Intranasal Surgical Approach for Malar Alloplastic Augmentation

Transcription

1 INTERNATIONAL CONTRIBUTION Facial Surgery Intranasal Surgical Approach for Malar Alloplastic Augmentation Jose Abel de la Peña-Salcedo, MD; Miguel Angel Soto-Miranda, MD; and Jose Fernando Lopez-Salguero, MD The concept of beauty has changed with the evolution of humankind. The depictions of the Renaissance artists show the ideal face as rounded and chubby, whereas in the modern era, the ideal features are angular and bold. Likewise, plastic surgeons are now aware of the anatomic changes brought about as the face ages; consequently, much attention has been paid in recent years to the loss of volume that occurs with the passage of the time. For decades, plastic surgeons have been seeking techniques that allow them to restore, rejuvenate, and restructure the face. The era of alloplastic malar augmentation began in 1974 when Dr. González-Ulloa published the first attempt to enhance the malar area with a silicone prosthesis. He entered through a rhytidectomy incision, augmented only the malar platform, and did not dissect the subperiosteal pocket. 1 The technique has evolved over time, through the research of Hinderer, 2 Whitaker, 3 Mladick, 4 Wilkinson, 5 Aesthetic Surgery Journal 32(1) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journalspermissions.nav DOI: / X Abstract Background: Alloplastic malar augmentation is becoming an increasingly common procedure for enhancement of the midface and an adjunct method of improving the effects of other rejuvenation procedures. Objectives: The authors present a new surgical approach for placement of malar implants by means of an intranasal incision, which they believe has several advantages over traditional techniques. They also propose a new classification for regions of the midface to assist in augmentation planning. Methods: Between 1990 and 2010, the authors treated 20 patients with an intranasal approach for alloplastic malar augmentation. Patients were preoperatively divided into three groups: Type 1 included those with adequate nostril opening, including good elasticity of the internal nasal mucosa, allowing a good exposure of the piriform aperture through the nasal speculum; Type 2a included those with inadequate nostril opening; and Type 2b included those who required an alar base correction. Implants were selected according to these classifications and placed with the authors technique. Results: Of the 20 patients treated, 18 were female and two were male. Ages ranged from 15 to 65 years. Average follow-up was 10 years, and all patients experienced favorable results. There were no major complications, no nerve or vascular supply compromise, and no cases of implant malposition. One patient requested removal of the implant at one year postoperatively despite her good postoperative outcome; overall patient satisfaction was 95%. Conclusions: The intranasal approach for alloplastic malar augmentation has shown good results for midface enhancement in the authors hands. In this patient series, results showed excellent overall patient satisfaction and a very low (nearly 0%) complication rate. Level of Evidence: 5. Keywords cheek implant, malar augmentation, midface enhancement, alloplastic implants, facial surgery Accepted for publication March 2, Ivy, 6 Yaremchuck, 7,8 Wellisz, 9-12 and Flowers. 13,14 Epker 15 published the largest series of malar augmentations in the surgical literature. Terino also has documented the excellent results that are possible with this technique. He divided the malar area into five subregions and classified patients into one of six groups based on their deficiencies. These algorithms assist surgeons in deciding which areas to augment and selecting an appropriate design for the malar implant From the Institute for Plastic Surgery, Mexico City, Mexico. Corresponding Author: Dr. Jose Abel de la Peña-Salcedo, Vialidad de la Barranca S/N, Huixquilucan, Estado de Mexico. abeldelapena@plasticsurgery.com.mx

2 28 Aesthetic Surgery Journal 32(1) This direct vision avoids any damage to the small branches of the facial nerve (which can be identified by direct vision or with a nerve stimulator and thus protected). No sutures are required for closure; once the implant is adapted to the malar bone, its position will be stable. 2 Methods Figure 1. Zones of the midface. Zone 1: The malar area, encompassing the anterior surface of the maxillary bone and the malar bone itself, as well as the first two-thirds of the zygomatic arch. Zone 2: The paranasal area, encompassing the area just next to the piriform aperture. Zone 3: The submalar area, which is the inferior continuation of the malar area (Zone 1). Note that Zone 1 does not include the infraorbital foramen, thus avoiding any injury during augmentation of this zone. Currently, there are five accepted approaches for malar augmentation: intraoral, transpalpebral, transconjunctival, transcoronal, and through a rhytidectomy incision. 19 The intraoral approach is the most frequently utilized. With this technique, the surgeon enters through an upper sulcus mucosal incision, divides and retracts the muscles to gain exposure to the anterior buttress of the maxilla just above the canine tooth, and dissects a subperiosteal pocket for implant insertion. 19 In the transpalpebral approach, an incision is made 3 to 4 mm beneath the ciliary border, with dissection of a skin-muscle flap on the lower orbital bony margin and penetration of the suborbicularis oculi fat (SOOF) layer in the lateral aspect of the orbit down to the bone. 10 To prevent ectropion, the distension of skin in the lower lid that occurs due to the greater prominence of the malar region must be considered when performing excision. 2 In the rhytidectomy approach, the pocket is dissected after a rhytidectomy flap has been raised in the usual way. Through the soft tissues over the lateral aspect of the malar bone at the junction with the zygomatic arch, a subperiosteal pocket is dissected easily and in an area where no major facial nerve branches are endangered. 19 Between 1990 and 2010, we treated 20 patients who presented for alloplastic malar augmentation with our intranasal approach. Preoperatively, we classified patients into one of three groups and described their anatomy according to one of three facial zones. Although the previously-published Terino classification systems reflect the historical evolution of the augmentation technique and have proven useful in the past, we have found these classifications to be somewhat confusing and therefore propose the following alternative algorithms. Patient Classification Type 1: Patients with adequate nostril opening, including good elasticity of the internal nasal mucosa that allows for good exposure of the piriform aperture through the nasal speculum Type 2a: Patients with inadequate nostril opening Type 2b: Patients who require alar base correction Facial Anatomy Classification (Figure 1) Zone 1: The malar area, encompassing the anterior surface of the maxillary bone and the malar bone itself, as well as the first two-thirds of the zygomatic arch Zone 2: The paranasal area, encompassing the area just next to the piriform aperture Zone 3: The submalar area, which is the inferior continuation of the malar area (Zone 1) We then selected one of three implant types (which differ only in terms of projection) to augment the areas in accordance with each patient s preoperative classification (Figure 2; Table 1). Zone 1 (malar) and Zone 2 (paranasal) can be augmented separately, but Zone 3 (submalar) should always be augmented with Zone 1. We rarely augmented the part of Zone 1 above the zygomatic arch because this maneuver widens the transverse diameter of the midface, which is a modification rarely needed in our specific ethnic population. It is our preference to carve the implants from a silicone rubber block, so they can be customized to fit each patient s individual anatomy. Nonetheless, it is also possible to utilize a preformed implant and finely carve it to the desired final shape. If the latter method is selected, the

3 de la Peña-Salcedo et al 29 Figure 2. Configuration of midface implants: red (malar, Zone 1), white (malar-submalar unit, Zone 1 and Zone 3), black (paranasal, Zone 2). (A) Frontal and (B) oblique views. Note that the posterior surface of the implant should have the exact concave form to fit with the convex bone platform. Table 1. Facial Zone Classifications With Corresponding Implants implant should be carved into the required tridimensional form; it is particularly important to pay specific attention to the posterior surface of the implant, which must fit exactly with the convex surface of the bone platform. When augmenting Zone 2, we always inserted a separated implant (Figures 1-3). Surgical Technique Major Dimension Minor Dimension Projection Malar implant 60 mm 18 mm 4 mm, 6 mm, 8 mm Paranasal implant 15 mm 10 mm 3 mm, 5 mm, 7 mm Malar-submalar implant 60 mm 28 mm 4 mm, 6 mm, 8 mm Note that the implant should be customized exactly in every zone and every patient and should be carved in a tridimensional manner to fit perfectly to the bone platform. Preoperative markings were made the morning of the surgery. The patient was placed in a supine position on the operating table, and general anesthesia was administered. Local anesthesia was also generously infiltrated into the tissues (lidocaine 0.2% concentration with an epinephrine concentration of 1:500,000) to help provide a nearly bloodless field (Figure 3A). The customized implants, which were dissected or carved intraoperatively, were placed in a rifampicin solution until the pocket was ready for implant insertion. For patients in the Type 1 group (those with good nostril opening), a 2-cm vertical incision was made in the nasal mucosa with a number 15 blade, at the base of the piriform aperture at the edge of the ascending process of the maxillary bone (Figure 3B). The incision continued until the bone was reached and a cuff of periosteum had been raised. Then, we utilized several dissectors to create a subperiosteal pocket, which extended to a specific length decided preoperatively based on the patient s anatomy. The whole pocket was dissected subperiosteally to avoid any risk of injury to the soft tissue structures. External manual palpation over the malar region facilitated a precise dissection of the malar space beneath the external markings on the midfacial skin (Figure 3). It was essential to search for the emergence of the infraorbital vessels and nerves so as to avoid any injury; they were protected with a retractor to prevent inadvertent sliding of the periosteal elevator. At this point, the implants were removed from their soaking solution and carved, to achieve the final desired shape. Once the pocket was dissected, hemostasis verified, and implant carving finalized, we inserted the implant (Figure 3C) with a no-touch technique by utilizing a clamp. The implant was inserted as gently and atraumatically as possible (Figure 3D-F), and finger manipulations were avoided. The implant was designed to fit loosely in the pocket. We immobilized the implant with a nylon stitch that crossed one implant edge, passed through the skin, and was secured with a bolster suture. Once the desired implant position was achieved and verified, the nasal mucosal incision was closed with two or three stitches of 4-0 monocryl. After incision closure, the

4 30 Aesthetic Surgery Journal 32(1) opposite site of the patient s face was then treated with the same approach, which minimized implant contamination. In Type 2a or Type 2b patients, we took advantage of the wider exposure made possible with a nasal alar base incision. In these patients, we began with an incision in the nasal-cheek junction to raise the nasal ala (Figure 4) before proceeding with the technique in the same way we previously described (Figure 5). Figure 3. A patient with Type 1 anatomy is shown intraoperatively. (A) The field is infiltrated with a solution of lidocaine with epinephrine. (B) The mucosal incision is made. (C) The silicone implant is carved in a customized shape. (D) The implant is ready for insertion. (E) The implant is inserted with a no-touch technique by utilizing a clamp. (F) The implant has been positioned inside the pocket.

5 de la Peña-Salcedo et al 31 Figure 5. A patient with Type 2 anatomy is shown intraoperatively. The technique proceeds generally as shown in Figure 3, with the modification described in Figure 4. After alar base incision and resection along with pocket dissection, the implant is inserted with an atraumatic technique (A). (B, C) The implant is positioned inside the pocket with the help of a blunt dissector. The implant should fit loosely in the pocket. (D) The immediate postoperative result is shown, with the bolster sutures fixing the implant. Figure 4. For Type 2 patients, an incision is made in the alar base (A, B) before alar resection and (C, D) dissection of the pocket.

6 32 Aesthetic Surgery Journal 32(1) Figure 6. (A, C, E) This 23-year-old man presented with Type 2b midfacial anatomy. (B, D, F) Two years after intranasal augmentation of the Zone 1 region (malar area). This patient also underwent an open rhinoplasty and placement of mandibular angle implants and a chin implant.

7 de la Peña-Salcedo et al 33 Figure 7. (A) This 18-year-old woman presented with Type 1 midfacial anatomy. She requested alloplastic malar augmentation. (B) Six months after augmentation of the Zone 1 (malar) region and buccal fat pad resection. Results Patients in this series (18 women, two men) ranged in age from 15 to 65 years. The median follow-up time was 10 years. With our anterior technique, we obtained favorable results in all patients. Specifically, we were able to satisfactorily insert the implant in all cases (100%; 20 patients). The technique allowed us to selectively augment all three zones, obtaining individualized postoperative results. This technique allowed us to insert an implant of any size for midface enhancement, even when Zone 3 (submalar area) augmentation was required. Although our results were similar to those achievable with traditional approaches, we experienced fewer complications, specifically with regard to inferior malposition of the implant and infection. Surgical time ranged from 15 to 35 minutes per side (average, 25 minutes per side). This included the time spent carving the implants, which was an average of 10 minutes per side. In all patients, healing was uneventful, and postoperative edema resolution was fast, with unimpaired vascularity and innervation. There were no cases of hematoma, infection, distortion of the midface area, or psychological complications. None of our patients experienced any neurological complications related to stretching of the facial nerve branches or symptoms related to infraorbital nerve dysfunction. One in every five patients experienced postoperative pain or tenderness, which lasted approximately three days. There were no cases of postoperative implant malposition. One patient requested removal of the implants at one year postoperatively, despite her good postoperative outcome. Clinical results are shown in Figures 6 to 11. Each of these patients required different sizes and types of midfacial implants. Discussion Malar augmentation for aesthetic purposes has become increasingly common. Prominent malar bones are considered a mark of beauty in the Western world, and they contribute to a more youthful appearance. Many individuals, both men and women, have a compromised youthful appearance early in life because of the lack of malar prominences, and we therefore see more patients presenting at a younger age for correction in these areas. In our practice, we have relied on malar augmentation increasingly to treat either younger patients (to enhance the aesthetic appearance of the midface) or older patients (as an adjunctive procedure to restore a more youthful appearance). Alloplastic malar augmentation is a surgical procedure that has improved concurrently with our better understanding of the malar-submalar anatomy. As techniques have improved, we have gained a better control of the final result and the ways in which it is influenced by the implant material, the fixation technique, and the insertion approach. We found the intranasal approach described in this series to be significantly easier than the intraoral approach.

8 34 Aesthetic Surgery Journal 32(1) Figure 8. (A, C, E) This 25-year-old woman presented with Type 1 midfacial anatomy and requested a midface enhancement. (B, D, F) One year after augmentation of the Zone 2 (paranasal) region. This patient also underwent a closed rhinoplasty. Currently, silicone implants appear to be the most frequent, simplest, and most predictable manner by which to achieve malar augmentation. 6 Silicone implants have several advantages over their porous counterparts, particularly with our surgical approach. First, they are more flexible and therefore more suitable for an intranasal insertion. This flexibility also helps the implant to fit perfectly in the surgical pocket. Second, they can be carved more easily than the porous implants, thus making it simpler to achieve the desired final shape and to obtain symmetry in preoperatively-asymmetric midfaces. Third, they are less expensive than porous implants.

9 de la Peña-Salcedo et al 35 Figure 9. (A, C, E) This 29-year-old woman presented with Type 1 midfacial anatomy and requested malar implants and a rhinoplasty. (B, D, F) Nine months after augmentation of the Zone 2 (paranasal) region. This patient also underwent a closed rhinoplasty.

10 36 Aesthetic Surgery Journal 32(1) Figure 10. (A, C, E) This 36-year-old woman presented with Type 2a midfacial anatomy and requested a midface enhancement. (B, D, F) Eight years after augmentation of Zone 1 (malar) and 2 (paranasal) regions. Fourth, there is no need to fix them with screws. Last, the rate of infection with silicone implants is lower than with porous material. In terms of preoperative planning, it is important that each zone of the midface be evaluated separately from the others, to carefully document size and the projection desired. Most patients have asymmetrical facial anatomy, so it is important to customize the implants to achieve as much symmetry as possible. On the basis of our experience with this technique in 20 patients over the past 20 years, we believe it has several advantages over traditional approaches. First, the

11 de la Peña-Salcedo et al 37 Figure 11. (A, C) This 47-year-old woman presented with Type 1 midfacial anatomy and requested a facelift. We also recommended a malar augmentation, rhinoplasty, and chin implants. (B, D) Three years after augmentation of Zones 1 (malar) and 3 (submalar). Note the rejuvenating effect of the malar implants. technique allows the placement of midface implants of any size at any location, which allows treatment of patients with any number of anatomic deformities. Furthermore, with an intranasal approach, no muscle is dissected, so the inflammation period is shorter and the patient s anatomy is preserved with no muscle damage. This contributes to an overall shorter recovery period. Also, the pocket dissection is completely horizontal, which helps to maintain a sturdy ledge upon which the implant can rest, with no risk of inferior displacement of the implant and therefore no risk of inferior malposition. The nasal flora is less aggressive, and bacterial concentration is lower, than with an oral incision. (This is particularly true regarding anaerobic flora.) This contributes to a lower rate of infection. In this series, we had no cases of infection. When combined with an alar base-plasty, this technique is by far the approach that provides the best exposure. We believe this approach could be the gold standard for alloplastic midface augmentation in patients who require alar base resection. Since the pocket is dissected subperiosteally, we believe it could be possible to perform the procedure under local anesthesia only, even though all the patients in this series were placed under general anesthesia. In our patient population, we frequently needed to augment the paranasal area and resect the buccal fat pad. In these cases, it is important to consider that buccal fat pat resection will enhance the postoperative results of the midface implant, and therefore smaller implants are more appropriate. On the basis of our experience in this patient series, we have devised a series of recommendations for implant selection and insertion. First, differently-sized implants are usually selected for each side of the face for patients

12 38 Aesthetic Surgery Journal 32(1) who have asymmetric midfaces preoperatively. Second, every case should be individualized regarding the severity of the hypoplasia of the midface; as a general rule, more severe hypoplasia requires a larger implant. Also, when in doubt about selecting between two implant sizes, we recommend placing the smaller of the two. In men, we usually avoid augmenting the submalar area (Zone 3). In women, however, we augment the submalar area (Zone 3) in conjunction with the malar area (Zone 1). When patients present for rejuvenation, we usually select smaller implants; conversely, when the goal is to obtain definition, angularity, and/or bold facial traits, we recommend larger implants. Last, when implants are being placed concurrently with buccal fat pad resection, we recommend smaller implants because the resection enhances the impact of the malar implant. Conclusions In this article, we described the results from a series of 20 patients treated over 20 years with an intranasal approach for alloplastic malar augmentation, with an average of 10 years follow-up. We also suggested two new algorithms for classifying patient anatomy, which can be helpful in categorizing preoperative deficiencies and selecting corresponding implants to improve them. Overall, our intranasal approach for malar augmentation is a suitable operation for enhancement of the midface area in patients of all ages. In our hands, we achieved predictable positive results, an excellent rate of patient satisfaction, and a complication rate of nearly 0%. 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. González-Ulloa M. Building out the malar prominences as an addtion to rhytidectomy. Plast Reconstr Surg 1974;53: Hinderer TT. Malar implants for improvement of the facial appearance. Plast Reconstr Surg 1975;56: Whitaker LA. Aesthetic augmentation of the malar-midface structures. Plast Reconstr Surg 1987;80: Mladick RA. Alloplastic cheek augmentation. Clin Plast Surg 1991;18: Wilkinson TS. Complications in aesthetic malar augmentation. Plast Reconstr Surg 1983;71: Ivy EJ. Malar augmentation with silicone implants. Plast Reconstr Surg 1995;96: Yaremchuck MJ. Secondary malar augmentation. Plast Reconstr Surg 2008;121: Yaremchuck MJ. Making concave faces convex. Aesthetic Plast Surg 2005;29: Wellisz T. Clinical experience with the Medpor porous polyethylene implant. Aesthetic Plast Surg 1993;17: Wellisz T, Dougherty WR. The role of alloplastic skeletal modification in the reconstruction of the facial burn. Ann Plast Surg 1993;30: Wellisz T, Lawrence M, Jazayeri MA, Golshani S, Zhou ZY. The effects of alloplastic implant onlays on bone in the rabbit mandible. Plast Reconstr Surg 1995;96: Wellisz T, Dougherty WR, Gross J. Craniofacial applications for the Medpor porous polyethylene flexblock implant. J Craniofac Surg 1992;3: Flowers RS, Ceydeli A. Mag-5: a magnificent approach to upper and midfacial magid. Clin Plast Surg 2008;35: Flowers RS. Correcting suborbital malar hypoplasia and related bone deficiencies. Aesthetic Surg J 2006;26: Epker BN. Esthetic Maxillofacial Surgery. Malvern, PA: Lea & Febiger; Terino EO. Malar, mandible and chin augmentation by alloplastic techniques. In: Ousterhout D, editor. Aesthetic Contouring of the Craniofacial Skeleton. Boston: Little, Brown, Terino EO. Complications of chin and malar augmentation. In: Peck G, editor. Complications and Problems in Aesthetic Plastic Surgery. New York: Gower Medical Publishers; Terino EO. Alloplastic facial contouring: surgery of the fourth plane. Aesthetic Plast Surg 1992;16: Terino EO. Alloplastic facial contouring of the malar, midface, and premandibular jawline. In: Nahai F, editor. The Art of Aesthetic Surgery: Principles and Techniques. Atlanta, GA: Quality Medical Publishing; 2005.