Overview of Facial Implants
Facial implants are a medical procedure used to improve the appearance of the face, whether it’s due to aging, lack of development, or irregularities caused by injuries or birth defects. They are commonly placed in areas like the chin, cheekbones, and jaw corners. In fact, the American Society of Plastic Surgeons found that cheekbone implant surgery was the top facial implant surgery in 2020, and the third most common cosmetic surgery. Since 2000, the popularity of these treatments has skyrocketed, increasing by 938%. Chin implants also experienced a significant rise in popularity, with an increase of 63%.
The best type of implants are those that are chemically inert (they don’t react with the body), biocompatible (they work well with the body), and can be easily shaped. However, because they are foreign objects introduced into the body, they do carry some risks. Facial implants can either be made from organic or synthetic materials. In the U.S., the most commonly used synthetic materials are polyethylene, silicone, and titanium. Autogenic grafts, which come from the patient’s body, were once popular but are less frequently used now because of their unpredictable long-term effects.
One of the most common issues with facial implants is poor cosmetic outcome, often due to unevenness. More serious, but less common, complications include infection and bone erosion. Thankfully, if these issues occur, healthcare providers can remove the implants. Implants that allow the growth of soft tissues into them are more difficult to remove than those which form a fibrous capsule.
To determine the appropriate surgery for a patient’s facial irregularities, health care providers use software-aided, comprehensive analysis. This analysis is becoming more advanced with the emergence of three-dimensional (3D) treatment planning. For example, two-dimensional (2D) images can easily compare bone structures and help determine what will work best for the associated soft tissues. While technology is advancing, further research is needed to aid evaluation, particularly for deficiencies in the midface.
Various criteria have been developed to help healthcare providers base their decisions on objective facts. Of course, societal trends and patient preferences also play a role. The success of facial implant treatment depends on accurate diagnosis, thorough facial analysis, choosing the right implant, and skilled surgical execution.
Anatomy and Physiology of Facial Implants
When surgeons are placing facial implants, they have to be very careful not to harm key structures in the face like sensitive nerves, blood vessels, and muscles.
When we speak of nerves in the face, the most important one is called the trigeminal nerve, also known as cranial nerve V (CN V). This nerve is responsible for feeling in your face and helps some muscles work properly. This nerve comes out of the skull in three parts from different holes, and some ends reach to the surface of the face and into soft tissues. Some of these nerve branches can risk getting harmed while placing implants.
The first part of the nerve (CN V1) exits the skull from a gap called the superior orbital fissure. This nerve divides into three main branches. They supply the feeling to the upper eye lid, the white part of the eye called conjunctiva, and the scalp. The smallest among the three branches is called the lacrimal nerve. This nerve connects with another nerve – the zygomatic nerve, supplies feeling for the outer corner of the eye and also contributes in making your eyes watery.
The second part (CN V2) of the trigeminal nerve comes out of the skull from a hole known as the foramen rotundum. This part divides into two main branches that give feeling to the area from the lower eyelid to the upper lip. These nerves also provide feeling to the temple region and the cheekbone. These nerves can be at risk of injury when there’s surgical work called subperiosteal dissection in the zygomatic (cheekbone) area.
The third part (CN V3) exits the skull via the foramen ovale. This branch mainly supplies the muscles that help in chewing. This nerve is not usually at risk during implant procedures as it is located outside the surgical area.
One part of CN V3, the inferior alveolar nerve, goes through the lower jaw and comes out through a hole called the mental foramen below two specific teeth – the 1st and 2nd premolars. This nerve provides feeling to the lower lip, chin, and gums of the lower front teeth. This nerve often gets in the way during a surgical procedure called genioplasties.
Another important nerve is the facial nerve or CN VII. It controls the muscles that help us express emotions on our faces. These nerves can get harmed during certain facial implants by stretches or compression. These nerves provide control to the muscles near the forehead, eye, upper cheek, and lower lip areas.
The blood supply to the facial region comes from branches from a major artery known as the external carotid artery. The major blood vessels are at risk during the first cut of the surgery since they exist within soft tissues.
The muscles that help in making facial expressions are located just under the skin in the facial and neck region. Most of these muscles are connected to bones or tough tissues and help in creating our facial expressions. These muscles are also controlled by the facial nerve or CN VII.
Why do People Need Facial Implants
Facial implants are used for medical or cosmetic reasons, including if you’ve lost some of the soft tissues that support your face, if you’ve lost volume in your face, if one side of your face is bigger or smaller than the other, or if you have certain birth defects.
As we grow older, some of the bones in our faces start to shrink, particularly in our thirties and forties. This is most noticeable in the areas below our eyes and around our upper jaw. When these areas shrink, it can make the middle of our face look sunken. Our faces also have certain structures that connect our bones, muscles, and skin. These structures can weaken and lose elasticity over time, making our skin saggy.
Our faces are made up of different layers of fatty tissues, which can also start to shrink as we get older. For example, the area of the face that’s around and below our cheekbones contains layers of fat that can shrink over time, causing a saggy appearance. Similarly, sagging skin and fat around the lower edges of our jawbones can lead to the development of jowls – an issue which remains even after a surgical procedure to improve the shape of the chin. For this reason, some people might need a specific kind of surgery called prejowl implant surgery, which can help to correct this problem.
There can also be natural differences in the size and shape of our faces due to the way our bones grow. Our bones grow in different directions, which can affect the overall shape of our face. Any changes from the usual pattern of growth can cause our faces to look longer or shorter than normal. Once we stop growing, which usually happens in our mid to late teens, these differences in facial shape remain. In these cases, we can use braces to fix any issues with our teeth, but we might need surgery or facial implants to correct the bone structure of our face.
Some birth defects can affect the development of the bones in our face, causing certain areas to be smaller than they should be. In these cases, facial implant surgery might be a good option. For example, craniofacial microsomia is a condition that affects the development of the bones in the face and is the second most common birth defect after cleft lip and palate. Facial implants can be useful for people with less severe forms of this condition or for those who have already had surgery to correct some of the issues associated with this condition.
Another example is that people with clefts often have a smaller middle part of the face. Though certain types of surgeries can help with some aspects of this problem, the use of facial implants may also be beneficial in correcting deficiencies that persist after these surgeries.
When a Person Should Avoid Facial Implants
Sometimes, a facial implant surgery might not be suitable for some people due to several reasons:
– If someone is still growing, it’s not the best time to have this surgery as the shape and size of their face will continue to change.
– If a person has a large amount of loss in facial volume, there might be better treatment options for them.
– If there’s an existing infection, it can increase the risks during surgery.
– Also, if there isn’t enough bone or soft tissue in the face to act as support for the implant, the procedure might not work.
How much a person has grown and will grow in the future is important to consider when thinking about facial implants. It’s worth noting that females generally start and stop growing earlier than males.
The term “growth cessation” or when one stops growing, can be defined in different ways. One definition is when growth is less than 0.1 mm per year. Another definition is when the growth rate slows down to less than 10% of the time when growth was at its fastest. To figure out when growth has stopped, serial cephalograms (a type of X-ray of the head) can help by comparing the growth rate over a period of time.
People with irregularities in the alignment of their teeth and jawbones (dental malocclusions) might be better off with orthognathic surgery, which deals with the surgical correction of the jaws. If a person needs a larger change in their facial structure, osteotomies, or surgery to cut and reshape the bones, might be the recommended choice. However, some people might prefer getting an implant. If the tissue in the face is thin, it can limit where the implant can go because it might be seen or felt under the skin.
Equipment used for Facial Implants
A variety of materials can be used for facial implants, depending on what best suits your situation. These include:
Titanium mesh: This non-absorbable, stiff, and unreactive implant is made with lots of little holes (known as fenestrated) to enable the surrounding tissue to grow into it and provide stability. Often, it is used to enhance the shape of the jawline by adding length and width.
High-density porous polyethylene (HDPE): These are firm, non-compressible, and heat mouldable implants. They come in various densities and pore sizes. These pores influence the kind of tissue growth that occurs after implantation. HDPE implants can be reshaped by heating them to 180 °F before cutting with a scalpel. They, however, require to be fixed in place to prevent disruption of the formation of new blood vessels.
Silicone: These implants do not have pores. They may be formed from solid silicone or dimethylsiloxane subunits. Since these implants don’t allow tissue growth, they are encapsulated after being fixed to the bone. Fixation is needed to minimize the space between the implant and bone, reducing the likelihood of tissue growth and fluid accumulation, and preventing bone absorption and aesthetic issues.
Autogenous implant: This is a type of implant using one’s own tissues. However, its use is limited due to unpredictable bone absorption. One reason is that the bone needs to be under stress to prevent absorption – a principle known as Wolff’s Law. Additionally, using autogenous tissues can complicate the surgery and resulting recovery, and increase the surgical time.
During the surgery, you will either be put to sleep (general anesthesia) or numbed significantly (intravenous deep anesthesia). Further numbing with local anesthetics will then be administered to the surgical area. The specific incision will be made using either a precise surgical knife or a device that uses heat to cut and coagulate tissue.
The tools used in the surgery depend on the type and location of the implant but generally include materials and equipment for numbing the area, making the incision, fixing the implant in place, lifting the tissue, closing the incision, retracting the tissue, and other miscellaneous items. Before the surgery, you may be given antibiotics to prevent infection, and after the surgery, you may be provided with pain management medications and antibiotics for a short period.
Who is needed to perform Facial Implants?
The team for a surgery can be as small as two people – the main surgeon and their assistant. Sometimes, there’s another surgeon working together with the main one. There may also be another team involved, which includes an anesthesiologist (a doctor who specializes in giving anesthesia, or medicine to prevent pain) and possibly a nurse who also specializes in anesthesia. They help the surgeon by providing deep or general anesthesia (medicine that makes you unconscious or deeply relaxed).
Nurses and technicians who work in the operation room also play important roles when general anesthesia is being used. Oral maxillofacial surgeons (surgeons who focus on surgeries involving the face, mouth, and jaw) are capable of giving deep anesthesia during the procedure. However, it’s common to have an anesthesia provider as part of the surgical team.
During facial implant surgery, nerve testing is not usually done because the procedure allows for careful movement of tissue without affecting nerves. Nerves that become exposed during the surgery, like the mental and infraorbital nerves (nerves in the lower part of the face and around the eyes), are easily spotted and kept safe during the operation.
Preparing for Facial Implants
Advancements in 3D technology have improved the way doctors assess facial cosmetics. At the moment, doctors use 2D and 3D images alongside photographs taken from different angles to help them visualize the structure of the face. One type of structural image, called a lateral cephalogram, provides incredibly important information and is carefully reviewed by doctors to understand the relationships between both bone and soft tissue in the face.
Different measures are used to analyze the chin’s position and the structure of the lower face. Here are some common techniques:
– Holdaway Ratio: This method compares the position of the chin to the lower front teeth. It involves measuring distances between a specific set of points on the face, and ideally these measurements should be equal. If the distance is off by more than 4mm, a correction could be needed.
– Zero Degree Meridian Line: This line helps evaluate the position of the chin. Depending on the gender, the distance between an established point on the chin and this line should be within a certain range.
– True Vertical Line: This line is used to assess whether or not the lower jaw is too far back or too far forward, even if it isn’t easy to see with the naked eye.
– Labiomental Angle: This angle represents the curve between the lower lip and the chin. Depending on the nature and angle of the chin, larger implants might be feasible.
Facial implants could also be used to adjust the width of the lower jaw. This measure, known as the bigonial width, is the distance across the jaw from point to point.
Analyzing the middle part of the face can be a bit tricky, but there are different ways to identify any deficiencies. Depending on the identified issue, different implant shapes and placements might be required. For instance, a deficiency could mean a lack of projection or loss of soft tissue volume, or a combination of both. Based on the type of deficiency, a tailored approach may be taken to enhance the facial structure, which could involve different types of implants placed in specific locations.
How is Facial Implants performed
Antibiotics are very important to make sure facial implants work well. Doctors often give antibiotics before, during, and after surgery. A common choice for cuts outside the mouth is an antibiotic called cefazolin. This helps protect against bacteria on the skin such as Staphylococcus. Doctors also use antibiotics like amoxicillin to protect against bacteria inside the mouth when cuts are made there. There is some debate among doctors about how long to give antibiotics after surgery.
Next, the surgical team gets your face ready for the surgery by cleaning it with iodine and injecting a local anesthetic to numb the area. The type of anesthetic depends on how the surgery will be done. The implant is normally placed while you are either under general anesthesia (completely asleep) or IV sedation (partially asleep).
Let’s look at malar implants, which are used to enhance your cheeks. The surgeon makes a small cut inside your mouth, just above your gums and behind your canine tooth. Then, the surgeon carefully separates the tissues to create a space for the implant. It’s very important for the surgeon to identify and protect a bundle of nerves and blood vessels called the infraorbital neurovascular bundle, which runs along the lower part of your eye socket.
The surgeon then measures the space using a sizer, which is a tool made by the implant manufacturer to make sure the implant will fit properly. Another tool that can be used is a 3D printed model of your face, which helps visualize the implant size and placement. Both the implants and the sizers are soaked in antibiotics before use for additional protection against bacteria.
After the implant is placed, it is secured with stitches or screws. The cut inside your mouth is then stitched up, and a compression bandage is applied to your face. This bandage helps reduce swelling and helps the tissues heal properly.
Let’s now move on to chin implants. The surgeon makes an incision either inside the mouth or under the chin. If the incision is made inside the mouth, it is very important to leave a little bit of muscle attached to the bone and lip. This helps the muscle heal properly and prevents drooping. The surgeon then creates a pocket for the implant by separating the tissues, making sure space is larger than the implant itself to avoid complications.
Again, a sizer is used to confirm that the pocket is the right size for the implant and that the nerve near your chin (the mental nerve) is safe. The surgeon then irrigates (cleans) the surgical area and the implant is secured with stitches or screws. Once the implant is secure, the surgeon stitches the cut made inside your mouth.
For implants on the lower jaw (mandibular angle implants), the process is somewhat similar. Depending on the implant’s size and type, the surgeon may make the incision inside the mouth or on the skin. The surgeon creates a pocket for the implant and secures it with screws, stitching the incision closed afterwards. It’s important to remember that the nerves in the area are identified and protected throughout the process.
After the surgery, it is very important to see your doctor regularly to make sure everything is healing properly. If you’ve had surgery to enhance the lower jaw, it’s recommended that you stick to soft foods for a while, as chewing can be difficult.
Possible Complications of Facial Implants
After facial implant surgery, some people might experience complications either immediately after the procedure or even months to years later. In this context, we’re defining “early” complications as things that can happen in the first few weeks as your body heals from the procedure. These could include:
- Hematoma: This is when blood collects outside of the blood vessels, which might require drainage.
- Seroma: This is when a pocket of clear fluid collects in a part of the body where tissue has been removed.
- Infection: This occurs when harmful bacteria enter the body.
- Wound Dehiscence: This is when a surgical wound opens along the stitch line.
- Alveolar Ridge Resorption: This is a loss of bone in the jaw.
- Poor or Undesired Aesthetic Outcome: This is when the final result of the surgery doesn’t look as good as expected.
- Displacement or Malpositioning: This happens when the implant does not stay in its intended place or is not properly positioned.
- Scarring: This is the formation of fibrous tissue after your body attempts to heal a wound.
- Nerve Injury: This happens when nerves are damaged during surgery.
Early complications like bleeding may happen due to poor control of blood flow during surgery. Hematomas and seromas can arise due to the body’s response to the surgical procedure, and treatment options may include antibiotics, fluid drainage, and additional surgery if needed.
Later complications could include infection, shifting of the implant, the implant coming out through the skin, or the loss of bone. Infections have been reported in 0.7% to 14.6% of people who receive non-biological facial implants, with infection rates for silicone implants reported to be 1%.
Procedures involving incisions inside the mouth are often used to avoid visible scars. However, these incisions may slightly increase the risk of infection. If an infection occurs and doesn’t go away with antibiotic treatment, the implant may need to be removed.
There can be higher chances of erosion in the bone underneath the implant with solid implants than with porous ones. Implants that are too large or too rigid can also increase the risk of bone erosion. This erosion can happen due to implant mobility, inflammation, and stress on the tissue over the implant.
Problems can arise if the implant is not the right size, shape, or if it’s not placed correctly. When it comes to chin implants, the pressure of facial muscles on the implant can cause bone erosion. To prevent this, the implant can be placed in areas with thicker bone and away from muscle insertions. Securing the implant can also help to prevent small movements that lead to bone erosion. Over time, the erosion might stop on its own.
If the implant moves or folds, it can cause unevenness of facial appearance which can be corrected by securing the implant better or replacing it with a more appropriately sized and shaped one in a follow-up surgery.
Poor healing of the muscles in the chin after surgery can result in drooping of the chin, also known as “witch’s chin”. In such cases, surgeons can consider using a different surgical approach with an incision under the chin to avoid this problem; however, this may leave a visible scar.
Finally, numbness or unusual sensations can occur if there’s damage to the nerve that provides sensation to the chin and lower lip during chin augmentation. This happens in around 2.4% of cases, often due to bone loss in the jaw. Removal or replacement of the implant might be needed if the nerve dysfunction continues.
What Else Should I Know About Facial Implants?
Facial implant surgery is a flexible option that offers an alternative to more intense procedures, such as operations to move the jawbone (genial horizontal osteotomies). Less intense procedures are generally cheaper, using less expensive tools and easier types of anesthesia, and take less time in surgery. Normally, facial implant surgeries are performed under general anesthesia and being sedated through an IV. However, in some cases, the implants can also be put in place while the patient is awake and under local anesthesia. Reducing the use of general anesthesia can decrease risks and save money for individuals who want facial implant surgery but have health issues or limited funds. The recovery period after implant surgery is based on how quickly the soft tissues around the implant heal, which usually only takes a few weeks. This is much quicker than the healing time required after surgery involving the bones.
Chin implants can extend the chin both to the sides and forward. They can also remodel the chin to look narrower. These implants can help make your face look more balanced, without needing surgery on the bones. Malar implants, placed in the middle of the face, can make the face appear more balanced and youthful.
Implants in the jaw angles can enhance the jawline and broaden the lower face. A wider jaw can be achieved with implants in patients who need jaw reconstruction after a trauma or need to correct abnormal facial growth. This type of implant surgery can also help people seeking a more masculine look in their face as part of a gender affirmation surgery. Implants can improve a face that has lost volume and skeletal support due to aging, making it fuller and more balanced.
With the right training and practice, placing facial implants can be a safe and quick procedure. Whether a patient is seeking a more balanced face, a younger look, or a facial structure that matches their gender identity, facial implants can offer an alternative to more intense operations. This method also enables different professionals like ear, nose, and throat specialists and anesthesiologists to collaborate on surgeries that affirm a person’s gender affirmation.
