Alloplastic Esthetic

7/18/2019 Alloplastic Esthetic

1/14

Alloplastic Esthetic

Facial Augmentation

C H A P T E R 7

Bruce N. Epken D DS

M5D,

PhD

Alloplastic esthetic facial augmentation of

the chin, mandibular angles and inferior

borders, skeletal nasal base, and cheeks is

the standard of

care,

as opposed to autoge-

nous a ugme ntation. A variety of approved

alloplastic facial implants are available to

the surgeon. In general, marketed

implants are proven nontoxic, noncar-

cinogenic, and nonantigenic, and they are

inert in body fluids.' ^ Moreover, the opti-

mal material is user friendly; it is easily

modified, maintains the desired shape, is

not mobile, and is cost effective.

No single implant possesses all of

these optimal properties, yet some are

clearly closer to these ideals than others.

The more commonly employed esthetic

facial implants, which most closely achieve

these ideals, include porous polyethylene,

silicone, and polytetrafiuoroethylen e

{PTFE) and high-density polyethylene. It

is not the intent of this article to compare

and contrast these facial implant materials

as they are all approved and acceptable

and each is espoused by different surgeons

as the preferred material for cosmetic

esthetic facial augmentation.

To achieve predictable and successful

results with alloplastic esthetic facial

augmentation, special attention to the

differential diagnoses established via a

detailed patien t evaluation,^ ^' meticu -

lous surgical technique, proper modifica-

tion, and placement of the implant are

essential. Accordingly, this chapter

emphasizes and details these aspects of

esthetic facial augmentation.

An additional item discussed herein is

still controversialthe use of antibiotics

with surgery for alloplastic facial augmen-

tation. recent survey of surgeons revealed

a spectrum of opinions. Approximately

30%

of surgeons use no antibiotics or

intravenous antibiotics only during

surgery. About an additional 30% co ntinue

antibiotics for 1 to 3 days postoperatively,

and 40% use them for 4 to 7 days postoper-

atively.'^ Unfortunately, the incidence of

infection with the various regimens is not

available; however, the overall incidence is

very low. I use a single intraoperative dose

of intravenous antibiotics at the com-

mencement of surgery; generally, I use

cephalosporin regardless of whether an

extraoral or intraoral approachistaken.'^''*

Finally, alloplastic nasal augm entation

is not discussed he re as, in general, I prefer

autogenous m aterials for this purp ose.

The Chin

Alloplastic chin augmentation is generally

reserved for the patient w ho has lax and/or

redundant soft tissues or who is undergo-

ing simultaneous neck surgery, such as

cervicofacial liposuction, platysma plica-

tion, or rhytidopiasty. When this approach

is used, special care is directed to evaluat-

ing for a tapered chin appeara nce or ma r-

ionette grooves, which frequently exist in

the older patient population. Many com-

mercially available alloplastic chin

implants

do not

provide adequate lateral

augmentation and posterior extension in

the parasymphysis regions to correct these

problems. Therefore, the modification or

selection of a properly sized and shaped

alloplastic implant is important.

Preoperative planning consists of a

systematic sequ ential esthetic clinical eval-

uation and a lateral cephalometric evalua-

tion to determine the specific shape and

magnitude of the augmentation.

Chin augmentation has long been an

esthetic adjunct to numerous orthognathic,

craniofacial, and cosmetic p rocedures. Var-

ious authors have proposed and extolled

the advantages of their modifications of

this basic operation, but, despite its wide-

spread application, its esthetic demands

and results are not yet well specified.'^'''

This procedure is planned to achieve

specific esthetic objectives:

Frontally, a well-defined smooth infe-

rior border of the mandible that sepa-

rates the lower third of the face from


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1 4 3 6 Part 9: Facial Esthetic Surgery

the neck proper is importan t for good

esthetics. A lack of this distinct bo rder

detracts from good chin-neck esthet-

ics.

A posteriorly well-extended

implant and proper inferior place-

ment, at the inferior mandibular bor-

der, help to achieve this objective.

The esthetically attractive chin is bal-

anced in width with the other facial

features, especially the bizygomatic

and bigonial facial widths. Many indi-

viduals with recessed chins also have

dolichocephalic facial features, or

what has been described as the point-

ed chin or witch's chin. W hen this

condition exists and is not deliberate-

ly modified, augmentation of the chin

often results in an accentuation of the

existing pointed chin. In persons with

this facial structure, augmentation of

the chin should be accomplished by

enhanced l ter l augtnentation This is

accomplished by modifying standard

chin implants as described in the sur-

gical techniqu e discussion to follow.

The esthetically attractive chin has no

evidence of parasymphyseal depres-

sions or grooves. These soft tissue mar-

iotiette grooves may exist indepen-

dently of or in concert with the

pointed chin. This condition is accen-

tuated in m ost older individuals. When

these grooves exist, special attention is

given to lateral or parasym physeal aug-

mentation, similar to that used to

improve the pointed chin.

The esthetics of anteroposterior chin

position is determined by evaluating

the cephalometric values: NB:Pog,

A:Pog, and subnasale perpendicular.

The no rma l relations of these are as fol-

low: NB:Pog line has the lower incisor

tip and bony chin prominence on a 2:1

to 1:1 relationship. Line A:Pog has the

tip of the lower incisor on or to 2 mm

posteriorly positioned. The soft-tissue

chin is 4 mm distal to SN perpendicu-

lar.These values are used to determine

the optima] relationship of the hard

and soft tissues of the chin relative to

lower incisor position, lower lip, and

upper lip. Two qualifiers regarding

esthetic anteroposterior chin augmen-

tation are important in the context of

the proposed cephalometric treatment

planning. First, do not advance the

bony chin beyond the anterior position

of the lower incisor as determined by

the NB:Pog and A:Pog criteria, even

when subnasale perpendicular soft tis-

sue values suggest otherwis e. Second, in

older individuals, often those un dergo-

ing cervicofacial liposuction, rhytido-

plasty, or both, anteroposterior aug-

mentation of the chin toits ideal hard

and soft tissue values generally results

in an excessive amount of chin projec-

tion

in the eyes of the patient

This is

perhaps because the individual has had

the deficient condition for so many

years that he or she has becom e accus-

tomed to it.

In sum, before performing esthetic

chin augmentation, consider all of these

criteria and do not rely primarily on

achieving the ideal anteroposterior chin

position; otherwise, the esthetic results in

a significant number of patients will fall

short of the desired results.'^

This procedure is most often per-

formed under local anesthesia with seda-

tion, along with other procedures such as

blepharoplasty, rhinoplasty, cervicofacial

liposuction, and rhytidoplasty.

With a surgical m arking pen, the true

chin and neck midlines are marked to aid

subsequently in precise implant position-

ing; also, the planned submental incision

is marked.'^ When this procedure is being

performed under local anesthesia with

sedation, bilateral inferior alveolar nerve

blocks are given with 2% lidocaine with

1:1 epinephrine. Next, the subm en-

tal area where the incision is to be made

and the entire area to be undermined sub-

periosteally are infiltrated with about 7 to

10 cc of local anes thetic with epine phrin e.

Seven to 10 minutes are allowed to pas

after infiltration of the local anesthetic.

The implant is to be placed through

submental incision of about 5 cm, mad

just distal to the norm al su bmental creas

When the incision is made in the natura

ly occurring submental crease, it ca

accentuate this crease and cause an une

thetic dimp ling in that area. The incision

made through the skin and subcutaneou

tissue, and hemostasis is obtained wit

needle-point diathermy. The incision

then carried directly down to the inferio

border of the mandible and through th

periosteum with diathermy cutting.

After identification and exposure o

the inferior border of the mandible, a sub

periosteal dissection is completed alon

the entire inferior aspect of the mandibu

lar symphysis,

well

posterioron each side

the region of the gonial notch. Followin

exposure of the inferior border, the subpe

riosteal dissection is carried superior

beginnin g anteriorly. Laterally it is extend

ed superiorly only enough to allow th

mental neurovascular bundles to be iden

tified and visualized. No attempt is mad

to expose them extensively because doin

so increases the potential for neurosenso

defects to the lower lip and chin.

An extended preformed implant

generally selected, one that is configured i

such a way that it extends posteriorly in

the molar region.^-'''-'^ In patients with

tapered (pointed) chin or marionet

grooves, the selected implant is modifie

The selected implant is 2 to 4 mm great

in the anteroposterior dimension than th

desired anteroposterior augmentation

This dimension is reduced at surgery an

in essence, accentuates the parasymphys

augmentation to improve the pointed ch

or parasymphysis depressions. These alte

ations are made to provide a more later

(parasymphysis) augmentation than

available in most preformed alloplast

chin implan ts (Figure 70-1). |

After trial insertion of the implant, th

surgeon determines the need for add itio


3/14

Alloplastic Esthetic Facial Augme ntation 1 4

FIGURE 70-1 Reduction of the anteroposterior

thickness effects a roundingofthe china ndvisibly

changesa pointedchininto a moreroundedone.

Adaptedft om EpkerBN.' p. 27.

al adaptations in either the implant or the

subperiosteal dissection to ensure that it

rests passivelyon th e lateral and inferior

borders of the mandible. The mental neu-

rovascular bundles are visualized during

the trial insertion to make certain that the

implant does not encroach o n them . If this

does occur, these areas are marked in situ

on the implant, and the implant is

removed and these areas reheved.

On completion of all adaptations,

two holes are drilled through the implant

and outer cortex of the underlying bone.

The implant midline and marked facial

midline are checked, and the implant is

then stabilized with titanium screws to

prevent inadvertent early postoperative

displacement a nd to avoid mobility of the

implant. If the implant is porous, it is

vacuum impregnated with an antibiotic

solution before it is definitively stabilized

into position.

The incision is closed in layers with 4-

0 polyglactin 910 platysma m uscle sutures,

4-0 chromic gut subcutaneous sutures, and

5-0 braided polyester or monofilament

nylon skin sutures. Antibiotic ointment

and a perforated film absorbent dressing

(Telfa) are placed over the incision, and a

multiple-layered 1.25 cm tape dressing is

placed to reduce edema and or hematoma

formation. The dressing is left in place for

48 hours. When additional neck surgery is

done, as is frequently the case with this

procedure, a more extensive neck pressure

dressing may be placed. Generally, intrao p-

erative antibiotics are used and no postop-

erative antibiotics given.

Sutures are removed on the fifth post-

operative day, and after 7 to 10 days any

areas of irregularity caused by edema or

hem atom a are treated by deep massage and

heat. No other special treatment is needed.

Complications that occur witb this pro-

cedure vary and are generally minimal. *

The patient seen in Figure 70-2 is

shown before and after alloplastic chin

augmentation, emphasizing lateral

parasymphysis augmentation to reduce

the pointed appearance of the chin and the

marionette grooves.

Ma ndibular Angle and Inferior

Border

well-defined mandibular angle and infe-

rior mandibular border are important to

an esthetically pleasing face. Indeed, prop-

er

definition in this region is the very basis of

visually separating the face from the neck,

thereby making them distinct from one

another. When this area is not well

defined, the face and neck become conflu-

ent and unattractive. Accordingly, in

selected individuals esthetic augmentation

of the mandibular angles and inferior

mandibular borders is to be considered.'^

The differential diagnosis of poor def-

inition of tbe angle and inferior mandibu-

lar borders is important; one m ust consid-

er whether it results from abnormal

skeletal suppo rt, cervicofacial lipomato sis,

soft tissue redundancy, or a combination

of these conditions

A routine clinical evaluation via mul-

tidirectional observation and palpation

can readily allow the surgeon to diagnose

cervicofacial lipom atosis an d/or soft tissue

redundancy. A standard lateral cephalo-

metric evaluation of the mandibular plane

angle is used to determine the presence

and degree of an underlying skeletal sup-

port abnormality. The normal mandibular

plane angle (FH:Go-Gn) is 24. One then

draws the normal inferior border line

angle. This in essence represen ts the newly

to be constructed inferior mandibular

border and allows the surgeon to deter-

mine the specifics of vertical and antero-

posterior implant design.

The vertical linear distance between tbe

two mandibular planes (the patient's and

the constructed norm al) in the gonial angle

is measured. This distance is the am ount of

vertical change in the angle that would be

indicated to create ideal skeletal support.

Generally, the older the patient, the less one

augments this area all the way to the ideal.

The lateral superior height is measured so

that it extends to above the midramus.

Anteroposteriorly the mental foramen is

generally the limiting extent of the implan t.

Finally, frontal face esthetics is evaluated to

determine the approximate desired lateral

width of the implant in the angle-ramus

area. In the esthetically pleasing face, tbe

mandibular angle area is medial to the

zygomatic area so that tbe face tapers slight-

lyfi-omhe zygomatic area.

When soft tissue conditions coexist

with the defined underlying skeletal

abnormalities, correction of the skeletal

deformity may produce significant

improvements in the associated soft tissue

conditions. Finally, when identifiable

skeletal and major associated soft tissue

problems coexist, the skeletal surgery

described herein can be done either pri-

marily or simultaneously with liposuction

or rhytidoplasty; however, I prefer to per-

form tbe face- and neck-lift secondarily.

Once the above data are established, a

preformed porous polyethylene implant is

selected and appropriately modified at

surgery as discussed in the surgical tech-

niqu e section to follow. ^-*

Surgery can be performed with gener-

al anesthesia or intravenous sedation and

local anesthesia.'^ Inferior alveolar nerve

blocks are given bilaterally. In addition, a

2% local anesthetic containing

1:200 000


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1 4 3 8

Part 9: Facial Esthetic Surgery

D

FIGURE 70-2 Preoperative A and C) and postoperative B and D) photographs of a patient who underwent chin augmentation to reduce a pointed chin app ea

ance illustrating more lateral augmentations.

epinephrine is infiltrated bilaterally just

lateral to the mandible from midramus to

the angle and along the entire lateral

aspect of the mandibular body to the

region of the mental neurovascular bun-

dle. App roximately 10 cc of local anesth et-

ic is infiltrated on each side. The surgical

procedure is begun about 7 to 10 minutes

after injection of the local anestbetic.

The incision is begun posterolaterally,

just anterior to the bulge of the fat pad,

midway down to the depth of the sulcus.

This incision is made through the

mucosa, buccinator , and per iosteum,

anteriorly to the region of the canine

tooth; however, as one proceeds anterior-

ly into the prem olar region, the incision is

initially carried only through the mucosa

to avoid inadvertently transecting the

mental neurovascular bun dle.

After the mental neurovascular b undle

is exposed, the remainde r oft he dissection

is done entirely in th e subperiosteal tissue

plane. This begins anteriorly with deliber-

ate mobilization of the tissues around the

mental neurovascular bu ndle, carrying the

dissection inferiorly subposteriorly to the

inferior border of the mandible. The dis-

section is next carried posteriorly to the

angle of the mandible, while tbe masseter

muscle is elevated superiorly about half

way up the ascending mandibular ramus.

No attempt is made to penetrate the

periosteum at the inferior and posterior

borders of the mandible.

In the region ofthe mandibular angle

and along the posterior border, a J-shaped

periosteal elevator is used to com plete the

subperiosteal dissection Figure 70-3).

Once the lateral body and ascending

ramus ofth e mandible are exposed in the

subperiosteal tissue plane, the periosteum

can be opened with fmger dissection at

the inferior aspect, as necessary for ade-

quate relaxation.

My preferred augmentation material

is porous polyethylene, which is available

in several preformed sizes and shapes. The

approxim ate size and shape ofthe implant

should be determined previously, as dis-

cussed in the previous section. On the

basis of the measurements, the preformed

implant is modified during the actual sur-

gical procedure. After the initial modifica-

tions, before a try-in placement, the

implant is vacuum impregnated with an

antibiotic solution. This is achieved by

placing the implant into a 60 or 90 cc

syringe in which the antibiotic solution is

present, inserting the plunger of the

syringe and evacuating all air, and repea

edly withdrawing the plunger forcefull

while holding a finger over the end of th

syringe. This removes the air from th

porous impl nt nd replaces it with th

concentrated antibiotic solution. The pro

cedure requires considerable effort an

pressure, often taking a few minute

When this process reaches its end poin

the implan t sinks in the solution. |

The initial try-in is then d one. Add

tional modifications are often necessar

such as notching the implant in th

region of tbe mental neurovascular bu

dle and molding it slightly into a curve

IGUR

70-3 seof a J-shaped elevator to rem

the tenacious angle muscle attachments. Adapt

from Epker BW^ p 84 .


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Alloplastic sthetic FacialAugmentation

1

configuration to adapt it more precisely

to the lateral aspect of the ramus and

body of the mandible. To bend the

implant, it is placed in sterile hot saline;

this removes its original memory and

allows it to be readily molded.

The implant is inserted into position.

Once inserted and its inferior and posteri-

or aspects locked beneath the posterior

and inferior borders of the mandible, the

implant is inspected for any final adapta-

tions.

At this point the implant is remove d,

placed back into the antibiotic, and the

wound packed.

The identical dissection is then com-

pleted on the opposite side, and before

insertion of the second implant, the same

basic modifications are made to a second

implant so that the implants are virtual

mirror images of one another. This

assumes that the patient has a symmetric

deformity in this area. When asymmetry

exists, it is identified and recorded preop-

eratively, and the modification of the

implants for independent shaping of the

right and left sides is done preoperatively.

After completion of the dissection on

the second side and the try-in of tbe sec-

ond implant, both implants are ready for

final insertion. The implants are irrigated

free of blood and debris and vacuum

impregnated again with the antibiotic

solution. One or two monocortical titani-

um screws are placed to stabilize the

implant (Figure 70-4).

The implant is inserted on one side

first, and the incision is closed in two lay-

ers.

The first layer is the periosteal and

buccinator muscle, which is closed with

3-0 chromic sutures. Then, with a runn ing

3-0 chromic horizontal mattress suture,

the mucosal layer is closed. Interrupted

sutures are finally placed as needed to

effect a watertight closure of the incision.

After completion of closure on one

side,

the second antibiotic-impregnated

implant is placed into the opposite side,

and the stabilization and layered closure

are completed.

FIGURE 70 -4

Stabilization of the implant with

monocortical titanium screws. Adapted from

Epker BN. ^p. 89.

A multilayered 1.25 cm tape dressing

is placed so that the tape extends from the

cheek area well inferiorly into the neck,

thereby applying primarily lateral pressure

to this area to minimize postoperative

edema and he matom a. When this dressing

is applied, it is placed so that the pressure

is directly applied laterally. Tbis dressing is

left in place for 48 hours. On removal of

the tape dressing, the patient is instructed

to use heat to decrease the swelling.

Postoperatively the patient is placed

on a clear liquid diet for the first 24 hours

and then advanced to a full liquid diet for

4 to 5 days. After this time, he or she may

begin a mechanical soft diet for 10 to

14 days until the intra oral incision lines are

completely healed. After approximately

2 weeks, the im plants are self-stabilized by

fibrous soft tissue ingrowth, and the inci-

sions are completely healed; at this time

unlimited physical activity is permitted.

At the 2-week period patients general-

ly have some limitation in the range of

mandibular motion because of the surgery

and its sequelae. Accordingly, they are

placed on a regimen of active jaw exercis-

es, three times a day for approximately

5 minutes each. These exercises consist of

maximum interincisal opening, protru-

sion, and clenching. Generally, within 7 to

14 days asymptomatic full range of

mandibular motion is obtained.

This procedure is designed to accen-

tuate and normalize the mandibular

angle and inferior mandibular border to

set the lower third of the face off clearly

from the neck, making each into a dis-

crete esthetic unit. Additionally, this pro-

cedure effects some tightening of tbe

overlying soft tissues, affecting a mini

face-Hft in individuals who have slight

skin laxity and/or mild jowls (Figure 70-

5) . The procedure is often done in con-

cert with other orthognathic, reconstruc-

tive,and cosmetic facial procedures.

Skeletal Nasal Base

The indication for skeletal nasal base aug-

mentation is based on a clinical esthetic

facial evaluation in individuals who are

not Class III maxillary deficient. This con-

dition is frequently associated with inher-

ent nasal deformities.'^^** The typical clin-

ical esthetic findings are outlined below.

Frontally the alar base width is high-

ly variable but most often is somewhat

narrow, and the upper lip vermilion is

often deficient or exhibits a gullwing

appearance. Moreover, the patient has

deficiency in the paranasal areas, as

opposed to prominent soft t issue

nasolabial folds (Figure 70-6A). In pro-

file, flat to concave paranasal anatomy

and a groove ratio of nasal tip-subnasale

to subnasale-alar is approximately 1:1

instead of the norm al 2:1 . In add ition,

the following most often coexist: a rela-

tively prominent nose, poor nasal tip

projection, unesthetic nasal tip rotation

(droop), and lack of a supratip break

(Figure 70-6B).^^

Anatomically, the skeletal nasal base is

the area that, in part, determines paranasal

fullness, alar base position, nasal tip sup-

port,

relative

nasal prom inence, and inter-

nal nasal valve (liminal valve) function.

Accordingly, the esthetics of these areas

depends on but is not totally determined

by the underlying skeletal anatomy.


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1 4 4 0 Part9:FacialEsthetic Surgery

IGUR 70-5

Preoperative (A and Q andpostoperative(B and D)photographs

ofa patient who underwent mandibular angle-inferior border augmentation.

Note the tightening of softtissueswith areductionof the laxity,especiallyin the

jowl.Reproduced withpermissionfromEpker

BNJ

p 94 .

IGUR

70-6 A

and B, Patient with a lassIocclusionand classic features ofskeletal nasal basedefi-

ciency.ReproducedwithpermissionfromEpkerBN. ^ p 116.

The cephalometric analysis may o

may no t exhibit evidence of maxillary defi

ciency in the presence of a Class I occlu

sion. This is true because these cephalo

metric values have traditionally been

determined by measures around a poin

that may not be deficient. However, the

piriform rims per se, as well as the imme

diate adjacent areas of the maxilla, are defi

cient. Unfortunately, these areas are no

amenable to measurement or evaluation

with conventional lateral cephalometrics.

Individuals to be considered for skele

tal nasal base augmentation are those with

isolated skeletal nasal base deficiency w ho

possess a functional Class I relationship

and are not candidates for orthognathic

surgical consideration. In some individu

als, in whom a skeletal Class III deformity

exists in the mandible and is corrected

with an osteotomy to set back the

mandible, the skeletal nasal base deficien

cy can be simultaneously corrected by

skeletal nasal base augmentation.^ Finally

this procedure is indicated in certain indi

viduals who present for rhinoplasty

and/or septorhinoplasty.^-^

Two approaches to the surgery ar

used, depending on the severity of the

deficiency as determined by the clinica

findings: a limited approach and an

extended approach. The limited approach

is used when the magnitude of augmenta

tion planned is minimal (2-3 g of hydrox

ylapatite per side). In such individuals th

alar base width is generally normal, and in

profile the nasal size, tip projection, and

supratip area are essentially normal. Thi

approach does not noticeably affect the

upper lip vermilion exposure.

Conversely, the extended approach per

mits alar base width adjustment and contro

of upper lip vermilion exposure (increased

exposure). Also, since it is used for large

augm entatio ns (46 g per side), it effects a

relative decrease in nasal size, increasing th

tip projection and s upratip break.

The procedure can be readily per

formed under either general or local anes


7/14

Alloplastic sthetic FacialAugmentation 1

thesia with or without sedation. Before

injection of the local anesthetic, the alar

base width is measured and an esthetic

determination is made as to its most desir-

able postoperative width. About 10 min-

utes before initiation of the actual surgery,

the infraorbital nerves are blocked bilater-

ally, and 10 cc of 2 lidoca ine with

1:200,000

epin eph rine is infiltrated from

the zygomatic-alveolar crest area on one

side to the same area on the opposite side,

up into the region of the

fi-ontal

process of

the maxilla. When the limited augmenta-

tion is to be done, about 2 to

3

g of hydrox-

ylapatite are used on each side, as opposed

to 4 to 6 g for the extended au gme ntations.

The limited approach is achieved

through two vestibular incisions. On each

side a diagonal incision is made from the

piriform rim area in the depth of the

vestibule down to the level of the attached

gingiva in the canine region. This incision

is carried directly down to bo ne. The ante-

rior maxilla is then subperiosteally exposed

so that the surgeon can visualize the piri-

form rim of the nose medially and extend-

ed superiorly and laterally by the desired

amo unt (Figure 70-7). The au gmentation-

al material is perhaps most easily delivered

by means of the syringe technique. About

FIGURE 70 7

When less augmentation isnecessary,

the limited incision approach isused.A dapted from

EpkerBNJ p. 126.

2 to 3 gof nonres orbable hydroxylapatite is

mixed with sterile saline and a collagen

hemostatic and placed into a 3 cc syringe

that has had the delivery end cut

off.

Clo-

sure is performed with running 3-0

chromic horizontal mattress sutures. No

dressings are placed. Gentle external mas-

sage is done to ensure symmetry.

For the extended augmentation

approach, a standard horizontal incision is

made in the depth of the maxillary

vestibule from the second premolar area

on one side to the same area on the op po-

site side. This incision is carried directly

down to bone, and the entire anterior

maxilla is exposed subperiosteally. The

exposure

extends posteriorly only to the

anterior aspect of the zygom atic alveolar

crest then superiorly to expose the infra-

orbital nerve and medially above the nerve

onto the infraorbital rim. The lateral and

inferior region of the bony piriform rim is

exposed including the anterior nasal spine.

The periosteum in this region is carefully

mobilized over the piriform rim and into

the nasal cavity for about 5 mm. In this

phase of the subperiosteal dissection, care

is exercised not to tear the periosteum and

enter the nasal cavity. When this occurs it

is best to suture this communication to

avoid possible postoperative infection.

Before augmentation, sutures are

placed to control the alar base width. A

hole is drilled in the anterior nasal spine.

Depending on the predetermined esthetic

desires for alar base width changes, these

sutures are variably tightened to control

the alar base width at its presurgical width,

permit it to widen, or allow it to somew hat

narrow. This latter objective is seldom in di-

cated in this condition because the alar

base width is most often narrow, and the

patient generally benefits from some con-

trolled degree of alar base widening. How-

ever, when this area is not controlled with

alar base retention sutures as described, it

widensunpredictahly and often excessively.

Two separate 2-0 slowly resorbable sutures

are placed through a single hole drilled

through the anterior nasal spine region.

Next, the upp er

Hp

is grasped, and the fore-

finger is placed facially, precisely over the

inferior alar rim while the lip vestibule is

retracted with the intraorally placed

thumb. With toothed forceps the area in

the vestibular incision directly adjacent to

the everted alar rim is firmly grasped. This

tissue is a combination of the fibroareolar

extension of the lower lateral cartilage and

the lateral nasalis muscle; occasionally, a

small sesamoid accessory of cartilaginous

component is noted (Figure 70-8). When

the proper tissue is grasped and the lip

released from the fingers while maintain-

ing the tissue grasped with forceps, the alar

base is readily advanced medially toward

the columella; the alar base is then

observed and measured facially. Some-

times several attempts at grasping the

proper tissue with the forceps must be

made to identify the tissue that perm its vir-

tually unrestricted medial movement of

the alar base. For the alar base cinch proce -

dure to be effective, the proper tissue in

this area must be identified bilaterally to

effect sy mm etric control of the alar bases.

Once the proper tissue is identified,

while it is maintained in the forceps, a

Burnell or figure-of-eight tendon-type

suture is placed with a 2-0 polyfilament

slowly absorbable suture. A separate

suture is passed throu gh each side first and

the needle left attached to the suture (Fig-

ure 70-9). Then each needle is passed

FIGURE70-8 Alarcinchwith attentiontoprop-

ertissue selection an dsuture technique. Adapted

from pkerBN. ^p. 123.


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4 4 Part 9: Facial Esthetic Surgery

FIGURE 70-9

Independe nt suturing ofeach side

to anterior nasal spine. Adapted from Epker

BN. ^p. 124.

through the hole placed in the anterior

nasal spine. These sutures are later tied

after the actual augmentation.

The skeletal nasal base augmentation

is performed with a nonabsorbable mix-

ture of particulate hydroxylapatite and a

hemostatic collagen preparation, moist-

ened with sterile saline. Only enough col-

lagen hemostatic material is used to form

a dough mass that does not flow.

Generally, between 8 and 12 g of

hydroxylapatite are used in the extended

approach, depending on the relative sever-

ity of the skeletal nasal base deficiency. The

mixture is separated into two equal por-

tions so that equal augmentation is

attained on bo th sides. After placem ent, it

is molded with a periosteal elevator to

conform it to the underlying bone. Most

often this material is extended superiorly

to the infraorbital nerve and often more

medially to the infraorbital rim. Care is

taken not to place much of the material

into the region of the frontal process of the

maxilla because this unesthetically widens

the nose. Once the implants are placed

bilaterally, equally and symmetrically

adapted, and contoured to create facial

symmetry, the incision is closed.

First, the alar base sutures are tied.

Each suture is independently hand tied

while tha t side s alar base width is

observed (measured) facially. As a general

principle, the alar base should be nar-

rowed 2 mm more than desired because

some widening tends to occur postopera-

tively. Next, the vestibular incision is

closed with deliberate attention to control

of the upper pfullness and the amount of

exposed vermilion. Often, after the alar

base cinch sutures are tied, the labial

mucosa is somewhat tethered superiorly

and must be undermined in the region of

the alar base cinch suture. This is impor-

tant to avoid reduction of the upp er lip s

vermilion exposure with the subsequent

vestibular closure.

When there is no desire to alter the

preexisting upper Hp esthetics, the mucos-

al portion of the incision is closed in the

usual V-Y fashion, with the vertical extent

of the Y being about 10 to 15 mm. This

basically avoids reduction in exposure of

the upper lip vermilion (Figure 70-10).

More often, it is desirable to increase

the exposure of the upper lip vermilion,

especially when the preoperative lip has

gullwing characteristics. In these instances

an extended closure is done, requiring

extensive undermining of the upper lip

mucosa. While the lip is retracted with a

single skin hook placed precisely in the

midline and with a retractor placed later-

ally, undermining of the lip mucosa is per-

formed with small scissors. The extent of

the mucosal undermining is determined

by the desired esthetic changes in the

upper lip. When maxim al increased expo-

sure of the upper lip vermilion is wanted,

as is the case with a gullwing upper lip

appearance, extensive undermining is

achieved anteriorly almost to the wet line

of the lip and an equivalent amount poste-

riorly. When this und ermining is complet-

ed, it is critical that the surgeon be able to

pass the scissors freely from one side to the

other, demo nstrating a continuous pocket.

Next, the horizontal vestibular limbs are

closed with interrupted or continuo us 45

angled sutures to reduce tension and fur-

ther advance the mucosa.

When the extensive mucosal under-

mining is done with a V-Y closure, a den-

tal cotton roll coated with an antibiotic

ointment is inserted into the depth of the

labial vestibule in the midline, and tape i

placed tightly over tbe lip to maintai

pressure. The tape is extended inferiorl

over the lip mucosa. When this is no

done, considerable lymphedema occurs i

the midline of the upper lip. The cotto

roll and tape dressing are left in place fo

48 hours and then removed. Similarly, lay

ered tape dressings are applied to th

paranasal regions and maintained fo

48 hours. Cold is applied to the face du

ing this time.

After surgery and the removal of th

dressing, the patient must maintain a liq

uid to very soft diet for 7 to 10 days unt

the vestibular incision is well healed. Afte

3 to 4 days he or she is instructed to begi

forceful lip exercises to further reduc

edema. At this time, when the edema i

resolving, the surgeon gently palpates th

paranasal areas to ensure symmetry. Th

implanted material can be gently molde

for about 5 to 7 days before it assumes

solid state witho ut flow prope rties. |

The limited exposure approach is don

primarily to reduce mild paranasal depres

sions (Figure 70-11). The extended proce

dure produces esthetic changes consisten

with improved frontal face esthetic

FIGURE 7 0-10

V- Yclosure is done to enhan

exposure of upper lip vermilion. Adapted fto

pkerBN. ^ p 127.


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Alloplastic sthetic FacialA ugmentation

1

FIGURE 70-11 The limited exposure can be performed witiiout significant effech on the nose or upper lip.

including improved upper hp fullness,

increased exposure of the upper lip ver-

milion, improved balance of the alar base

width w ith the remainder o fth e facial fea-

tures, and decreased prominence of the

nasolabial folds. In profile the concave-to-

fiat paranasal region becomes normally

convex. Prominence of the nose is

decreased, nasal tip projection is

improved, often with the creation of a

supratip break, and som e cephalic rotation

oft he nasal tip is achieved (Figure 70-12).

This extended procedure is frequently

used with other skeletal/soft tissue cos-

metic maxillofacial procedures, especially

rhinoplasty.

The Cheek

Esthetic cheek augmentation may be indi-

cated as an isolated esthetic maxillofacial

surgical procedu re or be performed in con-

cert with other skeletal/soft tissue facial

esthetic surgeries.^'^''' As with the other

procedures discussed in this chapter, this

statement implies that the patient both

possesses

the deformity (albeit to highly

variable degrees) and

desires

enhancement.

Moreover, it must be appreciated that three

patients with the same degree of anatomic

deformity may each desire different

degrees of augmentation, much tbe same

as occurs with breast au gmen tation.

Esthetic cheek augmentation is indi-

cated in individuals who frontally exhibit

poor lateral cheek projection {bizygomatic

width) in relation to the bigonia and

bitemporal widtbs. Many such patients

appear

to exhibit vertically long faces, even

though they do not possess any of the

FIGURE 70 -1 2 Preoperative A and C) postoperative B and D ) appearances after an extended approach with an alar cinch and a V-Y augmentation ofthe up

lip.

Reproduced with permission from EpkerBN.^

p

130-1.


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1 4 4 4 Part 9: Facial Esthetic Surgery

objective criteria of the long-face syn-

drome. This is because of the abnormal

facial length-to-width relationships caused

by the abnormal narrow bizygomatic

width. Similarly, poor cheek projection is

noted in tbe three-quarter oblique view. In

profile these same individuals possess vari-

able degrees of inadequate cheek and/or

lateral infraorbital rim projection.' ^'^^

Adetailed systematic estheticexamina-

tion

of this area is performed because the

evaluation of this area of the face must be

multidirectional. Esthetic judgments

made exclusively from a single view are

incomplete witb respect to the specificity

of the deficiency.

Frontally the area of maximum cheek

prominence is located about 10 mm lateral

and 15 mm to 20 mm inferior to the later-

al canthus. The cbeek prominence is posi-

tioned more laterally than the mandibular

angle. The bizygomatic width of the esthet-

ically attractive face is the widest dimen-

sion of the face, with the bitemporal width

and bigonial widths following. Silver has

defmed a malar prominence triangle,

which very closely locates the malar prom i-

nence to this same location.^^

From the profile perspective, the

cheek prominence and infraorbital rim in

the esthetically attractive individual are

situated so that the infraorbital rim is

about equally projected with the anterior-

most projection of the globe, and the

cheek prominence is located several mil-

limeters anterior to the globe. This rela-

tionship results in the cheek area being

clearly convex

in its configuration, as

opposed to flat or concave.

Most analyses of the malar promi-

nence that have been described in the lit-

erature are from the three-quarters view.

These include Hinderer's, Wilkinson's,

Powell and colleagues', and Prendergast

and Sc hoe nro ck' s methods. ^ -* * T hese

methods result in highly variable ideal

locations for the malar prominence, both

vertically and laterally. Specifically, Hin-

derer's method is too nonspecific, Wilkin-

son's locates the prominence quite inferi-

orly, and Prendergast and Schoenrock's

locates it medially. Powell and colleagues'

analysis is comparable with the frontal

view values recommended by tbe author.

In the three-quarters oblique esthetic

assessment, the esthetically attractive con-

tralateral cheek prominence extends well

beyond a line from the lateral commissure

of the mouth to the lateral canthus. Its

most prominent location is about 15 to

20 mm benea th the lateral canthus.

The basal view simply supplements

the findings from the other perspectives

and also reveals both the true lateral and,

to a levSser degree, anterior projections of

the cheeks. This view is important to best

determine the sym metry of tbe cbeeks.

The surgeon must not only evaluate

the cheek prominence proper but also the

buccal area be cause excessive fullness in th e

buccal region can lead the surgeon to the

erroneousiMpression that cheek deficiency

exists. When cheek deficiency and buccal

fullness coexist, the surgeon must exercise

caution with respect to whether and how

much cheek augmentation versus buccal

fat pad reduction is to be performed.

markismade on the face in the ideal

region of the cheek eminence, 10 mm lat-

eral and 15 to 20 mm inferior to the later-

al canthus. This mark aids in the proper

superoinferior and lateral positioning of

the cheek implant. Similarly, it helps in

predetermining the desired lateral and

anteroposterior thickness of the cheek

augmentation. It is important to create a

gentle convex surface curvature beginning

in the infraorbital area and extending infe-

riorly 15 to 20 mm. In concert with this

marking, a tangent from the soft tissue

gonial angle to this region is constructed

with a ruler to estimate the desired later-

al projection as determined by the criteria

previously discussed.

The procedure can be readily per-

formed under either general anesthesia

supplemented with a local anesthetic

with 1:200 000 epinephrine, or local

FIGURE 70-13 Extent of underm ining for th

placement of a cheek implant. Adapted from

pkerBN. ^p. 147.

anesthesia and sedation. About 10 min

utes before surgery the infraorbital nerve

are blocked bilaterally with a few cubi

centimeters of 2% lidocaine wit

1:200 000 epinephrine. A few minute

later the entire maxillary vestibule is infil

trated transorally with approximatel

10 cc of the same agent, from the zygo

matic-alveolar crest area on one side t

the same area on the opposite side. I

addition, the subperiosteal dissectio

extends laterally along the zygomatic arch

FIGURE 70-14

Symm etric and good stabiliza

tion of the right and left cheek implants is be

achieved with screw fixation. Adapted fro

pkerBN. p 152.


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Alloplastic sthetic Facial Augmentation 1

A horizontal vestibular incision is

made with diathermy in the depth of the

vestibule from the canine region distally to

that of the molars. This incision is carried

tangentially down to bone, and the entire

malar area is sequentially exposed subpe-

riosteally. This exposure extends superiorly

to the infraorbital nerve and then medially

above the nerve to expose the infraorbital

rim. Next, the superior and lateral extents

of this subperiosteal dissection are com-

pleted. Superiorly, lateral to the infraorbital

nerve, the lateral infraorbital rim is

exposed. The subperiosteal dissection is

then extended along the lateral aspect of

the zygomatic arch posteriorly. The dissec-

tion must be liberal enough to create an

adequate pocket into which the implan t

can beplaced passively(Figure 70-13).

Once the subperiosteal dissection is

completed, the predetermined desired size

and shape of the implant is adapted for a

try-in. Currently a large number of differ-

ent-shaped cheek implants exist, construct-

ed from various materials. Moreover, vari-

able techniques and even locations for their

placement are espoused. I currently prefer

porous polyethylene implants because they

do not have complete memory, are readily

modifiable at surgery, are porous (resulting

in tissue ingrowth and self-stabilization),

and are able to be optimally molded after

heating in sterile hot saline. When porous

polyethylene is used, it is vacuum impreg-

nated with an antibiotic as described

above. Careful adaptation of the pre-

forrhed implants is necessary to obtain

optimal results.

After initial trial the implant is

revised with a surgical blade and/or heat-

ing to mold it to the underlying bone.

The need for any additional adjustments

D

IGUR 70-15

Preoperative A, C and E) andpostoperative B, D, and f} appearancesof a patient w ho underwent a

cheekaugmentation.Reproduced withpermissionfrom pkerBNJ p 156-7.


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1 4 4 6

Part

9:

acialEsthetic Surgery

is determined at this time while the

implant is held in its proper position,

visualized through the incision, and

facially palpated.

After the final adjustments are com-

pleted on the first side, the contralateral

implant is modified to be a mirror image

so that perfect right-to-left symmetry is

achieved, unless the patient possesses

some asymmetry. The identical vestibular

incision and subperiosteal dissection is

then carried out on the opposite side.

The implants are then both rinsed in

the antibiotic solution, placed carefully

into their proper location, and stabilized

with one or two titanium screws. It is

essential that the po sitioning an d stabiliza-

tion of the right an d left cheek im plants be

precisely symmetric and that they exhibit

no tendency to rotate or displace. If either

of the latter is evident on one or both

sides, a second screw is placed to prevent

this movement (Figure 70-14).

Any asymmetry or instability of one

or both implants at the termination of

surgery will become clinically evident after

resolution of the edema following surgery;

this is the most frequent cause for postoper

ative patient concern after this procedure.

The vestibular incision is closed with a

single-layered 3-0 plain horizontal mat-

tress gut suture. A layered tape dressing is

applied for 48 hours. After removal of the

dressing the patient maintains a liquid to

very soft diet for 7 to 10 days until the

vestibular incisions are well healed. After

complete healing of the vestibular inci-

sions,

the patient is instructed to begin

vigorous lip exercises to expedite resolu-

tion of residual edema and to improve

natural lip motion.

This procedure may be performed

independently or in concert with other

skeletal/soft tissue esthetic maxillofacial

procedures as described in the introduc-

tory section of this chapter. The results

obtained with this procedure can be

predictable and esthetically impressive

(Figure 70-15).

Summary

Alloplastic facial augmentation has

become a standard of

care.

Careful preop-

erative detailed system atic esthetic evalua-

tions permit the various areas of the face

to be augmented precisely.

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Alloplastic Esthetic

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