Enhancing Facelift With Simultaneous Submalar Implant Augmentation

Enhancing Facelift With Simultaneous Submalar Implant Augmentation Abstract Background The midface is particularly prone to the senescent changes of soft tissue ptosis and volume loss, which in individuals with aging or low adiposity can manifest as submalar hollowing. Facelift alone in those with submalar hollowing inadequately addresses the volume loss and may result in a gaunt appearance postoperatively. Submalar implant augmentation is a powerful tool for permanent midface volume restoration for a more youthful and natural contour, as opposed to soft tissue fillers that diminish over time. When performed together, submalar augmentation and facelift synergistically enhance facial rejuvenation results. Objectives Determine the long-term safety and efficacy of submalar implant augmentation as an adjunct to facelift. Methods Retrospective review evaluating results and complications in all consecutive patients who had submalar implant augmentation with SMAS-plication facelift in a single surgeon private practice setting from January 1, 1991, to December 31, 2017. Results Forty-eight patients underwent submalar augmentation with simultaneous facelift with an overall satisfaction rate of 95.7%. Complications included 2.1%transient infraorbital hypoesthesia, 1.1% prolonged swelling, and 1.1% capsular contraction that required a minor adjustment under local anesthesia. No infection, implant migration, or extrusion or facial nerve injury occurred. Conclusions Submalar implant augmentation is a safe and effective means of enhancing facelift results through midface volume restoration, subperiosteal release, and improved soft tissue suspension in a more favorable vector. Submalar implant augmentation performed simultaneously with facelift may be an attractive alternative to repeated soft tissue filler or fat injections for patients with submalar hollowing who are interested in facial rejuvenation surgery. The “submalar triangle” encompasses an inverted triangle bounded by the malar eminence superiorly, nasolabial fold medially, and masseter laterally.1,2 This region of the midface is particularly prone to the effects of aging. With loss of skin elasticity and descent of the malar fat pad, suborbicularis oculi fat and orbicularis oculi muscle, the infraorbital rim and nasolabial and nasojugal folds become more conspicuous. The cumulative effect of these involutional soft tissue changes, compounded by maxillary bony resorption and gravity, culminates in a gaunt appearance, or “submalar hollowing” (Figure 1).3 Submalar hollowing is a diagnostic finding of critical importance to address at the time of facial rejuvenation surgery. Figure 1. View largeDownload slide The “submalar triangle” encompasses an inverted triangle bounded malar eminence superiorly, nasolabial fold medially, and masseter laterally. This photograph demonstrates a 65-year-old woman with submalar hollowing contributing to a gaunt appearance. Figure 1. View largeDownload slide The “submalar triangle” encompasses an inverted triangle bounded malar eminence superiorly, nasolabial fold medially, and masseter laterally. This photograph demonstrates a 65-year-old woman with submalar hollowing contributing to a gaunt appearance. Traditional concepts in facial rejuvenation have focused primarily on the treatment of soft tissue descent as a cornerstone of facial rejuvenation surgery. Facelift techniques have evolved to suspend progressively deeper facial structures with the goal of achieving longer-lasting midface soft tissue lift, beginning with skin-only excisions to the superficial muscular aponeurotic system (SMAS), deep plane, composite, and subperiosteal lifts. While contemporary lift procedures resuspend the midface soft tissue and fat pads, the fundamental issue of submalar volume loss remains unaddressed by a lift procedure alone.4 Gonzalez-Ulloa first reported malar augmentation in 1974 as a means of enhancing rhytidectomy results by improving facial contour and thus creating a fuller and more youthful appearance.5 Shortly after that, Binder, Terino, and Whitaker described implant augmentation as a powerful tool for midface rejuvenation.1,6–9 While traditional concepts focused on redraping facial soft tissue, current surgical philosophies now emphasize volume restoration. Although midface alloplastic implant augmentation was first described over 40 years ago, recent trends in facial plastic surgery and dermatology have pushed soft tissue fillers and fat injection to the forefront with almost no mention of permanent implants in the contemporary literature. In 2017, in the United States, 14,277 cheek implants were placed while 2,691,265 soft tissue fillers were injected.10 While autologous fat transfer and fillers can be used to restore submalar volume to the submalar region, the effectiveness of these injected materials is limited by their impermanence and lack of definitive form.11,12 The variable reabsorption of transplanted fat may lead to inconsistent results with the potential for asymmetry and need for repeated injections. Furthermore, because the transferred fat is biologically active, unwanted fat hypertrophy may occur with weight gain.12 The efficacy of these soft tissue filler and fat injections is also dependent on the skill of the injector, and asymmetric injections or injections into the wrong tissue planes can occur. As practitioners and patients come to experience “filler fatigue” from repeated injections and mounting costs, alloplastic implants may serve as a valuable alternative as a 1-time, permanent solution for volume augmentation. Alloplastic implants in the midface replenish bony and soft tissue volume and expand anterolateral projection, thereby reducing skin laxity and nasolabial fold depth. When performed together, submalar implants and SMAS-plication facelift have a synergistic effect. The convexity and volume of the submalar implant soften the sharp angles of the aging face. The implants facilitate an improved vector of tissue elevation, resulting in less skin excision and a more natural and youthful contour, and avoid a stretched or mask-like appearance.1 Not every patient seeking facial rejuvenation may benefit from submalar augmentation. While the changes observed in the aging face are nearly universal, they are not manifested in everyone, particularly those with a high body fat percentage whose adiposity compensates for the aging-related volume loss. Conversely, submalar hollowing can be especially prominent in personal trainers, long-distance runners, and those with lipodystrophy, whose lack of fat tissue amplifies their soft tissue descent. Patients who stand to benefit from submalar augmentation have adequate malar projection but flat and dull-appearing faces with submalar hollowing. Individuals with submalar hollowing who undergo soft tissue suspension alone without volume replenishment may demonstrate a suboptimal skeletonized appearance after surgery (Figure 2). Figure 2. View largeDownload slide A 66-year-old male who had a facelift 11 years prior with excellent longevity in his lifting results. (A, D) His photographs from before his facelift showed a flattened midface, suggesting submalar hollowing for which he may have benefited from submalar implant augmentation at the time of his initial surgery. Eleven years later, the patient desired additional facial rejuvenation and underwent another facelift, this time with submalar implant augmentation. (B, E) He is shown 11 years after the initial facelift and (C, F) 8.5 months after the second facelift with submalar implant augmentation. Figure 2. View largeDownload slide A 66-year-old male who had a facelift 11 years prior with excellent longevity in his lifting results. (A, D) His photographs from before his facelift showed a flattened midface, suggesting submalar hollowing for which he may have benefited from submalar implant augmentation at the time of his initial surgery. Eleven years later, the patient desired additional facial rejuvenation and underwent another facelift, this time with submalar implant augmentation. (B, E) He is shown 11 years after the initial facelift and (C, F) 8.5 months after the second facelift with submalar implant augmentation. William Binder last reported his experience performing submalar augmentation as a preliminary, adjunctive procedure to enhance facelift results in 56 patients in 1990.1 There have been no other studies reported in the literature examining facelift with submalar augmentation in the 28 years since. In this study, we aim to evaluate the long-term safety and efficacy of simultaneous submalar augmentation with SMAS-plication facelift. METHODS A retrospective review was performed on all consecutive patients who underwent submalar augmentation and SMAS-plication facelift in the senior author’s (R.W.H.K.) university-affiliated private practice between January 1991 and June 2017. The study was performed in accordance with the Declaration of Helsinki. Information on demographics, surgical details, complications, and patient satisfaction were reviewed. Patient satisfaction was assessed from direct questioning at their last follow-up visit and patient request for implant revision or removal. Surgical Technique Antibiotic prophylaxis covering commensal oral flora begins 1 day before surgery and continues for 7 days. The patient is marked before surgery in the upright position to demonstrate the effects of gravity. Submalar implant sizers are used to estimate the amount of volume restoration necessary. With traction on the face simulating the soft tissue redistribution with the facelift, tracings of the implants are drawn and measured to ensure symmetry. Asymmetries between the 2 sides of the face should be noted and may require different-sized implants. We prefer submalar augmentation at the start of the combined surgery, as the creation of the pocket for the implant becomes more difficult after the overlying soft tissue has been pulled taut and resuspended laterally. Additionally, elevation of the malar periosteum provides an additive effect to the facelift results, which will be discussed later. A 2 cm incision is placed slightly superior to the gingiva in the gingivobuccal sulcus at the lateral canine fossa, avoiding the parotid puncta and preserving sufficient mucosa inferiorly to permit a tension free and water-tight closure. The periosteum is incised and a subperiosteal pocket developed obliquely over the maxilla towards the zygomatic arch and over the white tendinous attachments of the masseter, using the preoperative skin markings as a guide. A curved instrument is used to avoid inadvertent injury to the overlying midface soft tissue and facial nerve, particularly over the convexity of the lateral zygoma. The zygomatic retaining ligaments may be encountered along the inferior border of the zygomatic arch and can be released.13 It is essential to create a pocket of sufficient size to permit complete unfurling of the implant and to prevent capsular contraction. Dissection over the zygoma and anterior zygomatic arch is performed blindly, but with the assistance of external manual palpation; inadequate dissection of this region may result in the medial displacement of the implant. We favor the paddle-shaped, preformed Conform Binder Submalar Implants (Implantech Associates, Inc., Ventura, CA) for submalar augmentation. The pliability and grid-backing of the implant are designed to conform readily to the underlying structures for greater adaptability to irregular bony surfaces, reduces the chance of movement, and minimizes dead space between the implant and underlying bone. The tapered margins of the implant blend with the adjacent bony structure to create an imperceptible transition between implant and recipient site.2 Sterile sizers are utilized in the subperiosteal pocket to determine the optimal size for volume restoration. The bulk of the implant is placed over the anterior maxilla, corresponding to the center of the submalar hollowing. The tapered, lateral extension of the implant rests on the zygomatic arch to provide a small amount of malar augmentation (Figure 3). If increased malar projection is not desired, the lateral extension of the implant can be trimmed so that the implant augments the medial cheek only. When the final implant size has been decided upon, its outlines are again marked on the skin surface, along with locations of the fenestrations on the implants, and the distances from the lateral canthus and ala are carefully measured to help achieve symmetry. Figure 3. View largeDownload slide The paddle-shaped submalar implant is placed in against the maxilla and zygoma, with the maximal projection medially in the center of the submalar hollowing, and the tail of the implant curves upward to rest laterally on the zygomatic arch and the tendinous insertions of the masseter. (A) The lateral extension of the implant increases malar projection slightly. If malar augmentation is not desired, this part of the implant can be trimmed. The small notch at the superior, medial edge of the implant is designed to straddle the infraorbital foramen (arrow) inferiorly. The edges of the implant are tapered to minimize visibility. (B) Position of the submalar implant (arrow) as seen from a sky view. The pliability and adaptability of the silicone elastomer allows the implant to adapt to the underlying irregular bone structures to minimize dead space and blend in with surrounding structures inconspicuously. Note: Blue sizers are used for illustration. The actual silicone implants are clear. Figure 3. View largeDownload slide The paddle-shaped submalar implant is placed in against the maxilla and zygoma, with the maximal projection medially in the center of the submalar hollowing, and the tail of the implant curves upward to rest laterally on the zygomatic arch and the tendinous insertions of the masseter. (A) The lateral extension of the implant increases malar projection slightly. If malar augmentation is not desired, this part of the implant can be trimmed. The small notch at the superior, medial edge of the implant is designed to straddle the infraorbital foramen (arrow) inferiorly. The edges of the implant are tapered to minimize visibility. (B) Position of the submalar implant (arrow) as seen from a sky view. The pliability and adaptability of the silicone elastomer allows the implant to adapt to the underlying irregular bone structures to minimize dead space and blend in with surrounding structures inconspicuously. Note: Blue sizers are used for illustration. The actual silicone implants are clear. Some patients with severe submalar hollowing that extends inferiorly into the lower cheek may require a small amount of filler injection after implant augmentation, as the submalar implant rests against the maxilla and zygoma, under the periosteum, and not in the soft tissue of the lower cheek. The submalar augmentation may accentuate progressive buccal fat atrophy that occurs with aging if the buccal volume deficiency is untreated. Two-point transcutaneous non-absorbable sutures secure the implants during the initial healing phase. A 3-0 polypropylene (Ethicon, Inc., Somerville, NJ) is passed through the external skin marking, through the soft tissue, into the subperiosteal pocket, and through the implant fenestrations superficial to deep then deep to superficial, then from the pocket back through the skin. It is important to inspect the implant once more to ensure that it lies flush against the zygoma and the lateral end is unfurled. The implants are bathed in an antibiotic solution, which is also used to irrigate the dissection pocket before and after implantation. The external skin sutures are tied over dental rolls to protect the underlying skin and covered with a transparent film dressing. Some believe that the implants should be screw fixated to the maxilla, which may minimize dead space and reduce the implant mobility. However, we have found that that when the implants are placed in a sufficiently large subperiosteal pocket we have not required rigid fixation to ensure symmetry, prevent implant migration, or minimize dead space. Even with the creation of a large subperiosteal pocket, soft tissue contraction occurs rapidly following surgery and eliminates most dead space within 48 hours.11 Furthermore, by not placing a screw in the maxilla on each side, one avoids the potential risks for cantilevered movement of the implant and communication with the maxillary sinus, which may serve as a conduit for infection during sinusitis. The intraoral incisions are closed in 2 layers using 4-0 chromic sutures. The transcutaneous bolsters are kept for 5 days, while a capsule forms around the implants to fix them in place. On removal, the exposed suture is prepped with povidone-iodine to avoid contamination of the implant, and the subperiosteal pocket as the suture is pulled through. The intraoral chromic sutures dissolve within 3 weeks. Chlorhexidine gluconate mouth rinses are used for 5 days to maintain oral hygiene. RESULTS From 1991 to 2017, 50 patients were identified who had undergone simultaneous submalar augmentation and SMAS-plication facelift. Of these patients, records for 48 patients were located. Eleven (23%) patients were male and 37 (77%) female. The mean age was 56.4 years (range, 28-73). Nine (19%) of the patients had prior facelifts. The mean and median lengths of follow up were 3.9 years and 1.25 years, respectively (range, 1 month-21 years) (Table 1). Table 1. Patient Demographics Patient Demographics Total patients 48 Age, years  Mean 56.5  Range 28-73 Gender, n (%)  Male 11 (23%)  Female 37 (77%) Ethnicity, n (%)  Caucasian 44 (92%)  Hispanic 2 (4%)  Asian-Pacific Islander 1 (2%)  African-American 1 (2%) Length of follow-up  Mean 3.9 yrs  Median 1.25 yrs  Range 1 mo-21 yrs Previous facelift, n (%) 9 (19%) Patient Demographics Total patients 48 Age, years  Mean 56.5  Range 28-73 Gender, n (%)  Male 11 (23%)  Female 37 (77%) Ethnicity, n (%)  Caucasian 44 (92%)  Hispanic 2 (4%)  Asian-Pacific Islander 1 (2%)  African-American 1 (2%) Length of follow-up  Mean 3.9 yrs  Median 1.25 yrs  Range 1 mo-21 yrs Previous facelift, n (%) 9 (19%) yrs = years, mo = month View Large Table 1. Patient Demographics Patient Demographics Total patients 48 Age, years  Mean 56.5  Range 28-73 Gender, n (%)  Male 11 (23%)  Female 37 (77%) Ethnicity, n (%)  Caucasian 44 (92%)  Hispanic 2 (4%)  Asian-Pacific Islander 1 (2%)  African-American 1 (2%) Length of follow-up  Mean 3.9 yrs  Median 1.25 yrs  Range 1 mo-21 yrs Previous facelift, n (%) 9 (19%) Patient Demographics Total patients 48 Age, years  Mean 56.5  Range 28-73 Gender, n (%)  Male 11 (23%)  Female 37 (77%) Ethnicity, n (%)  Caucasian 44 (92%)  Hispanic 2 (4%)  Asian-Pacific Islander 1 (2%)  African-American 1 (2%) Length of follow-up  Mean 3.9 yrs  Median 1.25 yrs  Range 1 mo-21 yrs Previous facelift, n (%) 9 (19%) yrs = years, mo = month View Large A total of 95 submalar implants were placed. Forty-seven of the 48 (97.9%) patients underwent bilateral submalar augmentation. One patient (2.1%) had significant unilateral submalar hollowing that required a single implant. One (2.1%) patient had malar implants placed by another surgeon that not only did the patient dislike but were also placed in an incorrect plane, resulting in implant mobility. These malar implants were exchanged for newer submalar implants placed in the proper subperiosteal plane. Of the patients who had bilateral submalar augmentation, most received medium-sized implants (63.8%), followed by large (12.7%), small (6.4%), and extra-large (2.1%) implants. Different-sized implants were used 14.9% of the time for patients with asymmetric submalar hollowing (Table 2). Table 2. Size of Implants Used Size of Implants Placement Small Medium Large Extra-large Different sizes Bilateral 3 (6.4%) 30 (63.8%) 6 (12.7%) 1 (2.1%) 7 (14.9%) Unilateral 0 0 1 (100%) 0 --- Size of Implants Placement Small Medium Large Extra-large Different sizes Bilateral 3 (6.4%) 30 (63.8%) 6 (12.7%) 1 (2.1%) 7 (14.9%) Unilateral 0 0 1 (100%) 0 --- View Large Table 2. Size of Implants Used Size of Implants Placement Small Medium Large Extra-large Different sizes Bilateral 3 (6.4%) 30 (63.8%) 6 (12.7%) 1 (2.1%) 7 (14.9%) Unilateral 0 0 1 (100%) 0 --- Size of Implants Placement Small Medium Large Extra-large Different sizes Bilateral 3 (6.4%) 30 (63.8%) 6 (12.7%) 1 (2.1%) 7 (14.9%) Unilateral 0 0 1 (100%) 0 --- View Large None of 95 (0%) implants developed an infection that required implant irrigation or removal. One (2.1%) patient presented 1 year after surgery with 10 days of mild, dull, aching pain, representing an inflammatory process mimicking infection. On examination, the intraoral incision was well healed, the implant was nonmobile, and there was no erythema, edema, fluctuance, or lymphadenopathy. The discomfort resolved with a conservative 7-day course of oral amoxicillin-clavulanate. Transient facial nerve buccal branch paresis was observed in 1 (2.1%) patient who also had an ipsilateral concomitant parotidectomy for excision of a pleomorphic adenoma at the time of facelift. The buccal branch weakness likely represented neuropraxia from the parotidectomy rather than injury during the implant placement. No other patients experienced facial nerve injury. Prolonged unilateral swelling that lasted nearly 1 year was noted with 1 (1.1%) of the implants. One (2.1%) patient reported unilateral numbness over the medial cheek that resolved within 1 month. No patients experienced permanent infraorbital hypoesthesia. None of the patients had implant migration or extrusion, hematoma, or seroma. One (2.1%) patient required a minor adjustment for an implant that developed capsular contraction. Under local anesthesia, the capsule was expanded successfully through the same transoral approach. Forty-six (95.8%) of the patients were happy with the appearance of their submalar augmentation based on in-office questioning during follow-up visits. One (2.1%) patient desired more submalar fullness, which was satisfactorily treated with hyaluronic acid filler injection. Another (2.1%) patient felt the implants were slightly too large but declined an implant exchange to a smaller size. A summary of complications is listed in Table 3 (Figures 4–6). Table 3. Complications Complications n (%) Comment Infection requiring implant removal 0 (0%) Infection requiring implant irrigation 0 (0%) Facial nerve injury 0 (0%) Transient buccal branch paresis in a patient who had undergone ipsilateral parotidectomy for the excision of a pleomorphic adenoma not counted. Infraorbital nerve hypoesthesia 1 (2.1%) Unilateral cheek numbness that fully recovered within 1 month. Prolonged swelling 1 (1.1%) Prolonged unilateral swelling that resolved nearly 1 year after surgery. Post-operative asymmetry 1 (1.1%) Capsular contracture of an implant corrected with minor adjustment Implant migration or extrusion 0 (0%) Hematoma or seroma formation 0 (0%) Overall complication rate 5.3% Complications n (%) Comment Infection requiring implant removal 0 (0%) Infection requiring implant irrigation 0 (0%) Facial nerve injury 0 (0%) Transient buccal branch paresis in a patient who had undergone ipsilateral parotidectomy for the excision of a pleomorphic adenoma not counted. Infraorbital nerve hypoesthesia 1 (2.1%) Unilateral cheek numbness that fully recovered within 1 month. Prolonged swelling 1 (1.1%) Prolonged unilateral swelling that resolved nearly 1 year after surgery. Post-operative asymmetry 1 (1.1%) Capsular contracture of an implant corrected with minor adjustment Implant migration or extrusion 0 (0%) Hematoma or seroma formation 0 (0%) Overall complication rate 5.3% View Large Table 3. Complications Complications n (%) Comment Infection requiring implant removal 0 (0%) Infection requiring implant irrigation 0 (0%) Facial nerve injury 0 (0%) Transient buccal branch paresis in a patient who had undergone ipsilateral parotidectomy for the excision of a pleomorphic adenoma not counted. Infraorbital nerve hypoesthesia 1 (2.1%) Unilateral cheek numbness that fully recovered within 1 month. Prolonged swelling 1 (1.1%) Prolonged unilateral swelling that resolved nearly 1 year after surgery. Post-operative asymmetry 1 (1.1%) Capsular contracture of an implant corrected with minor adjustment Implant migration or extrusion 0 (0%) Hematoma or seroma formation 0 (0%) Overall complication rate 5.3% Complications n (%) Comment Infection requiring implant removal 0 (0%) Infection requiring implant irrigation 0 (0%) Facial nerve injury 0 (0%) Transient buccal branch paresis in a patient who had undergone ipsilateral parotidectomy for the excision of a pleomorphic adenoma not counted. Infraorbital nerve hypoesthesia 1 (2.1%) Unilateral cheek numbness that fully recovered within 1 month. Prolonged swelling 1 (1.1%) Prolonged unilateral swelling that resolved nearly 1 year after surgery. Post-operative asymmetry 1 (1.1%) Capsular contracture of an implant corrected with minor adjustment Implant migration or extrusion 0 (0%) Hematoma or seroma formation 0 (0%) Overall complication rate 5.3% View Large Figure 4. View largeDownload slide A 65-year-old female is shown who underwent facelift with bilateral submalar augmentation, upper blepharoplasty, and perioral CO2 laser skin resurfacing. (A, C) Preoperative photographs showing pronounced submalar hollowing and slightly asymmetric zygomas. (B, D) Eight months after surgery, showing an improvement in the submalar volume loss and greater malar definition from the zygomatic extension of the submalar implant. Figure 4. View largeDownload slide A 65-year-old female is shown who underwent facelift with bilateral submalar augmentation, upper blepharoplasty, and perioral CO2 laser skin resurfacing. (A, C) Preoperative photographs showing pronounced submalar hollowing and slightly asymmetric zygomas. (B, D) Eight months after surgery, showing an improvement in the submalar volume loss and greater malar definition from the zygomatic extension of the submalar implant. Figure 5. View largeDownload slide A 55-year-old female who underwent facelift with bilateral submalar augmentation and endoscopic brow lift (A, C) before surgery and (B, D) 8 months after surgery. (E, G) Preoperative base and sky views. (F, H) Base and sky views 3.5 months after surgery. Figure 5. View largeDownload slide A 55-year-old female who underwent facelift with bilateral submalar augmentation and endoscopic brow lift (A, C) before surgery and (B, D) 8 months after surgery. (E, G) Preoperative base and sky views. (F, H) Base and sky views 3.5 months after surgery. Figure 6. View largeDownload slide A 69-year-old female who had undergone facelift, upper and lower blepharoplasty, and bilateral submalar cheek implantation. She subsequently had a full-face CO2 laser skin resurfacing 11 months after her facelift. (A, C) Before surgery and (B, D) 15 months after surgery. Figure 6. View largeDownload slide A 69-year-old female who had undergone facelift, upper and lower blepharoplasty, and bilateral submalar cheek implantation. She subsequently had a full-face CO2 laser skin resurfacing 11 months after her facelift. (A, C) Before surgery and (B, D) 15 months after surgery. DISCUSSION In this study, we have shown that submalar implant augmentation is a safe and long-lasting method of enhancing SMAS-plication facelift, with minimal complication rates (overall 5.3%) and greater than 95% patient satisfaction in 48 patients with a mean follow-up time of almost 4 years. To our knowledge, this is the largest and only study of its kind since William Binder last reported his results 28 years ago. The submalar implant is a workhorse to enhance facelift in a patient with submalar hollowing by adding midface volume and projection and facilitating a more natural vector of facial soft tissues redraping during soft tissue suspension. Submalar augmentation provides a consistent and effective means of midface volume restoration, as reflected by the 95.7% of our patients who were satisfied with their submalar augmentation. Although 2 (4.3%) patients were not completely happy with the size of their submalar implants, both declined revision surgery. Inherent asymmetries between the 2 sides of the face can be addressed at the time of submalar augmentation, as seen in 14.9% of our patients who received different-sized implants. As with the selection of any facial implant, open communication between the surgeon and patient regarding his/her expectations and aesthetic goals is essential for maximizing patient satisfaction and aesthetic results. Computer imaging and asking patients to provide images of individuals with their desired facial contour may be helpful for the surgeon in selecting the appropriate implant size. Patient-specific implants using computed tomography is now commercially available, but is quite expensive.14 Alternatively, preformed silicone submalar implants can be carved to suit each individual’s particular needs. Facial implants provide an aesthetically desirable dimensionality to the midface that injected fat and fillers deposited as amorphous aliquots, and at the mercy of pressure from the overlying tissue, cannot.11 Autologous fat transfer involves potential donor site morbidity, does not augment solitary facial regions well, suffers from variable resorption, and may hypertrophy with weight gain.12,15 “Filler fatigue” in patients can develop with the multiple, repeated series of injections that are often necessary to achieve and maintain equivalent volume attained with submalar implants. Compared to submalar fat and filler injections, the initial cost (surgeon’s fee, anesthesia time, and material cost) for submalar implants is quickly offset by the continuing expense of multiple injections and office visits over the years.16 Our longest patient, with follow-up of 21 years, saved thousands of dollars that otherwise would have been spent on repetitive injections. For patients concerned about the “invasiveness” of implant placement, when a surgical procedure such as a facelift is planned that is already “invasive,” it is reasonable to place permanent implants at the same time. The ideal implant is biocompatible, inert, non-carcinogenic, anatomically molded, and does not induce a foreign-body reaction.5 Implant-grade solid silicone satisfies all these requirements.17 Alloplastic implants provide a 3-dimensional shape designed to permanently restore volume and enhance the submalar triangle to create a more natural and youthful appearance. Its smoothness and flexibility allow for ease of manipulation and insertion. Several days after implantation, a capsule forms around the implant, helping to secure it in place without the need for screw fixation. Unlike fat or filler injections, submalar implants can be repositioned or removed because there is minimal inflammation and no bio-integration. While mandibular bony erosion with chin implants had been reported, midface bony erosion has not been observed, which is thought to be due, in part, to the large surface contact area relative to the bone, relatively laxity of the midface soft tissue, and minimal muscular pull against the bone in this region.6,9 The advantages of submalar implants alone for midface hollowing and effects of rhytidectomy with and without subperiosteal dissection on the midface soft tissue have been well documented. Here, we are adding both together to get an enhanced result. Although midface volume restoration is the primary objective of submalar augmentation, subperiosteal dissection over the zygoma and release of the medial zygomatic retaining ligaments during placement of submalar implants enhance SMAS-plication facelift outcomes by allowing a higher degree of mobilization of a thicker composite musculo-cutaneo-periosteal flap with soft tissue suspension. This concept is analogous to cutting the arcus marginalis when doing an endoscopic forehead lift. Because submalar augmentation and SMAS-plication facelift are performed in different surgical planes, performing both surgeries at the same setting does not require a change in surgical technique and does not adversely affect the normal healing process. The periosteal elevation used for submalar implant placement has a similar effect as a subperiosteal lift. Submalar implants that are placed in this deep layer with thick overlying tissue rarely become exposed or extrude.2 In our series, long-lasting SMAS soft tissue suspension and midface volume restoration were achieved for all patients with submalar augmentation with SMAS-plication facelift, without the need for a deep plane technique, as the results attest. Submalar augmentation is a safe procedure associated with minimal risks. Binder reported an overall 10.8% complication rate in his series of 56 patients with combined submalar augmentation and facelift (1.8% implant infection, 3.6% transient infraorbital hypoesthesia, 5.4% postoperative asymmetries that required implant adjustment).1 In our series of 48 patients, we observed a slightly lower overall complication rate of 5.3% (2.1% transient infraorbital hypoesthesia, 2.1% postoperative asymmetries that required implant adjustment, 1.1% prolonged swelling, 0% implant infection). In Hopping’s review of 100 patients who received malar and chin augmentation with facelift, 8 of 300 (2.7%) implants became infected, and 6 necessitated removal.18 Rubin and Yaremchuck observed a 1.2% infection rate in 404 silicone malar implants.19 Binder saw a similar infection rate of 1.3% in 78 patients with submalar implants alone, and 1.8% in 56 patients with combined submalar augmentation and facelift.1,6 Our infection rate was 0%, as no patients experienced an implant infection that required implant irrigation or removal. Excess fluid accumulation in the dissection pocket may contribute to higher infection rates by serving as a nidus of infection, and may occur with inadequate hemostasis or implant mobility secondary to placement of the implant in the wrong plane. Open communication with the maxillary sinus may also serve as a possible conduit for infection.9 Although the role of biofilms in implant infection has been a well-studied subject in orthopedics, its role in facial implant infection remains to be elucidated.20 In the meanwhile, early detection of the signs of infection, which include pain, erythema, edema, purulence, and drainage, and timely treatment are imperative for optimal surgical outcomes. Surgery in the oral cavity is inherently nonsterile. Due to the risk of intraoral bacteria transference, sterile technique, perioperative antibiotics, irrigation with an antibiotic solution during surgery, and chlorhexidine mouth rinses following surgery are our choice to minimize the risk of infection. The process of capsular fibrosis is essential for maintaining the implants in their proper position against the facial skeleton after several days of temporary 2-point suture fixation without the need for screw fixation.9,21 However, excessive capsular contraction may distort the silicone implant, resulting in asymmetry. Binder reported that 5 of 78 (6.4%) patients with submalar implants developed asymmetries that required minor revisions.6 In our series, 94 of 95 (98.9%) implants had no issues with malposition or distortion, and only 1 implant (1.1%) experienced distortion due to a capsular contraction, which was corrected with a minor adjustment under local anesthesia. The exact etiology of capsular contraction remains unclear but may be multifactorial. We have found that it is essential to create a large enough subperiosteal pocket for the implant to prevent capsular contraction. Prolonged unilateral swelling that was not significant enough to warrant implant exchange or removal was seen in 1 (2.1%) of our patients. Swelling from the subperiosteal dissection can be expected and usually resolves within 8-10 weeks. Inadequate hemostasis or placement of the implant in an incorrect plane might contribute to prolonged swelling. While it is important for the physician to counsel the patient as the swelling subsides, one must also be vigilant for potential signs of infection, which can also present with localized edema. Due to the proximity of the infraorbital nerve to the dissection pocket, its inadvertent injury may occur during periosteal elevation. Binder reported transient upper lip numbness in 6.4% of his patients who had submalar implants alone.7 In our series, 1 (2.1%) patient experienced transient upper lip numbness that resolved within a month. Familiarity with the location of the infraorbital foramen within the canine fossa, typically 8 mm inferior to the infraorbital rim and directly above the second premolar, is necessary for avoiding inadvertent injury to its contents.22 Given the inferior placement of the submalar implant on the maxilla, full circumferential exposure of the infraorbital nerve is unnecessary. Making of the gingivobuccal incision lateral to the maxillary canine can also help avoid unnecessary dissection in the vicinity of the nerve. Although direct injury to the infraorbital nerve is uncommon, tension on the nerve may result in neuropraxia, resulting in temporary numbness that usually resolves within days to weeks. Prolonged numbness over the malar eminence is expected, because the zygomaticofacial nerve is sacrificed during implant placement, as the implant is placed directly over the nerve’s foramen, and patients should be counseled on this. Although no patients experienced facial nerve injuries related to implant placement in our study, facial nerve injury may occur with inadvertent puncture through the overlying midface soft tissue during subperiosteal elevation. This serious complication can be avoided by staying on bone during the periosteal elevation, particularly laterally over the zygomatic arch, and through the use of broad, curved, and tapered instruments. Limitation of this study includes the retrospective nature of the review, subjectivity of patient satisfaction, and lack of a comparative control group. Validated patient satisfaction scales have only recently become widely used. However, this study goes back 27 years when there was no agreed-upon standardized instrument to measure patient satisfaction. Instead, we relied on our long-term in-person patient satisfaction questioning in a large group of subjects with extended follow-up and low revision rate (2.1%). Future prospective studies may benefit from using currently available patient-reported outcome measures, such as Face Q.23 At present, a comparison of patients with facelift alone to those who had submalar augmentation with facelift would not provide meaningful information. Preoperative and postoperative measurements can vary drastically, as the degree of midface augmentation is affected by the size of the implant used, the size and symmetry of the underlying bony structure, and the variable amount of soft tissue present. Same-patient, half-face studies with and without submalar implant augmentation in individuals without bony and soft tissue asymmetries would theoretically provide more meaningful measurements, but are indeed not feasible or desirable, especially if you are the patient. Now that we have newly validated patient satisfaction metrics, studies going forward should include them. CONCLUSIONS Techniques that offer only soft tissue suspension but not volume restoration in individuals with submalar hollowing may result in a skeletonized appearance after surgery. Modern facial rejuvenation emphasizes both soft tissue re-suspension and volume restoration to achieve a more youthful and natural appearance. For patients with submalar hollowing who are undergoing SMAS-plication facelift for facial rejuvenation, permanent submalar augmentation may be a viable alternative to repeated fat or filler injection. When performed as the first part of the combined procedure, the subperiosteal elevation and release of zygomatic retaining ligaments during submalar augmentation, analogous to cutting the arcus marginalis during a brow lift, enhance facelift results by allowing mobilization of a thicker composite flap. Because of the deep subperiosteal release and implant volume added, enduring midface volume restoration and soft tissue suspension can be achieved with submalar augmentation and SMAS-plication facelift alone, without the need for deep-plane or subperiosteal rhytidectomy techniques. In this study, we showed that submalar implant augmentation could be safely and effectively performed in conjunction with SMAS-plication facelift to achieve a synergistic revitalization of the midface. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Binder WJ . Submalar augmentation: a procedure to enhance rhytidectomy . Ann Plast Surg . 1990 ; 24 ( 3 ): 200 - 212 . Google Scholar CrossRef Search ADS PubMed 2. Binder WJ , Moelleken , Tobias GW . Aesthetic facial implants . In: Facial Plastic & Reconstructive Surgery . 2nd ed . Stuttgart, Germany : Thieme ; 2006 . Google Scholar CrossRef Search ADS 3. Mendelson BC , Hartley W , Scott M , McNab A , Granzow JW . Age-related changes of the orbit and midcheek and the implications for facial rejuvenation . Aesthetic Plast Surg . 2007 ; 31 ( 5 ): 419 - 423 . Google Scholar CrossRef Search ADS PubMed 4. Hamra ST . A study of the long-term effect of malar fat repositioning in face lift surgery: short-term success but long-term failure . Plast Reconstr Surg . 2002 ; 110 ( 3 ): 940 - 951 ; discussion 952–959. Google Scholar CrossRef Search ADS PubMed 5. González-Ulloa M . Building out the malar prominences as an addition to rhytidectomy . Plast Reconstr Surg . 1974 ; 53 ( 3 ): 293 - 296 . Google Scholar CrossRef Search ADS PubMed 6. Binder WJ . Submalar augmentation. An alternative to face-lift surgery . Arch Otolaryngol Head Neck Surg . 1989 ; 115 ( 7 ): 797 - 801 . Google Scholar CrossRef Search ADS PubMed 7. Terino EO . Alloplastic facial contouring by zonal principles of skeletal anatomy . Clin Plast Surg . 1992 ; 19 ( 2 ): 487 - 510 . Google Scholar PubMed 8. Binder WJ , Schoenrock LD , Terino EO . Augmentation of the malar-submalar/midface . Facial Plast Surg Clin North Am . 1994 ; 2 ( 3 ): 265 - 283 . 9. Whitaker LA . Aesthetic augmentation of the malar- midface structures . Plast Reconstr Surg . 1987 ; 80 ( 3 ): 337 - 346 . Google Scholar CrossRef Search ADS PubMed 10. ASPS National Clearinghouse of Plastic Surgery Procedural Statistics . 2017 Plastic Surgery Statistics Report . https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf. Accessed May 9, 2018. 11. Binder WJ , Azizzadeh B . Malar and submalar augmentation . Facial Plast Surg Clin North Am . 2008 ; 16 ( 1 ): 11 - 32 , v. Google Scholar CrossRef Search ADS PubMed 12. Lam SM . The potential of autologous fat transfer as a valuable tool for cosmetic and reconstructive purposes: ackowledged risks, limitations, and benefits . JAMA Facial Plast Surg . 2018 Mar 29. doi: https://doi.org/10.1001/jamafacial.2018.0126 . [Epub ahead of print] 13. Furnas DW . The retaining ligaments of the cheek . Plast Reconstr Surg . 1989 ; 83 ( 1 ): 11 - 16 . Google Scholar CrossRef Search ADS PubMed 14. Binder WJ , Bloom DC . The use of custom-designed midfacial and submalar implants in the treatment of facial wasting syndrome . Arch Facial Plast Surg . 2004 ; 6 ( 6 ): 394 - 397 . Google Scholar CrossRef Search ADS PubMed 15. Krastev TK , Beugels J , Hommes J , Piatkowski A , Mathijssen I , van der Hulst R . Efficacy and safety of autologous fat transfer in facial reconstructive surgery: a systematic review and meta-analysis . JAMA Facial Plast Surg . 2018 Mar 29. doi: https://doi.org/10.1001/jamafacial.2018.0102 . [Epub ahead of print] 16. Kridel RWH , Patel S . Cheek and chin implants to enhance facelift results . Facial Plast Surg . 2017 ; 33 ( 3 ): 279 - 284 . Google Scholar CrossRef Search ADS PubMed 17. Constantinides MS , Galli SK , Miller PJ , Adamson PA . Malar, submalar, and midfacial implants . Facial Plast Surg . 2000 ; 16 ( 1 ): 35 - 44 . Google Scholar CrossRef Search ADS PubMed 18. Hopping SB , Joshi AS , Tanna N , Janjanin S . Volumetric facelift: evaluation of rhytidectomy with alloplastic augmentation . Ann Otol Rhinol Laryngol . 2010 ; 119 ( 3 ): 174 - 180 . Google Scholar CrossRef Search ADS PubMed 19. Rubin JP , Yaremchuk MJ . Complications and toxicities of implantable biomaterials used in facial reconstructive and aesthetic surgery: a comprehensive review of the literature . Plast Reconstr Surg . 1997 ; 100 ( 5 ): 1336 - 1353 . Google Scholar CrossRef Search ADS PubMed 20. Walker TJ , Toriumi DM . Analysis of facial implants for bacterial biofilm formation using scanning electron microscopy . JAMA Facial Plast Surg . 2016 ; 18 ( 4 ): 299 - 304 . Google Scholar CrossRef Search ADS PubMed 21. Soares DJ , Silver WE . Midface skeletal enhancement . Facial Plast Surg Clin North Am . 2015 ; 23 ( 2 ): 185 - 193 . Google Scholar CrossRef Search ADS PubMed 22. Raschke R , Hazani R , Yaremchuk MJ . Identifying a safe zone for midface augmentation using anatomic landmarks for the infraorbital foramen . Aesthet Surg J . 2013 ; 33 ( 1 ): 13 - 18 . Google Scholar CrossRef Search ADS PubMed 23. Klassen AF , Cano SJ , Scott A , Snell L , Pusic AL . Measuring patient-reported outcomes in facial aesthetic patients: development of the FACE-Q . Facial Plast Surg . 2010 ; 26 ( 4 ): 303 - 309 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Enhancing Facelift With Simultaneous Submalar Implant Augmentation

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© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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Abstract

Abstract Background The midface is particularly prone to the senescent changes of soft tissue ptosis and volume loss, which in individuals with aging or low adiposity can manifest as submalar hollowing. Facelift alone in those with submalar hollowing inadequately addresses the volume loss and may result in a gaunt appearance postoperatively. Submalar implant augmentation is a powerful tool for permanent midface volume restoration for a more youthful and natural contour, as opposed to soft tissue fillers that diminish over time. When performed together, submalar augmentation and facelift synergistically enhance facial rejuvenation results. Objectives Determine the long-term safety and efficacy of submalar implant augmentation as an adjunct to facelift. Methods Retrospective review evaluating results and complications in all consecutive patients who had submalar implant augmentation with SMAS-plication facelift in a single surgeon private practice setting from January 1, 1991, to December 31, 2017. Results Forty-eight patients underwent submalar augmentation with simultaneous facelift with an overall satisfaction rate of 95.7%. Complications included 2.1%transient infraorbital hypoesthesia, 1.1% prolonged swelling, and 1.1% capsular contraction that required a minor adjustment under local anesthesia. No infection, implant migration, or extrusion or facial nerve injury occurred. Conclusions Submalar implant augmentation is a safe and effective means of enhancing facelift results through midface volume restoration, subperiosteal release, and improved soft tissue suspension in a more favorable vector. Submalar implant augmentation performed simultaneously with facelift may be an attractive alternative to repeated soft tissue filler or fat injections for patients with submalar hollowing who are interested in facial rejuvenation surgery. The “submalar triangle” encompasses an inverted triangle bounded by the malar eminence superiorly, nasolabial fold medially, and masseter laterally.1,2 This region of the midface is particularly prone to the effects of aging. With loss of skin elasticity and descent of the malar fat pad, suborbicularis oculi fat and orbicularis oculi muscle, the infraorbital rim and nasolabial and nasojugal folds become more conspicuous. The cumulative effect of these involutional soft tissue changes, compounded by maxillary bony resorption and gravity, culminates in a gaunt appearance, or “submalar hollowing” (Figure 1).3 Submalar hollowing is a diagnostic finding of critical importance to address at the time of facial rejuvenation surgery. Figure 1. View largeDownload slide The “submalar triangle” encompasses an inverted triangle bounded malar eminence superiorly, nasolabial fold medially, and masseter laterally. This photograph demonstrates a 65-year-old woman with submalar hollowing contributing to a gaunt appearance. Figure 1. View largeDownload slide The “submalar triangle” encompasses an inverted triangle bounded malar eminence superiorly, nasolabial fold medially, and masseter laterally. This photograph demonstrates a 65-year-old woman with submalar hollowing contributing to a gaunt appearance. Traditional concepts in facial rejuvenation have focused primarily on the treatment of soft tissue descent as a cornerstone of facial rejuvenation surgery. Facelift techniques have evolved to suspend progressively deeper facial structures with the goal of achieving longer-lasting midface soft tissue lift, beginning with skin-only excisions to the superficial muscular aponeurotic system (SMAS), deep plane, composite, and subperiosteal lifts. While contemporary lift procedures resuspend the midface soft tissue and fat pads, the fundamental issue of submalar volume loss remains unaddressed by a lift procedure alone.4 Gonzalez-Ulloa first reported malar augmentation in 1974 as a means of enhancing rhytidectomy results by improving facial contour and thus creating a fuller and more youthful appearance.5 Shortly after that, Binder, Terino, and Whitaker described implant augmentation as a powerful tool for midface rejuvenation.1,6–9 While traditional concepts focused on redraping facial soft tissue, current surgical philosophies now emphasize volume restoration. Although midface alloplastic implant augmentation was first described over 40 years ago, recent trends in facial plastic surgery and dermatology have pushed soft tissue fillers and fat injection to the forefront with almost no mention of permanent implants in the contemporary literature. In 2017, in the United States, 14,277 cheek implants were placed while 2,691,265 soft tissue fillers were injected.10 While autologous fat transfer and fillers can be used to restore submalar volume to the submalar region, the effectiveness of these injected materials is limited by their impermanence and lack of definitive form.11,12 The variable reabsorption of transplanted fat may lead to inconsistent results with the potential for asymmetry and need for repeated injections. Furthermore, because the transferred fat is biologically active, unwanted fat hypertrophy may occur with weight gain.12 The efficacy of these soft tissue filler and fat injections is also dependent on the skill of the injector, and asymmetric injections or injections into the wrong tissue planes can occur. As practitioners and patients come to experience “filler fatigue” from repeated injections and mounting costs, alloplastic implants may serve as a valuable alternative as a 1-time, permanent solution for volume augmentation. Alloplastic implants in the midface replenish bony and soft tissue volume and expand anterolateral projection, thereby reducing skin laxity and nasolabial fold depth. When performed together, submalar implants and SMAS-plication facelift have a synergistic effect. The convexity and volume of the submalar implant soften the sharp angles of the aging face. The implants facilitate an improved vector of tissue elevation, resulting in less skin excision and a more natural and youthful contour, and avoid a stretched or mask-like appearance.1 Not every patient seeking facial rejuvenation may benefit from submalar augmentation. While the changes observed in the aging face are nearly universal, they are not manifested in everyone, particularly those with a high body fat percentage whose adiposity compensates for the aging-related volume loss. Conversely, submalar hollowing can be especially prominent in personal trainers, long-distance runners, and those with lipodystrophy, whose lack of fat tissue amplifies their soft tissue descent. Patients who stand to benefit from submalar augmentation have adequate malar projection but flat and dull-appearing faces with submalar hollowing. Individuals with submalar hollowing who undergo soft tissue suspension alone without volume replenishment may demonstrate a suboptimal skeletonized appearance after surgery (Figure 2). Figure 2. View largeDownload slide A 66-year-old male who had a facelift 11 years prior with excellent longevity in his lifting results. (A, D) His photographs from before his facelift showed a flattened midface, suggesting submalar hollowing for which he may have benefited from submalar implant augmentation at the time of his initial surgery. Eleven years later, the patient desired additional facial rejuvenation and underwent another facelift, this time with submalar implant augmentation. (B, E) He is shown 11 years after the initial facelift and (C, F) 8.5 months after the second facelift with submalar implant augmentation. Figure 2. View largeDownload slide A 66-year-old male who had a facelift 11 years prior with excellent longevity in his lifting results. (A, D) His photographs from before his facelift showed a flattened midface, suggesting submalar hollowing for which he may have benefited from submalar implant augmentation at the time of his initial surgery. Eleven years later, the patient desired additional facial rejuvenation and underwent another facelift, this time with submalar implant augmentation. (B, E) He is shown 11 years after the initial facelift and (C, F) 8.5 months after the second facelift with submalar implant augmentation. William Binder last reported his experience performing submalar augmentation as a preliminary, adjunctive procedure to enhance facelift results in 56 patients in 1990.1 There have been no other studies reported in the literature examining facelift with submalar augmentation in the 28 years since. In this study, we aim to evaluate the long-term safety and efficacy of simultaneous submalar augmentation with SMAS-plication facelift. METHODS A retrospective review was performed on all consecutive patients who underwent submalar augmentation and SMAS-plication facelift in the senior author’s (R.W.H.K.) university-affiliated private practice between January 1991 and June 2017. The study was performed in accordance with the Declaration of Helsinki. Information on demographics, surgical details, complications, and patient satisfaction were reviewed. Patient satisfaction was assessed from direct questioning at their last follow-up visit and patient request for implant revision or removal. Surgical Technique Antibiotic prophylaxis covering commensal oral flora begins 1 day before surgery and continues for 7 days. The patient is marked before surgery in the upright position to demonstrate the effects of gravity. Submalar implant sizers are used to estimate the amount of volume restoration necessary. With traction on the face simulating the soft tissue redistribution with the facelift, tracings of the implants are drawn and measured to ensure symmetry. Asymmetries between the 2 sides of the face should be noted and may require different-sized implants. We prefer submalar augmentation at the start of the combined surgery, as the creation of the pocket for the implant becomes more difficult after the overlying soft tissue has been pulled taut and resuspended laterally. Additionally, elevation of the malar periosteum provides an additive effect to the facelift results, which will be discussed later. A 2 cm incision is placed slightly superior to the gingiva in the gingivobuccal sulcus at the lateral canine fossa, avoiding the parotid puncta and preserving sufficient mucosa inferiorly to permit a tension free and water-tight closure. The periosteum is incised and a subperiosteal pocket developed obliquely over the maxilla towards the zygomatic arch and over the white tendinous attachments of the masseter, using the preoperative skin markings as a guide. A curved instrument is used to avoid inadvertent injury to the overlying midface soft tissue and facial nerve, particularly over the convexity of the lateral zygoma. The zygomatic retaining ligaments may be encountered along the inferior border of the zygomatic arch and can be released.13 It is essential to create a pocket of sufficient size to permit complete unfurling of the implant and to prevent capsular contraction. Dissection over the zygoma and anterior zygomatic arch is performed blindly, but with the assistance of external manual palpation; inadequate dissection of this region may result in the medial displacement of the implant. We favor the paddle-shaped, preformed Conform Binder Submalar Implants (Implantech Associates, Inc., Ventura, CA) for submalar augmentation. The pliability and grid-backing of the implant are designed to conform readily to the underlying structures for greater adaptability to irregular bony surfaces, reduces the chance of movement, and minimizes dead space between the implant and underlying bone. The tapered margins of the implant blend with the adjacent bony structure to create an imperceptible transition between implant and recipient site.2 Sterile sizers are utilized in the subperiosteal pocket to determine the optimal size for volume restoration. The bulk of the implant is placed over the anterior maxilla, corresponding to the center of the submalar hollowing. The tapered, lateral extension of the implant rests on the zygomatic arch to provide a small amount of malar augmentation (Figure 3). If increased malar projection is not desired, the lateral extension of the implant can be trimmed so that the implant augments the medial cheek only. When the final implant size has been decided upon, its outlines are again marked on the skin surface, along with locations of the fenestrations on the implants, and the distances from the lateral canthus and ala are carefully measured to help achieve symmetry. Figure 3. View largeDownload slide The paddle-shaped submalar implant is placed in against the maxilla and zygoma, with the maximal projection medially in the center of the submalar hollowing, and the tail of the implant curves upward to rest laterally on the zygomatic arch and the tendinous insertions of the masseter. (A) The lateral extension of the implant increases malar projection slightly. If malar augmentation is not desired, this part of the implant can be trimmed. The small notch at the superior, medial edge of the implant is designed to straddle the infraorbital foramen (arrow) inferiorly. The edges of the implant are tapered to minimize visibility. (B) Position of the submalar implant (arrow) as seen from a sky view. The pliability and adaptability of the silicone elastomer allows the implant to adapt to the underlying irregular bone structures to minimize dead space and blend in with surrounding structures inconspicuously. Note: Blue sizers are used for illustration. The actual silicone implants are clear. Figure 3. View largeDownload slide The paddle-shaped submalar implant is placed in against the maxilla and zygoma, with the maximal projection medially in the center of the submalar hollowing, and the tail of the implant curves upward to rest laterally on the zygomatic arch and the tendinous insertions of the masseter. (A) The lateral extension of the implant increases malar projection slightly. If malar augmentation is not desired, this part of the implant can be trimmed. The small notch at the superior, medial edge of the implant is designed to straddle the infraorbital foramen (arrow) inferiorly. The edges of the implant are tapered to minimize visibility. (B) Position of the submalar implant (arrow) as seen from a sky view. The pliability and adaptability of the silicone elastomer allows the implant to adapt to the underlying irregular bone structures to minimize dead space and blend in with surrounding structures inconspicuously. Note: Blue sizers are used for illustration. The actual silicone implants are clear. Some patients with severe submalar hollowing that extends inferiorly into the lower cheek may require a small amount of filler injection after implant augmentation, as the submalar implant rests against the maxilla and zygoma, under the periosteum, and not in the soft tissue of the lower cheek. The submalar augmentation may accentuate progressive buccal fat atrophy that occurs with aging if the buccal volume deficiency is untreated. Two-point transcutaneous non-absorbable sutures secure the implants during the initial healing phase. A 3-0 polypropylene (Ethicon, Inc., Somerville, NJ) is passed through the external skin marking, through the soft tissue, into the subperiosteal pocket, and through the implant fenestrations superficial to deep then deep to superficial, then from the pocket back through the skin. It is important to inspect the implant once more to ensure that it lies flush against the zygoma and the lateral end is unfurled. The implants are bathed in an antibiotic solution, which is also used to irrigate the dissection pocket before and after implantation. The external skin sutures are tied over dental rolls to protect the underlying skin and covered with a transparent film dressing. Some believe that the implants should be screw fixated to the maxilla, which may minimize dead space and reduce the implant mobility. However, we have found that that when the implants are placed in a sufficiently large subperiosteal pocket we have not required rigid fixation to ensure symmetry, prevent implant migration, or minimize dead space. Even with the creation of a large subperiosteal pocket, soft tissue contraction occurs rapidly following surgery and eliminates most dead space within 48 hours.11 Furthermore, by not placing a screw in the maxilla on each side, one avoids the potential risks for cantilevered movement of the implant and communication with the maxillary sinus, which may serve as a conduit for infection during sinusitis. The intraoral incisions are closed in 2 layers using 4-0 chromic sutures. The transcutaneous bolsters are kept for 5 days, while a capsule forms around the implants to fix them in place. On removal, the exposed suture is prepped with povidone-iodine to avoid contamination of the implant, and the subperiosteal pocket as the suture is pulled through. The intraoral chromic sutures dissolve within 3 weeks. Chlorhexidine gluconate mouth rinses are used for 5 days to maintain oral hygiene. RESULTS From 1991 to 2017, 50 patients were identified who had undergone simultaneous submalar augmentation and SMAS-plication facelift. Of these patients, records for 48 patients were located. Eleven (23%) patients were male and 37 (77%) female. The mean age was 56.4 years (range, 28-73). Nine (19%) of the patients had prior facelifts. The mean and median lengths of follow up were 3.9 years and 1.25 years, respectively (range, 1 month-21 years) (Table 1). Table 1. Patient Demographics Patient Demographics Total patients 48 Age, years  Mean 56.5  Range 28-73 Gender, n (%)  Male 11 (23%)  Female 37 (77%) Ethnicity, n (%)  Caucasian 44 (92%)  Hispanic 2 (4%)  Asian-Pacific Islander 1 (2%)  African-American 1 (2%) Length of follow-up  Mean 3.9 yrs  Median 1.25 yrs  Range 1 mo-21 yrs Previous facelift, n (%) 9 (19%) Patient Demographics Total patients 48 Age, years  Mean 56.5  Range 28-73 Gender, n (%)  Male 11 (23%)  Female 37 (77%) Ethnicity, n (%)  Caucasian 44 (92%)  Hispanic 2 (4%)  Asian-Pacific Islander 1 (2%)  African-American 1 (2%) Length of follow-up  Mean 3.9 yrs  Median 1.25 yrs  Range 1 mo-21 yrs Previous facelift, n (%) 9 (19%) yrs = years, mo = month View Large Table 1. Patient Demographics Patient Demographics Total patients 48 Age, years  Mean 56.5  Range 28-73 Gender, n (%)  Male 11 (23%)  Female 37 (77%) Ethnicity, n (%)  Caucasian 44 (92%)  Hispanic 2 (4%)  Asian-Pacific Islander 1 (2%)  African-American 1 (2%) Length of follow-up  Mean 3.9 yrs  Median 1.25 yrs  Range 1 mo-21 yrs Previous facelift, n (%) 9 (19%) Patient Demographics Total patients 48 Age, years  Mean 56.5  Range 28-73 Gender, n (%)  Male 11 (23%)  Female 37 (77%) Ethnicity, n (%)  Caucasian 44 (92%)  Hispanic 2 (4%)  Asian-Pacific Islander 1 (2%)  African-American 1 (2%) Length of follow-up  Mean 3.9 yrs  Median 1.25 yrs  Range 1 mo-21 yrs Previous facelift, n (%) 9 (19%) yrs = years, mo = month View Large A total of 95 submalar implants were placed. Forty-seven of the 48 (97.9%) patients underwent bilateral submalar augmentation. One patient (2.1%) had significant unilateral submalar hollowing that required a single implant. One (2.1%) patient had malar implants placed by another surgeon that not only did the patient dislike but were also placed in an incorrect plane, resulting in implant mobility. These malar implants were exchanged for newer submalar implants placed in the proper subperiosteal plane. Of the patients who had bilateral submalar augmentation, most received medium-sized implants (63.8%), followed by large (12.7%), small (6.4%), and extra-large (2.1%) implants. Different-sized implants were used 14.9% of the time for patients with asymmetric submalar hollowing (Table 2). Table 2. Size of Implants Used Size of Implants Placement Small Medium Large Extra-large Different sizes Bilateral 3 (6.4%) 30 (63.8%) 6 (12.7%) 1 (2.1%) 7 (14.9%) Unilateral 0 0 1 (100%) 0 --- Size of Implants Placement Small Medium Large Extra-large Different sizes Bilateral 3 (6.4%) 30 (63.8%) 6 (12.7%) 1 (2.1%) 7 (14.9%) Unilateral 0 0 1 (100%) 0 --- View Large Table 2. Size of Implants Used Size of Implants Placement Small Medium Large Extra-large Different sizes Bilateral 3 (6.4%) 30 (63.8%) 6 (12.7%) 1 (2.1%) 7 (14.9%) Unilateral 0 0 1 (100%) 0 --- Size of Implants Placement Small Medium Large Extra-large Different sizes Bilateral 3 (6.4%) 30 (63.8%) 6 (12.7%) 1 (2.1%) 7 (14.9%) Unilateral 0 0 1 (100%) 0 --- View Large None of 95 (0%) implants developed an infection that required implant irrigation or removal. One (2.1%) patient presented 1 year after surgery with 10 days of mild, dull, aching pain, representing an inflammatory process mimicking infection. On examination, the intraoral incision was well healed, the implant was nonmobile, and there was no erythema, edema, fluctuance, or lymphadenopathy. The discomfort resolved with a conservative 7-day course of oral amoxicillin-clavulanate. Transient facial nerve buccal branch paresis was observed in 1 (2.1%) patient who also had an ipsilateral concomitant parotidectomy for excision of a pleomorphic adenoma at the time of facelift. The buccal branch weakness likely represented neuropraxia from the parotidectomy rather than injury during the implant placement. No other patients experienced facial nerve injury. Prolonged unilateral swelling that lasted nearly 1 year was noted with 1 (1.1%) of the implants. One (2.1%) patient reported unilateral numbness over the medial cheek that resolved within 1 month. No patients experienced permanent infraorbital hypoesthesia. None of the patients had implant migration or extrusion, hematoma, or seroma. One (2.1%) patient required a minor adjustment for an implant that developed capsular contraction. Under local anesthesia, the capsule was expanded successfully through the same transoral approach. Forty-six (95.8%) of the patients were happy with the appearance of their submalar augmentation based on in-office questioning during follow-up visits. One (2.1%) patient desired more submalar fullness, which was satisfactorily treated with hyaluronic acid filler injection. Another (2.1%) patient felt the implants were slightly too large but declined an implant exchange to a smaller size. A summary of complications is listed in Table 3 (Figures 4–6). Table 3. Complications Complications n (%) Comment Infection requiring implant removal 0 (0%) Infection requiring implant irrigation 0 (0%) Facial nerve injury 0 (0%) Transient buccal branch paresis in a patient who had undergone ipsilateral parotidectomy for the excision of a pleomorphic adenoma not counted. Infraorbital nerve hypoesthesia 1 (2.1%) Unilateral cheek numbness that fully recovered within 1 month. Prolonged swelling 1 (1.1%) Prolonged unilateral swelling that resolved nearly 1 year after surgery. Post-operative asymmetry 1 (1.1%) Capsular contracture of an implant corrected with minor adjustment Implant migration or extrusion 0 (0%) Hematoma or seroma formation 0 (0%) Overall complication rate 5.3% Complications n (%) Comment Infection requiring implant removal 0 (0%) Infection requiring implant irrigation 0 (0%) Facial nerve injury 0 (0%) Transient buccal branch paresis in a patient who had undergone ipsilateral parotidectomy for the excision of a pleomorphic adenoma not counted. Infraorbital nerve hypoesthesia 1 (2.1%) Unilateral cheek numbness that fully recovered within 1 month. Prolonged swelling 1 (1.1%) Prolonged unilateral swelling that resolved nearly 1 year after surgery. Post-operative asymmetry 1 (1.1%) Capsular contracture of an implant corrected with minor adjustment Implant migration or extrusion 0 (0%) Hematoma or seroma formation 0 (0%) Overall complication rate 5.3% View Large Table 3. Complications Complications n (%) Comment Infection requiring implant removal 0 (0%) Infection requiring implant irrigation 0 (0%) Facial nerve injury 0 (0%) Transient buccal branch paresis in a patient who had undergone ipsilateral parotidectomy for the excision of a pleomorphic adenoma not counted. Infraorbital nerve hypoesthesia 1 (2.1%) Unilateral cheek numbness that fully recovered within 1 month. Prolonged swelling 1 (1.1%) Prolonged unilateral swelling that resolved nearly 1 year after surgery. Post-operative asymmetry 1 (1.1%) Capsular contracture of an implant corrected with minor adjustment Implant migration or extrusion 0 (0%) Hematoma or seroma formation 0 (0%) Overall complication rate 5.3% Complications n (%) Comment Infection requiring implant removal 0 (0%) Infection requiring implant irrigation 0 (0%) Facial nerve injury 0 (0%) Transient buccal branch paresis in a patient who had undergone ipsilateral parotidectomy for the excision of a pleomorphic adenoma not counted. Infraorbital nerve hypoesthesia 1 (2.1%) Unilateral cheek numbness that fully recovered within 1 month. Prolonged swelling 1 (1.1%) Prolonged unilateral swelling that resolved nearly 1 year after surgery. Post-operative asymmetry 1 (1.1%) Capsular contracture of an implant corrected with minor adjustment Implant migration or extrusion 0 (0%) Hematoma or seroma formation 0 (0%) Overall complication rate 5.3% View Large Figure 4. View largeDownload slide A 65-year-old female is shown who underwent facelift with bilateral submalar augmentation, upper blepharoplasty, and perioral CO2 laser skin resurfacing. (A, C) Preoperative photographs showing pronounced submalar hollowing and slightly asymmetric zygomas. (B, D) Eight months after surgery, showing an improvement in the submalar volume loss and greater malar definition from the zygomatic extension of the submalar implant. Figure 4. View largeDownload slide A 65-year-old female is shown who underwent facelift with bilateral submalar augmentation, upper blepharoplasty, and perioral CO2 laser skin resurfacing. (A, C) Preoperative photographs showing pronounced submalar hollowing and slightly asymmetric zygomas. (B, D) Eight months after surgery, showing an improvement in the submalar volume loss and greater malar definition from the zygomatic extension of the submalar implant. Figure 5. View largeDownload slide A 55-year-old female who underwent facelift with bilateral submalar augmentation and endoscopic brow lift (A, C) before surgery and (B, D) 8 months after surgery. (E, G) Preoperative base and sky views. (F, H) Base and sky views 3.5 months after surgery. Figure 5. View largeDownload slide A 55-year-old female who underwent facelift with bilateral submalar augmentation and endoscopic brow lift (A, C) before surgery and (B, D) 8 months after surgery. (E, G) Preoperative base and sky views. (F, H) Base and sky views 3.5 months after surgery. Figure 6. View largeDownload slide A 69-year-old female who had undergone facelift, upper and lower blepharoplasty, and bilateral submalar cheek implantation. She subsequently had a full-face CO2 laser skin resurfacing 11 months after her facelift. (A, C) Before surgery and (B, D) 15 months after surgery. Figure 6. View largeDownload slide A 69-year-old female who had undergone facelift, upper and lower blepharoplasty, and bilateral submalar cheek implantation. She subsequently had a full-face CO2 laser skin resurfacing 11 months after her facelift. (A, C) Before surgery and (B, D) 15 months after surgery. DISCUSSION In this study, we have shown that submalar implant augmentation is a safe and long-lasting method of enhancing SMAS-plication facelift, with minimal complication rates (overall 5.3%) and greater than 95% patient satisfaction in 48 patients with a mean follow-up time of almost 4 years. To our knowledge, this is the largest and only study of its kind since William Binder last reported his results 28 years ago. The submalar implant is a workhorse to enhance facelift in a patient with submalar hollowing by adding midface volume and projection and facilitating a more natural vector of facial soft tissues redraping during soft tissue suspension. Submalar augmentation provides a consistent and effective means of midface volume restoration, as reflected by the 95.7% of our patients who were satisfied with their submalar augmentation. Although 2 (4.3%) patients were not completely happy with the size of their submalar implants, both declined revision surgery. Inherent asymmetries between the 2 sides of the face can be addressed at the time of submalar augmentation, as seen in 14.9% of our patients who received different-sized implants. As with the selection of any facial implant, open communication between the surgeon and patient regarding his/her expectations and aesthetic goals is essential for maximizing patient satisfaction and aesthetic results. Computer imaging and asking patients to provide images of individuals with their desired facial contour may be helpful for the surgeon in selecting the appropriate implant size. Patient-specific implants using computed tomography is now commercially available, but is quite expensive.14 Alternatively, preformed silicone submalar implants can be carved to suit each individual’s particular needs. Facial implants provide an aesthetically desirable dimensionality to the midface that injected fat and fillers deposited as amorphous aliquots, and at the mercy of pressure from the overlying tissue, cannot.11 Autologous fat transfer involves potential donor site morbidity, does not augment solitary facial regions well, suffers from variable resorption, and may hypertrophy with weight gain.12,15 “Filler fatigue” in patients can develop with the multiple, repeated series of injections that are often necessary to achieve and maintain equivalent volume attained with submalar implants. Compared to submalar fat and filler injections, the initial cost (surgeon’s fee, anesthesia time, and material cost) for submalar implants is quickly offset by the continuing expense of multiple injections and office visits over the years.16 Our longest patient, with follow-up of 21 years, saved thousands of dollars that otherwise would have been spent on repetitive injections. For patients concerned about the “invasiveness” of implant placement, when a surgical procedure such as a facelift is planned that is already “invasive,” it is reasonable to place permanent implants at the same time. The ideal implant is biocompatible, inert, non-carcinogenic, anatomically molded, and does not induce a foreign-body reaction.5 Implant-grade solid silicone satisfies all these requirements.17 Alloplastic implants provide a 3-dimensional shape designed to permanently restore volume and enhance the submalar triangle to create a more natural and youthful appearance. Its smoothness and flexibility allow for ease of manipulation and insertion. Several days after implantation, a capsule forms around the implant, helping to secure it in place without the need for screw fixation. Unlike fat or filler injections, submalar implants can be repositioned or removed because there is minimal inflammation and no bio-integration. While mandibular bony erosion with chin implants had been reported, midface bony erosion has not been observed, which is thought to be due, in part, to the large surface contact area relative to the bone, relatively laxity of the midface soft tissue, and minimal muscular pull against the bone in this region.6,9 The advantages of submalar implants alone for midface hollowing and effects of rhytidectomy with and without subperiosteal dissection on the midface soft tissue have been well documented. Here, we are adding both together to get an enhanced result. Although midface volume restoration is the primary objective of submalar augmentation, subperiosteal dissection over the zygoma and release of the medial zygomatic retaining ligaments during placement of submalar implants enhance SMAS-plication facelift outcomes by allowing a higher degree of mobilization of a thicker composite musculo-cutaneo-periosteal flap with soft tissue suspension. This concept is analogous to cutting the arcus marginalis when doing an endoscopic forehead lift. Because submalar augmentation and SMAS-plication facelift are performed in different surgical planes, performing both surgeries at the same setting does not require a change in surgical technique and does not adversely affect the normal healing process. The periosteal elevation used for submalar implant placement has a similar effect as a subperiosteal lift. Submalar implants that are placed in this deep layer with thick overlying tissue rarely become exposed or extrude.2 In our series, long-lasting SMAS soft tissue suspension and midface volume restoration were achieved for all patients with submalar augmentation with SMAS-plication facelift, without the need for a deep plane technique, as the results attest. Submalar augmentation is a safe procedure associated with minimal risks. Binder reported an overall 10.8% complication rate in his series of 56 patients with combined submalar augmentation and facelift (1.8% implant infection, 3.6% transient infraorbital hypoesthesia, 5.4% postoperative asymmetries that required implant adjustment).1 In our series of 48 patients, we observed a slightly lower overall complication rate of 5.3% (2.1% transient infraorbital hypoesthesia, 2.1% postoperative asymmetries that required implant adjustment, 1.1% prolonged swelling, 0% implant infection). In Hopping’s review of 100 patients who received malar and chin augmentation with facelift, 8 of 300 (2.7%) implants became infected, and 6 necessitated removal.18 Rubin and Yaremchuck observed a 1.2% infection rate in 404 silicone malar implants.19 Binder saw a similar infection rate of 1.3% in 78 patients with submalar implants alone, and 1.8% in 56 patients with combined submalar augmentation and facelift.1,6 Our infection rate was 0%, as no patients experienced an implant infection that required implant irrigation or removal. Excess fluid accumulation in the dissection pocket may contribute to higher infection rates by serving as a nidus of infection, and may occur with inadequate hemostasis or implant mobility secondary to placement of the implant in the wrong plane. Open communication with the maxillary sinus may also serve as a possible conduit for infection.9 Although the role of biofilms in implant infection has been a well-studied subject in orthopedics, its role in facial implant infection remains to be elucidated.20 In the meanwhile, early detection of the signs of infection, which include pain, erythema, edema, purulence, and drainage, and timely treatment are imperative for optimal surgical outcomes. Surgery in the oral cavity is inherently nonsterile. Due to the risk of intraoral bacteria transference, sterile technique, perioperative antibiotics, irrigation with an antibiotic solution during surgery, and chlorhexidine mouth rinses following surgery are our choice to minimize the risk of infection. The process of capsular fibrosis is essential for maintaining the implants in their proper position against the facial skeleton after several days of temporary 2-point suture fixation without the need for screw fixation.9,21 However, excessive capsular contraction may distort the silicone implant, resulting in asymmetry. Binder reported that 5 of 78 (6.4%) patients with submalar implants developed asymmetries that required minor revisions.6 In our series, 94 of 95 (98.9%) implants had no issues with malposition or distortion, and only 1 implant (1.1%) experienced distortion due to a capsular contraction, which was corrected with a minor adjustment under local anesthesia. The exact etiology of capsular contraction remains unclear but may be multifactorial. We have found that it is essential to create a large enough subperiosteal pocket for the implant to prevent capsular contraction. Prolonged unilateral swelling that was not significant enough to warrant implant exchange or removal was seen in 1 (2.1%) of our patients. Swelling from the subperiosteal dissection can be expected and usually resolves within 8-10 weeks. Inadequate hemostasis or placement of the implant in an incorrect plane might contribute to prolonged swelling. While it is important for the physician to counsel the patient as the swelling subsides, one must also be vigilant for potential signs of infection, which can also present with localized edema. Due to the proximity of the infraorbital nerve to the dissection pocket, its inadvertent injury may occur during periosteal elevation. Binder reported transient upper lip numbness in 6.4% of his patients who had submalar implants alone.7 In our series, 1 (2.1%) patient experienced transient upper lip numbness that resolved within a month. Familiarity with the location of the infraorbital foramen within the canine fossa, typically 8 mm inferior to the infraorbital rim and directly above the second premolar, is necessary for avoiding inadvertent injury to its contents.22 Given the inferior placement of the submalar implant on the maxilla, full circumferential exposure of the infraorbital nerve is unnecessary. Making of the gingivobuccal incision lateral to the maxillary canine can also help avoid unnecessary dissection in the vicinity of the nerve. Although direct injury to the infraorbital nerve is uncommon, tension on the nerve may result in neuropraxia, resulting in temporary numbness that usually resolves within days to weeks. Prolonged numbness over the malar eminence is expected, because the zygomaticofacial nerve is sacrificed during implant placement, as the implant is placed directly over the nerve’s foramen, and patients should be counseled on this. Although no patients experienced facial nerve injuries related to implant placement in our study, facial nerve injury may occur with inadvertent puncture through the overlying midface soft tissue during subperiosteal elevation. This serious complication can be avoided by staying on bone during the periosteal elevation, particularly laterally over the zygomatic arch, and through the use of broad, curved, and tapered instruments. Limitation of this study includes the retrospective nature of the review, subjectivity of patient satisfaction, and lack of a comparative control group. Validated patient satisfaction scales have only recently become widely used. However, this study goes back 27 years when there was no agreed-upon standardized instrument to measure patient satisfaction. Instead, we relied on our long-term in-person patient satisfaction questioning in a large group of subjects with extended follow-up and low revision rate (2.1%). Future prospective studies may benefit from using currently available patient-reported outcome measures, such as Face Q.23 At present, a comparison of patients with facelift alone to those who had submalar augmentation with facelift would not provide meaningful information. Preoperative and postoperative measurements can vary drastically, as the degree of midface augmentation is affected by the size of the implant used, the size and symmetry of the underlying bony structure, and the variable amount of soft tissue present. Same-patient, half-face studies with and without submalar implant augmentation in individuals without bony and soft tissue asymmetries would theoretically provide more meaningful measurements, but are indeed not feasible or desirable, especially if you are the patient. Now that we have newly validated patient satisfaction metrics, studies going forward should include them. CONCLUSIONS Techniques that offer only soft tissue suspension but not volume restoration in individuals with submalar hollowing may result in a skeletonized appearance after surgery. Modern facial rejuvenation emphasizes both soft tissue re-suspension and volume restoration to achieve a more youthful and natural appearance. For patients with submalar hollowing who are undergoing SMAS-plication facelift for facial rejuvenation, permanent submalar augmentation may be a viable alternative to repeated fat or filler injection. When performed as the first part of the combined procedure, the subperiosteal elevation and release of zygomatic retaining ligaments during submalar augmentation, analogous to cutting the arcus marginalis during a brow lift, enhance facelift results by allowing mobilization of a thicker composite flap. Because of the deep subperiosteal release and implant volume added, enduring midface volume restoration and soft tissue suspension can be achieved with submalar augmentation and SMAS-plication facelift alone, without the need for deep-plane or subperiosteal rhytidectomy techniques. In this study, we showed that submalar implant augmentation could be safely and effectively performed in conjunction with SMAS-plication facelift to achieve a synergistic revitalization of the midface. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Binder WJ . Submalar augmentation: a procedure to enhance rhytidectomy . Ann Plast Surg . 1990 ; 24 ( 3 ): 200 - 212 . Google Scholar CrossRef Search ADS PubMed 2. Binder WJ , Moelleken , Tobias GW . Aesthetic facial implants . In: Facial Plastic & Reconstructive Surgery . 2nd ed . Stuttgart, Germany : Thieme ; 2006 . Google Scholar CrossRef Search ADS 3. Mendelson BC , Hartley W , Scott M , McNab A , Granzow JW . Age-related changes of the orbit and midcheek and the implications for facial rejuvenation . Aesthetic Plast Surg . 2007 ; 31 ( 5 ): 419 - 423 . Google Scholar CrossRef Search ADS PubMed 4. Hamra ST . A study of the long-term effect of malar fat repositioning in face lift surgery: short-term success but long-term failure . Plast Reconstr Surg . 2002 ; 110 ( 3 ): 940 - 951 ; discussion 952–959. Google Scholar CrossRef Search ADS PubMed 5. González-Ulloa M . Building out the malar prominences as an addition to rhytidectomy . Plast Reconstr Surg . 1974 ; 53 ( 3 ): 293 - 296 . Google Scholar CrossRef Search ADS PubMed 6. Binder WJ . Submalar augmentation. An alternative to face-lift surgery . Arch Otolaryngol Head Neck Surg . 1989 ; 115 ( 7 ): 797 - 801 . Google Scholar CrossRef Search ADS PubMed 7. Terino EO . Alloplastic facial contouring by zonal principles of skeletal anatomy . Clin Plast Surg . 1992 ; 19 ( 2 ): 487 - 510 . Google Scholar PubMed 8. Binder WJ , Schoenrock LD , Terino EO . Augmentation of the malar-submalar/midface . Facial Plast Surg Clin North Am . 1994 ; 2 ( 3 ): 265 - 283 . 9. Whitaker LA . Aesthetic augmentation of the malar- midface structures . Plast Reconstr Surg . 1987 ; 80 ( 3 ): 337 - 346 . Google Scholar CrossRef Search ADS PubMed 10. ASPS National Clearinghouse of Plastic Surgery Procedural Statistics . 2017 Plastic Surgery Statistics Report . https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf. Accessed May 9, 2018. 11. Binder WJ , Azizzadeh B . Malar and submalar augmentation . Facial Plast Surg Clin North Am . 2008 ; 16 ( 1 ): 11 - 32 , v. Google Scholar CrossRef Search ADS PubMed 12. Lam SM . The potential of autologous fat transfer as a valuable tool for cosmetic and reconstructive purposes: ackowledged risks, limitations, and benefits . JAMA Facial Plast Surg . 2018 Mar 29. doi: https://doi.org/10.1001/jamafacial.2018.0126 . [Epub ahead of print] 13. Furnas DW . The retaining ligaments of the cheek . Plast Reconstr Surg . 1989 ; 83 ( 1 ): 11 - 16 . Google Scholar CrossRef Search ADS PubMed 14. Binder WJ , Bloom DC . The use of custom-designed midfacial and submalar implants in the treatment of facial wasting syndrome . Arch Facial Plast Surg . 2004 ; 6 ( 6 ): 394 - 397 . Google Scholar CrossRef Search ADS PubMed 15. Krastev TK , Beugels J , Hommes J , Piatkowski A , Mathijssen I , van der Hulst R . Efficacy and safety of autologous fat transfer in facial reconstructive surgery: a systematic review and meta-analysis . JAMA Facial Plast Surg . 2018 Mar 29. doi: https://doi.org/10.1001/jamafacial.2018.0102 . [Epub ahead of print] 16. Kridel RWH , Patel S . Cheek and chin implants to enhance facelift results . Facial Plast Surg . 2017 ; 33 ( 3 ): 279 - 284 . Google Scholar CrossRef Search ADS PubMed 17. Constantinides MS , Galli SK , Miller PJ , Adamson PA . Malar, submalar, and midfacial implants . Facial Plast Surg . 2000 ; 16 ( 1 ): 35 - 44 . Google Scholar CrossRef Search ADS PubMed 18. Hopping SB , Joshi AS , Tanna N , Janjanin S . Volumetric facelift: evaluation of rhytidectomy with alloplastic augmentation . Ann Otol Rhinol Laryngol . 2010 ; 119 ( 3 ): 174 - 180 . Google Scholar CrossRef Search ADS PubMed 19. Rubin JP , Yaremchuk MJ . Complications and toxicities of implantable biomaterials used in facial reconstructive and aesthetic surgery: a comprehensive review of the literature . Plast Reconstr Surg . 1997 ; 100 ( 5 ): 1336 - 1353 . Google Scholar CrossRef Search ADS PubMed 20. Walker TJ , Toriumi DM . Analysis of facial implants for bacterial biofilm formation using scanning electron microscopy . JAMA Facial Plast Surg . 2016 ; 18 ( 4 ): 299 - 304 . Google Scholar CrossRef Search ADS PubMed 21. Soares DJ , Silver WE . Midface skeletal enhancement . Facial Plast Surg Clin North Am . 2015 ; 23 ( 2 ): 185 - 193 . Google Scholar CrossRef Search ADS PubMed 22. Raschke R , Hazani R , Yaremchuk MJ . Identifying a safe zone for midface augmentation using anatomic landmarks for the infraorbital foramen . Aesthet Surg J . 2013 ; 33 ( 1 ): 13 - 18 . Google Scholar CrossRef Search ADS PubMed 23. Klassen AF , Cano SJ , Scott A , Snell L , Pusic AL . Measuring patient-reported outcomes in facial aesthetic patients: development of the FACE-Q . Facial Plast Surg . 2010 ; 26 ( 4 ): 303 - 309 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Aesthetic Surgery JournalOxford University Press

Published: May 28, 2018

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