What Can Be Done To Prevent Cheek Sagging After Implant Removal?

Q:  Dr. Eppley, I am planning on removing silicone malar implants without replacement that I had done 8 years ago. I am hoping that my skin will contract down once the imlant is removed. However, I realize that sagging is a possibility due to the stretching of my soft tissues from the cheek implants. I do not want any kind of implant again and a subperiosteal resuspension surgery is something that I would want to avoid at my age. Therefore, I was wondering if surgical adhesives, like a fibrin glue sealant would be useful in preventing or at least minimizing sagging and would help the tissues to better redrape the face. Would there be any potential complications from using surgical adhesives?

A: Your concern and questions about cheek implant removal are good ones. Like all implants in the body that push off of the underlying bone, their effects are seen by the stretching of the overlying tissues. Whether this soft tissue stretch is significant, and would result in malar tissue sagging after their removal, depends on how large an implant was originally used and how much elastic deformation of the skin was created. For some patients with smaller cheek implants, no significant malar sagging will occur. For other patients with larger implants and more significant cheek hypoplasia to begin with, the sagging may very well be noticeable.

Regardless of the size of the implant, the question is whether any surgical manuever (from the intraoral approach) during cheek implant removal surgery can prevent sagging and maintain a better soft tissue position on the underlying cheek bones. I think there are two options. As you have mentioned, tissue adhesives can be used. Whether they can really glue the outer capsular lining to the inner capsular lining on the bone is debatable (the surrounding cheek implant capsule is not removed so these two layers are present) But there are no risks to doing so. I would use an autologous tissue adhesive made from the patients’s own blood, like that obtained from the GPS III system. (Biomet) Another option is to place several sutures between the capsular layers to prevent the outer capsular lining, of which the cheek soft tissue are attached, from sliding off of the inner capsular lining and bone below. This is, in reality, a subperiosteal suspension done from below. That is a more likely effective manuever that would be more secure than tissue adhesives.

Dr. Barry Eppley

Indianapolis, Indiana