During the last 25 years, surgeons who perform cosmetic surgery have been more likely to appreciate and understand that when they take something away in facial rejuvenation, they should put something back, according to Joe Niamtu, III, D.M.D., an oral and maxillofacial surgeon with a practice limited to cosmetic facial surgery in Richmond, Va.
“This something can be fat, fillers a midface lifting procedure or implants,” he says.
Dr. Niamtu says he isn’t a fan of fat for the midface because it’s not reversible, and he believes fat placed in the cheek area will droop over time, becoming saggy.
“The fat you put in today may be in a different place in 20 years,” he says.
And midface lifting procedures will eventually fall, according to Dr. Niamtu. That’s where implants or fillers come in.
“It really has only been in the last 15 years where we’ve had predictable fillers that are thick enough to volumize the midface and had sufficient longevity,” he says.
The problem with fillers is they dissolve, and coming back repeatedly for filler treatments can get expensive for patients.
“If you do fillers two or three times, you’ve already paid for facial implants,” he says.
His go-to procedure for mid-face rejuvenation involves using cheek implants. The approach, he says, is relatively easy for the surgeon and patient, safe when implants are secured, permanent and reversible.
Cheek implants have been around for decades, and have improved thanks to the likes of William J. Binder, M.D., and Edward Owen Terino, M.D., who developed a series of implants customized to fit just about any human skeletal facial architecture, according to Dr. Niamtu.
“These implants come in an array of sizes and shapes to allow surgeons to customize how much and where the volume restoration is placed,” he says.
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Cheek Implants 1-2-3
Dr. Niamtu gives cheek implants a thumbs up for multiple reasons.
One, the procedure takes about 20 minutes in experienced hands.
Two, he secures all his implants with one or two micro-screws, so those implants become part of the facial skeleton.
“They can never move. They will never displace. And they will always remain,” he says.
Three, implants are placed through a hidden incision, which is made through the mouth.
Four, despite the procedure’s permanence, implants can be removed or changed for different sizes, and, even that, is relatively easy to do.
Patient shown before and after cheek implant placement with micro screws. Photo courtesy Joe Niamtu III, D.M.D.
“There are not many things in cosmetic surgery that are permanent yet revisable,” Dr. Niamtu says. “I’ve done, probably, several thousand facial implants in my 30 years of doing surgery. I have them in my own face.”
Dr. Niamtu frequently uses facial implants along with his facelifts, laser resurfacing and other facial rejuvenation procedures. In older patients, for example, he’ll often combine cheek implants with other surgical and nonsurgical approaches. In younger patients, he is more likely to use only the implants.
“I would say that 80% of implants I place are done with some other procedure. Probably a third of my facelift patients get either cheek or chin implants. I would say 90% are candidates for it,” he says.
Dr. Niamtu says he typically makes a small incision in the maxillary sulcus, just above the canine tooth.
He dissects subperiosteally and makes a subperiosteal pocket.
“The only significant anatomy in that region is the infraorbital neurovascular bundle, and that has to be avoided,” he says. “The dissection is commensurate with the size of the implant you’re putting in. I think one thing novice surgeons do is they make too big of a pocket. And when you have oversized pocket, you’re inviting dead space, hematoma and a mobile implant. So, you want to keep your pocket tight.”
To prevent future problems with the implants, it’s important that surgeons make sure the silicone implants are not impinging on the infraorbital nerve.
And one of Dr. Niamtu’s most important pearls is that he does not place implants in the facial cheeks without securing them.
Patient shown before and after cheek implant placement with micro screws. Photo courtesy Joe Niamtu III, D.M.D.
“I see patients from all over the country and a number of patients that I see have implants that are mobile or displaced, so I really think it’s important to secure them. The other situation is if you do have some mobility with an implant, it can become a foreign body and be reactive with the underlying bone. I think you see less resorption problems with secured implants,” he says.
Finally, he irrigates the implant and pocket with antibiotic solution before closing the incision with gut sutures. He doesn’t use a dressing.
“I tell patients that for about 10 days they’re going to have a little bit of a weaker pucker and smile, and that will be a temporary situation. They’ll probably also have some temporary numbness of the upper lip. And I usually tell people that the recovery for a cheek implant is anywhere between a week and two weeks. However, I would say the vast majority of my patients are in the one week range. Some people have some swelling for a little longer than that,” Dr. Niamtu says.
Cheek Implant Complications
In a study published earlier this year in JAMA Facial Plastic Surgery, researchers found that, among 39 adverse event cases from facial implant procedures reported to the FDA, infection and implant migration were the most common complications. When they reviewed In 12 malpractice cases involving facial implants in publicly available court proceedings, inadequate informed consent and the need for additional surgical intervention to remove the implants were the most commonly cited factors in the court cases.
Complications from implants are rare, however, according to Dr. Niamtu. Yes, the implants could displace if not secured, he says.
“I have seen minor infections over the years, but if an implant is secured with screws, you can usually treat that infection with drainage and antibiotic irrigation; whereas, if you have an infected implant that is not secured and immobile, it’s pretty much a foreign body and has to come out,” Dr. Niamtu says. “I would say I see an infection once every three or four years and most are treatable.”
