Malar and Submalar Implants 

Prominent malar eminences are a hallmark of beauty in many cultures, and fullness of the malar region conveys a youthful appearance. Over time, attenuation of the retaining ligaments results in descent of the malar soft tissue complex. The convex malar soft tissue complex of the midface descends from a youthful location that lies over the zygoma and orbital rim inferomedially to deepen the melolabial crease. Additionally, the aging process results in loss of volume in the malar fat pad.

The primary goal of midfacial contouring is to produce a natural appearance of youth and beauty by enhancing or restoring structure and creating the smooth facial contour that tends to be lost with age. Submalar augmentation may be used to efface deep melolabial folds and provides elegance to the midfacial area. Malar and submalar augmentation with alloplastic implants is a safe and simple technique that yields highly satisfying results and may complement other facial rejuvenation procedures, such as a midface lift.

An image of a patient before and after malar implantation can be seen below.

Tessier initially described malar augmentation in craniofacial reconstruction using autogenous bone grafts.^[1] However, the use of autogenous bone grafts had limitations such as limited availability, donor site morbidity, and unpredictable resorption. Gonzalez-Ulloa was among the first surgeons to describe malar augmentation with alloplastic implants.^[2] Although alloplastic implants do not have the inherent limitations of autogenous bone grafts, according to Scales and Winter, the ideal implant (biocompatible, chemically inert, no foreign body reaction, noncarcinogenic, easily shaped) remains elusive.

Since the use of silicone implants for facial augmentation, various other alloplastic implants (eg, porous polyethylene [Medpor]) have been developed.^[3] In addition, subcutaneous augmentation material (SAM) facial implants are available for malar augmentation. The SAM preformed shapes for facial implantation are manufactured from expanded polytetrafluoroethylene (ePTFE) and reinforced with fluorinated ethylene propylene, thus providing rigidity to the otherwise soft and flexible ePTFE.

Several authors have described techniques to characterize the types of malar deficiency and to determine appropriate implant size and placement. A patient may demonstrate a lack of anterior projection of the malar eminence, or the point of maximal projection may lie too far medially; both disrupt facial harmony and create a disproportionately widened mid face. As described by Silver, when the malar prominence falls more than 5 mm posterior to the nasolabial groove, a deficiency in the malar area exists.^[4] Hinderer's method of crossed lines describes a line drawn from the oral commissure to the ipsilateral lateral canthus that intersects a line drawn from the nasal ala to the superior tragus.^[5] During augmentation, the implant is placed in the upper outer quadrant delineated by the intersecting lines.

In 1983, Wilkinson proposed another method for locating the malar prominence.^[6] In this method, a vertical line is dropped from the lateral canthus to the mandibular border. When this line is divided into thirds, the malar prominence should fall just lateral to a point one third of the distance from the canthus. Powell et al created a practical division of the malar region by dropping a vertical line from the lateral canthus.^[7]

Malar deficiency is divided into anteromedial and posterolateral components or a combination. The vertical dimension is made at or just below the Frankfort horizontal. Analysis of the malar mound by Prendergast and Schoenrock noted that the malar eminence was the most prominent point on the malar mound below the lateral canthus on oblique view.^[8] With a line drawn from the lateral canthus to the oral commissure, the malar prominence should fall one third of the distance down the line. In clinical practice, most surgeons use a combination of these techniques or rely on their subjective sense of aesthetic proportion balanced with the patient's requests. The facial plastic surgeon should be mindful that malar/submalar defects vary among patients and may differ from one side of the face to the other.

Individuals with strong, high cheekbones convey a healthy, youthful look. A hypoplastic flat malar area can make the face appear tired and contributes to a prematurely aged appearance. This tired, aged, sunken look is due to hypoplasia of the mid face and/or atrophy and ptosis of the soft tissues. Submalar implants help correct this problem. Some individuals with small malar bones have increased lower cheek and mandibular soft tissue and bony prominences. The malar implant helps counterbalance these unfavorable facial prominences.

Patients may not be aware of the contribution the mid face makes to overall facial harmony; instead, they may tend to focus on concerns regarding the nose, eyes, or redundant or ptotic facial skin. When ptosis and volume loss of the midfacial soft tissue occur in conjunction with pseudoherniation of orbital fat, a double convexity contour is noticeable and the nasojugal groove, or tear trough deformity, deepens. The facial plastic surgeon may educate patients by describing how malar and submalar augmentation serves to efface the melolabial folds and provide elegance to the midfacial area. In patients who lack the supporting bony architecture, a midface lift in conjunction with malar or submalar implants results in a more youthful-appearing midfacial unit.

Malar and submalar augmentation is performed on an elective basis. Patients may present with obvious changes associated with aging, such as hollowing of the cheeks and ptosis of the midfacial soft tissue. Enhanced effacement of the melolabial folds is created with the placement of malar-submalar implants. Patients with midface hypoplasia, a dish-face deformity, gain aesthetic benefit from improved facial contour. Other indications for malar-submalar augmentation include posttraumatic and posttumor resection deformities. Patients with mild hemifacial microsomia may also benefit. Other patients may request facial augmentation to produce a dramatic high and sharp cheek contour. Placement of a malar-submalar implant often enhances the result of a rhytidectomy or rhinoplasty by further improving facial balance and harmony.

Binder created a classification of midfacial deformities.

• Type I deformity: This deformity occurs in a patient with adequate midfacial fullness but insufficient malar skeletal development. Correction is provided by a malar implant to augment the zygoma and create a higher arched and more projecting cheekbone.
• Type II deformity: Atrophy of the midfacial soft tissues in the submalar area with adequate malar development is seen in the type II deformity. Patients with this deformity have wide or flat faces and benefit from the placement of a submalar implant.
• Type III deformity: This deformity is seen in patients with prominent malar eminences and thin skin. A skeletonlike appearance results from the sudden transition to a hollowed submalar region. A submalar implant may be used to soften the transition and to provide anterior projection to the deficient submalar area.
• Type IV deformity: A combination of malar hypoplasia and submalar soft tissue deficiency creates a volume-deficient face, known as the type IV deformity. Placement of a combined malar-submalar implant provides correction.
• Type V deformity: In the type V, tear-trough deformity, a pronounced nasojugal fold may be effaced by placement of a silastic or Gore-Tex implant.

Terino has described 5 zones of facial contouring.^[9]

• Zone 1: Zone 1 includes the major portion of the malar bone and the first third of the zygomatic arch. Projection of the malar eminence, creating a high, sharp, angular appearance, is produced when this region is augmented.
• Zone 2: The middle third of the zygomatic arch constitutes zone 2. When this area is augmented with zone 1, the upper third of the face appears broader, as the cheekbone is accentuated laterally.
• Zone 3: Zone 3 lies between the infraorbital foramen and the nasal bone. Augmentation of the paranasal area creates medial fullness in the infraorbital region.
• Zone 4: The posterior third of the zygomatic arch comprises zone 4. Augmentation in this area is avoided because it creates an unnatural appearance and places branches of the facial nerve at risk.
• Zone 5: Zone 5 is the submalar triangle.

The safest plane of dissection in the face is the subperiosteal plane, which is directly on bone. Dissection in this plane provides the greatest amount of protection for the facial nerve, prevents unnecessary bleeding, and maximizes the amount of soft tissue coverage of the implant. Implants attach to facial bones by capsular fibrosis and stabilize in a few days.

Although malar-submalar augmentation with silastic implants is a safe and simple technique, surgeons should exercise caution when considering implants in certain patients. These include patients with excessively thin skin, significant facial asymmetry, or extremely prominent bone structure. In addition, patients with a history of irradiation or malar fractures with exposed sinus mucosa are not generally candidates for midfacial contouring.