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Background:  In facial augmentation there are three methods to do so…injectable fillers, injectable fat and synthetic implants. Each has their own distinct advantages and disadvantages but none of these methods are perfect. With some surgeons advocate one over the other the reality is that they all have a valuable role to play and one often leads to another.

This is seen in the synthetic filler to implant transition. It is very common to see patients that have had prior or indwelling synthetic fillers present for facial implants, particularly custom facial implants. A common question in this situation is whether the injectable fillers should be dissolved during the implant design process and before the actual surgery. That would depend on how much filler volume is present and how long it has been there.

But some injectable fillers are not reversible and only time will make them absorbed. This is true for Radiesse injectable filler which is also the only injectable filler capable of being seen radiographically. It shows up quite clearly on 3D CT scan due to its mineralized content of hydroxyapatite spheres. With this type of injectable filler one would have to wait up to a year or longer for it to go away. Or one could measure the volume that it currently occupies and use that in how to design the implants.

Case Study: This male presented for custom cheek and jawline implants. He previously had Radiesse filler placed into his cheeks mainly and some along his jawline. A 3D CT scan showed the bulk of the material in the cheeks measuring  11ccs of volume.

Custom cheek and jawline implants were designed around the volume of the implants as well as their location. By the location of the injectable filler it was evident he as trying to achieve a high cheekbone look. The custom cheek implant volume (9ccs)m replicated closely that of the existing filler volume but had a much more distinct shape as would be expected from an implant.

The scattered filler location along the jawline provided a guide for the perimeter of the jawline implant design. The custom jawline implant design was strong in its dimensions with a substantial lowering of the jaw angle. It also had a non-linear design due to the thick facial tissues of the patient. Given the size of the jaw angles a. two-piece design was done to aid its intraoperative placement.

Under general anesthesia and through a high vestibular incisions under the upper lip, the cheek implants were placed by complete subperiosteal pocket creation including around the infraorbital nerves over the face of the maxilla and out onto the posterior zygomatic arch.

For the custom jawline implant an external submental incision for the chin and Intraoral posterior vestibular incisions were made to create the jaw angle pockets and connect them to the chin. Using a back to front insertion technique the jawline implant was inserted in two pieces, reunited in the middle and secured with screws.

Injectable fillers can serve as a guide for custom facial implant designs. They do not provide the specifics of the implant dimensions but their placement location and volume provide a guide as to what type of aesthetic result the patient may be seeking.

Case Highlights:

1) Injectable fillers are often the first step in facial augmentation and can serve as a guide for desired volumes and location of permanent facial implants.

2) With injectable fillers in place the design of custom facial implants must take their eventual resorbing volumes into consideration.

3) Custom infraorbital-malar and jawline implants are done together to create a strong facial masculinization effect.

Dr. Barry Eppley

Indianapolis, Indiana

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