Implant Selection

The greatest pitfall for the novice implant surgeon is understanding what implant is appropriate for a given aging indication. What implants to use and where to put them can be confusing. Although this is related to personal preference, this author has refined choices to three broad categories that are effective for almost all cosmetic (or reconstructive) patients.

The basis of implant selection lies in the recognition of where the aging changes have occurred in the face and if they are single or multiple in nature. As most patients age, they lose volume in the submalar region. The submalar area includes the hollow area of the infraorbital, anterolateral maxillary, and canine fossa regions. If the surgeon pays close attention, they will notice that loss of facial volume represents early aging change (late third, early fourth decade) that is apparent in virtually all patients regardless of gender.

Many aesthetic practitioners and most patients are unaware of this phenomenon unless it is pointed out to them. If the surgeon hands the patient a mirror and asks them to smile, the lip elevators lift the ptotic malar fat and produce a more youthful look. This simulation will cause many patients to comment, “This is how I looked when I was younger.” If you hold the elevated tissues in place with your thumb and index finger and ask the patient to relax their smile, the midface volume quickly drops to its aged position lower in the face when the fingers are relaxed. In essence, the youthful cheek fat later becomes the jowls. Having the patient recline in the exam chair will also “reposition” the ptotic cheeks to a more youthful position and can be used to illustrate aging and predictive correction. Close observation will show that many of these patients have a hollow submalar region but adequate and well-defined zygomatic and malar aesthetics. That is to say that despite having lost submalar fat, they have adequately projected cheekbones. This type of patient is best treated with only submalar fill, since their problem (and solution) is not malar deficiency but rather the loss of submalar volume.

An example of submalar deficiency is illustrated in Figure 10-2, A. Figure 10-3, A shows the approximate positioning of the submalar implant. The submalar implant (ImplanTech Inc., Ventura, CA) is used in approximately 95% of my midface implant patients and is thus by far my most common implant.

FIGURE 10-2 A, Patient in need of submalar augmentation. B, Patient with adequate submalar fill but in need of zygomatic and malar augmentation. C, Patient in need of zygomatic, malar, and submalar augmentation.

FIGURE 10-3 Approximate positioning of the submalar implant (A), the malar shell implant (B), and the combined submalar shell implant (C).

The second type of common facial aesthetic deficiency is apparent in patients who have adequate submalar and anterior maxillary fill but have deficient “cheekbones” (see Figure 10-2, B). This is the patient who has hypoplasia of the zygomaticomalar regions or simply desires a more defined or “chiseled” appearance, or in layman’s terms, “higher cheekbones.” I treat these patients with the malar shell implant (ImplanTech Inc.) (see Figure 10-3, B), which I use in approximately 1% to 2% of patients.

The third type of common midfacial aging change is seen in the patient with submalar deficiency and a need for zygomaticomalar augmentation. These patients benefit from both anterior maxillary (submalar) fill and malar (“high cheekbone”) augmentation (see Figure 10-2, C). These can be patients who have lost volume as a result of aging in both areas, or those patients who have underdeveloped skeletal anatomy. Such patients are well suited for treatment with the combined submalar shell implant (ImplanTech Inc.) (see Figure 10-3, C). This implant is designed to augment the submalar region as well as zygomatic and malar regions; it constitutes 4% to 5% of my implant cases.

Figure 10-4 shows approximate skeletal positioning of the described implants. As stated earlier, these three implant configurations are used for the described aging changes and satisfy all of the author’s aesthetic midfacial enhancement indications.

FIGURE 10-4 The submalar (A), malar shell (B), and combined submalar shell (C) are shown in their approximate position on a dried specimen.

Preoperative Planning

Prior to surgical placement, the practitioner and the patient must decide upon the area(s) to be enhanced and the size and configuration of the implant. This can be difficult for the novice surgeon, and beginning with easier and more straightforward cases can assist the surgeon with the learning curve. Younger patients with basic submalar implants are a good starting point.

As with other facial procedures, laying the patient back in the chair and negating gravity will allow the ptotic tissues to assume a normalized position and give the surgeon and patient an idea of the surgical result (Figure 10-5).

FIGURE 10-5 Laying the patient back in the chair will allow the ptotic facial tissues to normalize, which can give the surgeon and patient an idea of the surgical result.

Drawing the approximate implant position on the cheeks or outlining a sample implant will provide guidance for the surgeon when the implant is placed. Care is given to making sure that both implant outlines are symmetric and in the region of desired augmentation (Figure 10-6).

FIGURE 10-6 Tracing a sample implant in the desired position preoperatively will assist the surgeon in correct positioning. In this patient, the hypoplastic region is outlined by tracing a large submalar implant on the patient’s cheek. When she smiles and elevates the ptotic tissues, the implant outline lies in a favorable position.

It is important to note, discuss, and document existing asymmetries with the patient before surgery. It is common for patients to have one side of the cheeks or midface bigger than the other. In extreme cases, a medium implant may be placed on one side and a large implant on the other. Most frequently, the degree of asymmetry is such that it does not alter the final result when using the same implant on both sides. To illustrate the difference in symmetry, I keep a picture of me in each consult room that shows my normal portrait and a mirrored image of the right and left halves of my face (Figure 10-7). The difference is remarkable, and I explain to the patient that the average person has similar asymmetry. Numerous times over the years, I have had to construct a similar image of a patient to point this out to them.

FIGURE 10-7 The author in a normal portrait (B). Both right halves mirrored (A), and both left halves mirrored (C). This type of asymmetry exists in most patients to some degree.

Implants can also be placed on the patient’s face just before placement; indexing marks are made to verify symmetric positioning (Figure 10-8). Noting where the medial edge of the implant lies can serve as a guide for comparison when the implants are placed intraorally. In other words, if the medial edge of the implant lies in line with the pupil or limbus, this can serve as an indexing guide when the implant is in place.

FIGURE 10-8 Placing the actual implants on the patient’s face just prior to placement and making index marks can also guide the surgeon in symmetric implant placement.

During preoperative evaluation, it is also important to evaluate the patient’s oral health. Placing implants in the presence of dental or periodontal disease can severely compromise the case and result in infection (Figure 10-9). Patients with oral disease must be treated to achieve a normal state of oral health prior to implant placement.

FIGURE 10-9 Patients with active dental or periodontal disease are not candidates for transoral implant placement.

The preoperative consent process should discuss the common sequelae and complications experienced with midface implants. The midface is a vascular region, and significant swelling can occur and take up to several weeks to resolve. In some cases, the swelling can last longer, and the patient must understand that it may take 6 weeks to begin to see the true level of augmentation. Almost all patients will experience temporary paresthesia, but permanent numbness is rare. Oral animation will be temporarily affected owing to the disruption of lip elevators and orbicularis oris muscles. Patients must be made aware that smiling and puckering and possibly speech may be temporarily affected. This dysanimation usually resolves in the first 2 weeks. Infection is rare and in my experience is more common in smokers, who are not optimum candidates for midface implant placement. The possibility of overcorrection, undercorrection, and asymmetry must also be discussed. Fortunately, it is very easy to remove midface implants, and that is a comforting point for prospective patients. It also helps patients to realize that cheek implants are serviceable, and larger or smaller implants can be placed in lieu of their current implants. Replacement is easier and less traumatic than primary placement, because the pocket is already dissected from the previous surgery.

Surgical Placement

The surgical armamentarium is relatively simple for midface implant placement and does not require highly specialized instruments (Figure 10-10). A number 9 periosteal elevator, a long thin-tipped tonsil hemostat, an Aufricht nasal retractor, and a Minnesota cheek retractor are useful instruments.

FIGURE 10-10 This basic instrument tray is used by the author to place facial implants.

The placement of midfacial implants is a simple and straightforward surgical procedure for those surgeons with maxillofacial experience and easily learned by others. With experience, actual placement can be performed in less than 10 minutes. The implants are always placed in the subperiosteal plane, and this must remain an axiom of insertion. With the exception of the infraorbital neurovascular bundle, there is little vulnerable anatomy in the midface region when dissecting in the subperiosteal plane. Midface implants can be placed with local anesthesia, although IV sedation is frequently utilized. The implants can be placed as a solitary cosmetic procedure or concomitantly with other aesthetic procedures.

The procedure is begun by injecting about 5 mL of 2% lidocaine, 1 : 100,000 epinephrine transcutaneously in the subperiosteal plane along the region to be dissected. Since many surgeons outline the implant on the cheek, the marked area serves as a template for local injection, and the local is taken 1 cm past all margins. This usually includes the anterior maxilla, malar region, and anterior zygomatic arch region. Additionally, approximately 3 mL of the same anesthetic are infiltrated in the soft-tissue planes in the mouth above the canine tooth, primarily to reduce incisional bleeding. A 1-cm incision is made approximately 10 to 15 mm above the canine tooth (Figure 10-11). Using a radiowave microneedle to incise the mucosa and soft tissues is hemostatic, and the incision is carried to the periosteal level of the canine fossa region. The oral mucosa is very pliable, and even with a small incision, the surgical site can be well visualized when retracted (Figure 10-12). The extent of the dissection is dictated by the shape and size of the intended implant. Small or medium submalar implants require smaller dissection than combined submalar or malar shell implants. The larger or more superolaterally placed implants require a larger dissection pocket to accommodate them. The combined submalar and shell implants also require more dissection over the malar and zygomatic regions. It is important to not overdissect the implant pocket; a large pocket can contribute to implant mobility. The dissected pocket should be just slightly larger than the actual implant (Figure 10-13).

FIGURE 10-11 The initial incision is made 10 to 15 mm above the canine tooth in the unattached gingival mucosa.

FIGURE 10-12 There is no need to make a large incision; the oral mucosa stretches considerably. Excessive incision can lessen the implant stabilization and disrupt surrounding anatomy, which can lengthen recovery.

FIGURE 10-13 Making the dissection pocket just slightly larger than the anticipated implant will assist in stabilizing the implant and lessen recovery. Too large a pocket encourages implant movement with oral function and facilitates hematoma formation.

When beginning the dissection, it is unnecessary to dissect medially to the pyriform (also spelled piriform) aperture (nasal region), because no part of the implant lies in this region. The subperiosteal dissection is begun in the anterior maxillary region, and the initial dissection vector is superior, so it is important to protect the infraorbital neurovascular bundle (Figure 10-14, A). The implants rarely impinge on the infraorbital nerve, and therefore aggressive infraorbital dissection is unnecessary. An exception is placing cheek implants in edentulous patients. These patients have less maxillary bone and ride higher, which can impinge on the nerve. A relief notch can be made to accommodate the nerve when necessary (Figure 10-15). When performing the initial subperiosteal dissection on the anterior maxilla, a smaller neurovascular bundle may be encountered and mistaken for the infraorbital nerve (Figure 10-16, A). The surgeon should keep in mind that the actual infraorbital nerve is 5 to 8 mm inferior to the orbital rim and not confuse it with this smaller vessel which can be sacrificed. Figure 10-16, B shows the actual infraorbital nerve exiting the foramen.

FIGURE 10-14 The initial subperiosteal dissection vector is superior (A), then the dissection is directed in a superolateral direction heading over the malar and zygomatic regions (B). The orbit is protected with the finger of the operating hand.

FIGURE 10-15 In certain cases, the implant can impinge on the infraorbital neurovascular bundle. Notching the implant for relief is mandatory, or nerve damage and pain can occur.

FIGURE 10-16 A smaller neurovascular bundle is sometimes encountered on the anterior maxilla (A) and should not be mistaken for the actual infraorbital nerve (B).

After the anterior maxilla is dissected, the periosteal elevator is angled, and the remainder of the dissection is primarily in an oblique vector (see Figure 10-14, B). This oblique vector of dissection is carried out over the malar region and extends over the medial portion of the zygomatic arch. For small or medium submalar implants, minor zygomatic dissection is required, but for combined submalar and malar shell implants, more aggressive malar and zygomatic dissection is necessary. These larger implants also require more aggressive inferolateral dissection. It is not uncommon to encounter the origin of the masseteric tendon (or muscle) while dissecting in the area (Figure 10-17). There is no need to violate or dissect this tendon or muscle, because the silicone implant can safely lie over these soft-tissue structures without a problem and frequently do with the larger-style implants.

FIGURE 10-17 A, The area of the masseteric tendon and the zygoma (circle). B, Same area in a live patient.

(A Courtesy Primal Pictures Ltd., London, www.primalpictures.com.)

If the submalar implant is used, not much dissection is necessary over the zygomatic region, only enough to accommodate the tail. For larger implants such as the malar shell and combined submalar shell, more dissection may be required to accommodate the implant. By performing a sweeping maneuver in the lateral pocket, the pocket is expanded (Figure 10-18). This is especially useful over the masseteric tendon area. For very large implants, extended dissection over the malar and zygomatic arch may be necessary (Figure 10-19).

FIGURE 10-18 A sweeping maneuver is made by using the periosteal elevator at the lateral implant pocket, which assists in expansion of the dissection pocket.

FIGURE 10-19 Larger implant styles may require more aggressive dissection at the malar and zygomatic regions.

After the implant pocket is dissected, the area is checked for hemostasis, which is imperative to prevent hematoma formation. The pocket is then irrigated with antibiotic solution and the implant placed. A long, thin tonsil clamp facilitates placement in the narrow pocket (Figure 10-20). An Aufricht nasal retractor or a Minnesota retractor is also convenient to assist visualization and placement in the pocket. The implant is grasped so that the tail is stabilized and placed into the pocket. If the pocket is correct for the implant, the prosthesis will lie passively and self-seat (Figure 10-21).

FIGURE 10-20 A long, thin tonsil hemostat is useful to place the pliable implant into a small cavity.

FIGURE 10-21 The implant is placed into the pocket (A–B), and if the pocket is correctly dissected, the implant should seat in a relatively stable position. Implants are anatomically constructed to adapt to average midface hard-tissue anatomy (C).

When inserting the implant, caution is exercised to prevent the thin implant tail from folding over on itself (Figure 10-22). Implants can be easily trimmed with scissors to further control position and augmentation.

FIGURE 10-22 Since some implant configurations have thin leading tails, care must be exercised to not fold the tail under the implant during placement; otherwise a palpable and visible prominence will result.

After the implant is inserted into the dissection pocket, it is again irrigated with antibiotic solution (Figure 10-23, A). The surgeon then pushes on the external cheeks and manipulates the upper lip (see Figure 10-23, B). If these maneuvers displace the implant from the pocket or cause it to protrude out of the incision, the pocket is enlarged or the implant trimmed (see Figure 10-23, C). Trimming implants to customize them for specific anatomy is common, and there is no harm in doing this. If an implant does not fit, the surgeon can expand the pocket, trim the implant, or use a smaller configuration.

FIGURE 10-23 A, The surgical site is irrigated with antibiotic solution. B, The lips are stretched and (C) pressure is placed on the cheeks. D, If the implant is displaced or extruded, then the pocket is enlarged or (E) the implant is trimmed.

When the implant is successfully placed, a decision is made in reference to fixation. A well-conforming implant in a tight pocket can be placed without fixation, and experience has shown the implants to remain stable; some surgeons forego fixation. If the pocket is considerably larger than the implant, if the implant does not stay in the desired position, or if there is increased mobility of the implant, a single fixation screw can be placed. I have placed well over 100 cheek implants without screw fixation, but experience has shown that the procedure is more predictable when using a single fixation screw. I have since utilized rigid fixation screws on an additional several hundred cheek implants, and it is now my standard of care. I have never experienced a single case of implant shifting since switching to screw fixation and hence, recommend it. The easiest means of using screw fixation is to use 1.5- or 2-mm diameter self-drilling screws (Figure 10-24, A). This allows easy seating of the screw without the need for a drill. I generally place the screw through the implant towards its periphery (as opposed to the thick center of the implant) so a shorter screw can be used. It is important not to overtighten the screw, or it can sink into the soft implant and not hold. Additionally, the self-drilling screws are usually not available in lengths longer than 8 mm. It is important not to place the fixation in the thin bone of the anterior sinus wall; it is vulnerable to perforation or loss of fixation. The fixation screw is best placed in the thicker bone of the buttress area (see Figure 10-24, B to D). An alternate means of fixation is to place a 4-0 Vicryl suture from the anterior medial portion of the implant to the deep tissues in that area, but this is a mobile fixation and not as stable as a screw. Many facial plastic surgeons advocate the use of transcutaneous bolster sutures. I have never used these and don’t feel they are necessary. In addition, this is an unpleasant experience for the patient—no one appreciates stitches protruding through their cheek.

FIGURE 10-24 A, A typical 2-mm self-drilling screw fixation set as shown with the microscrews shown in the insert on a screwdriver blade. B, The self-drilling screw is placed through the implant into the thickest bone available. Care is used to not push the small screw through the thin anterior sinus wall. C–D, Both implants have been stabilized with self-drilling rigid fixation screws.E, To confirm symmetric placement, the implant edges should be compared to each other in reference to a fixed point such as the tooth margins or index lines on the face. F, Incisions are closed in a single layer with 4-0 gut suture. G, The surgical sites are compressed with gauze and palm pressure for several minutes after the surgery to compress the dissection pockets.

The final step is to confirm that both implants are placed in the correct position and symmetrically. This can be estimated by observing the position of the implant relative to the teeth or predrawn index marks on the face (see Figure 10-24, E).

The incision is closed with interrupted 4-0 gut suture (see Figure 10-24, F). At the end of the procedure, several layers of 4 × 4 gauze are placed on the external cheeks and palmed with the hand for 5 minutes to compress the surgical pocket (see Figure 10-24, G).

Postoperative Care

No dressings are required, although some surgeons use compressive garments. Postoperative care includes analgesics, antibiotics, and tapering steroids if desired. The patient is instructed to refrain from significant talking and animation for the first 48 hours and is asked to follow a liquid or soft diet for the same time period. Ice packs are used for the first several days. The amount of swelling can be quite variable. Whereas some patients look great at 3 days, others may have significant swelling for 3 weeks. No immediate follow-up care is required, since the sutures are resorbable. Postoperative appointments are generally scheduled for 2 weeks, 1 month, and 3 months.

Sequelae and Complications

Although numerous complications have been described,^22–28 they have been rare in the author’s experience.

Significant edema can occur in the early postoperative period, especially if large implants are used or when implants are placed concomitantly with other cosmetic facial procedures (Figure 10-25). Cold packs and tapering steroids are routinely used. Severe swelling may indicate hematoma formation, and if the surgeon feels there is a significant hematoma, it must be drained (Figure 10-26). This can usually be done by opening the incision and suctioning the blood or clot from under or around the implant, without compromising the result (Figure 10-27). An extremely large hematoma or a continued bleeding source will require implant removal and replacement. Minor hematomas or seromas will usually heal uneventfully without treatment but in rare instances are aspirated.

FIGURE 10-25 This patient is shown preoperatively (A), 24 hours postop (B) after undergoing facelift, brow lift, quad eyelid surgery, CO₂ laser, and lip implants. The swelling is very significant but resolves quickly with heat and steroids. C, The patient 4 weeks after surgery.

FIGURE 10-26 Significant ecchymosis is an uncommon finding but like any surgery can happen. This patient is shown 1 week after bilateral cheek implant placement and lower lid laser skin resurfacing.

FIGURE 10-27 Hematoma is a rare complication with cheek implants, and ensuring a blood-free field before wound closure is generally preventive. If a hematoma is suspected or documented, the incision can be opened, and a small liposuction cannula can be used to evacuate the collection under the implant without removing the implant. A, Major hematoma from cheek implant 24 hours after surgery. B, Evacuation with a small liposuction cannula.

Occasionally subconjunctival or periorbital ecchymosis is seen but remains an uncommon finding (Figure 10-28).

FIGURE 10-28 Although seromas are rare, serous collections can happen and can be aspirated intraorally or percutaneously.

Infection has been an uncommon experience. It usually manifests in the first week or two and appears to be more common in smokers. Infection is generally manifested by one side failing to heal, with complaints of pain, increased swelling, periorbital edema, and purulent drainage with a bad taste. (Figures 10-29 and 10-30). The incision site will frequently be very inflamed and sometimes open. It is possible to salvage a minor infection with open incision and drainage, irrigation, and systemic antibiotics. If an implant becomes infected and is secured with screw fixation, I will attempt salvage with incision and drainage, antibiotic rinses, and systemic antibiotics. The lack of mobility assists in healing. In my experience, attempting to salvage a mobile implant is futile and should not be attempted. Resistant infections warrant implant removal, and the implant can be replaced after healing. Because the explanted site will have scar tissue and remnant implant capsule, the result is often unnoticeable. I have taken out a single implant and not replaced it, without any noticeable cosmetic deficit. In other cases, the deficient side is noticeable and must be reimplanted.

FIGURE 10-29 A, This patient is shown 2 days post cheek implant placement, with a significant developing left-sided infection. B, The patient on postop day 3 just before incision, drainage, and implant removal. C, The patient on postop day 5 with complete resolution. The implant was uneventfully replaced 6 weeks later.

FIGURE 10-30 A, Infected incision site in a smoker. B, Because of the amount of purulence, the smoking, and the delayed infection (3 weeks), the implant was removed.

The patient must be warned that during the first 1 to 2 weeks, they will experience abnormal animation when smiling and puckering and possibly have difficulty pronouncing some words (Figure 10-31). The initial implant dissection violates the orbicularis oris and lip elevator musculature, which heals uneventfully with the return of normal animation. Patients must be made aware of this in the consent process. Occasionally, return of normal animation can take longer.

FIGURE 10-31 This patient was unhappy with her symmetry; the right cheek implant was in a lower position compared to the normally placed left side. The implant was removed and superiorly repositioned.

Perhaps the most commonly encountered problems relate to implant position and symmetry and are usually operator dependent. There is no exact science to placing cheek implants; the exact position is a guess at best. Preoperative marking can assist, as well as careful attention to reproducing each step of the procedure in a similar manner. This includes similar dissection, similar implant position, and similar alignment. Even in the most carefully planned cases, it is possible to have a preexisting asymmetry in the patient’s anatomy that can cause a disharmony from one side to the other. All of this must be covered in the informed consent process. It is not uncommon for one side to look considerably different from the other, and the patient must understand that many or most of the initial asymmetries will disappear with edema resolution. I have had numerous patients who felt that the augmentation was too drastic and wanted the implants removed in the first several weeks of placement. My staff and I were able to reassure them and wait out the edema instead of removing the implants. Most often these patients were very happy when the swelling resolve/>