Facelift surgery is performed on a wide variety of patients, regardless of age, gender, race or medical condition. There are nuances in facelift surgery for all of these differing patient considerations that can alter the technique and the tissues manipulated to optimize outcomes. The greatest nuances amongst facelift techniques is in what tissues below the skin are lifted, resuspended or excised.
HIV patients can very safely undergo facelift surgery and are not usually at any increased risk of infection if their cell counts are adequate. What is unique about the HIV patient, whether they are young or old, is the change in the fat compartments of the face. For many HIV-positive patients, facial fat wasting (lipoatrophy) is well known and is believed to be the result of antiretroviral therapies. While facial wasting is the most recognized facial fat change in HIV, some patients will develop a more generalized lipodystrophy syndrome which can include unencapsulated fatty deposits, often seen around the parotid glands and into the neck.
In the September 2013 issue of the Annals of Plastic Surgery, an article appeared entitled ‘Facelift in a Patient With Benign Symmetric Lipomatosis and HIV Facial Lipoatrophy’ In this case report, this peculiar combination of fat deformities was managed with a modified facelift and fat excision. Recurrence of the abnormal fat collections did not recur. This report is unique in that it is one of the few in the medical literature that uses a facelift approach for treating the abnormal fat collections in the face.
The most common treatment of the HIV face is that of soft tissue volume augmentation. The mild to severe wasting in the cheeks and temples creates a classic appearance that can only be corrected by fat injection, synthetic fillers, implants or combinations of any of these three augmentation methods. In my Indianapolis plastic surgery practice, the combination of malar-submalar shell and temporal shell implants with dermal-fat grafts added to the lower midface region has been a very successful approach to sustained correction of these volume-deficient facial areas.
But as the HIV patients ages, loose skin develops on the face, jawline and neck as it would in any other person. The development of loose skin may be exaggerated by the fat volume loss that is present. Thus some older HIV patients will benefit by a combined facelift (usually without any SMAS manipulation) with the placement of a dermal-fat graft into the shrunken buccal fat pad space. This can be combined with malar (cheek) implants) for an even more complete facial rejuvenation/voluminization effect.
Of all the potential areas of facial skeletal augmentation, cheek implants are the second most commonly performed location. Having noticeable and strong cheek bones is considered just about part of every aesthetically pleasing face, There are gender and other ‘look’ differences in the dimensions of the cheek prominences but their presence is a key aesthetic element of an attractive and proportionate face.
Unlike the chin or the nose, the cheeks represent a paired area of facial bone prominences and this accounts for some of the unique considerations when surgically enhancing them. The cheek implants must not only be symmetrically placed but must have the right shape and size to give the cheeks their desired look.
While cheek implants used to be thought as two oblong shapes that were positioned right over the front edge of the zygomas (cheeks), that original approach was just the first step in how far cheek augmentation has come today. Understanding the different shapes of contemporary cheek implants can create a cheek look that best suits their face. They fundamentally break down into three types based on what area of the cheek they augment.
The traditional cheek implant is now described as a Malar Shell. It is called that because it sits over the curved zygoma and augments it in a near 120 degree arc. It most closely mimics the natural shape of one’s zygoma and just makes it bigger. For people with flat cheekbones from the lateral infraorbital rim down, particularly those who have a negative vector, this implant produces a natural and not overly prominent effect.
In the mid-1990s, the submalar implant was a revolutionary improvement in the few cheek implant styles that were available. It is designed to sit on the lower half of the cheek bone, creating more fullness below the cheekbone prominence and helping to pick up any sagging cheek tissues. It was even touted as a volumetric midface lift. It creates that effect in the patient with midface aging as well as one who has submalar hollowing from facial lipoatrophy.
For those patients who are in need of a more total cheek augmentation effect combining the malar and submalar areas, there is the Submalar Shell implant which can also be called the Midface Implant. Putting the two together gives a combined bone augmentation to the cheek prominence and a volumetric fill to the area below…a combined bone and soft tissue effect.
While not a different style, several features have been added to these cheek implant shapes that help them adapt to the bone better and provide increased soft tissue fixation. The Conform feature is that implant is no longer a solid piece but has a grid pattern on its backside that allows the ultimate in adaptability to the bone. (increased flexibility) The addition of a 0.3mm layer of Gore-Tex on the outside of the silicone implant provides a semi-porous outer layer for soft tissue to quickly grow into and fix the implant in position. (if a screw is not being used)
Selecting the cheek zones to augment is the key in selecting the proper cheek implant style. Selecting the right size of implant, however, is more of an art than an exact science as there is no quantitative measurement to make that determination. But in general it is usually better to be more conservative (smaller) than one would think as these broader surface area cheek implants of today can create a bigger effect than one might think when just holding them in your hand.
The one facial feature that is most associated with a youthful looking face is that of the cheeks. Firm uplifted and rounded cheeks are what is seen in younger people, flat deflated cheeks are usually seen as many people age. It is the loss of cheek volume that contributes to a tired looking and aged appearance. While browlifts and eyelid surgery for the upper face and neck and jawline lifts for the lower face have been around for decades, the intervening zone between the two has caught a lot more interest of late.
Cheek and midface rejuvenation is the last facial region to receive a lot of attention from both surgical and non-surgical treatments. Numerous good options exist today including the use of synthetic implants , cheek lifts , fat injections and expanded uses of injectable fillers. While each of these cheek enhancement treatments have their advocates and critics, it is important to realize that the controversy is more about indications and less about effectiveness.
One of the first treatments for midface rejuvenation was that of silicone cheek implants, specifically the submalar implant style. By adding volume to the underside of the cheekbone, a subtle but visible lift of the midface was obtained through a combined voluminization and positional effect. Restoring fullness to the ‘apple’ area of the cheek removes the midface flatness. The submalar cheek implant has now been expanded to incorporate more of the cheek area through a new style known as the malar shell. The biggest benefit of using implants is that they create permanent volume but yet can be completely and easily reversed if needed. Any concern about implant stability or shifting is removed by screw fixation to the bone. There is never any concern about implant settling/erosion in the cheek bones. Such facial implants have proven over the years to be very safe and effective when well placed with a very low risk of problems.
While cheek lifts (midface lifts) were the rage a decade ago for midface rejuvenation, they have fallen considerably out of favor. Beyond the complication risk of lower eyelid deformity (ectropion), the concept of lifting up fallen or sagging cheeks has not proven to be effective or sustainable alone over the long -term. Cheek lifts, as part of an extended blepharoplasty, still have a midface rejuvenation role but they need to be combined with the addition of volume through the concurrent insertion of cheek implants or with fat injections.
The real revolution in cheek enhancement has been through the use of injectable fillers. This has not only made it possible for a wide array of practititoners to engage in midfacial augmentation but the number of filler options is considerable. With injectable fillers, it is theoretical possible that just about every patient over 40 years of age could benefit by some degree of volume addition. Younger patients may only need a single syringe or less while older patients may need multiple syringes over broader areas.
The injection location for filler placement is based on an understanding of aesthetic cheek anatomy. A youthful cheek has a three-dimensional shape with the greatest projection producing a light reflex at the apex of the cheek. This point is often described by the intersection of lines drawn down from the lateral canthus of the eye to one drawn from the corner of the mouth to the tragus of the ear. But the injector must use an artistic assessment as to what looks best for each patient.
While many fillers exist for midface injection, the hyaluronic acid-based (HA) fillers are associated with the best safety profiles. The more robust HA fillers, such as Juvederm, works best as their higher G prime (stiffness) allows the cheek tissues to be lifted effectively with less volume than other fillers. A game changer in cheek fillers has been the introduction of Voluma late last year. As an extension of the HA product Juvederm, Voluma was specifically made and studied for the cheeks/midface. Its unique properties allow it to lift tissues effectively and it persists for over a year.
Fat injections has grown tremendously in popularity over the past decade and the cheeks is one of its prime targets in the face. It is a treatment option between injectable fillers and synthetic implants. It offers a more less invasive option than implants but with the potential for a longer-lasting result than injectable fillers. The key variable in this equation is the unpredictability of how well injected fat survives. While the cheek is one of the most favorable areas for fat survival in the face, it is still wildly unpredictable. The appeal of its natural composition is counterbalanced by the risk of partial or complete resorption.
When factoring all the advantages and disadvantages of every cheek enhancement option, it is a balance of the magnitude of the problem vs. how much effort one wants to invest in the treatment. For the younger patient with early facial aging concerns, injectable fillers are the best treatment unless they are having surgery for other aesthetic issues (e.g., rhinoplasty, breast augmentation, liposuction). Then fat injections would be worth the effort in the hope for a long lasting result. For the older patient with more moderate to more advanced midfacial aging, implants are the best treatment as other facial rejuvenation procedures are being simultaneously done. Fat injections are a good choice for those patients who are opposed to implants but they should not expect the same predictable volume result.
One of the key features of an attractive and youthful face is the cheek area. The desire for fuller cheeks, however, is driven more than just by that of model and celebrity faces. Part of the aging process is losing volume (fat) in the cheeks and temple areas, creating more hollowed or gaunt type look. For those that start out with thinner faces, this process is more accentuated even earlier in the aging process. This form of facial aging can not be treated by any form of a facelift or tissue shifting approach. It requires restoration of facial volume.
So it is no surprise that plastic surgeons over the years have used every available option in their armamentarium to reshape and lift the cheek area. While once only able to be treated by synthetic implants up to the early 1990s, injectable fillers of differing compositions for cheek enhancement became a dominant force over the past two decades as they have surged in popularity. The use of autologous fat in just a few short years has also become now a major tool for use in the cheek.
The single greatest advantage to synthetic injectable fillers for cheek enhancement is its immediate result. The hyaluronic acid-based fillers, such as Restylane or Juvederm, offer the greatest margin of safety because of their lack of inflammatory response and assured resorption profiles. Other fillers such as Radiesse and Sculptra offer longer results but a somewhat higher risk of soft tissue reactions to their particulated content. Composition aside, the biggest disadvantage to fillers is that they are temporary. (which is also their advantage) This makes them expensive to maintain over time if one likes the result. But they are actually a low cost approach to doing a trial cheek enhancement that is completely reversal. Using a microcannula delivery technique, injectable fillers can now be delivered painlessly and without bruising.
On the surface, fat carries with it many of the same features as synthetic materials because it is injected. But beyond being injectable, it is a very different filler material. Because it is harvested from each individual patient, there is no chance of any inflammatory reaction and a very low risk of infection. It’s other tremendous advantage is that there is no limit on the volume that can be injected (in the small face) and its inherent composition of stem cells has its own list of theoretical advantages. In addition, it is done for a set procedure price rather than by a cc cost for synthetic fillers. It is similarly injected by small cannulas so placement can be very exact without bruising. The best fat placement is down at the bone level and in the muscle, where survival is better. But with all these advantages comes two distinct disadvantages…it is a minor surgical procedure and there is no assurance as to how much fat will survive. For these reasons, fat grafting is often advocated when the patient is in surgery for other procedures (e.g., facelift, lkipsouction etc) or the patient has been previously qualified by having had successful cheek augmentation with synthetic fillers.
Implants offer the one permanent method of cheek enhancement. With no external scarring as a result of being placed from inside the mouth, implants are not only permanent but can provide the most dramatic of cheek augmentation effects. The most difficult aspect of using cheek implants is selecting the proper style and size. With dozens of implant options the choices can be overwhelming and there is no clear-cut quantitative way to know what effect the implant will create in any particular patient. It can also be surprising how much change can occur in the cheeks from what appears to be a relatively small implant.The cheek is a very volume-sensitive area. So it is always better to ‘undersize’ or choose a size below what you think you should use in many cases. The disadvantages to cheek implants are infection, displacement and asymmetry. Fortunately infections are very uncommon and displacement can be circumvented by securing the implant position with small self-tapping screw fixation. Avoiding asymmetry is a matter of experience and matching carefully the position of the implant in reference to various bony landmarks.
With three cheek augmentation options available, how does any patient know what is best for them? Cheek augmentation is a lot more art than it is science and appreciating the underlying bony anatomy, the overall facial shape and what look the patient is after is key. But you have to take the whole patient into analysis not just the cheeks. Thin people with low body fat may do poorly with fat grafting, the devout non-surgery patient can only have synthetic fillers, or those seeking the most efficient and long-term method may opt for implants. Good cheek results defy a cookie-cutter approach and the most natural outcomes come from knowing how to use all three…occasionally even blending two of the techniques together.
Implant augmentation of the cheeks provides a valuable facial structural enhancement as well as is useful for an anti-aging effect. For many women, it may be the most critical aesthetic facial prominence (short of the nose) in contrast to men where it is the chin and the jawline. The cheek in both genders, however, can make the face more bold, defined and attractive. But cheek augmentation is a procedure that is harder to predict the implant’s effect on males or females because it is a curved facial feature that defies any exact mathematical measurement like most other facial features.
When one factors in the many different styles and sizes of cheek implants, not to mention the different manufacturers and materials, there may be upwards of near100 different cheek implants to choose from. How does one know what is the best cheek implant to choose for this midfacial area? There are numerous factors to consider but the first is to recognize the gender differences in desired cheek shapes. Men desire and look better with a more chiseled cheek appearance that is often described as angular . This is a high more sharply defined cheek look. Conversely, women usually desire and look better with a less angular fuller cheek. This round cheek creates a softer more feminine appearance.
Because the cheek is not seen at its best in either a frontal or a profile view, it defies any exact measuring system. The influence of the cheek is best seen in a quarter or oblique profile view which is how most people see your face anyway. It is possible to isolate the most optimal area of cheek enhancement by the intersection of an oblique line drawn from the corner of the mouth to the corner of the eye and a horizontal line drawn outward from the top of the nostrils. Higher up from this intersection is where male cheek prominence should be while more near the intersection is where female cheek prominence should be. But no measurement can tell one about the best cheek implant size. This is where the role of intraoperative implant sizers and the aesthetic judgment of the surgeon comes into play.
Cheek implants are used for four types of aesthetic facial issues. The most common indication is for inadequate cheek volume or an underdeveloped cheek area. The cheeks simply did not develop with the desired amount of aesthetic projection. Asymmetry of the cheeks is another indication which can occur from mild to more severe forms of facial hypoplasia or from cheekbone fractures that were not adequately treated or not diagnosed at the time of the injury. Ethnic cheek augmentation is a third use of implants that represent a form of cheek ‘underdevelopment’ but is really more of an effort to change one’s basic facial shape.This is most commonly seen in Asian and African-American patients where improved cheek projection is desired as one of the maneuvers to change their facial shape. Lastly, which is not really a bone-problem, are the effects of aging. The soft tissues of the cheek are pulled downward towards the mouth area, revealing what appears to be a cheek deficiency. Pushing the soft tissue upwards with an implant is more important here than pure bone augmentation.
When selecting the style of cheek implants, it is important to realize what area of the cheek bone needs to be augmented. If it is a high angular look that one wants, then the cheek implant should be more narrow so that it does not augment the lower or front edge of the cheek bone. For rounder fuller cheeks, the implant needs to be wider to cover the entire cheek bone including its lower edge. To widen the face, which means the posterior edge of the cheek bone and onto the zygomatic arch, the implant design needs to extend further back or be positioned further back on the cheek bone. If the soft tissue of the cheek needs to be lifted, then the implant should have its greatest prominence on the bottom of the cheek bone or the submalar area. Thinking about how the shape of the cheek bone needs to be changed is how the style of cheek implant is selected and one can then easily work their way through the maze of implant options.
One cheek implant issue that is chronically debated is the choice of implant material, which is fundamentally either silicone or Medpor. While there are advocates of either material, what really matters is whether it have the right shape for the area of desired cheek augmentation. Your body does not really care which material is implanted. It will react the same by enveloping it a capsule of scar. The only real difference is that a Medpor implant will be harder to remove or adjust its position but not impossible. Regardless of the material, it is always best to secure the cheek implant into permanent position with a self-tapping 1.5mm screw, one for each side.
Cheek augmentation is done for a variety of different aesthetic reasons. Besides the obvious need to fill out a sunken in cheek appearance and improve facial balance, they are just as commonly used for an anti-aging effect. By augmenting the soft submalar tissue to fill midfacial hollows, the lifting of this tissue provides a facial rejuvenating effect and may even soften the depth of the nasolabial fold beneath it. This tissue lifting or anti-aging effect is unique amongst facial implants.
The shape of the cheekbone and its location between the convex orbital rim and the concave maxillary wall make it the most complex facial area to augment from an aesthetic standpoint. Where along the cheekbone should the implant be positioned and what shape and size of implant should be used are what the plastic surgeon ponders. There really are no guidelines as to how to exactly to make these selections. Artistic technique is as important as any type of scientific approach. This high degree of variability lends to revision rates that are higher than any other facial implant currently used.
Cheek implant complications usually are of two types, undesired aesthetic outcome and implant shifting or migration. Unhappy outcomes come from either an implant that is too big or positioned in the wrong location. Either way, an unnatural appearance often results. Because of where cheek implants are located, they catch attention almost as much as one’s nose or eyes. Cheek implants come in a variety of sizes and shapes but can fundamentally be divided into malar and submalar implants. Malar implants being placed on top of the zygomatic bone and submalar implant highlighting the underside of the bone. (submalar hollow or buccal space) Malar implants have different extension that either go back further onto the zygomatic arch, up around the lateral orbital wall , or anteriorly along the underside of the orbital rim. Because of these variable implant shapes, it takes a good aesthetic eye and communication with a patient beforehand to get a good result.
Cheek implants are also unique because of where they are positioned on the zygomatic bone. They often are sort of hanging from the side of the cliff, which makes them prone to shifting. Shifting will usually occur in a downward direction from whence they were initially inserted, which is usually through the mouth. For this reason, it is possible for cheek implants to shift around and end up with asymmetry. This is particularly true if the implant is made from silicone which is very smooth and slippery. Other implant composition have a much greater frictional grip on the bone and will not move as easily.
One interesting silicone cheek implant design which can effectively address the shifting problem is that of the Conform midfacial implant. Its undersurface is not smooth silicone but rather a pebbly or nubbed surface. The many little ‘’fingers’ of silicone allow it to develop some degree of frictional gripping to the bone surface. Also when soft tissue grows around it, the capsule will absolutely lock it into place. This is very similar to the concept of placing a textured surface on a breast implant which was developed nearly twenty years ago. Its shape also allows it to be trimmed and used as either a malar or submalar implant.
As one ages, the entire face changes. Some parts of facial aging are more obvious than others as the face does differentially age. The forehead, brows, eyes, mouth, jawline and neck are all areas whose aging is well recognized. The aging of the midface and cheek areas, however, has only become more recently recognized.
With the aging process, the fatty tissue that normally drapes over the cheekbones can begin to sag. The result is less prominent cheekbones, and a droopy fold of skin and fat between the nose and the cheek (the nasolabial fold). The sagging cheek fat can also alter the appearance of the lower cheek. For example, bagginess of the lower eyelids often becomes more apparent after the fat of the upper cheek begins to sag. This in essence ‘unveils’ the bagginess of the lower lids, which have always been there. In addition to sagging of the skin and fat of the midface, there is also volume loss in the cheek due to loss of fat and muscle.
A number of cheek lift or midface lift procedures exist to address this aging area. The goal of all of them is to lift up droopy cheek tissue over the cheekbone restoring the more prominent youthful contour, improving the tear trough and bagginess of the lower lids, and softening the undesirable cheek fold. Fundamentally, they may be divided into lifting approaches vs volumetric addition. In some cases, they may even be done together.
Lifting approaches aim to reposition the sagging fat of the cheek over the cheekbone to restore the youthful fullness of the cheeks. Such midface lifts use differing access including the lower eyelid, scalp, and temporal incisions using open incisional or endoscopic instrumentation. Implants have also been devised to provide less invasive options including suspension sutures and bone-anchored lift devices. The plethora of differing lifting approaches suggests that no one of them is universally successful.
Contrarily, cheek implants have also been used to help create a degree of cheek lifting. By placing an implant through the mouth onto the cheek bone, some fullness is added to the volume-depleted cheek and the cheek tissue on top of the implant is pushed upward. While not creating as dramatic effect as a lifting procedure, it is far simpler and with fewer complications. This cheek lift approach, using a specially designed submalar implant which fits on the underside of the cheek bone, has been around for nearly two decades. When used in the right patient and properly sized, it can have a good cheek enhancement effect. But it is also easily overused and overdone (too large a size) as older celebrity faces are rife with examples of odd-looking and peculiar cheek prominences due to oversized implants.
Given the choices between cheek lifts and cheek implants, which is the most helpful for cheek rejuvenation? The answer is no one of them is best for all patients. Over the years, I have used almost of all of them in my Indianapolis plastic surgery practice….and have also seen and learned the downsides to each of them. Midface or cheek rejuvenation is as much an art form as almost any area of anti-aging facial surgery. Given the potential complications that can occur with lifting procedures, most specifically lower eyelid ectropion, their use should be reserved for the most severe sagging cheek problems. More moderate cases with less prominent cheekbones may benefit with a small to moderate-sized implant. In all cases, moderation is the key…not too much lift or too big of an implant. The midface is one area that does not look good overdone and is easy to do.
Cheek implants are a fairly simple and effective method for adding projection of various areas of the zygomatic midface. Because they are various shapes of cheek implants that are available, there is a fair amount of art as opposed to science in selecting style and size of implant to get the patient’s desired effect. Because these implants are placed on the side or underside of a bony surface, they are also prone to postoperative migration in an inferior direction of they are not secured.
Cheek implants are typically shown in textbooks, journals, and patient results in patients who have teeth. By having teeth, the vertical distance from a positioned implant to the maxillary vestibule (highest area under the upper lip) is maximized. There will always be a good soft tissue buffer between the implant and the inside of the mouth. This lessens the long-term likelihood of implant exposure should it ever migrate downward. (if one secures the implant with screws, this will not happen)
In the patient without teeth, however, the use of cheek implants can be more problematic as the facial anatomy has changed…unfavorably. The loss of upper teeth changes the structural integrity of the face. The vertical dimension of one’s occlusion (bite), or the height of the bite formed by the contact of the upper and lower rows of teeth, determines the shape and length of the cheeks. When a patient becomes edentulous, the mouth closes too fully with no teeth to separate the jaws, thus contributing to a sunken in appearance of the cheeks. Without teeth, the cheeks tend to wrinkle, the angle between the nose and the lips changes, the ridges that hold the teeth flatten, and the tongue may splay out to fill the open mouth space. These changed features often make the edentulous patient seek midface volume replacement.
The fundamental concern in placing cheek implants in a patient who wears an upper denture is two-fold. First, the distance between the cheek bone and the maxillary vestibule has shortened considerably. There is less soft tissue coverage between the implant and the oral mucosa. This makes the use of certain types of cheek implants, the submalar implant specifically, more risky. Because it sits on the underside of the zygomatic bone, it is even closer to the lining of the mouth. Secondly, the flange of an upper denture can be an erosive source causing implant exposure. A high-riding denture flange may eventually cause pressure necrosis of the thin soft tissue between it and the implant. At the least, it can be a source of irritation and discomfort.
Cheek implant selection is critical in the edentulous maxilla. The implant should be placed on the zygomatic prominence and its maxillary extension trimmed if necessary to keep it from hanging too low. The implant should absolutely be secured in place by a screw. If the implant needs to be extended for midface volume, it should go as close to the infraorbital nerve (without compression) as possible. The canine fossa area should be avoided, as tempting as it is to help this volume deficient area. Lastly, the patient’s dentist should be consulted to shorten the posterior flange of the maxillary denture before surgery. The broad palatal surface provides enough surface area for retention that the flanges can be shortened without sacrificing denture stability.
Cheek implants can work effectively in the typical older edentulous patient who usually suffers midfacial volume depletion and sag. Several alterations in surgical technique are necessary to avoid the increased risk of eventual implant problems caused by vertical maxillary shortening.
Implants are very useful for producing three-dimensional facial changes. By extending the outer boundaries of bony prominences, the proportions and shape of the face can be changed dramatically. Implants essentially camouflage facial bony deficiencies or enhance a normal prominence. Traditional and well known facial implants are that of the chin, cheeks, ornose. Jaw angle implants are also becoming more commonplace today.
Most facial implant use is for one region only (e.g., chin) even if the area of enhancement has two sides. (e.g., cheeks) Multiple sites of enhancement at one procedure can also be done and are associated with more significant facial changes. The use of combination cheek and chin augmentation or even chin, cheek and jaw angle augmentation are traditional implant duets and trios.
Another good facial implant combination is in the use of camouflaging a midface deficiency. Some midface hypoplasias are obvious, other are more subtle. Either way, there is an apparent flatter or less convex facial profile. In its severest form, the facial profile will actually be concave. The degree of midface underdevelopment is most evident by looking at one’s teeth or bite relationship. There may be an underbite or an edge-to-edge bite at the incisors. Someone may have had prior orthodontics so the ‘true’ bite relationship may have become obscured.
Midface deficiency is marked by flatter cheekbones and a ‘sunken’ base to the nose, known as the paranasal region. The entire midfacial skeleton is recessed from below the eyes down to the upper teeth. This bony position will have an impact on other facial areas making the nose and chin look bigger and the upper lip look smaller and thinner.
In young patients or more severe midfacial deficiencies, one should consider moving part or all of the midfacial bones. Traditional LeFort osteotomy patterns in conjunction with orthodontics is the standard approach. For patient’s with less significant deficiencies or who are not desirous of making that degree of surgical effort, augmenting the deficient bone is another option.
The combination of cheek and paranasal implants is a good facial augmentation combination for this problem. Using four implants (two cheek and two paranasal) placed through two incisions under the upper lip, the midface area can be brought out for greater facial convexity. It is important to secure these implants to the cheek and maxilla with small screws to prevent movement or migration after surgery.The choice of implant material is not important but good sizing and placement position is.
With an improved midfacial profile, the nose will appear smaller and may not require any alteration. For others, changing the shape of the nose through a rhinoplasty may be simultaneously beneficial. This can be determined before surgery through computer prediction imaging.
Facial wasting is a very specific condition of the face in which specific areas of fat are resorbed and, in its severest form, is unique to the HIV patient taking retorviral medication. Nobody knows exactly why fat from the faces specifically goes away on people taking anti-HIV drugs, but a significant percentage of such patients willexperience it depending on their particular retroviral medication regimens. It seems to occur particularly in men of low body weight who are over the age of forty.
Facial wasting can present in a variety of appearances from subtle to very dramatic, based on the amount of fat under the skin that has been lost. Patients typically present with sunken-in cheeks, very prominent cheek bones not covered by the usual fat layer, and hollow temples. This also creates loose facial skin due to the lack of underlying fullness.
Facial wasting can be treated by a variety of plastic surgery methods. The most popularized is the injectable approach using Sculptra or other long-lasting fillers such as Radiesse. While injectable fillers definitely provide a benefit, I don’t find them to be the best value, given what they cost and the repeated treatment sessions necessary. In my experience, several surgical options are more effective with injectable fillers or fat grafts used to supplement them.
I find that cheek implants, specifically submalar implants, are a good foundation to build out the sunken face. These implants come in a wide variety of shapes and sizes so some customization of them can be done for each patient. These implants provide a good fill of the lost volume of the buccal fat pad and are easy to place through an incision inside the mouth. Once in the proper position, I prefer to place a screw through them to hold them permanently to the underlying cheek bone. There is some mild swelling after surgery but one can go back to work and resume all normal activities within just a few days. The advantage of an implant is that its volume will remain stable over time unlike injectable fillers. I have yet to experience any infections with cheek implants in the HIV patient nor do I think that such patients are at an increased infection rate from such procedures.
But augmentation of the bony cheek and submalar area can treat the full extent of the facial wasting. This requires soft tissue augmentation using an injectable approach to fill in around the edges of the implants and beyond. Often there can be a step-off or obvious demarcation from the implant to the surrounding skin in cases where the facial wasting is quite severe. In more mild cases, this may not be necessary. Fat injections are very versatile but they require having some subcutaneous fat tissue into which to be placed. In severe facial wasting I have used dermal-fat grafts, harvested from the abdomen, to be placed below the cheek through a nasolabial incisional approach.
When the facial wasting is associated with loose skin, a modified facelift can also be very helpful. Changing the facelift to more of a jowl-neck tuck-up helps stretch out the loose cheek and facial skin. When done in combination with submalar cheek implants and fat grafts, some really nice facial improvements can be achieved.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.