Three-Dimensional Alloplastic Midface Volumization
Edward O. Terino
INTRODUCTION
Public demand and expectations for aesthetic facial surgery, in both males and females, have increased dramatically over the last two decades. This has challenged surgeons and scientists to develop more natural and longer-lasting enhancements that are safe, ethical, and scientifically validated. Today’s augmentation technology far exceeds earlier fads such as the well-publicized 1970s silicone injections to accentuate “cheekbones” and facial contours. Such interventions resulted in horrific complications and ultimately led to the necessary medical advances seen today.
At the turn of century, the search for safer and more durable alloplastic materials continued to develop out of necessity in the treatment of contour defects secondary to congenital (e.g., cleft deformities) or traumatically acquired (e.g., modern warfare, automobile accidents) facial skeletal deformities. Among the first materials used successfully were nonreactive metals such as stainless steel and Vitallium. The past four decades of scientific research in solid-state synthesis, material sciences, and facial contour aesthetic theory have yielded a new applied clinical science with an armament of tools that are reliable, reproducible, and minimally invasive. These surgical techniques can be permanent, but are easily reversible, if required.
Effect of Altering the Facial Skeleton
When we look at a person, our attention inevitably focuses on the eyes, lips, eyebrows, and hair. Yet, these are merely the adornments of the underlying facial framework. What determines the full extent of a person’s facial physical appearance is the unique volumetric contour created by their underlying skeletal architecture. The skin is the canvas of the face. When distributed over the facial framework, in a smooth and attractively contoured manner, it presents a youthful and aesthetically pleasing appearance. As years go by, this canvas becomes coarse and wrinkled, while the underlying soft tissues and bone atrophy in accordance to the genetically programmed process of aging. Every face takes on the stigmata of advancing age.
When a surgeon strategically augments the underlying bony architecture of the aging face, a new and dramatic visage can be achieved. Although people are clearly identifiable by their individual facial features, a more general and youthful appearance can be achieved with the purposeful augmentation of their underlying bony architecture. Stated differently, balance in facial volume is what gives the face its maximum harmony, which is perceived as beauty.
Interrelationships of the Facial Promontories
There are three major facial promontories of volume and mass. In order of importance, they are the nose, the two zygomatic-malar eminences, and the chin-jawline (Fig. 33.1). The supraorbital ridges constitute a fourth promontory, which is of lesser significance and will not be discussed in this chapter. By altering the
interrelationships of these three major promontories, a surgeon can uniquely create or restore facial harmony, balance, and beauty. By mathematical law, the diminution or enhancement of any one of the three promontories directly and inversely affects the aesthetic importance of the others (Fig. 33.2). Over the decades, facial surgery has evolved dramatically. Surgical procedures that were once simple skin-tightening techniques now entail the complementary restoration of anatomic suspension and facial volumization.
interrelationships of these three major promontories, a surgeon can uniquely create or restore facial harmony, balance, and beauty. By mathematical law, the diminution or enhancement of any one of the three promontories directly and inversely affects the aesthetic importance of the others (Fig. 33.2). Over the decades, facial surgery has evolved dramatically. Surgical procedures that were once simple skin-tightening techniques now entail the complementary restoration of anatomic suspension and facial volumization.
 FIGURE 33.1 Artist’s rendering of facial architecture illustrating major promontories of mass and volume: the nose, malar-midface, and mandible jawline. |
The restructuring of the various facial layers still has limitations. Patients who display round, full, fleshy facial contours with an abundance of subcutaneous adipose tissue rarely typify the aesthetic ideal placed forward by contemporary standards. This is also observed among exceptionally lean individuals who display a longer facial contour with inadequate skeletal promontories in the malar and/or mandibular regions. It is within these extremes of facial types, as well as innumerable patients who have combinations of volume deficiencies in varying anatomic locations, that significant improvements in facial harmony can be achieved with targeted alloplastic augmentation techniques. Furthermore, contour surgery of the facial skeleton should also be complemented by a wide variety of other sound coordinated facial procedures (Fig. 33.3).
Zonal Anatomy of the Malar-Midface Region
The region of the facial skeleton that, when appropriately augmented, produces an aesthetic change in the midfacial contour can be called the “malar-midface space.” To determine the most aesthetic augmentation of this region, it is useful to partition the midface into five distinct anatomic zones (Fig. 33.4). By understanding these five zones, and their interrelationships, the surgeon can vary cheek and midface shapes to accommodate each unique patient.
Zone 1, the largest area, includes the major portion of the malar bone and the first third of the zygomatic arch. Augmentation of this entire zone produces the greatest volumetric filling of the cheek and also maximizes the projection of the maxillary eminence (Fig. 33.5).
Zone 2, the second most important site, overlies the middle third of the zygomatic arch. Enhancement of this zone along with zone 1 increases accentuation of the cheekbone laterally, giving a broader dimension to the upper third of the face and creating a high-arched appearance. This change in contour is particularly useful for individuals with a narrow upper face or a long-face syndrome. When, however, zones 1 and 2 are augmented in excess, an abnormal and unattractive protuberance may result (Fig. 33.6).
Zone 3 is the paranasal area, which lies medial to the infraorbital foramen. A line drawn vertically down from the infraorbital foramen marks the medial extent of the usual dissection for malar augmentation. This line also represents the lateral border of zone 3. When paranasal augmentation in zone 3 occurs, medial fullness of the face is created, often in the upper nasolabial area, which can be highly unattractive. The skin and
subcutaneous tissues are notably thin, and any implant placed there must be carefully sculptured and tapered. Augmentation of zone 3 is indicated for certain reconstructive purposes, following trauma or other heredity deficiencies (Fig. 33.7). Often this deficiency is accompanied with adjacent zone 1 and 2 deficiencies, which commonly need volume correction.
subcutaneous tissues are notably thin, and any implant placed there must be carefully sculptured and tapered. Augmentation of zone 3 is indicated for certain reconstructive purposes, following trauma or other heredity deficiencies (Fig. 33.7). Often this deficiency is accompanied with adjacent zone 1 and 2 deficiencies, which commonly need volume correction.
 FIGURE 33.2 Example of a 36-year-old male with disproportion and imbalance of malar midface to the mandibular chin-jawline aesthetic segment. A dramatic improvement in facial harmony was created by augmenting the central mentum, mandibular angles, and malar region. |
Zone 4 overlies the posterior third of the zygomatic arch. Augmentation in this area is never needed, as it would produce an unnatural appearance. Moreover, dissection here may be dangerous, since it is very possible
to injure the zygomaticotemporal or orbicularis oculi branches of the facial nerve. Infrequently, deformities have been observed that resulted from operations in this area.
to injure the zygomaticotemporal or orbicularis oculi branches of the facial nerve. Infrequently, deformities have been observed that resulted from operations in this area.
 FIGURE 33.3 A 56-year-old female who demonstrates the significant benefits from upper midface suspension, malar-submalar augmentation, and rhytidectomy techniques. |
 FIGURE 33.4 Anatomic facial contour zones of the midface. These are critically important in understanding the aesthetics of the face when choosing the proper location to place an implant to achieve a desired appearance. |
 FIGURE 33.5 Three examples of type 1 face with relative or absolute malar-zygomatic deficiency. Postoperative views show attractive malar-midface contour from zone 1, 2 malar volume enhancements. |
Zone 5, the submalar zone or “submalar triangle,” is bounded posteriorly by the tendinous surface of the masseter muscle and anteriorly by the canine fossa region of the maxilla. The superior boundary of zone 5 is the inferior margin of the malar bone, which constitutes the first two-thirds of the zygomatic arch. The medial
extent of the submalar space ends at the lateral border of the nasolabial mound and sulcus. Its anterior limit is bounded by the inferomedial portion of the roof of the entire malar-midface space. It contains the overlying facial musculature, fat, skin, and subcutaneous of the midface region. The inferior limit is selected by the surgeon, the natural dissection plane that separates the masseter from the overlying facial musculature according to the desired configuration of midface fullness selected by the patient.
extent of the submalar space ends at the lateral border of the nasolabial mound and sulcus. Its anterior limit is bounded by the inferomedial portion of the roof of the entire malar-midface space. It contains the overlying facial musculature, fat, skin, and subcutaneous of the midface region. The inferior limit is selected by the surgeon, the natural dissection plane that separates the masseter from the overlying facial musculature according to the desired configuration of midface fullness selected by the patient.
 FIGURE 33.6 A 35 year-old model whose postmalar-zygomatic implant appearance that is too strong and skeletal looking due to the wrong implant size, shape, and position. Postoperative view shows significant improvement by using a generous malar shell in zone 1 and SM5. |
 FIGURE 33.7 A 41-year-old male, with extreme suborbital volume deficiency. Postoperative view taken 1 year following correction with a combined tear trough-malar implant (large size with 5-mm tear trough thickness and a malar thickness of 4 mm projection (placed through a transconjunctival approach). |
Today, we find ourselves in a new era of facial augmentation with an ever-expanding armatorium including classical tissue transfer, injectable fillers, and alloplastic implants. Recent history has seen the introduction of silicone rubber (Silastic), Proplast I and II, Mersilene, Teflon, Dacron, Gore-Tex, acrylic, methyl methacry-late, polyethylene, and hydroxyapatite, among others. We will endeavor in this chapter to describe the facial architectural concepts I developed for a more anatomically precise and reproducible result in alloplastic facial rejuvenation.
HISTORY
When evaluating a patient for total alloplastic facial augmentation, the following items are used in the history of the patient as part of the global assessment:
What problem does the patient want you to solve?
Get the patient’s verbal description of his/her “ideal scene” appearance of facial change.
Patient “homework assignment”: Bring magazine photos of specific “do’s and don’ts” on desired anatomic part changes.
Have older patients bring a variety of earlier personal photos
Use computer face photos (5 views) and imaging technology to do the consultations.
Use an anatomic facial zone model and facial type analysis as an integral part of the physical exam.
Additionally, for each patient, a comprehensive past medical and surgical history is obtained. By nature, surgical facial augmentation is an elective procedure, and each patient is to be assessed with regard to suitability to undergo a general anesthesia. Conditions including diabetes, coagulopathy, autoimmune, congenital, and syndrome are evaluated on a case-by-case basis. Questions regarding previous surgical interventions and radiation treatments are of importance and can have considerable surgical repercussions.
PHYSICAL EXAMINATION
Understanding of the facial contour according to one of the following facial types can facilitate the process of physical examination:
Type 1 facial aesthetic consists of a deficiency in the upper malar bone segment of the malar-midface. This specific contour weakness encompasses zones 1 and 2. Augmentation of zone 1 creates upper cheek fullness that pleasingly simulates bony contour. When a large implant is used to augment zone 2, as well as zone 1, widening of the upper midface occurs, which shortens the appearance of a long and narrow face.
The transverse dimensions of the malar bone in the upper malar-midface measure from 4.5 to 6.5 cm from the infraorbital foramen to the posterior third of the zygomatic arch. Vertically, there is, on average, 3.0 to 4.0 cm in distance from the lateral canthus to the inferior margin of the malar bone. Overaccentuation of zone 1 in females may result in a masculine, sharp, angular, harsh, or skeletal appearance.
Type 2 facial aesthetic deficiencies consists of a soft tissue contour depression specifically in the lower aspect of the midfacial aesthetic unit called the submalar zone 5 (SM5) or submalar “triangle.” This deficiency resides over the masseter tendon and the canine fossa lying under the inferior border of the malar bone and zygomatic arch. A large malar shell implanted over the inferior aspect of the malar bone in zone 1 and extending into the submalar space below the border of the malar bone creates the illusion of a round, full “apple cheek” in females.
The soft tissues overlying the skeleton of the midface, malar, and submalar areas undergo environmentally influenced predetermined genetic-based atrophy. A modest 3- or 4-mm implant thickness can augment and rejuvenate an aging face.
Augmenting the submalar region creates the youthful appearance of soft tissue fullness in the midface as well as the illusion of a larger malar bone. This is especially useful in the aging face where atrophy and the midface soft tissue descent create a more pronounced nasolabial fold. The inferior limit of the submalar zone space is variably created by dissecting the soft tissue roof (buccinator, zygomaticus muscles, and superficial musculoaponeurotic system [SMAS]) from the masseter tendon. As the SM5 space is dissected and augmented in a more inferior direction, a larger, rounder cheek contour is produced, which simulates both bony and soft tissue fullness. This type of midface contour is exemplified in the images of actresses Bo Derek and Linda Evans or today’s Angelina Jolie.
By definition, a comprehensive augmentation of the entire malar-midface unit may require an implant shell with maximal transverse dimensions of 5.5 cm across and 4.5 cm vertically. A type 2 face has adequate malar bone prominence but is deficient in similar soft tissue volume. This creates a flat, older, midface contour. This frequently occurs in the aging face of both males and females. In a young individual with strongly defined cheekbones and yet deficiencies in the midface soft tissues, a similar augmentation produces aesthetic softness and adds youthful fullness to the face. Some people feel strongly that a similar implant can lift the nasolabial sulcus and give the illusion of facial tightening that will postpone the perceived need for rhytidectomy. The authors have not observed this occurrence and favor volume filling of the midface just posterior to the nasolabial mound in order to de-emphasize the appearance of fullness and simultaneously correct the soft tissue volume deficiency in the midface.
Type 3 facial aesthetic deficiencies consist of a very strong malar-zygomatic superstructure and a very sunken submalar infrastructure. Such faces often have thin skin and subcutaneous support requiring a generous submalar augmentation with a projecting implant thickness (5 to 8 mm). This facial type occurs with aging as well as from ancestry (Fig. 33.8). The appearance is that of an emaciated, drawn, haggard, and even sick countenance. This can result from soft tissue disease states such as Romberg’s hemifacial atrophy and HIV lipodystrophy. The remedy, for any etiology, is the same: a generous volume filling of the SM5 (Fig. 33.9).
Type 4 facial type consists of extreme volume deficiency in both malar zones 1 and 2 and the SM5 regions and may also include the suborbital and paranasal zone 3 areas. It is more common in men than in women. It is identified by a “flat face” appearance. It also has been described as the “polar bear” syndrome because of a suborbital skeletal deficiency, which contributes to a proptotic, bulging appearance of the globe
of the eye. Due to bony deficiency of the infraorbital region, a downward or vertical descent of the lower eyelid may result in scleral show.
of the eye. Due to bony deficiency of the infraorbital region, a downward or vertical descent of the lower eyelid may result in scleral show.
 FIGURE 33.8 Upper left photo (A) shows a 28-year-old female who disliked her inherited submalar soft tissue recession, while (B) demonstrates a 47-year-old female with aging midfacial atrophy resulting in a tired haggard emaciated look. Submalar zone 5 is anatomically below the lower border of the malar bone. It may be volume deficient either by heredity (A) or from aging atrophy (B). An appropriate submalar implant placement provides excellent aesthetic improvement. |
 FIGURE 33.9 Tissue atrophy occurs universally with the aging face. When there is adequate malar bone prominence in a type 2 or type 3 face, a large malar shell placed in the submalar region (SM5) restores a youthful fullness to the face. |
A comprehensive shell implant that fills the medial tear trough, the suborbital rim, and the upper malar zones improves this aesthetic imbalance significantly. For some patients, a large shell implant to fill malar zones 1 and 2 as well as SM5 is all that is necessary. Theoretically, the shell implant may also add support and elevate the eyelid into a more attractive horizontal position. However, lateral canthopexy techniques may be necessary to benefit patients with this facial type.
Type 5 aesthetic facial deficiency exists as a weakness of facial structure in the suborbital “tear trough” region. This creates a tired and “hollow” appearance around the eyes, especially in the lower orbital region. There may also be a tendency for the eyeball itself to look proptotic due to the “negative vector” orbit (Fig. 33.10).
 FIGURE 33.10 Before and after pictures of a patient with a type 4 face demonstrating the improvement of an extreme volume deficiency of the entire maxilla and a “negative” vector suborbital bony rim using a comprehensive extended tear trough-malar shell. This helps to correct a flat or dish-face appearance. |
 FIGURE 33.11 Illustration showing a suborbital tear trough-malar implant and the technique for insertion around the infraorbital nerve. |
Volume deficiency in this area is especially viewed to be unattractive in females. A uniquely designed tear trough implant that extends from the medial canthus to the lateral orbital malar rim considerably improves this deficiency.
Adipose tissue grafting along the inferior orbital rim has been considered by some to be advantageous but by others to be of high risk. In general, my experience is that all autologous soft tissue grafting in this region manifests unpredictable shrinkage and may produce irregularities or result in negligible improvement with added risks.
When this volume deficiency is also accompanied by significant malar-zygomatic hypoplasia, the new suborbital tear trough-malar shell (SOTTM) is indicated (Fig. 33.11). Autogenous tissue transplants of adipose tissue, muscle, galea and temporalis fascia into this area by a variety of authors have been only partially successful because all autologous grafts, due to unpredictable cell death, demonstrate variable shrinkage and contour irregularities. Their success and complication rate are still debated. More recent techniques for suborbital orbicularis oculi fat (SOOF) infraorbital dissections which release and elevate the suborbital cheek and malar soft tissue structures beneath the orbital rim and transpose intraorbital adipose tissue exist are more successful in correcting this deficiency but still remain dependent on the locally available tissue mass.
Tissue repositioning techniques whether “Deep Plane,” “FAME,” “SOMME,” or “Subperiosteal” are still undergoing evaluation for their long-term persistence and reproducibility. Used in conjunction with the guaranteed permanence of alloplastic malar or suborbital augmentation, this tissue repositioning achieves optimum aesthetic appearances and reproducible surgical results. A silicone rubber implant has been specially designed to fit around the lower pyriform aperture. It is easily placed either directly onto the bone through intraoral or intranasal incisions. Its natural anatomic shape and posterior contour provide stability when positioned properly (Fig. 33.12).
In my practice, physical examination is conducted with the aid of computer imaging to provide a more objective analysis of the patient’s anatomic contours. Using a mirror held by the patient is also necessary.
Facial Asymmetries
One of the most important points in the physical examination is to identify precisely the various asymmetries, which the patient’s face has both bone and soft tissues. It is imperative to get the patient to understand the severe limitations in correcting them. Natural facial asymmetry is universal. A form of hemifacial microsomia occurs
in more than 90% of patients. On careful examination, the left and right side of the face are usual quite different in size, shape, or volume. One side is wider and has a greater volume of bone and soft tissue. Also, one orbit, eyebrow, and eye complex is usually lower than the other (Fig. 33.13).
in more than 90% of patients. On careful examination, the left and right side of the face are usual quite different in size, shape, or volume. One side is wider and has a greater volume of bone and soft tissue. Also, one orbit, eyebrow, and eye complex is usually lower than the other (Fig. 33.13).
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