Facial implants refer to prosthetic devices inserted into the face to provide more fullness, improved symmetry, or changes in one’s appearance. They are generally used to create a younger looking face by restoring volume where it has been lost due to the aging process, or to create a more attractive face by harmonizing facial proportions.
FACIAL CONTOURING PRINCIPLES
- Strong skeletal contours enhance beauty
- Smooth contours mask the aging process
The greatest advantage to facial implants is that they may provide predictable, powerful, and permanent results. They are suited for both men and women, and when placed properly, can feminine or masculine the face depending on the desired outcome.
Implants exist in several sizes and shapes to conform the facial skeleton. Or, they can be custom created to fit perfectly and create a very specific desired look. More on custom facial implants can be found here.
Facial implants are generally composed of a soft silicone and are often either secured to bone with a small screw or stitched into place. Or, of polytetrafluoroethylene (ePTFE) which are soft, porous devices that allow the body’s tissue to network and grow into it. This property adds some degree of tissue fixation to reduce mobility. Both silicone and ePTFE implants can be removed easily, unlike its older cousins that were too porous, such as polyethylene (Medpor).
Below are the different forms (biomaterials) of facial implants:
- Silicone elastomer (Silastic ®)
- High-density porous polyethylene (Medpore ®)
- Expanded polytetrafluoroethylene (ePTFE) (Gore-Tex ®)
- Polyester finer mesh (Mersilene)
- Titanium (not commonly used for augmentation)
Below are a wide variety of ePTFE and silicone implants.
Volumization with Facial Implants
Facial implants provide volume to the face. Volume in the face in essence is the hallmark of youth. Consider a baby’s face. How would you describe it? Is is a ball of fat. And a ball of fat is the starting point for all of us. As we age, fat is lost and tissues descend. Thus, to restore youth one must restore volume, suspend tissues that have dropped, or both.
Dermal fillers work their magic in transforming faces into younger and beautiful versions by adding volume. However, for the most part their results are temporary. Implants are permanent. Below compares the permanent volume addition with implants to the temporary volume additions with dermal fillers. It doesn’t take long to appreciate the cost effectiveness of facial implants over fillers.
Volume of Various Facial Implants
- Medium Sized Extended Anatomical Chin Implant: 2.5 cc
- Medium Sized Mittleman Pre-Jowl Implant: 1.5 cc
- Medium Terino Malar Shell Implant: 2.5 cc
- Medium Binder Submalar Implant: 1.22 cc
- Large Combined MidFace Implant: 4.6 cc
- Large Temporal Shell Implant: 6.85 cc
*Estimated volumes based on 3-D model or implant weight according to Implantech.
The following areas of the face are modified with facial implants:
- Submalar region
- Nasal spine
Of note, there are no male and female facial implants. That is, facial implants exist in many shapes and forms. They are unisex. But they may be used wonderfully to heighten or diminish feminine or masculine features.
General Principles of Facial Implant Surgery
Facial implants not only add volume and function to balance a face by improving dimensions and proportions, they aid in the redistribution of tissue from the retaining ligament releases necessary to place the implants. With released retaining ligaments, soft tissues elevate. The spacer theory, as described by Dr. William Binder, tells us that the implant also functions to prevent the suspended tissue from adhering down to the bone where it once was, prior to its elevation to place the implant.
Below is an illustration of the nine retaining ligaments that may be released when placing facial implants.
Below is an illustration of the nine retaining ligaments that may be released when placing facial implants.
Make no mistake. Fat transfer is a wonderful procedure to create permanent fullness to the face. It is often the preferred surgery for facial rejuvenation or modification. Fat transfer is very safe with infection rates far lower than with implants. In addition, fat does not carry the added risk of migration and extrusion. The biggest downside to fat transfer is its unpredictable survival and its inability to create drastic changes in facial structure. Thus, the choice between fat and implant must be carefully weighed against the goals of surgery and the potential risks.
One other disadvantage of fat that does not exist with implants deals with the dynamic nature of living fat. Injected fat that survives can potentially grow or shrink with weight fluctuations. Generally speaking, mild weight changes will not generate any significant changes in graft size. However, with weight fluctuations over 40 pounds, grafted fat may become visibly larger or smaller with weight gain or weight loss, respectively.
There are more limitations to the amount of volume or projection one can achieve with fat transfer than with implants because only so much fat can survive in any region at any given transfer session. Thus, for more radical facial modifications, implants are the superior choice. Or, multiple fat grafting sessions may be required.
Certain regions of the face are more amenable to fat survival than others. The temple and lips are often areas of the face that don’t do as well with fat transfer as the cheeks and jawline. Thus, for permanent lip and temple augmentation, silicone implants may be the preferred option in certain individuals. Other options that exist for temporal augmentation included fillers or Sculptra ®. More on fillers can be found here.
Advantages and disadvantages of fat transfer and facial implants are summarized below.
Advantages of Fat Transfer
- Smaller incisions
- Far less risk of infection
- No risk of malposition
- No risk of extrusion
- Smaller risk of asymmetry
- No risk of masseter muscle dehiscence (deformity)
- Stem cells within the fat can improve skin quality
Advantages of Facial Implants
- More powerful changes can be achieved
- More predictable outcome than fat
- Far better correction in the temples and lips than with fat
- Does not require a separate donor area
- Consistent facial volume rejuvenation
- Custom implants available
- Better for soft tissue lifting (suspension)
- Might be more cost effective than fillers or fat
- **“Spacer Concept” for lifting
**The spacer concept in facial implant surgery was first described by Dr. William Binder. Because an implant becomes an interface between bone and soft tissue, the tissues will stay elevated because the tissues can not heal (and adhere) onto the bone. The result is a suspension of tissues that will affect tissues below the implant, and provide a filling effect farther than the actual dimensions of the implant.
Fore more information on facial implants, visit the FAQ section here.
Silicone temporal implants exist in two forms. There is a standard model and an extended version (see photo below). The standard temporal implant fills the temporal hollow just lateral to the orbit.
The extended implant fills both the temporal hollow and extends further into the forehead. Both standard and extended temporal implants can be inserted through a single hidden two centimeter incision by means of to possible approaches as illustrated below. The surgery can be performed safely under local anesthesia in the office.
A 2 cm incision is made approximately 2-3 cm above the root of the ear and 2-3 cm behind the hairline (see green markings below). The incision is oriented parallel to the hairline. The skin is incised and dissection is carried down to the deep temporal fascia. The fascia is incised an a natural tissue plane opens up between the muscle and the fascia.
The pocket for the implant is dissection and the implant is curled up and inserted through the small incision. Once in place, the implant is unfurled to fit the pocket. There is no need to secure the implant with a screw since the implant should remain snug and immobile in its pocket.
Two to three stables are placed to approximate the wound edges. No deeper stitches are places since deep stitches in this area may cause damage to the hair follicles and impair hair growth
Root of the Ear Approach
In men (or women) who enjoy very short hair, the root of the ear approach may be preferred over the temporal approach. The dissection is slightly more complex because the incision is further from the pocket. And, the surgery requires that the top of the ear be partially separated from the head. Details below explain the added steps:
A 2 cm curvilinear incision is made right where the ear attaches (see red markings). A dissection is carried below the skin until the deep temporal fascia is reached. Once at the deep temporal fascia, the same dissection is performed as above.
Once the implant is in place, the ear is secured against the head with stitches. The skin
incision is then closed in multiple layers since there are no hair follicles in the incision that could potentially become injured.
Candidates for Temporal Augmentation
The aging process of the face is marked by volume loss. The temporal regions is not spared. With atrophy of the temporals muscle and temporal fat loss, the temples and lateral foreheads become increasingly concave, turning men and women into “peanut heads”. The wide upper third of the face that was once present in youth disappears, generating a relative “bottom heavy” face.
To restore youth of the face, the temple is unfortunately all too frequently ignored. It is the neglect of this region along with volume addition to the cheek that
too often turns patients into unnatural looking atrocities. The cheek and the temple must be considered a married unit. To augment one while ignoring the other runs the risk of imbalancing the face.
Thus, men and women who wish to restore youth or convert a long face into a more trapezoidal or heart-shaped face may be good candidates for temporal augmentation with implant.
“It is volume to the upper third of the face that truly is the hallmark of youth and beauty.” – Tim Neavin, MD
Potential Complications of Temporal Implants
It could be argued that temporal implants are one of the easiest, if not the easiest, implants to place. The dissection required for implant pocket formation is well known to general surgeons since it is the same dissection required to fix zygomatic arch fractures. And zygomatic arch fractures are no stranger to plastic surgery residents who get their fill of facial trauma during their residency.
Nonetheless, despite their relative ease, temple implant surgery can have its problems. But thankfully complications are rare and often not severe in nature.
Any prosthetic implant runs the risk of infection and malposition. And because two are often placed at a time (right and left), an added risk of asymmetry exists. Infections of temporal implants are uncommon given the great vascularity of the face and scalp, and if they do occur, they can often be treated with antibiotics. In rare circumstances, the implant may need to be removed. In such cases, it is wise to wait three months before replacing the implant.
More common than infection is malposition. An implant malposition refers to the misplacement of the implant. While it is unlikely, the implant may shift after surgery. However, given the swelling that occurs during surgery, it is possible that the added bulk to the tissues from swelling or local anesthesia may mask the true position of the implant. Such small imperfections in placement may manifest in very thin individuals weeks to months after surgery. Correction of malposition is very easy and can be performed under local anesthesia in the office.
Asymmetry may result from either slight asymmetric placements of the implant, implant shifting after surgery, or be the result of pre-exisitng asymmetries. The latter is the most common cause for asymmetry. Silicone implants can be cut and reshaped to a degree to help combat some of the bone or soft tissue asymmetries inherent in each and every face. For more precise asymmetry correction, customized implants can be created. For more on custom facial implants please click here.
The use of nasal implants to improve appearance has its roots in the history books with various creative devices, ranging from gold, silver, cork, stones from the Black Sea, rubber, lead, and even a toothbrush handle.
Today, when plastic surgeons consider non-autogenous products for the nose (tissue from oneself), they generally stick to silicone, ePTFE, or cadaver graft. These products are usually considered after autogenous options fail or are absent (cartilage, fascia, rib, etc.) Cadaver graft falls into the category of homologous material. These grafts are formed from human cadavers, then prepared and sterilized for use.
Some plastic surgeons argue that prosthetic (also called alloplastic) and homologous nasal implants such as silicone, rib, or cadaveric cartilage should supersede rib cartilage use given the scar, risk of lung injury, and pain associated with a rib harvest. This is a fair argument, particular since rib grafts can warp or partially absorb.
The most common nasal implants used today serve to augment the dorm of the nose, the dorm and columella, or the nasal spine (the area where the upper lip meets the nose).
Images of these three implants are shown below. Note, the pyriform implant, while used to augment the nose, is also considered a maxillary implant. This implant is discussed in more detail below.
Doral implants are commonly used in patients of Asian or African descent to lengthen the nose. With the addition of a columellar leg to the dorsal implant (dorsal columella implant), projection of the nose can also be enhanced.
Above is depicted a dorsal implant to add height to the nose. Below, a dorsal columellar graft is added to increase both heath and projection.
Nasal Implant Surgery
Nasal implant surgery is almost always combined with rhinoplasty. Nasal implants can be placed via both open and closed rhinoplasty techniques. While it is possible to place nasal implants under local anesthesia, it is an uncommon practice since it is often combined with more extensive rhinoplasty techniques that require airway protection.
Patients are given antibiotics prior to surgery and the implant and nasal pocket is washed with antibiotic solution prior to placement. It is usually not necessary to secure the implant with screws or stitches since the pocket dissection is created to fit the implant snugly. Mobility of the implant post operative is almost always not an issue for which to be concerned.
Nasal Implant Complications
Over correction or under correction are unfortunate complications from the use of nasal implants. The use of sizers intraoperatively can reduce this risk. Ideal augmentation goals can be determined pre operatively by going with the patient over aesthetic ideals and their desired outcome. Implants placed that are either too big or too small can be easily removed and replaced often under local anesthesia in the office.
Perhaps the greatest fear when it comes to nasal implant surgery is implant infection. Infections that overwhelm the tissues and cannot be controlled adequately with antibiotics necessitate the removal of the implant. In most case an implant can be replaced in three months after the tissues have healed.
Erosion of the implant, particularly at the tip, is a rare and devastating complication. Erosion a nasal implant can occur from oversizing the implant, poor healing, or infection. An exposed implant will need to be removed.
Nasal Implant Surgery Recovery
Any nose surgery will result in prolonged edema of the tip. The degree of nose edema will be proportional to the amount of surgery and the thickness of the skin. A splint or tape will be applied for a week and stitches will be removed at seven days if the open technique was performed. Patients should continue taking antibiotics for a week after surgery.
A negative vector facial morphology refers to the relationship between the mid face and the rest of the face. A good way to illustrate this and its importance in its role in beauty is to study the illustration below.
The term negative applies to the descent and fat loss (atrophy) of the malar fat compartment when the angle of the cheek is posterior (behind) the surface of the eye. This unfavorable bony relationship becomes an enemy as one ages. Tissue decent can develop earlier in men and women with this morphology, and lower lid bags may become prominent. Definition of the midface such as the cheeks and cheekbones is lost. There is a general lack of support when the lower orbital rim sits behind the upper orbital ridge. Thus, the addition of support with augmentation of the lower orbital rivaling with soft tissue manipulations are powerful players in facial beautification and rejuvenation.
Note how above the addition of volume, in this case a cheek implant, can convert a negative vector into a positive vector. In men and women with negative vector faces, cheek implants or fat transfer become wonderful options.
Cheek implants, commonly referred to as cheek augmentation, are inserted onto the cheek bone to enhance the cheeks or make the cheeks look fuller. Fuller cheeks generally translate into more youthful appearances since the cheek mass shrinks and falls as we age. They may also balance the face by either feminizing it or masculinizing it depending on the starting point, the implant, and the desire.
Cheekbone implants have existed since the 1950s and have been proven to be very safe devices inside the body. Like the previously mentioned facial implants, cheek implants are composed of silicone or ePTFE. They are relatively easy to insert, easy to remove, and easy to re-insert if necessary.
There are three main categories of cheek implants:
Malar implants are the most common cheek implants used and are often equated with cheek implants. Malar implants are placed directly on the bone resulting in more projection to the cheekbone or zygoma. Implants in this location contour the side of the face and provide a wider and more chiseled facial architecture. Malar implants are secured with a screw or stitches.
Submalar implants are placed lower in the face. These implants do not augment the cheek bone. These implants instead provide more fullness in the midface region. Submalar implants can powerfully augment gaunt faces into full, and healthier looking faces.
Combined malar and submalar implants
Combined malar and submalar implants augment both the cheekbone and midface to create more pronounced cheeks and a fuller, less gaunt midface.
Cheek Implant Surgery
Most surgeons will prefer to perform cheek implant surgery under general anesthesia. Working inside the mouth may not only be uncomfortable for the surgeon, it may also make the surgery more difficult for the surgeon. For these reasons as well as the possible increased risk of oral contamination in the awake patient, general anesthesia almost always makes the most sense. Endonasal intubation is often preferred to endotracheal anesthesia because the breathing tubes are difficult if not impossible to disinfect during surgery.
Intravenous antibiotics will be given prior to surgery and the implant, mouth, and surgical pocket will be raised with betadine and antibiotics.
A 2 cm incision is made inside the gingivobuccal sulcus. Dissection is carried right down to bone. The soft tissues are elevated off the bone marching up and lateral to expose the surface of the maxilla and zygoma. Because the pocket created is larger than the implant (as it must be to access the proper implant site), the implant must be secured with either a titanium screw or stitches in the form of an external bolster.
Patients usually go home the same day after surgery.
The intraoral incision will be closed with a dissolvable stitch. If a suture buster is placed it will be removed by 48 hours.
Cheek Implant Surgery Recovery
One should expect the cheeks to remain swollen for several weeks after surgery. The degree of pain associated with cheek implant surgery is generally far less than with many body surgeries. Special head wraps are sometimes preferred for a week to help reduce swelling and keep implants in place if they were bolstered. Patients should take antibiotics for up to a week following surgery and maintain a soft diet for three to five days. The mouth should be rinsed with Peridex or Listerine after every meal for a week.
Largely unknown to the general population, lip implants exist and they work very well to create permanent fullness to the lips. The most common implants use are called PermaLip permanent lip implants. They come in 3 sizes, 3 mm, 4mm, and 5mm diameter and are made of a soft silicone.
PermaLip permanent lip implants are placed int the office safely under local anesthesia through a small incision in the corner of the mouth. They implants, because they are soft an pliable, do not affect lip movement. And they feel very natural. Lip implants may prove to be more cost effective than serial dermal filler injections.
For more on PermaLip permanent lip implants, click here.
Chin implant surgery is commonly referred to as chin augmentation. The most common implants used for chin augmentation are made of silicone. Their pliable nature allows the implant to be placed through 2 cm incisions. The most common approaches for chin augmentation are from inside the mouth (itraoral) and externally through an incision below the chin where the chin meets the neck. This area is called the submental crease, and incisions here heal very well leaving almost an invisible scar.
Chin implants come in various shapes and sizes. For more on chin augmentation click here.
Jaw implants, also referred to as mandible implants, have become increasingly popular in the last five years. And they are not used exclusively in men. Defined jawlines are the hallmark of youth in both men and women. They can strengthen the lower third of the face or create more balance and harmony to the rest of the face. While many women ascribe strong jawlines to masculinity, a quick glance at Hollywood’s leading beauties such as Angelina Jolie and Scarlett Johansson dispels this myth entirely.
Mandible implants can add both horizontal and vertical fullness to the jawline. That is, they can either widen or lower the lower third of the face. Jaw implants can be combined with chin implants as a one piece custom implant. Or, they can be customized to add a certain amount of width or length desired by the patient based on CT imaging studies.
Below is an example of a mandibular implant to augment the angle of the jaw width and an implant to lengthen the jaw. Both are placed through the same approach but lend itself to very different looks.
Below is an illustration of how a jaw implant may sit on the angle of the jaw to create a sharper angle
Jaw Implant Surgery
Mandibular implants can be placed via intraoral or external incisions. An external incision can me made just below the angle of the jaw. This approach likely reduces the risk of implant infection. However, by far the mot common approach is intraorally because it can avoid a visible scar.
The surgery is done by means of general anesthesia preferable from an endosal intubation. This is because the breathing tube is difficult if not impossible to totally disinfect. Intravenous antibiotics are given and the patient will continue taking oral antibiotics for a week after surgery.
Through a 2.5 cm incisions in the back of the mouth, the masseter muscle is exposed. The masseter muscle is teased off the angle of the mandible to create a pocket for the implant. Once the implant is in place, a screw is placed via an external approach to secure the implant against the jaw.
Below is an illustration of the dissection and screw fixation
Jaw Implant Surgery Recovery
Because the masseter muscle is detached from the bone, expect pain in the jaw to last up to a week. One should consume only a soft diet for the first 5 days and risen their mouth with Peridex or Listerine after every meal. Swelling will persist for about a week to two weeks. If the intraoral approach was performed, the stitches will dissolve in the span of a week or two. If an external approach was performed, the stitches will be removed in the office in a week.
Potential Complications of Jaw Implant Surgery
Approximately four percent of jaw implants will become infected. This number can be reduced by having the jaw implant placed through an external incision for the trade off of a small permanent scar. For most people, a greater than 90 percent success rate versus a permanent scar is an easy decision to make. Most will assume the infection risk. However, it is important to present both intramural and external approaches with the patient so they can make an informed decision how to proceed.
Another potential complication, and one that may in fact be more common, is asymmetry. No man or woman is born with perfectly symmetrical jawlines. Asymmetry may be the result of bone or soft tissue, in both horizontal and vertical dimensions. In cases were asymmetry of the jawline is obvious, customized jaw implants can better reduce but not eliminate asymmetry.
Migration of the implant is unlikely since the implant is secured into the bone with a screw.
Two other potential complications of jaw implant surgery is visibility of the implant in very thin patients or from a malposition or the development of a masseter deformity if the masseter muscle completely detaches from the angle of the jaw. A masseter deformity is an unlikely complication, particularly if the implant used was one to only increase jaw width. Implants to increase height require more dissection of the muscle off the bone. In the rare instance a masseter deformity becomes evident, fat grafting may improve the appearance. In very thin patients who have implant visibility, the options to improve the appearance may include fat transfer to pad the implant, implant repositioning, removal of the implants with fat transfer, or customized jaw implants.
The large majority of patients are very pleased with their implants and their new jawline, but understanding potential complications is always important for patients.
Pyriform implants, also known as paranasal implants or maxillary implants, may increase the convexity of the lower face to make the nose appear less prominent. This is achieved by the implant’s ability to increase projection at the nasal base.
Another advantage of this implant is that it increases the nasolabial angle, which is the angle between the upper lip and the nose. Ideal nasolabial angles for men are between 90 and 100 degrees. Ideal nasal labial angles for women are between 100 and 110 degrees. These implants are made of silicone or ePTFE and come in various shapes and sizes to address different ideals that may be absent from midface retrusion.
Candidates for pyriform implants (also referred to as nasal spine implants or paranasal implants) are men or women with midface retrusion or midface concavity and a short nose.
Below is an example of a maxillary implant. There are several different shapes and sizes available.