Current approaches to facial rejuvenation focus on volume addition and mobilization in order to achieve a more youthful appearance. Techniques no longer focus on simply tightening or removing tissue. This is based on the clearer understanding of the underlying processes that occur with aging. Whereas in the past the assumption was that skin and soft tissue are subject primarily to the effects of gravity, it is now clear that three dimensional loss of volume occurs as well. This involves not only the loss of facial fat but also the bony skeletal framework. Increasing facial projection in volume deficient areas also improves facial balance and therefore creates a more pleasing appearance.
For decades, plastic surgeons have used implants made from foreign materials to add volume to specific areas of the face. Most commonly, solid silicone have been used as they are well tolerated by the body and do not incite allergic reactions or other systemic problems. The most common areas where such silicone implants have been used are the cheeks and chin. While some surgeons and dermatologists would argue that fillers or fat are better alternatives for volume addition, such implants are still commonly used. One reason for their continued use is the improved design of the implants to create a more natural appearing result that is often customized and fitted for the individual patient.
People with sunken and hollow midfacial and cheek areas are good candidates for implants. Cheek implants are designed to add volume to the cheek bone arch (malar) and the area just below (submalar). Combined malar/submalar implants exist as well. Typically the patient will be fitted for the specific size and type with a sizer by the surgeon prior to the surgical procedure. The sizers are the identical size and shape as the actual implant.
Patients with “weak” chins are good candidates for chin implants. Often such people appear to have poorly defined neck angles from the side view. Some will have prominent noses as well. To determine if the patient truly has a weak chin, he/she needs to be assessed from the side view, with the head in a standardized anatomic position known as the Frankfort plane. This position is reached when an imaginary line between the ear canal with the lower eye socket rim is horizontal, parallel with the floor. From this position, a vertical line is dropped from the edge of the lower lip. In men, the chin should touch the vertical line or extend just beyond it. In women, the chin should be just behind the line. Using this simple and objective assessment, one can determine if the chin is truly in need of added projection. Patients are also sized for chin implants before the surgical procedure. The design and shape of chin implants have advanced significantly over time to appear more “anatomic” and less like the “button” shape that early versions created.
Cheek implants are performed under either conscious sedation or general anesthesia. The optimal route for placing the implant is through the mouth, just above the upper gum line. An incision is made through the lining above the teeth and a pocket is created beneath the dense layer that covers the cheek bone called the periosteum. A pocket is created that is slightly larger than the implant in order to allow it to fit tightly and properly. During the surgery care is taken not to injure the nerve and blood vessels that supply sensation and blood supply to the cheek. Some surgeons choose to suture the implant in place. The incision is typically closed with dissolvable sutures.
The chin implant is performed either under local anesthesia with sedation or under general anesthesia. The implant can be placed either through the lower gum line (intraoral) or through an incision placed in a crease under the chin (submental). Some surgeons feel that the route under the chin is less likely to result in an infection because the bacteria of the mouth do not come in contact with the implant. Other surgeons feel that with proper preoperative sterilization of the mouth the risk of infection is minimal. They also feel that because the intraoral approach avoids an external incision it is preferable. In reality, both techniques work well. With both approaches, a pocket is created under the periosteum as well and the implant is secured tightly with or without an anchoring stitch. Care is taken to avoid injury to the nerve that supplies sensation to the chin and bottom lip. The intraoral incision is closed with dissolvable sutures and the submental incision is closed with stitches that need to be removed.
Recovery from both procedures includes mild swelling and moderate pain and soreness. The pain results from dissection that is performed right on the bone when creating the subperiosteal pocket. This usually lasts a week and is treated with oral pain medication. If stitches are placed under the chin they are removed one week after surgery. Oral antibiotics are prescribed before and after the procedure to minimize the risk of infection.
The most common potential side effect is improper placement of the implant. This can sometimes be corrected with manual massage but may need to be repositioned surgically. Other potential side effects include injury to the nearby sensory nerve. The most devastating complication is infection of the implant. This is often difficult to treat as there is no blood supply for the implant and the antibiotics cannot be delivered to the implant. Such a complication may require intravenous antibiotic therapy. If this fails to eradicate the infection, the implant will have to be removed and then replaced well after the infection has cleared.
Volume restoration of the cheeks and improvement of the chin projection can be achieved effectively with silicone implants. Though both involve surgical procedures (as opposed to injectable treatments) they have the advantage of being customizable, permanent and feeling like natural facial structures. Volume augmentation is a key component of modern facial rejuvenation.
Alloplastic contouring for suborbital, maxillary, zygomatic deficiencies. Terino EO, Edwards MC. Facial Plast Surg Clin North Am. 2008 Feb;16(1):33-67, v. Review
Influence of the chin implant on cervicomental angle. Dayan SH, Arkins JP, Antonucci C, Borst S. Plast Reconstr Surg. 2010 Sep;126(3):141e-3e.