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.

Side view of patient before and after insertion of malar implants.

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, 4, 5] 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.[6] 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.[7] 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.[8] 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.[9]

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.[10] 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.[11] 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.[12] 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.

A study by Kaptein et al found that the malar prominence occupies a consistent vertical position among individuals, with the average ratio of cheek height (from the chin to the malar prominence) to canthus height (from the chin to the canthus of the eye) being 0.793. The measurements were derived from a group of 67 individuals, with no significant difference found based on age or gender or between whites and Hispanics.[13]

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.[14]

• 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.

Silastic implants remain one of the most common materials used for malar and submalar augmentation. Silastic implants possess many characteristics of the ideal facial implant, including ease of placement and the ability to be readily exchangeable, malleable, conformable, nonimmunogenic and noncarcinogenic, resistant to infection, and easily tailored by the surgeon. Recently designed facial implants have been very successful, based in part on their anatomic conformability to the facial skeleton. The projecting contour of the bone is accommodated by the posterior surface of the implant as it molds over the surface.

In addition, the larger surface area of the implants allows them to fit the facial contour more effectively and minimizes malposition, migration, and displacement. Solid silastic implants prevent actual tissue ingrowth, and a resultant dense fibrous capsule forms around the implant. Some surgeons prefer to fixate the implants into position with the use of titanium screws or nonresorbable sutures, thus securing the implant in position and minimizing the complication of implant migration.

More recently, expanded polytetrafluoroethylene (ePTFE) has been used for facial augmentation; the advantages of ePTFE include rapid stabilization and limited capsule formation. A basic science study demonstrated less capsule formation and increased neovascularization with ePTFE reinforced with fluorinated ethylene propylene when compared with silicone implants.

Additionally, high-density porous polyethylene (Medpor) has gained popularity in facial augmentation. However, a considerable ingrowth of fibrous tissue results, which makes the removal of the implant challenging.

A prospective study by Khiabani et al indicated that mild to moderate malar depression can be successfully corrected with buccal fat pad pedicle flaps. In the study, 13 patients underwent the procedure either for aesthetic purposes or in response to imprecisely reduced zygomaticomaxillary complex fractures. At 1-year follow-up, resorption averaged 0.376 mm. No major complications, such as massive hematoma, asymmetry, intense pain, parotid duct injury, or prolonged bruising, were found in association with the procedure.[15]

Prior to performing augmentation procedures for facial rejuvenation, the surgeon should critically analyze youthful faces. Youthful qualities include full cheeks with smooth, symmetric contours. Actual measurements of facial proportion are not usually performed prior to the placement of malar and submalar implants. Instead, the facial plastic surgeon should develop a sense of aesthetic facial proportion and consider the patient's requests. The patient is evaluated in at least 6 views, including frontal, right/left lateral, right/left oblique, and basal views.

The surgeon may find analysis of the frontal view with the patient smiling and in repose helpful. Photographic documentation of all these views is recommended. The malar eminence is evaluated in context of other facial features, including overall facial shape, contour and strength of the mandible, and size and shape of the nose. The surgeon should carefully analyze and identify patterns of midface deficiency so as to choose the most appropriate implant that yields the best surgical result. Any facial asymmetries should be brought to the patient's attention and documented.

The surgeon should assess both the underlying skeletal support and the character of the overlying skin and soft tissue. The thickness and quality of soft tissue influences implant size and positioning. The size, shape, and position of the implant to be placed can change the facial contour in a precise and controlled way. Customized implants based on a sculpted moulage or 3-dimensional CT scan are available.

Detailed preoperative counseling allows the surgeon and the patient to discuss the desired changes and those that are possible. Computer imaging provides a useful tool for communication between the patient and surgeon. Care must be taken to ensure that the images produced are not construed as a guaranteed result. In addition, asking the patient to provide photographs of him or herself at a younger age or photos of people (eg, actors, models) with the desired facial contour may reveal patient expectations and uncover unrealistic ones. Careful documentation and frank discussion are critical components of the preoperative workup. The implant to be placed is chosen based on patient's anatomy and the result desired.

Once the appropriate implant is chosen, it is placed on the skin overlying the malar-submalar area, and the surgeon subjectively determines the proper positioning. Then, the edges of the prosthesis are outlined on the skin. The procedure can be completed with the patient under general anesthesia or local anesthesia with sedation. Perioperative antibiotics are recommended.

Soft tissue elevation is facilitated by infiltrating a diluted local anesthetic agent to create a hydrodissected plane. Excellent hemostasis is required to provide accurate visualization and proper implant placement.

Several approaches may be used to place a malar-submalar implant, including intraoral, subciliary, rhytidectomy, and transconjunctival approaches. The following describes a technique for intraoral placement of malar and/or submalar implants, which is the most common approach.

Make a 1-cm diagonal incision in the gingivobuccal sulcus mucosa with electrocautery on the cutting setting. Dissect down to the periosteum and maintain hemostasis with monopolar cautery. Incise the periosteum of the malar eminence and elevate it with a wide periosteal elevator. Elevation proceeds in a superolateral direction. Use short, firm, controlled pushes to elevate the periosteum. Keep the location of the infraorbital nerve in mind to avoid nerve injury. Dissection in the subperiosteal plane protects the facial nerve branches from injury.

The surgeon's free hand constantly palpates as the internal dissection is completed. Place a sizer in the created pocket. Sizers of different shapes and positions are used to determine the optimal placement for the actual implant. Pocket size should accommodate passive placement of the implant because a pocket that is too small pushes the implant in the opposite direction, leading to possible extrusion. Binder et al report that 4 mm of projection is the most commonly used thickness of malar implant.[16] Irrigate the pocket and soak the implant in antibiotic solution of bacitracin and gentamicin; a no-touch technique is used. If transcutaneous fixation is desired, pass a long Keith needle suture through the most lateral aspect of the implant and then transcutaneously through the hairline. Then, gently tie the suture over a dental roll bolster.

The senior author prefers fixation of the implant with a single 6-mm titanium screw to prevent migration of the implant; place a single screw at the inferomedial extent of the implant to prevent migration. Not all authors agree on the need for fixation, and several recent articles emphasize creation of a precise pocket over suture fixation. A long, nonserrated clamp can be used to assist in positioning and can be retracted without difficulty. Manipulate the implant into position and pass a periosteal elevator anterior and posterior to the implant to ensure that no folding has occurred. Inspect and simultaneously palpate the implants from the head of the bed to check for symmetry.

For the submalar or combined malar-submalar implant, create a pocket by elevating the soft tissue that overlies the masseter muscle. The tendons of masseter are characteristically glistening white and should be maintained intact to provide support for the implant. Place the submalar implant below the zygoma and zygomatic arch, overlying the masseter tendon, or position it more superiorly over bone. The incision is closed in 2 layers using 3-0 chromic for muscle and 2-0 chromic for mucosa.

Some authors suggest placing elastic tape or stretch bandages over the implant site to maintain compression during the immediate postoperative period. The patient should maintain head elevation for 24-48 hours, and ice packs or cold compresses should be applied for the first 24 hours. Antibiotics are continued for 5 days. Caution the patient to consume a soft diet for the first week to avoid unnecessary motion and strain around the implant site.

The surgeon should evaluate the patient within the first 12-24 hours to check for any facial asymmetry that may develop secondary to hematoma or seroma. If placed for fixation, bolsters and sutures can be removed on the third postoperative day.

Given the safety and simplicity of malar-submalar augmentation, complications occur infrequently. Complications that occur in the placement of malar and submalar implants are largely dependent on technique and selection. Complications include implants that are malpositioned, asymmetrical, or inappropriately sized. Improper positioning of the implant is the most common complication, followed by improper implant size. When asymmetry or malposition occurs, removal of the implant, replacement of the implant, and subperiosteal mid-face resuspension is advocated.[17]

In addition, the implant may become exposed or extruded. The patient may develop a hematoma or seroma, which may require only surgical drainage, or the patient may develop an infection around the implant, which may require its removal. After resolution of the process, an implant may be reinserted in 6-8 weeks. Problems with local tissue reactions and capsule formation causing abnormal ridging and projections may also necessitate removal. Reimplantation should be avoided in these situations.[18]

Nerve injury is usually transient if the infraorbital nerve is stretched during the dissection. Numbness may last 2-6 months. Facial nerve injury is rare and transient. Paresthesias may persist if the implant impinges on a nerve. Persistent cheek pain may cause some patients to demand removal of the implants. Transverse mucosal/muscular incisions that divide the zygomaticus muscles may cause transient or even permanent partial muscle weakness. The patient's smile may be altered as normal lip elevation is inhibited.

Placement of malar-submalar implants via a subciliary or transconjunctival approach may be complicated by lower eyelid malposition or ectropion.

Unlike the findings of bone erosion associated with silastic chin implants, malar and submalar implants maintain facial contour without compromise to the underlying skeleton.

A retrospective study by D’Agostino et al of 42 patients with 116 zygomatic implants found, at 5-year follow-up, that the severe complication rate for these implants was lower than for other treatments for extreme upper jaw atrophy. There was an assessment of one zygomatic bone fracture, with sinusitis reported in eight patients and oro-antral communications found in two. As measured using preoperative and postoperative Lund-Mackay scores, sinonasal disease underwent a statistically significant increase. Mucositis was associated with 21 implants, and gingival recession with eight implants.[19]

Alloplastic facial augmentation produces permanent and effective 3-dimensional changes that result in a more youthful-appearing midface. Silastic implants have demonstrated consistent results and remain the implant of choice for the senior author. In 2003, a prospective multicenter study was conducted to evaluate the safety and efficacy of subcutaneous augmentation material (SAM) preformed facial implants for malar augmentation. One implant became infected and required removal. The infection rate (3.8%) was consistent with that previously reported in the literature. No implant migration was reported. The aesthetic results of the implants were evaluated by a panel of facial plastic surgeons and demonstrated a satisfactory-to-good aesthetic result. Results from studies that evaluated the efficacy and safety of ePTFE in the malar region have demonstrated similar results.[20]

Yaremchuk performed a retrospective study of malar augmentation with porous polyethylene (Medpor); his long-term results demonstrated no evidence of late complications.[21] A later study by Deshpande and Munoli concluded that high-density porous polyethylene implants are an alternative to autogenous grafts for facial skeletal augmentation. They had good long-term results and a low incidence of complications, provided vascular soft tissue cover was adequate.[22]

Malar and submalar augmentation with alloplastic implants can be used to enhance and restore facial harmony and balance. Defects that have developed as a result of aging or trauma as well as congenital defects may be addressed. Strong skeletal contours enhance beauty. Redraping, reshaping, and redistributing the soft tissue over a strong facial skeleton enhance restoration and rejuvenation of the face. Successful malar and submalar augmentation results from proper patient and implant selection as well as appropriate facial analysis and surgical technique. Alloplastic facial augmentation produces reliable, durable, predictable results with little morbidity and high patient satisfaction.