Facial Implants

Anatomy and Physiology

Vital structures must be noted when placing facial implants. The most important are the face's sensory and motor nerves, vasculature, and musculature.

Trigeminal Nerve

Cranial nerve V (CN V), the trigeminal nerve, supplies sensation to the face and motor control to a select muscle group. CN V has divisions V₁ to V₃, each exiting the skull through a different foramen. Some of these nerves' terminal branches reach the viscerocranium's facial surface and penetrate their targeted soft tissue.[5] Some trigeminal nerve branches are at greatest injury risk from implant placement at their exit points.

CN V₁, the ophthalmic division, exits the skull through the superior orbital fissure. This nerve has 3 main branches: frontal, lacrimal, and nasociliary. The frontal branch travels through the orbit, exits superiorly, and forms the supraorbital and supratrochlear nerves. These nerves supply the sensory innervation of the upper eyelid, conjunctiva, and scalp. The lacrimal nerve is the smallest of CN V₁'s branches. This nerve communicates with the zygomatic nerve, supplies small skin and conjunctival areas in the lateral upper eyelid, and contributes to lacrimal gland innervation. The nasociliary nerve diverges while inside the orbit. This nerve's terminal branches include the infratrochlear and external nasal nerves, which supply the medial aspect of the upper lid and dorsum of the nose. 

CN V₂, the maxillary division, exits the skull through the foramen rotundum. This division has 2 main branches, the infraorbital (IO) and zygomatic. The IO nerve reaches the viscerocranium's surface via the maxilla's IO foramen and supplies the soft tissues from the lower lid to the upper lip. The zygomatic branch travels along the lateral orbit before dividing into zygomaticotemporal (ZT) and zygomaticofacial (ZF), which exit through foramina with the same names and supply the temple region and malar eminence's skin. All 3 nerves risk injury during subperiosteal dissection with zygomatic implants.

CN V₃, the mandibular division, exits the skull via the forament ovale. This nerve has numerous branches, including the pterygoid, masseteric, deep temporal, buccal, auriculotemporal, lingual, and inferior alveolar nerves. The mandibular division arises from trigeminal motor and sensory fibers that fuse before exiting the skull. This division supplies the mastication muscles. The mandibular division is not at risk of injury during implant placement as the fibers penetrate their target muscles outside the dissection plane.  

The inferior alveolar nerve enters the mandibular ramus medially. This nerve travels through the mandible's body and becomes the mental nerve as it exits laterally at the mental foramen apical to the 1st and 2nd premolar (see Image. Mental Nerve). The foramen is approximately 1.5 cm superior to the mandible's inferior border.[6]

After exiting its foramen, the mental nerve gives off 3 branches that run deep to the depressor anguli oris muscle. This nerve supplies sensation to the lower lip, chin, and gingival tissue associated with the mandibular incisors. The mental nerve is often encountered in genioplasties.[7]

Facial Nerve

Cranial nerve VII (CN VII), the facial nerve, supplies the facial expression muscles. CN VII branches are not directly encountered during dissection for facial implants. However, these nerves may be injured by stretching or compression during the procedure. CN VII exits the skull through the stylomastoid foramen before entering the parotid gland. The nerve has 5 branches, coursing deep to the superficial muscular aponeurotic system (SMAS). The facial nerve branches are the temporal, zygomatic, buccal, mandibular, and cervical nerves.

The temporal branch travels superiorly to innervate the frontalis and orbicularis oculi's superior aspect. The zygomatic and buccal branches course deep below the masseteric fascia. These nerves pass near the dissection plane and are thus at a higher risk of injury during subperiosteal dissection for zygomatic implant placement. The zygomatic branch innervates the orbicularis oculi's inferior aspect and nasal area muscles. The buccal branch innervates the upper lip and cheek muscles. The marginal mandibular nerve exits the parotid at the mandibular angle and follows the angle's inferior border. Injury to this nerve weakens the mentalis and depressor anguli oris—the muscles that move the lower lip. The facial nerve's cervical branch innervates the platysma.[8]

Facial Vasculature

The facial blood supply arises from external carotid artery branches. Major vessels are at the highest risk during the initial incision as they travel through the soft tissue, and dissection is carried out in the subperiosteal plane. An exception to this is when they form a neurovascular bundle and exit the viscerocranium. For example, the infraorbital and mental nerves travel with arteries and veins of similar names as they leave their foramina.

Facial Musculature

The facial expression muscles lie subcutaneously in the anterior and posterior scalp, face, and neck. Most facial muscles attach to bone or fascia, producing facial expressions by pulling the skin. The facial nerve innervates all facial muscles. Table 1 below summarizes important information about the muscles of facial expression.

Table 1. Facial Muscles

Mastication Muscles

Chin and malar implants are placed in areas where the mastication muscles attach or closely interact with facial bones. These muscles are essential for chewing and speaking and also aid in making facial expressions. Motor supply to the mastication muscles is via the anterior mandibular nerve trunk of CN V₃. Poorly placed implants can result in discomfort and impaired function of these muscles. Important information about the mastication muscles is summarized in Table 2.

Table 2. Mastication Muscles

Indications

Facial implant indications are functionally or esthetically driven and include the following:

• Loss of soft tissue support
• Volume loss
• Facial asymmetry secondary to growth discrepancies
• Congenital syndromes

Bony viscerocranial atrophy occurs in the 3rd and 4th decades of life. Decreased skeletal support can accentuate aging, especially since resorption is not even. Areas with more pronounced resorption include the infraorbital and pyriform maxillary areas, leading to midfacial deficiency. Osseocutaneous ligaments, including the zygomatic and mandibular, attach to the corresponding bone's periosteum and overlying skin.[9] The masseter ligaments span from the muscle to the skin. Weakening and decreased elasticity of these ligaments contribute to the ptotic effect of gravity.

The face consists of several fat pads separated by septa and fascia. These fat pads atrophy with age. The malar fat pads consist of superficial and deep fat pads separated by the superficial musculoaponeurotic system (SMAS). Jowls, for example, form from the bilateral descent of the superficial subcutaneous fat over the inferior mandibular borders. Jowls are due to fat loss, skin and muscle ptosis, and bony support loss. Genioplasty alone will not correct a prejowl sulcus. An osteotomy performed as part of a genioplasty can deepen a prejowl sulcus. Therefore, prejowl implant surgery is the treatment of choice for correction, although augmentation can occur at the chin alone, prejowl, or both.[10]

Asymmetries are present in numerous congenital deformities and vary in presentation. Human skull growth occurs in multiple vectors: transverse, sagittal, and vertical. The maxilla typically grows anteriorly, inferiorly, and laterally, while the condyles grow superoposteriorly, pushing the mandible anteroinferiorly. The chin stops growing before the rest of the mandible, which continues to develop transversely and vertically.[11] Deviations from the typical growth pattern introduce mandibular rotation, creating a dolichocephalic (long, retrognathic, and vertical) or brachycephalic (short, prognathic, and horizontal) appearance. Growth usually stops at 14 to 16 years old in female individuals and 16 to 18 in male individuals.[12] Individuals with hypoplastic mandibles can correct the dental malocclusion with orthodontics if present. However, the remaining skeletal defect permits further correction with orthognathic surgery, implant augmentation, or both.[13]

Congenital syndromes that involve the 1st and 2nd brachial arch cause various craniofacial defects. Craniofacial microsomia, for example, commonly affects the maxilla, mandible, and orbits, among other structures. This condition is the 2nd most common congenital deformity after cleft lip and palate. Craniofacial microsomia presents diversely, and multiple classification systems exist.[14] Implants may be an excellent choice for people with milder forms of the disorder. Implant procedures may also be attempted in individuals with craniofacial microsomia who previously underwent corrective procedures like orthognathic surgery. (see Image. Zygomatic Submalar Implant).

Patients with clefts usually have a midfacial deficiency, often with a hypoplastic malar region. Although Le Fort I osteotomies aid in some midface deficiencies, eg, in the lip and nasolabial angle, the role of Le Fort osteotomies in correcting the malar region is controversial. Implants can correct deficient areas after orthognathic surgery.[15]

Contraindications

Facial implant surgery has few contraindications, which include:

• Incomplete growth
• Large volume deficit better treated by other means
• Current infection
• Inadequate bony and soft tissue support

Growth patterns and predictions are important to consider when evaluating facial implants. Female individuals start and stop growing on average sooner than male individuals.[16] "Growth cessation" has many different definitions. The Craniofacial Growth Consortium Study compared different definitions of this term. Growth cessation was defined in 1 of 2 ways: growth less than 0.1 mm per year or growth rate less than 10% of the peak growth velocity. Serial cephalograms help determine growth cessation. Linear distances of series cephalograms are used to compare the growth rate.[17]

Skeletal with dental malocclusions are better suited for orthognathic surgery. Osteotomies are indicated for more extensive augmentations. However, patient preference may favor implant placement. Thin tissue limits the implant placement area size due to the increased risk of implant visibility and palpation.

Equipment

Standard facial implants are alloplastic and may consist of 1 of the following materials:

• Titanium mesh: Titanium implants are inert, nonresorbable, and rigid. Titanium implants are used for recontouring deficient mandibular angles, adding length and width. The mesh is fenestrated to allow tissue ingrowth and create stability.[18]

• High-density porous polyethylene (HDPE): These polymeric implants are rigid, noncompressible, and thermoplastic. HDPE implants come in various pore sizes and densities, ranging from 80 to 400 microns.[19] Pore size influences the tissue ingrowth type, ie, bone or fibrous tissue, occurring after implantation. The range of about 100 to 250 microns has been shown to allow bony ingrowth. However, implants with such pore sizes require fixation to prevent neovascularization disruption.[20] HDPE implants come in preformed shapes but may be recontoured owing to their thermoplasticity. Recontouring may be done by increasing the implant's temperature to 180 °F before carving with a scalpel.[21]

• Silicone: These implants are nonporous and may be composed of solid silicone or dimethylsiloxane subunits. Nonporous implants do not allow tissue ingrowth and become encapsulated, thus requiring fixation to the underlying bone for immobilization. Implant fixation can reduce the dead space between the implant and bone, reducing the chance of tissue ingrowth and seroma formation. Fixation also limits bony resorption, migration, and unaesthetic results.[22]

• Autogenous implant: Autograft use in cosmetic augmentation is limited due to bony resorption unpredictability. One reason is that autograft bone must be under stress to prevent resorption, an example of Wolff's Law. This law states that bone will adapt and remodel to withstand stress. Thus, minimal impact on implant sites leads to decreased bone density due to the absence of stimulation.[23] Autografts also create donor site morbidity, increased surgical time, and complexity.[24]

During the procedure, intravenous (IV) deep or general anesthesia induction can help attain the desired anesthesia depth. Local analgesia is then obtained using lidocaine and a longer-lasting anesthetic like marcaine. Local anesthetics are usually drawn from a vial and administered with a dental syringe and a 27-gauge needle. A #15 blade or bovie electrocautery is used for the appropriate incision.

The surgical armamentarium is similar regardless of the implant location and type. The table below summarizes the materials and equipment used for various aspects of the procedure.

Table 3. Materials and Equipment for Facial Implant Surgery

Personnel

The surgical team may be comprised of as few as 2 individuals: the surgeon and the assistant. However, a cosurgeon will often be present. A 2nd team may be composed of an anesthesiologist, with or without a nurse anesthetist, and may assist the surgeon by providing deep or general anesthesia.

Operating room nurses and technicians also play active roles in general anesthesia cases. Oral maxillofacial surgeons can administer deep anesthesia during procedures, but surgical teams typically have an anesthesia provider on board. Nerve testing is not routine in facial implant surgery, as the dissection plane allows tissue reflection without nerve involvement. Exposed nerves, such as the mental and infraorbital nerves, are easily identifiable and protected throughout the surgery.

Preparation

Human facial cosmetic evaluation advances as 3D technology improves. Currently, providers use 2D photos that complement both 2D and 3D radiographs. Photos are taken with the patient looking directly at the camera, at a 45° angle, and in profile view. Each photo allows facial volume visualization from different angles. The lateral cephalogram should be well studied and analyzed, as it contains critical data used for facial analysis. Well-known facial bone and soft tissue relationships are determined from this radiograph. 

The chin's position and the lower facial structural relationships may be classified based on numerous measurements. Frequently used parameters include the following:

• Holdaway Ratio (see Image. Holdaway Ratio)
• Zero Degree Meridian Line (see Image. Zero Degree Meridian)
• True Vertical Line (see Image. True Vertical Line)
• Labiomental Angle (see Image. Labiomental Angle)

The Holdaway ratio compares the chin's bony position to the lower incisor tips. This ratio involves 4 points: the pogonion (Po), lower incisor tip (L1), nasion (N), and B point (B). Po is the bony chin's most anterior aspect. B is the anterior mandible's most concave aspect. N denotes the nasofrontal suture area. To get the Holdaway ratio, the vertical line connecting N to B is measured. The distance in millimeters from Po to N-B and L1 to N-B should be equal, ie, must have a 1:1 ratio. A deviation of more than 4 mm warrants correction. Excessive lower incisor proclination increases this ratio and distorts accurate analysis. 

The zero-meridian line is a perpendicular line that crosses the Frankfort horizontal (FH) line at the nasion. This line evaluates the chin position. The FH line connects the top of the external auditory meatus to the orbit's lowest point. The distance between the pogonion and the zero-meridian line should be 0 mm for female individuals and up to 2 mm for male individuals.

The true vertical line is perpendicular to FH and transects the subnasale (Sn), the point where the nasal columella and upper lip intersect. Niani found that mandibular retrusion of up to 4 mm or protrusion of up to 2 mm from the true vertical line may not be visibly noticeable to people without specialized facial surgical training.[25]

The labiomental angle is the soft tissue convexity between the lower lip and chin. Chin structure may be classified based on convexity, a feature directly related to the labiomental angle. Convex, vertical, and posteriorly angled chins can support larger implant sizes. Vertical chins require about 8 mm implants. Posteriorly angled chins require the greatest augmentation—12 mm or more.[26] Horizontal growth patterns are associated with well-developed chins and a deep labiomental groove. Providers should not augment the thickest point of a convex labiomental angle with an implant larger than 4 mm. 

Facial implants may also augment the posterior mandible in the transverse dimension. The bigonial width is the distance between the right and left mandibles' most inferior, lateral, and posterior edges. Farkas described the average bigonial widths of female and male individuals of Caucasian descent in relation to their bizygomatic width. The male bigonial width was found to be 34 mm shorter than their bizygomatic width. In contrast, the female bigonial width was found to be 36 mm shorter than their bizygomatic width.

Various soft tissue analyses target midfacial deficiencies. However, midfacial evaluation with cephalograms remains challenging. Powell stated that the malar eminence positioned at the FH plane is the most ideal aesthetically, with the malar eminence's location being 2 to 2.5 cm lateral to the lateral canthus. Meanwhile, Bell used the malar eminence's relation to the eye's cornea to determine their ideal positions. Bell stated that the eminence should be anterior to the cornea by 4 to 8 mm. Frey noted that among white individuals, the malar eminence is about 2 mm anterior to the cornea.[27] The Hinderer point, the malar region's most prominent aspect, is about 15 to 20 mm inferior and 10 mm lateral to the lateral canthus.[28]

Binder classified midfacial deficiencies into 3 categories:

• Type 1 deficiency involves a loss of malar projection secondary to skeletal hypoplasia
• Type 2 deficiency involves a loss of submalar soft tissue volume and is the most common type
• Type 3 deficiency is a combination of types 1 and 2

Each of these types warrants a different implant shape and location. Type 1 deficiency may be enhanced by a malar shell implant to increase projection and lateralization. Type 2 can improve with a submalar implant placed below the zygoma on the anterior maxilla. Type 3 may require a larger, combined implant.

Technique or Treatment

Antibiotics are essential for facial implant success. Broad-spectrum antimicrobials are routinely given preoperatively, intraoperatively, and postoperatively. Prophylactic cefazolin is a common choice for extraoral incisions to cover skin flora, including Staphylococcus species. Simultaneous administration of amoxicillin or other 3rd-generation penicillins helps cover oral gram-positive aerobes and anaerobes during intraoral incisions.[29] Ampicillin-sulbactam and cefazolin can serve as intraoperative replacements.[30] Postoperative antibiotics are controversial. Consensus is lacking regarding the timing of administration if postoperative antimicrobials are prescribed.[31]

The surgical team completes preparing the face with iodine sterilization followed by a local anesthetic injection. The anesthesia level varies. Implants are routinely placed under IV sedation or general anesthesia. The provider must consider the dissection approach to determine the anesthetic depth required for the procedure. Some anesthetic techniques are more time-intensive than others. Some procedures, like malar implant surgeries with a transconjunctival approach, may warrant paralytic administration. Other anesthetic considerations include general anesthesia costs and provider experience.

Malar implants are routinely inserted via an intraoral incision. An incision is made 0.5 to 1.0 cm above the gingival margin within the mucosa, posterior to the canine fossa. Blunt dissection with a periosteal elevator is then carried out subperiosteally posterolaterally along the anterior maxilla. Dissection proceeds superiorly to the infraorbital rim, identifying and protecting the infraorbital neurovascular bundle. Adequate dissection is essential for larger implants that may infringe upon the infraorbital foramen.

With type 2 and 3 defects, dissection is carried laterally to the masseteric tendon to allow passive seating in the submalar region. Dissection should exceed the implant size. Providers should use implant sizers to confirm the correct size and dissection. Sizers are implant manufacturer-specific and can be ordered separately or as part of a package. A 3D steriolith is a printed 3D model of the patient's face (see Image. Silicone Malar Implants). Providers may use it to visualize the correct implant size and aid in trimming. Implants and sizers are soaked in antibiotics before use. The dissection pocket is also rinsed with antibiotics before insertion. Sizers confirm the correct esthetic outcome and implant size and also ensure that the dissection is adequate.

The implant is inserted carefully to limit folding and improve facial symmetry. Nonresorbable sutures or titanium screws secure the implant (see Image. Malar Implant). The incision is then closed, and the compressive wrap is placed to help compress any dead space created during surgery. Various compressive therapies are available. An elastic compressive head wrap is a noninvasive type generally worn continuously for the first 7 days after showering. After the 1st week, the dressing is worn only during sleep. Lymphatic drainage improves, and swelling subsides while the area is relieved of compression.[32]

Cheek bolsters, which consist of cotton rolls fixated with transcutaneous sutures, allow for more invasive malar implant placement. Bolsters permit firm and constant compression and are easily removed 1 to 2 days postsurgery. The periosteum and bone will reapproximate within 24 to 48 hours.

Chin implants are inserted either intraorally or submentally. An intraoral incision is made in the anterior mandibular vestibule, spanning from canine to canine. The incision is made with a blade or bovie electrocautery device through the mucosa until the mentalis muscle is visualized. The muscle bellies can be cut with a bovie electrocautery device, scissors, or a blade. A cuff of mentalis muscle should be left attached to the mandible and lip.

Muscle tissue on opposing sides of the incision will help reapproximation and prevent ptosis. The mandible is exposed using blunt subperiosteal dissection. Dissection should extend laterally along the mandible's inferior border before proceeding superiorly to identify the mental foramen and nerve (see Image. Mentalis Dissection). Dissection proceeds from the symphysis' inferior border and then superiorly to just beyond the planned implant size's border. Dissection should be larger than the planned implant size to avoid complications such as implant migration, symmetry, and soft tissue compression.

Sizers are placed to confirm dissection and implant size adequacy, serving as guides to avoid injuring the mental nerve. Aufricht retractors help improve visualization and protect the nerve if lateral dissection is inadequate. The surgical site is irrigated in the same manner as previously discussed. The implant is secured using either a nonresorbable suture or a titanium tacking screw. Layered closure is then performed. The mentalis muscle layer is closed first, completed by reapproximating the opposing cuffs using 2 to 4 3-0 Vicryl single interrupted sutures. The mucosa is then reapproximated using a faster resorbing suture like a 3-0 chromic gut.  

Subperiosteal dissection exposes the mandibular angles and ramus to the sigmoid notch. A pterygomasseteric-sling release allows titanium mesh implant placement on the inferior and posterior mandibular border. Monocortical titanium screws fixate the implant, and the dissection is closed in layers.

Mandibular angle implants may be inserted via an intraoral or extraoral incision, depending on the implant type and size. A 1.5 cm intraoral incision lateral to the external oblique ridge is made above the depth of the vestibule. Subperiosteal dissection exposes the mandibular angle and ramus to the sigmoid notch. Soft tissue is then stripped from the anterior, inferior, lateral, and posterior aspects of the mandible and the pterygomasseteric sling. The pterygomasseteric sling is released to place titanium mesh implants on the inferior and posterior mandibular borders.

Monocortical titanium screws fixate the implant, and the dissection is closed in layers. The mandibular nerve is identified and protected if a nonmaleable implant is placed and a larger incision is needed. A transcutaneous incision lateral to the implant facilitates the use of a trocar system to anchor the implant to the lateral ramus and body with titanium monocortical screws. Securing the implant decreases dead space and allows for predictable augmentation volumes. Layered closure using resorbable sutures decreases infection and scar formation risk.

Close follow-up is essential to detecting and treating early or late complications.[33] A soft-food diet is recommended for posterior mandibular augmentation, which requires mastication muscle stripping.

Complications

Facial implant complications may occur early during recovery or months to years after placement. The definition of "early" and "late" varies between research studies. For this activity, "early" refers to the first few weeks of soft-tissue healing.[34] Complications may include the following.

• Hematoma
• Seroma
• Infection
• Wound dehiscence
• Alveolar ridge resorption
• Poor or undesired aesthetic outcome
• Displacement or malpositioning
• Scarring
• Nerve injury

Bleeding is an early complication and may result in an expanding hematoma requiring drainage. This complication is secondary to poor hemostasis during surgery. Seromas are also reported after implant placement, arising from inadvertent local gland dissection or the body's inflammatory response to the implant or surgical manipulation. A conservative dissection can help prevent fluid collection. Treatment options include observation with or without antibiotic administration, fluid drainage, and follow-up surgery for bleeding control. 

Late complications include infection, mobilization, extrusion, and bone resorption. Stringer reported an infection risk of 0.7% to 14.6% for alloplastic facial implants. Infection occurrence ranged from 0.9% to 12.5%. For silicone implants, the infection rate has been reported to be as low as 1%.

Intraoral incisions help avoid visible scars. The infection rate may increase with these incisions, but this view is controversial. Nevertheless, the implant must be removed if an infection develops and persists despite antibiotic therapy.

The risk of bony erosion occurs more frequently with solid implants than with porous implants. The erosion depth increases as the implant size increases or becomes more rigid.[35] Theories as to why bony erosion occurs include mobility, inflammation, and stress on the overlying soft tissue.

Improper implant size, shape, or placement can result in lip incompetence. For chin implants, active engagement of the mentalis muscle, which strains to compensate for weakness, increases pressure on the underlying implant. Placing the implant at the inferior mandibular border where the cortex is thicker and further from the mentalis insertion has been shown to cause less resorption. Implant fixation helps eliminate micro-movements that can contribute to continual erosion. Although controversial, erosion has been reported to be self-limiting. Fixation is assumed to play a role in self-limiting erosion.

Esthetic asymmetry can occur from implant folding or migration from poor fixation, above-periosteum placement, or dissection-size inadequacy. Sizers can help with proper implant sizing when used before final implant placement. Poor placement or displacement is corrected with a second operation to secure the implant at the proper position or replace it with a more appropriately sized and shaped implant.

Another cause of poor cosmesis is poor mentalis muscle reapproximation. The mentalis muscle is encountered and incised with an intraoral approach in chin implant procedures. The mentalis originates from the mandibular incisive fossa and inserts on the chin's dermis. The mentalis elevates the chin. Poor dissection, incision, and reapproximation techniques may result in ptosis or "witch's chin." An extraoral incision eliminates the risk of mentalis ptosis. However, this incision can create an extraoral scar at the submental fold. 

Dysesthesia, hypoesthesia, and anesthesia can occur if the mental nerve is damaged. The mental nerve supplies sensation to the ipsilateral chin and lower lip. This nerve must be identified and protected during chin augmentation. Mental nerve injury has been reported to occur in 2.4% of cases, often secondary to alveolar ridge resorption. The implant may be removed or exchanged for a better-fitting prosthesis if nerve dysfunction persists.

Clinical Significance

Facial implant surgery is highly versatile and offers an alternative to more invasive procedures, such as genial horizontal osteotomies. Less invasive procedures generally reduce costs using inexpensive hardware and anesthetic alternatives and incur less surgical time. Facial implant procedures are routinely performed under general anesthesia and intravenous sedation. However, awake implant placements under local anesthesia may also be performed. A 2014 UCLA research revealed that operating room costs could reach $35 per minute.[36] Alternative anesthetics reduce general anesthetic risk and monetary constraints for individuals who want to undergo facial implant surgery but have health and monetary restrictions. Patient recovery after implant placement is based on soft-tissue healing and requires only a few weeks. In contrast, bony surgery requires a significantly longer period to be considered stable. 

Chin implants can increase the chin's projection both laterally and anteriorly. Chin implants may also be placed to make the chin look narrow. These implants can provide a more balanced facial appearance without the need for osteotomies. Malar implants increase midfacial projection, making the face appear more harmonious and youthful.

Angle implants can provide a better-defined jawline and widen the lower face. An increased bigonial width, ie, a wider jaw, may be created by implant placement in patients needing posttraumatic jaw reconstruction and facial growth abnormality correction. Individuals seeking a more masculine facial structure as part of gender affirmation surgery may also undergo mandibular angle implant surgery. Implants can enhance the aging face, which loses volume and skeletal support in 3 dimensions.

Given the proper training and practice, facial implant placement can be a safe and quick procedure. Whether a patient is seeking facial harmonization, a more youthful appearance, or a facial structure that aligns with their gender identity, facial implant surgery gives patients an alternative option to more extensive surgeries. This procedure also allows interprofessional teams like otorhinolaryngology and anesthesia to come together for gender-affirmation surgeries.

Enhancing Healthcare Team Outcomes

An interprofessional approach enhances facial implant surgery outcomes. The primary care or cosmetic physician first recognizes the problem and refers the patient to the appropriate surgeon. Specialists who can perform the procedure include plastic and maxillofacial surgeons and otolaryngologists. Once evaluated by the surgeon, active patient participation throughout the planning, surgical, and recovery stages is essential to ensure the procedure's success.

In outpatient settings, local anesthesia may be given by the surgical specialist if an awake procedure is preferred. The anesthesiologist lends expertise if the patient requires deep anesthesia or more complex pain management techniques like nerve blocks, whether in an in-hospital or outpatient setting. The nurse assists the surgeon during the procedure, monitors the patient while recovering from anesthesia, administers medications, and reinforces patient education. The collaborative approach helps ensure patient safety and high-quality care.

The Food and Drug Administration closely monitors implantable medical devices, but the range of FDA-approved materials is ever-growing. The team must inform the patient of the risks of using the selected implantable device. For instance, silicone materials show no increase in reactive oxygen species or genotoxicity but may cause bony erosion when placed on the chin, as previously mentioned.[37]