Synthetic implants are commonly used for augmentation of numerous facial bone sites for cosmetic augmentation or reconstruction of defects and asymmetries. Facial implants are available in a wide variety of styles and sizes for such areas as the cheek, orbit, chin and jaw angle, to name the most common. Most of these implants are composed of materials that allow for relatively easy shaping, trimming and otherwise custom adaptation.

But some facial cosmetic and reconstructive needs can not ideally be met by using off-the-shelf implants, no matter how they are shaped and modified. In some more uncommon cases, only a custom designed facial implant will suffice. As uncommon as the need for such implants are, they are more frequently used in reconstruction of facial defects and more rarely for cosmetic augmentation.

The fabrication of custom facial implants is a process that initially begins by getting a facial skeletal model of the patient. This is initially done by the patient obtaining a 3-D craniofacial CT scan done with high resolution 1mm cuts. Such a scan can be obtained at just about any CT facility today as 3-D software is commonplace. Once the scan is obtained, it is then sent to a model fabrication manufacturer. I use Medical Modeling (Golden, CO) but there are numerous other manufacturers that can create similar models. They can make a patient’s model in numerous ways including an Osteoview (radiopaque) or a Clearview (translucent) model. For custom implant fabrication, I usually use an Osteoview model as the view of underlying structures such as nerve and teeth are not usually necessary and it is less expensive.

Once the patient’s facial model is obtained, a mock-up of the implant is then made. This is done by sculpting it by hand on the model. At one time, I used acrylic as the modeling material but this requires grinding after being set and that makes it a more difficult fabrication process. Currently, soft modeling clay is used but it is of the type that does not dry out with extended use and can be cured by baking once the final shape is obtained. Such modern clays are much easier to use than older clay materials for this purpose.

The cured clay implant(s) is then sent to a silicone manufacturer (e.g., Implantech) for the manufacture and sterilization of the final implant(s). Currently, custom facial implants can only be made in silicone. Other implant materials, such as Medpor and Gore-Tex, have to be machined and not poured and cured into a mold made from a custom implant design. (this makes them considerably more expensive)

Contrary to popular perception, custom facial implants for cosmetic facial enhancement are not made magically by some computer technology. They are done by hand by traditional sculpting off of a model made by computed tomographic scanning. It is a total process that takes about 6 to 8 weeks from the time the CT scan is obtained until the actual sterile implants are in hand. I have found them to be particular useful for mandibular augmentation (e.g., vertical lengthening) which, due to its large surface area of bone, has contours that may not be able to be met by conventional preformed implant shapes.    

Dr. Barry Eppley

Indianapolis, Indiana

Aging has an obvious effect on how the face looks from the outside with many recognized soft tissue changes. Wrinkles, deepening nasolabial folds,  crow’s feet and jowls are but a few of the effects that gravity and time cause. This understanding has led to the many well known plastic surgery procedures whose intent is to resuspend sagging skin as well as skin removal/reduction.

But much like beauty, aging goes the whole way down to the bone and is not spared. In many ways it is somewhat reflective of what has happened on the outside. Multiple studies in plastic surgery have looked at how the face ages beneath the skin. Volume loss, primarily of fat, creates an overall facial ‘deflation’ and this understanding has led to the widespread use of synthetic injectable fillers and injections of your own fat to help plump up the aging face. But loss of the deepest tissue, the bone, also makes a contribution to this volume.

Since the bone provides a scaffold onto which the overlying soft tissues drape onto, it is logical to assume that the facial skeleton changes as well. Recent studies using CT scans have looked at various areas of the facial bones and their aging changes. The width and size of the eye (orbit) increases with an almost sagging appearance to the outer lower orbital rim. The glabella (bone between the brows) and the upper rims of the eyes (brow bones) flatten. The maxilla is affected by loss of pyriform aperture and a decrease in the maxillary angle. The length and height of the lower jaw (mandible) shortens with resorption of the jaw angle. (enlarged mandibular angle)

All of these facial bony alterations with age can be correlated to associated outward soft tissue changes. The dropping of the brows and the piling of eyelid skin is a reflection of the loss of underlying bone support. The deepening nasolabial folds and the sagging cheeks are reflective of the maxillary resorption. A weaker chin, jowling and lax neck tissues are partially effected by the loss of lower jaw volume.

The facial skeletion does change with age, primarily with loss of volume of key bony support areas. This results in lessening areas of soft tissue adherence and sagging and deflated overlying soft tissues. This in addition to the loss of facial fat creates the appearance of the aging face.

Bone augmentation of the aging face with implants can be a useful surgical strategy for some patients. Reversing the age-related changes (atrophy) of certain facial bone areas can be done very simply with implants, adding volume to where it has been lost. Implants can do this in two ways, filling out concavities and bulking up weakened convexities. Tear troughs and paranasal deficiencies are examples of deepening concavities. Orbital rims, cheeks, chin and jaw angles are areas of weakened convexities.

Skeletal facial implants, while often thought of as just for younger patients seeking better facial highlights, can be useful for the aging face patient as well. They offer a permanent solution to specific aging facial areas that have ongoing resorption which contributes to loss of overlying soft tissue and skin support. They can be used in conjunction with any of the soft tissue redraping procedures to help create a better facial rejuvenative effect.

Dr. Barry Eppley

Indianapolis, Indiana   

Facial reconstruction patients can benefit today from custom-made bone replacements and bone fixation aids to optimize for the postoeprative form and function. High-resolution computed tomography (CT) modeling allows plastic surgeons to custom-design implants prior to reconstructive surgery. They are particularly useful for facial bone defects of the lower jaw (mandible), skull and the forehead and eye (orbital) areas.

Severe facial and eye (orbital) bone deformities and defects may be present at birth or can occur following facial trauma or, most commonly, facial tumor removal. Surgery to correct such defects aims to restore the original anatomy and the patient’s appearance by inserting an implant made either of the individual’s own bone and tissue or synthetic materials. The traditional use of implant materials in facial reconstructive surgery, which are shaped during surgery, often do not recreate ideal three-dimensional contours in the face and take a lot of time working with them as the patient is asleep. Designing synthetic implants beforehand improves theirprecision and contours and helps shorten the time of surgery.

I have looked at my series of ten facial reconstructive patients done over the previous nine years who received computer designed and generated custom implants and were more than one year after their surgery. The six men and four women were between the ages of 31 and 67 years, with an average age of 46.1 years. The defects were caused by either trauma (2), tumor resection (6), or a congenital deformity (2). Most of the patients (7) had a history of prior failed reconstructive efforts. The patients underwent three-dimensional high-resolution CT scanning of the face from which customized implants composed of either pure titanium (bone fixation device) or HTR (porous hard tissue replacement bone substitute) were made. All implants was surgically placed and fixed using titanium plates and screws.

Example #1

This 62 year-old female had a right mandibular angle bone resection secondary to an intraoral carcinoma. She never had any radiation treatments. The defect was only spanned by a reconstruction plate which had fractured three separate times over the past eight years. A 3-D CT scan showed the defect and the mandibular segment contraction. She did not want a fibular free flap reconstruction.

A custom titanium dual plate and mesh construct was designed to hold the bone segments apart in anatomic position and contain an iliac marrow graft. Through a neck incision approach, the old fractured plate was removed and the new 3-D engineered construct placed. The resultant mandibular form, occlusion and jaw opening was excellent.

Example #2

This 65 year-old male had a history of esthesioneuroblastoma with a resection by frontal craniotomy and removal of his left heminasal cavity and maxillectomy. He received radiation afterwards. Over the enduing ten years, he developedorbital floor bony resorption due to osteomyelitis and dropping of the eye downward. His orbital condition and eye position eventually stabilized as his osteomyelitis resolved. A 3-D CT scan shows the loss of orbital floor bone and the orbital dystopia.

A custom HTR orbital floor implant was manufactured to match the opposite orbital floor shape and volume. Through a lower eyelid incisional approach, the implant was placed and secured to the orbital rim with titanium plates and screws. He had much improved postoperative globe symmetry. He went on to have eye muscle surgery and a dermal fat graft to fill out the soft tissue atrophy of the lower eyelid and cheek region.

During an average of over four years of follow-up, none of the patients experienced any implant-related complications including infection, extrusion, or displacement of the implants. Healing around the implant sites was uneventful. All of the patients had sustained improvement of facial deformities including mouth opening in those that involved the lower jaw.

While numerous types of implant materials have been used for reconstructive facial surgery, one important aspect of their success is proper design and engineering. Time spent before surgery evaluating the exact dimensions of the bone defect and then custom designing the implant has numerous advantages. Having an implant that is not bigger or oversized for the defect lowers the risk of potential extrusion. A near perfect fit makes for good facial contour restoration. Oral function and occlusion is more assured if the lower jaw reconstruction is as precise as possible. Donor site pain and morbidity is eliminated or reduced with maximal use of synthetic replacement parts. Operative times can be reduced significantly, often cutting the length of an operation in half. Implants are also structurally stable and will not resorb or change their shape over time. Any synthetic implant no matter how well designed and engineered, however, has limitations. Good healthy soft tissue flaps over the synthetic reconstruction is extremely important to avoid potential infection and exposure problems.

Dr. Barry Eppley

Indianapolis Indiana

1.      What are the different types of facial implants?

All facial implants are designed to highlight or augment weak facial bone structures. Most commonly, three specific areas are most commonly done including the cheeks, chin, and jaw angles. As a result, there are numerous sizes and styles for these frequently used implants.

But there are other areas of the face for which implants also exist including the nose, paranasal, maxilla, premaxillary, orbit, forehead and temple areas. Even if specifically shaped implants are not commercially available, carving blocks of various materials are available to ‘make your own’ for any specific facial need.

2.      What are facial implants made of? Is one material better than another?

There are several synthetic materials from which most facial implants are manufactured. These include silastic (silicone), Gore-tex (polytetrafluoroethylene, and Medpor. (polyethylene) Each has some different handling properties which affects the flexibility and stiffness of the implants. While they are all chemically and structurally different, the body sees them all the same way…as a foreign material which it tolerates by surrounding it with scar tissue. (capsule)

Each plastic surgeon may have their preference but that is not based on whether it is a ‘better’ implant material. It is a function of what they are familiar with and have had good experiences. For me, I am more interested in the shape of the implant that I need to treat the patient’s problem and the ease with which it can be placed in the correct anatomic position. The actual material composition is not that the most critical factor.

3.      How are facial implants placed?

The method of introduction, or incision, is most commonly done through the mouth. Short of farway places on the skull and orbit, all facial implants locations can be reached intraorally. This approach offers numerous advantages over an external skin approach. The one exception to this is for chin implants. They usually are best inserted through a skin incision under the chin which is associated with fewer potential complications.

4.      How do you select the right size of a facial implant?

The sizing of any specific implant has a lot to do with experience and an artistic judgment. Some facial areas, like the chin, can be measured and the exact amount of augmentation needed can be precisely determined.

But most facial augmented areas are not profile structures so they lack a silhouette or outline which can be easily measured. This is why many implants have intraoperative sizers. By initially placing a temporary implant to determine what effect it creates, a final sterile implant is not opened until one is certain the effect matches what the patient wants.

5.      What can go wrong with facial implants?

Like any synthetic material placed into the body, there is the risk that it can become infected. When infection occurs around an implant, it can be difficult to eradicate with antibiotics alone. Often the implant may need to be removed. Many people mistakenly think an infection is the body rejecting the implant but that is not so.

While infection is the worst complication of a facial implant, it is fortunately very uncommon. The more common problems are aesthetic…size and position issues. Implants can be too big or not big enough, creating too strong or too weak of an effect. The implant(s) can be off center (chin) or asymmetric. (cheeks and jaw angles)They can also shift for their desired position after surgery. This is why some plastic surgeons secure them into position with a screw.

6.      Can multiple implants be used in a single facial surgery?

Yes. Implants are often part of many combined facial procedures. Most commonly, chin implants are used in rhinoplasty and facelift surgery to improve the lower facial profile. A multiple implant strategy is part of sculpting the male face and may include cheek, chin and jaw angle implants all together. Cheek and maxillary implants can bring out a flat or recessed midface.

The use of facial implants is only limited by the imagination and artistic eye of the plastic surgeon. Computer imaging can help one understand what effect one or more facial implants may cause.

7.      When should facial implants not be used?

The long-term success of facial implants is primarily determined by the amount of healthy soft tissue around them. A good barrier or buffer of soft tissue is needed between the overlying skin and the inside of the mouth.

Implants have a much higher rate of complications in facial sites that have received radiation or been scarred by prior surgery or injury. Patients that are edentulous (without teeth) are also at risk as they have less bone and overlying soft tissue onto which to place and keep an implant adequately covered.

Dr. Barry Eppley

Indianapolis, Indiana

Facial implants remain a good and simple way to highlight existing or deficient facial anatomy. While everyone  knows the most common facial implants, such as cheeks and chins, there are numerous other areas of the face that can implanted.

In the midface, there are the standard implants of the cheeks and nose. These areas represent convex facial areas that are more commonly implanted because their lack of prominence is well recognized and aesthetically more obvious.

The midface also has areas of concavities that can benefit from bony augmentation. These areas are less well recognized because they are cancavities to begin with. As such, the benefits of their expansion or augmentation are not as apparent.

These midfacial areas are known as the maxillary, pre-maxillary, and paranasal areas. To some degree, these three areas all run together and are contiguous. But they are separate implants for each ‘subarea’. They all address areas of flatness or excess concavity to the midfacial area.

The paranasal implant addresses flatness underneath the base of the nose. This can occur from a congenital problem such as cleft lip and palate but most commonly is just the natural development of one’s face. The midface is flatter overall and one will frequently have cheek deficiencies as well. Most noticeable is that the nose is less pronounced and the base of the nose is positioned behind the projection of the upper front teeth in profile.

Premaxillary implants help bring out the entire base of the nose. They bring projection to the entire nasal base, most prominently the anterior nasal spine area. By using an implant across this area, the nasolabial angle is opened up by being brought forward. This can also give the illusion of increased nasal tip projection as well.

 The maxillary implant is the least used facial implant of them all. It is really an extended paranasal implant which extends back along the maxilla above the roots of the upper teeth. It can also be used for paranasal or base of the nose augmentation but adds more fullness to the entire lower midface as well. Their effects are somewhat similar to what a LeFort I advancement osteotomy (2 to 4mms) may do.

 Like all midface implants, they can be placed through an intraoral approach through a high vestibular incision. The periosteum needs to be elevated and the implants should be secured to the bone with screw fixation.

There are no definite methods of assessment that can determine the indications for these types of facial implants. Their use is based on an artistic or aesthetic sense of facial balance and the results can not be well predicted based on some form of computer analysis or prediction. In my Indianapolis plastic surgery practice, I find that their use is most commonly done with other facial procedures such as rhinoplasty, chin and cheek augmentation and mid- and lower facelifts.   

Dr. Barry Eppley
Indianapolis, Indiana

There is no doubting the influence that a strong jawline has on the appearance of the male face. From a well-defined chin back to the jaw angle, a straight and strong jawline creates a favorable lower third of the face which is aesthetically important in men. But creating a good jawline for those who don’t have one is not as simple as it may seem.

What makes up the jawline? It is a single bone of the mandible (lower jaw) that incorporates three distinct aesthetic regions. These include the chin, the body, and the jaw angles. The combination of all three ideally create a well-defined line (at the lower border of the jaw) that runs smoothly from the chin back to the jaw angle. It is broken up into three areas based on how it must be surgically approached. The use of chin implants for the front and jaw angle implants for the back are well known. But it is the central zone, the body, that poses the most challenging area to aesthetically augment.

If the body area is augmented with an implant, this poses three potential problems. First, there is no standard implant that is available or pre-fabricated for this application. As a result, one has to custom carve during surgery the shape and length of implant needed. Secondly, placing a body implant in between a chin or jaw angle implant creates a three-piece jawline implant that has the real potential of being able to feel the transition zones between them. This is particularly true at the back end of a chin implant and the front end of the body implant. Lastly, the purpose of most jaw body implants is to provide more projection to the edge or bottom side of the jawline. This makes placing it and holding it in place after surgery a potential challenge.

For these reasons, I feel that a custom fabricated one-piece jawline implant is almost always best. This requires preoperative modeling and an implant design which certainly adds to the cost of the operation. But if one is looking for a more vertical elongation to the entire jawline, this is definitely the way to go. One-piece implants, regardless of size, are always easier to place and will have less potential for postoperative problems.

When lateral jawline augmentation is desired, then the three-piece approach is more reasonable. The body and jaw angle implants can be placed inside the mouth while the chin implant is placed through an incision underneath the chin. Screw fixation is used for all implants as this is best way to prevent shifting or migration of the implant.

Every jawline patient must be looked at individually and a specific implant approach used for each depending upon their goals and aesthetic desires. The concept of jawline augmentation with multiple plastic surgery options intermingles a variety of factors that defies one standard approach.

For the older male, creating a stronger jawline must take into account the development of jowling from aging and gravity. A facelift (neck-jowl lift) would be a necessary part of the plan. The use of one or two implants, at the chin and jaw angle, may be all that is needed to recreate a more well-defined jawline prominence.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Facial implants are a common and assured method of building out skeletally deficient areas such as the chin, cheeks, and jaw angles. While many are aware of these popular locations for esthetic facial enhancement, there are many more implant styles and locations than most envision. This is particularly true in the midfacial area.

The midface (between the lower eye sockets and the upper teeth)has the most complex external anatomical shape of any area on the craniofacial skeleton. From the prominences of the cheek bone to the concave surface of the pyriform aperture, no one single-shaped implant can be adapted to all of them. For this reason there are at least nine (9) different midfacial implant styles.

Cheek implants are the most commonly used midfacial implant. But there are four (4) different styles to choose from for the differing areas of esthetic deficiency on this bone. The standard cheek implant, also known as a malar implant, fits on top of the cheek bone and has a broad surface area that covers most of its surface area. The two (2) styles of this standard cheek implant differ in that the more extended version has a portion that goes up higher to make a smooth transition into the lateral orbital bone. For flat cheek bones, these implants styles will generally work well.

The submalar cheek implant, however, is indicated when the cheek soft tissues are a little droopy and the area under the cheek prominence is a little sunken in. This implant fits on the bottom or underside of the cheek bone which helps lift up sagging cheek tissues, fills out the submalar space and may even soften the deep nasolabial fold a little. The submalar cheek implant comes in two styles which differ in how much fullness is added to the submalar space.

The tear trough midfacial implant is a specialized lower orbital rim (eye socket) implant. It augments the depressed suborbital groove that some people have naturally or develops from aging and tissue atrophy. This groove runs between the inside of the eye across the lower orbital rim often ending below the cheek. While some use fat injections for augmentation of this area, a carefully placed tear trough implant provides permanency to this contour problem.

The pyriform aperture implant fits along the bone which forms the side rim of the nasal cavity. It is designed to build out the base of the nose where the side of the nostril meets the lower cheek tissues. I have most commonly used this implant in secondary cleft surgery to build out the deficient bone area where the cleft went through. While bone grafts are commonly used for this problem, the pyriform aperture may still remain depressed even with a well done bone graft.

The premaxillary or peri-pyriform implant builds out the entire base of the nose from one side of the pyriform aperture to the other. This includes anterior nasal spine area as well. For very flat midfaces, this implant can really help provide augmentation to the nose and upper lip.

The nasolabial or melo-labial groove implant fits onto the bone to the side of the nose and helps soften or build-out the very deep nasolabial fold or groove. Rather than using temporary injectable fillers placed beneath the skin, this implant placed on the underlying bone serves to provide the same push.

The Lefort or maxillary implant, the least common of all midfacial implants, is designed to be used during or after a LeFort I osteotomy. This implant would fit above the osteotomy line so that the midface would not look more deficient as the maxillary teeth come forward.

All midfacial implants, while being very different in shape and indication, share two common features. First, they are all placed from an incision inside the mouth so no skin incision is ever needed. Secondly, they are all best secured into position with a screw as their position is critical in getting the desired esthetic result.

Dr. Barry Eppley

Indianapolis, Indiana

While many types of implant materials have been tried for use in the face, only a limited few have enjoyed a history of good clinical success. Today’s facial implants are composed of the synthetic polymers dimethysiloxane (silicone), polyethylene (Medpor), polytetrafluoroethylene (Gore-tex), and polyester. (mersilene)

The use of solid silicone rubber (solid, not liquid silicone) have been used as facial implants material for nearly four decades. Silicone implants are by far the most type that are used in the face. Silicone is a essentially a form of plastic created from interlinking silicon and oxygen into a compound known as dimethylsiloxane (SiO(CH3)2) . Its chemical advantage is that it is very resistant to breaking down to the very strong and stable silicon-oxygen bonds. When converted into a polymer and vulcanized, a solid silicone rubber which is elastic and very flexible is formed. When shaped into a facial implant, it has the advantages of ease of placement through small incisions due to its flexibility, can be easily cut and shaped if necessary during surgery, and are of low cost.

Like the material used in coats and shoes, Gore-Tex has been used as a facial implant since 1994. It has been used as more traditional shaped implants for the cheeks and chin as well as soft tubes to be used right under the skin as a soft tissue filler. Gore-Tex is really polytetrafluoroethylene, a fluorocarbon which has a carbon ethylene backbone to which is attached four fluorine molecules (PTFE). The bonding of highly reactive fluorine to carbon creates an extremely stable biomaterial which the body can not break down due to the lack of any known human enzyme to disrupt the fluorine-carbon bonds. The material is extremely flexible and is easily cut and shaped. The fabrication of Gore-Tex results in small interconnected pores on its surface and throughout the material which may allow for some tissue ingrowth. The advantage of tissue ingrowth is probably more theoretical than of any practical significance.

Medpor, known chemically as polyethylene (PE) has been used in the face for over a decade. It is different than Gore-Tex (PTFE) as it has no fluorine molecules in it. The chemical structure may be simple but it has a very firm consistency that makes it the hardest facial implant used. It comes in different facial shapes and sizes and, although it can be shaped, it is not easy. The material does have small channels through it which allows for tissue ingrowth into it. That makes it harder to remove if necessary due to the sticky scar.

Mersilene is a knitted plastic mesh material most commonly used to fix abdominal hernias. It has been historically used in facial surgery where it has been used as a chin implant. The mesh material is rolled onto itself, shaped, and then sewn together to create the implant. Because the implant is a mesh, it has lots of holes in it for tissue ingrowth. The few surgeons who use mersilene do it because they like to fashion their own implants and can do so at a lower cost than buying other off-the-shelf implants.

Your plastic surgeon may use any of these materials for your facial implant surgery. While silicone rubber is the most commonly used, all other materials are acceptable and very well tolerated by the face. Tissue ingrowth into facial implants with pores or channels, while theoretically appealing, has not been proven to offer any advantages over completely solid silicone rubber implants.

Dr. Barry Eppley

Indianapolis, Indiana

Chin, cheek, and jaw angle implants are very common cosmetic plastic surgery procedures to effect a change in one’s facial profile and appearance. Implants work well in the face because they are well tolerated. Let us not confuse that with them becoming part of the body. That they never do. Implants do not integrate and become a natural part of your body. The end stage healing response to all synthetic materials is that they are walled off and surrounded by scar, otherwise known as fibrous encapsulation. This serves to separate the body from the foreign material, saying you are not a part of me but I can live with you. (as long as we live in separate areas!) All synthetic materials implanted in the face will develop this surrounding scar tissue, regardless of the material’s chemical composition or physical shape.

Good quality and quantity of soft tissue around a facial implant is the most critical factor in their long-term success, usually far more important than the implant’s chemical composition. Soft tissue coverage over an implant should be as thick as possible. Those facial implants that are more deeply placed (i.e., next to the bone) rarely implant-related problems such as infection, exposure or extrusion. Implants placed immediately under the skin or in areas of the face where the tissues are thin with little muscle or fat have a much higher incidence of postoperative complications.

Another important principle of facial implant use is that antibiotics should be given during the surgery.The reason for antibiotic use is to prevent or eliminate any bacterial sticking to the implant during its insertion. And those few that might will then be killed. Most plastic surgeons will also wash or soak the implant in antibiotics prior to its insertion. They may be some patients, or surgeons for that matter, who may be concerned about the overusage of antibiotics. But the risk of developing an infection, and losing the whole reason the surgery is being performed, isn’t worth it.

Dr. Barry Eppley

Indianapolis, Indiana