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Background:  Enhancing a face can imply a wide range of procedures. But for the younger patient who does not have appreciable signs of facial aging, it refers to improving its underlying structural support. Having the bone structure become more visible creates a more defined facial appearance. This augmentation of the facial bones can be done  at three different levels and includes the brow bones (upper), cheeks and undereyes (middle) and the lower jaw. (lower) The key here is to understand that it is augmentation of the existing convex/flat bone structures throughout much of their surface area which is always horizontal in orientation.  

For male facial enhancement the most common areas to augment are the middle and lower bony levels. While once thought of as cheek and chin augmentation, a more contemporary and effective approach is to think of level augmentations which means infraorbital-malar and jawline surface areas. This can only be effectively achieved by custom implants that are designed to augment the entire horizontal lengths of the bone. In these design concepts, as opposed to the use of standard implants, implant volumes are just as important as any linear thickness location along the implant. They truly represent the concept of ‘a little bit goes a long way’.

Combining infraorbital-malar and jawline implants for men is a very common aesthetic facial surgery. By doing both together it maximizes the eventual facial result, makes the recovery more efficient and optimizes the use of the implant design and manufacturing process. But by doing both mid and lower facial level enhancements simultaneously implant design and placements and the recovery process has numerous issues to consider.                  

Case Study: This male desired to have facial masculinization of the mid and lower levels. He did not have a weak facial structure in terms of the traditional horizontal augmentation perspective. Rather he had a vertically anterior short jawline with a flat mandibular plane, lack of a well defined cheek line with undereye hollows and a thicker overlying soft tissue cover.

With a flat mandibular plane angle it is important to understand the effects of vertical jawline lengthening, the differential lengths that are needed (mainly in the chin and very little at the jaw angles) and how this affects the cervicomental angle. Like all facial structural changes preoperative computer imaging is essential to help the patient determine if such a change is seen as aesthetically beneficial.

In two level custom facial implant placements, it is important to the ‘cleanest’ procedure first which would be the infraorbital-malar area since it avoids going through the mouth. While the implant is quite long it is not necessary to use a full lower eyelid incision to place it. Working through a small eyelid incision with loupe magnification, fiberoptic lighting and small instruments allows the full extent of the subperiosteal pocket to be developed. Once the implant is inserted and positioned a single screw fixation usually all that is needed at the upper cheek area. If there is any positioning/stability concerns about the thinner infraorbital section of the implant an additional screw can be placed there as well.

The jawline implant is always done second because, as part of the procedure is done intraorally, you don’t want to use instruments that have been exposed to the oral cavity on other implant procedures. While the submental incision is the only recognizable incision of its placement the paired intraoral incisions are invaluable to get the back ends of the implant into proper position and secured. This is of particular value when the inferior border of the jawline must be elevated for proper fit of the implant. In the jawline implant design a midline marker is placed into the chin portion which is almost always confused by the patient as trying to make a midline cleft. It only goes 1mm deep into the implant’s surface so a blue marker material can be placed into it. This aids the initial midline chin positioning of the implant which must be done first. Setting the back ends of the implant relies on proper positioning of the front end of the implant.

While the immediate effects of multi-level custom facial implants is significant, the swelling that ensues over the first few days after surgery can be significant and psychologically distressing. And when two levels of facial augmentation are done the swelling is more than if just one level was done. The jawline implant swelling is prolonged because the swelling at the level above it drifts down by gravity through the tissues to add to its swelling and the prolongation of it. Patients should expect it to take 4 to 6 weeks until much of the real effect of the procedures can be seen.

Case Highlights:

1) Male facial masculinization typically involves cheek and jawline augmentations for which custom implant designs offers the best enhancement surface area coverage.

2) For male midface enhancement this usually means a horizontal line of augmentation along the infraorbital-malar bony anatomy. (high cheekbone look)

3) For male lower facial enhancement jawline augmentation is done along the entire mandibular line from one jaw angle to the other.

Dr. Barry Eppley

Indianapolis, Indiana

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