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MIDFACE CUSTOM IMPLANTS

Custom Cheek Implants

Cheek asymmetries, inadequate primary cheek implant results and infraorbital rim deficiencies create the main reasons for the fabrication of custom cheek implants. Custom cheek implants come in two basic styles, 1) implants that cover the cheek and zygomatic arch areas (which are placed intraorally) and 2) infraorbital-malar Implant designs that encompass the infraorbital rim and turn the corner to extend out into the zygomatic arch. (which are usually placed through a lower eyelid incision) Both of these custom cheek implant styles exist because they cover and augment more bony surface areas than standard cheek or any other type of midface implant. Many think that a custom cheek implant design means an implant that is bigger or has more projection, (and this is occasionally the case) But a custom cheek implant approach usually means an extended surface area coverage of the zygomatic-orbital bones that creates a unique augmentation effect not obtainable with performed cheek implant styles.

Style 1 custom cheek implants is most commonly done when the patient has had an unsatisfactory result using standard cheek implant styles.  The most problem with standard cheek implants is that they create an anterior full ness or apple cheek effect. While this may be fine for some women it almost never is for a male. Many patients today seek a more contemporary cheek augmentation effect that has the augmentation going more posterior back along the zygomatic arch. This follows the natural shape of the zygomatic bone as it covers most of the zygomatic arch. This is often referred to as the ‘high cheekbone look’ but anatomically is a more complete coverage of the zygomatic bone.

For patients with infraorbital rim recession, there are no standard implants that can even be modified to use for augmentation. The limited bone surface of the orbital rim area requires an implant that is specifically made for it to sit properly along its edges and feather into the medial and lateral orbital rim areas without palpable or visible step-offs. But almost all cases of infraorbital rim recessions and negative orbital vectors have malar deficiency as well. Thus the style 2 custom cheek implant is an infraorbital rim implant that almost always has a malar extension. (custom infraorbital-malar implant also known as a custom IOM implant) How much infraorbital rim augmentation is done and how far back along the cheek/arch it extend and its various thicknesses along the way will differ based on each patient’s aesthetic needs.

Custom style 1 cheek implant design that covers the entire zygomatic bone and arch that far exceeds what the prior cheek implants could achieve.
The key in achieving a high cheekbone look is taking the implant design back along the zygomatic arch, past the zygomatic arch suture line to the zygomatic process of the temporal bone..
Standard cheek implants, in this case a submalar style, keeps their effect to the anterior cheek region. A style 1 custom cheek implant relocates the cheek fullness to a higher level and further back along the zygomatic arch.
The top view is one of the best way to shows the effects of arch augmentation which is completely absent in any standard cheek implant style.
Style 2 custom cheek implants have an infraorbital component to them that wrap around the main cheekbone area and extend out into the zygomatic arch to build out the upper horizontal line of the midface.
Wrapping around the upper midface from the nasal bone out onto the end of the zygomatic arch is the custom infraorbital-malar cheek implant style that offers improvement in undereye hollows as well as a high cheekbone augmentation effect.
Custom infraorbital-malar implant design with a maxillary extension for increased anterior cheek fullness as well.
Custom IOM implant with maxillary extension adds submalar/maxillary projection.
Larger custom infraorbital-malar implants, as defined by significant vertical infraorbital rim and anterior cheek augmentation, may require a split design to be placed through small lower eyelid incisions.
For deep under eye hollows and flat cheeks, which often go together, larger custom IOM implant dimensions are needed.
An effective strategy for the high cheekbone look is to keep the implant design high up along the cheekbone staying clear of the submalar bone area leaving it uncovered.
The high cheekbone effect in the under eye hollows patient creates a horizontal line of augmentation from the nasal bones out to the tail of the zygomatic arch.
Style 1 custom cheek implants that can inserted intraorally. They provide a high cheekbone look but with some anterior cheek projection as well. The maxillary extension provides a convenient registration method along the posterior maxillary buttress which can be removed after screw fixation is applied if desired.
Custom style 2 infraorbital-malar implants for the high cheekbone look in the lean male face.
Custom infraorbital-malar implants with a maxillary extension for submalar augmentation as well.
Custom infraorbital-malar implants to build out the upper midface that was left ‘behind’ by the LeFort I osteotomy done below it.

Custom Midface Implants

While midface implants are typically envisioned as cheek or infraorbital types, a custom implant approach allows augmentation designs not previously seen or imagined for this part of the face. The entire midface can be covered in a variety of designs that can replicate what LeFort advancement osteotomies (minus the tooth movements) can traditionally do. Whether it is more limited premaxillary-paranasal or an an inferiorly extended infraorbital-malar implant designs or a total midface mask design, custom implants for the midface open up potential new methods of facial augmentation.

Custom total midface implant for anterior projection in an Asian male patient.

Custom two-piece midface mask implant that required combined in-traoral and lower eyelid incisions due to extensions over the infraorbital rims and up along the lateral orbital wall.

Custom midface mask implant that could be inserted intraorally as there was no saddling of the infraorbital rims.

Custom limited midface implant for reconstruction of traumatic bony de-formities of the pyriform aperture regions.

Custom forehead and midface implants in Asian female for exclusive an-terior facial projection.

Custom female infraorbital-maxillary implants for midface asymmetries and age-related changes.

Custom paranasal, extended cheek, chin and jaw angle implants for female facial augmentations.

Custom infraorbital-malar-maxillary implant design for male with midface deficiency.

Custom midface-malar implant design for center and lateral midface deficiency.

Custom midface implant after LeFort I osteotomy form complete midface advancement.

The custom midface mask concept is to bring the entire midface forward, usually without adding any cheek width. This provides a more complete total midface augmentation effect than ant form of a LeFort osteotomy.
A custom midface mask style implant can be done in an inadvertent fashion from the patient’s perspective. In this patient he first had custom infraorbital-malar implants (green color) and ‘discovered’ years later that he wanted a more complete midface augmentation effect. A second custom infraorbital-maxillary implant (teal color) was added from an intraoral approach to create more total midface horizontal projection.
Infraorbital-malar bony recession is often associated with an overall maxillary deficiency as all the midface bones develop together. Sometimes augmenting one part of the overall facial deficiency (custom infraorbital-malar implants in green) eventually draws attention to what still remains deficient. (custom infraorbital-maxillary implant in teal color)

Custom Orbital Implants

Custom orbital implants are used to augment or correct deficiencies of the orbital rims and orbital floor. Providing precise augmentation to the delicate contours of the orbital rims and infraorbital volume are good indications for a custom implant approach using the patient’s 3D CT scan. Tear troughs and undereye hollows due to infraorbital bone recession are common aesthetic indications for their use. Reconstructive indications are orbital rim asymmetries, infraorbital rim-orbital floor asymmetries due to vertical orbital dystopia and correction of depressed infraorbital rim-floor from prior orbito-zygomatic (ZMC) fractures.

Custom infraorbital rim implants for undereye hollows combined with a custom jawline implant in a male.

Custom right periorbital implant for orbital asymmetry after multiple prior reconstructive efforts.

Right vertical orbital dystopia of 3mms correction with custom orbital rim-floor implant.

Bilateral custom cheek implants with right orbital rim-floor extension for orbital asymmetry correction.

Custom infraorbital-anterior malar implants for correction of a negative orbital vector.

Custom brow bone implants combined with custom inferolateral orbital rim implants for a new circumferential orbital rim augmentation effect.

Custom lateral infraorbital rim implants for congenital lateral infraorbital rim defects.

Left 5mm custom orbital rim-floor implant for vertical dystopia correction.
Being able to achieve a precise match to the opposite normal orbital rim and floor is of tremendous benefit in vertical orbital dystopia surgery.

Custom Nasal Implants

Designing implants for the small area of the nose is the least commonly performed custom facial implant. When it is done it is usually done as part of an extension from a brow bone or forehead-brow bone implant. While designed as an extension from the brow bone above, it is manufactured and placed as a separate implant.

Custom nasal implant as part of numerous custom facial implants. Such implants are often designed as part of/an extension of a brow bone implant.

Custom nasal implants as part of custom forehead-brow bone, midfacial and jawline implants.