Midface Implants

Q: Dr. Eppley, I have a question about midface implants. A  maxillofacial surgeon recommended to me maxillary advancement to correct midface hypoplasia. Can you produce similar results through midface implants? 

A: The aesthetic benefits of onlay midface implants can rival if not be superior to maxillary advancement surgery. The only area in which the deficiency will remain is at the tooth or occlusal level as one’s bite will remain the same. Not changing the position of the anterior maxillary teeth does effect upper lip support and this is one aesthetic component of the midface which will not be improved by skeletal augmentation above it. Midface implants come in a wide variety of styles and sizes from the cheeks, infraorbital rims and tear trough, premaxillary-paranasal as well as maxillary implants. With the exception of the lower orbital rim implants, all midface implants are placed from incisions inside the mouth. Because of the location of midface implants on the side of the face, they are usually best secured with small titanium microscrews. When covering larger areas of the midface, it is often best to have custom midface implants made so that maximal midface augmentation in a smooth manner is achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Midface Implants

Q: Dr. Eppley, my facial problem is that I am very skinny. I have no volume in my face with flat cheekbones. The doctors say my maxilla is also very small and is retrusive by 6mms.has a reduction of 8mm. Even though my body is not skinny, I have talked with surgeons because I want more volume as my face is very flat/skinny. They placed implants in my maxilla on both side of the nose. Even tough my profile is good, my face still looks skinny and I cannot smile because the implants change my smile completely.

I want to remove these implants. I want to have my smile back and more volume in my face, but I’m afraid if I put new ones in, the result will be exactly the same. I want to talk with a new surgeon so I can get a more satisfactory facial profile result. I have attached numerous pictures of my face so you can see my deficient midface profile.

A: Thank you for sending all of your pictures. If I understand your surgical history correctly, you currently have in certain types of midface implants. (malar and paranasal implants – four total implants) You mentioned malar but I wanted to be certain that you also have in paranasal (side of the nose) implants. Paranasal implants would be the culprit of affecting your smile, not the malar implants. Overall facial volume enhancement could be improved by fat injections which would provide a more global effect. Although I would not want to see you remove your existing malar implants as they are undoubtably providing some facial volume effect. I would have to know more about your paranasal implants as the style and size in place may be the problem not just paranasal implants per se.

Dr. Barry Eppley

Indianapolis, Indiana

Can MIdface Augmentation Create A LeFort Advancement Effect?

Q: Dr. Eppley, I am interested in midface augmentation. I’m 25 years old and I have problems with my facial aesthetics. My forehead is more protruding than my midface and my lower third. This is easily observeable in sunny places, my forehead is highlighted but the rest of the face (except the nose) in shadow. Since my bite is good and my jaw quite strong, I would think a chin implant is a good idea, but is there an really effective method to bring the midface forward without a LeFort osteotomy?

A: As for the chin implant I would need to see pictures to make a helpful comment on its benefits for you. There is a very effective method to bring the level of the face around the nose forward which would create the equivalent of LeFort I osteotomy effect. Combined paranasal/premaxillary- maxillary implants can have a very powerful midface augmentation effect. Cheek implants are also useful but they create a zygomatic augmentation (upper midface) not a maxillary (lower midface) augmentation effect.

Dr. Barry Eppley

Indianapolis, Indiana

Do Midface Implants Become Exposed With Aging?

Q: Dr. Eppley, I have a few questions about facial implants. Do tear trough, cheek implants, and orbital rim implants become visible as the skin ages? If I need to get them removed will it leave obvious scars? If I get the facial implants but later decide to get a cheekbone reduction would it affect the implants? Thank you!

A: This is a good question about facial implants and is not the first time I have heard it. I have not seen increased visibility of midface implants with aging but that does not mean it does not exist. It would depend on the patient’s face and whether they suffer significant fat loss in the face as they age. It would also depend on how much fat one has in their face and the number and size of midface implants placed.

The removal of implants does not usually any more scars than those that were used to place them. If you get cheek implants and then elect later to have cheekbone reduction, the implants may or may be in the way based on how far back the tail of the cheek implant goes. Usually the implant would be in the way but it could easily be displaced so that the cheekbone osteotomies could be done.

Dr. Barry Eppley

Indianapolis, Indiana

What Type Of Midface Implants Do I Need?

Q: Dr. Eppley, I am interested in midface augmentation using malar shell implants but I have not yet had the procedure because of certain concerns. I am concerned about the submalar fullness which I had noticed in photos of female patients who have had the submalar cheek implants placed. Although I definitely have the concavities in the submalar area which would benefit from some augmentation, I did not want “apple” or “cherub” cheeks. (Check out Barry Manilow’s face now). This type of fullness can look artificial and certainly looks better on females than males. I know that the implant can be modified by removing some projection from the underneath side of the submalar portion of the implant.  Of course, a lot would depend upon how much fullness is already present in the submalar area. I am also unsure of whether the implant would make my face look wider and somewhat “chubby” rather than more sculpted (more attractive on males).  I have a round face lacking in strong structural features. But I was not so sure about what the midface augmentation would accomplish .  In addition, the lower eyelid area concerned me.  Actually, I thought that if the midface implant were placed high on the bone close to the orbital rim, it  would have the nice collateral benefit of minimizing the tear trough area, but I did not know how much an improvement this would be, given the design of the implant. 

A: In looking at your face and all the current styles of performed midface implants, none would be appropriate for what you are looking for. You are correct in assuming that your face would get wider  and would dimensionally change you in the wrong direction. What you need is more anterior or forward projection across the orbital rims and down onto the face of the maxilla. This is actually the ‘missing’ zone of facial augmentation in regards to current implant designs because it is concave facial area and not a convex one.

What you really need is an orbito-maxillary facial implant that improves midface projection but not malar width. This can only be properly designed through a custom implant approach based on a 3D CT scan.

Dr. Barry Eppley

Indianapolis, Indiana

What Are The Best Facial Implants For A Concave Face?

Q: Dr. Eppley, I am 26 years old and have a very flat midface. I would like to do something that will give my midface more projection but I don’t know what is the best thing to do. I read that some doctors use implants while other recommend injectable fillers. I have been through orthodontics to correct my crossbite and it is now perfect. But my face is still pushed in and unattractive with deep nasolabial folds. What do you recommend?

A: By description and as evidenced by your orthodontic treatment, you likely have some amount of natural midface retrusion with a corrected Class III malocclusion. This would indicate a more panfacial or significant midface deficiency of which injectable fillers would be a poor treatment choice. It would take a fair amount of filler volume to achieve a visible improvement not to mention the need for repeated treatments, provided a good aesthetic change could be achieved. There are a variety of facial implant options which can provide both improved midface projection and a permanent result. Malar, submalar, paranasal, premaxillary and infraorbital rim implants are all potential options for augmentation depending upon the amount and location of the midface retrusion. Most patients do well with combined malar and paranasal implants. However the malar deficicency usually has an infraorbital component as well. Similarly, the nasal base deficiency may include a more extensive premaxillary retrusion and not just the lateral pyriform aperture areas. A good eye is needed to determine the type of implant styles that would best treat any patient’s specific concave facial shape.

Dr. Barry Eppley

Indianapolis, Indiana

Is Injectable Fillers or Implants Better For Midface Deficiencies?

Q: Is there no way to bringing out the midface with dermal fillers? Are the results not so good as with implants? What is the material of which midface implants are made of? What the advantages and disadvantages of injectable fillers vs implants for midface deficiencies?

A: For midfacial deficiency, albeit of the cheeks, maxilla, or paranasal region, synthetic implants are the preferred treatment. They are far superior to injectable fillers in both results and cost effectiveness. Injectable fillers are intended to treat small soft tissue deficiencies of the facial skin such as wrinkles or folds. They were never intended to be used for more significant bone-based facial deficiencies but rather to be placed into or just under the skin. The sheer cost of placing large volumes of injectable fillers down at the bone level would quickly equal or come close to the cost of implant surgery. When you factor in that they are all temporary, the value proposition of injectable treatments for facial skeletal deficiencies becomes quite poor.

Most facial implants, including those of the midface region, are primarily composed of solid silicone. Silicone is one of the most biocompatible of all implant materials and also offers the largest array of facial implant designs. All midfacial implants are introduced and placed through incisions inside the mouth so there is no external scarring with their use.

Dr. Barry Eppley

Indianapolis Indiana