AUGMENTATION OF CHEEKS, CHIN, & NOSE
Alloplastic implant augmentation of the face offers a simple and effective technique for correcting acquired or congenital facial deformities and enhancing aesthetic appearance with low morbidity in appropriately selected patients.
Aesthetic implant augmentation surgery of the face is guided by principles of aesthetic facial analysis. Earlier implant approaches to facial anatomy regarded the aesthetic units of the face as discrete units that did not overlap or relate to each other. Implants were small and designed to address only the specific area of deficit. Except for the mildest defects, augmentation with small implants resulted in inadequate correction with palpable and sometimes visible step-offs, capsular scar contractures, and implant migration.
Over the last three decades, aesthetic understanding of the face has evolved into a more sophisticated analysis pioneered by Terino. In this analysis, aesthetic units of the face are extended beyond their traditional boundaries and divided into zones. The chin is evaluated in continuity with the jawline and the cheek is evaluated in continuity from the paranasal region to the lateral extent of the zygomatic arch. Terino calls this concept “zonal anatomy” (Figure 12–1). Furthermore, the overall harmony of the face is balanced between the upper two-thirds of the face and the lower third, rather than considering each third of the face separately and of similar contribution to the overall aesthetic impression.
Terino’s zonal anatomy of the face. The cheek is divided into five zones: 1, infraorbital foramen to the medial third of the zygomatic arch; 2, middle third of the zygomatic arch; 3, paranasal region; 4, lateral third of the zygomatic arch; 5, submalar zone—the site of age-related soft tissue atrophy and descent as well as lipodystrophy of other etiologies. Zones 1 and 2 comprise the malar region. The chin is divided into four zones: CM, central mentum zone; ML, midlateral zone; PL, posterolateral zone; SM, submandibular zone.
Recognition of the aesthetic significance of the extended zonal anatomy of the face has led to the development of modern-day implants. These implants have prefabricated shapes that extend well beyond the obvious area of augmentation into the surrounding areas. Such implants are referred to as “anatomic” or “extended” implants and are commercially available in a variety of materials and dimensions. Placement of an extended implant results in augmentation of the target area with smooth contour transition into the surrounding areas. This technique results in dramatic aesthetic results that are natural and subtle. Almost any area of the face is amenable to augmentation for aesthetic or reconstructive purposes (Figure 12–2).
Diagram shows the incisions frequently used to access the areas of the facial skeleton that can be corrected with alloplastic implant augmentation. Solid lines = cutaneous incisions; dotted lines = mucosal incisions.