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Background:  Soft tissue atrophy of the face most commonly occurs due to aging or weight loss. There are also some well known medical conditions that also can cause it. This atrophy is primarily fat-related and most significantly affects the temporal and cheek areas where the largest subcutaneous and compartmentalized fat exists. Whatever the cause the more gaunt facial appearance is classic above and below the bony projections of the orbital and cheekbones.

The treatment of facial atrophy for volume addition runs the spectrum of synthetic fillers and fat to implants. Whether these treatment options should be viewed as an ‘aesthetic ladder’ where one starts with injectable fillers, proceeds to fat injections when tired of fillers and only resorts to implants when all else has failed can be debated. Regardless of what rung on this ladder the patient chooses the temporal region has established options for all three methods. When it comes to the lateral face, which should differentiated from the more common cheek area, only synthetic fillers and fat are acknowledged options.

Lateral facial atrophy should be differentiated from cheek atrophy even though they are usually connected by proximity. Cheek atrophy is the concave area that appears below the main body of the cheekbone and can be more significant due to the loss of the large buccal fat pad. Lateral facial atrophy is what occurs lateral or to the side of the cheek area and extends all the way back to the ear. It often is less concave due to the support of the parotid gland and masseter muscle and is the result of loss of more spread out and less thick subcutaneous fat. It often becomes more of an issue when the cheek atrophy is treated by implants which can only effectively target and the lateral concave area behind it remains.

If the patient has tried synthetic fillers and fat and these have failed are there implant options to treat it?

Case Study: This female sought surgical improvement of her temporal and buccal facial lipoatrophy. She had cheek implants placed previously, which provided improvement in the cheek area anteriorly, but not behind it. There remained a concavity below the zygomatic arch back to the ear. The goal was to augment the areas above and below the zygomatic arch on both sides.

Standard extended temporal implants of 3mm thicknesses were chosen for the area above the zygomatic arch. Since there are no standard subcutaneous facial implants, 2mm sheets of ultrasoft solid silicone were used to custom cut to the size of the marked defect areas.

Under general anesthesia and through a 2cm incision in the temporal hairline temporal implants were placed in the subfascial pocket location.

Her prior facelift incision was opened at the retrotragal preauricular location. A subcutaneous pocket was developed underneath the marked area on the side of the face. The implants were prepared by placing multiple 3mm holes through them to allow for postoperative tissue ingrowth. They were inserted and positioned so their back ends were sufficiently anterior to the incisional closure.

The goal of the surgery was to fill out the hourglass shape of the face caused by the loss of fat. Long term results show that it was an effective approach without visible implant edging. The more skeletonized appearance of the face was changed to a softer less sunken in appearance.

Temporal implants, while a relatively new type of facial implant, has now been around long enough to be a known reliable method of temporal augmentation. Augmenting the concave contour below the zygomatic arch of the face, however, is a different matter. Only fat injections are a recognized method of augmentation of this part of the face. Besides fat injections, however, there is a graft option that can be used which is allogeneic dermis. (e.g., Alloderm) It comes in sheets of various thicknesses up to 2mms. This is a supple graft would be a logical choice as a soft tissue augmentation material. Implant options dow exist and the two materials would be ePTFE and silicone. While ePTFE has been used as a soft tissue augmentation material for decades it is a bit stiff/hard and is to the option in a subcutaneous site. Solid ultrasoft silicone sheeting can be also be used, as in this case, and is a better soft tissue augmentation material because it is softer and more supple.

Case Highlights:

1) The first line treatment for temporal and lateral facial atrophy is autologous fat injections.

2) Temporal implants can be either a first line treatment for temporal hollowing or a secondary approach if fat grafting fails.

3) In lateral facial atrophy implants are not ever considered due to lack of awareness of what to implant. A good implant option is ultraist solid silicone sheeting.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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