medial surface of the ramus. Both the masseter and
medial pterygoid muscles have strong tendinous insertions
that adhere in proximity to the periosteum and at the infe­
rior border of the mandible, often referred to as the ptery­
gomasseteric sling. It is important to limit disruption of the
pterygomasseteric sling when freeing the inferior border of
the posterior mandible for angle augmentation. Disruption
of the sling can result in a loss of soft tissue. Subsequent
contraction of the masseter elevates the disinserted edge
of the muscle, increases the skeletonized area, and exag­
gerates the deficiency by causing a soft tissue bulge26 (Fig.
26.28).
Masseter reattachment requires exposure of the inferior
border of the mandible and mobilization of both the anterior
and posterior surfaces of the masseter muscle. The inferior
border of the mandible is therefore approached through a
Risdon incision placed just below the angle of the mandible.
The platysma is divided and care is taken to avoid injury to
the marginal branch of the facial nerve or to the facial ar­
tery. After identifying the inferior border of the mandible,
subperiosteal dissection of the anterior surface of the man­
dibular ramus is performed. This allows identification of the
posterior surface and, subsequently, the detached inferior
edge of the superiorly retracted masseter muscle. Drill holes
are placed in the inferior border of the mandible to reattach
the inferior edge of the masseter muscle with a nonabsorb­
able suture26 (Fig. 26.29). If a mandibular angle implant is
present, the muscle can be secured to the inferior edge of the
implant. Additional implants may be required as an onlay to
smooth any residual contour irregularities.
Nerve Injury in Alloplastic Mandibular
Augmentation
A branch of the mandibular nerve (V3), the inferior alveolar
nerve enters the mandibular canal with the inferior alveo­
lar vessels through the mandibular foramen located in the
inner aspect of the mandibular ramus. The neurovascu­
lar bundle courses obliquely from the ramus to the body,
where the mental nerve exits through the mental foramen
at the level of the first or second premolar. Cadaveric stud­
ies show that the mental foramen is located at the level of
the second mandibular premolar tooth in approximately
two thirds of cases.27 Vertically, the mental foramen is lo­
cated almost halfway from the tip of the alveolar process to
the lower border of the mandible, about 1.5 cm above the
mandibular border.28 The terminal mandibular canal is an
Fig. 26.29 Intraoperative masseter reattachment. (a) Through a Ris­
don incision just below the angle of the mandible, the edge of the
masseter has been identified. Sutures have been placed through the
inferior edge of the muscle and through drill holes in the inferior bor­
der of the mandible. (b) The sutures have been tied down, bringing
the masseter into a more anatomic position. (c) A piece of acellular
dermal matrix has been sutured over the repair to ensure a smooth
contour. (Reproduced from Thomas MA, Yaremchuk MJ. Masseter
muscle reattachment after mandibular angle surgery. Aesthet Surg
J 2009;29(6):473–476.)
a
b
c

SECTION IV AESTHETIC SURGERY
392
minimal infecting dose of Staphylococcus aureus in an ani­
mal model because of impaired bacterial clearance. If mi­
croorganisms are not eliminated rapidly from an implant
surface they will adhere to the implant initially by nonspe­
cific physical forces and then by the formation of biofilms
characterized by clustering together in an extracellular ma­
trix attached to the implant. Biofilms protect bacteria from
host defenses and antibiotics. Only aggressive débridement
and long-term suppressive therapy have been effective in
treating orthopaedic implant–related infections.30 This ap­
proach is usually not appropriate in facial implant patients
because both débridement and chronic infection may be
deforming in this appearance-conscious population. Be­
cause antibiotic treatment alone is usually not successful,
facial implant–related infections are usually treated by
implant removal, antibiotics, and appropriate wound care.
Implants may be replaced in 6 to 12 months (Fig. 26.30).
Other Complications in Alloplastic
Facial Skeletal Augmentation
Hematoma
Hematoma after alloplastic facial skeletal augmentation is
not uncommon. Although we routinely place suction drains
at the operative site, they merely serve to help detect rather
than prevent hematoma formation. Not only does hema­
toma cause more swelling and contour distortion, blood
and serum products are also nidus for implant infection.
It is therefore imperative to take all necessary measures
to minimize postoperative hematoma. This includes tight
blood pressure control in the preoperative, intraoperative,
and immediate postoperative period; use of a vasocon­
strictive agent in combination with the local anesthetic;
avoidance of traumatic tissue dissection that causes exces­
sive intraoperative bleeding; head elevation; and adequate
postoperative nausea and pain control.
Implant Infection
In 2003, I (A.Y.) reported my personal experience with po­
rous implants used for facial skeletal reconstruction, based
on experiences with 162 patients who were operated on
over an 11-year period (1990 to 2001).29 In this series the
infection rate was 3%. Since that report no patient has pre­
sented with a late infection (longer than 6 to 8 weeks after
surgery). Late presentation of implant infection most likely
reflects small bacterial contamination during surgery that
was initially suppressed by perioperative antibiotic ad­
ministration. The presence of a foreign body decreases the
Fig. 26.30 An infected left infraorbital rim implant 6 days after sur­
gery. The patient was treated by surgical exploration, removal of
the infected implant, irrigation, and a full course of antibiotics. The
implant was subsequently replaced 6 months later.
References
1. Yaremchuk MJ. Skeletal augmentation. In: Neligan P, ed.
Plastic Surgery. Vol 2. 3rd ed. London: Elsevier; 2012
2. Yaremchuk MJ, Doumit G, Thomas MA. Alloplastic aug­
mentation of the facial skeleton: an occasional adjunct or
alternative to orthognathic surgery. Plast Reconstr Surg
2011;127(5):2021–2030
3. Doumit G, Abouhassan W, Yaremchuk MJ. Aesthetic re­
finements in the treatment of graves ophthalmopathy.
Plast Reconstr Surg 2014;134(3):519–526
4. Pessa JE, Desvigne LD, Lambros VS, Nimerick J, Sugunan B,
Zadoo VP. Changes in ocular globe-to-orbital rim position
with age: implications for aesthetic blepharoplasty of the
lower eyelids. Aesthetic Plast Surg 1999;23(5):337–342
5. Yaremchuk MJ, Kahn DM. Periorbital skeletal augmen­
tation to improve blepharoplasty and midfacial results.
Plast Reconstr Surg 2009;124(6):2151–2160
6. Farkas LG, Hreczko TA, Kolar JC, Munro IR. Vertical and
horizontal proportions of the face in young adult North
American Caucasians: revision of neoclassical canons.
Plast Reconstr Surg 1985;75(3):328–338
7. Rubin JP, Yaremchuk MJ. Complications and toxicities of
implantable biomaterials used in facial reconstructive
and aesthetic surgery: a comprehensive review of the lit­
erature. Plast Reconstr Surg 1997;100(5):1336–1353
8. Rees TD, LaTrenta GS. The role of the Schirmer’s test and
orbital morphology in predicting dry-eye syndrome after
blepharoplasty. Plast Reconstr Surg 1988;82(4):619–625
9. Jelks GW, Jelks EB. The influence of orbital and eye­
lid anatomy on the palpebral aperture. Clin Plast Surg
1991;18(1):183–195
10. Yaremchuk MJ. Infraorbital rim augmentation. Plast
­Reconstr
Surg
2001;107(6):1585–1592,
discussion
1593–1595
11. Yaremchuk MJ. Restoring palpebral fissure shape af­
ter previous lower blepharoplasty. Plast Reconstr Surg
2003;111(1):441–450, discussion 451–452
12. Raschke R, Hazani R, Yaremchuk MJ. Identifying a safe
zone for midface augmentation using anatomic land­
marks for the infraorbital foramen. Aesthet Surg J
2013;33(1):13–18
13. Yaremchuk MJ, Israeli D. Paranasal implants for cor­
rection of midface concavity. Plast Reconstr Surg
1998;102(5):1676–1684, discussion 1685
14. Wilkinson TS. Complications in aesthetic malar augmen­
tation. Plast Reconstr Surg 1983;71(5):643–649
15. Whitaker LA. Aesthetic augmentation of the malar-
midface structures. Plast Reconstr Surg 1987;80(3):
337–346

393
Chapter 26 Alloplastic Implants for Facial Contouring
25. Zide BM. The mentalis muscle: an essential component
of chin and lower lip position. Plast Reconstr Surg 2000;
105(3):1213–1215
26. Thomas MA, Yaremchuk MJ. Masseter muscle reattach­
ment after mandibular angle surgery. Aesthet Surg J 2009;
29(6):473–476
27. Hwang K, Lee WJ, Song YB, Chung IH. Vulnerability of the
inferior alveolar nerve and mental nerve during genio­
plasty: an anatomic study. J Craniofac Surg 2005;16(1):
10–14, discussion 14
28. Hazani R, Rao A, Ford R, Yaremchuk MJ, Wilhelmi BJ. The
safe zone for placement of chin implants. Plast Reconstr
Surg 2013;131(4):869–872
29. Yaremchuk MJ. Facial skeletal reconstruction using porous
polyethylene implants. Plast Reconstr Surg 2003;111(6):
1818–1827
30. Costerton JW, Stewart PS, Greenberg EP. Bacterial bio­
films: a common cause of persistent infections. Science
1999;284(5418):1318–1322
16. Mladick RA. Alloplastic cheek augmentation. Clin Plast
Surg 1991;18(1):29–38
17. Yaremchuk MJ. Secondary malar implant surgery. Plast
Reconstr Surg 2008;121(2):620–628
18. Bucky LP, Bartlett SP, Whitaker LA. Avoiding pitfalls and
managing complications of aesthetic contouring of the
craniofacial skeleton. Clin Plast Surg 1997;24(3):613–622
19. Yaremchuk MJ. Atlas of Facial Implants. Philadelphia:
Elsevier-Saunders; 2007
20. Doumit G, Gharb BB, Rampazzo A, et al. Surgical anatomy
relevant to the transpalpebral subperiosteal elevation of
the midface. Aesthet Surg J 2015;35(4):353–358
21. Yaremchuk MJ. Improving aesthetic outcomes after al­
loplastic chin augmentation. Plast Reconstr Surg 2003;
112(5):1422–1432, discussion 1433–1434
22. McCarthy JG, Ruff GL. The chin. Clin Plast Surg 1988;
15(1):125–137
23. Yaremchuk MJ. Mandibular augmentation. Plast Reconstr
Surg 2000;106(3):697–706
24. Flowers RS. Alloplastic augmentation of the anterior
mandible. Clin Plast Surg 1991;18(1):107–138
Discussion by Edward O. Terino
Lacking extended formal training in advanced tech­
niques of craniofacial reconstruction, most plastic
surgeons practicing aesthetics are not familiar with
the significant possibilities of using alloplastic materi­
als to alter facial skeletal and soft tissue contours. The
development of anatomically designed midface and
mandible implants and of newer biocompatible allo­
plastic materials has made it possible to successfully
use these devices for contouring faces. Public demand
for aesthetic surgical facial contouring has exploded
and is motivating aesthetic plastic surgeons to explore
alloplastic facial implant technology, which is particu­
larly applicable in the chin, as opposed to the malar and
midface regions.1,2 Central chin augmentation has been
practiced since the 1950s and 1960s. The surgical tech­
niques are relatively simple. They provide a very satis­
factory improvement of the facial profile and are now
widely accepted and used worldwide.3
Midface augmentation and alloplastic enhancement
of other areas of the facial skeleton have been less popu­
lar among surgeons, because the operations require dis­
sections into the midface. Moreover, surgeries in this
area have been less commonly used because of their po­
tential to produce an artificial appearance (Fig. 26D.1).
Soft tissue planar techniques, both superficial and
deep, are well established and are being used by newly
trained aesthetic surgeons. However, these are two-
dimensional techniques only. In the 1990s, all aspects
of facial aesthetic surgery were brought together in a
new comprehensive, three-dimensional model, which
Fig. 26D.1 An artificial-looking, bad aesthetic result of a mid­
face malar implant surgery.

SECTION IV AESTHETIC SURGERY
394
is now regarded as a form of living sculpture. Aesthetic
surgeons have now adopted these three-dimensional
concepts, which I presented in early talks and publica­
tions, that significantly contour the bony architecture
of the face and the soft tissues.4 To achieve these goals,
alloplastic techniques are an important advancement
in aesthetic facial surgery. The use of midface soft tis­
sue suspension techniques combined with midfacial im­
plants and premandible implant contouring constitutes
the final phase in the evolution of true three-dimen­
sional artistry in facial aesthetic surgery.4
Published data on unfavorable results and complica­
tions of alloplastic techniques have been limited.5–7 To
gather accurate up-to-date data, I conducted an unpub­
lished survey among members of the American Society
of Plastic Surgery (ASPS) in 1990. Of the 3,200 members
at that time, 9% responded. These respondents seemed
to represent surgeons who favored malar and chin
augmentations in their usual armamentarium (Video
26D.1). The survey data indicated that chin implant pro­
cedures and malar or chin procedures were performed
at that time by 300 surgeons of the 3,200 respondents.
It was obvious from the survey results that the use of al­
loplastic materials was definitely increasing.
Another unpublished survey was performed in
1998. Of the 1,200 members of the American Society
for Aesthetic Plastic Surgery (ASAPS) at that time, 400
members (33%) responded. Again, it appeared that the
respondents were mainly surgeons who used these al­
loplastic techniques and performed them commonly. In
fact 95% of the respondents reported using alloplastic
materials in their aesthetic facial procedures. The 1998
ASAPS survey showed that more than 96% of surgeons
used premandible and chin alloplastic procedures,
whereas only 74% augment the malar and midface re­
gion. Approximately 30% performed some form of pre­
maxillary augmentation, and only 16% addressed fore­
head and temple problems. The suborbital tear trough
implant procedure was being performed by only 15% of
responding members at that time.
In other words, more than 80% of the respondents
were using alloplastic materials for more than 20 years.
Only 3% (the newer surgeons) had been using alloplas­
tic techniques for less than 5 years (Table 26D.1). Two
thirds of the surgeons who responded felt that alloplas­
tic facial contouring techniques were very useful (50%)
and most desirable (12%). An additional 38% considered
them occasionally useful. No physicians responded with
the description “never useful” (Table 26D.2).
Facial Aesthetics
Any discussion about unfavorable results and compli­
cations with alloplastic materials and implants must
include a brief presentation of the relevant aesthetic
principles of surgical contouring of the malar and mid­
face and the mandible and jawline regions.
Facial Balance
The first basic consideration in facial aesthetics is bal­
ance. Balance is the summation of the size, shape, and
form of the soft tissue, skeletal elements, and facial
features, all of which are responsible for an attractive
or unattractive facial appearance. The face is consid­
ered pleasing when the basic relevant anatomical facial
structures are similar in size. These basic relevant ana­
tomic structures or promontories consist of the nose,
the chin and jawline, and the midfacial anatomy. These
three elements are the major anatomic areas of volume
and shape that can and should be altered with allo­
plastic augmentation to achieve facial attractiveness or
beauty. The relationship of these structural aesthetic
units is well covered in the chapter.
Table 26D.2 1998 ASAPS survey:
attitudes toward alloplastic facial
contouring
Attitude
Physician responses (%)
Very useful
50
Most desirable
12
62
Occasionally useful
38
Never useful
0
Abbreviation: ASAPS, American Society for Aesthetic Plastic Surgery.
Note: Unpublished data.
Table 26D.1 1998 ASAPS survey:
duration of use of alloplastic
materials
Duration (years)
Physician responses (%)
0–5
3
6–10
17
11–20
47
 21+
35
82
Abbreviation: ASAPS, American Society for Aesthetic Plastic Surgery.
Note: Unpublished data.
}
}

395
Chapter 26 Alloplastic Implants for Facial Contouring
Types of Facial Implants
Optimal Characteristics
For a natural appearance that simulates soft tissue aug­
mentation, an alloplastic implant must have a generous
surface area (12–15 cm2) that bridges the malar and ex­
tends into the submalar zone inferior to the malar bone.
Therefore I developed a comprehensive malar shell de­
sign to provide anatomically natural-looking augmen­
tations that simulate both the soft tissues and the bone
in the midface zones. I also developed anatomic-style
implants (commercially available) for surgeons to eas­
ily create pleasing and relevant natural contour changes
to the mandible and jawline aesthetic facial units (Fig.
26D.2, Video 26D.2).
Traditional chin implants used in the 1950s and
1960s were centrally placed and often produced an
unattractive central protuberant chin appearance
(“witches chin”). The long extension wings of anatomi­
cally designed implants cover the anterior and mid­
lateral zone segments of the anterior jawline and are
largely responsible for creating the natural contour. A
uniquely shaped implant I designed = in 1978 (which is
also currently commercially available) provides vertical
augmentation to lengthen the face from the lower lip to
the inferior chin line. This implant extends below the
lower border of the mandible but comfortably fits the
bony surface. It also can make a significant correction to
the marionette groove or anterior mandibular prejowl
sulcus. I also designed and patented a Peri-Pyriform pre­
maxillary implant. Lack of volume in that area is most
obviously unattractive in persons with genetic midface
retrusive deficiencies, but subtle volume is also needed
in persons with midfacial bony regression associated
with aging or genetic inheritance to restore youthful
midface volume. Alloplastic materials therefore provide
excellent improvement for such deficiencies.
Implant materials are of special importance in de­
termining malar, midface, mandible, and jawline con­
touring (Video 26D.3). Undesired complications and un­
favorable results may occur from the misuse of certain
implant shapes and designs or the improper selection
of materials.
The 1998 ASAPS survey revealed that silicone (poly­
siloxane) is by far the implantable material of choice
among plastic surgeons8,9 (Table 26D.3). Nearly 90% of
responding surgeons consider it to be their material of
choice. Other materials were used by only 8 to 15% of
the membership surveyed.
A smooth silicone implant placed directly on the
surface of the bone in a subperiosteal fashion becomes
fixed securely and rapidly and resists the biomechani­
cal forces of fibrotic encapsulation. The most desirable
feature of silicone implants is the ease with which they
Table 26D.3 1998 ASAPS survey:
choice of implant material
Material
Physician responses (%)
Silicone rubber
88
Gore-Tex
18
Porex
15
Methylmethacrylate
15
Hydroxyapatite
10
Soft form
0
 Abbreviation: ASAPS, American Society for Aesthetic Plastic Surgery.
Note: Unpublished data.
Fig. 26D.2 Anatomically designed midface and mandible–chin silastic implants. (a) Malar shell. (b) Various shapes of anterior
chin implants.
a
b

SECTION IV AESTHETIC SURGERY
396
can be removed and exchanged for an implant of an­
other size or shape when necessary or desired. Medium-
grade silicone is easily implantable and conformable. It
is flexible enough to be inserted through small tissue
apertures and soft enough to mold to the external con­
tour of the bone. When implants made of silicone rubber
are finely tapered at the margins they are not palpable
through the soft tissues. Other implant materials such
as Medpor (Stryker), hydroxyapatite, and Gore-Tex (W.L.
Gore & Associates) are manufactured with less finesse
and of a harder consistency, with surface textures that
may be both visible and palpable through the skin sur­
face. Silicone implants also have the favorable feature of
being easily carved, shaped, and modified at the oper­
ating table or before surgery with scissors, scalpels, or
dermabraders.
Inflammation surrounding silicone implants can of­
ten be treated without removing them. Even purulent
infection is not an absolute indication for removal. The
judicious use of antibiotics, drainage procedures, and
perhaps continuous irrigation can prevent implant loss
in a number of cases.
Other Materials
Other commonly used materials are porous10: Poly­
ethylene (Medpor),11,12 and methyl methacrylate, hy­
droxyapatite, or Gore-Tex (polytetrafluoroethylene).
According to the survey, they are not commonly used
by plastic surgeons, although some surgeons, espe­
cially oromaxillary and craniofacial ones, prefer them
for chin or jawline augmentations. Porous materials
offer the advantage of immediate implant stability be­
cause of rapid stabilization by fibrous tissue ingrowth.
In every series reported, however, these materials can
present special problems of difficult placement and re­
moval and increased rates of infection because of their
porous matrix characteristics.13 Moreover, their hard
and sometimes irregular consistency can create prob­
lems of external contour or shape, size, and palpability.
At present, nonporous, nonadherent, smooth implants
that encapsulate firmly onto bone but can easily be re­
moved and replaced when a correction of size or shape
is desired are preferable. The most comprehensive re­
view of the world literature regarding the complica­
tions and toxicities of implantable materials was pub­
lished by Rubin and Yaremchuk14 in 1997.
Technical Factors Contributing to
Complications and Unfavorable Results
Most complications and unfavorable results in plastic
and reconstructive surgery relate more to errors in sur­
gical planning than to technical skills. Plastic surgeons
should keep in mind that “an ounce of prevention is
worth a pound of cure.” Successful alloplastic contour­
ing depends entirely on a specific perception of the aes­
thetic parameters of the human face. The surgeon must
duplicate accurately and precisely the patient’s expres­
sion of his or her expectations and make certain that
the patient truly understands the doctor’s statements
about what he or she can realistically accomplish.
Then there must be an appropriate choice of implant.
The size, shape, and positioning of the implants and
the type of implantable material must be suitable to
establish the image agreed on by both the patient and
surgeon. This is a tall order! The principles of facial aes­
thetics, zonal analysis, and facial typing are not written
in stone for surgeons to use to determine facial aesthet­
ics and understand the facial anatomy pertinent to fa­
cial contouring and improve their techniques. Surgeons
must choose their own methods of analyzing facial
balance and create their own specific techniques and
capabilities that will enable them to achieve a natural
appearance, which results in a mutually desired result.
Avoiding Unfavorable Results and
Complications
The surveys of the ASPS and the ASAPS completed in
1991 and 1998, respectively, reveal the following cat­
egories of unfavorable results of midface facial implant
placement:
1. Patient and doctor dissatisfaction
2. Asymmetries
3. Inappropriate shape or malposition
4. Hematoma or seroma
5. Inflammations and infections that necessitate
removal
6. Nerve dysfunctions
Notably, in the 1998 survey, more than 90% of the sur­
geons responding indicated the unfavorable results of
alloplastic facial augmentation are relatively insignifi­
cant, both emotionally and physically (with a rating
of 1–3 on a scale of 1–10). Hypothetically, this may be
because most untoward sequelae are either temporary
(asymmetries), partial (nerve dysfunctions), or revers­
ible and changeable by easy removal. Nerve dysfunc­
tions can be motor or sensory. Specific nerves damaged
in the malar and midface region are those to the nose,
the frontalis muscle, and the orbicularis oculi muscle
(Fig. 26D.3) and occasionally involve the zygomatic
muscles, which in turn affect lip elevation and smiling.
The most common sequela after chin and jawline
mandible augmentations is nerve dysfunction with in­
juries to the mentalis sensory nerve. Occasionally, but

397
Chapter 26 Alloplastic Implants for Facial Contouring
Fig. 26D.3 Facial nerve injuries are rare after facial
implant surgery and are usually temporary. This
patient had temporary damage to the frontalis
and orbicularis branches of the left facial nerve af­
ter malar augmentation.
rarely, damage to nerves of the lower lip depressor and
mentalis muscles produce other dysfunctions, all of
which have resolved completely over several weeks or
months in my experience (Fig. 26D.4). The other com­
monly reported problems associated with chin and jaw-
line augmentations are similar to those associated with
midface malar augmentations and include the following:
•• Surgeon and patient dissatisfaction with implant
size, shape, and contour
•• Asymmetries, inappropriate shape, and malposition
•• Hematomas or seromas
•• Inflammations, infections, or extrusions
necessitating implant removal
•• Symptoms related to mental nerve dysfunction
Bone remodeling (“erosion””) is also reported and is
explained later in the discussion. I do not consider it to
be a serious, dangerous, or very problematic sequela.
Patient Dissatisfaction
Patient dissatisfaction is the most common unfavorable
result of all facial implant contouring procedures. In
both surveys, disappointment with size, shape, or con­
tour of the cheek or jawline was expressed by 81% of
the respondents. This was approximately equal to the
80% reported rate of dissatisfactions regarding asym­
metries. The best ways to avoid patient dissatisfactions
are for the surgeon to do the following:
•• Understand the most prominent face complaints
and corresponding anatomic bone deficiencies as
they pertain to the facial aesthetics.
•• Spend as much time as necessary to understand
thoroughly (“duplicate”) the patient’s expectations
regarding shape, size, and specifics of regional facial
contours.
•• Surgically create precise subperiosteal spaces as
opposed to inadequate dissections smaller than or
larger than necessary.
•• Very carefully place implants accurately to produce
the desired contours.
•• Place an implant of the correct size and shape and if
in doubt, when necessary, request help.
Implant Positioning
The subperiosteal location has proven to be the most
desirable because of the rapid fixation of implants to
the bone or underlying structures such as the masseter
muscle. Subcutaneous placement commonly results in
implant mobility, because encapsulation occurs within
elastic and movable soft tissue.
Fig. 26D.4 This patient had early but temporary augmentation
paralysis of the right branches of the facial nerve to the orbicu­
laris. This injury totally resolved in 6 weeks.

SECTION IV AESTHETIC SURGERY
398
Fibrous ingrowth into porous materials or through
implant fenestrations is unnecessary when smooth im­
plants are used. The correction of a malposition simply
requires that a new, accurately located space be created
directly on the bone level and beneath all anatomic tis­
sue planes, including scar tissue and previous capsules.
Dissection of a tissue space of slightly larger capacity
facilitates placement of the implant without buckling,
infolding of the edges, or an abnormal bulging with ex­
ternal deformity.
Facial Asymmetry
Natural facial asymmetry is universal. A form of hemi­
facial 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 vol­
ume. One side is weaker and has a greater volume of
bone and soft tissue, including muscle. Also one orbit,
eyebrow, and eye complex is often lower than the other.
Sometimes the asymmetry is more prominent in the
upper half of the face and sometimes in the lower half.
Patients can be very particular and obsessed with
asymmetries. Natural asymmetries commonly go un­
noticed before facial implant contouring. It is imperative
therefore to evaluate facial asymmetries meticulously,
note them in the medical record, and explain them in
detail to the patient. It is also necessary to warn patients
that asymmetries will most likely be present after sur­
gery as well, even when implants of different sizes are
chosen and positioned to try to compensate for the vari­
ations in volume, shape, and position that already exist
(Fig. 26D.5). Asymmetries can be documented in the
patient’s chart by computer imaging or photographic
modalities. Preoperative documentation helps to pre­
vent criticism of the surgeon if the asymmetry is still
apparent to the patient. Although CAD CT can be used
to create customized models with a symmetrical skull
anatomy, at the present time such advanced methods
are usually used only for the most complicated prob­
lems, because they are time-consuming and expensive.
Their advantage is the anatomic configuration of the
posterior side of the customized implant to match the
surface irregularities of the patient’s own bony anatomy.
Nevertheless, advances in computerized technology
are rapidly evolving and will soon enable aesthetic plas­
tic surgeons to correlate implant size and shape with de­
sired external changes in facial form and contour.
Choosing implants to correct asymmetries is pres­
ently more a matter of intuition and artistic judgment
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 tissue volume. Similarly,
for jawline asymmetries in the posterior mandibular
and midlateral zones, implants that provide additional
thickness of 1 to 3 mm can be used on the side of the
deficient mandible.
Perhaps the most important principle for the sur­
geon to remember is that minor asymmetries tend to
become less noticeable within a 6-month postoperative
healing period, during which relaxation of the collag­
enous capsular matrix around the implants allows the
contours to appear softer.
Postoperative Infection and Removal
The third-most common complications cited in the two
surveys included hematoma, cellulitis, infection, and
extrusion requiring implant removal. These problems
were noted by 57 to 70% of the surgeons. In my experi­
ence, the occurrence has been less than 0.5% at all facial
implant procedures performed since 1971.
The type of implant material is significant in rela­
tion to the cause of infection.15 In all the reported series
of intraorally placed implants, the incidence of postop­
erative infection, extrusion, and necessary removal was
highest when the obsolete porous material Proplast was
used.16 With porous implant substances (e.g., Medpor,
a
b
Fig. 26D.5 (a) This 32-year-old woman had a signifi­
cant natural asymmetry of the face. (b) Improved facial
symmetry has been achieved by augmenting the malar
and mandibular regions with implants of different sizes
placed in slightly different positions.

399
Chapter 26 Alloplastic Implants for Facial Contouring
hydroxyapatite, and Gore-Tex), tissue, blood, and bac­
teria can enter the interstices of the implant structure,
where a perfect environment for organism proliferation
and growth is maintained.17 With smooth Silastic (Dow
Corning) rubber implants, the infection rate is very low
and the implants can be salvaged even when inflamma­
tion, cellulitis, or gross purulence is present. This is the
major reason I prefer the latter material.
Infections resolve adequately and promptly when
traditional regimens of antibiotics, warm compresses,
rest, or even drainage and irrigation are instituted.
Sound surgical judgment combined with courage, close
surveillance, and prompt intervention when necessary
are the elements required for the successful manage­
ment of inflammation around facial implants. Hydroxy­
apatite and Porex have been reported to resist implant
infection as well as Silastic rubber. However, several
statistical reports are available that do not substanti­
ate this claim.
When inflammation, cellulitis, and infection develop
in tissue surrounding a Gore-Tex implant, immediate re­
moval is necessary. These problems will not resolve with
the traditional treatments mentioned if a Gore-Tex im­
plant has been used.
Infection in the midface is a significant hazard that
surgeons should not risk. The prognosis for a patient
with cellulitis and inflammation surrounding a Silastic
facial implant is very favorable. Ultimate control and res­
olution of such infectious processes have been the norm
in my extensive experience.
Common contaminants are skin and intraoral or­
ganisms such as Staphylococcus aureus that for the most
part are sensitive to penicillin derivatives and the cepha­
losporins. Acute inflammation, cellulitis, and impending
infection are often alleviated with 750 mg of ciprofloxa­
cin taken twice daily for 10 days or levofloxacin 500 mg
taken once a day for 10 days. An additional 2 or 3 weeks
of less potent antibiotic suppression is indicated after
the acute process has subsided. When necessary, intra­
venous antibiotics may be administered for a course of
several days. If an acute inflammatory process does not
improve rapidly, immediate measures must be taken to
drain the area adequately or to remove the prosthesis,
even when Silastic has been used. Drainage of a malar or
chin implant abscess or seroma by percutaneous needle
aspirations in addition to systemic antibiotic therapy is
indicated when palpable or visible evidence of a fluid
collection around the implant is noted. This may be per­
formed for several consecutive days.
Occasionally continuous vacuum suction drainage
should be instituted. A small percutaneous angiocath­
eter suction drain can be placed into the implant cavity
externally through the submalar cheek region to insti­
tute midfacial drainage (Fig. 26D.6). An effective means
of preventing the accumulation of blood after the pri­
mary surgery is the placement of a 7-mm catheter from
within the implant space to penetrate the scalp behind
the temporal hairline. Thorough and continuous irriga­
tion with antibiotic solution, soaking of implants in an­
tibiotic solution, and using a “no touch” (instruments
only) handling of the implant are additional standard
measures to prevent contamination and subsequent in­
fection.
Extrusion
Extrusion of facial implants, either in the malar and
midface or the premandible regions, rarely occurs. In
general, extrusion can be prevented by creating a sub­
periosteal space that is comfortable for the implant and
by providing adequate tension-free soft tissue coverage
in layers.18
Extrusion can follow and can displace an implant,
particularly in the recovery and postoperative healing
phase. Inadequate healing of the wound after implant
placement may be caused by the following:
1. Wound tension during insertion and closure
2. Ischemic tissue damage after overly traumatic dis­
sections
3. Internal hematoma or seroma, which create inter­
nal pressure and subsequent wound dehiscence
Even placement of the largest available extended ana­
tomic premandible, posterior angle, malar or midface
implant should not result in problematic wound heal­
ing or extrusion. These complications are technical and
can be avoided by following the technical guidelines
described in the chapter.
Fig. 26D.6 Percutaneous suction drainage can be combined
with antibiotic therapy to manage a midface suppurative in­
fection.

SECTION IV AESTHETIC SURGERY
400
Bone Erosion
I do not consider bone erosion a serious sequela.18
Many investigators have extensively reviewed this sub­
ject, and yet it is noteworthy that very few cases of den­
tal damage have been cited.19 This was also true in my
recent surveys. Bone erosion was not specifically men­
tioned as causing complications in the comments and
data provided by 100 surgeons who returned the ques­
tionnaire. For unknown reasons, bone “erosion” re­
modeling exists in a significant percentage of patients
with facial implants.20–22 I refer to bone “erosion” as
remodeling. The question of whether subperiosteal as
opposed to supraperiosteal placement is a significant
causative factor to remodeling has not been established
for anything in my data. In my experience, the degree
of erosion appears to be minimized with extended im­
plants. Perhaps this is because the forces of overlying
tissue pressure become dispersed underneath the im­
plant. Remodeling is also occasionally observed under
malar implants placed 8 to 15 years previously. It also
occurs under other materials. Apparently for the malar
bone, remodeling would produce a significant problem
and produce a gross contour deformity if an implant
were removed permanently, which seems unlikely. A
small series of Silastic malar implants were recently
reported as eroding through the thin maxillary but­
tress into the maxillary sinus after 20 to 25 years. The
common symptom was a form of pain and discomfort
that persisted in the area. This penetration into the
sinus was confirmed by three-dimensional CT.18 Bone
remodeling associated with older centrally based chin
implants was not unusual and could produce cavities
of depths of 2 to 8 mm into the outer table of the bone.
Obviously, this could present a problem needing surgi­
cal correction if there was interference in the position­
ing of a new implant. However, fortunately the design
of the recent anatomically shaped implants with their
lateral extensions produces a suitable cover over the
remodeled and recessed region of the bone. Reports
of implants eroding into tooth roots have been very
scarce.
Bony irregularities from the remodeling process are
easily corrected with grafting of autogenous tissue into
the defects, such as temporalis fascia or galea, or even
autologous fat transplants. I have had success with all
of these.
Theoretically, if bone remodeling creates significant
problems, considerable scientific data reflecting dental
problems, tooth root impingements, or abscesses should
be published frequently. However, innumerable success­
ful implants have been used over the last 60 to 70 years
without such reports in the scientific literature.
There is greater concern about the structural integ­
rity of the bone when an atrophic aging mandible is aug­
mented. This theoretical complication also has not been
frequently reported as a problem. However, it should be
considered when dealing with older patients or patients
with frequent dental problems. Mandibular resorption
with aging occurs from the tooth socket down toward
the mental foramen, whereas implants are placed in­
ferior to the mental foramen, an area that typically re­
mains sufficiently intact throughout later life.
Dental manipulations including cleaning procedures
present bacterial risk to facial implant health. Therefore
antibiotics should be given prophylactically for 12 to 24
hours before any dental procedures or cleaning.
Ultimately, bone remodeling presents a hazard that
is more potential than real but should always be within
the awareness and consideration of the surgeon.
Conclusion
Malar, midface, and mandibular augmentation tech­
niques have evolved since the 1970s and 1980s and
have constituted the bulk of my practice. They have
achieved popular status with both physicians and pa­
tients. This technology continuously evolves. Comput­
erized technology can now routinely correlate accurate
external facial imaging with accurate internal implant
design, resulting in precision implant production and
choices. Untoward sequelae are not rare. On the other
hand, they do not occur in statistically or prohibitively
high numbers. Future modifications in both implants
and techniques, as well as increased physician experi­
ence, will result in more accurate diagnosis and execu­
tion. The incidence of patient dissatisfaction or unde­
sirable sequelae will then dramatically decrease.
References
1. Terino EO. The Art of Alloplastic Facial Contouring.
Philadelphia: WB Saunders; 1999
2. Mladick RA. Alloplastic cheek augmentation. Clin
Plast Surg 1991;18(1):29–38
3. Binder WJ, Kamer FM, Parkes ML. Mentoplasty—a
clinical analysis of alloplastic implants. Laryngoscope
1981;91(3):383–391
4. Terino EO. Alloplastic contouring in the malar mid­
face—middle third facial aesthetic unit. In: Terino EO,
Flowers RS. The Art of Alloplastic Facial Contouring.
St Louis: Mosby; 2000:79–96
5. Cuzalina LA, Hlavacek MR. Complications of facial
implants. Oral Maxillofac Surg Clin North Am 2009;
21(1):91–104, vi–vii

401
Chapter 26 Alloplastic Implants for Facial Contouring
6. Eppley BL. Alloplastic implantation. Plast Reconstr
Surg 1999;104(6):1761–1783, quiz 1784–1785
7. Terino EO. Alloplastic facial contouring. In: Goldwyn
RM, Cohen MS. The Unfavorable Result in Plastic Sur­
gery. 3rd ed. Lippincott, Williams & Wilkins; 2001; 57:
1011–1031
8. Morehead JM, Holt GR. Soft-tissue response to syn­
thetic biomaterials. Otolaryngol Clin North Am 1994;
27(1):195–201
9. Ivy EJ, Lorenc ZP, Aston SJ. Malar augmentation with
silicone implants. Plast Reconstr Surg 1995;96(1):
63–68, discussion 69–70
10. Mole B. The use of Gore-Tex implants in aesthetic
surgery of the face. Plast Reconstr Surg 1992;90(2):
200–206
11. Rubin L. Polyethylene as a bone and cartilage substi­
tute: a 32 year retrospective. In: Rubin L, ed. Bioma­
terials in Reconstructive Surgery. St Louis: Mosby;
1983:474–493
12. Yaremchuk M, Sims D, Casanova R, et al. Long-term
follow-up of expanded polyethylene implants for aes­
thetic and reconstructive facial skeletal surgery. Pre­
sented at the 6th International Congress of Craniofa­
cial Surgery, Saint Tropez, France, Oct 21–24, 1995
13. Merritt K, Shafer JW, Brown SA. Implant site infection
rates with porous and dense materials. J Biomed Ma­
ter Res 1979;13(1):101–108
14. Rubin JP, Yaremchuk MJ. Complications and toxicities
of implantable biomaterials used in facial reconstruc­
tive and aesthetic surgery: a comprehensive review
of the literature. Plast Reconstr Surg 1997;100(5):
1336–1353
15. Costantino PD, Friedman CD, Lane A. Synthetic
­biomaterials in facial plastic and reconstructive sur­
gery. Facial Plast Surg 1993;9(1):1–15
16. Cohen SR, Kawamoto HK Jr. Infection of proplast ma­
lar implants following dental injections. Plast Recon­
str Surg 1992;89(6):1148–1151
17. Hasson O, Levi G, Conley R. Late infections associated
with alloplastic facial implants. J Oral Maxillofac Surg
2007;65(2):321–323
18. Maducdoc M, Pejman M, Shamoelian D, Hanwerker
J, Terino EO, Wong JH. Delayed extrusion of malar
implants: inherent problem or technical error? (in
­progess)
19. Hoffman S. Loss of a silastic chin implant following a
dental infection. Ann Plast Surg 1981;7(6):484–486
20. Lilla JA, Vistnes LM, Jobe RP. The long-term effects of
hard alloplastic implants when put on bone. Plast Re­
constr Surg 1976;58(1):14–18
21. Robinson M. Bone resorption under plastic chin im­
plants. Follow-up of a preliminary report. Arch Oto­
laryngol 1972;95(1):30–32
22. Friedland JA, Coccaro PJ, Converse JM. Retrospective
cephalometric analysis of mandibular bone absorp­
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constr Surg 1976;57(2):144–151

402
CHAPTER
27

Perioral Aesthetic Surgery
Christopher D. Knotts, Byron D. Poindexter,
Robert K. Sigal, and George W. Weston
The perioral region has traditionally been ignored or un­
dertreated as a part of facial rejuvenation, despite being
a key element of facial beauty. Although not every patient
considering a facelift is a candidate for perioral surgery, a
significant number would benefit from some sort of peri­
oral procedure. A key difference with regard to perioral
surgery is that most patients do not know they would
benefit from it. A patient with small breasts asks for larger
breasts. A patient with a large nose knows they would like
it made smaller. But a patient with an aging face rarely
recognizes the mouth as a contributing factor. Leaving an
aged mouth untouched when surgically addressing the
rest of the face leaves a result that is disharmonious, un­
natural, and “done.”
With age, the upper lip lengthens, covering the upper in­
cisors. The corners of the mouth droop. The vermilion thins,
deflates, and rolls inward. The philtrum flattens and disap­
pears. Nasolabial and marionette folds form and deepen.
Each of these changes in perioral anatomy is symbolic. A
thin lip may mimic rigidity. A downturned mouth corner
signifies displeasure. Deep folds are associated with age. Yet
although a patient’s facial appearance may “show” a nega­
tive emotion, this does not necessarily match their internal
emotional state. It is this incongruence that leads patients to
seek plastic surgery. Perioral surgery aims to align the inter­
nal state with the external symbolism. Although the mouth
is occasionally surgically addressed alone, it is usually one
component of a larger facial surgical rejuvenation.
Adding volume to the face is currently in vogue, espe­
cially the lips. This trend is spurred by societal trends, but
also by non–plastic surgeon practitioners who have filler
as one of their limited number of tools to rejuvenate the
aging mouth. This single-minded strategy toward perioral
rejuvenation has led to new complications of overfilling and
injection sequelae and usually does not address the other
underlying signs of aging.
The burden is on the surgeon to not only diagnose an
aged mouth as part of the overall issue, but to be able to
discuss with the patient during the consultation why not
addressing the mouth at the time of facial rejuvenation is
potentially a setup for dissatisfaction because of a lack of
balance and facial harmony. Surgical planning must take into
account whether the perioral issues to be treated will re­
quire volume, skin resurfacing, direct surgical incisions, or
a combination of any or all to achieve harmony. This chap­
ter focuses specifically on perioral surgery to include the lip
lift, corner mouth lift, vermilion advancement, and direct
excision of nasolabial folds and marionette lines. It also dis­
cusses how to avoid complications when performing these
procedures.
Plastic surgeons have been reluctant to place incisions
around the mouth and lips for cosmetic reasons, but we be­
lieve this is a mistake. A surgeon will place a scar directly on
the eyelid to rejuvenate the eye, or directly onto the face to
rejuvenate the cheek, and it follows that an incision is often
needed around the mouth to rejuvenate the lips. A facelift
cannot be pulled tight enough to smooth a deep nasolabial
fold, and a midface lift will not change the position of the
oral commissure. Direct surgical approaches are required
to remove the sequelae of aging from the perioral region.
Basic Procedures for Perioral Surgery
Lip Lift
Lip lifting procedures were first presented in the 1970s by
the Brazilians,1 and we have been using them successfully
at our practice since the early 1980s to shorten a long up­
per lip,2 with proven effect.3 The procedure uses a surgical
incision just beneath the nostril sill to remove skin from
the upper lip, and although there are several variations, the
general concept is the same in all4 (Fig. 27.1).

403
Chapter 27 Perioral Aesthetic Surgery
Vermilion Advancement
The main goal of a vermilion advancement procedure is to
expose more vermilion of the lower lip by placing a surgical
incision along the vermilion border and removing adjacent
nonvermilion skin, effectively advancing the vermilion to a
more visible position. Because this is performed in patients
Corner Mouth Lift
The goal of the corner mouth lift is to again make visible
the vermilion of the upper lip near the commissure that
becomes hidden with age. A “wraparound” can be added to
lift a downturned commissure at the expense of a scar that
extends around the commissure4 (Fig. 27.2).
Fig. 27.1 A variety of lip lift excision patterns are shown in gray. (Reproduced from Nahai F. The Art of Aesthetic Surgery. 2nd ed. New York:
Thieme Medical Publishers; 2016.)
Fig. 27.2 Wraparound corner mouth lift. The upper incision is placed along the upper vermilion border and extended medially, not to cross
the philtral column. The lower incision allows the commissure to be lifted, the skin resection above the upper lip allows more upper vermil­
ion show, resulting in a final scar that wraps around the corner of the mouth. (Reproduced from Nahai F. The Art of Aesthetic Surgery. 2nd
ed. New York: Thieme Medical Publishers; 2016.)

SECTION IV AESTHETIC SURGERY
404
patient is presented Fig. 27.5 along with her postoperative
result. Another patient undergoing liplift and corner mouth
lift is shown in Video 27.1 with analysis of anatomy, sur­
gical markings, intraoperative snippets, and early and late
postoperative results.
Lip Lift
There are certain characteristics that make a scar more vis­
ible, and these need to be identified in advance so realistic
expectations can be set. For example, in patients being con­
sidered for a lip lift, the surgeon must examine the patient
whose lip has collapsed inside the mouth with age, the
postoperative aim is returning the lip tissue to its normal
anatomic position. Wet mucosa is not advanced beyond its
normal border. Lip advancement can be done on the upper
and lower lips, although scarring is more acceptable on the
lower lip and on the lateral portions of the upper lip.
Direct Excision of Nasolabial and
Marionette Folds
The goal of direct excision of nasolabial and marionette
folds is to remove the deep and stubborn folds using direct
incisions and replace them with a flat and hidden scar (Fig.
27.3).
Avoiding Unfavorable Results
and Complications in Perioral
Aesthetic Surgery
a
b
Fig. 27.3 (a) This patient was seen preoperatively for direct excision
of her marionette folds. Her left fold was longer and deeper and
branched distally. She also wore lipstick below the true vermilion
margin of her lower lip, in essence mimicking a vermilion advance­
ment. (b) After undergoing direct marionette fold excision, typical
scars are seen. These are visible at 3 months from very close with­
out makeup but are nearly imperceptible at conversational distance.
With time the scar improves and becomes more inconspicuous.
Summary Box
Most Common Complications in
Perioral Surgery
•• Visible scar
•• Scar contracture
•• Underdone result
•• Overdone result
•• Asymmetry of lift
•• Infection
Most unfavorable results after perioral surgery result from
either (1) choosing the wrong patient or (2) choosing the
wrong procedure. The right patient for surgery is willing
to accept a scar for a more harmonious result. Illustrating
this to the patient with high-quality before and after photo­
graphs of other patients is critical. The trade-off for perioral
surgery is an imperceptible scar at conversational distance
for a more youthful mouth. The ideal patient is older, be­
cause the scars tend to be better in these patients. Caution
is suggested in young patients with a propensity to form
hypertrophic scars (Fig. 27.4). In general, perioral surgical
scars heal well and are barely noticeable. Caution should be
exercised in those with a history of poor scarring.
When evaluating the perioral region, the surgeon should
note the length of the upper lip, the visibility of maxillary
teeth, the ratio of upper lip skin to vermilion, the ratio of up­
per lip vermilion to lower lip vermilion, the position of the
corners of the mouth, perioral wrinkling, lip deflation, wrin­
kling or creases, and occlusal class. An analysis of a typical
Fig. 27.4 This patient underwent a lip lift with a central component
to shorten a long upper lip and make a more prominent Cupid’s
bow. She had a hypertrophic scar postoperatively that was very vis­
ible and was treated with injectable steroids and topical silicone un­
til resolution.

405
Chapter 27 Perioral Aesthetic Surgery
When considering a patient for a lip lift, simply hav­
ing a long lip is not by itself an indication. A patient with
a long lip also needs to have minimal or no incisal show. If
a patient has significant incisal show, regardless of the lip
length, there is a risk of giving the patient the appearance
of vertical maxillary excess if the lip is significantly short­
ened. Although the lip height is determined on a case-by-
case basis, one general consideration is that an upper lip
should not be shortened beyond 10 mm, because this can
produce facial disharmony. The patient in Fig. 27.7 has in­
cisal show at rest and also has a long upper lip. This means
only a conservative resection can be performed to prevent
the patient from showing too much incisor. Fat grafting
along the distal vermilion border at the time of lip lift can
increase the red vermilion height and create more tooth
coverage. If there is inadequate red lip vermilion to accept
fat grafting, an intraoral mucosal advancement of wet ver­
milion can be performed, but this is rarely used in our prac­
tice.6 For a patient with inadequate incisal show and a lip
from a lateral viewpoint to judge the nasolabial angle. An
obtuse angle means the scar will be more visible on fron­
tal view.5 Similarly, the sill of the nose must be evaluated
before the lip lift. In patients with a blunted sill anywhere
along the nasal base, a scar in that area will be more notice­
able. Both of these cases are illustrated in Fig. 27.6. This
patient has an ill-defined sill beneath the columella and
an obtuse nasolabial angle. Without a defined sill beneath
the columella, the scar will be present as a fine line where
there was previously not one. Although not having sill defi­
nition, often in the setting of an obtuse nasolabial angle, is
not ideal, it is not a contraindication to a lip lift. The patient
must be counseled preoperatively about the scar visibility.
Rhinoplasty can be safely performed at the time of lip lift
and can enhance sill definition to better camouflage the
scar. For a patient with a well-defined sill beneath the colu­
mella but a blunted sill beneath the nares, the scar can be
carried intranasally to camouflage it in an already-blunted
location.
Fig. 27.5 (a) This patient exhibited typical signs of perioral aging. She had a long upper lip, a well-defined nasal sill, loss of vermilion show
near the commissures, prominent and asymmetrical nasolabial and marionette folds, multiple vertical lip rhytids, and overall thin lips with
a relatively normal ratio of upper to lower vermilion height. (b) The same patient with markings for a lip lift, corner mouth lift, direct mari­
onette excision, fat grafting to the perioral rhytids, and facelift with liposuction of the face and neck. (c) At 3 months postoperatively the
scars around her mouth are nearly imperceptible. The deep marionette folds and distal nasolabial folds are obliterated by excision. The
proximal nasolabial fold above the excision pattern is still quite deep. The patient declined fat grafting or lower lip advancement for fear
of looking operated.
a
b
c
Fig. 27.6 (a,b) This patient was seen preoperatively for a lip lift. Note the ill-defined sill, incisal show in repose, and obtuse nasolabial angle
along with multiple perioral rhytids and deflated lips. (c) After a lip lift and fat grafting. Her overall perioral aesthetic is improved, but this
case illustrates the potential for lip lift scar visibility in patients with an obtuse nasolabial angle and the need for a conservative lift along
with fat grafting in the distal vermilion margin in patients with preoperative incisal show.
a
b
c

SECTION IV AESTHETIC SURGERY
406
ral. By evaluating the mouth in detail and as an overall com­
ponent of the facial aesthetic, the correct procedure can be
chosen for the patient.
Corner Mouth Lift
When assessing a patient for a corner mouth lift, there are
two key anatomic components to consider. First is the po­
sition of the vermilion as it approaches the commissure.
With age, the vermilion of both lips disappears laterally
near the commissure, and part of a corner mouth lift is
making the upper lip vermilion more apparent and youth­
ful. Second, special attention must be paid to any downturn
of the commissure. If the commissure has significant droop,
then a wraparound corner mouth lift (see Fig. 27.2) can ad­
dress the commissure as well as the disappearance of the
upper vermilion near the commissure. This can be a power­
ful procedure, and there is potential to overdo the result by
turning up the corners too much (see Fig. 27.7). If the com­
missure does not appear low but the vermilion disappears
laterally approaching the corner of the mouth, a standard
corner mouth lift without a scar that wraps around the
commissure may be performed. This is a gentle elliptical
excision of skin only. As long as the lower portion of the re­
section margin is placed exactly at the junction of the ver­
milion, the scar heals well. Any diversion from the surgical
plan that takes a scar out laterally from the commissure, and
thus at a 90-degree angle to the nasolabial fold, is notice­
able and should be avoided.7 There is a degree of relaxation
postoperatively after a corner mouth lift, although less so
than with a lift lip, which relaxes ­significantly (Fig. 27.8).
The on-the-table result should be slightly overdone to ac­
shorter than 10 mm, cosmetic dentistry to lengthen the
teeth is a good option.
A long lip must be assessed as part of the global mouth
and face. If a long lip with downturned corners undergoes
lip lift alone, the Cupid’s bow can become too lifted relative
to the corners, producing a doll-like mouth that is unnatu­
Fig. 27.8 This patient underwent isolated lip lift and is seen preoperatively (a), with markings (b), at 1-week suture removal (c), and at 3
months postoperatively (d). The long upper lip had visible lower incisors preoperatively, with a transition to upper incisor show postopera­
tively. The degree of relaxation is significant and must be accounted for during surgical planning.
a
b
Fig. 27.7 (a) This patient was seen preoperatively for a ­wraparound
corner mouth lift. She had downturned corners extending
into ­marionette folds and the associated unpleasant symbol­
ism. (b) ­Postoperative result. This case illustrates the power of
the ­wraparound corner mouth lift to lift the commissure into an
­overdone position. Her marionette folds are improved, and with the
lifted ­corners, the grumpy symbolism is gone.

407
Chapter 27 Perioral Aesthetic Surgery
potential for disfigurement has led us to abandon advance­
ment of the central upper lip. For a patient with collapse of
the upper vermilion along the entire width of the lip, there
is almost always also a long upper lip, and a combination
of lip lift and corner mouth lift with fat grafting is then our
procedure of choice.
Direct Excision of Nasolabial and
Marionette Folds
It is a matter of experience to determine whether volume
correction with fat grafting alone will completely resolve a
deep fold around the mouth,10 or whether direct excision is
required. Often patients may be reluctant to undergo direct
excision of nasolabial or marionette folds at the time of facial
rejuvenation because of the concern of what the scar will be
like, and surgeons unfamiliar with direct excision are unable
to disabuse them. It is reasonable to blunt a deep nasolabial
or marionette fold with fat grafting alone at the time of facial
rejuvenation with the understanding that a later procedure
may be required. As long as the patient understands the fold
may not be alleviated by volume alone and that a secondary
procedure is a possibility down the road to directly excise
the fold under local anesthesia, the patient expectations are
set and they will not be disappointed after surgery if an exci­
sion needs to be secondarily performed.
For those patients who are willing to have a small facial
scar for a more dramatic improvement, it is important to
perform the direct excision portion of the procedure before
the facelift. Once the direct excision is performed and closed,
the facelift can be performed to the normal desired tension
without risking a wound that is too tight to close. One ­useful
count for this.8 A result that looks perfect in the operating
room will appear underdone in several months (Fig. 27.9).
Vermilion Advancement
Vermilion advancement is also a powerful procedure and
aims to “roll out” the collapsed and deflated appearance
of the vermilion that happens with age. Along the lower
lip, the scar at the red junction is well tolerated and nearly
imperceptible. Caution should be exercised along the up­
per lip, because crossing over the Cupid’s bow can leave
an unnatural appearance (Fig. 27.10). If the scar along the
peaks of the bow does contract and become tight, the scar
is nearly impossible to correct (Fig. 27.11). Surgeons have
shown good results with upper lip advancement,9 but the
Fig. 27.10 This patient underwent upper lip advancement all the
way across the vermilion border from commissure to commissure.
It resulted in an unnatural and operated look by surgically creating
a Cupid’s bow with direct excision. A surgical incision should gener­
ally not be placed across the Cupid’s bow.
Fig. 27.11 This patient underwent upper lip advancement with an
incision spanning from commissure to commissure across both Cu­
pid’s bows. She has a contracted scar postoperatively that is ex­
tremely distorting on animation. For this reason, an incision across
the Cupid’s bow is not recommended.
a
b
Fig. 27.9 This patient is seen preoperatively (a) and postoperatively
(b) after a lip lift and corner mouth lift. Although her aesthetic is
improved, both procedures are slightly underdone. The upper lip is
still slightly long without incisal show in repose, and the corner lift
does reveal more vermilion out toward the commissure, but is un­
derdone by approximately a millimeter. These results were under­
done by not accounting for the degree of postoperative relaxation
that typically occurs.

SECTION IV AESTHETIC SURGERY
408
Managing Unfavorable Results
and Complications in Perioral
Aesthetic Surgery
The most common complication after perioral surgery is a
visible scar. Our initial scar management includes topical
silicone and SPF, though some scars still do not turn out
perfectly. This is managed depending on the scar charac­
teristic to be addressed. We routinely use filler beneath
depressed scars, skin bleaching, needling or laser for pig­
mented scars, surgical revision for wide scars, injectable
steroids and 5-fluoruracil for keloid or hypertrophic scars
(see Fig. 27.4), and tattooing for poor color match in scars.
In general, however, the scars after perioral surgery are no
worse than with other facial surgery, and with meticulous
detail and tension-free closure, scar complications are rare.
After more than 1,300 corner mouth lifts and 1,500 lip lifts
since 1978, we have seen hypertrophic scars in only the
single digits at best.
The spectrum of results from underdone to overdone is
partially a personal aesthetic. As a general guideline regard­
ing the procedures discussed, the lip lift and corner mouth
lift are most prone to being underdone because there is
significant relaxation that occurs postoperatively (see Fig.
27.9). The direct excision and lip advancement tend to relax
less by comparison. An underdone result is relatively easy to
fix with another “enhancement” procedure, but overdone re­
sults are the more difficult, and caution should be exercised
in those learning the techniques.
Postoperative asymmetry is often simply unrecognized
preoperative asymmetry. This is especially true with regard
to the height of Cupid’s bows, commissures, and length of
tool to determine whether excess skin exists at the lower
face that might require excision is to mimic the lift achieved
with a facelift by holding gentle traction in front of the ear. If
there is significant redundant skin while mimicking the face­
lift, it is unlikely that facelift and nasolabial volume alone
will correct the deep furrows around the mouth. This patient
can be counseled about the possibility of having a direct
excision at the time of facelift or as a secondary procedure.
Markings of the direct excision have been described
previously.4 The ideal scar position is chosen, and then a
stretch technique is used to mimic the amount of desired
effect. Holding a marking pen at the ideal scar position and
then releasing skin stretch, allowing the pen to drag along
the skin, sets the appropriate margin of resection. The final
markings resemble an ellipse (see Fig. 27.5b,c).
a
b
Fig. 27.12 (a) This patient was seen preoperatively for lower lip ad­
vancement, corner mouth lift, and fat grafting. She had significant
lower lip collapse, with the lip falling into her mouth, and her lips had
a deflated appearance. (b) Postoperatively the patient was unhappy
with the resulting asymmetry. On careful inspection, the vertical
vermilion height of her lower lip was longer on her left than on her
right. She also had a small notch at the medial extension of the right
corner lift that required scar revision.
Fig. 27.13 This patient developed a herpes infection after perioral
dermabrasion and went on to heal without issue after aggressive
oral antiviral therapy.
a
b
Fig. 27.14 (a) This patient had multiple scarred abscess tracts as a
result of mycobacterium infection after facial fat grafting. (b) Once
the infection was resolved with long-term oral antibiotic therapy,
the tracts underwent subcision and further filling to achieve a flat­
ter result.

409
Chapter 27 Perioral Aesthetic Surgery
quired to camouflage or excise scarred tissues (Fig. 27.14).
As a preventive measure, fat grafts can be treated with anti­
biotics during the processing phase. We are unaware of any
long-term studies showing what this does to the viability of
the fat, but as devastating as multiple cutaneous abscesses
can be after an otherwise uneventful facial rejuvenation, the
benefits seem to outweigh the risks.12
Although not all of the grafted fat lives after injection,
we do not believe the surgeon should overtreat to compen­
sate for the fat grafts that will resorb. Overtreating with fat
grafting can lead to large and unsightly graft deposits that
require surgical excision to remove (Fig. 27.15).
Conclusion
Perioral surgery is an integral component of full facial re­
juvenation. A patient who has had a good facelift and has
an aged mouth that is untouched still looks aged and op­
erated because of the disharmony this produces. Although
the decision to operate around the mouth is made easy by
the previous argument, the details of which surgery to do
and which patient to do it on are sometimes daunting. It is
our goal that by carefully reading the nuances of this chap­
ter, plastic surgeons who regularly treat the aged face will
gain the confidence to address the aged mouth with these
techniques; we hope that readers will use our experiences
with perioral complications and lessons learned to better
treat their own patients.
nasolabial and marionette folds. It is imperative to point
out the preoperative asymmetry preoperatively, because
the face is always asymmetrical. It is also important to re­
alize patients usually see themselves as symmetrical in the
mirror. By showing them a photograph of themselves, and
having them look at both that and their reflection in the
mirror, they can better understand their own facial asym­
metry before surgery and any plans to improve it or leave it
be. On occasion, postoperative asymmetry can result despite
adequate tissue removal. This can usually be corrected with
scar revision (Fig. 27.12).
Infection is a rare complication after perioral surgery.
Preoperative antibiotics are given within 1 hour before the
incision and discontinued within 24 hours postoperatively.
For patients undergoing surgery around the mucosa or re­
surfacing, antiviral medications are recommended to pre­
vent herpetic reactivation (Fig. 27.13).
As a referral center for perioral surgery, we often see
complications from other surgeons, including noncore prac­
titioners. Although the focus of this chapter is perioral sur­
gery, there are significant complications that can arise with
less invasive modalities such as fat grafting and laser resur­
facing.
Fat grafting can have the devastating effect of mycobac­
terial infection and must be suspected in any late draining
or red areas after fat grafting.11 With early recognition and
long-term antibiotic therapy, the draining sinuses can typi­
cally be resolved, but further filling or excision may be re­
Fig. 27.15 (a) This patient presented after having fat grafting of the lips done at another institution and was unhappy with her overfilled
appearance. (b) A bilateral lip reduction was required to remove the multiple lobules of viable fat from the lip. (c) After several months,
a more natural and symmetrical appearance was achieved. The patient also underwent a lip lift and corner mouth lift at the same time.
a
b
c
References
1. Cardoso AD, Sperli AE. Rhytidoplasty of the upper lip.
In: Heuston JT, ed. Transactions of the Fifth International
Congress of Plastic and Reconstructive Surgery. Butter­
worth, Australia; 1971
2. Austin HW. The lip lift. Plast Reconstr Surg 1986;77(6):
990–994
3. Penna V, Iblher N, Bannasch H, Stark GB. Proving the effec­
tiveness of the lip lift for treatment of the aging lip: a mor­
phometric evaluation. Plast Reconstr Surg 2010;126(2):
83e–84e
4. Sigal RK, Poindexter BD, Austin HA, Weston GW. Reju­
venation of the aging mouth. In: Nahai F, ed. The Art of
Aesthetic Surgery, 2nd ed. New York, NY: Thieme Medical
Publishers; 2016
5. Knotts CD, Sigal RK, Weston GW. Rejuvenation of the ag­
ing mouth. Presented at the American Society of Plastic
Surgeons. Boston, MA; 2015
6. Haworth RD. Customizing perioral enhancement to ob­
tain ideal lip aesthetics: combining both lip voluming
and reshaping procedures by means of an algorithmic ap­
proach. Plast Reconstr Surg 2004;113(7):2182–2193
7. Weston GW, Poindexter BD, Sigal RK, Austin HW. Lifting

SECTION IV AESTHETIC SURGERY
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Discussion by Randal D. Haworth
Reshaping the perioral area in a convincingly natu­
ral way provides the missing link to create true visual
harmony in facial rejuvenation. It is a privilege and an
honor to share my thoughts and experience gleaned
from more than 20 years of surgically reshaping the lips.
The perioral region is a cue to a person’s true age,
more so than even the neck and hands. Indeed, despite
undergoing an elegant rhytidoplasty, blepharoplasty,
browlift, and fat transfer, a visual incongruency would
likely arise if the aging mouth was not addressed as well.
Unfortunately, most plastic surgeons consider aesthetic
improvement of the lips only as an afterthought, and
adding filler or transferring fat is the most they will do
for fear of creating more harm than good.
When planning for upper and lower lip enhance­
ment, whether for rejuvenation or purely beautification
purposes, I follow the immutable rule of “shape before
volume,” just as I do when formulating a surgical plan to
rejuvenate a breast. In the same way a breast becomes
ptotic from the toll of time, gravity, pregnancy, and
nursing, the cutaneous upper lip elongates from a pro­
vocatively curved arch into a flat, straight-edged sheet.
The actual mouth widens while the oral commissures
variably droop and the lower lip becomes ptotic. In so
doing, the superiorly located wet border of the lower
lip arches inferiorly, exposing the lower incisors, which
ironically mirrors those characteristics of a youthful up­
per lip. Compounding this scenario is the gradual ero­
sion of the very foundation of the lips themselves, the
maxilla and mandible, causing the lip vermilion to in­
vert to varying degrees. Finally, the exterior fabric of the
perioral region becomes atrophic, manifested as vermil­
ion involution, thinner skin, and radial rhytides. It is ob­
vious that simply adding volume to the vermilion will do
little to address any of these age-related characteristics
and may, in fact, makes things worse, including exac­
Fig. 27D.1 (a) This 44-year-old patient was concerned about her “old and dragging” lip appearance. She realized that fillers could
no longer achieve the “model look” she desired. (b) In addition to fat transfer, an orbicularis oris suspension (OOS) upper lip lift, a
bilateral medialized corner lip lift (MECLL), and a modified lower V-Y–plasty was performed, followed by immediate laser-assisted
skin healing (LASH) to the freshly closed incision. The quality of the scars is exceptional.
a
b
lips: 28 years of experience using the direct excision ap­
proach to rejuvenating the aging mouth. Aesthet Surg J
2009;29(2):83–86
8. Guerrissi JO, Sanchez LI. An approach to the senile upper
lip. Plast Reconstr Surg 1993;92(6):1187–1191
9. Fanous N. Correction of thin lips: “lip lift”. Plast Reconstr
Surg 1984;74(1):33–41
10. Coleman SR. Facial augmentation with structural fat
grafting. Clin Plast Surg 2006;33(4):567–577
11. Dessy LA, Mazzocchi M, Fioramonti P, Scuderi N. Con­
servative management of local Mycobacterium chelonae
infection after combined liposuction and lipofilling. Aes­
thetic Plast Surg 2006;30(6):717–722
12. Girard AC, Mirbeau S, Gence L, et al. Effect of washes and
centrifugation on the efficacy of lipofilling with or with­
out local anesthetic. Plast Reconstr Surg Glob Open 2015;
3(8):e496

411
Chapter 27 Perioral Aesthetic Surgery
erbation of ptosis and the creation of a priorly absent
aesthetic dissonance. This would be akin to performing
a breast augmentation for a Regnault’s grade III ptotic
breast without a mastopexy.
I perform the following surgeries, among others:
•• Paranasal upper lip lift: This operation is very
powerful and results in generally imperceptible
scars if principles to alleviate tension across the
scar are followed. The operation not only shortens
the upper lip but also provides additional aesthetic
benefits. As the straight flat upper lip is converted
into a youthful arch, the upper incisors become
unveiled in 90% of cases, the pink vermilion is
everted to a mild degree, and the distance between
the oral commissures narrows. I prefer to perform
this surgery based on the sole indication of a long
cutaneous upper lip (Fig. 27D.1).
•• Medialized external corner lip lift (MECLL): This
is a combination of a lateral upper vermilion
advancement with a traditional corner lip lift. It
gives the surgeon unprecedented nuanced control
over the shape of the upper lip, while addressing
commissural ptosis and marionette folding in the
process. With meticulous planning, it produces
dramatic results with minimal scarring. This is
different than a complete vermilion advancement
because scars are kept outside of the topographical
feature of the white roll, which even in young
ethnic females is rarely longer than 60% of the
distance from the Cupid’s bow and the commissure.
Aside from cleft lip surgery, trauma, and cancer
reconstruction, incisions within the white roll itself
should be avoided whenever possible. No matter
how precisely executed, vermilion advancements
carried over the white roll will obliterate that
vital topographical landmark, resulting in a flat,
unnatural appearance from both anterior and lateral
views.
•• Traditional corner lip lift: Though more limited in
scope, this time-tested operation is nonetheless
powerful in elevating the corner of the lip and
addressing the marionette fold.
•• Depressor anguli oris (DAO) release: This intraoral
corner lip lift produces subtle and less consistent
corner elevation than the former two. However,
it can be useful in redirecting inferior tilt of the
commissure in the absence of marionette folds and
upper vermilion inversion.
•• Upper and lower lip mucosal advancement V-Y–
plasties: Used primarily to reverse either congenital
or age-related vermilion inversion, this technique
is particularly effective in correcting disharmony
between the upper and lower lips through strategic
eversion and protrusion of flattened and inverted
areas of vermilion.
•• Fat transfer: Once shape and harmony have been
established, volume either with filler or fat can
be added. Fat transfer is wonderful to not only
augment volume but also to alter shape in subtle
ways. However, it is important to be aware of what
any filler can or cannot do to avoid producing
irregularities, asymmetries, and the lampooned
“cartoon duck” lip. At my referral center for lip
enhancement, I have seen unfortunate deformities
from the cavalier placement of fat and other volume
enhancers, including silicone microdroplets, dermal
grafts, and various temporary fillers. Of course,
some are fairly straightforward to fix, whereas
others are not.
•• Cutaneous resurfacing: Persistence of radially
orientated oral rhytides can detract from an
otherwise excellent result. Fractionated lasers allow
treatment of a greater range of age-related changes
with less complications and shorter recovery.
In handling complications, it is helpful to remind the
patient that there are three players acting in main roles
determining the outcome of plastic surgery: the pa­
tient, the surgeon, and Mother Nature. In other words,
some complications are preventable, but others are not.
Lip Reshaping Complication
Categories
Scarring
First and foremost, the quality of a plastic surgical scar
is ultimately dependent on tension running across it.
The other influencing factors are, of course, genetics
and postoperative care. Scars within the oral cavity
tend to heal to a point of being imperceptible, whereas
scars located on the perioral cutaneous element can be­
come widened, raised, indented, irregularly webbed or
pitted, hyperpigmented, and/or imperceptible. I would
add dermabrasion with diamond fraise to any postop­
erative treatment, because it can be exceedingly effec­
tive in smoothing out any pits or webbing (Fig. 27D.2).
Although quite minor in nature, these irregularities can
be a tremendous bother because makeup accumulates
in and around them. I usually perform the dermabra­
sion as early as postoperative month 3 after any hyper­
trophic element has been successfully flattened with a
dilute triamcinolone and 5-fluorouracil admixture.

SECTION IV AESTHETIC SURGERY
412
Perioral scars are no worse than those from any
other facial surgery, but they can have more of a nega­
tive emotional influence than other scars. This is es­
pecially true for those in their mid-40s and younger
who generally have yet to manifest perioral rhytides
and atrophic skin. Consequently, any form of scarring
is potentially more noticeable and less accepted in this
group.
Similar to the hands, the lips move hundreds of
thousands of times a day during speech, ingestion, kiss­
ing, and voluntary and unconscious expression. This
places an added strain on any recently closed wound
and immature scar, especially in the upper lip. There­
fore I perform a paranasal upper lip lift via an orbicu­
laris oris suspension (OOS) onto the periosteum around
the piriform aperture. In the same way the deep subcu­
taneous fascial closure of an abdominoplasty alleviates
tension from the visible, superficial aspect of the fresh
scar, transferring the “heavy lifting” to the deeper tissue
of the upper lip dramatically reduces tension and thus
the probability of a noticeable scar. The trade-off of the
OOS method is more prolonged edema, induration, and
stiffness deep to the scar itself.
Immediately after closing the skin in the perioral re­
gion, I use laser-assisted skin healing (LASH) with a frac­
tionated CO2 laser on the incision at a moderately low
density, energy, and spot size. This has further improved
the final quality of the scars, both in terms of healing
time and visibility (see Fig. 27D.1). Despite uncertainty
as to its exact mechanism, efficacy of such an approach
has been documented in the literature, especially with
the pulsed-dye laser.1 A nonablative fractional laser
could also have scar preventive benefits similar to those
achieved with pulsed-dye laser, particularly from the
temperature elevation in the dermis.2,3
Finally, regarding cicatricial contraction of either
the substance of the vermilion or its border, preven­
tion is again the best approach. I have seen this early
on in five of my own patients when I used tunnels from
commissure to commissure to accommodate either der­
mal grafts, Bichat’s buccal fat pad, or an alloplastic im­
plant such as Gore-Tex (W.L. Gore and Associates). Es­
sentially, any long linear scar placed transversely across
the pliable structure of the lip is a potential setup for
an unpredictable cicatricial contraction. This can have
serious functional and cosmetic consequences that are
challenging from both a technical and emotional stand­
point. Except for cases of reduction cheiloplasty, I have
abandoned techniques incorporating tunnels or lengthy
transverse scars along the visible vermilion. For lip re­
ductions, I place the incision behind the wet–dry junc­
tion and close it in an alternating 2- to 3-mm sawtooth
pattern to additionally insure against this dreaded phe­
nomenon while potentially providing maximum ex­
pansile capacity during expression.
Collateral Distortion
Collateral distortion of the surrounding anatomy gen­
erally falls into the following four categories:
1. Labial–alar/alar base descent
2. The apostrophe lip
3. Marionette fold migration
4. Exaggerated lower lip ptosis
Labial–Alar/Alar Base Descent
A paranasal upper lip lift can result in inferior migra­
tion of the alar base, specifically at the labial–alar junc­
tion. This can sometimes be aesthetically advantageous
by imparting a more obtuse nasolabial angle. However,
many patients seeking a consultation for a lip lift spe­
cifically want assurance that no downward descent of
their alar base will occur. Of course, the surgeon cannot
give them the promises they want, but by understand­
ing the pathophysiology of the unwanted complication,
I have been able to modify my technique to minimize
the problem.
a
b
Fig. 27D.2 (a) This patient underwent a concomitant upper lip
lift with rhinoplasty by another surgeon. In addition to obvious
scarring, she had alar base descent and an asymmetrical apos­
trophe lip. (b) Two months after a medialized external corner
lip lift to correct the asymmetrically exaggerated, lateral upper
vermilion sloping and inversion (positive apostrophe lip). She
also underwent an endonasal elevation of her alar base as well
as dermabrasion of her upper lip lift scar.

413
Chapter 27 Perioral Aesthetic Surgery
After 8 years of performing lip lifts via skin exci­
sion and closure only, I soon realized the advantages of
elevating the lip via its associated muscle. By securing
the orbicularis oris bidirectionally to the periosteum,
the lift of the upper lip is achieved independently of the
nose itself. Contrasted with the lift of a skin-only tech­
nique, which relies solely on the approximation of the
cutaneous upper lip to the skin of the nose, this OOS lift
technique is better equipped to withstand gravity and
the unremitting movements of the mouth itself. Similar
Fig. 27D.4 (a) This patient underwent cleft lip repair as a child along with subsequent revisions and rhinoplasties. Chief among
the findings at consultation were asymmetrical nasal sills, a scarred dystopic right alar base, a retracted columellar base, both an
obliterated right philtral column and white roll, and a long upper lip with relative lower lip inversion. (b) After an orbicularis oris
suspension upper lip lift, lower V-Y–plasty, concomitant quaternary rhinoplasty, alar base pexy, and dermabrasion of her cleft lip
scar. (c,d) A nuanced yet dramatic improvement resulted from the re-creation of her right philtral column and white roll through
repeated injections of Bellafill (Suneva Medical) and Aquamid (Contura International, essentially permanent fillers) postoperatively
for more than a year. By careful and artistic injections of the superficial dermis, the skin and scar were teased into a fair represen­
tation of the morphology of the philtrum and white roll.
a
c
b
d
Fig. 27D.3 (a) After having undergone a “skin-only” upper lip lift in 2004, this 58-year-old woman had inferior migration of her alar
base. (b) At 3-month follow-up in 2016 after suspension of her alar base to the bony piriform aperture. In addition to other facial
procedures performed throughout the years, she also underwent a medialized external corner lip lift and a secondary orbicularis
oris suspension upper lip lift and lower V-Y–plasty.
a
b

SECTION IV AESTHETIC SURGERY
414
to a solid canthopexy, the OOS technique provides supe­
rior longevity, less collateral distortion of the nose, and
better scarring because of the minimal-to-no tension
required in closing the skin.
The other rule of thumb in preventing alar base de­
scent is to avoid the well-motivated attempt to hide the
scar by carrying the skin excision into the nasal sill it­
self, even if it appears absent without a topographical
ridge. Cutting into the sill will disrupt the integrity of
the nasal annulus (defined by the alar sidewall, nasal
sill, columella, and soft triangle) and allow the nares to
essentially vertically unfurl at the lateral junction of the
ala nasi and nasal sill.
Should this vertical unfurling at the alar–labial junc­
tion occur, with or without actual descent, an endona­
sal alar–labial pexy, whereby the inferior most extent
of the alar facial sulcus is approximated superiorly via
a transcutaneous approach with a PDS suture to a drill
hole in the inferolateral element of the bony piriform
aperture, can be used. As with most operations of the
upper and lower lip, judicious overcorrection is recom­
mended (Fig. 27D.3; see also Fig. 27D.2). This alar base
pexy can also be incorporated into a Wier excision con­
comitantly to create a highly customized approach, such
as in the woman in Fig. 27D.4 who had a cleft lip nasal
deformity (Video 27D.1).
The Apostrophe Lip
Apostrophe lip, or premature inversion of upper lateral
lip vermilion, is most likely a genetic expression, yet it
can be significantly exacerbated by well-meaning but
ultimately naive attempts to improve the shape of the
lips. The two common iatrogenic culprits are (1) excess
weight of the upper lateral lip stemming from too much
filler placement and (2) an upper lip lift performed as a
single procedure despite concomitant pre-existing cor­
ner lip ptosis.
Excessive augmentation of the lips with an off-the-
shelf filler or via fat transfer can result in its own set of
problems. For example, it is known that the corners of
the mouth can be superiorly rotated a certain degree by
strategically placing filler within the lateral most extent
of the upper vermilion as well as tangentially in varying
directions lateral to the commissures themselves. How­
ever, a tipping point is reached where “a little more of a
good thing is not necessarily better.” Adding more vol­
ume to further elevate the corners can suddenly have a
paradoxic effect whereby the corners of the lip become
weighted down, while the lateral vermilion rolls inward
(Fig. 27D.5a), what I term the apostrophe lip, which can
either be positive, negative, or neutral depending on the
cant of the corners. In cases such as this, any temporary
fillers should either be dissolved or allowed to resorb as
dictated by their respective chemical compositions. In
cases of excessive fat, an attempt to atrophy it with di­
rect injections of triamcinolone acetate and 5-flurouracil
help, but failing that, direct excision through incisions
behind the wet–dry junction is indicated, especially if
discrete irregular lumps are present.
However, despite selective volume reduction, addi­
tional intervention to normalize the apostrophe lip with
a medialized external corner lip lift will most likely be
indicated. I conceptualized this operation as a fusion of
lateral upper vermilion advancement and a traditional
corner lip lift as originally described by Austin.4 The ME­
CLL everts the upper lateral vermilion, elevates the oral
commissures, and diminishes the difficult-to-treat mari­
onette fold by extending the excision superolaterally to­
ward the superior edge of the auricular helix.
In the presence of bilateral commissural ptosis, an
upper lip lift will shorten the upper lip but will do little
to nothing to elevate the corners. Indeed, in many cases,
an exaggerated downward slant of the commissures will
arise, turning a neutral into a negative apostrophe lip
(see Fig. 27D.3). Again, an MECLL can dramatically im­
prove this exaggerated visual incongruency and has
proven to be a very versatile addition to my lip reshap­
ing armamentarium.
Marionette Fold Migration
One of the benefits from Austin’s traditional corner lip
lift4 and my MECLL is the diminishment of the upper
marionette fold. This is a direct result from the skin ex­
cision lateral to the commissure. This works synergisti­
cally with a rhytidoplasty to address the upper portion
of the fold as it arises from the commissure, which a
facelift alone cannot effectively do. Furthermore, fillers
of any kind including fat, combined with or without a
DAO release, generally cannot match the results in cor­
recting the upper marionette fold.
The wraparound corner lip lift and the Valentine
anguloplasty were cleverly designed to confine scars to
the upper and lower vermilion border but sacrificed any
potential to tackle the fold.5 Furthermore, in my experi­
ence, performing this surgery in the face of a prominent
marionette fold will shift the superior origin of the fold
interiorly from the oral commissure, which can result in
an unnatural accentuation of the fold itself that is dif­
ficult to treat (see Fig. 27D.5c). These surgeries are best
used for isolated cases of commissural ptosis only.
Exaggerated Lower Lip Ptosis
Lower lip ptosis and its consequences of lower incisor
show with flattening, inversion, and lengthening of the
vermilion are a natural result of aging. Unfortunately,