Three-Dimensional Alloplastic Midface Volumization



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.






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.






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.






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.






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.


Oct 7, 2018 | Posted by in OTOLARYNGOLOGY | Comments Off on Three-Dimensional Alloplastic Midface Volumization

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