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Posts Tagged ‘malar implants’

Understanding the Zones of Midface Implants

Monday, June 14th, 2010

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

Indianapolis, Indiana

Common Questions about Cheek Augmentation (Implants)

Saturday, January 16th, 2010

The appearance of a well-defined cheekbone helps provide a sculpted and youthful look as it provides midfacial prominence and give the appearance of a thinner lower face. Flat cheekbones can make a large nose look larger and a receding chin smaller. The cheekbones are one of the three convex prominences that help define your face, highlighting the eyes and adding balance to your features.

Cheek augmentation (also known as malar augmentation or malar implants) is a surgical method to bring the cheeks into better balance with your other facial features.

  1. How do I know I am a good candidate for cheek augmentation?

People who benefit by cheek implants have smaller or flatter cheek bones naturally and/or have sagging of the cheek soft tissues due to normal aging. With aging can also come deflation, or loss of healthy fat which normally lies just under the cheek bones. This can give a gaunt look to one’s face.

A cheek implant can build out the flat cheek bone, provided a lifting effect to sagging cheek skin, and can partially fill out a sunken in look. Think of it as adding substance which may just make the cheekbone bigger or help hold up sagging or collapsed tissues.

That being said, whether anyone would benefit by a cheek implant is as much an  artistic feel as a facial feature that can be precisely defined. Unlike other facial implants, such as chins or jaw angles which can be measured and morphed with computer imaging, cheek implants defy such analytical evaluation as the area is not a clean profile or silhouette. This is an area that requires a good evaluation and discussion with your plastic surgeon using a mirror and finger technique.

2. What are cheek implants made of?

The vast majority of cheek implants are made of solid silicone rubber that is very flexible. While there are a few other materials of which they are made, they are not very popular. What material they are made of is not as important as two other critical issues; what styles and sizes are available and how easy are they to insert. This is where silicone rubber has a huge advantage over other materials.

One type or style of cheek implant is not right for everyone. The cheek bone shape and geometry and the soft tissue overlying them is different for each patient. Just like the obvious benefits of different sizes, style or shape of the implant needs to be individualized. That is why there are nearly a half-dozen different cheek implant styles. Only a silicone rubber material can offer this diversity of selection.

The flexibility of silicone rubber and the ability to have feathered edges allows it to be the easiest material to position on the bone without having an edge that can be felt or seen.

3. How is cheek augmentation surgery done?

There are two approachs to placing the implant, from inside the mouth and through the lower eyelid. By far, the intraoral method from a small incision up high under the lip is preferred. The only reason to use the eyelid approach is if a midface lift or suspension is being done at the same time.

From inside the mouth, a path is made up onto the cheek bone. It can be extended out onto the zygomatic arch if necessary. Sizers are used to determine what will look the best. The final implant is then inserted. Some plastic surgeons secure the implant in place with a small titanium screw, others do not. Closure of the incision is done with dissolveable sutures.

4. Is cheek implant surgery painful? How long does the swelling last?

I would not call it painful, rather it is more uncomfortable due to the swelling. Often there is some numbness of the cheek skin  which goes away in the first month after surgery. There rarely is any bruising because the surgery is very deep on the surface of the bone. Any bruising that occurs will not be seen on the skin but will present only as swelling. While remnants of swelling take six to eight weeks to completely go away, you will look fairly normal within two to three weeks. The initial abnormal fullness will have go away by then.

5. What are the risks and complications that can occur?

The standard surgical risks of bleeding and infection apply but they are very uncommon. The risk that is more significant and probably accounts for most instances of revision or secondary surgery is implant asymmetry or sizing issues. Because the cheeks have two sides, the placement of the implants must be perfectly symmetrical. That may seem easy but even slight changes in orientation of the implant may be able to be seen. Implants can also shift or slide downward towards the direction in which they were placed. Oversized cheek implants are especially noticeable because they can make the face look very unnatural. Cheek implants are always best done smaller than bigger.

One risk of having cheek implants is delayed infection, even many years later. This is caused by one specific event…dental injections. This can happen when your dentist is numbing your upper teeth. The needle can tract bacteria near or onto the implant. Advise your dentist if you have cheek implants.

6. I’d like higher cheekbones but I don’t want them to look fake. How can this be avoided?

There are many well known examples of famous people that look strange and overdone after facial rejuvenation surgery. In some of these cases, it is obvious they had cheek implants and it is because they are too big. This ‘error’ is most likely to occur when cheek augmentation for anti-aging purposes and are being used to fill out sagging cheek tissues. A cheek implant is not the same as a breast implant…its size should not be pushed to do too much.

7. I have very flat cheeks that extend down below my eyes. It makes me look sad. Will cheek implants help?

Having flat cheekbones can give the face a long drawn look that many may describe as sad. In the facial expression of smiling, we naturally see more prominence in the cheek area. When it is flatter it adversely affects how one’s smile looks. More fullness in the cheek allows a more  youthful look, whether one is smiling or not.

Dr. Barry Eppley

Indianapolis, Indiana 

Cheek Augmentation – Preventing Complications and Improving Outcomes

Thursday, November 19th, 2009

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. 

Dr. Barry Eppley

Indianapolis, Indiana

 

  

 


Dr. Barry EppleyDr. Barry Eppley

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.

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