Injectable fillers have come a long way since the approval of the first non-collagen based product in 2002. While once conceived as only a way to make lips bigger and nasolabial folds less deep, injectable fillers have evolved into an aesthetic technology that has a wide number of facial uses. Aiding the expanded uses has been helped by the large number of different filler compositions offering variability in viscosity and flow charactistics as well as in longevity and in how they create their effects.

Fundamentally, injectable fillers are used for two main aesthetic applications, spot filling and volumetric enhancement. It is the latter that is often coined as ‘non-surgical facial sculpting’. That term is probably more accurate than not as it definitely takes skill and a good eye to get pleasing facial volume results with fillers. There is more art to it than science.

When it comes to facial volumetric enhancement with fillers, they are often compared to and even viewed as a substitute for surgical solutions to the same problems. Some injectors view synthetic fillers as  a better treatment choice as they are easier to do and have less risk of complications than surgery. While that is true, that does not mean they always give better aesthetic results or offer the best value for the money invested to do them.  There are advantages and disadvantages with both approaches depending upon exactly what facial application to which one is referring.

For skeletal augmentation of the three facial highlights, chin, cheek and jaw angles, injectable fillers can be used to create a visible external effect. When placed down at the bone level, I prefer Radiesse. Its calcium hydroxyapatite composition makes it the most viscous filler which provides a better push of the overlying soft tissues per cc of volume.  But when comparing it to synthetic facial implants that have been used for decades, it has several disadvantages. It takes a fair amount of syringe volume to get a visible effect, often at least two or three syringes depending upon the area. (chin = 1 syringe, cheeks = 2 syringes, jaw angle angles = 3 to 4 syringes) This makes it relatively expensive. In addition, the effect will never be as significant as a surgical implant and the filler material will go away by about one year or so after injection. This makes using an injectable filler for facial skeletal augmentation very patient selective. Filler are best used for skeletal augmentation when one is uncertain about how a surgical implant may look (trial ‘implant’) or if the need/result is time dependent based on an upcoming event and one doesn’t want to recover from surgery.

Other injectable fillers can be used for a skeletal effect but are placed in the subcutaneous tissues and not down at the bone level. In these cases, a hyaluron-based filler like Juvederm or Perlane are preferred which have higher material concentrations and will last about a year also.

The face is made up of a lot of non-skeletal areas that are not supported by underlying bone. These include two large areas in the lateral face and the temples. In the triangular area between the cheeks, chin and jaw angles lies the lateral facial region whose shape is not dependent on any bony support. It can be concave, flat or convex depending upon the shape of one’s face and the thickness of the underlying soft  tissues. This area has garnered a lot of attention in facial aging as it becomes more concave in some people as they age due to fat atrophy. Plumping it up with fillers has become popular as a rejuvenative manuever. I prefer Sculptra for the lateral facial triangle because of the volume of material needed. Using an 8cc per bottle reconstitution of Sculptra creates an almost pure watery form. This makes it  easy to get a good amount of material over this large area and have a low risk of creating any lumps. Sculptra does not work immediately and it takes time and three total injection sessions to get the best result. But it will last for up to two years.

The temple area is another soft tissue supported area. Muscle and fat make up its shape and it is smaller than the lateral facial triangle but still has a sizeable surface area. Sculptra seems to work best in this area because of the volume needed. But the result and its persistence can not be compared to the relatively simple placement of a subfascial implant. Again, fillers here are more of a trial to determine if an implanted result is worth the effort.

Injectable fillers can also be used in the nose for limited amounts of reshaping. This has led to the concept of the ‘non-surgical rhinoplasty’. In truth, this moniker has a large marketing slant to it because fillers can not obviously replicate what a surgical rhinoplasty does.  But to temporarily mask an upper nasal bump, fill in some asymmetries or do a little tip lifting,  the judicious use of fillers can make some aesthetic nasal improvements.

Dr. Barry Eppley

Indianapolis, Indiana

There are many reasons that patients request surgical changes to their face. With over twenty different facial regions that can be altered, there are seemingly endless options and combinations. But when you break it down, there are two main reasons for making cosmetic changes to the face. I divide these into either facial anti-aging surgery and facial structural surgery. For the most part, this is the difference between soft vs hard tissue facial surgery.

Anti-aging facial surgery includes many of the most recognizeable procedures such as a facelift, blepharoplasty (eyelid tucks) and skin resurfacing. These are done to counteract the effects caused by time, age and sun exposure. Changes are made to the soft tissues of the face, largely the outer skin layer. Facial structural surgery goes much deeper and makes changes to the bone and cartilage. The most common structural procedure historically is rhinoplasty but today includes everything from forehead augmentation and brow reduction down the face to chin and jaw angle augmentation.

Besides the tissue levels which these two types of cosmetic facial surgeries affect, there are also very significant psychological differences between them. Anti-aging facial surgery is more psychologically comfortable for patients because the goal is to take them back to once how they looked, a place in which there is familiarity. The surgery and recovery may be scary but the end result is a look that the patient can recognize and has known in the past. In contrast, structural facial surgery is very different. The end result is one that is not familiar. It is a new look, an alteration of a face that one has known their whole life.

Having done many facial structural procedures in my practice from rhinoplasty to jawline enhancement, I have made several observations about these types of plastic surgery. Some of these are not new and have been known in plastic surgery for a long time. But new technologies and biomaterials have changed what is possible today and with that comes new psychological ramifications for patients.

Changing the structure of one’s face obviously requires an understanding as to what the patient’s goals are. Patients provide that information by descriptions of their concerns and often provide visual aids such as drawings, self-photographs and photographs of other people. These are all really helpful and collectively important. But one concerning issue is the overuse of model or celebrity facial photos. Seeing too many of these or having a patient show a whole notebook of other people’s or famous face may be a sign of unrealistic expectations after surgery. While everyone willingly acknowledges that they can not look like someone else, whether they believe that or not may be another story.

To aid presurgical discussions and goals, I consider computer imaging essential to any facial structural surgery. For the psychological reasons previously mentioned, I rarely do it for anti-aging facial surgery but consider it essential for structural changes. But computer imaging can be misinterpreted and often is. It is not a guarantee of results and such imaged results may never actually be achieved. It is a communication tool about surgical goals and what a patient wants changed and the degree of those changes. It is only as good as the person doing it and is really an integration of surgical experience and how well one knows computer imaging technology. This is why a plastic surgeon should be doing the imaging, for only they know what can really be achieved by different types of facial surgery. But even in the best of hands, a patient should not assume that is exactly the way they will look after surgery. It is an estimate or prediction but human tissues induce more variables than pixels on a computer screen.

When going through structural facial surgery, the recovery is going to be longer and more psychologically difficult that most patients envision. The swelling and bruising on the face can be quite shocking and no patient is ever really prepared for it. When the dressings, splints or sutures come out days or a week later, it is not a moment of celebration or expectation. It is just the first step in the recovery process. One is not looking at the final result and, depending upon the procedure(s) being done, full recovery is not just a few weeks away.

Facial areas will be puffy, swollen and distorted and usually far more than one anticipates. It may be significant or not all that bad, but this is not the time to judge the results. More importantly, and I have seen this many times, one should not assume that the changes are too big and need an immediate revisional surgery. What appears too big at two or three weeks after surgery may be just perfect at two or three months. My minimal time for judgment of facial structural surgery results is three months and I will not consider any revision before then unless they are compelling medical reasons. (e.g., infection) One should not attempt aesthetic revision on a moving target.

When three or more structural facial procedures are done at the same time, the appearance of the face the first few weeks after surgery can be very disturbing. Patients will often feel that they have made a mistake and even wish to return to how they looked before even though they obviously did not care for that appearance. Such after surgery appearances disrupt work and social interactions but are part of the process. If one thinks they will go back to work in two or three weeks after such surgery and will look perfectly normal…this is not realistic. Plan accordingly and I mean this from a psychological perspective. Living through the process of facial swelling resolution and tissue adapation around the bone or implant shape requires tolerance, explanations and even an openness about what has been done if necessary.

One of the most important considerations about structural facial surgery is an appreciation that the risk of needing revisional surgery is significant. At the least, it is much higher than that of a facelift or eyelid surgery. On the most simplistic level, let’s compare the risk of complications/revisional surgery of eyelid surgery (1 % to 2%) vs a chin implant (5% to 7%) in my experience. Both are fairly straightforward and relatively simple procedures. But the use of an implant introduces issues of infection, malposition and size and shape issues that do not exist as much in manipulating one’s natural skin. Now multiple that times the number of facial structure procedures being done, each with their own percent of risk, and it is easy to see why the risk of revisional surgery in facial structural surgery is significant.

For example, take a patient who is having rhinoplasty (5% revision risk), a chin implant (5% revision risk) and jaw angle implants (10% revision risk) done as a single procedure. On an additive risk basis, the real risk of revisional surgery in this case is 20% or higher, If you take more extreme cases of five or more facial structural procedures being done at the same time (a not uncommon collection of procedures in my practice), the potential risk of revisional surgery could be as high as 50%. This doesn’t mean that the complications are devastating or severe but are almost always about symmetry and the size of the changes done in the various areas. It is hard aesthetically to make so many facial changes and have them all look perfect afterwards…particularly when one is not precisely sure how they will interpret the changes.

Facial structural surgery can make significant aesthetic changes to either give the face a better shape, more definition and improved balance or to improve asymmetries between the two sides. But it is harder surgery to undergo both in planning and during recovery and has a higher risk of the need for revisional surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Implants have been an important part of aesthetic facial surgery for over fifty years. Starting originally as just small implants for chin augmentation, they have evolved into a large line of bone-based implant shapes and sizes. They are commercially available today for just about every conceivable area of facial bone augmentation from the skull down to every zone region of the mandible. While chin and cheek implants constitute the most widely used facial implants, many other augmentation areas are becoming more recognized as useful such as jaw angles, submalar, infraorbital and temporal implants.

With the emergence of synthetic injectable fillers and autogenous fat injections, many surgeons have chosen to use these less invasive techniques for facial augmentation. While their simplicity is very appealing, such injectable filling methods are best used for soft tissue augmentation of facial areas not supported by bone. While they can be effective for augmenting facial bony prominences, their cost and lack of guaranteed volume preservation ensures that synthetic implants will continue to play a valuable role in aesthetic facial augmentation.

Like any implant placed in the body, there are known complications with their use. While infection, implant malposition and implant exposure are the medical risks of facial implants and always require revisional surgery to sure, there are also aesthetic risks as well, These include implants that are too big, too small, or the creation of an undesired aesthetic effect. While good surgical technique and implant placement are extremely important keys to prevent the medical complications, the aesthetic complications can be more difficult to avoid as this remains the artistic side of the procedure.

Over the years, I have come to appreciate several aesthetic guidelines of using facial implants successfully. These relate to the more obscure principles of facial implants that have little to do with surgical technique. It is about how to select and place the best implant style and size.

The first aesthetic facial principle is that the biomaterial composition of the implant is not that important. Implant selection should first focus on the right style and design of the implant regardless of its material composition. While many different manufacturers and surgeons tout the benefits of different biomaterials, the reality is that none are perfect. All of them have different handling and placement characteristics but they all work equally well from a biologic standpoint. The body sees all implant materials as the essentially the same, not a natural part of the body. It will create a layer of scar around all implant materials known as a capsule. Implants with more porous or irregular surfaces will have this capsule become more adherent to it but this should not be confused with true integration into one’s own tissues.

The second aesthetic facial implant principle is that the effects of facial volume change from implants is not completely predictable. While both surgeons and sometimes even patients take measurements on x-rays, drawings and computer images in an attempt to select the right implant size, the overlying facial soft tissues will not necessarily respond in a 1:1 or direct linear fashion. Measurements taken on pictures and facial skeleytal models can not take into account the thickness of the soft tissues between the implant and the outer facial appearance. While it is important to have some method in choosing an implant’s size, patients should know that it is far from an exact science. The most common implant size problem is that it is too big, usually not because it is too small. This is particularly true as one moves up to facial bone areas above the mandible where the soft tissues become thinner. When in doubt, choose a smaller implant size. It can be surprising how much of a difference a small implant off of the operating table.

The third aesthetic facial principle is that implants may need be modified during surgery. Implants are made based on average dimensions and in a range of sizes to try and fit the most number of patients possible. But not every implant style and all sizes for any given facial area can be available for every procedure. The use of implant sizers, which are available from most manufacturers, is very helpful during surgery particularly in choosing implant size. But when in doubt shape or carve implants for custom adaptation if needed. All implant materials are fairly easy to shape with either a scalp, scissors or even a burr for more inelastic materials.

Applying these three aesthetic facial implant principles, best implant style regardless of material composition, conservative size selection and intraoperative implant modification if needed, will help improve aesthetic results and decrease the need for revisional surgery.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

While facial implants are commonly used to highlight the convex bony prominences of the cheeks, chin and jaw angle for purely cosmetic purposes, they have applications to other facial regions and problems as well. They can be very useful in bony deficiencies as well such as midface and mandibular hypoplasias as an orthognathic surgery alternative.

In these orthognathic deficiencies, the face is deficient in the cheek, paranasal and jawline regions but their occlusion is perfectly normal…or has already been orthodontically corrected. This obviates the use of maxillary and mandibular osteotomies to correct the facial appearance. But the use of implants can be used to simulate what would otherwise be achieved through bony movements.

Chin implants are the most well known example of  an orthognathic surgery alternative. Bringing the bony prominence of the chin forward can virtually replicate the identical lower facial change to that of mandibular advancement osteotomies. While a mandibular osteotomy can only bring the chin forward as far as the distance that makes the occlusion fit, implants are much more versatile. Not only differing in the horizontal thickness of the implants, they also can add width and different shapes to the central chin. (square to more angular) If custom implants are used, the chin can also be vertically lengthened as far back as to the jaw angles.   

Some elements of midface or central facial deficiencies are the result of a very concave pyriform aperture shape. This makes the nose undersupported making it appear flat with wide or even flared nostrils. This can also extend onto the base of the nose under the columella where it is supported by the projection of the anterior nasal spine. A short spine or near absent spine allows the columella to be recessed and one have a 90 degree or less nasolabial angle. Augmentation of the paranasal region (pyriform aperture) can simulate the effect of a LeFort I maxillary osteotomy using either paranasal, premaxillary or both implant types. This helps pull out the nose and its base with increased central projection and less flattening.

If one goes above the level of the maxilla, most people quickly think about flat or weak cheek bones. As a general rule, if the cheeks are flat the entire midface below it will also be. But cheek flatness usually also involves the infraorbital rim medial to it as well. This zone is one of the least appreciated areas of midfacial skeletal deficiency. A variety of midface implants are available for the cheek and infraorbital rim that create the visual effect of a LeFort III osteotomy. When the bony deficiency extends across the cheek to the nose, cheek implants alone may accentuate the existing infraorbital rim recession.

Implants can be used to simulate the appearance of facial skeletal osteotomies in patients with either normal or orthodontically corrected occlusions. Often a combination of facial implants is used, particularly in the midface, to create the overall effect of increased skeletal projection.   

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Facial skeletal imbalances present in many manifestations. Most commonly these are perceived from the profile view as maxillary and mandibular discrepancies in the mid- to lower face. Often they are reflected as changes in one’s occlusion when the bone deficiencies become significant enough. In these cases, orthognathic surgery is used for facial skeletal correction. Despite this surgery, all areas of facial bony deficiencies may not be aesthetically improved.

Facial osteotomies only change certain bony prominences and aesthetic facial highlights. It is important in orthognathic surgery, therefore, to recognize what will or will not be changed by maxilla-mandibular repositioning. A perfect occlusion is great but an opportunity to add to an improvement in one’s facial appearance can be missed if not diagnosed and treatment planned.

In combination with or after orthognathic surgery, several treatment areas exist. The level of the commonly-performed LeFort I osteotomy is below the cheek and orbital area. It only moves the tooth-bearing portion of the upper jaw. (maxilla) This leaves the cheek bones and the infraorbital rim unchanged. Cheek implants and newer styles of infraorbital rim implants can do what no osteotomy can. Ideally, the benefits of such implants are recognized before the orthognathic surgery so they can be done simultaneously. This is particularly convenient for cheek implants which are placed through the same incision as that of the maxillary osteotomy. Paranasal and premaxillary implants offer increased projection of the nasal base, the central portion of the midface above the teeth. They can be safely used at the same time as a LeFort osteotomy.

Mandibular osteotomies do a great job of changing horizontal position but no changes ever happen in width. This can leave the jaw angles deficient which often occurs after a sagittal split mandibular osteotomy. Implants can dramatically change the shape and width of the jaw angle but should not be used at the time of an osteotomy due to increased risks of infection and impairment of bony healing. They may be desired later, particularly if some bony resorption of the jaw angle has occurred which is not rare. The common chin implant has a role both during and after jaw repositioning surgery. While an osteoplastic genioplasty is often done for additional chin advancement at the time of an osteotomy, one can always substitute a chin implant if the main movement desired is solely horizontal in direction. Good preoperative treatment planning should avoid the need for chin implants later. But bony irregularities and asymmetries may be treated by extended or even custom chin and jawline implants.

For those patients who have residual facial bone deficiencies after orthognathic surgery or have bony deficiencies recognized as part of orthognathic surgery treatment planning, facial implants offer a viable option. The variety in size and shape of facial implants, whether off-the-shelf or from custom designs, today offers numerous safe and effective treatments as an adjunct to orthognathic surgery to create the visual illusion of actual bony movements.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Facial implants are an effective method of creating specific areas of volume augmentation as well as providing bony highlights and improving facial symmetry. Over the past two decades, the available options in facial implants has expanded tremendously and more patients who undergo cosmetic facial surgery are receiving implants than ever before. With such widespread use of facial implantation, the number of postoperative complications have also increased.

Complications with facial implants generally fall into several categories including implant selection, placement technique, nerve injuries and infection. Almost all of these potential problems can be minimized by specific techniques, although not always completely avoidable.

IMPLANT SELECTION

With such a large number of different facial implant styles and sizes, it is no wonder that an incorrect implant choice can be made. This can occur in both the style and size of the implant. Despite knowing the exact measurements and shape of an implant, there is no way to guarantee what the final influence on the external shape of the face will be. This has a lot to do with the quality of the overlying tissues, the thickness of the skin, fat and muscle layers, as well as the shape of the underlying bone. In terms of facial predictability amongst the three most commonly used implants, chin implants are better than cheek and jaw angle implants.

Cheek and jaw angle implants have a significant rate of revision and dissatisfaction due to selection issues. The three-dimensional shape of the cheek area requires a very careful analysis and discussion with the patient as to exactly what they want to achieve. The adjoining shape of the orbit and maxilla also influences how cheek augmentation may look. The cheek is clearly the most ‘artsy’ of all facial implants as there is no precise measurement method of such a curved bony area. Jaw angle implants must consider the width and height of the angle area to avoid giving someone just a wider lower face. Many patients need vertical lengthening as well as increased width and not every jaw angle implant style is designed to make that change.

DISPLACEMENT AND ASYMMETRY

Implants can shift around after surgery as the pocket dissected to place them is always greater than the size of the implant itself. While certain implant materials do slide on the bone less than others due to increased frictional resistance, complete implant stability requires screw fixation. While most surgeons don’t use them as they feel suture or no fixation at all is sufficient, the extra time and cost to use them pays dividends with decreased complications. There are no risks with using screws so there is little reason not to use them.

With the exception of the chin, most facial implants are done on both sides. (bilateral) While it seems that it should be easy to do exactly the same thing to both sides, it is not. Symmetrical implant placement is as much an art as it is a science. The implant cavities are never open to unimpeded view and can not usually be seen at the same time. Landmarks from the surrounding anatomy must be used but not every patient has perfectly symmetric anatomy either. Surgeons are usually one-handed and often work from just one side of the patient. This can create unintentional distortions in the perception of implant positioning.

Cheek implants have the highest rate of implant asymmetry due to the thinner tissues of the cheek as opposed to the chin or jaw angles. Great attention must be paid to how the implants line up along the bone using landmarks of the adjoin nerve and the lower teeth.

NUMBNESS

While every patient will have some temporary numbness of the overlying skin under which it is placed, cheek and chin implant can cause nerve distribution problems. The infraorbital nerve of the cheek and the mental nerve of the chin can be injured during dissection (very uncommon) or from impingement of the implant on the nerve as it exits from the bone. (most common) Prolonged numbness, and more pertinently sharp pain, beyond a few weeks after surgery should raise suspicion of impingement. Early intervention and implant repositioning and/or trimming is needed to prevent permanent numbness and pain. The best way to avoid nerve impingement with an implant is to see the nerve and where the implant edges. Screwing the implant in will also prevent it from shifting over and touching the nerve as well.

INFECTION

While rare, infection with facial implants can occur. It does seem to occur more commonly with porous implant materials than smooth silicone in my experience. To decrease the risk of infection, the use of antibiotics is done intravenously, the implant soaked in a solution of it, and oral antibiotics are used afterwards. But I think the most important step is the use of sizers during surgery. These are used to judge the pocket and size of the implant, thus the final implant can go from package into the implant pocket directly with minimal handling. (one-time pass)

When infection occurs, the standard treatment is to remove the implant and let the infection resolve. But this is not always necessary and the implant procedure can sometimes be salvaged. The implant can be removed, the pocket irrigated and a new implant can be simultaneously placed. The risk for recurrent infection is higher with this approach but I have seen it work numerous times. The key is to get out the inoculated implant as that is the source of the infection.

BONE EROSION

I mention it as a complication but only as a sidebar. I have read about it for many years, and seen numerous patients, who had severe ‘bone erosion’. (always in the chin with very highly positioned implants which have been in a long time) Many facial implant patients ask beforehand about this risk. Largely, I think it is a non-entity. Implants, particularly chin implants, can settle into the bone a few millimeters which is a passive pressure-relief phenomenon. But implants eating into the bone is a myth not a reality.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Synthetic implants are commonly used for augmentation of numerous facial bone sites for cosmetic augmentation or reconstruction of defects and asymmetries. Facial implants are available in a wide variety of styles and sizes for such areas as the cheek, orbit, chin and jaw angle, to name the most common. Most of these implants are composed of materials that allow for relatively easy shaping, trimming and otherwise custom adaptation.

But some facial cosmetic and reconstructive needs can not ideally be met by using off-the-shelf implants, no matter how they are shaped and modified. In some more uncommon cases, only a custom designed facial implant will suffice. As uncommon as the need for such implants are, they are more frequently used in reconstruction of facial defects and more rarely for cosmetic augmentation.

The fabrication of custom facial implants is a process that initially begins by getting a facial skeletal model of the patient. This is initially done by the patient obtaining a 3-D craniofacial CT scan done with high resolution 1mm cuts. Such a scan can be obtained at just about any CT facility today as 3-D software is commonplace. Once the scan is obtained, it is then sent to a model fabrication manufacturer. I use Medical Modeling (Golden, CO) but there are numerous other manufacturers that can create similar models. They can make a patient’s model in numerous ways including an Osteoview (radiopaque) or a Clearview (translucent) model. For custom implant fabrication, I usually use an Osteoview model as the view of underlying structures such as nerve and teeth are not usually necessary and it is less expensive.

Once the patient’s facial model is obtained, a mock-up of the implant is then made. This is done by sculpting it by hand on the model. At one time, I used acrylic as the modeling material but this requires grinding after being set and that makes it a more difficult fabrication process. Currently, soft modeling clay is used but it is of the type that does not dry out with extended use and can be cured by baking once the final shape is obtained. Such modern clays are much easier to use than older clay materials for this purpose.

The cured clay implant(s) is then sent to a silicone manufacturer (e.g., Implantech) for the manufacture and sterilization of the final implant(s). Currently, custom facial implants can only be made in silicone. Other implant materials, such as Medpor and Gore-Tex, have to be machined and not poured and cured into a mold made from a custom implant design. (this makes them considerably more expensive)

Contrary to popular perception, custom facial implants for cosmetic facial enhancement are not made magically by some computer technology. They are done by hand by traditional sculpting off of a model made by computed tomographic scanning. It is a total process that takes about 6 to 8 weeks from the time the CT scan is obtained until the actual sterile implants are in hand. I have found them to be particular useful for mandibular augmentation (e.g., vertical lengthening) which, due to its large surface area of bone, has contours that may not be able to be met by conventional preformed implant shapes.    

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Aging has an obvious effect on how the face looks from the outside with many recognized soft tissue changes. Wrinkles, deepening nasolabial folds,  crow’s feet and jowls are but a few of the effects that gravity and time cause. This understanding has led to the many well known plastic surgery procedures whose intent is to resuspend sagging skin as well as skin removal/reduction.

But much like beauty, aging goes the whole way down to the bone and is not spared. In many ways it is somewhat reflective of what has happened on the outside. Multiple studies in plastic surgery have looked at how the face ages beneath the skin. Volume loss, primarily of fat, creates an overall facial ‘deflation’ and this understanding has led to the widespread use of synthetic injectable fillers and injections of your own fat to help plump up the aging face. But loss of the deepest tissue, the bone, also makes a contribution to this volume.

Since the bone provides a scaffold onto which the overlying soft tissues drape onto, it is logical to assume that the facial skeleton changes as well. Recent studies using CT scans have looked at various areas of the facial bones and their aging changes. The width and size of the eye (orbit) increases with an almost sagging appearance to the outer lower orbital rim. The glabella (bone between the brows) and the upper rims of the eyes (brow bones) flatten. The maxilla is affected by loss of pyriform aperture and a decrease in the maxillary angle. The length and height of the lower jaw (mandible) shortens with resorption of the jaw angle. (enlarged mandibular angle)

All of these facial bony alterations with age can be correlated to associated outward soft tissue changes. The dropping of the brows and the piling of eyelid skin is a reflection of the loss of underlying bone support. The deepening nasolabial folds and the sagging cheeks are reflective of the maxillary resorption. A weaker chin, jowling and lax neck tissues are partially effected by the loss of lower jaw volume.

The facial skeletion does change with age, primarily with loss of volume of key bony support areas. This results in lessening areas of soft tissue adherence and sagging and deflated overlying soft tissues. This in addition to the loss of facial fat creates the appearance of the aging face.

Bone augmentation of the aging face with implants can be a useful surgical strategy for some patients. Reversing the age-related changes (atrophy) of certain facial bone areas can be done very simply with implants, adding volume to where it has been lost. Implants can do this in two ways, filling out concavities and bulking up weakened convexities. Tear troughs and paranasal deficiencies are examples of deepening concavities. Orbital rims, cheeks, chin and jaw angles are areas of weakened convexities.

Skeletal facial implants, while often thought of as just for younger patients seeking better facial highlights, can be useful for the aging face patient as well. They offer a permanent solution to specific aging facial areas that have ongoing resorption which contributes to loss of overlying soft tissue and skin support. They can be used in conjunction with any of the soft tissue redraping procedures to help create a better facial rejuvenative effect.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana   

Facial reconstruction patients can benefit today from custom-made bone replacements and bone fixation aids to optimize for the postoeprative form and function. High-resolution computed tomography (CT) modeling allows plastic surgeons to custom-design implants prior to reconstructive surgery. They are particularly useful for facial bone defects of the lower jaw (mandible), skull and the forehead and eye (orbital) areas.

Severe facial and eye (orbital) bone deformities and defects may be present at birth or can occur following facial trauma or, most commonly, facial tumor removal. Surgery to correct such defects aims to restore the original anatomy and the patient’s appearance by inserting an implant made either of the individual’s own bone and tissue or synthetic materials. The traditional use of implant materials in facial reconstructive surgery, which are shaped during surgery, often do not recreate ideal three-dimensional contours in the face and take a lot of time working with them as the patient is asleep. Designing synthetic implants beforehand improves their precision and contours and helps shorten the time of surgery.

I have looked at my series of ten facial reconstructive patients done over the previous nine years who received computer designed and generated custom implants and were more than one year after their surgery. The six men and four women were between the ages of 31 and 67 years, with an average age of 46.1 years. The defects were caused by either trauma (2), tumor resection (6), or a congenital deformity (2). Most of the patients (7) had a history of prior failed reconstructive efforts. The patients underwent three-dimensional high-resolution CT scanning of the face from which customized implants composed of either pure titanium (bone fixation device) or HTR (porous hard tissue replacement bone substitute) were made. All implants was surgically placed and fixed using titanium plates and screws.

Example #1

This 62 year-old female had a right mandibular angle bone resection secondary to an intraoral carcinoma. She never had any radiation treatments. The defect was only spanned by a reconstruction plate which had fractured three separate times over the past eight years. A 3-D CT scan showed the defect and the mandibular segment contraction. She did not want a fibular free flap reconstruction.

A custom titanium dual plate and mesh construct was designed to hold the bone segments apart in anatomic position and contain an iliac marrow graft. Through a neck incision approach, the old fractured plate was removed and the new 3-D engineered construct placed. The resultant mandibular form, occlusion and jaw opening was excellent.

Example #2

This 65 year-old male had a history of esthesioneuroblastoma with a resection by frontal craniotomy and removal of his left heminasal cavity and maxillectomy. He received radiation afterwards. Over the enduing ten years, he developed orbital floor bony resorption due to osteomyelitis and dropping of the eye downward. His orbital condition and eye position eventually stabilized as his osteomyelitis resolved. A 3-D CT scan shows the loss of orbital floor bone and the orbital dystopia.

A custom HTR orbital floor implant was manufactured to match the opposite orbital floor shape and volume. Through a lower eyelid incisional approach, the implant was placed and secured to the orbital rim with titanium plates and screws. He had much improved postoperative globe symmetry. He went on to have eye muscle surgery and a dermal fat graft to fill out the soft tissue atrophy of the lower eyelid and cheek region.

During an average of over four years of follow-up, none of the patients experienced any implant-related complications including infection, extrusion, or displacement of the implants. Healing around the implant sites was uneventful. All of the patients had sustained improvement of facial deformities including mouth opening in those that involved the lower jaw.

While numerous types of implant materials have been used for reconstructive facial surgery, one important aspect of their success is proper design and engineering. Time spent before surgery evaluating the exact dimensions of the bone defect and then custom designing the implant has numerous advantages. Having an implant that is not bigger or oversized for the defect lowers the risk of potential extrusion. A near perfect fit makes for good facial contour restoration. Oral function and occlusion is more assured if the lower jaw reconstruction is as precise as possible. Donor site pain and morbidity is eliminated or reduced with maximal use of synthetic replacement parts. Operative times can be reduced significantly, often cutting the length of an operation in half. Implants are also structurally stable and will not resorb or change their shape over time. Any synthetic implant no matter how well designed and engineered, however, has limitations. Good healthy soft tissue flaps over the synthetic reconstruction is extremely important to avoid potential infection and exposure problems.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis Indiana

Facial implants have come a long way in the past two decades with the introduction of dozens of different styles. One of the expanding facial implant areas is that of the midface. Known commonly as the cheek, it has become recognized that its anatomy is more complex than a single implant design can adequately treat. With the numerous midface implants now available, more patients than ever are being implanted. With increasing numbers of midface augmentations comes complications. The vast majority of these complications are cosmetic in nature, meaning the final result was not what the patient had hoped.

Undesired midface implant results are usually the result of a mismatch between the patient’s aesthetic concerns and the implant type and size. The large number of implant options may seem confusing, but midface augmentation can be thought of as three zones or implant locations. These include the malar, submalar, and suborbital tear trough malar regions. There are more anatomic zones to the midface, but based on desireable facial changes, these three areas can be effectively enhanced.

The malar area is the most midface zone enhanced and makes up the major aspect of the zygomatic or malar bone. This extends from the infraorbital nerve to the middle third of the zygomatic arch. Malar implants create a high, strong cheekbone which is for men who want a more sculpted facial appearance or by younger women who want more of an exotic look.

The submalar area lies below the zygomatic bone. It actually sits on the top portion of the masseter muscle where it comes up and attaches to the underside of the zygomatic bone. This facial area has become recognized as significant because fat is lost in this area with aging. Submalar hollowing can also be created in the younger person with a fuller face by buccal fat pad removal. Augmenting the submalar area can help reestablish a more youthful appearance by building it out again. When introduced over a decade ago, the submalar implant was touted as a substitute for a midface lift by being able to lift up sagging cheek tissues. This probably overstates the effect that it actually does create.

The newest midface zone to be effectively implanted is the suborbital tear trough area. Extending from the medial canthus, over the top of the infraorbital nerve, and along the lateral orbital rim extending into the malar area, this implant fills out suborbital flattening and tear trough depressions. Because of its location, this implant must be inserted from a different direction than all midfacial implants…from above (through the eyelid) rather than from below. (through the mouth)

While these three types of midfacial implants augment areas in close proximity, their effects can produce dramatically different facial changes. Subtle changes in the midface are easily detectable because of their proximity to the eye, a visual focal point in all conversations. The rise in the number of midfacial implants has led to, not surprisingly, an increased rate of complications. Many times the correct zone is augmented but the implant is too big. It is always best to undersize a midfacial implant in most cases. Unless there is a significant facial bone deficiency (e.g., maxillary hypoplasia), large midfacial implants should not be used. What make look like a significant improvement on the operating table can look dramatic in real life afterwards. Other times, the effect the implant created was different than the patient expected. This is most commonly seen with the submalar implant when it is used for a cheek tissue lifting effect and all the patient sees afterwards is unnatural fullness.

The three primary midfacial implants add an effective arsenal to a variety of congenital and age-related midfacial changes. Complications can be avoided by an implant size and type that is suited to the patient’s aesthetic concern. While the midface is one of the hardest facial areas to accurately computer image, such analysis furthers the dialogue between patient and plastic surgeon.  

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana