CHAPTER 70

Alloplastic Esthetic
Facial Augmentation
Bruce N. Epken DDS, 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 autogenous augmentation. A variety of approved
alloplastic facial implants are available to
the surgeon. In general, marketed
implants are proven nontoxic, noncarcinogenic, and nonantigenic, and they are
inert in body fluids.'"^ Moreover, the optimal 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 polytetrafiuoroethylene
{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 patient evaluation,^"^' meticu-

lous surgical technique, proper modification, 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 augmentation. A 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% continue
antibiotics for 1 to 3 days postoperatively,
and 40% use them for 4 to 7 days postoperatively.'^ 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 commencement of surgery; generally, I use
cephalosporin regardless of whether an
extraoral or intraoral approach is taken.'^''*
Finally, alloplastic nasal augmentation
is not discussed here as, in general, I prefer
autogenous materials for this purpose.

The Chin
Alloplastic chin augmentation is generally
reserved for the patient who has lax and/or
redundant soft tissues or who is undergoing simultaneous neck surgery, such as

cervicofacial liposuction, platysma plication, or rhytidopiasty. When this approach

is used, special care is directed to evaluating for a tapered chin appearance or "marionette grooves," which frequently exist in
the older patient population. Many commercially 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 sequential esthetic clinical evaluation and a lateral cephalometric evaluation to determine the specific shape and
magnitude of the augmentation.
Chin augmentation has long been an
esthetic adjunct to numerous orthognathic,
craniofacial, and cosmetic procedures. Various authors have proposed and extolled
the advantages of their "modifications" of
this basic operation, but, despite its widespread 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 inferior border of the mandible that separates the lower third of the face from

1436

Part 9: Facial Esthetic Surgery

the neck proper is important for good

esthetics. A lack of this distinct border
detracts from good chin-neck esthetics. A posteriorly well-extended
implant and proper inferior placement, at the inferior mandibular border, help to achieve this objective.
The esthetically attractive chin is balanced in width with the other facial
features, especially the bizygomatic
and bigonial facial widths. Many individuals with recessed chins also have
dolichocephalic facial features, or
what has been described as the "pointed chin" or "witch's chin." When this
condition exists and is not deliberately 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 lateral augtnentation. This is
accomplished by modifying standard
chin implants as described in the surgical technique discussion to follow.
The esthetically attractive chin has no
evidence of parasymphyseal depressions or grooves. These soft tissue mariotiette grooves may exist independently of or in concert with the
pointed chin. This condition is accentuated in most older individuals. When
these grooves exist, special attention is
given to lateral or parasymphyseal augmentation, 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 normal relations of these are as follow: 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 1 to 2 mm
posteriorly positioned. The soft-tissue
chin is 4 mm distal to SN perpendicular.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 augmentation 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 tissue values suggest otherwise. Second, in
older individuals, often those undergoing cervicofacial liposuction, rhytidoplasty, or both, anteroposterior augmentation of the chin to its "ideal" hard
and soft tissue values generally results
in an excessive amount of chin projection 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 become accustomed 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 performed under local anesthesia with sedation, along with other procedures such as
blepharoplasty, rhinoplasty, cervicofacial
liposuction, and rhytidoplasty.
With a surgical marking pen, the true
chin and neck midlines are marked to aid
subsequently in precise implant positioning; 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
1:100,000 epinephrine. Next, the submental area where the incision is to be made
and the entire area to be undermined subperiosteally are infiltrated with about 7 to
10 cc of local anesthetic with epinephrine.

Seven to 10 minutes are allowed to pass

after infiltration of the local anesthetic.
The implant is to be placed through a
submental incision of about 5 cm, made
just distal to the normal submental crease.
When the incision is made in the naturally occurring submental crease, it can
accentuate this crease and cause an unesthetic dimpling in that area. The incision is
made through the skin and subcutaneous
tissue, and hemostasis is obtained with
needle-point diathermy. The incision is
then carried directly down to the inferior
border of the mandible and through the
periosteum with diathermy cutting.
After identification and exposure of
the inferior border of the mandible, a subperiosteal dissection is completed along
the entire inferior aspect of the mandibular symphysis, well posterior on each side to
the region of the gonial notch. Following
exposure of the inferior border, the subperiosteal dissection is carried superiorly
beginning anteriorly. Laterally it is extended superiorly only enough to allow the
mental neurovascular bundles to be identified and visualized. No attempt is made
to expose them extensively because doing
so increases the potential for neurosensory
defects to the lower lip and chin.
An extended preformed implant is
generally selected, one that is configured in
such a way that it extends posteriorly into
the molar region.^-'''-'^ In patients with a
tapered (pointed) chin or marionette
grooves, the selected implant is modified.
The selected implant is 2 to 4 mm greater
in the anteroposterior dimension than the
desired anteroposterior augmentation.'''
This dimension is reduced at surgery and,
in essence, accentuates the parasymphysis
augmentation to improve the pointed chin
or parasymphysis depressions. These alterations are made to provide a more lateral
(parasymphysis) augmentation than is
available in most preformed alloplastic
chin implants (Figure 70-1).
|
After trial insertion of the implant, the
surgeon determines the need for addition-

Alloplastic Esthetic Facial Augmentation

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, intraoperative antibiotics are used and no postoperative antibiotics given.
Sutures are removed on the fifth postoperative day, and after 7 to 10 days any
areas of irregularity caused by edema or
hematoma are treated by deep massage and
heat. No other special treatment is needed.
Complications that occur witb this procedure vary and are generally minimal."*
FIGURE 70-1 Reduction of the anteroposterior
The patient seen in Figure 70-2 is
thickness effects a rounding of the chin and visibly
shown
before and after alloplastic chin
changes a pointed chin into a more rounded one.
Adaptedft-om Epker BN.'"p. 27.
augmentation,
emphasizing
lateral
parasymphysis augmentation to reduce
al adaptations in either the implant or the the pointed appearance of the chin and the
subperiosteal dissection to ensure that it marionette grooves.
rests passively on the lateral and inferior
borders of the mandible. The mental neu- Mandibular Angle and Inferior
rovascular bundles are visualized during Border
the trial insertion to make certain that the A well-defined mandibular angle and infeimplant does not encroach on them. If this rior mandibular border are important to
does occur, these areas are marked in situ an esthetically pleasing face. Indeed, propon the implant, and the implant is er definition in this region is the very basis of
removed and these areas reheved.
visually separating the face from the neck,
On completion of all adaptations, thereby making them distinct from one
two holes are drilled through the implant another. When this area is not well
and outer cortex of the underlying bone. defined, the face and neck become confluThe implant midline and marked facial ent and unattractive. Accordingly, in
midline are checked, and the implant is selected individuals esthetic augmentation
then stabilized with titanium screws to of the mandibular angles and inferior
prevent inadvertent early postoperative mandibular borders is to be considered.'^
displacement and to avoid mobility of the
The differential diagnosis of poor defimplant. If the implant is porous, it is inition of tbe angle and inferior mandibuvacuum impregnated with an antibiotic lar borders is important; one must considsolution before it is definitively stabilized er whether it results from abnormal
into position.
skeletal support, cervicofacial lipomatosis,
The incision is closed in layers with 4- soft tissue redundancy, or a combination
0 polyglactin 910 platysma muscle sutures, of these conditions
4-0 chromic gut subcutaneous sutures, and
A routine clinical evaluation via mul5-0 braided polyester or monofilament tidirectional observation and palpation
nylon skin sutures. Antibiotic ointment can readily allow the surgeon to diagnose
and a perforated film absorbent dressing cervicofacial lipomatosis and/or soft tissue
(Telfa) are placed over the incision, and a redundancy. A standard lateral cephalomultiple-layered 1.25 cm tape dressing is metric evaluation of the mandibular plane
placed to reduce edema and or hematoma angle is used to determine the presence
formation. The dressing is left in place for 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 represents the newly
to be constructed inferior mandibular
border and allows the surgeon to determine the specifics of vertical and anteroposterior implant design.
The vertical linear distance between tbe
two mandibular planes (the patient's and
the constructed normal) in the gonial angle
is measured. This distance is the amount 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 implant.
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 slightlyfi-omthe 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 primarily or simultaneously with liposuction
or rhytidoplasty; however, I prefer to perform 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 technique section to follow.^""^-*
Surgery can be performed with general 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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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 appearance 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 bundle. Approximately 10 cc of local anesthetic 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 periosteum,
anteriorly to the region of the canine
tooth; however, as one proceeds anteriorly into the premolar region, the incision is
initially carried only through the mucosa
to avoid inadvertently transecting the
mental neurovascular bundle.
After the mental neurovascular bundle
is exposed, the remainder ofthe dissection
is done entirely in the subperiosteal tissue
plane. This begins anteriorly with deliberate mobilization of the tissues around the
mental neurovascular bundle, carrying the
dissection inferiorly subposteriorly to the
inferior border of the mandible. The dissection 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 complete the
subperiosteal dissection (Figure 70-3).
Once the lateral body and ascending
ramus ofthe mandible are exposed in the
subperiosteal tissue plane, the periosteum
can be opened with fmger dissection at
the inferior aspect, as necessary for adequate relaxation.
My preferred augmentation material
is porous polyethylene, which is available
in several preformed sizes and shapes. The
approximate size and shape ofthe implant
should be determined previously, as discussed in the previous section. On the
basis of the measurements, the preformed
implant is modified during the actual surgical procedure. After the initial modifications, 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 repeatedly withdrawing the plunger forcefully
while holding a finger over the end of the
syringe. This removes the air from the
porous implant and replaces it with the
concentrated antibiotic solution. The procedure requires considerable effort and
pressure, often taking a few minutes.
When this process reaches its end point,
the implant sinks in the solution.
|
The initial try-in is then done. Additional modifications are often necessary,
such as notching the implant in the
region of tbe mental neurovascular bundle and molding it slightly into a curved

FIGURE 70-3 Use of a J-shaped elevator to remove

the tenacious angle muscle attachments. Adapted
from Epker BW^ p. 84.

Alloplastic Esthetic Facial Augmentation

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 posterior aspects "locked" beneath the posterior
and inferior borders of the mandible, the
implant is inspected for any final adaptations. At this point the implant is removed,
placed back into the antibiotic, and the
wound packed.
The identical dissection is then completed 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 preoperatively, 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 second 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 titanium 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 layers. The first layer is the periosteal and
buccinator muscle, which is closed with
3-0 chromic sutures. Then, with a running
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 hematoma. 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 intraoral incision lines are
completely healed. After approximately
2 weeks, the implants are self-stabilized by
fibrous soft tissue ingrowth, and the incisions are completely healed; at this time
unlimited physical activity is permitted.
At the 2-week period patients generally 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 exercises, three times a day for approximately
5 minutes each. These exercises consist of
maximum interincisal opening, protrusion, and clenching. Generally, within 7 to

14 days asymptomatic full range of

mandibular motion is obtained.
This procedure is designed to accentuate 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 discrete esthetic unit. Additionally, this procedure 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 705). The procedure is often done in concert with other orthognathic, reconstructive, and cosmetic facial procedures.

Skeletal Nasal Base

The indication for skeletal nasal base augmentation is based on a clinical esthetic
facial evaluation in individuals who are
not Class III maxillary deficient. This condition is frequently associated with inherent nasal deformities.'^^** The typical clinical esthetic findings are outlined below.
Frontally the alar base width is highly 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 tissue
nasolabial folds (Figure 70-6A). In profile, flat to concave paranasal anatomy
and a groove ratio of nasal tip-subnasale
to subnasale-alar is approximately 1:1
instead of the normal 2:1. In addition,
the following most often coexist: a relatively 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 support, relative nasal prominence, and internal 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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Part 9: Facial Esthetic Surgery

The cephalometric analysis may or

may not exhibit evidence of maxillary deficiency in the presence of a Class I occlusion. This is true because these cephalometric values have traditionally been
determined by measures around a point
that may not be deficient. However, the
piriform rims per se, as well as the immediate adjacent areas of the maxilla, are deficient. Unfortunately, these areas are not
amenable to measurement or evaluation
with conventional lateral cephalometrics.
Individuals to be considered for skeletal nasal base augmentation are those with
isolated skeletal nasal base deficiency who

possess a functional Class I relationship

and are not candidates for orthognathic
surgical consideration. In some individuals, 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 deficiency can be simultaneously corrected by
skeletal nasal base augmentation.^'' Finally,
this procedure is indicated in certain individuals who present for rhinoplasty
and/or septorhinoplasty.^-^

Two approaches to the surgery are

used, depending on the severity of the
deficiency as determined by the clinical
findings: a limited approach and an
extended approach. The limited approach
is used when the magnitude of augmentation planned is minimal (2-3 g of hydroxylapatite per side). In such individuals the
alar base width is generally normal, and in
profile the nasal size, tip projection, and a
supratip area are essentially normal. This
approach does not noticeably affect the
upper lip vermilion exposure.
Conversely, the extended approach permits alar base width adjustment and control
of upper lip vermilion exposure (increased
exposure). Also, since it is used for larger
augmentations (46 g per side), it effects a
relative decrease in nasal size, increasing the
tip projection and supratip break.
FIGURE 70-6 A and B, Patient with a Class I occlusion and classic features of skeletal nasal base defi- The procedure can be readily performed under either general or local anesciency. Reproduced with permission from Epker BN.'^ p. 116.
FIGURE 70-5 Preoperative (A and Q and postoperative (B and D) photographs
of a patient who underwent mandibular angle-inferior border augmentation.
Note the tightening of soft tissues with a reduction of the laxity, especially in the
jowl. Reproduced with permission from Epker BNJ'^ p. 94.

Alloplastic Esthetic Facial Augmentation

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 desirable postoperative width. About 10 minutes before initiation of the actual surgery,
the infraorbital nerves are blocked bilaterally, and 10 cc of 2% lidocaine with
1:200,000 epinephrine is infiltrated from
the zygomatic-alveolar crest area on one
side to the same area on the opposite side,
up into the region of thefi-ontalprocess of
the maxilla. When the limited augmentation is to be done, about 2 to 3 g of hydroxylapatite are used on each side, as opposed
to 4 to 6 g for the extended augmentations.
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 bone. The anterior maxilla is then subperiosteally exposed
so that the surgeon can visualize the piriform rim of the nose medially and extended superiorly and laterally by the desired
amount (Figure 70-7). The augmentational material is perhaps most easily delivered
by means of the syringe technique. About

1441

2 to 3 g of nonresorbable hydroxylapatite is through the anterior nasal spine region.

mixed with sterile saline and a collagen
Next, the upper Hp is grasped, and the forehemostatic and placed into a 3 cc syringe finger is placed facially, precisely over the
that has had the delivery end cut off.'^ Clo- inferior alar rim while the lip vestibule is
sure is performed with running 3-0 retracted with the intraorally placed
chromic horizontal mattress sutures. No thumb. With toothed forceps the area in
dressings are placed. Gentle external mas- the vestibular incision directly adjacent to
sage is done to ensure symmetry.
the everted alar rim is firmly grasped. This
For the extended augmentation tissue is a combination of the fibroareolar
approach, a standard horizontal incision is extension of the lower lateral cartilage and
made in the depth of the maxillary the lateral nasalis muscle; occasionally, a
vestibule from the second premolar area small sesamoid accessory of cartilaginous
on one side to the same area on the oppo- component is noted (Figure 70-8). When
site side. This incision is carried directly the proper tissue is grasped and the lip
down to bone, and the entire anterior released from the fingers while maintainmaxilla is exposed subperiosteally. The ing the tissue grasped with forceps, the alar
exposure extends posteriorly only to the base is readily advanced medially toward
anterior aspect of the zygomatic alveolar the columella; the alar base is then
crest, then superiorly to expose the infra- observed and measured facially. Someorbital nerve and medially above the nerve times several attempts at grasping the
onto the infraorbital rim. The lateral and proper tissue with the forceps must be
inferior region of the bony piriform rim is made to identify the tissue that permits virexposed including the anterior nasal spine. tually unrestricted medial movement of
The periosteum in this region is carefully the alar base. For the alar base cinch procemobilized over the piriform rim and into dure to be effective, the proper tissue in
the nasal cavity for about 5 mm. In this this area must be identified bilaterally to
phase of the subperiosteal dissection, care effect symmetric control of the alar bases.
Once the proper tissue is identified,
is exercised not to tear the periosteum and
while
it is maintained in the forceps, a
enter the nasal cavity. When this occurs it
is best to suture this communication to Burnell or figure-of-eight tendon-type
suture is placed with a 2-0 polyfilament
avoid possible postoperative infection.
Before augmentation, sutures are slowly absorbable suture. A separate
placed to control the alar base width. A suture is passed through each side first and
hole is drilled in the anterior nasal spine. the needle left attached to the suture (FigDepending on the predetermined esthetic ure 70-9). Then each needle is passed
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 somewhat
narrow. This latter objective is seldom indicated in this condition because the alar
base width is most often narrow, and the
patient generally benefits from some controlled degree of alar base widening. However, when this area is not controlled with
alar base retention sutures as described, it
widens unpredictahly and often excessively.
FIGURE 70-7 When less augmentation is necessary,
FIGURE 70-8 Alar cinch with attention to propTwo separate 2-0 slowly resorbable sutures er tissue selection and suture technique. Adapted
the limited incision approach is used. Adapted from
EpkerBNJ''p. 126.
are placed through a single hole drilled from Epker BN.'^p. 123.

1442

Part 9: Facial Esthetic Surgery

tively. Next, the vestibular incision is

closed with deliberate attention to control
of the upper Hp fullness 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 important to avoid reduction of the upper lip's
vermilion exposure with the subsequent
FIGURE 70-9 Independent suturing of each side vestibular closure.
to anterior nasal spine. Adapted from Epker
When there is no desire to alter the
BN.'^p. 124.
preexisting upper Hp esthetics, the mucosthrough the hole placed in the anterior al portion of the incision is closed in the
nasal spine. These sutures are later tied usual V-Y fashion, with the vertical extent
of the Y being about 10 to 15 mm. This
after the actual augmentation.
The skeletal nasal base augmentation basically avoids reduction in exposure of
is performed with a nonabsorbable mix- the upper lip vermilion (Figure 70-10).
ture of particulate hydroxylapatite and a
More often, it is desirable to increase
hemostatic collagen preparation, moist- the exposure of the upper lip vermilion,
ened with sterile saline. Only enough col- especially when the preoperative lip has
lagen hemostatic material is used to form gullwing characteristics. In these instances
a dough mass that does not flow.
an extended closure is done, requiring
Generally, between 8 and 12 g of extensive undermining of the upper lip
hydroxylapatite are used in the extended mucosa. While the lip is retracted with a
approach, depending on the relative sever- single skin hook placed precisely in the
ity of the skeletal nasal base deficiency. The midline and with a retractor placed latermixture is separated into two equal por- ally, undermining of the lip mucosa is pertions so that equal augmentation is formed with small scissors. The extent of
attained on both sides. After placement, it the mucosal undermining is determined
is molded with a periosteal elevator to by the desired esthetic changes in the
upper lip. When maximal increased expoconform it to the underlying bone. Most
often this material is extended superiorly sure of the upper lip vermilion is wanted,
to the infraorbital nerve and often more as is the case with a gullwing upper lip
medially to the infraorbital rim. Care is appearance, extensive undermining is
taken not to place much of the material achieved anteriorly almost to the wet line
into the region of the frontal process of the of the lip and an equivalent amount postemaxilla because this unesthetically widens riorly. When this undermining is completthe nose. Once the implants are placed ed, it is critical that the surgeon be able to
bilaterally, equally and symmetrically pass the scissors freely from one side to the
adapted, and contoured to create facial other, demonstrating a continuous pocket.
Next, the horizontal vestibular limbs are
symmetry, the incision is closed.
First, the alar base sutures are tied. closed with interrupted or continuous 45
Each suture is independently hand tied angled sutures to reduce tension and furwhile that side's alar base width is ther advance the mucosa.
observed (measured) facially. As a general
When the extensive mucosal underprinciple, the alar base should be nar- mining is done with a V-Y closure, a denrowed 2 mm more than desired because tal cotton roll coated with an antibiotic
some widening tends to occur postopera- ointment is inserted into the depth of the

labial vestibule in the midline, and tape is

placed tightly over tbe lip to maintain
pressure. The tape is extended inferiorly
over the lip mucosa. When this is not
done, considerable lymphedema occurs in
the midline of the upper lip. The cotton
roll and tape dressing are left in place for
48 hours and then removed. Similarly, layered tape dressings are applied to the
paranasal regions and maintained for
48 hours. Cold is applied to the face during this time.
After surgery and the removal of the
dressing, the patient must maintain a liquid to very soft diet for 7 to 10 days until
the vestibular incision is well healed. After
3 to 4 days he or she is instructed to begin
forceful lip exercises to further reduce
edema. At this time, when the edema is
resolving, the surgeon gently palpates the
paranasal areas to ensure symmetry. The
implanted material can be gently molded
for about 5 to 7 days before it assumes a
solid state without flow properties.
|
The limited exposure approach is done
primarily to reduce mild paranasal depressions (Figure 70-11). The extended procedure produces esthetic changes consistent
with improved frontal face esthetics,

FIGURE 70-10 V-Y closure is done to enhance

exposure of upper lip vermilion. Adapted ftom
Epker BN.'^ p. 127.

Alloplastic Esthetic Facial Augmentation

FIGURE 70-11

1443

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 vermilion, improved balance of the alar base
width with the remainder ofthe facial features, and decreased prominence of the
nasolabial folds. In profile the concave-tofiat 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 some cephalic rotation
ofthe nasal tip is achieved (Figure 70-12).
This extended procedure is frequently

used with other skeletal/soft tissue cosmetic maxillofacial procedures, especially

rhinoplasty.

variable degrees) and desires enhancement.

Moreover, it must be appreciated that three
patients with the same degree of anatomic
deformity may each desire different
The Cheek
degrees of augmentation, much tbe same
Esthetic cheek augmentation may be indi- as occurs with breast augmentation.
cated as an isolated esthetic maxillofacial
Esthetic cheek augmentation is indisurgical procedure or be performed in con- cated in individuals who frontally exhibit
cert with other skeletal/soft tissue facial poor lateral cheek projection {bizygomatic
esthetic surgeries.^'^''' As with the other width) in relation to the bigonia! and
procedures discussed in this chapter, this bitemporal widtbs. Many such patients
statement implies that the patient both appear to exhibit vertically long faces, even
possesses the deformity (albeit to highly though they do not possess any of the

FIGURE 70-12 Preoperative (A and C) postoperative (B and D ) appearances after an extended approach with an alar cinch and a V-Y augmentation ofthe upper
lip. Reproduced with permission from Epker BN.^'' p. 130-1.

1444

Part 9: Facial Esthetic Surgery

son's locates the prominence quite inferiorly, 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 contralateral cheek prominence extends well
beyond a line from the lateral commissure
A detailed systematic esthetic examina- of the mouth to the lateral canthus. Its
tion of this area is performed because the most prominent location is about 15 to
evaluation of this area of the face must be 20 mm beneath the lateral canthus.
multidirectional. Esthetic judgments
The basal view simply supplements
made exclusively from a single view are the findings from the other perspectives
incomplete witb respect to the specificity and also reveals both the true lateral and,
of the deficiency.
to a levSser degree, anterior projections of
Frontally the area of maximum cheek the cheeks. This view is important to best
prominence is located about 10 mm lateral determine the symmetry of tbe cbeeks.
and 15 mm to 20 mm inferior to the laterThe surgeon must not only evaluate
al canthus. The cbeek prominence is posi- the cheek prominence proper but also the
tioned more laterally than the mandibular buccal area because excessive fullness in the
angle. The bizygomatic width of the esthet- buccal region can lead the surgeon to the
ically attractive face is the widest dimen- erroneous iMpression that cheek deficiency
sion of the face, with the bitemporal width exists. When cheek deficiency and buccal
and bigonial widths following. Silver has fullness coexist, the surgeon must exercise
defmed a malar prominence triangle, caution with respect to whether and how
which very closely locates the malar promi- much cheek augmentation versus buccal
nence to this same location.^^
fat pad reduction is to be performed.
A mark is made on the face in the ideal
From the profile perspective, the
cheek prominence and infraorbital rim in region of the cheek eminence, 10 mm latthe esthetically attractive individual are eral and 15 to 20 mm inferior to the latersituated so that the infraorbital rim is al canthus. This mark aids in the proper
about equally projected with the anterior- superoinferior and lateral positioning of
most projection of the globe, and the the cheek implant. Similarly, it helps in
cheek prominence is located several mil- predetermining the desired lateral and
limeters anterior to the globe. This rela- anteroposterior thickness of the cheek
tionship results in the cheek area being augmentation. It is important to create a
clearly convex in its configuration, as gentle convex surface curvature beginning
in the infraorbital area and extending infeopposed to flat or concave.
Most analyses of the malar promi- riorly 15 to 20 mm. In concert with this
nence that have been described in the lit- marking, a tangent from the soft tissue
erature are from the three-quarters view. gonial angle to this region is constructed
These include Hinderer's, Wilkinson's, with a ruler to "estimate" the desired laterPowell and colleagues', and Prendergast al projection as determined by the criteria
and Schoenrock's methods.^^"-*"* These previously discussed.
The procedure can be readily permethods result in highly variable ideal
locations for the malar prominence, both formed under either general anesthesia
vertically and laterally. Specifically, Hin- supplemented with a local anesthetic
derer's method is too nonspecific, Wilkin- with 1:200,000 epinephrine, or local
objective criteria of the long-face syndrome. 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 variable degrees of inadequate cheek and/or
lateral infraorbital rim projection.'"^'^^

FIGURE 70-13 Extent of undermining for the

placement of a cheek implant. Adapted from
Epker BN.'^p. 147.

anesthesia and sedation. About 10 minutes before surgery the infraorbital nerves
are blocked bilaterally with a few cubic
centimeters of 2% lidocaine with
1:200,000 epinephrine. A few minutes
later the entire maxillary vestibule is infiltrated transorally with approximately
10 cc of the same agent, from the zygomatic-alveolar crest area on one side to
the same area on the opposite side. In
addition, the subperiosteal dissection
extends laterally along the zygomatic arch.

FIGURE 70-14 Symmetric and good stabilization of the right and left cheek implants is best
achieved with screw fixation. Adapted from
Epker BN.'''p 152.

Alloplastic Esthetic Facial Augmentation

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 subperiosteally. 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 completed. 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 dissection must be liberal enough to create an
adequate "pocket" into which the implant
can be placed 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 different-shaped cheek implants exist, constructed from various materials. Moreover, variable 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 impregnated with an antibiotic as described
above. Careful adaptation of the preforrhed implants is necessary to obtain
optimal results.
After initial trial the implant is
revised with a surgical blade and/or heating to mold it to the underlying bone.
The need for any additional adjustments

D
FIGURE 70-15 Preoperative (A, C and E) and postoperative (B, D, and f} appearances of a patient who underwent a
cheek augmentation. Reproduced with permission from Epker BNJ^ p. 156-7.

1445

1446

Part 9: Facial Esthetic 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 completed 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 positioning and stabilization of the right and left cheek implants 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 postoperative patient concern after this procedure.

The vestibular incision is closed with a

single-layered 3-0 plain horizontal mattress 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 incisions, the patient is instructed to begin
vigorous lip exercises to expedite resolution 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 introductory 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 preoperative detailed systematic esthetic evaluations permit the various areas of the face
to be augmented precisely.

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