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Posts Tagged ‘submalar 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

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

 

  

 

Midfacial Implants – Different Styles for Cheek, Orbital, and Maxillary Augmentation

Friday, May 29th, 2009

Facial implants are a common and assured method of building out skeletally deficient areas such as the chin, cheeks, and jaw angles. While many are aware of these popular locations for esthetic facial enhancement, there are many more implant styles and locations than most envision. This is particularly true in the midfacial area.

The midface (between the lower eye sockets and the upper teeth)has the most complex external anatomical shape of any area on the craniofacial skeleton. From the prominences of the cheek bone to the concave surface of the pyriform aperture, no one single-shaped implant can be adapted to all of them. For this reason there are at least nine (9) different midfacial implant styles.

Cheek implants are the most commonly used midfacial implant. But there are four (4) different styles to choose from for the differing areas of esthetic deficiency on this bone. The standard cheek implant, also known as a malar implant, fits on top of the cheek bone and has a broad surface area that covers most of its surface area. The two (2) styles of this standard cheek implant differ in that the more extended version has a portion that goes up higher to make a smooth transition into the lateral orbital bone. For flat cheek bones, these implants styles will generally work well.

The submalar cheek implant, however, is indicated when the cheek soft tissues are a little droopy and the area under the cheek prominence is a little sunken in. This implant fits on the bottom or underside of the cheek bone which helps lift up sagging cheek tissues, fills out the submalar space and may even soften the deep nasolabial fold a little. The submalar cheek implant comes in two styles which differ in how much fullness is added to the submalar space.

The tear trough midfacial implant is a specialized lower orbital rim (eye socket) implant. It augments the depressed suborbital groove that some people have naturally or develops from aging and tissue atrophy. This groove runs between the inside of the eye across the lower orbital rim often ending below the cheek. While some use fat injections for augmentation of this area, a carefully placed tear trough implant provides permanency to this contour problem.

The pyriform aperture implant fits along the bone which forms the side rim of the nasal cavity. It is designed to build out the base of the nose where the side of the nostril meets the lower cheek tissues. I have most commonly used this implant in secondary cleft surgery to build out the deficient bone area where the cleft went through. While bone grafts are commonly used for this problem, the pyriform aperture may still remain depressed even with a well done bone graft.

The premaxillary or peri-pyriform implant builds out the entire base of the nose from one side of the pyriform aperture to the other. This includes anterior nasal spine area as well. For very flat midfaces, this implant can really help provide augmentation to the nose and upper lip.

The nasolabial or melo-labial groove implant fits onto the bone to the side of the nose and helps soften or build-out the very deep nasolabial fold or groove. Rather than using temporary injectable fillers placed beneath the skin, this implant placed on the underlying bone serves to provide the same push.

The Lefort or maxillary implant, the least common of all midfacial implants, is designed to be used during or after a LeFort I osteotomy. This implant would fit above the osteotomy line so that the midface would not look more deficient as the maxillary teeth come forward.

All midfacial implants, while being very different in shape and indication, share two common features. First, they are all placed from an incision inside the mouth so no skin incision is ever needed. Secondly, they are all best secured into position with a screw as their position is critical in getting the desired esthetic result.

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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