Facial Implant Surgery in Santa Barbara
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.
Before and After Photos
Facial Contouring Principles
1) Strong skeletal contours enhance beauty
2) 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.
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.
Nasal Implants (Nose Implants)
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 common 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.
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.
Pyriform Implants (Maxillary Implants)
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.
Midface Retrusion and the Negative Vector Morphology
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.
Jaw Implants (Mandible implants)
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.
Defined jawlines is beauty and youth.
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.
The intra oral incision is closed with an absorbable stitch.
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.
What are facial implants made from?
Facial implants are most commonly made from silicone of ePTFE. ePTFE stands for polytetrafluoroethylene. It is a soft, porous material that allows the body’s tissue to grow into the device. The silicone used in facial implants is generally very soft and malleable. However when they are placed on the bone they feel very firm. The malleable nature of silicone implants allows the surgeon to place them through small incisions.
Are facial implants safe?
Yes. Every surgery has its own unique set of risks and complications. However, the surgery involved in facial implants is considered a very safe surgery because there are no major nerves or vessels in the path of the dissection. Of course, there are risks of infection, bleeding, extrusion, malposition, and asymmetry. But for the most part, these are not life threatening problems and leave no permanent sequela. Infections may be treated with antibiotics. In some case the implant may need to be removed. Infected implants can be replaced generally after three months. Any asymmetry can be improved by re-positioning the implant, trimming the implant, or placing custom implants.
Where do the implants sit?
Some facial implants sit on the bone, such as chin implants, cheek implants, submalar implants, jaw implants, and certain nasal implants. Temporal implants sit on the muscle. Lip implants sit within the lip substance.
What do facial implants feel like?
For the most part, the implants feel very much like the tissue they are augmenting. Silicone and ePTFE are soft materials. But when they sit on bone they fell firm. And when they sit in the soft tissues of the lips they feel soft. This is one of the wonderful products of silicone and ePTFE.
Will people be able to tell if I have a facial implant?
If the implant is chosen and placed properly, the results should look and feel very natural. Most facial implants require no external incision. The exception to this are temporal implants, but even these incisions can be hidden well. Lip implants are placed through the corner of the mouth leaving no discernible scar. Chin implants are placed are placed either through the mouth or under the chin. The external approach to chin augmentation is more common than the intra-oral approach and leaves a small scar that heals very well.
Are facial implants screwed in?
Some facial implants are secured with a screw, others with stitches. Some however, like lip, temporal and chin implants do not require any type of fixation since the implant sits snug in a precisely developed pocket.
What are the different areas plastic surgeons place facial implants?
Virtually every area on the face can be augmented with facial implants, but the most common areas include the temples, the forehead, the mid-face, the nose, the chin, the cheeks, the lips, and the jawline.
Why do some people with cheek implants look fake?
Only the unnatural results are discernible. And many of the older generation implants are inferior in shape and placement to the new styles and surgeries. Lastly, implants may become visible decades after placement in the background of poor placement and facial fat atrophy. However, this has become less common with the newer and more natural looking facial implants and advanced techniques.
What are the risks of facial implants?
The main risks of facial implants differ from area to area. In general the main disadvantages to facial implants include prolonged swelling in the mid-face as occurs from cheek implants, asymmetry, infection, and extrusion. Studies indicate that the risk of a facial implant infection is about 4%. In some cases infections of facial implants can be treated with antibiotics. In other cases the implant must be removed. If the implant is removed, filler can be placed to temporarily reduce asymmetry (assuming one—not both implants, are infected and removed), and an implant can be replaced in about three months.
How long do facial implants last?
Silicone and ePTFE do not dissolve. Thus, they may potentially last a lifetime in the body. They do not require removal and replacement after an arbitrary number of years, nor do they wear-and-tear like tires. However, the tissues of the face DO undergo wear-and-tear thanks to the likes of gravity and aging. Soft tissues may need to be modified to enhance the implants after decades of aging. Everyone is different.
What if I don’t like my facial implant? Is it easy to remove?
Yes. Unlike Gore-Tex or injected silicone (both of which are generally avoided in the face nowadays), silicone and ePTFE implants are easy to remove. There is a saying in plastic surgery that the ideal implant should be easy-in, easy-out, and easy-in. Meaning, the reality of implant infection must be considered necessitating the removal—and later replacement of the implant. Silicone and ePTFE meet this criteria. They are both easy to place and remove. However, the removal of the implant at times does require the use of a screwdriver if a screw was placed to secure the implant. And, the surgeon must be adept at the dissection. Thus, for well trained surgeons with the proper tools, facial implants are easily removable and can almost always be removed and replaced through the same incisions they were originally placed.
What happens if a facial implant gets infected?
We all hope the day never comes, but the reality is that about 4 percent of facial implants will become infected at some point. Sometimes an infection may develop shortly after surgery. Other times an infection may brew slowly over months to years before it becomes clinically visible. In low grade infections caught early, the implants can be salvaged with antibiotics. In situations where an infection overwhelms the implant and soft tissues, the implant will have the be removed to allow the body to heal. It may be replaced, in most cases, at about three months.
How much do facial implants cost?
The cost of facial implants varies depending on the area of the face, to experience of surgeon, to the number of implants, to the geographic location of the doctor. Other factors include whether or not the surgery will take place under general anesthesia or local anesthesia, and whether or not the implants will be off-the-shelf or custom. As a general rule, expect to pay the same amount for a pair of facial implants if not more, than for a pair of breast implants. If the facial implants are custom, expect to pay at least $5,000 to $6,000 more to account for the imaging studies necessary to make the custom implants.
How do I go about choosing a doctor for facial implants?
Like anything else when it comes to finding a suitable doctor to meet your needs, it is advisable to do research. Some of the things to look for when researching a cosmetic surgeon are credentials, years of experience, and reviews. It is easy to check to see if your plastic surgeon is board certified by visiting the following website:
In addition to board certification, one can look at reviews online, read their blogs to see if they are being asked to speak at meetings on a particular topic, or see how involved they are in organizations (which may function as an indirect marker for desire to keep up with trends in the literature).
What are custom facial Implants?
Custom facial implants refer to the creation of silicone or ePTFE facial implants based off of imaging studies of the face to precisely match the contour of the underlying facial skeleton and fit precisely into soft tissue dimensions. A large array of off-the-shelf silicone and ePTFE facial implants exist, but in certain cases of large asymmetries or for cosmetic goals that cannot be achieved with off-the-shelf devices custom implants may be preferred.
How are custom facial implants made?
The creation of custom facial implants relies on imaging studies of the face. A CT of the face with 1 mm cuts is performed and sent to an implant engineer. The engineer along with the plastic surgeon discuss the underlying bone configuration as well as soft tissue parameters to develop implants that fit better than off-the-shelf implants. The process takes longer and costs more money, but the ability to improve symmetry to achieve the desired outcome is much easier with custom implants. The custom facial implants will be made of silicone or ePTFE and can be placed in the same manner as off-the-shelf implants.
Why would I want a custom facial implant over an off-the-shelf implant?
Off-the-shelf implants are by far the most popular implants chosen by surgeons and patients. They exist in various shapes and sizes and can accommodate most patients to achieve a desired outcome. The advantage of customizing facial implants is the ability to see that the implant sits more precisely in the pocket, to correct asymmetry better, and to provide different looking results that off-the-shelf implants may not be able to provide. A more precise fit may theoretically reduce the risk of implant problems, such as malposition, infection, and erosion. When revision surgery is taken into consideration, custom implants may prove to be the more cost effective method of facial augmentation.
What is better, fat transfer or implants?
This is a ferociously debated topic among plastic surgeons. In short, in some instances fat transfer is clearly advantageous. In other cases, facial implants are the better choice. It really depends on what the plan is, and what potential risks (and costs) the patient and doctor is willing to take on. It is important to note that fat transfer and facial implants, while similar in what they can achieve, do have significant differences and its own set of unique limitations. For patients seeking facial implants, upon further education with the physician he or she may find that fat transfer is more suitable to fit their needs. And vice vera. Generally speaking, facial implants can provide more drastic physical changes to the face with far more predictability. However, the risk of infection, movement of the implant post-operative, and extrusion of the implant make it sometimes less desirable to patients who are not looking for significant changes. It is difficult if not impossible to create very drastic results with fat. This is because not all of the fat injected will survive. An often overlooked advantage of fat transfer is that fat transfer has the added benefit of providing stem cells to help rejuvenate the skin and improve skin quality.
What is the biggest problem with facial implants?
The major disadvantages to facial implants include potential infection, malposition, asymmetry, implant visibility, and extrusion. Thankfully, most of the time none of these complications surface. And, the management of any of these complications is often straight forward. But these problems do not exist to the same degree with its competing procedure, fat transfer. Thus, benefits and risks must always be weighed before choosing facial implants over fat transfer or fillers.
What if a facial implant gets infected?
The good news is that in the large majority of cases, facial implants will not get infected. The downside of course is that if they do get infected they made need to be removed. They almost always can be replaced 3 months later. But in the interim, large facial asymmetries may exist (unless of course the removed implant was a chin implant). The surgery to remove facial implants is often easy, safe, and quick. They are designed to be inserted easily, removed easily, and replaced easily. But there of course are costs associated with these procedures.
Can facial implants be performed under local anesthesia?
Yes. Lip, temporal, and chin implants are easily performed under local anesthesia. While cheek and mandibular implants may be placed under local anesthesia, it is far more uncomfortable for the patient than some of the other facial implants. Nasal implants can be placed under local anesthesia too, but they are often combined with rhinoplasty which almost always requires general anesthesia.
Do facial implants hurt?
Surprisingly, face surgery generally does not hurt as much as body surgery. The more extensive the dissection, the more post-operative pain one can expect. Dissection for mandibular implants requires partial detachment of the masseter muscle, and may likely prove to be the most painful of the facial implants. However, all facial implant surgeries is generally well tolerated with oral pain medications and should not preclude one for doing activities of daily living after surgery.
Will I be able to feel my facial implant?
Yes and no. The implant will be palpable, but the real question is, “Will it feel like an implant or my body?” Most people feeling the face of someone who has facial implants will not be able to discern whether or not the implant is tissue, silicone, or ePTFE.