Clinics Reuiew Articles

FACIAL PLASTIC SURGERY CLINICSOF NORTH AMERICA

Minimally InuasiueProcedures in FacialPlastic SurgeryEDITORTheda C. KontisCONSULTING EDITORJ. Regan Thomas

MAY 2013

The Role of Fillers in FacialImplant SurgeryWilliam J. Binder, MDa-*, Karan Dhir, MDb,John Joseph, MDa'c

KEYWORDS

Facial implant surgery • Cheek augmentation • Malar augmentation1 Chin implant • Chin augmentation • Facial fillers

Facial alloplastic implantsFacial rejuvenation • Facial augmentation

KEY POINTS

• Achieving optimal, long-lasting results in facial rejuvenation requires knowledge of how the agingprocess affects all levels of the face including the skin, soft tissue, and underlying bone structure.

• Facial fillers and alloplastic implants are 2 methods commonly used to achieve the goal of volumeenhancement for rejuvenation of the face. It is important to understand the appropriate use of eachtechnique either as a sole modality or in conjunction with each other to attain optimal aestheticresults.

• Although minimally invasive soft-tissue augmentation procedures such as fillers have effectivelyimproved the midface treatment paradigm, chin augmentation with alloplastic implantation remainsthe mainstay of treatment of microgenia.

® Dr Joseph demonstrates midface facial filling with Sculptra and discusses his preparation of thematerials for tear trough and midface injection in a video that accompanies this article.

TREATMENT GOALS USING FILLERS ANDIMPLANTS

Augmentation of the midface and chin with allo-plastic implants has been performed with in-creasing frequency during the past 4 decadesand offers a long-term solution for augmentingskeletal deficiencies, restoring facial contour irreg-ularities, and rejuvenating the face.1'2 Specifically,chin augmentation with alloplastic implantation isthe fastest growing plastic surgery trend amongall major demographics. The media have alsowell publicized the advantages of this technique,which has been characterized as "chinplasty" inmainstream magazines, further heightening theawareness of both the aesthetic and psychologicalbenefits of treating microgenia.3

In contrast, rates of midface alloplastic implantprocedures have increased at a measured paceduring the past 2 decades because of the intro-duction of "less-invasive" techniques such asinjectable facial fillers and fat transfer.43 Alloplas-tic implantation of the chin remains the optimalchoice for projecting and repositioning the softtissue envelope, whereas facial fillers have gainedpopularity in rejuvenating the aging midface.5 Thismore recent reliance on less-invasive surgical andnonsurgical rejuvenation procedures has mini-mized the key role of the skeletal structure compo-nent of the aging midface. However, rather thanreplacing surgical augmentation techniques,fillers can enhance the ability to use midface im-plants more effectively to achieve long-termrejuvenation.

No financial disclosures.a Department of Head and Neck Surgery, University of California, Los Angeles, 120 South Spalding Drive, Suite340, Beverly Hills, CA 90212, USA; b Department of Head and Neck Surgery, Harbor-University of California,Los Angeles, 120 South Spalding Drive, Suite 340, Beverly Hills, CA 90212, USA; c Department of Head andNeck Surgery, University of California-Harbor, Los Angeles, 9400 Brighton Way, Suite 203, Beverly Hills, CA90210, USA* Corresponding author.E-mail address: info@doctorbinder.com

Facial Plast Surg Clin N Am 21 (2013) 201-211http://dx.doi.0rg/10.1016/j.fsc.2013.02.0011064-7406/13/$ - see front matter © 2013 Published by Elsevier Inc.

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202 Binder et al

The Process and Effects of Aging in the Face

Successful rejuvenation of the aging face entailsa multidimensional approach to correct the volu-metric changes involving the skin, deep softtissue, and bony skeleton.6~!

• Integumentary changes such as epidermalthinning, decrease in collagen, loss of skinelasticity, and deep tissue volume loss repre-sent the hallmarks of soft-tissue changes inthe aging face.6

• With advancing age, fat in the malar, buccal,temporal, and infraorbital regions atrophiesand produces volumetric changes.

• Fat atrophy extends beyond the subcuta-neous level and affects the deeper soft tissuesalong with the fat pad of Bichat. With con-tinued wasting of the fat pads and loss offascial support, these areas become progres-sively ptotic due to gravitational effects.

• The malar fat pad, suborbicularis oculi fat,and orbicularis oculi muscle descend inferi-orly, exposing the infraorbital rim, and pro-duce an elevation or "mound" lateral to thenasolabial fold and exaggerate its depth.

• The nasolabial and nasojugal folds deepen,leading to cavitary depressions and hollow-ness in the submalar regions.

• These changes may also flatten the midfaceand eventually unmask the underlying bonyanatomy.

Over time, the progressive cumulative effects ofaging transform the once full, angular, youthfulface into a predictably rectangular (or pear-shaped) face, which appears longer in configura-tion, aged, and fatigued.8

Most soft-tissue deficiencies in the aging mid-face are localized within the recess referred to asthe "submalar triangle," an inverted triangular areaof midfacial depression bordered superiorly by theprominence of the zygoma, medially by the nasola-bial fold, and laterally by the body of the massetermuscle. The aging midface exhibits a "doubleconvexity" curvature caused by weakening of thelower eyelid orbital septum and consequent pseu-doherniation of the lower orbital fat pads.2'8'9

Age-related morphologic skeletal changes, welldescribed by Shaw, must also be consideredduring the preoperative consultation. Overall, theaging face is characterized by the resorption ofbone along the orbit, midface, and mandible,which leads to a reduction in the skeletal frame-work and laxity of the overlying skin. The net resultof these topographic changes can make an other-wise healthy person appear gaunt.6'7 Thesechanges are further compounded if the patient

exhibits deficiencies in skeletal structure such asa negative vector of the infraorbital rim.

Midface Rejuvenation

The specific goals for midface rejuvenation areto8'9

1. Add contour to the upper midface or malar area2. Restore cheekbone fullness and reduce sub-

malar hollows3. Soften the nasolabial and marionette folds4. Reduce the vertical descent of the jowl5. Smooth out facial lines and wrinkles

Initially, facial rejuvenation techniques weretailored to improve skin laxity alone. In the1980s, Binder first introduced midface alloplasticaugmentation as an independent method for volu-metric enhancement of the aging face.2 Augmen-tation not only enhances the facial skeleton butalso achieves a suspensory effect that redistrib-utes the soft tissue in a more favorable position.By restoring lost facial soft tissue volume andincreasing the anterior projection of the area,midface augmentation reduces midface laxity,restores facial contour, and decreases the depthof the nasolabial fold. This result can be accom-plished with implantation alone and in combinationwith a rhytidectomy procedure, whereby augmen-tation can soften the sharp angles and depres-sions of the aged face, rendering a more naturalpostoperative result.8'9 For these patients, aug-menting the bony scaffold of the malar or maxillaryregions improve the fundamental base for sus-pending the facial tissues. This emphasis onvolume restoration continues to represent a keycontribution to facial rejuvenation.

Later, less-invasive soft-tissue volume restorationtechniques such as fat transfer and injectable facialfillers were developed to restore soft-tissue volumeloss in the midface.10" '2 Facial fillers are safe andeffective; require a short learning curve; and overthe more immediate term, are cost-effective fortreating mild to moderate soft-tissue volume loss.Numerous specialties have adopted their use inthe office setting, and often commercially producedfillers do not require a physician for their administra-tion. Fueled by increased public knowledge result-ing from direct consumer marketing andadvertising, facial fillers have proliferated in bothnumbers and types during the past few decades.Originally, soft-tissue fillers such as collagen wereused to smooth out superficial changes such asepidermal and dermal rhytids. Over the years,diverse types of fillers offering longer duration timesand improved standards of safety and immunoge-nicity have been introduced to restore volume and

Facial Implants & Fillers 203

contour to the aging face. Fillers are now used totreat nasolabial folds, lips, atrophic scars, theglabella, forehead, and Marionette lines. Thickerversions of hyaluronic acid-based fillers, calciumhydroxyapatite (Radiesse), and biostimulating fillerssuch as poly-L-lactic acid (Sculptra) and polymethyl-methacrylate (Artefill) have also been used forenhancing the volume of the midface, mental, andmandibular regions.12'13 Relying on minimally inva-sive techniques as a sole procedure, however,may harbor inherent limitations that frequently resultin suboptimal short-lived aesthetic effects. Similarly,alloplastic augmentation as a single modality doesnot address certain specific sites, such as the teartrough, the skeletonized periorbita, and the inferiorextension of the submalar hollowing into the lowerthird of the face. These represent potential areaswhere fillers can supplement treatment to achievean improved long-lasting result. Moreover, fillersmay be beneficial in overcoming potential chal-lenges in the perceptual ability to correctly sizeimplants and may ensure optimal volume restorationwhen conservatively choosing a smaller implant.Longevity in patient satisfaction and volume restora-tion can be enhanced with decreased amounts offiller during the postoperative period to improvesite-specific areas. However, the extent and type

of volume loss contributed by both soft-tissue andskeletal changes must be evaluated individually foreach patient to maximize the benefit of multipletreatment modalities.

Chin Augmentation

The goal of chin augmentation is to reposition androtate a rigid soft-tissue envelope to a moreprojected position along the inferior border of themandible. The procedure should optimally expandthe chin in a three-dimensional plane while pre-serving the labiomental sulcus and increase thevertical dimension on the frontal view (Fig. 1).

Anatomically, the soft-tissue "chin button" isa dense structural entity that has limited mobilityor ability to expand because of the followingfactors:

1. The amount of subcutaneous tissue betweenthe deep dermis and underlying mentalis mu-scle is minimal.

2. The mentalis muscle is not only attached to themandible but also intimately intertwined into thesoft tissue of the chin.

3. The anterior mental and more lateral mandibu-locutaneous ligaments hinder the leverage

Fig. 1. Chin implant increases vertical dimension by rotation of soft tissue anteriorly (A) and inferiorly (6).

204 Binder et at

necessary to expand and dissociate the soft-tissue envelope from underlying bone.

Therefore, treatment with either an alloplasticimplant or filler must overcome these factors toimprove the aesthetic outcome.1 Fillers have tradi-tionally been applied to improve a deep labimentalsulcus, soften a peau d'orange deformity, andefface the prejowl sulcus.5 However, all 3 authorsagree that because of the aforementioned ana-tomic inhibitory factors, the projection, rotation,and repositioning necessary for improving theaesthetics of the anterior chin cannot be accom-plished with fillers alone.

DECISION ALGORITHM FOR SELECTINGSURGICAL VERSUS NONSURGICAL OR LESS-INVASIVE APPROACHES FOR MIDFACEREJUVENATION

A thorough understanding of the aging face andaccurate preoperative assessment can guide thesurgeon in selecting the optimal treatment andavoiding undesirable aesthetic results. The treat-ment algorithm depends on each patient's needs,

which are dictated by the relative contributions ofsoft-tissue and skeletal deficiencies.

Filler Alone

In patients with mild to moderate soft-tissuevolume loss and minimal midface skeletal volumeloss, fillers or fat transfer alone can effectively reju-venate the face (Fig. 2). In addition, fillers cansuccessfully treat site-specific regions involvingthe tear trough and skeletonized periorbita, aswell as mild to moderate inferiorly extended sub-malar hollowness (Fig. 3).

The patients in Figs. 2 and 3 were treated withpoly-L-lactic acid (Sculptra) in multiple soft-tissueplanes.

DilutionThe treating author's (J.J.) method includesdiluting the product 1 day before injection.

• The dilution solution includes 7 mL of sterilewater and 3 mL of 2% plain lidocaine.

• Once the product is diluted, it is warmed to100°F to deter from the natural tendency ofthe product to aggregate on the day ofinjection.

Fig. 2. Before (A) and after (B) correction of moderate loss of soft-tissue volume using poly-L-lactic acid applied tothe tear trough, inferior orbital rim, and midface hollow in a case with adequate skeletal structure.

Facial Implants & Fillers 205

Fig. 3. Patient with adequate skeletal development injected to the tear trough, inferior orbital rim, submalarhollow, and prejowl region before (A) and after (8) injection with poly-L-lactic acid.

Anesthesia

• Local anesthesia is administered at 2 injec-tion sites: the first injection site is in the planeof the midpupillary line, and the second isslightly lateral to the lateral canthus.

Injection

• The injection sites are approximately at thejunction of the thin eyelid skin and thickermidface skin.

• A 3-ml_ syringe and a 23-gauge (1.5 in) nee-dle is then used for injecting the productbeginning at the lateral canthus injection site.

• First, the product is injected in a submuscu-lar/supraperiosteal plane along the inferiororbital rim in retrograde fashion.

• Next, the product is injected superiorly alongthe lower eyelid in a supramuscular plane toapproximately 1 cm from the tarsal plate.

• The product is then massaged superiorlytoward the tarsal plate to minimize the needletrauma to this area.

• Next, the needle is placed in the medial injec-tion site and the same injection technique isused to fill the inferior orbital rim, mediallower eyelid.

• A total of 3 ml_ on each side is injected persession.

• The midface and tear trough region may betreated at the same time by injecting intothe dermal-subcutaneous fat junction.

The average patient undergoes 3 sessions duringa 4-month period. Patients tolerate the injectionprocedure with minimal discomfort when injectingin the correct plane.

Treatment of Various Patterns of MidfaceDeformities with Implants

Recognizing patterns of midface deformity isessential for selecting the optimal implant shapeand size to obtain the best overall effects in facialcontouring (Table 1).

Patients with type I deformities exhibit goodmidfacial fullness but have insufficient malar skel-etal development. In these cases, a malar implantcan augment the zygoma and create the appear-ance of a lateral-projecting cheek bone (Fig. 4A).The second deformity (type lla) is characterizedby atrophy of the midface soft tissue and adequatemalar development. The submalar depressiondoes not extend interiorly past the inferior borderof the zygoma into the lower third of the face

206 Binder et al

Table 1Facial deformity types and recommended treatment approaches

Deformity Type

Soft Tissue Skeletal Augmentation Required Treatment Protocol

Mild to Adequate Subcutaneous tissuemoderate loss development volume in site-specific

areas

Type I Adequate volume Malarhypoplasia

Projection over themalar eminence

Type II Submalar volume Adequate(lla/llb) deficiency development

(primarily inupper half ofsubmalartriangle)

Type III Submalar volume Malardeficiency hypoplasia

Requires anteriorprojection

Implant placed overface of maxilla and/ormasseter tendon insubmalar space

Provides midfacial fill

Requires anterior andlateral projection;"volume replacingimplant" for entiremidface restructuring

May use fillers or fat transferfor mild subcutaneous loss,tear trough, skeletonizedinfraorbital rim/periorbita(thin skin). Marionettelines, and nasolabial folds

Conform malar implant:"shell type" extendinginferiorly into submalarspace for improvedcontour

Minimal amount of fillersor fat may be usedadjunctively for asymmetrywith sizing, tear trough,skeletonized intraorbitalrim (thin skin), andsubcutaneous loss

Conform submalar implantFiller or fat for site-specific

areas including lower halfof submalar triangle ifnecessary

Combined midface implant(malar-submalar)

Fills large midfacial voidFillers alone inadequate to

create project necessaryand may result inoverfilling of productand amorphous facialcontour

Adjunctive fillers or fatmay be used forsite-specific areas andsizing issues

(type Mb). The implant must provide a midfacialprojection. Type lla deformities are treated witha conform submalar implant (see Fig. 4B). TypeMb is a subtype II deformity involving a subset ofsubmalar depressions that extend into the lowerthird of the face. This condition is treated eitherwith filler alone or with a submalar implant placedin the submalar deficiency, with filler or fat placedinto the submalar extension lateral to the nasola-bial and Marionette line. A third variation (type IIIdeformity) arises from combined malar hypoplasiaand midfacial soft-tissue volume loss (seeFig. 4C). In this deformity, described as the"volume-deficient face," a combined implant

(malar-submalar) or the new conform midfacialimplant proportionally augments the deficientskeletal structure while filling the void created bymidfacial volume loss (Fig. 5).

PATIENT SELECTION

The normal aging process commences betweenthe third and fourth decades of life and rapidlyaccelerates through the fifth and sixth decades.This is consistent with Shaw's finding that statisti-cally significant losses in skeletal volume occurredon average between the ages of 24.7 and50.2 years.6 Although prospective candidates

207

Type Ideformity

Malarimplant

B

Type IIdeformity

f

,

\rimplant

\e III

detormrty

CombinedsuOmaiar

sheli tmpian!

\. 4. Implant placement by facial deformity type. (A) In type I deformity, malar shell implants rest in a more

superior and lateral position over the malar and zygomatic bone. (B) Submalar implants for type II deformityare situated over the anterior face of the maxilla. (Q For type III, combined malar-submalar implants coverboth the malar bony eminence and the submalar triangle. (From Binder WJ, Kim BP, Azizzadeh B. Aestheticmidface implants. In: Azizzadeh B, Murphy MR, Johnson CM, editors. Master techniques in facial rejuvenation.Philadelphia: Saunders; 2007. p. 197-215; with permission.)

208 Binder et al

Fig. 5. Patient with soft-tissue and skeletal volume loss before (A) and after (B) treatment with alloplastic implan-tation of the midface.

typically present during the midlife or later years,the surgeon's ability to recognize structural andsoft-tissue defects and alterations in anatomyplays a critical role in assessing a patient's eligi-bility for facial rejuvenation procedures. Beforeproceeding with any aesthetic procedure, assess-ing both the psychological status and medicalcondition of the patient is paramount. In addition,a thorough preoperative evaluation should ad-dress the patient's goals, management of expec-tations, and informed consent.

PREOPERATIVE PLANNING

Patients are instructed to withhold aspirin, nonste-roidal antiinflammatory drugs (NSAIDs), herbalsupplements, and any other anticoagulant therapyfor approximately 10 to 14 days.

PATIENT POSITIONING

• Markings are applied with the patient in theupright position before performing any reju-venation technique.

• Facial fillers are typically injected in theupright to semirecumbent position.

• Implants are generally placed in an operatingroom setting, with the patient in a supineposition.

• If the patient is intubated, it is important toavoid distorting the facial anatomy whensecuring the endotracheal tube to the face.

POTENTIAL COMPLICATIONS AND THEIRMANAGEMENT

Both traditional and minimally invasive approachesto facial rejuvenation can benefit from properpreoperative planning to minimize the risk ofpotential complications and maximize patientsatisfaction. Overall, technique-dependent andpatient-dependent variables can also contributeto the degree of expected complications. Earlyinjection site reactions, including swelling, bruis-ing, and erythema at the injection site, have beenreported in more than 90% of subjects treatedwith soft-tissue fillers in clinical studies.14 How-ever, in practice, the extent of superficial traumadepends on the gauge of the needle and viscosityof the filler; more viscous fillers requiring larger nee-dles can lead to greater disruption of the dermalstructures, with subsequent capillary leakage,

Facial Implants & Fillers 209

edema, and inflammation.14 In addition, the loca-tion of the injection may determine the extent oflocal trauma. For example, swelling and bruisingcan occur more frequently after injections of fillerin highly vascular areas, such as the lip or teartrough sulcus. Typically, swelling and bruising afterthe injection of soft-tissue fillers can persist for 4 to7 days but may be minimized by advising thepatient to avoid aspirin, NSAIDs, and vitaminsupplements for 7 to 10 days before the procedure.Hypersensitivity reactions to dermal fillers, particu-larly those containing bovine collagen, pose a theo-retical risk but have been reported in the publishedliterature.14 In addition to these potential complica-tions, improper technique and/or injection of toolittle or too much filler can lead to undesirableaesthetic results or lack of longevity (Fig. 6). Migra-tion and asymmetric resorption of tissue fillers mayalso occur (Fig. 7).

Catastrophic complications include vessel injurythan can result in skin infarction and ultimately skinloss. These complications are minimized when in-jecting within the correct plane. Injections of poly-L-lactic acid (Sculptra) as described earlier to theperiorbital and tear trough region may potentiallypresent with nodule formation, which typically

Fig. 6. Injection of excessive volumes of filler into themedial aspect of the midface can result in overfillingof the midface and an amorphous facial contour.

Fig. 7. Coronal computed tomographic image demon-strating calcium hydroxyapatite injected into the mid-face with migration and asymmetric resorption.

occurs in about 5% to 7% of the treated patients.9When visible or palpable to the patient, thenodules may be injected intralesionally with anequal dilution of triamcinolone acetonide (Kena-log), 10 mg/mL, and 5 Fluorouracil. Injections areadministered at 30- to 45-day intervals, and mostnodules resolve. Surgical removal is not indicatedfor most cases.

Fat transfer, an acceptable method for reme-dying medial and central rim skeletonization, canalso lead to complications. This approach gainedpopularity in the late 1990s and was championedby advocates such as Coleman.10 Long-termfollow-up, however, revealed a great deal of vari-ability in the amount of fat that remained viableafter harvest and injection, leading to the needfor multiple treatments. Moreover, complicationssuch as persistent fat nodules or lumps along theorbital rim occurred postoperatively.15 Retainedfat has also been found to preserve the donorsite characteristics, which increases its volumeindependently and amorphously with substantialweight gain.16'17

As with soft-tissue fillers, postoperative edemaafter implant placement is not uncommon. Ap-proximately 80% to 85% of edema resolves within3 to 4 weeks.9 Incorrect placement, insufficientpocket size, or inadequate fixation of the implantcan cause malpositioning of the implant; however,the implant should not extrude if proper techniqueis followed. Other complications include bleeding,hematoma, seroma, fistula, pain, and persistentinflammatory action. Approximately 1% of pa-tients receiving alloplastic silicone implants de-velop postoperative infections.16 Infraorbita/ andfacial nerve injury may also occur but is rarelypermanent.

210 Binder et al

POSTPROCEDURAL CARE AND RECOVERYFillers

Typically, no analgesics are prescribed for routinepain management in the postoperative period.The acute edema and erythema may be treatedwith ice packs for the first 24 hours. Follow-upcare is scheduled for 7 days after the procedure.Patients are instructed to contact the treatingphysician if signs of vascular compromise or im-pending skin necrosis occur, such as extremepain, superficial skin changes, fever, or expandingmass.

Implants

Facial implants are performed as an outpatientprocedure, and patients usually recover at home.Antibiotics, analgesics, and antiemetics are pre-scribed, and patients are advised to apply ice packsfor 3 to 4 days and to sleep, or rest, with the headelevated. The initial postoperative visit typicallyoccurs on the first or second day and the facialdressings, external sutures, and drains are removedif applicable. Most patients resume routine activityas early as 5 to 7 days postoperatively.

PROCEDURAL APPROACHESFillers

The choice of filler used varies depending on thepatients' specific needs and goals.

Hyaluronic acids are used for patients whowant an immediate but reversible correction withhyaluronidase. Permanent fillers approved by theUS Food and Drug Administration, such as poly-methylmethacrylate (Artefill), can also be sub-stituted for soft tissue, as well as for skeletalaugmentation. However, once injected, it cannotbe removed.

One of the authors (J.J.) often injects calciumhydroxyapatite supraperiosteally to augmentdeficiencies in the skeletal support structure anduses poly-L-lactic acid injected in the dermal-subcutaneous fat junction to replace lost softtissue in the midface and tear trough. These fillershave biostimulatory properties and confer longer-lasting effects over hyaluronic acid fillers whenused for these indications.

Midface Implantation

Surgical insertion of midface implants is a simple,straightforward procedure, which can be per-formed by an experienced surgeon in less than30 minutes using intravenous sedation or generalanesthesia. The implants are soaked in anantibiotic solution before insertion. During theoperation, the surgeon should have access to

a variety of implant sizes and shapes andmust be prepared to customize the implants ifneeded.

Chin Augmentation

Chin augmentation using alloplastic implants isa technically simple procedure that releases theanterior mental ligaments and allows for reposi-tioning of the soft-tissue button to a more anteriorand projected position. The implant is placedexternally through a submental incision or via anintraoral incision along the inferior gingival sulcus.The implant procedure can generally be com-pleted in less than 30 minutes.

The authors typically use the external route viaa 1.0- to 1.5-cm submental incision. Technicaland aesthetic advantages of the external ap-proach include preservation of the labiomentalsulcus by avoiding disruption of the mentalismuscle attachment to the mandible, avoidanceof intraoral bacterial contamination, direct accessto the mandibular border where the cortical boneis present, limited retraction of the mental nerve,the ability to easily detach the anterior ligamen-tous attachments near the submental incisionsite, and the ability to fixate the implant alongthe inferior mandibular border. Using eitherapproach, however, the surgeon must maintaindissection directly on bone in a subperiostealplane to create a firm, secure attachment of theimplant to the bony skeleton. One may finda condensation of fibrous attachments just lateralto the midline of the mentum. It is often necessaryto incise and detach these tendinous attachmentsto allow dissection to continue along the inferiorsegment of the mandible. Failure to recognizethese attachments may direct the lateral plane ofdissection superiorly, placing the mental nerve atrisk. Continued dissection laterally also providesan exponential benefit by elevating the deep peri-osteal attachments of the mandibulocutaneousligament.

COMPARISON OF TRADITIONAL VERSUSMINIMALLY INVASIVE SURGICALAPPROACHES

Published studies indicate that malar augmenta-tion with fillers can also enhance the upper cheekby secondarily lifting and elevating parts of thelower face. Theoretically, the volume of fillerplaced into the midface augments and elevatesthe soft tissue in an anterior-posterior plane. Onestudy of midface hyaluronic acid augmentationused an average volume of 3.9 ml_ in 72 patients(mean age, 43.6 years) and demonstratedsatisfactory results lasting from 4 to 64 weeks

Facial Implants & Fillers 211

(approximately 1-16 months). Midface volumeenhancement in cases with ample skeletal struc-ture may in fact elevate the lower third of theface; however, as facial skeletal volume decreasesduring midlife, augmentation of the soft-tissueplane without skeletal foundation does not allowfor adequate suspension of the face and, thus, ismore susceptible to gravitational forces. Thischange produces a deeper nasolabial fold andjowl, as well as aggregation of fillers in dependentareas, and can produce an amorphous facialcontour (see Fig. 6).

On the other hand, implantation can offera permanent, more durable option that is com-pletely reversible, and the implant can be removedand replaced under local anesthesia with minimaldissection. Collectively, these benefits make mid-face augmentation with implants an attractiveoption for enhancing volume over the long term.This technique also requires a substantially lessamount of filler for rejuvenating the aging faceover a protracted period.

CONCLUSION ON VOLUMIZING THE FACE

Minimally invasive and facial implantation tech-niques are safe, effective options for volumizingthe aging midface and chin. Achieving the optimalaesthetic result requires an understanding of themultidimensional aging process involving theskin, deep soft tissue, and facial skeleton. Fillershave proved to be a noninvasive option for finerhytids, nasolabial folds, prejowl sulcus, and thelabiomental crease. In addition, facial fillers canalso be used for facial contouring in patients withminimal facial bone resorption to achieve midfacerejuvenation.

However, the role of alloplastic implantation asa sole modality or in conjunction with either othersurgical procedures or minimally invasive soft-tissue augmentation techniques must be consid-ered during the preoperative consultation forboth midface aesthetic contour enhancementand facial rejuvenation in patients with skeletalvolume resorption. Although chin augmentationwith alloplastic implants remains the optimal treat-ment modality available, using alloplastic implantsin combination with minimally invasive approachesmay allow the surgeon to address multipleanatomic deficiencies and can promote greatercustomization of facial rejuvenation techniques.

SUPPLEMENTARY DATA

Supplementary data related to this article can befound online at http://dx.doi.org/10.1016/j-fsc.2013.02.001.

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