How one surgeon’s thinking—and practice—have changed
The term “facial implant” encompasses the full spectrum of solid and liquid implants, and may be temporary, semipermanent, or permanent. Solid implants, by their very nature, are intended to be semipermanent to permanent, because incision-based surgery is required to insert them into the desired facial region.
Liquid implants span the range from temporary fillers such as collagen and hyaluronic acid to more permanent options like liquid silicone (an off-label soft-tissue filler) and poly(methyl methacrylate) beads (which are pending US Food and Drug Admin-istration approval)
The resurgence of autogenous fat as a facial implant bridges the gap between solid and liquid implants. Fat is a solid, but it is handled and delivered as a liquid injectable.
This article is not intended to be an exhaustive scientific review of all of the options currently available for soft-tissue facial augmentation. Also, technical details that concern implantation or injection techniques lie beyond its scope.
I will focus primarily on the philosophical guidelines that have served me well in approaching the patient for facial enhancement. I will discuss how and why I select a solid versus a liquid implant as a matter of preference. More importantly, I will delve into the singular importance that facial-volume enhancement has come to play in my practice.
I would like to give credit to two major forces in the field of facial plastic surgery for helping me develop my philosophy. Edwin F. Williams, III, MD, FACS, structured my thoughts on different fillers, and Mark J. Glasgold, MD, refocused my attention and outlined an insightful philosophy on the important topic of facial-volume enhancement.
I would also like to state very clearly that I have no financial relationship of any kind with any company, manufacturer, or distributor. Finally, if it is not already patently evident, these opinions are not culled from rigorous scientific data but from personal observations, experience, and dialogue.
A New Paradigm
We are currently witnessing a revolutionary paradigm shift. Until now, almost all rejuvenation procedures have relied on some type of excision-based lifting surgery. Doing so has rendered individuals more tissue-depleted and hollow than before, leaving us to wonder whether we are indeed rejuvenating someone or making him or her worse off.
Sydney R. Coleman, MD, has led the charge to place facial-volume enhancement at the forefront of the rejuvenation arsenal,1 and I agree with him. Whereas at one point lifting procedures dominated my approach to facial rejuvenation, their role is now secondary to fat enhancement. But, unlike Coleman, I think that a judicious combination of lifting procedures and fat enhancement can provide the optimum solution to facial rejuvenation.
If your only tool is a hammer, the whole world is a nail. Not everyone needs fat, and not everyone is a candidate for fat enhancement. For example, if a patient’s weight fluctuates considerably, fat enhancement may not be an option because contour irregularities in the transplanted areas may become evident.
The True Objective
Some women are concerned about fine lines and wrinkles that are visible only under magnification. It is important to refocus a prospective patient’s attention on what others observe from 3 to 10 feet away. In most cases, volume and shape should take precedence over removing lines and wrinkles as the aesthetic objective.
A youthful female countenance is characterized by a heart-shaped face that features a prominent malar eminence and a full chin. Over time, as the malar and chin areas recede due to volume contraction, and as the jowls become heavy due to gravitational descent, the face is transformed into an undesirable, masculinized rectangle. The goals of facial rejuvenation are to restore the heart-shaped face via malar and chin fat enhancement with or without simultaneous elevation of the jowl complex via a rhytidectomy. Mild jowling can be camouflaged easily with fat enhancement along the prejowl region and the lateral mandible without a concurrent rhytidectomy.
Shift in Focus
During the past year, I have shifted my attention from the brow to the midface as the fundamental region for facial-volume rejuvenation. In the past, I was convinced that brow lifting was the most important aspect of facial rejuvenation because it transformed a sleepy, tired look into an alert, refreshed one.
Today, however, I perform significantly fewer brow lifts because I believe that lifting may at times artificially elevate the brow higher than where it was when the patient was younger. Also, an excessively raised brow can actually exacerbate the elongated rectangular configuration of aging rather than restore the heart-shaped appearance of youth. For the female patient with a truly ptotic brow that falls below the orbital rim, I still elect to perform a brow lift as the procedure of choice.
By comparing old photographs with superimposed current poses of aging patients, Val Lambros, MD, FACS, has shown quite eloquently that the midface does not truly descend over time but only involutes.2,3 Accordingly, I believe that the midface can be more effectively and correctly rejuvenated with volume enhancement rather than with a midface lift.
When I approach the midface for volume enhancement, I can contour specific deficiencies with fat. Areas of deficiency include the inferior orbital rim, the nasojugal groove, the lateral cheek eminence, the anterior cheek (including the depressed malar septum), the buccal region, the canine fossa, and the nasolabial fold.
Fat or Implants?
Malar augmentation with a solid implant simply fails to address the complexity of the aging cheek. An alloplastic malar implant can also exacerbate the infraorbital hollow, because the implant must be situated inferior to the infraorbital nerve.
Nevertheless, patients who are extremely gaunt and lack an adequate supply of adipose tissue to transfer should be considered for alloplastic malar augmentation. These patients include younger, athletic individuals who do not like the unhealthy appearance of their overly skeletonized face.
Ideally, some fat should be harvested, if possible, from donor areas such as the waist roll that descends from the supermedial midline of the back inferolaterally to the waist, and applied judiciously around the malar implant to provide cushioning and contouring. Fortunately, the mature woman often exhibits a very gaunt face along with an accumulation of fat in the thighs or lower abdomen, which are easy sites for harvesting and transferring.
An alloplastic solid implant is a very effective stand-alone procedure for more youthful faces that exhibit only hypoplastic bone contours—for example, for malar or chin enhancement. I prefer the extended-anatomic chin implant for both young and, especially, older patients with prejowl hollowness.
For mature patients with only mild chin retrusion and overall prejowl emptiness, I tend to use only fat for enhancement so as to effect only a subtle change in the chin contour. For more significant cases of hypoplasia without malocclusion, I elect to perform alloplastic chin augmentation with or without additional fat enhancement.
Although fat can be quite effective for recontouring the aging face, it may not be an ideal choice for lips and for deep lines, such as the nasolabial and labiomandibular folds. The use of fat in these areas tends to be fraught with difficulty. Fat infiltration for the lips is prone to tremendous postoperative edema and ecchymosis that can at times linger for several months. Furthermore, the aesthetic enhancement may not be sustained because fat viability in the lip region may be compromised.
Similarly, augmentation of the deep perioral folds with fat fails to achieve a durable effacement. I routinely put fat into the hypoplastic canine fossa located in the upper recess of the nasolabial fold, as well as the nasolabial fold itself, but not for the obvious reason of improvement in the appearance of the actual line.
As the malar and submalar regions are augmented with fat, I do not want the nasolabial line to appear even deeper due to lateral enhancement and the failure to enhance the line or the upper lip more medially. If a patient desires lip enhancement or line effacement, I prefer the many types of liquid-injectable fillers that are currently available.
Not Around the Mouth
For mobile regions of the face like the lips and the perioral region, I do not favor solid implants for many reasons. Solid implants are prone to extrusion and infection in highly mobile regions. In addition, the patient can often feel the actual implant in the treated area, even more than liquid fillers. Many solid implants that appear to be soft and distensible when handed to the patient for inspection can become contracted and indurated over time in mobile regions.
The lips are particularly problematic when it comes to solid implants. I have found that once a solid implant has been inserted, the implant can scar and tether the overlying mucosa to the orbicularis muscle and make lip enhancement with any product difficult, if not impossible. This is not always the case, but I have often observed this irreversible situation.
Unquestionably, for bony regions like the cheek and chin areas, I think that solid implants can provide a very natural and stable augmentation. If a patient is willing to undergo incision-based surgery, I prefer solid implants for malar and chin augmentation unless concomitant fat loss is present, in which case I would more readily undertake fat enhancement with or without alloplastic enhancement, as mentioned previously. Placing a solid malar or chin implant subperiosteally or in combination with a supraperiosteal plane provides stability along with relative imperceptibility and impalpability.
For Asian Patients
Because my practice has a large percentage of Asian patients, I also practice nasal augmentation with alloplastic materials. I think the current trend has been toward alloplastic materials along the dorsum combined with autogenous materials nearer the more mobile nasal tip for the reasons discussed above. However, many practitioners still conservatively enhance the entire nose with an alloplast, which I continue to do as well. Fixation sub-periosteally along the nasal bony dorsum is critical for keeping the implant immobile and for limiting the chance of extrusion.
The field of facial-volume enhancement with implants continues to expand rapidly, principally in the field of new soft-tissue fillers. With the resurgence of fat as a principal weapon against the aging face, facial-volume enhancement has become a major topic of discussion once again. Proper selection of the right material for a patient depends on thoughtful preoperative counseling and education. No ideal filler currently exists, or probably ever will.
I hope that the philosophy I have outlined in this article will help stimulate thought and curiosity rather than unquestioning, wholesale adoption. PSP
Samuel M. Lam, MD, is a double-board-certified facial plastic surgeon who practices in Plano, Tex, and Dallas. He is the coauthor of the textbooks Comprehensive Facial Rejuvenation: A Practical and Systematic Guide to Surgical Management of the Aging Face and Cosmetic Surgery of the Asian Face, and the upcoming Complementary Fat Grafting. He can be reached at (888) 866-3388 or via his Web site, www.lamfacialplastics.com.
1. Coleman SR. Structural Fat Grafting. St Louis: Quality Medical Publishing; 2004.
2. Lambros V. Periorbital aging—Are we achieving true rejuvenation?; Why is fat an issue? Presented at: Facial Cosmetic Surgery 2005; June 15–19, 2005; Las Vegas, Nev.
3. Lambros VS. A new model for the aging face. Plastic Surgery Products. 2005;15(7): 20–25.