Malar Implants Research Articles

Technical Pearls and Pitfalls of Facial Feminization Surgery: A Review of Techniques From a Single Institutional Practice.

Facial feminization surgery (FFS) is an emerging practice that falls under the broader umbrella of gender-affirming surgery. Various approaches exist to feminize the face, yet few published articles describe in detail the techniques of each component procedure. Considering the diversity of interventions employed, the objective of this manuscript is to highlight FFS techniques utilized by the senior author and create a corresponding media gallery. All patients with the diagnosis of gender dysphoria that were referred to the senior author for FFS consultation between June 2017 and August 2022 were reviewed. Data were retrospectively collected from electronic medical records according to the institutional review board (IRB)-approved study protocol. Data collected and analyzed included demographics, operative documentation, and postoperative follow-up. Multimedia material was collected intraoperatively and postoperatively. A total of 231 patients underwent 262 operations with a total of 1224 FFS procedures. The average follow-up time was 7.7 ± 11 months. Out of the 262 operations, 24 (9.2%) patients experienced minor complications, including 3 (1.1%) with wound dehiscence, 13 (5.0%) with hematomas, and 14 (5.3%) with postoperative infection requiring antibiotics. Of those, 3 (1.1%) required a return to the operating room for washout or removal of malar implants. Although there is a consensus on the fundamental surgical principles to achieve adequate feminization of the facial architecture, the specific techniques to do so differ according to individual practices. As techniques diverge, so do their risk profiles and outcomes; techniques must, thus, align with patients' interventional goals. The material presented here is one of many that can support trainees and junior surgeons as they build a gender-affirming practice.

Alloplastic malar implants in aesthetic facial surgery.

To examine the recent literature on aesthetic alloplastic malar implants. Alloplastic implantation is heavily favored in the oromaxillofacial literature. Recent articles have examined porous polyethylene and silicone implantation. Overall patient satisfaction is high and complications are low. Outcomes are likely comparable with alternative modalities to rejuvenate the face in the appropriate hands. Alloplastic implantation continues to be a reliable tool for malar augmentation.

EP.FRI.749 Facial augmentation surgery: Perception vs. Reality

Abstract Background In recent years, aesthetic surgeries have gained significant momentum. A recent audit identified that more than 28,000 cosmetic surgeries were performed in the United Kingdom (UK) in 2018.1. We present an unfortunate case of morbid complications related to the use of malar implant for cosmesis. Case Presentation A 63-year-old Caucasian female presented to the Emergency department with sepsis related to a large painful, tender swelling of the right side of the face. There was discharge of pus from two cutaneous sinuses with additional ectropion/chemosis of the right eye. An orocutaneous communication due to infection/migration of the implant was also noted. The patient reported a history of bilateral malar implants placement three years ago. The patient initially required emergency drainage & subsequent removal of the infected malar implant. Discussion Malar implants provide suitable volume enhancement providing structural and aesthetic benefits including the ‘high cheek bone’ appearance. It is generally considered to be a safe surgical technique with multiple approaches possible to insert the implant. including transoral approach). Spadafora (1971) & Hinderer (1972) first described the use of malar implants for facial augmentation.2,3 Rayess et al.(2017) conducted a 10 year review of complications related to facial implants & noted that 75% of complications related to malar implants were due to infection with 38% of these implants needing removal.4 Conclusion There is a surge in presentations of complications related to cosmetic facial surgery and knowledge of these adverse effects is essential to appropriately manage these patients & their concerns.

Standard and Customized Alloplastic Facial Implants Refining Orthognathic Surgery: Outcome Evaluation

Conventional orthognathic osteotomies provide appropriate functional outcomes but might be unable to correct midface deficiency, achieve a satisfactory outcome in asymmetrical cases, or allow sufficient chin advancement. We evaluated the outcome of both standard and customized facial high-density porous polyethylene implants used to refine the cosmetic outcome of orthognathic surgery. We implemented a retrospective study. The sample was composed of all patients who underwent facial alloplastic augmentation between June 2011 and October 2018 in our department. The complication rate was recorded after a mean follow-up period of 41months postoperatively, and patient satisfaction was assessed through a qualitative evaluation based on an 11-item questionnaire. The sample was composed of 24 implants placed in 14 patients: 13 mandibular angle implants, among which 4 were customized; 8 malar implants; and 3 chin implants. No physical complications such as hematoma, infection, migration, or hypoesthesia were observed. Two implants had to be removed because of early unsatisfactory esthetic outcomes. Of 14 patients, 11 answered our questionnaire. Eighty-two percent strongly agreed that the overall outcome was satisfactory. The results of this study confirm the low physical complication rate described in the literature, and the esthetic complication rate remains lower than the rates observed in previous reports. A high satisfaction rate was found among patients. The lowest mean satisfaction score was noted for appropriate implant symmetry (3.5), whereas the highest mean satisfaction score (3.8) was achieved when using customized implants. If standard high-density porous polyethylene implants appear to be relevant adjuncts to orthognathic surgery, customized implants seem to achieve higher satisfaction, although their prohibitive cost should be considered.

Correction of Facial Asymmetry Using Patient-Specific Implants: A Case Report

Dentofacial deformities can have a profound impact on patients’ function and facial aesthetics. Traditionally, dentofacial deformities and malocclusion have been managed with growth modification, orthodontic therapy, and orthognathic surgery, or a combination of these modalities. The aim of this article is to discuss the use of patient-specific alloplastic implants as an adjunct or alternative to orthognathic surgery in patients with dentofacial deformities. A 40-year-old man who previously underwent surgically assisted rapid palatal expansion followed by LeFort I osteotomy advancement, intraoral vertical ramus osteotomy setback (IVRO), rhinoplasty, and fat transfer to the malar region presented with a chief complaint of dissatisfaction due to significant facial asymmetry. Tear trough deformity, concave nasal dorsum with nasal tip deviation to the left, submalar fullness, chin deviation to the right, and a poorly defined mandibular border outline were all noted on physical examination. The patient was treated with lower lid blepharoplasty with fat repositioning, buccal fat pad reduction (bichectomy), and patient-specific malar and mandibular border implants. In a patient who has a moderate-to-severe malocclusion and dentofacial deformity, traditional treatment includes orthodontic correction and orthognathic surgery. Patients undergoing primary orthognathic surgery can benefit from alloplastic implants. For patients who have residual maxillary or mandibular asymmetry after orthognathic surgery, the treatment options are secondary orthognathic procedures or facial implants. These patients can benefit from treatment with alloplastic facial implants as an adjunct or alternative to orthognathic surgery to normalize skeletal contours and improve facial aesthetics. Patient-specific alloplastic implants can be used as a powerful adjunct or alternative to orthognathic surgery. Patients with mild occlusal and skeletal deformities who have traditionally been treated with orthodontic therapy alone can benefit from evaluation of alloplastic implants. Patients with residual asymmetries after orthognathic surgery can benefit from alloplastic implants as an adjunct with secondary osteotomies or as an alternative altogether.

Facial Implants: Controversies and Criticism. A Comprehensive Review of the Current Literature

Polyethylene (Medpor) and silicone are two of the most popular materials used today for facial skeleton implantation. Previous studies have identified common complications with the use of these implants, but patient follow-up has been short. This review of the literature examines complications and patient follow-up in cases using Medpor and silicone implants for reconstructive and aesthetic operations of the mid and lower face over the past 20 years. A literature search was conducted through the PubMed database. Keywords used were as follows: ("mandible implants" or "malar implants" or "chin implants") AND ("reconstruction" or "augmentation") AND ("Medpor" or "silicone"). There were nine studies with 626 patients in the Medpor group and five studies with 365 patients in the silicone group. The silicone group had a higher incidence of infections and displacements. The Medpor group showed a higher incidence of prominence problems. Exposure/extrusion rates were low for both implant types. Chin and mandibular implants were the safest, whereas malar implants had a high incidence of prominence problems. The average follow-up for Medpor was 36.6 months and 24 months for silicone. There were wide ranges of follow-up times, from 2 weeks up to 15 years. A limited number of articles included an averaged time within their ranges. Reported follow-up times were not linked to specific complications. Medpor implantation is more common than silicone. Complication rates are low with the use of both materials. Patient follow-up is deficient and has not improved in the past 20 years, raising questions on the reliability of complication rates.

Adverse Events in Facial Implant Surgery and Associated Malpractice Litigation.

Facial implants represent an important strategy for providing instant and long-lasting volume enhancement to address both aging and posttraumatic defects. To better understand risks of facial implants by examining national resources encompassing adverse events and considerations facilitating associated litigation. A cross-sectional study reviewed complications following facial implants. The procedures reviewed were performed on patients at locations throughout the United States from January 2006 to December 2016. Data collection was completed in March 2017. The Manufacturer and User Facility Device Experience database, which contains medical device reports submitted to the US Food and Drug Administration (FDA), was searched for complications that occurred from January 2006 to December 2016 involving facial implants made by Implantech, MEDPOR, Stryker, KLS Martin, and Synthes. Furthermore, the Thomson Reuters Westlaw legal database was searched for relevant litigation. The complications of facial implants were analyzed in relation to the location of implant and severity of complication. Litigation was analyzed to determine which factors determine outcome. Thirty-nine instances of adverse events reported to the FDA were identified. Sixteen (41%) involved malar implants, followed by 12 chin implants (31%). The most common complications included infection (18 [46%]), implant migration (9 [23%]), swelling (7 [18%]), and extrusion (4 [10%]). Thirty-two patients (83%) had to have their implants removed. Infection occurred at a mean (SD) of 83.3 (68.8) days following the surgery. One-third of complications involved either migration or extrusion. The mean (range) time to migration or extrusion was 381.1 (10-2400) days. In 12 malpractice cases identified in publicly available court proceedings, alleged inadequate informed consent and requiring additional surgical intervention (ie, removal) were the most commonly cited factors. Infection and implant migration or extrusion are the most common complications of facial implants. Most of these complications necessitate removal. These considerations need to be discussed with patients preoperatively as part of the informed consent process, as allegedly inadequate informed consent was cited in a significant proportion of resultant litigation, and there were overlapping considerations among adverse events reported to the FDA and factors brought up in relevant litigation. Cases resolved with settlements and jury-awarded damages encompassed considerable award totals. NA.

Cosmetic facial surgery: are online resources reliable and do patients understand them?

Our aim was to assess the quality and readability of online resources regarding common cosmetic maxillofacial procedures. We searched Google for “rhytidectomy”, “rhinoplasty”, “orthognathic surgery”, “genioplasty”, “malar implants”, “blepharoplasty”, “otoplasty”, and related terms. In each case we assessed the top 50 results for quality and readability. Quality was measured using the DISCERN questionnaire, benchmark criteria published by the Journal of the American Medical Association (JAMA), and accreditation by the HONcode (Health On the Net code). The Flesch-Kincaid reading grade, Flesch reading ease score, Gunning’s fog index, and the Coleman-Liau index, were used to measure readability. A total of 350 sites were assessed and 200 were included in the study. The mean (SD) JAMA and DISCERN scores for all included websites indicated poor quality (0.49/4 (1.07) and 32.77/80 (10.57), respectively). Only eight sites (4%) were certified by the HONcode. There was a significant association between low DISCERN scores and Google Ads (p=0.009) and between low DISCERN scores and the websites of private clinicians or hospitals (p<0.001). The mean (SD) Flesch reading ease score and Gunning’s fog score both indicated poor readability that required a moderately high level of literacy (50.59 (11.82) and 13.83 (2.76), respectively). The Flesch-Kincaid and Coleman-Liau scores indicated similar results. Adherence to the JAMA benchmark, certification by the HONcode, and relevant selection on Google Ads would improve quality. The avoidance of medical jargon and use of shorter sentences would improve readability and provide patients with comprehensible explanations that would allow them to have realistic expectations and take responsibility for their own health.

Intrasinus penetration of a silastic malar implant, which resulted in chronic sinusitis: A case report and literature review.

Background:Malar augmentation is a common cosmetic procedure utilizing silastic materials. We describe an uncommon complication of a silastic implant eroding into the anterior maxillary sinus wall resulting in chronic rhinosinusitis (CRS).Methods:A literature review is presented describing the presentation, surgical management and outcome of this uncommon adverse event.Results:An 80 year old female with a history of bilateral cosmetic malar implants placed approximately 25 years ago presented to our office with a 4–5 month history of left-sided symptoms consistent with chronic sinusitis, and was found to have intrasinus penetration of her left malar implant. Only one other case series of 5 cases in 4 patients is reported in the literature.Conclusions:Intrasinus malar implant migration is a rare complication of malar augmentation. The present experience suggests that removal of the offending foreign body often results in successful symptom resolution.

Bilateral Erosion of Malar Implants Into the Maxillary Sinuses

Augmentation malarplasty is a cosmetic procedure rarely associated with complications; however, some reported complications are severe. The authors describe a case of missed diagnosis in a patient with chronic sinusitis secondary to erosion of malar implants into the maxillary sinuses. A review of the literature demonstrates that all severe complications of implant-based malar augmentation involve bone erosion and occur many years after initial placement. Silicone implants may have a higher risk for bone erosion and severe complications; however, it is not clear whether this risk is only associated with implants that have not been adequately fixed to the underlying bone. Surgeons should ensure that implants will not move from their original location, and screw fixation is the most reliable method for this purpose. Patients undergoing augmentation malarplasty should be informed of this potential complication so that lengthy workups and unnecessary treatments can be avoided.

The "beauty arch: " a new aesthetic analysis for malar augmentation planning.

Midface is a critical area for the aesthetics of the face. Despite malar hypoplasia is often combined with a class III malocclusion, there are few studies focusing on the results of a combined approach of malar implants and Le Fort I. We describe a new aesthetic analysis, named "beauty arch" analysis, for the assessment of sagittal projection of the malar region. We took a reference group of 74 Italian women participating in a national beauty contest in 2011 on which we performed our analysis. We used the ideal values to elaborate the surgical treatment planning of a second group of 45 consecutive female patients affected by skeletal class III malocclusion.Twenty-three patients undergo simultaneous Le Fort I osteotomy and malar implants. From the descriptive statistical comparison of the patients' values before and after orthognathic surgery and malar implants with the reference values, we observed how all parameters considered got closer to the ideal population. We consider our beauty arch a useful help for surgeon in the treatment planning of patients with skeletal malocclusions and malar implants.

Anatomic Predictors of Unsatisfactory Outcomes in Surgical Rejuvenation of the Midface

To aid the aesthetic surgeon in midface analysis and selection of treatment plans offering the greatest likelihood of success in midface rejuvenation. We performed a retrospective review of all patients who underwent surgical midface rejuvenation by a single surgeon. We recorded demographics, history, procedures, outcomes, and complications. Results of physical examination and photography were used to classify patients by volume loss, midface ptosis, skin elasticity, and skeletal anatomy. Outcome was determined by patient satisfaction at the 12-month follow-up; unsatisfactory results were further analyzed by a blinded independent expert with more than 15 years' experience. We included 150 patients. Mean patient age was 51 years; 93.3% were women, and 20.7% had undergone previous procedures, including malar implants, autologous fat grafting, rhytidectomy, midface-lift, and extended lower blepharoplasty. Multimodality treatment was used in 34.0%. Patient dissatisfaction was encountered in 14.0% of cases; the expert concurred in each case. Autologous fat grafting alone demonstrated the greatest propensity for dissatisfaction (4 of 12 cases [33%]). Rate of dissatisfaction was significantly higher with malar hypoplasia (41% vs 7%; P < .001) or loss of elasticity (16% vs 3%; P = .01) but was not highly correlated with age (r = 0.15). Successful midface rejuvenation requires accurate diagnosis and avoidance of anatomic pitfalls. Many patients require multimodality therapy, including lifting and volumizing techniques. Unsatisfactory results are most common when midfacial aging is accompanied by skeletal insufficiency or loss of elasticity. Respective consideration of these defects should be given to placement of malar implants and rhytidectomy approaches targeting the midface.

Intranasal Surgical Approach for Malar Alloplastic Augmentation

Alloplastic malar augmentation is becoming an increasingly common procedure for enhancement of the midface and an adjunct method of improving the effects of other rejuvenation procedures. The authors present a new surgical approach for placement of malar implants by means of an intranasal incision, which they believe has several advantages over traditional techniques. They also propose a new classification for regions of the midface to assist in augmentation planning. Between 1990 and 2010, the authors treated 20 patients with an intranasal approach for alloplastic malar augmentation. Patients were preoperatively divided into three groups: Type 1 included those with adequate nostril opening, including good elasticity of the internal nasal mucosa, allowing a good exposure of the piriform aperture through the nasal speculum; Type 2a included those with inadequate nostril opening; and Type 2b included those who required an alar base correction. Implants were selected according to these classifications and placed with the authors' technique. Of the 20 patients treated, 18 were female and two were male. Ages ranged from 15 to 65 years. Average follow-up was 10 years, and all patients experienced favorable results. There were no major complications, no nerve or vascular supply compromise, and no cases of implant malposition. One patient requested removal of the implant at one year postoperatively despite her good postoperative outcome; overall patient satisfaction was 95%. The intranasal approach for alloplastic malar augmentation has shown good results for midface enhancement in the authors' hands. In this patient series, results showed excellent overall patient satisfaction and a very low (nearly 0%) complication rate.

Preliminary Experiences with Bio-Alcamid in HIV Facial Lipoatrophy

Background: Highly active antiretroviral therapy for HIV-infected patients causes metabolic changes known as the lipodystrophy syndrome. Autologous fat injections, dermal fat grafts, malar implants and injected fillers have been reported as treatment options. Objective: To evaluate the results of HIV-infected patients treated with Bio-Alcamid for facial lipoatrophy. Methods and Materials: Over a 3-year period, 13 HIV-infected patients with facial lipoatrophy had Bio-Alcamid injections for aesthetic purposes. The procedure was done under local anesthesia, and the amount of the injected material varied from 5 to 13 ml. Results were independently evaluated by patients and physicians. Results: Most of the patients felt they had good to excellent results. Touch-ups were necessary for 2 patients; the added volume was 2–3 ml for each. No major complications were recorded. A small hematoma was noted in 1 patient. Overcorrection was attained in 2 cases, and some of the filler was removed at the patient’s request. Conclusion: One of the greatest advantages of this filler is that, although permanent, it can be removed easily. We consider Bio-Alcamid to be a safe and useful correcting tool for patients suffering from drug-induced facial lipoatrophy.

Traitement durable des lipoatrophies faciales VIH et autres par implants malaires SAM GoreTex ® et hydrogel de polyacrylamide (Eutrophill ®). À propos de 90 cas consécutifs

HIV-related lipoatrophy (HIV LA) stands out with regard to its recent discovery, increasing incidence, multiple etiologies, relatively low morbidity, apparently irreversible effects, and unequivocal clinical features. The underlying cause of HIVLA is still controversial but there is an increasing demand of correction. We describe a technique using soft malar implants and acrylamid gel injections separately or in combination. Expanded polytetrafluoroethylene (Gore SAM ®) malar implants are used for augmentation of the most sunken areas below the eye; they should be placed subperiostealy and more medially than conventional implants. After trying sheets and custom made implants, preshaped GoreTex ® Sam implants are now used systematicaly. Eutrophill ® is a 2.5% polyacrylamide hydrogel obtained by polymerization of acrylamide monomers with an official half-life of 5 years. The soluable chains are more or less slowly released by enzymatic degradation and subsequently cleared via interstitial tissue without further metabolism or degradation. Injection should be performed continuously and evenly from one side to the other in the deepest part of the sunken area at the subcutaneous level only. A total of 90 consecutive patients were treated using implants alone in 11 cases, injections alone in 68 cases, and both implants and injections in 11 cases. Drawbacks were very few except three cases of chronic inflammation (dental conflict) with sheets and custom made implants which were never observed since the use of preshaped forms, and some very light bulgings with acrylamid injections which usually desapear in a few months. Mean follow-up was 17 months for injections and 29 for implants.

Long-term treatment for lipoatrophy associated or not with HIV infection using ePTFE implants and polyacrylamide gel

HIV-related lipoatrophy (HIVLA) is notable for its increasing incidence, multiple etiologies, relatively low morbidity, apparently irreversible effects, and unequivocal clinical features. The underlying cause of HIVLA is still controversial, but there is an increasing demand for correction. We describe a treatment approach using soft malar implants and polyacrylamide gel injections, separately or in combination. Expanded polytetrafluoroethylene (GORE-SAM, W.L. Gore & Associates, Flagstaff, AZ) malar implants were used for augmentation of the most sunken areas below the eye. They were placed subperiosteally and more medially than conventional implants. After trying sheets and custom-made implants, preshaped GORE-Tex SAM implants are now used systematically. Polyacrylamide gel (Eutrophill, Lab Procytech, Martillac, France) injections were performed continuously and evenly from one side to the other in the deepest part of the sunken area at the subcutaneous level only. A total of 85 consecutive patients were treated using implants alone in 8 cases, injections alone in 65 cases, and both implants and injections in 12 cases. The few adverse effects included 3 cases of chronic inflammation (dental conflict) after placement of sheets and custom-made implants; no such cases occurred using preshaped implants. Some very light bulges developed after polyacrylamide injections, which usually disappeared after a few months. Mean follow-up was 16 months for injections and 29 months for implants. Combination treatment using implants in sunken areas near the bone and fillers in soft tissue areas offers a balanced trade-off between benefits and risks and provides excellent long-term and natural results, as well as notable psychological benefits.

Avoidance and Treatment of Malar Implant Deformities

Avoidance and Treatment of Malar Implant Deformities

Elevating the midface with barbed polypropylene sutures

Barbed sutures, either used alone in a closed approach or as part of an open face lift procedure, may be combined with malar implants, soft tissue fillers, chemical peeling, and laser resurfacing. Because cephalad cheek repositioning affects adjacent facial areas, results may include shortening of the lower eyelid distance, flattening of the nasolabial fold, elevation of the submalar tissue, improvement of jowling, and decrease in submalar area fullness.

Youthful appearance malar implants and endoscopic midface lifting

Youthful appearance malar implants and endoscopic midface lifting

Malar augmentation with self-drilling single-screw fixation.

Augmentation with malar implants has traditionally relied on fixation techniques such as creation of a precise pocket, external taping, and transcutaneous fixation techniques with bolsters. We present an alternate technique that fixates the implants to the rigid facial skeleton rather than to the dynamic active facial soft tissues. To avoid the use of expensive drills, we describe use of self-drilling screws for fixation of malar implants. The technique avoids transconjunctival incisions, allows wide exposure, and is presented as an alternative to traditional fixation techniques.