The Role of Fillers in Facial Implant Surgery




Alloplastic facial implants and injectable fillers are currently used for facial rejuvenation and augmentation. Their respective roles in augmentation and volume replacement of the chin and midface are discussed. Treatment goals, patient selection, procedures, and patient recovery are detailed. In addition, there is a segment for surgeons presenting a decision algorithm for selecting surgical versus less-invasive or nonsurgical approaches for midface rejuvenation.


Key points








  • Achieving optimal, long-lasting results in facial rejuvenation requires knowledge of how the aging process 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 volume enhancement for rejuvenation of the face. It is important to understand the appropriate use of each technique either as a sole modality or in conjunction with each other to attain optimal aesthetic results.



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




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




Treatment goals using fillers and implants


Augmentation of the midface and chin with alloplastic implants has been performed with increasing frequency during the past 4 decades and offers a long-term solution for augmenting skeletal deficiencies, restoring facial contour irregularities, and rejuvenating the face. Specifically, chin augmentation with alloplastic implantation is the fastest growing plastic surgery trend among all major demographics. The media have also well publicized the advantages of this technique, which has been characterized as “chinplasty” in mainstream magazines, further heightening the awareness of both the aesthetic and psychological benefits of treating microgenia.


In contrast, rates of midface alloplastic implant procedures have increased at a measured pace during the past 2 decades because of the introduction of “less-invasive” techniques such as injectable facial fillers and fat transfer. Alloplastic implantation of the chin remains the optimal choice for projecting and repositioning the soft tissue envelope, whereas facial fillers have gained popularity in rejuvenating the aging midface. This more recent reliance on less-invasive surgical and nonsurgical rejuvenation procedures has minimized the key role of the skeletal structure component of the aging midface. However, rather than replacing surgical augmentation techniques, fillers can enhance the ability to use midface implants more effectively to achieve long-term rejuvenation.


The Process and Effects of Aging in the Face


Successful rejuvenation of the aging face entails a multidimensional approach to correct the volumetric changes involving the skin, deep soft tissue, and bony skeleton.




  • Integumentary changes such as epidermal thinning, decrease in collagen, loss of skin elasticity, and deep tissue volume loss represent the hallmarks of soft-tissue changes in the aging face.



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



  • Fat atrophy extends beyond the subcutaneous level and affects the deeper soft tissues along with the fat pad of Bichat. With continued wasting of the fat pads and loss of fascial support, these areas become progressively ptotic due to gravitational effects.



  • The malar fat pad, suborbicularis oculi fat, and orbicularis oculi muscle descend inferiorly, exposing the infraorbital rim, and produce an elevation or “mound” lateral to the nasolabial fold and exaggerate its depth.



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



  • These changes may also flatten the midface and eventually unmask the underlying bony anatomy.



Over time, the progressive cumulative effects of aging transform the once full, angular, youthful face into a predictably rectangular (or pear-shaped) face, which appears longer in configuration, aged, and fatigued.


Most soft-tissue deficiencies in the aging midface are localized within the recess referred to as the “submalar triangle,” an inverted triangular area of midfacial depression bordered superiorly by the prominence of the zygoma, medially by the nasolabial fold, and laterally by the body of the masseter muscle. The aging midface exhibits a “double convexity” curvature caused by weakening of the lower eyelid orbital septum and consequent pseudoherniation of the lower orbital fat pads.


Age-related morphologic skeletal changes, well described by Shaw, must also be considered during the preoperative consultation. Overall, the aging face is characterized by the resorption of bone along the orbit, midface, and mandible, which leads to a reduction in the skeletal framework and laxity of the overlying skin. The net result of these topographic changes can make an otherwise healthy person appear gaunt. These changes are further compounded if the patient exhibits deficiencies in skeletal structure such as a negative vector of the infraorbital rim.


Midface Rejuvenation


The specific goals for midface rejuvenation are to



  • 1.

    Add contour to the upper midface or malar area


  • 2.

    Restore cheekbone fullness and reduce submalar hollows


  • 3.

    Soften the nasolabial and marionette folds


  • 4.

    Reduce the vertical descent of the jowl


  • 5.

    Smooth out facial lines and wrinkles



Initially, facial rejuvenation techniques were tailored to improve skin laxity alone. In the 1980s, Binder first introduced midface alloplastic augmentation as an independent method for volumetric enhancement of the aging face. Augmentation not only enhances the facial skeleton but also achieves a suspensory effect that redistributes the soft tissue in a more favorable position. By restoring lost facial soft tissue volume and increasing the anterior projection of the area, midface augmentation reduces midface laxity, restores facial contour, and decreases the depth of the nasolabial fold. This result can be accomplished with implantation alone and in combination with a rhytidectomy procedure, whereby augmentation can soften the sharp angles and depressions of the aged face, rendering a more natural postoperative result. For these patients, augmenting the bony scaffold of the malar or maxillary regions improve the fundamental base for suspending the facial tissues. This emphasis on volume restoration continues to represent a key contribution to facial rejuvenation.


Later, less-invasive soft-tissue volume restoration techniques such as fat transfer and injectable facial fillers were developed to restore soft-tissue volume loss in the midface. Facial fillers are safe and effective; require a short learning curve; and over the more immediate term, are cost-effective for treating mild to moderate soft-tissue volume loss. Numerous specialties have adopted their use in the office setting, and often commercially produced fillers do not require a physician for their administration. Fueled by increased public knowledge resulting from direct consumer marketing and advertising, facial fillers have proliferated in both numbers and types during the past few decades. Originally, soft-tissue fillers such as collagen were used to smooth out superficial changes such as epidermal and dermal rhytids. Over the years, diverse types of fillers offering longer duration times and improved standards of safety and immunogenicity have been introduced to restore volume and contour to the aging face. Fillers are now used to treat nasolabial folds, lips, atrophic scars, the glabella, forehead, and Marionette lines. Thicker versions of hyaluronic acid–based fillers, calcium hydroxyapatite (Radiesse), and biostimulating fillers such as poly- l -lactic acid (Sculptra) and polymethylmethacrylate (Artefill) have also been used for enhancing the volume of the midface, mental, and mandibular regions. Relying on minimally invasive techniques as a sole procedure, however, may harbor inherent limitations that frequently result in suboptimal short-lived aesthetic effects. Similarly, alloplastic augmentation as a single modality does not address certain specific sites, such as the tear trough, the skeletonized periorbita, and the inferior extension of the submalar hollowing into the lower third of the face. These represent potential areas where fillers can supplement treatment to achieve an improved long-lasting result. Moreover, fillers may be beneficial in overcoming potential challenges in the perceptual ability to correctly size implants and may ensure optimal volume restoration when conservatively choosing a smaller implant. Longevity in patient satisfaction and volume restoration can be enhanced with decreased amounts of filler during the postoperative period to improve site-specific areas. However, the extent and type of volume loss contributed by both soft-tissue and skeletal changes must be evaluated individually for each patient to maximize the benefit of multiple treatment modalities.


Chin Augmentation


The goal of chin augmentation is to reposition and rotate a rigid soft-tissue envelope to a more projected position along the inferior border of the mandible. The procedure should optimally expand the chin in a three-dimensional plane while preserving the labiomental sulcus and increase the vertical dimension on the frontal view ( Fig. 1 ).




Fig. 1


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


Anatomically, the soft-tissue “chin button” is a dense structural entity that has limited mobility or ability to expand because of the following factors:



  • 1.

    The amount of subcutaneous tissue between the deep dermis and underlying mentalis muscle is minimal.


  • 2.

    The mentalis muscle is not only attached to the mandible but also intimately intertwined into the soft tissue of the chin.


  • 3.

    The anterior mental and more lateral mandibulocutaneous ligaments hinder the leverage necessary to expand and dissociate the soft-tissue envelope from underlying bone.



Therefore, treatment with either an alloplastic implant or filler must overcome these factors to improve the aesthetic outcome. Fillers have traditionally been applied to improve a deep labimental sulcus, soften a peau d’orange deformity, and efface the prejowl sulcus. However, all 3 authors agree that because of the aforementioned anatomic inhibitory factors, the projection, rotation, and repositioning necessary for improving the aesthetics of the anterior chin cannot be accomplished with fillers alone.




Treatment goals using fillers and implants


Augmentation of the midface and chin with alloplastic implants has been performed with increasing frequency during the past 4 decades and offers a long-term solution for augmenting skeletal deficiencies, restoring facial contour irregularities, and rejuvenating the face. Specifically, chin augmentation with alloplastic implantation is the fastest growing plastic surgery trend among all major demographics. The media have also well publicized the advantages of this technique, which has been characterized as “chinplasty” in mainstream magazines, further heightening the awareness of both the aesthetic and psychological benefits of treating microgenia.


In contrast, rates of midface alloplastic implant procedures have increased at a measured pace during the past 2 decades because of the introduction of “less-invasive” techniques such as injectable facial fillers and fat transfer. Alloplastic implantation of the chin remains the optimal choice for projecting and repositioning the soft tissue envelope, whereas facial fillers have gained popularity in rejuvenating the aging midface. This more recent reliance on less-invasive surgical and nonsurgical rejuvenation procedures has minimized the key role of the skeletal structure component of the aging midface. However, rather than replacing surgical augmentation techniques, fillers can enhance the ability to use midface implants more effectively to achieve long-term rejuvenation.


The Process and Effects of Aging in the Face


Successful rejuvenation of the aging face entails a multidimensional approach to correct the volumetric changes involving the skin, deep soft tissue, and bony skeleton.




  • Integumentary changes such as epidermal thinning, decrease in collagen, loss of skin elasticity, and deep tissue volume loss represent the hallmarks of soft-tissue changes in the aging face.



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



  • Fat atrophy extends beyond the subcutaneous level and affects the deeper soft tissues along with the fat pad of Bichat. With continued wasting of the fat pads and loss of fascial support, these areas become progressively ptotic due to gravitational effects.



  • The malar fat pad, suborbicularis oculi fat, and orbicularis oculi muscle descend inferiorly, exposing the infraorbital rim, and produce an elevation or “mound” lateral to the nasolabial fold and exaggerate its depth.



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



  • These changes may also flatten the midface and eventually unmask the underlying bony anatomy.



Over time, the progressive cumulative effects of aging transform the once full, angular, youthful face into a predictably rectangular (or pear-shaped) face, which appears longer in configuration, aged, and fatigued.


Most soft-tissue deficiencies in the aging midface are localized within the recess referred to as the “submalar triangle,” an inverted triangular area of midfacial depression bordered superiorly by the prominence of the zygoma, medially by the nasolabial fold, and laterally by the body of the masseter muscle. The aging midface exhibits a “double convexity” curvature caused by weakening of the lower eyelid orbital septum and consequent pseudoherniation of the lower orbital fat pads.


Age-related morphologic skeletal changes, well described by Shaw, must also be considered during the preoperative consultation. Overall, the aging face is characterized by the resorption of bone along the orbit, midface, and mandible, which leads to a reduction in the skeletal framework and laxity of the overlying skin. The net result of these topographic changes can make an otherwise healthy person appear gaunt. These changes are further compounded if the patient exhibits deficiencies in skeletal structure such as a negative vector of the infraorbital rim.


Midface Rejuvenation


The specific goals for midface rejuvenation are to



  • 1.

    Add contour to the upper midface or malar area


  • 2.

    Restore cheekbone fullness and reduce submalar hollows


  • 3.

    Soften the nasolabial and marionette folds


  • 4.

    Reduce the vertical descent of the jowl


  • 5.

    Smooth out facial lines and wrinkles



Initially, facial rejuvenation techniques were tailored to improve skin laxity alone. In the 1980s, Binder first introduced midface alloplastic augmentation as an independent method for volumetric enhancement of the aging face. Augmentation not only enhances the facial skeleton but also achieves a suspensory effect that redistributes the soft tissue in a more favorable position. By restoring lost facial soft tissue volume and increasing the anterior projection of the area, midface augmentation reduces midface laxity, restores facial contour, and decreases the depth of the nasolabial fold. This result can be accomplished with implantation alone and in combination with a rhytidectomy procedure, whereby augmentation can soften the sharp angles and depressions of the aged face, rendering a more natural postoperative result. For these patients, augmenting the bony scaffold of the malar or maxillary regions improve the fundamental base for suspending the facial tissues. This emphasis on volume restoration continues to represent a key contribution to facial rejuvenation.


Later, less-invasive soft-tissue volume restoration techniques such as fat transfer and injectable facial fillers were developed to restore soft-tissue volume loss in the midface. Facial fillers are safe and effective; require a short learning curve; and over the more immediate term, are cost-effective for treating mild to moderate soft-tissue volume loss. Numerous specialties have adopted their use in the office setting, and often commercially produced fillers do not require a physician for their administration. Fueled by increased public knowledge resulting from direct consumer marketing and advertising, facial fillers have proliferated in both numbers and types during the past few decades. Originally, soft-tissue fillers such as collagen were used to smooth out superficial changes such as epidermal and dermal rhytids. Over the years, diverse types of fillers offering longer duration times and improved standards of safety and immunogenicity have been introduced to restore volume and contour to the aging face. Fillers are now used to treat nasolabial folds, lips, atrophic scars, the glabella, forehead, and Marionette lines. Thicker versions of hyaluronic acid–based fillers, calcium hydroxyapatite (Radiesse), and biostimulating fillers such as poly- l -lactic acid (Sculptra) and polymethylmethacrylate (Artefill) have also been used for enhancing the volume of the midface, mental, and mandibular regions. Relying on minimally invasive techniques as a sole procedure, however, may harbor inherent limitations that frequently result in suboptimal short-lived aesthetic effects. Similarly, alloplastic augmentation as a single modality does not address certain specific sites, such as the tear trough, the skeletonized periorbita, and the inferior extension of the submalar hollowing into the lower third of the face. These represent potential areas where fillers can supplement treatment to achieve an improved long-lasting result. Moreover, fillers may be beneficial in overcoming potential challenges in the perceptual ability to correctly size implants and may ensure optimal volume restoration when conservatively choosing a smaller implant. Longevity in patient satisfaction and volume restoration can be enhanced with decreased amounts of filler during the postoperative period to improve site-specific areas. However, the extent and type of volume loss contributed by both soft-tissue and skeletal changes must be evaluated individually for each patient to maximize the benefit of multiple treatment modalities.


Chin Augmentation


The goal of chin augmentation is to reposition and rotate a rigid soft-tissue envelope to a more projected position along the inferior border of the mandible. The procedure should optimally expand the chin in a three-dimensional plane while preserving the labiomental sulcus and increase the vertical dimension on the frontal view ( Fig. 1 ).


Aug 26, 2017 | Posted by in General Surgery | Comments Off on The Role of Fillers in Facial Implant Surgery
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