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Oral Maxillofac Surg8:1420-1429, 2010
Essentials of Cheek and Midface Implants
Joe Niamtu III, DMD*
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his author has placed cheek implants sporadically forhe past 25 years. Previous to 2004, expanded polytet-afluoroethylene cheek implants were used, but sincehat time, only Silastic implants (ImplanTech, Ventura,A) have been placed.Since 2004, the authors practice has been limited
o cosmetic facial surgery and with this focus manyore implants were placed as a solitary procedure orore commonly with facelift or other cosmetic pro-
edures. From January 2004 to December 2007, 204ilastic cheek implants were placed in 102 patients.f these 204 implants, 3 implants were removed due
o infection for an infection rate of 1.5%. All 3 of theseere replaced after resolution of the infection. Threether patients had implants electively removed andeplaced with different size implants for a replace-ent rate of 3%. A single patient electively had im-lants removed and not replaced for an elective re-oval rate of 1%.In the authors experience, most implant infectionsanifest early in the recovery period, usually within
2 hours. The clinical manifestations are very similaro maxillary dentoalveolar infections and present withain, swelling, erythema, purulence, and drainage
rom the incision site. Delayed infections have beenare and could be associated with a mobile implantroducing a foreign body reaction or a sinus or dental
nfection whose spread can involve the implant.When a patient presents with a suspected infec-
ion, he or she is placed on antibiotics and, if there israinage, the incision is opened. Salvage may be at-empted for implants that have been secured withigid fixation screws and are not mobile. Any infec-ion associated with a mobile implant requires explan-ation. For the secured infected implant, the incisions opened and the purulence is expressed and thentire surgical site is copiously irrigated with an ap-ropriate antibiotic irrigation solution. The incision isot resutured and the patient is seen daily for irriga-ion. The author has salvaged several implants by this
*Private Practice, Richmond, VA.
Address correspondence and reprint requests to Dr Niamtu, III:
iamtu Alexander Keeney Harris and Associates, Oral/Maxillofacial
nd Cosmetic Facial Surgery, 10230 Cherokee, Richmond, VA
3235; e-mail: [email protected]
2010 American Association of Oral and Maxillofacial Surgeons
278-2391/6806-0035$36.00/0
boi:10.1016/j.joms.2009.12.004
1420
ethod and the incision will granulate and healingan be uneventful. If the infected implant does notuickly respond to this conservative therapy, ithould be removed. Cultures and gram stains areerformed before any surgical therapy. The authoroes not attempt salvage procedures on smokers, ashe continual perioral movement and fresh smokeecrease the chance of success.Reimplantation is always an option after infection
nd the author usually waits about 6 weeks for reim-lantation.Over the 48-month period, the author performed
27 facelifts and 27% of these patients (62/227) hadoncomitant cheek implants placed, underlining thetility and popularity of this procedure (Table 1).Table 1 shows the number of midface implants
imultaneously used in facelift patients.
iscussion
THE AGING MIDFACE
The aging midface is one of the most overlookedreas in cosmetic facial surgery. Many well-knownurgeons perform extensive surgery on the upper andower face and overlook the midface. One of theroblems associated with cosmetic facial surgery overhe past 30 years was the fact that after surgery weften made the patients face look tighter, but notounger. One of the primary advances in cosmeticacial surgery has been the realization of volume lossn aging and volume replacement in cosmetic surgery.ontemporary cosmetic facial surgeons routinely ad-ress midface issues in many ways; by making smallorrections in the midface, big changes are realized inhe final result. Synergy results in the situation whenhe total is greater than the sum of the parts; thishenomenon is common with simple midfacial aug-entation.Beauty equals youth and youth equals facial vol-
me. One of the main reasons that a person looksoung or beautiful is the abundance of midfacial vol-me. It short, it involves having the right amount ofat in the right areas of the face. It is the loss orenescent repositioning of this fat that is a main con-ributor to facial aging.1
The youthful midface is discernable as a singleonvexity in harmony with the lower eyelid esthet-cs, as shown in Figure 1A. In the younger patient,he lower eyelid periorbital fat is not visualized
ecause it lies tight behind the orbital septum.
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ging changes cause weakening of the lower eyelidrbital septum, resulting in pseudoherniation of the
ower orbital fat pads; this change is coupled withging changes to the overlying skin. The sum ofhese changes produces a double convexity profile,s shown in Figure 1B.
The youthful midface has voluminous and supe-iorly positioned malar fat pads. The malar fat pad istriangular structure with its base against the na-
olabial fold and its apex over the malar regionFig 2).
Due to actinic and senescent skin changes as wells gravity, fat atrophy, and deep connective tissueaxity, the malar fat pads lose volume and descendower into the face with age (Fig 3). The sum of theseging changes frequently yields a hollow or gauntidface.
TREATMENT OPTIONS
A plethora of treatment options for midfacialejuvenation include lifting procedures,1-7 inject-
IGURE 1. The youthful midface (A) consists of a single convexity,hile periorbital and midface changes produce a double convexity
acial curvature (B).
Table 1. SILASTIC CHEEK IMPLANTS WITHFACELIFT SURGERY
YearNumber of
FaceliftsNumber of CheekImplants (pairs) Percentage
2004 35 12 342005 47 13 282006 67 18 262007 78 20 26
Total 227 62 27
oe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg010.
moe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg010.
ble synthetic fillers,8-12 autologous fat,13-16 and fa-ial implants.17-21 Each treatment option carries ad-antages and disadvantages but, in this the authorspinion, midface implants are an optimum choice inhe average patient for multiple reasons. The maindvantage is that they are a permanent option whenompared with fillers and lifting procedures. Theheek midface implants lie in the subperiosteal plane,ight to the bone, and are not subject to the soft tissuehanges of the more superficial planes. In addition,hey are available in a vast array of anatomical sizesnd shapes to customize augmentation. They are eas-ly placed; the recovery is minimal, and the compli-ation rate is low. The silicone structure rendershem very biocompatible and they are not subjecto degradation seen with fillers and fat grafts. Fi-ally, and very importantly, they are very revers-
ble. Should the surgeon or patient be unhappyith the result, the implants are easily removednder local anesthesia, or they can be exchangedor larger or smaller sizes with minimal dissection.ecause silicone forms a well-developed capsule,he implants are much more easily removed oreplaced with no tissue damage compared withmplant materials that encourage tissue ingrowthhat complicates removal. The aforementionedoints make the placement of midface implants for
IGURE 2. The youthful malar fat pad has volume and lies superiorn the midface.
oe Niamtu. Cheek and Midface Implants. J Oral Maxillofac Surg010.
idfacial rejuvenation a very attractive procedure.
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1422 CHEEK AND MIDFACE IMPLANTS
FACIAL IMPLANTS
Cheek implants have existed for decades and haveallen in and out of favor for various reasons. One ofhe biggest problems with early implants was the lackf anatomical form. The early implants and the advo-ated positioning of them produced blocky andnnatural results that were very apparent. They werelso usually placed high in the zygomatico malar com-lex, giving patients an exaggerated and unnaturalppearance.
The last decade has brought a refinement of bothmplant form and placement. Contemporary midfacemplants are available in many sizes and shapes andave different indications dependent on the estheticeed. These anatomical implants have also given wayo more conservative surgical approaches that againre designed to provide targeted, precise, and natural-ppearing augmentation specific to various regions ofhe midface. Finally, with computer-assisted design/omputer-assisted manufacturing technology, cus-omized facial implants can be fabricated to personal-ze the augmentation as well as to correct defects andsymmetries or to accommodate personal prefer-nces on the part of the patient or surgeon.
IMPLANT SELECTION
Implants can be placed in most patients. Smokersan be problematic from the effects of heat and nic-tine on the incision line as well as the fact that theyenerally resume smoking immediately after surgerynd the continual perioral movement can disrupt un-
IGURE 3. The youthful midface is volumized and aging produceell as skin aging. The authors 8-year-old son pictured in (A), theidfacial aging over 3 generations of males.
oe Niamtu. Cheek and Midface Implants. J Or
