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Facial Plastic Surgery: An Essential Approach
Step by Step
Chapter: The Use of Implants in Facial Plastic Surgery
Edited by: Raffaelo Rauso
Published Date: August, 2014
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The Use of Implants in Facial Plastic
Surgery
Roberto Amore1* and Luca De Fazio MD2
1
Master’s degree in aesthetic surgery - Private practitioner, Pisa, Italy
2
Consultant Plastic and Reconstructive Surgery - Private practitioner, London, UK
*Corresponding author: Roberto Amore, Master’s degree in aesthetic surgery Private practitioner, Pisa, Italy, E-mail: [email protected]
Introduction
The process of re-evaluation of the face requires a multidimensional approach in order
to correct volume deficits involving the skin, soft tissue and bony skeleton (Table 1). These
deficits can be congenital or acquired:
• In congenital deficiency we are witnessing a primitive deficit that alters the relationships
between anatomical structures and facial balance (for example: receding chin, malar
hypoplasia, etc.) [1].
• In the acquired deficiency, mainly induced by the aging process, we are witnessing an
atrophy of soft tissue and skeletal bone resorption that results in loss of volume and laxity of
the overlying skin.
Affected Tissue
Description of Deformity
Mecchanism
Soft Tissues
Volumetric changes
- gravitational descent
- acquired hypoplasia
- congenital deficiency
Bone
Skeletal deficiency
- congenital
- acquired
Table 1: Classification of aging process regarding soft and hard tissues.
The reliance on recent rejuvenation techniques and surgical and not-surgical minimally
invasive techniques downplayed the key role of skeletal structures in the process of
rejuvenation. In contrast, optimal results and long-term results require knowledge of how the
process of aging regards all levels of the facial elements, including the skin, soft tissues and
bone structures. These elements share the intricate interactions and bear different effects of
aging, which in turn affect the aesthetic results [2-4]. Most common techniques have offered
up to now inherent limitations that frequently determine suboptimal results and short-term
aesthetic effects (Table 2):
Facelift Surgery, Even though they can affect more anatomical planes, pop up and restore
the volumetric soft masses, they cannot replace the lost shallow or deep soft tissue with aging.
Fillers Offer good short-term results but it comes to be rarely predictable long-term results
when it is required a significant increase in volume. When large amounts of material are injected
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into the soft tissue in order to redefine facial contours, the end point is easily accessible as the
planned expansion of the filler agent will start to migrate to adjacent areas; migration reduces
the result rather than improve it.
Lipo Filling can moderate increase the volume of soft tissue, but the aesthetic effects, the
percentage of resorption and the duration are not predictable.
Techniques
Weaknesses of the technique
Lifting
- Are addressed on a single anatomical level or on a single problem
- Can not replace the lost shallow or deep soft tissue with aging
- Probable effect “ skeletonization “
Filler
- The ability to volumizing filler is determined by the endpoint agent filler itself, when it starts to
migrate into adjacent areas, reducing the result rather than improve it
- Results unpredictable for long-term and large quantities used
Lipofilling
- Produces only moderate increases
- Unpredictable results in terms of durability and aesthetic effect
Table 2: Comparison of the inherent limitations of the techniques currently used for most facial revaluation.
Alloplastic facial implants can correct age-related changes at different levels and offer a longterm solution to increase skeletal deficits, restore the lost soft tissue volume and eliminate the
irregularities of the facial contour. The use of alloplastic implants gives multiple advantages.
First of all, it provides a permanent option and longer lasting. The facial implants are placed in
the subperiosteal plane closed to the bone, making them not vulnerable to the effects of future
degradation of the soft tissue. In addition to the simple increase in volume, the systems also
provide support to the soft tissue ptotic. The procedure also makes a dimensional site-specific
aesthetic desirable quality that also improves the overall proportion of the face. The implants
are available in a sufficient range of sizes and anatomical shapes, making them applicable to
the majority of the population and allowing an increase in custom. Finally, the increase with
the use of implants is reversible. The plant can be easily removed under local anesthesia or
changed with minimal dissection [5-7].
In particular, silicone implants, which become encapsulated after being positioned, do not
stimulate the regrowth of the tissue and they can easily be removed or replaced without tissue
damage (Table 3).
Benefits
multidimensional solution
long life
customizing the increase
volumization site-specific
simple procedure
minimal risk
easy to remove or replace
Table 3: Benefits arising from the use of facial implants.
The use of facial implants was launched for the first time by Binder in the 80s as an
independent method for the rejuvenation of the mid-face. The emphasis of binder in the
importance of volume recovery, as a significant component of contribution in facial aesthetics,
is the key area of facial rejuvenation. The use of implants was for cosmetic purposes for
the mid face and then chin implants were added and they were mostly used for congenital
deficiency (Figure 1). Cheekbones and chin implants are widely used today although the use
of these devices is much lower than the clinical pictures in which there is a real indication
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[8-10]. Other implants have been used for the evaluation of the oval of the face, but their role
is still debated and not universally accepted (for example the angle of the mandible implants,
eyelid implants, etc).
Figure 1: Mental sinphysis hypoplasia congenital corrected with chin implants.
Brief Anatomy
The surgery for the insertion and placement of zygomatic and chin implants does not
present particular risks knowing the anatomy of the regions concerned. Generally they are
inserted from the vestibule of the mouth and it is immediate the achievement of the right area
for the creation of the pocket, the subperiosteal one. This plan, avascular, is relatively safe
considering only 2 noblest present structures: the infra-orbital nerve and the mental nerve (see
the beginning of the description of the operation - nerve block). Their partial lesion could also
create many problems of sensitivity.
Anatomy for the zygomatic implants: The anterior surface of the maxilla is directed
forward and lateral ward. It presents at its lower part a series of eminences corresponding to
the positions of the roots of the teeth. Just above the incisor teeth there is a depression, the
incisive fossa, which gives origin to the depressor alae nasi. Lateral to the incisive fossa there
is another depression, the canine fossa: this is the point to log on. It is larger and deeper than
the incisive fossa, and it is separated from that by a vertical ridge that is the canine eminence,
corresponding to the socket of the canine tooth. Above the fossa there is the infraorbital
foramen, the end of the infraorbital canal that transmits the infraorbital vessels and nerve.
Above the foramen is the margin of the orbit. As carrying out the pocket it is necessary to
pay attention to the emergence of the nerve medially in the upper infraorbital. Lateral to the
anterior surface of the maxilla there is the front face of the cheekbone: convex, its apex, which
is the point of maximum front projection, it is the most important landmark for the creation
of the pocket (Figure 2). The implant must be placed centrally on the property. The posteroinferior border of zygomatic bone affords attachment by its rough edge to the masseter muscle.
The masseter muscle is inserted in the lower edge by means of a broad ligament tendon.
In case submalar and zygomatic-submalar implants are used (see below) the pocket should
extend caudally zygomatic bone and should also affect the cranial portion of the masseteric
tendon.
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Figure 2: Bone structure involved in the insertion of mid-face implants: the access to the subperiosteal plane in the canine fossa
allows you to create a channel along the body of the jaw in order to create the pocket on the front of the cheekbone (with or without
involvement of the ligament tendon of the masseter muscle instead of the caudal zygomatic bone).
Anatomy for chin implants: the external surface of the body of the mandible (Figure 3) is
marked in the median line by a faint ridge, indicating the symphysis. This ridge divides below
and it encloses a triangular eminence, the mental protuberance, whose base is depressed in
the centre but it is raised on either side to form the mental tubercle. Triangular eminence is
the correct area to create in the pocket and it is quickly accessible from the gingival sulcus
where you log on medially below. From triangular eminence, laterally on either side of the
dissection, it extends to the width of the prosthesis, paying attention to the mental nerve that
is located laterally and cranially to the breakaway.
Figure 3: External surface of the body of the mandible with the anatomical structures that are involved at positioning the chin
implant.
Pre-Operative Analysis
A thorough knowledge of the relative contributions of soft tissue and skeletal deficits, in
combination with an accurate preoperative assessment can guide the surgeon in determining
the optimal use of the system and the correct location, avoiding undesirable aesthetic results.
The preoperative analysis should evaluate the relationship of the region to be increased with
the rest of the face. In this regard, it is particularly useful to assess the face by comparing
three subunits: the upper third, middle, and lower face. Preoperative photographs, taken in
multiple perspectives, can help to assess the degree of lost volume, and any asymmetries
in the selection of appropriate plants (Figure 4). Although the choice of appropriate implant
ultimately depends on the need of the increase request (usually the facial implants come in
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different sizes: small, medium, large, cut-out), it is good to make some considerations:
• Implants exist with smooth surface and textured. The latter, more recent, is preferable
because it makes the system more stable by preventing dislocation [11-13].
• Implants exist in the standard version and anatomy. The anatomic implants for the
middle third differentiate into the right (for right hemiface) and left (for left hemiface).
The difference between the standard and anatomical implants is that the latter gives a
more natural result but requires greater precision in the production and placement of
the pocket because once it is placed, it can result with asymmetries and irregularities.
The anatomic implants are intended for the experienced surgeon and have to be avoided
only initially.
• Implants for the third medium must be assessed on the basis of this deficit in order to
be corrected (Table 4): malar, submalar or combined.
• Chin implants should be evaluated according to the mandibular profile: shape of the
chin, chin bumps, triangle chin. It is also important to assess lip eversion, anterior
teeth position, chin pad thickness, labiomental fold depth and height, dynamic chin pad
motion with smile.
Figure 4: Example of facial implants. Anatomical malar implant (left) and long chin implant (right).
Type
Type of deformity
I
Primary
malar
hypoplasia, Need for projection on malar Malar implant shell “shell-type”,
submalar soft tissue adequate eminence
extended inferiorly into submalar
development
space for a more natural result.
Increase required
Type of implants mainly used
II
Submalar Deficit, malar soft It needs anterior projection. Submalar implant (new type of
tissue adequately developed
Implant placed on the face of the conformation or first generation
jaw and/or on the messeterin of “submalar implants”)
tendon in the submalar space.
It also provides coverage in the
middle third.
III
Malar hypoplasia and submalar It requires anterior and lateral
deficiency
projection, implant for the
volume replacement for the
entire restructuring of the middle
third
Table 4: Patterns of deformity of the middle third.
“Combined” submalar implant/
shell-type
implant,
lateral
(malar) and front (submalar)
projection. It fills large gaps of
the middle third
The last decade has witnessed substantial improvements in form, in design and placement
of the implants. The first implants. Lacked in anatomical shape, in addition to their “historic”
location, high in the malar-zygomatic complex, they often produced an unnatural face block
with an exaggerated look. On the other hand, the contemporary implants, available in a
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variety of shapes and sizes, allow more conservative surgical approaches, that in turn provide
a targeted increase, an accurate, natural looking, tailored to the different regions of the face
(Figure 5). Progresses in design and computer - assisted manufacturing technologies have also
facilitated the realization of facial implants that can customize the increase on the preferences
of the patient or surgeon while correcting simultaneously defects and facial asymmetries [1417].
Figure 5: Deficiency of the middle third of type I with proper anatomic implants medium size type "shell - type".
Patients Preparation and Preoperative Design
As pointed out previously, the preoperative assessment is crucial for the choice of the
implant. The realization of the preoperative design before surgery is really important too. The
drawing must be performed with the patient in the upright position. When it comes to chin
implants (Figures 6-9) it is drawn first: the median line and the bottom edge of the jaw that
also corresponds to the bottom edge of the pocket. From the point of intersection of the median
line with the mandibular border, the surgeon will then mark the lateral margins (based on
the width of the implants) and the upper margin of the pocket (based on the height of the
implants). So when the design is completed by combining the lateral margins with the top
margin and referring to the characteristics of the implants (more oval, more flattened). In the
middle third implants (Figures 10-12) it is identified the zygomatic vertex; then outline the
bottom margin, it is identified the inferior-lateral orbital rim and the zygomatic arch. After
drawing these structures, the surgeon shows the margins of the implants according to the
needs of the increasing request and according to the type of deformity (malar, submalar or
combined). Particular attention should be given about maintaining the same design in both
two Hemifaces (the drawings must be specular) or in case of asymmetry, in order to eliminate
this defect [18].
Figures 6-9: Sequence of preoperative design for chin implants.
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Figures 10-12: Sequence of the preoperative plan for the middle third implants.
Surgical Procedure for the Placement of Implants
The surgical insertion of facial implants is a simple, linear procedure and it can be
performed by experienced surgeons, usually in less than 30 minutes. This procedure can be
performed using intravenous sedation or, in selected cases, pure local anaesthesia. Before
the insertion, the implant should be placed soaked in antibiotic solution. In the operating
room, the surgeon should have available a variety of implants with different sizes and shapes;
furthermore he must be ready and he must be able to customize the implant in case of need.
The implants are placed in a subperiosteal area. Generally it is used a trans-oral approach:
this approach remains the standard because it facilitates the insertion of the implant and the
direct visualization of all anatomical structures, including infraorbital and mental nerves.
There are Exceptions such as the implants placed in the context of other procedures (for
example facelift, lower blepharoplasty) [19].
Local Anaesthesia: The surgery begins with the nerve blockage of the infraorbital nerve
to the zygomatic implants and it begins with the nerve blockage of the mental nerve to the
chin implants. The infraorbital nerve (Figure 13), that is the terminal branch of the maxillary
nerve (n. trigeminus), exits out of the infraorbital foramen that is located above the canine
fossa, 4-7 mm below the orbital rim, in an imaginary line dropped out the medial limbus of
the iris or the pupillary midline. In order To perform an infraorbital nerve blockage by an
intra-oral approach, topical anaesthesia is placed on the oral mucosa at the vestibular sulcus
just under the canine fossa (between the canine and first premolar tooth) and left for several
minutes. The lip is then elevated and a 1.5-inch 27 gauge needle is inserted into the sulcus
and superiorly directed toward the infraorbital foramen. The needle does not need to enter
the foramen for a successful block. The anaesthetic solution only needs to contact the vast
branching around the foramen to be effective. It is imperative to use the other hand to palpate
the inferior orbital rim in order to avoid injecting the orbit. Two to four cc of 2 % lidocaine with
1:100,000 epinephrine is injected in this area for the infraorbital block.
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Figure 13: Exit of infraorbital nerve by eponymous hole at the centre of the front face of the maxillary bone, above the canine
fossa.
The mental nerve, a terminal branch of mandibular nerve (n. trigeminus) exits out of mental
foramen on hemimandible at the base of root of second premolar. The mental foramen is on the
average 11 mm inferior to the gum line (Figure 14). There is variability with this foramen, like
all foramina. However, the block is usually successful, by injecting 2 to 4 cc of local anaesthetic
solution about 10 mm inferior to the gum line or 15 mm inferior to the top of the crown of the
second premolar tooth. In patients without teeth, the foramen is oftentimes located much higher
on the jaw and can sometimes be palpated. This block is performed superiorly in the denturewearing patient. The foramen does not need to be entered because a sufficient volume of local
anaesthetic solution in the general area will be effective. By placing traction on the lip and pulling
it away from the jaw, the labial branches of the chin nerve can sometimes be seen traversing
through the thin mucosa. The mental nerve gives off labial branches to the lip and chin.
Figure 14: Technical infiltration with local anaesthetic to block the mental nerve.
Incision and dissection of the malar eminence: it starts with a cold knife incision of about
5 mm at the gingival sulcus, above the lateral canine fossa and the body of the maxillary bone
(Figure 15-16). It is not necessary to dissect medially at the piriformis opening, due to the
fact that no part of the implant must be located in this region. Following an oblique direction
upwards, the incision is made immediately and directly in the maxilla (Figure 16). Keeping
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a piece of gingival mucosa of 1 cm at least, greatly facilitates the closure at the end of the
procedure. The soft tissues placed on the body of the maxilla are elevated above and laterally
(Figure 17). We proceed with the dissection of the body of the maxilla along a virtual axis
that connects the access to the zygomatic eminence (Figure 18). At this stage, a meticulous
attention should be paid at avoiding extensive dissections, avoiding stretching the risers and
the surrounding region to the infraorbital foramen. The infraorbital nerve must be carefully
identified in order to avoid the placement of the implant above the foramen (if the proposed
implant is large or has a significant medial component). The dissection is then extended to
the zygomatic-maxillary junction and the zygomatic arch. The subperiostic plan is particularly
used for dissection of the lateral part of the zygomatic arch as the branches of the facial nerve
pass through this area only superficially.
The delicate and by blunt dissection at the level of half of the zygomatic arch will help
prevent damage to the temporal branch of the facial nerve. Utilizing the preoperative design,
the free hand of the surgeon outside plays a critical role in guiding and extending the dissection
(Figure 19).
Figure 15: Trans-oral approach.
Figure 16: Oral incision for the insertion of the implant. The gingival-oral incision is made above the lateral portion of the canine
fossa.
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For the initial incision it is required only 5 mm as the lining stretches and provides adequate
exposure of the skeletal structure of the mid -face. About 1-1.5 cm in gingival mucosa is kept
lower.
Figure 17: Soft tissue located above the maxilla is lifted upwards and laterally in order to facilitate the insertion of the dissector
and progress for the subperiosteal dissection.
Figure 18: After creating a directly access to the maxilla, a subperiosteal plane must be followed in the craniolateral direction
towards the zygomatic eminence.
Figure 19: From the body of the maxillary bone the dissection moves towards the zygomatic-maxillary junction and it extends to the
zygomatic arch, according to the design that was shown on the preoperative skin.
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During the dissection the free hand (in this case the left) plays a key role in guiding the
dissector.
Incision and dissection of the chin: They make a cold blade incision of about 10 mm
at the gingival sulcus, medially, maintaining a 1 cm strip of gingival mucosa. They reach
immediately the periosteum (Figure 20). Keeping the lower lip pulled down, it goes towards
the dissection of the entire triangular eminence and following the preoperative design, they
extend laterally, taking care not to damage the l left and right tractional mental nerves. The
blunt dissection should proceed slowly and should not extend beyond the drawing (Figure 21).
Figure 20: Incision and dissection of the chin area.
Figure 21: Exposure of mental protuberance, left and right mental tubercles and exposure of the lower margin of the mandible.
Exposing is immediate and direct unlike inserting the zygomatic implants in the chin pocket during the surgery.
Exposure of the region and creation of the pocket: in the middle third, once implants
have been exposed to the zygomatic eminence, you can proceed with the creation of the pocket.
The outer hand of the surgeon guides the dissector that gently proceeds to create the pocket
according to the design that was shown on the preoperative skin. Patients with type II and type
III deficit of the middle third (see tab. 4) need to expose the submalar space that is obtained
by extending the subperiosteal dissection, inferiorly to the cheekbone, above the upper tendon
that is the origin of the masseter muscle (Figure 22). Elevating the soft tissue gently that
overlies the deep plane of the tendon; the surgeon can see the gleaming white of the tendon of
the masseter auctions. The auctions of the muscle are not switched off here as they serve as
a platform, supporting surface that is crucial for the lateral portion of the submalar implant.
Posteriorly, the submalar space becomes narrower and is not easily accessible. The surgeon
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can gently detach the rear limit, by advancing one blunt tip dissector along the zygomatic
inferior arch that will prevent the displacement of the implant after surgery. The chin implants
procedure is similar: it realizes the pocket, according to the preoperative plan. In this case the
operation is simpler than the previous one because the pocket is achieved by direct exposure.
Also in this case the external hand of the surgeon guides the dissection according to the design
shown in the preoperative skin. It is then created a subperiosteal pocket below the preoperative
design that is big enough to accommodate the implant (Figure 23). Considering the fact that
if an implant is placed in a pocket in the wrong set, it will move itself, so the final space shall
be larger than the implant to be implanted and to allow the positioning without compression
of the surrounding tissues, in particular in the posterior region. The migration or extrusion of
the implant may also occur due to inadequate exposure and constriction of the postero-lateral
portion of the pocket, pushing the implant frontally. As a rule, the surgeon should be able to
move the implant at least 3-5 mm in all directions. The anatomic implants that are customized,
find frequently the correct position, but caution should be exercised in order to prevent the
thin tail folds on itself. Generally, the periosteum and soft tissues rearrange immediately after
surgery and obliterate the dead space within 24-48 hours.
Figure 22: The area between the dotted lines represents the submalar dissection above the upper portion of the tendon of
the masseter muscle.
Figure 23: On the basis of the preoperative drawing it is created the subperiosteal pocket: this pocket must be large enough to
accommodate the implant in order to allow the positioning without compression of the surrounding tissues, in particular in the
posterior region. As a rule, the implant must be moved 3-5 mm in all directions.
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Positioning of the implant: The right position of the implants is dictated by the results
of the preoperative analysis of the face, it is then dictated by the type of deformity and by the
request of the patient. In patients with deformities of type 1, the shell of the malar implants
remains above the malar and zygomatic bone in a most upper and lateral position. Submalar
implants for deformities of type 2 are generally above the front face of the maxilla. Malarsubmalar implants for deformity of type 3 shall cover instead both malar bone eminences
both the submalar triangle. The placement of an implant in the submalar triangle requires
more subjectivity than the positioning on the malar eminence and it generally requires a
careful judgment to achieve the desired changes in the contour of the face. After inserting the
implants, the surgeon must evaluate the facial asymmetry with a ruler to measure distances
from the medial border of the implants to the midline. The positioning of the head on the
operating table usually helps in the assessment of the symmetry of the outline. The asymmetry
may be particularly evident in patients with thin skin or with bony prominences that are
particularly evident. In these cases, the edges and the outline of large systems tend to be thick
and palpable with visible irregularities if they are not carefully evaluated during the initial
procedure. Correcting a pre-existing facial asymmetry can be very challenging and require a
careful analysis of the topography of bony and soft tissues. In these cases, a surgeon may need
to cut-out implants and/ or choose a different placement for each implant [20].
Ensure the implant: recent implants, textured and well-conforming, are not prone
to migration and they generally do not require anchoring. However, the implants can be
anchored with a technique that provides a direct external fixation (Figures 23-24). Implants
have generally preformed fenestration. The position of the fenestration should be marked
externally on the skin before inserting the implants. The surgeon can confirm the symmetry
by measuring and comparing the distance of each sign with the median line. Before placing the
implant, the surgeon passes a double-needle 3-0 silk thread through the medial and lateral
fenestration with a loop around the deep surface of the implant. The needles are then inserted
into the pocket and passed perpendicularly through the scarred skin corresponding with each
perforation. The implant is then inserted into the pocket and it is secured in the correct
position and symmetry. The sutures are gently tied over a roll of cotton that is placed on the
overlying skin (Figures 25-26). This also helps the compression of the tissues, reducing any
potential dead space and preventing liquid that might be collected in the subperiosteal pocket.
Sutures and the roll of cotton are generally removed after 1-2 days.
The management of post–operation: patients are discharged a few hours after surgery
and can safely perform recovery at home. They are normally prescribed antibiotics, analgesics,
disinfectants for the oral cavity and patients should apply ice for 15’ 3-4 times a day for 3-4
days and they should sleep with their head elevated. After surgery follow-up visits are usually
carried out on the second day, when their external anchors are removed. Patients are regularly
followed up until the facial edema resolution. Most patients normally resume their routine
activities starting from 5 days after surgery (Figure 27-28).
Potential Complications: significant edema is not uncommon in the post-operative phase.
Approximately 80-85 % of edema resolves in 3-4 weeks, while the remaining 15-20 % subsides
gradually over the next 6 months. The displacement of the implant may occur because of
an improper insertion or because of an insufficient pocket size or because of an inadequate
implant fixation.
The extrusion of the implant should not occur if the technique is correctly performed.
Capsular contracture is really rare and the removal of the implant is often not required. Other
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complications include bleeding, hematoma, seroma, fistula, pain, and chronic inflammation.
Approximately 1% of patients who are implanted with facial implants develop postoperative
infections. Damages at the infraorbital nerves chin and face may also occur but they are rarely
permanent [21].
Figure 23-24: Fixing the implant. The double needle suture is passed through the implant and externally through the skin.
Figures 25-26: Fixing the implant. The double-needle thread that is passed through the system and out through the skin, is then
tied over a cotton pad/piece of gauze. The fixing is permanently removed 1-2 days after surgery.
Figure 27: Comparison in patient who implanted zygomatic implants: on the left side preoperative picture and on the right side 1
week after surgery picture.
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Figure 28: Pre and post-operative picture of a patient subjected to malar congenital hypoplasia (type I deficiency). She was fixed
with malar–submalar implant (as requested by herself although she needed only malar implant).
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Facial Plastic Surgery: An Essential Approach Step by Step
Edited by: Raffaelo Rauso
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