Effect of altering the facial skeleton

When you look at a person, your attention inevitably focuses on his or her eyes, lips, eyebrows, and hair. Yet, these are merely the adornments of the underlying facial framework. What determines the full extent of a person’s facial physical attractiveness is the unique volumetric contour created by their underlying skeletal architecture.

The skin is the “canvas of the face”. When distributed over the facial framework in a smooth and attractively contoured manner, it presents a youthful and aesthetically pleasing appearance. As years go by, this canvas becomes coarse and wrinkled, and the underlying soft tissues and in some areas bone atrophy according to a genetically programmed cellular process of aging. Faces then take on the stigmata of advancing age.

When a surgeon strategically augments the underlying bony architecture of the aging face, a new and dramatic visage can be achieved. Although persons are clearly identifiable by their individuality displayed by their adorning features, i.e., eyes, lips, nose and eyebrows; a youthful and attractive appearance can be achieved with the purposeful alteration of the contours of their underlying bony architecture.

Therefore, balance in facial bone structure is what gives the form of the face its maximum attractiveness perceived as beauty.

Interrelationships of the facial promontories

These are three major promontories of volume and mass. In order of importance, they are the nose, the two malar zygomatic eminences, and the chin–jaw line (Fig. 78.1). The supraorbital ridges, constitute a fourth promontory, which are of lesser significance (and will not be discussed in this chapter).

Fig. 78.1 Artist’s rendering of facial architecture illustrating major promontories of mass and volume: the nose, malar-midface and mandible jawline.

By altering the interrelationships of the three major prominentories, a surgeon can uniquely create or restore facial harmony, balance, and beauty. By mathematical law, the diminution or enhancement of any one of the three promontories directly and inversely affects the aesthetic importance of the others. Facial aesthetics is the art and science of achieving beauty by creating a balance in all three elements of facial skeletal anatomy. One important method by which the aesthetic surgeon can accomplish this balance is by properly employing alloplastic implants (Fig. 78.2). Recent advances in applied alloplastic implant technology now make it possible for the surgeon to make subtle or dramatic changes in the facial promontories with ease and predictability.

Fig. 78.2 Example of a 36-year-old male with disproportion and imbalance of malar mid face to the mandibular jaw line aesthetic segment, showing an improvement in facial harmony by augmenting the central mentum, mandibular angles, and malar region.

Over the past decades, aesthetic surgery has evolved dramatically. Surgical procedures have gone from simple skin-tightening techniques to removal or addition of subcutaneous fat, to lifting or plication of the submuscular aponeurotic system (SMAS) as well as suspension techniques of the brow and midface and more recently the introduction of a vast array of injectable fillers including autologous fat.

The restructuring of all these layers still has many limitations. Patients who display round, full, fleshy facial contours with an abundance of subcutaneous fat rarely appear beautiful by contemporary standards. Conversely, there are lean-faced individuals with a tendency to a longer facial contour with inadequate skeletal promontories in the malar or mandibular regions or both. Both extremes of these facial types, as well as innumerable patients who have combinations of volume deficiencies in varying anatomic locations can be significantly improved by rearranging the balance of their skeletal promontories with targeted alloplastic augmentation techniques. Furthermore, contour surgery of the facial skeleton should also be complemented by a wide variety of other sound coordinated facial procedures (Fig. 78.3).

Fig. 78.3 A 56-year-old female who demonstrates the significant benefits from upper midface suspension, malar-submalar augmentation, and rhytidectomy techniques.

Zonal anatomy of the malar and premandible regions

That part of the facial skeleton which, when appropriately augmented, produces an aesthetic change in the contour of midface can be called the “malar-midface space”. To determine the most aesthetic augmentation to select for that space, it is useful to partition the midface region into five distinct anatomic zones (Terino, 1992) (Fig. 78.4). By understanding these five zones and their interrelationships, the surgeon can vary cheek and/or midface shapes to accommodate each unique patient.

Fig. 78.4 Anatomic facial contour zones of the midface.

Summary of zones

Zone 1, the largest area, includes the major portion of the malar bone and the first third of the zygomatic arch. Augmentation of this entire zone produces the greatest volumetric filling of the cheek and also maximizes the projection of the maxillary eminence (Fig. 78.5).

Zone 2, the second most important site, overlies the middle third of the zygomatic arch. Enhancement of this zone along with zone 1 increases accentuation of the cheek bone laterally, giving a broader dimension to the upper third of the face, and creating a high, arched appearance. This change of contour is particularly useful for individuals with a narrow upper face or a long-face syndrome. When, however, zones 1 and 2 are augmented in excess, an abnormal and unattractive protuberance may result (Fig. 78.6).

Zone 3 is the paranasal area, which lies medial to the infraorbital foramen and nerve. A line drawn vertically down from the infraorbital foramen marks the medial extent of the usual dissection for malar augmentation. This line also represents the lateral border of zone 3. When paranasal augmentation in zone 3 occurs, medial fullness of the face is created, often in the upper nasolabial area, which can be unattractive or can produce a “chipmunk-cheek” effect. The skin and subcutaneous tissues are thin in that region; consequently, any implant placed there must be carefully sculptured and tapered. Augmentation of zone 3 is indicated for certain reconstructive purposes, following trauma or other heredity deficiencies (Fig. 78.7).

Zone 4 overlies the posterior third of the zygomatic arch. Augmentation in this area is never needed as it would produce an unnatural appearance. Moreover, dissection here may be dangerous, since it is very possible to injure the zygomaticotemporal or orbicularis oculi branches of the facial nerve, and even the capsule of the temporomandibular joint. Infrequently, deformities have been observed that resulted from operations in this area.

Zone 5, the submalar zone or “submalar triangle,” is bounded posteriorly by the tendonous surface of the masseter muscle, and anteriorly by the canine fossa region of the maxilla. The superior boundary of zone 5 is the inferior margin of the malar bone, which constitutes the first two thirds of the zygomatic arch. The medial extent of the submalar space ends at the lateral border of the nasolabial mound and sulcus. Its anterior limit is bounded by the inferomedial portion of the roof of the entire malar-midface space. It contains the overlying facial musculature, fat, skin, and subcutaneous of the midface region. The inferior limit is selected by the surgeon in the natural dissection plane that separates the masseter from the overlying facial musculature according to the desired configuration of midface fullness selected by the patient. This equates to creating certain breast shape by choosing the lower limit of the submammary sulcus.

Fig. 78.5 Malar hypoplasia and the resulting malar-midface contour from Zone 1, 2 malar volume enhancement.

Fig. 78.6 A postop appearance that is too strong and skeletal looking, due to the wrong implant size, shape and position. Postop view shows significant improvement by using a generous malar shell in zone 1 and submalar, zone 5.

Fig. 78.7 Suborbital volume deficiency and placement of tear trough implants.

In order to orchestrate aesthetic alloplastic augmentation, an understanding of facial types is necessary. Facial type 1 consists of a deficiency in the upper malar bone segment of the malar/midface. This specific contour weakness encompasses zones 1 and 2. Augmentation of zone 1 creates upper cheek fullness that pleasingly simulates bony contour. When a large implant is used to augment zone 2, as well as zone 1, widening of the upper midface occurs which shortens the appearance of a long and narrow face.

The transverse dimensions of the malar bone in the upper malar/midface measure from 4.5 to 6.5 cm from the infraorbital foramen to the posterior third of the zygomatic arch. Vertically, there is, on average, 3.0 to 4.0 cm in distance from the lateral canthus to the inferior margin of the malar bone. Over-accentuation of zone 1 in females may result in a masculine, sharp, angular, harsh or skeletal appearance.

A type 2 facial aesthetic deficiency consists of a soft tissue contour depression specifically in the lower aspect of the midfacial aesthetic unit called the submalar zone 5 (SM5) or submalar “triangle”. This deficiency resides over the masseter tendon and the canine fossa lying under the inferior border of the malar bone and zygomatic arch. A large malar shell implanted over the inferior aspect of the malar bone in zone 1 and extending into the submalar space below the border of the malar bone creates the illusion of a round, full “apple cheek” in females.

The soft tissues overlying the skeleton of the midface, malar, and submalar area undergo environmentally influenced predetermined genetic-based atrophy. A modest 3 mm or 4 mm implant thickness can augment and rejuvenate an aging face.

Augmenting the submalar region creates the youthful appearance of soft tissue fullness in the midface as well as the illusion of a larger malar bone. This is especially useful in the aging face where atrophy and the midface soft tissue descent create a more pronounced nasolabial fold. The inferior limit of the submalar space is variably created by dissecting the soft tissue roof (buccinator, zygomaticus muscles, and SMAS) from the masseter tendon. This is similar histologically to the inframammary sulcus created during breast augmentation. As the SM5 space is dissected and augmented in a more inferior direction, a larger, rounder cheek contour is produced which simulates both bony and soft tissue fullness. This type of midface contour is exemplified in the images of actresses Bo Derek and Linda Evans, or today’s Renee Zellweger and Angelina Jolie.

By definition, a comprehensive augmentation of the entire malar-midface unit may require an implant shell with maximal transverse dimensions of 5.5 cm across and 4.5 cm vertically. A type 2 face has adequate malar bone prominence, but is deficient in submalar soft tissue volume. This creates a flat, older, midface contour. This frequently occurs in the aging face of both males and females. In a young individual with strongly defined cheekbones and yet deficiencies in the midface soft tissues, a submalar augmentation produces aesthetic softness, and adds youthful fullness to the face. Some people feel strongly that a submalar implant can lift the nasolabial sulcus and give the illusion of facial tightening that will postpone the perceived need for rhytidectomy. The authors have not observed this occurrence. The authors favor volume filling of the midface just posterior to the nasolabial mound, in order to de-emphasize the appearance of fullness and simultaneously correct the soft tissue volume deficiency in the midface.

A type 3 facial aesthetic deficiency in a face consists of a very strong malar zygomatic superstructure and a very sunken submalar infrastructure. Such faces often have thin skin and subcutaneous support requiring a generous submalar augmentation with a projecting implant thickness (5–8 mm). This facial type occurs with aging, as well as from heredity (Fig. 78.8). The appearance is that of an emaciated, drawn, haggard and even sick countenance. This can result from soft tissue disease states such as Romberg’s hemi-atrophy and HIV lipodystrophy. The remedy, for any etiology, is the same: a generous volume filling of the submalar zone 5 (SM5) (Fig. 78.9).

Fig. 78.8 Submalar zone 5 is anatomically below the lower border of the malar bone. It may be volume deficient either by hereditary or from aging atrophy. An appropriate submalar implant placement provides excellent aesthetic improvement.

Fig. 78.9 Fat atrophy occurs universally with aging face. This can produce a sunken, tired, older look. When there is adequate malar bone prominence in a type 2 or type 3 face, a large malar shell placed in the submalar region (SM5) restores a youthful fullness to the face.

A type 4 facial type consists of extreme volume deficiency in both malar zones 1 and 2 and the submalar zone 5 (SM5) regions and may also include the suborbital and paranasal zone 3 areas. It is more common in men than in women. It is identified by a “flat face” appearance. It also has been described as the “polar bear” syndrome because of a suborbital skeletal deficiency, which contributes to a proptotic, bulging appearance of the globe of the eye. Due to bony deficiency of the infraorbital region, a downward or vertical descent of the lower eyelid may result in scleral show.

A comprehensive shell implant which fills the medial tear trough, the suborbital rim, and the upper malar zones, improves this aesthetic imbalance significantly. For some patients a large shell implant to fill malar zones 1 and 2 as well as submalar zone 5 is all that is necessary. Theoretically, the shell implant may also add support and elevate the eyelid into a more attractive horizontal position. However, lateral canthopexy techniques may be necessary to benefit patients with this facial type.

Type 5 aesthetic facial deficiency exists as a weakness of facial structure in the suborbital “tear trough” region. This creates a tired and “hollow” appearance around the eyes, especially in the lower orbital region. There may also be a tendency for the eyeball itself to look proptotic due to the “negative vector” orbit (Fig. 78.10).

Fig. 78.10 Before and after pictures of a patient with a type 4 face demonstrating the improvement of an extreme volume deficiency of the entire maxilla and a “negative” vector suborbital bony rim using a comprehensive extended tear trough–malar shell. This helps to correct a “flat or dish-face” appearance.

Volume deficiency in this area is especially viewed to be unattractive in females. A uniquely designed tear trough implant extends from the medial canthus to the lateral orbital malar rim, considerably improves this deficiency. Fat grafting along the inferior orbital rim has been considered by some to be advantageous but by most to be highly risky. In general, the authors’ experience is that all autologous soft tissue grafting in this region manifests unpredictable shrinkage and may produce irregularities or result in negligible improvement with added risks.

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