Our panel looks at the factors that affect the use of implants in the face and body
At first blush, implants may seem to consumers like the latest Palm Pilot that’s sweeping the nation—the modern personification of Microsoft Outlook. Of course, we know that implants have little to do with computers. The idea behind implants is to allow plastic surgeons to give patients a solution that can improve the appearance of the face, and, more recently, the body.
Breast implants, of course, have been used for many years. Yet, for the purpose of this article, we will explore all other implant uses, especially since more public awareness has been associated recently with implants in plastic surgery.
The use of implants began in the orthopedic specialty during the early 1900s, when “plates” were used to help repair bone fractures. Implants in plastic surgery today are actually made from a firm, semisolid material that fits in front of the bones of the cheek, chin, jaw, and other areas of the face; and, more recently, in the pectoral area, calves, or buttocks.
Now, the numbers. In 2005, according to the American Society for Aesthetic Plastic Surgery, more than 9,000 patients proceeded with cheek implants, approximately 31,000 underwent the chin-augmentation procedure (mentoplasty) with possible implants, 542 proceeded with buttock implants, 263 had a calf augmentation, and 172 pursued pectoral implants. We also know that more than 82,000 proceeded with maxiofacial surgery and close to 400,000 underwent some form of reconstructive surgery.1
Although we don’t know whether all of these patients received implants, we do know that the use of implants in plastic surgery can serve many patients. Let’s explore some of the major factors surrounding implants as seen by our panel of plastic surgeons (pages 48 and 49).
The Goal of the Procedure
Of course, several options are available to build volume in a poorly refined area or to provide balance and harmony to the face. Many surgeons have determined that implants work best to enhance the bony framework in stationary areas such as the chin or upper cheek. By stationary, we mean those areas that do not move during facial or body expressions. In other words, some surgeons believe that implants should be avoided in mobile soft-tissue areas of the face and body.
Anatomy is an important factor in the selection of the right treatment plan. Patients who suffer from bone deformity often respond well to the implant procedure, but those who suffer from volume loss due to age may be better served with an injection or fat-transfer procedure. Some of these patients may be best served with a combination treatment plan that includes solid implants, fat transfers, or other injectibles. Younger patients with substantial elastic soft tissue may respond well to an implant-only procedure.
Surgeons considering the use of implants for a patient will evaluate the need to use an implant alone or in combination with another treatment plan. In fact, combination treatments are often used to produce a fully satisfactory outcome. For example, a chin with a deep indentation or a flat “cutoff” appearance may require the use of a fat transfer and an implant.
|Maurice M. Khosh, MD, FACS, is a board-certified plastic surgeon in private practice at Facial Plastic and Reconstructive Surgery in New York City and an assistant clinical professor at the Columbia University College of Physicians and Surgeons. He specializes in aesthetic and reconstructive surgery of the face. He can be reached at (212) 262-0056.|
|Gary M. Brownstein, MD, is a board-certified plastic surgeon in private practice at Cherry Hill Cosmetic Surgery in Cherry Hill, NJ. He can be reached at (856) 795-7000 or via his Web site, www.cherryhillcosmeticsurgery.com.|
|Zoran Potparic, MD, PA, is a board-certified plastic surgeon in private practice in Fort Lauderdale, Fla. He can be reached at (954) 567-1300 or via his Web site, www.drzoran.com.|
|J. Charles Finn, MD, is a board-certified facial plastic surgeon in private practice at Aesthetic Solutions in Chapel Hill, NC. He can be reached at (919) 403-6200 or via his Web site, aesthetic-solutions.com.|
|Minas Constantinides, MD, is a board-certified facial plastic surgeon and otolaryngologist in private practice in New York City and the Director of Facial Plastic and Reconstructive Surgery in the Department of Otolaryngology at New York University Medical Center. He can be reached at (212) 263-5882 or via his Web site, www.newyork facialplastics.com.|
|Munish K. Batra, MD, FACS, is a board-certified plastic surgeon in private practice at Coastal Plastic Surgeons in San Diego. He can be reached at (858) 847-0800 or via his Web site, www.coastalplastic surgeons.com.|
|Andrew Cohen, MD, is a board-certified plastic surgeon in private practice in Los Angeles. He can be reached at (310) 659-8771 or via his Web site, www.drandrewcohen.com.|
The size of the treatment area is also an important evaluation factor. While some surgeons use implants in the cheek area—perhaps in the upper or, less often, the lower cheek—the emergence of injectibles has presented an alternative for this and other body areas. Injectible choices include those that are temporary and those that are considered longer-lasting or permanent, provided that the procedure is successful.
The Fat-Transfer Option
For instance, the fat-transfer procedure has become increasingly popular for treating the midface. By the same token, it may be considered very time-consuming and may require a highly skilled surgeon—all of which are special considerations for both the patient and the surgeon. Larger areas requiring treatment often respond better with implants, whereas smaller treatment areas may respond better to a fat transfer or other injectible. Depending upon the patient’s needs, other injectibles may be more appropriate than an implant or a fat transfer.
Whether a patient suffers from a genetic “default” causing an imbalanced facial appearance, or a bony deformity resulting from disease, trauma or age, he or she is presented with all the available alternatives during the consultation. Some patients wish to avoid surgery and prefer a fat transfer or other injectible. In this case, a more temporary solution may make more sense. Other patients demand a more “permanent” solution, such as an implant.
The best facial-implant candidates are those with loose skin around the face and with surrounding skin that is elastic enough to be repositioned for a positive appearance. Also, a weakened jawline and the appearance of reduced bone structure can be improved with a facial implant. Finally, it may be necessary to incorporate facial implants with a facelift or other plastic surgery procedure. When determining the appropriate treatment, careful planning that includes safety, ease of use, recovery duration, and associated risks and costs is important to patients.
The special considerations for a body implant are similar to those for a facial implant. In the case of a body implant, it is important for patients to understand that, over time, the body might lose body-fat content that can cause the implant to become more palpable or visible under the skin. Second, the body implant may need to be replaced at a later date.
Despite the supporting body-implant research, some patients may be concerned about having a “foreign” object in their body and may opt for a body-fat transfer instead. Informed fat-transfer patients know that if they lose weight, the fat-transfer area may lose volume. Patients who choose implants must also understand the risks: infection, fluid formation, capsular contracture, asymmetry between areas, migration, or implant incompatibility. In the end, patients may feel that the risks associated with an implant procedure are low compared to the possible benefits.
Return on Investment
The “bottom line” in the implant decision is patient satisfaction. Therefore, surgeons must choose the best option for each patient. For example, patients may not be candidates for surgery and may be better served with injectibles, including fat transfers. In fact, fat transfers are comparatively easy to obtain and reusable in a sense. Fat grafting may offer the best return on investment (ROI).
On the other hand, implants may be the right patient choice and may more effectively produce a positive ROI because they allow surgeons to treat areas that cannot be effectively treated otherwise.
Yet, the biggest ROI is a satisfied patient. Patient satisfaction may equate to additional procedures and more word-of-mouth referrals. Simply put, the ability to address patient concerns is highly desirable for both the patient and the surgeon. Therefore, a surgeon who understands the patient’s needs and has expertise in the procedure can create a win-win solution.
To choose a vendor, you need a multi-faceted plan of attack. Attending annual meetings held by professional organizations so that you can see demonstrations, and compare the benefits, of various implants and injectibles can go a long way toward helping you choose the right vendor. Attending courses and lectures about the various implants, injectibles, or fat-transfer techniques can help further solidify your decision.
It is crucial to not underestimate the importance of references. They can be provided by the vendors themselves or may be obtained by posting an inquiry on organizations’ message boards. In this inquiry, it might be helpful to ask about the following implant specifics:
the infection rate;
the malposition rate;
the type of materials;
how long the implant has been in use by the medical community; and
the associated bone-erosion rate.
Because other staff members may be speaking to patients about implants, fat transfers, and injectibles, it is important that your entire staff interacts with the vendors.
Unlike implants produced in the past, whereby blocks of silicone were manufactured for the surgeon to create the “right” patient mold, today’s implants are offered in a variety of shapes and sizes. In fact, some surgeons have found that they do not have to shave down the implant to fit it to the patient. Today’s implant designs appear to complement the natural contours of the bone quite well and have more porous materials inside them that provide better tissue fixation. Softer materials are more comfortable and provide a better shape than harder materials.
There is also a variety of material types to choose from, including silicone, hydroxyapatite, polyethylene, polytetrafluoroethylene (PTFE), and cadaver bones.2 These offer more versatility and biocompatibility, and better patient tolerance than implants from yesteryear.
What Should You Offer?
A priority list and budget are equally important. Understanding your market, the training time associated with the investment for all possible treatment options, the technique itself, and the materials costs is important in your decision to offer all options at your practice. For example, the best body-fat-transfer technique is associated with a high fat-survival rate. Surgeons prepare injectible fat cells differently. Some will “spin” the fat cells before injecting them into the treatable area; others will not.
Technique is very important in the case of fat transfers. The level of training for this technique can vary as well. Some surgeons may spend 1 day with the “right” professional to learn the technique. Others may require more training. In the end, knowing the extent of training required for the procedures you perform is important for your analysis.
Based on your priority list and budget, you can address other concerns. For instance, in the case of an implant, ask yourself the following questions:
Does the vendor offer a wide variety of implant sizes and shapes so that customization can be easily accomplished?
Is the material easy to use?
Is the material easy to modify?
Is the material easy to remove?
Is there a return policy?
The evaluation of support is also significant, because the level of support can vary among manufacturers. For example, “user support” addresses simple issues relating to basic product knowledge. Numerous levels of support may also be required in a practice to address urgent orders and special customization needs.
The form of support is also important. Face-to-face support by local sales representatives may be necessary. Support may also be provided via e-mail or over the phone, in some cases 24 hours per day. The manufacturing representative’s accessibility is an important consideration in vendor selection.
Final Thoughts on Implants
Many implant options are available today to help patients who want aesthetic or reconstructive procedures. At the end of the day, though, you need to offer procedures that work for your particular practice. Whether you choose to stick with facial implants, expand your practice with body implants, or maintain your current procedure “status,” understanding the differences between these options can go a long way toward helping your patients.
This is true from the perspective of the patient, who will appreciate the up-to-date information you can provide and may return the favor with more referral patients to your practice. This is also true from the perspective of your staff members, who can now fulfill all patient inquires. PSP
Lesley Ranft is a contributing writer for Plastic Surgery Products.
1. American Society for Aesthetic Plastic Surgery. 2005 Cosmetic Nurgery National Data Bank statistics. Available at: http://www.surgery.org/ download/2005stats.pdf Accessed April 5, 2006.
2. Loftus Plastic Surgery Center. Chin & cheek augmentation. Available at: http://www.infoplasticsurgery.com/facial/chincheekaug.html Accessed April 12, 2006.