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18.07.2016
Aging has an obvious effect on how the face looks from the outside with many recognized soft tissue changes. Since the bone provides a scaffold onto which the overlying soft tissues drape onto, it is logical to assume that the facial skeleton changes as well. All of these facial bony alterations with age can be correlated to associated outward soft tissue changes.
The facial skeletion does change with age, primarily with loss of volume of key bony support areas.
Bone augmentation of the aging face with implants can be a useful surgical strategy for some patients.
Skeletal facial implants, while often thought of as just for younger patients seeking better facial highlights, can be useful for the aging face patient as well.
The use of injectable fillers has been revolutionary in the augmentation of facial soft tissues. But like all good things, injectable fillers can also be overused or injected for ill-advised purposes. While there is no physical harm that is likely to ever come from using fillers for facial bone augmentation, it offers a poor value as facial aesthetic procedures go.
For bone augmentation, injectable fillers are at a disadvantage compared to facial implants. With the increasing recognition of the value of a stable platform onto which to resuspend aging and sagging facial soft tissues, solid implants are superior to injectable fillers.
Both injectable fillers and solid implants offers excellent options for facial enhancement, but they are not interchangeable.
From a recently presented study from the University of Rochester, new insights have been provided by studying facial CT scans.
Since the jaw is the principal support for the lower face, its shape and size affects the overlying soft tissues. This raises the question of the role of facial augmentation as part of the rejuvenation strategy to the aging face. One bone change that I have seen that is particularly advantageous is inferior border augmentation.
But there is also another way to think about facial plastic surgery procedures, and that is from an underlying psychologic or motivational perspective. The anti-aging procedures are very well known and include facelifts, blepharoplasty, browlift, midface (cheek)lift, lip lifts, and neck lifts. Structural facial procedures, some of which are well known  while others are not, include rhinoplasty, otoplasty, forehead reshaping, and a variety of facial implants. The psychological difference between anti-aging and structural facial surgery is significant.
In some cases, most commonly anti-aging surgery, the two types of facial plastic surgery procedures are simultaneously used. While the benefits of chin augmentation have long been recognized for balancing one’s face seen in profile, enhancing the jaw angle helps the face from a frontal perspective. Weak jaw angles are evident if the lower face is narrow and the cant of the jawline is steep (oblique) rather than more horizontal. Different plastic surgeons may have their preference but that choice is not based on whether it is a ‘better’ implant material. Through an incision behind the posterior molar teeth along the ascending ramus of the jaw, the bone and the front edge of the masseter muscle are immediately found. Proper positioning of the jaw angle implant is the most important factor in keeping it from moving around after surgery. Because it is a submuscular (under the muscle) operation, there is some significant discomfort and swelling afterwards. But there are other areas of the face for which implants also exist including the nose, paranasal, maxilla, premaxillary, orbit, forehead and temple areas.
Each plastic surgeon may have their preference but that is not based on whether it is a ‘better’ implant material. The sizing of any specific implant has a lot to do with experience and an artistic judgment. But most facial augmented areas are not profile structures so they lack a silhouette or outline which can be easily measured. Like any synthetic material placed into the body, there is the risk that it can become infected.
While infection is the worst complication of a facial implant, it is fortunately very uncommon. The use of facial implants is only limited by the imagination and artistic eye of the plastic surgeon. The long-term success of facial implants is primarily determined by the amount of healthy soft tissue around them. Implants have a much higher rate of complications in facial sites that have received radiation or been scarred by prior surgery or injury. Another good facial implant combination is in the use of camouflaging a midface deficiency. Midface deficiency is marked by flatter cheekbones and a ‘sunken’ base to the nose, known as the paranasal region.
In young patients or more severe midfacial deficiencies, one should consider moving part or all of the midfacial bones. The combination of cheek and paranasal implants is a good facial augmentation combination for this problem.
With an improved midfacial profile, the nose will appear smaller and may not require any alteration.
Facial implants remain a good and simple way to highlight existing or deficient facial anatomy. There are no definite methods of assessment that can determine the indications for these types of facial implants.
Synthetic implants are the only method for increasing the size and prominence of the jaw angles. Like any implant surgery, proper sizing and placement of the implant is essential for a good outcome. My experience has been, however, that even the largest jaw angle implant commercially available (silicone) may be too small for most men. While they do make a difference, particularly when done bilaterally, some of my patients certainly comment thaty they wish they were bigger and provided even more definition. When vertical jaw angle lengthening is needed, the only option is a Medpor jaw angle implants. They may have a cleft lip, bulging ear, burns, a crooked smile, webbed fingers and other problems related to hands and legs.
Many people are not satisfied with the way they look and they want to reshape certain parts of their body. Skin becomes less elastic and loose with age; this process helps to tighten the skin muscles. Those you are willing to get the features of their choice can have facial surgeries based on laser treatments. Wrinkles, deepening nasolabial folds,  crow’s feet and jowls are but a few of the effects that gravity and time cause.
Recent studies using CT scans have looked at various areas of the facial bones and their aging changes.
The dropping of the brows and the piling of eyelid skin is a reflection of the loss of underlying bone support. This results in lessening areas of soft tissue adherence and sagging and deflated overlying soft tissues. Reversing the age-related changes (atrophy) of certain facial bone areas can be done very simply with implants, adding volume to where it has been lost.
They offer a permanent solution to specific aging facial areas that have ongoing resorption which contributes to loss of overlying soft tissue and skin support.
The wide array of different filler compositions and their immediate results with a minimal complication rate has enabled patients to enjoy facial enhancements that could not be envisioned just over a decade ago. Their simplicity of use makes them easy to place anywhere, literally right down to the bone.


While it is obvious that injectable fillers are temporary and must be repeated, they end up being much more costly than using a facial implant. It is much more difficult to get a smooth and confluent layering that can match that of the shape of any facial implant. They are not only permanent, but they will feel more like natural bone structure and are much more likely to be symmetrical in cheek and jaw angle augmentation.
Injectable fillers are for soft tissue volume improvement while implants are for bony augmentation. Bone resorption along facial bony prominences occurs  as well and this contributes to the falling tissue process.
Researchers used a computer program to measure the length, width, and angle of the lower jaw bone and compared the results for different age groups.
As the size of the jaw decreases with age, the soft tissues of the lower face and neck also loses support.
The list of potential plastic surgery procedures for cosmetic enhancement numbers over one hundred. Why is one having the procedures and how does this influence one’s preparation and expectations from the surgery? These are exclusively soft tissue-based because the restoration comes from removing and lifting (nips and tucks so to speak) excess or sagging skin and soft tissues.
One who undergoes a facelift, for example, wants to know many aspects about the procedure (recovery, risks, etc) but is not overly concerned about the outcome.
It is critically important that a good connection and rapport is developed between plastic surgeon and these surgery patients to avoid a misunderstood outcome.
But one of them is the dominant approach and the opposite facial procedure is complementary. From angle to angle, the lower jaw (mandible) is a curved bone that is most recognized by its frontal prominence, the chin. Flaring the jaw angle outward and making the jaw angle more square (angular)makes the entire jaw line a more prominent facial feature. It is a function of what they are familiar with and have had good handling and placement experiences. This is the most direct route underneath the masseter muscle to where the implant needs to go without creating any external scar. Most of the entire masseter muscle must be lifted off the bone to properly place the jaw angle implant into the correct position. Silicone, which is very smooth and slick, is much more likely to shift from its intended position than Medpor which has a much higher frictional (gripping) surface. More pertinently, every patient will have some difficulty opening one’s mouth very wide for several weeks after. Most commonly, three specific areas are most commonly done including the cheeks, chin, and jaw angles.
Even if specifically shaped implants are not commercially available, carving blocks of various materials are available to ‘make your own’ for any specific facial need. Short of farway places on the skull and orbit, all facial implants locations can be reached intraorally.
Some facial areas, like the chin, can be measured and the exact amount of augmentation needed can be precisely determined.
When infection occurs around an implant, it can be difficult to eradicate with antibiotics alone. Computer imaging can help one understand what effect one or more facial implants may cause. A good barrier or buffer of soft tissue is needed between the overlying skin and the inside of the mouth.
Patients that are edentulous (without teeth) are also at risk as they have less bone and overlying soft tissue onto which to place and keep an implant adequately covered.
By extending the outer boundaries of bony prominences, the proportions and shape of the face can be changed dramatically. Traditional LeFort osteotomy patterns in conjunction with orthodontics is the standard approach. Using four implants (two cheek and two paranasal) placed through two incisions under the upper lip, the midface area can be brought out for greater facial convexity. For others, changing the shape of the nose through a rhinoplasty may be simultaneously beneficial. While everyone  knows the most common facial implants, such as cheeks and chins, there are numerous other areas of the face that can implanted. These areas represent convex facial areas that are more commonly implanted because their lack of prominence is well recognized and aesthetically more obvious. This can occur from a congenital problem such as cleft lip and palate but most commonly is just the natural development of one’s face. They bring projection to the entire nasal base, most prominently the anterior nasal spine area. It is really an extended paranasal implant which extends back along the maxilla above the roots of the upper teeth. The periosteum needs to be elevated and the implants should be secured to the bone with screw fixation. Their use is based on an artistic or aesthetic sense of facial balance and the results can not be well predicted based on some form of computer analysis or prediction.
Jaw angle implants are available from only a few manufacturers with limited designs and sizes. While it is possible to double stack jaw angle implants on top of each other (larger one against the bone and a smaller on top), I advise against this due to a high likelihood of shifting and displacement.
Implant sizes go up to 11mms in width and 10mms in vertical lengthening which is more than adequate for most patient’s aesthetic needs. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience.
They may undergo such reconstructive surgeries to reconstruct and repair the defects and enhance their look. Surgeons may perform rhinoplasty to correct problems between the lips and nose, functional disorders and to change the size of shape of nostrils. Surgeons prefer performing this surgery on children in their teenage because at young age, it can be performed more accurately and by the time children reach their teenage, ear growth has already occurred. The width and size of the eye (orbit) increases with an almost sagging appearance to the outer lower orbital rim.
The deepening nasolabial folds and the sagging cheeks are reflective of the maxillary resorption. Implants can do this in two ways, filling out concavities and bulking up weakened convexities. They can be used in conjunction with any of the soft tissue redraping procedures to help create a better facial rejuvenative effect.
As filler techniques are taught to an ever-widening array of injector backgrounds, I have seen an increasing number of patients in whom they are being used for facial bone augmentation purposes. Because an injection method can not get into a consistent and widespread subperiosteal layer, uneven material deposition is the norm not the exception.
As the soft tissues slide off of the face with aging, that process is accentuated by loss of bone structure. Jaw resorption is well known to occur with tooth loss (edentulism) and this is the result of loss of alveolus or the top part of the jaw bones. This loss of bony volume may contribute to sagging facial skin, decreased chin projection, and loss of jawline definition.
The influence of a chin implant with a facelift is a well recognized combination that produces a very noticeable improvement.
Vertical lengthening of the chin and back along the edge of the jawline adds vertical facial height.
By this view, cosmetic facial procedures can be classified into structural and anti-aging operations. The word, restoration, is deliberately used because the goal is to try and make one look younger or rejuvenated, trying to return to an earlier look that one had years ago.


To no surprise, these are foundational anatomic structures onto which the overlying soft tissues attach and are suspended.
While no one wants to look overdone or unnatural from a facelift (the most common patient concern), the comfort lies in going to a place where one once was. It is also vital that computer imaging is done before surgery to aid this communication process and lower the potential revision rate. For me, I am more interested in the shape of the jaw angle implant and how it matches the patient’s jaw angle need. While it is certainly possible to place the implant through an incision right below the jaw angle (as in mandibular fracture repair), this would not only leave a scar but would be more painful and disrupt more muscle tissue. Regardless of the material, I always secure it with a screw when possible to eliminate any doubt about potential implant migration. Known as trismus, this is the direct result of pain and stiffness from the traumatized muscle.
For me, I am more interested in the shape of the implant that I need to treat the patient’s problem and the ease with which it can be placed in the correct anatomic position. By initially placing a temporary implant to determine what effect it creates, a final sterile implant is not opened until one is certain the effect matches what the patient wants. Most commonly, chin implants are used in rhinoplasty and facelift surgery to improve the lower facial profile.
The use of combination cheek and chin augmentation or even chin, cheek and jaw angle augmentation are traditional implant duets and trios. This bony position will have an impact on other facial areas making the nose and chin look bigger and the upper lip look smaller and thinner. For patient’s with less significant deficiencies or who are not desirous of making that degree of surgical effort, augmenting the deficient bone is another option. It is important to secure these implants to the cheek and maxilla with small screws to prevent movement or migration after surgery.  The choice of implant material is not important but good sizing and placement position is. By using an implant across this area, the nasolabial angle is opened up by being brought forward. It can also be used for paranasal or base of the nose augmentation but adds more fullness to the entire lower midface as well.
By so doing, particularly when done on both sides, the width of the back of the jawline is increased creating a stronger and more masculine facial appearance.
Most commonly, the implant is designed close to an L-shape with about 4.5 cms of vertical height and horizontal length to it and no greater than 6 to 8mms in width. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery.
There are advanced techniques in this surgery that can reduce or increase the width and height of your nose.
Mentoplasty involves enhancing the jaw line, improving chin structure; creating or removing a cleft and most importantly correcting any injured part. Volume loss, primarily of fat, creates an overall facial ‘deflation’ and this understanding has led to the widespread use of synthetic injectable fillers and injections of your own fat to help plump up the aging face.
A weaker chin, jowling and lax neck tissues are partially effected by the loss of lower jaw volume.
As jaw volume decreases, soft tissue of the lower face has less support, resulting in a softer, oval appearance to the lower face and sagging skin, which also affects the aging appearance of the neck. Is its effect a function of improved chin projection or the appearance of a large jaw bone overall? These procedures change or alter the face and create a look that is not genetic or how one was destined to appear. When one is undergoing a rhinoplasty, for example, the concerns about the outcome are much different.
From famous actors like Brad Pitt to male models, a prominent jaw angle and jaw line cast an image of masculinity and virility.
While they are all chemically and structurally different, the body sees them all the same way…as a foreign material which it tolerates by surrounding it with scar tissue.
When comfortable, patients should start on range of motion exercises to resume their normal oral opening as soon as possible. Many people mistakenly think an infection is the body rejecting the implant but that is not so. A multiple implant strategy is part of sculpting the male face and may include cheek, chin and jaw angle implants all together.
Most noticeable is that the nose is less pronounced and the base of the nose is positioned behind the projection of the upper front teeth in profile. Their effects are somewhat similar to what a LeFort I advancement osteotomy (2 to 4mms) may do. How one can tell if they would benefit from facial implant surgery and how such implants may enhance the overall appearance of the face were interesting topics of discussion.
At these dimensions, the implant can certainly fit onto most jaws angles without being oversized.
This is more expensive than silicone rubber implants but is more effective when bigger sizes are needed.
To achieve greater than that amount, a custom implant design manufactured off of the patient’s 3D CT scan and model is needed. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery.
A surgery that helps you to improve the visual appearance of features and face is cosmetic surgery.
Skin is pulled to lessen the number of elastic tissues and surgeons make an incision inside hairline. The maxilla is affected by loss of pyriform aperture and a decrease in the maxillary angle.
Just like trying to use solid implants for soft tissue augmentation, the use of injectable fillers for bone enhancement is likewise limited. This is a very appropriate phrase because the clock will continue to tick and one will eventually return to looking older.
They usually are best inserted through a skin incision under the chin which is associated with fewer potential complications. The degree of midface underdevelopment is most evident by looking at one’s teeth or bite relationship. If measurements are taken on each patient, there is never a problem with fitting these implant sizes to the jaw, even in women.
These Gore-tex blocks are also not as smooth and slippery as silicone and this increased frictional gripping is also helpful when one can not get or does not want to place screws for fixation. Facelifts, rhinoplasty, eye lifts, Otoplasty, cheek and chin implants are some common procedures of facial plastic surgery. The length and height of the lower jaw (mandible) shortens with resorption of the jaw angle. At that cost, he was well on his way to two-thirds of the cost of having jaw angle implants which are permanent! Even though one knows that the goal is to look better, not being exactly familiar with what that is can be unsettling. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques.
The term that is bantered about by plastic surgeons is a ‘balanced or more proportionate’ look. It is for this reason that many structural facial patients will spend a great deal of time analyzing their photos, doing drawings and measurements, and in general doing much more research before the procedure(s).
Someone may have had prior orthodontics so the ‘true’ bite relationship may have become obscured. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.



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