Implants have been an important part of aesthetic facial surgery for over fifty years. Starting originally as just small implants for chin augmentation, they have evolved into a large line of bone-based implant shapes and sizes. They are commercially available today for just about every conceivable area of facial bone augmentation from the skull down to every zone region of the mandible. While chin and cheek implants constitute the most widely used facial implants, many other augmentation areas are becoming more recognized as useful such as jaw angles, submalar, infraorbital and temporal implants.
With the emergence of synthetic injectable fillers and autogenous fat injections, many surgeons have chosen to use these less invasive techniques for facial augmentation. While their simplicity is very appealing, such injectable filling methods are best used for soft tissue augmentation of facial areas not supported by bone. While they can be effective for augmenting facial bony prominences, their cost and lack of guaranteed volume preservation ensures that synthetic implants will continue to play a valuable role in aesthetic facial augmentation.
Like any implant placed in the body, there are known complications with their use. While infection, implant malposition and implant exposure are the medical risks of facial implants and always require revisional surgery to sure, there are also aesthetic risks as well, These include implants that are too big, too small, or the creation of an undesired aesthetic effect. While good surgical technique and implant placement are extremely important keys to prevent the medical complications, the aesthetic complications can be more difficult to avoid as this remains the artistic side of the procedure.
Over the years, I have come to appreciate several aesthetic guidelines of using facial implants successfully. These relate to the more obscure principles of facial implants that have little to do with surgical technique. It is about how to select and place the best implant style and size.
The first aesthetic facial principle is that the biomaterial composition of the implant is not that important. Implant selection should first focus on the right style and design of the implant regardless of its material composition. While many different manufacturers and surgeons tout the benefits of different biomaterials, the reality is that none are perfect. All of them have different handling and placement characteristics but they all work equally well from a biologic standpoint. The body sees all implant materials as the essentially the same, not a natural part of the body. It will create a layer of scar around all implant materials known as a capsule. Implants with more porous or irregular surfaces will have this capsule become more adherent to it but this should not be confused with true integration into one’s own tissues.
The second aesthetic facial implant principle is that the effects of facial volume change from implants is not completely predictable. While both surgeons and sometimes even patients take measurements on x-rays, drawings and computer images in an attempt to select the right implant size, the overlying facial soft tissues will not necessarily respond in a 1:1 or direct linear fashion. Measurements taken on pictures and facial skeleytal models can not take into account the thickness of the soft tissues between the implant and the outer facial appearance. While it is important to have some method in choosing an implant’s size, patients should know that it is far from an exact science. The most common implant size problem is that it is too big, usually not because it is too small. This is particularly true as one moves up to facial bone areas above the mandible where the soft tissues become thinner. When in doubt, choose a smaller implant size. It can be surprising how much of a difference a small implant off of the operating table.
The third aesthetic facial principle is that implants may need be modified during surgery. Implants are made based on average dimensions and in a range of sizes to try and fit the most number of patients possible. But not every implant style and all sizes for any given facial area can be available for every procedure. The use of implant sizers, which are available from most manufacturers, is very helpful during surgery particularly in choosing implant size. But when in doubt shape or carve implants for custom adaptation if needed. All implant materials are fairly easy to shape with either a scalp, scissors or even a burr for more inelastic materials.
Applying these three aesthetic facial implant principles, best implant style regardless of material composition, conservative size selection and intraoperative implant modification if needed, will help improve aesthetic results and decrease the need for revisional surgery.
Dr. Barry Eppley