CUSTOM FACIAL IMPLANTS: MALAR, CHEEK, CHIN & MID FACE
The combination of facial features, proportion, and balance determines facial beauty. Whether a conscious or subconscious act, we are all sensitive to the shape and dimension of our own face and the faces of others. When the balance is pleasing, the eye and the mind are attracted to the faces of others. When they are out of proportion, we tend to consider them unattractive. We use our aesthetic sense to correctly perceive the three-dimensional interaction of all of one’s features. Well-defined, balanced facial features are considered a sign of beauty. Facial implants are one of the few procedures in plastic surgery that can best achieve these goals.
In general, people are aware of areas of their face that are either excessive or deficient. This may occur in the form of a weak chin, flat cheek bones, round face, a narrow jawline or pointed chin. It is important to correctly analyze the magnitude of nasal profile, the size and shape of the cheek bones, or angularity of the jawline on the overall impact they exert on facial beauty. For example, a stronger nose will accentuate a weak chin. Small cheekbones make the nose appear larger, and a square jawline diminishes the significance of the upper part of the face.
Gaining insight by extensively studying sculpture and the art of facial proportion, Dr. Binder developed the method and the design for facial implants that appropriately and anatomically enhance specific areas of the face. The use of these newly-designed implants in the late 1980’s launched a new field in plastic surgery called facial contouring. Dr. Binder has provided and restored healthy, natural-appearing facial contours to celebrities whose careers depend on their looks, to accident victims whose faces have been badly injured,. In addition to an extensive list of published peer-reviewed articles on this subject, Dr. Binder edited the book, Facial Contouring and Alloplastic Implants, which is hailed as the first surgical text of its kind.
Three-dimensional computer technology currently produces a new generation of more accurate anatomic facial implants that permit more effective, long-lasting and pleasing results in facial augmentation. Facial contouring, a major step in the evolution of facial aesthetic surgery, is the art and science of merging plastic surgical techniques with these newer implant designs to improve the relative balance of facial features. These newer facial implants not only aesthetically improve bone structure, but can also be used to help reverse the signs of aging. Contemporary facial implants are contoured to imitate the natural bone structure and youthful form of the overlying soft tissues. They may extend over smaller or larger areas with different thicknesses to create varying projections, thus enhancing either a portion or the entire cheek or jawline. For example, one patient may select a higher arched type of cheekbone look, while another may desire a rounder, apple cheek appearance. One may want to broaden his or her jaw in front and another may wish to broaden the back angle of the jaw. The goals for facial contouring may differ for each age group. Individuals in their late teens and 20’s usually desire specific structural change in the nose, chin, or cheeks. Those in their mid 30’s start to realize issues of facial aging that might require relatively small surgical procedures to effect major change. Modern implants can be used separately to improve features in any age group, or in combination with other rejuvenation procedures.
Most people are concerned about the safety of the implant material. The majority of facial implants are composed of solid silicone elastomer or rubber. Solid silicone elastomer, the most common biomaterial used for implantation, has been used safely for over 60 years in almost every field of medicine and surgery. It is used as a covering for cardiac pacemakers, in neurosurgery, cardiology, ear and eye surgery, and orthopedic surgery, to name a few. Silicone elastomer is NOT the same material that is used in gel-filled breast implants. Another material commonly used is ePTFE (commonly known to the public under the trade name Goretex®). There are now textured ePTFE-coated silicone “composite” implants, which combine the advantages of both materials. It is extremely rare for any of these materials to produce tissue reactions or be rejected by the body. To date, both silicone and ePTFE have the best track record of the biomaterials used for implantation, truly standing the test of time; and each with its own advantages. The preformed silicone elastomer implants or the ePTFE-coated silicone core implants maintain both shape and flexibility, and thus, feel perfectly natural over the facial structure. Another material, Polyethylene (Teflon), is also used as an implant material, but because of significant tissue ingrowth and the difficulty of removal, Dr. Binder prefers not to use this material for most routine implant procedures.
Dr. Binder first noticed that available facial implants were really “non-anatomic” and did not achieve the desired results he was striving to attain. He endeavored to design facial implants that were smoother, rounder, and more accurate in simulating normal facial anatomy. Unfortunately, the existing technology at the time did not satisfy Dr. Binder’s requirements for an improved implant design. With the assistance of the PC and Computer Aided Design Software, Dr. Binder designed the first anatomical implant. Today, all facial implants are currently designed and manufactured using the same method. This first step launched plastic surgery into the computer age. Subsequently, Dr. Binder, in conjunction with Dr. Alan Kaye, combined CAT scans and molding technology to produce the first custom-generated facial implant for reconstructing posttraumatic or congenital facial deformities. Dr. Binder then applied this ground-breaking technology to design the first custom implant used for aesthetic surgery.
CHEEKBONE AND MIDFACIAL IMPLANTS
Cheek or midfacial (submalar) augmentation are performed when a patient desires to improve his or her cheek bone structure or wishes to remedy symptoms of midfacial hollows, depressions and folds caused by aging. Cheek or midfacial augmentation can be performed as a single remedy, or in combination with other facial procedures, such as a face lift.
Cheek augmentation achieves one of the more dramatic improvements in facial appearance. High cheekbones are a sign of beauty. Unfortunately, not everyone is born with that look. Today, the newer cheek implants provide a more natural high cheekbone as compared to their predecessors. The illusion of a high cheekbone is actually created only partially by bone, while the soft tissue covering the bone structure comprises the remaining component. Both of these anatomic components contribute to the desired effect. The older cheek implants, which often created an artificial appearance, have been eliminated by the new, anatomically-designed cheek implants. These newer implants take into account the entire area that we perceive as “cheekbones” and compensate for both the bone and soft tissue components that comprise the aesthetically desirable “high cheekbone effect”. From subtle to dramatic, the shapely enlargement can add an attractive, as well as, youthful appearance.
One of the strongest characteristics of youth is fullness of the cheeks, indicating an abundance of healthy midfacial soft tissues and subcutaneous fat beneath the skin. Problems in appearance due to midfacial aging arise in a variety of ways. The aging process itself causes erosion of the soft tissues that normally provide a pleasing and smooth contour to the skin. If there is inadequate supporting bone structure, the combined effects result in drooping or sagging of the skin. Folds and wrinkles develop around the mouth, and areas behind the folds can become flattened, depressed, or hollow. Restructuring the midface by midfacial or submalar augmentation can effectively correct these problems.
The submalar implant acts to reposition relaxed or sagging skin upward and outward to fill the midfacial hollows and depressions and soften the folds and wrinkles. In submalar augmentation, we do not change bone structure, but merely use the implant to provide a scaffolding to support the collapsed midfacial soft tissues. Submalar augmentation is thus able to simulate midfacial soft tissue replacement and provides a means of restoring the youthful appearance of adequately padded skin at healthy levels of distention and elasticity. This is the necessary component of a youthful face. The importance of the submalar implant procedure in facial rejuvenation can be easily illustrated by just smiling. This elevates the sagging tissues to the position occupied in youth. While smiling, hold up your cheeks with your fingers, now relax the smile. When letting go, the cheeks will drop. The implant supports and restores volume to the face similar to the action produced by smiling.
Midfacial (cheek or submalar augmentation) is relatively simple, takes approximately 45 to 90 minutes, and can be performed alone, or in combination with forehead, eyelid, facelift, nasal or chin surgery. If the implant procedure is performed separately, the anesthesia usually consists of I.V. sedation or “twilight sleep” administered by a M.D. Anesthesiologist. If performed in combination with other procedures, general anesthesia may be given. In either case, the patient is asleep, a long-acting, local anesthetic is administered. This provides several hours of numbness and comfort to the area after the procedure is over. Antibiotics are typically given before, during, and after surgery to decrease the risk of infection.
Most midfacial implant procedures are performed through the mouth. The incision is made high above the gum line and a pocket is created over the bone. The implants come in numerous shapes and sizes. The choice depends on your particular case and the desired effect to create the most ideal shape and natural looking result. Different portions of the implant can be carved to further customize the implant to each individual’s unique structure. The appropriately-sized implant is then inserted and properly positioned within the pocket and stabilized to prevent it from moving out of place. Supportive tissue forms around the implant after a few weeks, and once healed, it feels like your normal underlying bone structure.
After cheek or submalar implant surgery, some swelling (but rarely, any bruising) can be expected. The main swelling is gone within two weeks and the fine definition and final form of new facial contours gradually emerge after four to six weeks.
CHIN IMPLANTS, MANDIBULAR IMPLANTS, & MANDIBULAR ANGLE IMPLANTS
One of the most common implants used by patients are chin (or “mandibular”) implants. The new designs of mandibular implants wrap around the entire chin and mandible, providing a more natural look from both the front and side views than the older button-like chin implants that were used years ago.
Creating subtle but correct proportion, size, and projection to a small, recessive chin may add immeasurably to one’s appearance. Many people have a small chin – one that recedes or is not prominent enough. A small chin can make a person’s nose appear more prominent than it really is, whereas a chin that is more in harmony with other facial features can draw attention away from the nose and give the entire profile a more pleasing balance. Improving the profile and extending out the chin can also be performed using a procedure called a “genioplasty”, which involves cutting the bone horizontally and sliding the chin bone-segment forward and fixing it in position. Although done for more extreme cases (see article published by Dr. Binder on “Double Sliding Genioplasty”), I believe that with the types of materials, advanced designs and lack of complications, augmentation using an implant versus a more major procedure such as genioplasty is considerably more practical as well as versatile in achieving overall better results in the majority of patients.
Narrow jaws can also be enhanced with the use of “mandibular angle” implants. These implants are place through incisions along the gum line at the back of the mouth. These implants are considered to be extremely powerful in having an ability to make dramatic changes in the shape of the jaw and entire lower third of the face. Recently, as demonstrated in his video (produced for the American Academy of Facial Plastic and Reconstructive Surgery), Dr. Binder was able to show, for the first time, using a custom implant how a total mandibular implant could be placed and the how the dramatic change in shape and size of the entire jaw was changed.
Mandibular augmentation is a relatively minor procedure, performed as an outpatient and takes between 30 to 40 minutes. It can be performed alone, or in combination with facelift, nose, eyelid, or cheek implant surgery. If the implant procedure is performed separately, the anesthesia given can be local or I.V. sedation (“twilight sleep”) administered by our M.D. Anesthesiologist. If performed in combination with other procedures, general anesthesia may be given. In either case, once you are asleep, a long-acting, local anesthetic is administered, providing several hours of numbness and comfort to the area after the procedure is over. Normally antibiotics are given before, during and after surgery to decrease the risk of infection.
The procedure is performed by making a small incision either in the small crease line under the chin or inside the mouth where the lower lip joins the teeth. Placing the incision in the submental crease, below the chin makes the scar (via the external route) virtually inconspicuous. A small pocket is created directly over the bone to approximate the size of the implant. Different size and shape implants may be tried during surgery to find the most appropriate one that will create the most ideal shape and natural looking result for each individual patient.
Chin implant procedures are used in almost 20% of patients who undergo Rhinoplasty
The procedures go hand-in-hand. Overall profile, must be considered when performed either one of the procedures. For example, a receding chin will accentuate one’s nose. Placement of a chin implant will restore balance between the mid and lower thirds of the face and ensuring that the nose will be a better fit for the face and reducing the chances of “overcorrecting the nose” due to a weak chin. Building up a small chin can also dramatically improve the configuration of the jaw-neck line to effectively reduce the “double chin” when performed in conjunction with facelift. Mandibular augmentation is also easily combined with removal of submental fat (via liposuction) from under the chin which also improves significantly the overall affect of mandibular augmentation.
- 20%
CUSTOM-DESIGNED IMPLANTS USING 3-DIMENSIONAL COMPUTER MODELING
Dr. William Binder, believing that the application of computer technology will undoubtedly play an ever expanding role in facial plastic and reconstructive surgery, combined three-dimensional (3-D) “CT” scanning with today’s computer capabilities. He designed a system capable of fabricating custom-designed implants that enable the reconstruction of most facial contour defects with much greater accuracy than ever before possible.
The correction of facial contour defects has always posed a challenge to the reconstructive surgeon. Traditionally, major facial deformities with functional disability were treated with orthognathic surgery. This involves cutting, moving and grafting of bone. For many patients, these procedures are not possible due to the enormous expense of the surgery and cost of hospitalization. The ability to procure precise implants or grafts to be used to accurately reconstruct facial contour defects due to congenital, posttraumatic, or acquired conditions has also been difficult. Carving and modifying bone or cartilage grafts or using “off-the-shelf” implants to reconstruct complex contour deformities have often been unsatisfactory due to their failure to conform precisely to the underlying surface. However, advances in computerized X-ray imaging such as the CT or CAT scan and computer technology utilizing the 3-D Accuscan® process have now been able to solve most of these contour problems.
This process begins with a CAT scan taken of the anatomical area surrounding the defect. A computerized three-dimensional image is created from the scan and is available for examination through a video screen. The image is then transformed into an exact life-size physical model of the skeletal structure. The anatomical model is then used to produce an extremely accurate implant that will exactly correct the actual contour deformity. The back surface of the implant fits the contour of the bony defect with extreme precision and interlocks with the underlying bone to provide long-term stability and prevent movement or slippage.
Three-dimensional computer imaging technology expedites surgery for ease of application and for more exacting results. Since most of the work to create the exact implant is performed prior to surgery and requires very little modification during the actual operation, the guesswork and time of carving old fashioned implants or bone while the patient is under anesthesia is reduced. The actual procedure is minimized, operative time is shortened and the procedure can usually be performed on an outpatient basis with less complications and a considerable reduction in cost. 3-D Accuscan, provides a reliable and accurate method of contour restoration for complex facial deformities.
Dr. Binder originally presented this technique at major national conventions and published it in the prestigious Plastic and Reconstructive Surgery Journal. In recognition of the significant contribution of this work to reconstructive and aesthetic surgery, the American Academy of Cosmetic Surgery honored Dr. Binder with the Outstanding Achievement Award.
The procedure is performed by making a small incision either in the small crease line under the chin or inside the mouth where the lower lip joins the teeth. Placing the incision in the submental crease, below the chin makes the scar (via the external route) virtually inconspicuous. A small pocket is created directly over the bone to approximate the size of the implant. Different size and shape implants may be tried during surgery to find the most appropriate one that will create the most ideal shape and natural looking result for each individual patient.