Malar implants (cheek bone augmentation) or temple implants
Definition and principles
The surgeon enlarges or restructures the face using hard silicon malar or temple implants. This technique is notably used when a face is lacking in bone structure: asymmetry or a structure that is not sufficiently defined. Malar (cheek bone) implants also enable a face seen as too feminine to be made to look more masculine or to give the face a more Slav-like appearance.
The operation aims at surgically embellishing the face by modifying one or more facial aspects that the patient does not like, whilst preserving a natural and credible appearance with respect to the morphology.
The desired shape is defined by the patient and surgeon through analysis of photographic mock-ups that enable the definition of the best compromise between:
1. the psychological aspect (what the patient would like and what would be best adapted to their personality)
2. the morphological and aesthetic aspect (what would be best adapted to the shape of the face)
3. the technical aspect (what the surgeon believes to be technically achievable.)
After the operation, skin elasticity enables it to adapt to the new frame. Skin quality and reaction will therefore be key to the final result. The project is based on a virtual image: the surgeon cannot promise that the final result will be exactly super imposable, but will do everything to achieve a result as close to the mock-up as possible.
The operation can be performed on its own or, when an overall improvement of the facial structure is desired, at the same time as a rhinoplasty (nose job) and / or a genioplasty (aesthetic surgery on the chin.) The operation can only be performed once growth has finished (16 to 18 years of age.)
Temple implants are put in place via an incision under the hair.
Malar implants are slid in via the mouth and the surgeon performs the entirety of the operation via the mouth. It is imperative that the patient undergoes a dental check-up before the operation, since a latent dental infection could spread and negatively affect the final result.
Warnings and therapeutic alternatives
Non surgical alternatives:
Fillers or filling product injections
By means of targeted injections of filler such as hyaluronic acid, it is now possible to slightly modify volumes in order to increase the malar volume or fill the temporal depression.
Nevertheless, experience shows that with fillers to keep a natural look it is important to remain reasonable in terms of volume injected so as not to unbalance the ratio osseous tissues/soft tissues. Consequently this technique is more indicated for concealing the soft tissue melting (after weight loss or with age) and less to treat defect of the bones frame.
Injections are not very pleasant and results are temporary (1 to 2 years) but the effect is immediate, aftereffects are very light, with no or little social exclusion. Last but not least augmentation can be achieved progressively with several sessions.
For more information on fillers, please refer to the page “filling products” in the facial rejuvenation section of this website.
Lipostructure also called lipofilling, fat micro-graft, Coleman … consists in creating more volume by using the patient’s fat. It is also applicable to increase malar volume or fill the temples.
The fat graft has a better durability than the fillers. Fat grafting demands a more complex procedure than an simple injection of filler (an operation with fat collection and re-implantation), involves some uncertainties concerning the fat survival, and requires a stable weight patient in order to avoid later too visible variations of the grafted fat.
Like for filling product, it is important to remain reasonable in terms of volume injected so as not to unbalance the ratio osseous tissues/soft tissues. This technique is consequently also more indicated for concealing the soft tissue melting (after weight loss or with age) and less to treat defect of the bones frame.
For more information on fat micro-graft, please refer to the page “lipostructure” in the facial rejuvenation section of this website.
Concentric Malar Lift
The concentric malar lift aims at treating mid-face ageing by returning surgically the fat tissues displaced with structural aging in the fat pocket and in the malar bag to their original location (mostly the hollowing of the eye). A restoration is thus obtained without adding any unnecessary volume that would turn “unnatural”.
As a result of this rejuvenation the cheekbone volume is replaced in its initial position and look fuller (along with the correction of the tear trough, eyelid …)
This option is recommended when fat tissues are not missing but have been externalized with the ageing process: it is the structural ageing of the mid face that needs to be treated.
For more information about the concentric malar lift, please refer to the page “Eyelid” in the facial rejuvenation section of this website.
Autogenous bones grafting provides for a more natural malar augmentation than the plastic implant (hard silicone) since it is the patient hard tissues that are used to increase the volume.
However the procedure is a lot more heavier since it is necessary to harvest the bone grafts in a site (cranial or iliac in most case) before adjusting them to the receiving site.
Since hard silicone is very well tolerated by the tissues (to the contrary of liquid silicone source of many inflammatory reactions), the bone grafts technique is not indicated, on account of its seriousness, for simple aesthetic purposes like increasing the malar region or filling the temporal area.
On the other hand it is quite acceptable when it is performed during an important maxillo facial surgery which involves already other bones restructurations.
It must be noted that whatever the surgical choice, the risk of infection exists and may in some cases conduct a failure: graft bone wasting or necessity to remove the implant
To conclude about the possible alternatives
- To conceal soft tissues disappearance a lipostructure (fat transplant) or injection of a filler are the more recommended options.
- To treat soft tissues displacement, a Concentric Malar lift is much more suitable.
- To treat a defect of the bones frame implants or bones graft are indicated.
The surgery does not treat pre-existing asymmetries unless treatment targets them specifically. However, like after any aesthetic operation, it is usual for the patient to look at and analyse themselves more, and, since the features that they did not like have been treated, certain patients come not to like a pre-existing asymmetry that they had seen as insignificant prior to the operation. Therefore, it can be useful to discuss possible corrections of asymmetry prior to the operation. In some cases the overall profile may need to be analysed and the possibility of also performing a rhinoplasty should be discussed to avoid disappointment after the operation.
Please note that contrary to what can be observe in a mirror when the cheek is “lifted” with the fingers, one should not expect major improvement on the upper part of the naso-labial fold when undertaking a malar augmentation. As a matter of fact, due to soft tissues elasticity and to the limited volume that one can reasonably add (if a natural look is contrived), the tightening effect on the skin last usually only temporary.
Finally on elderly patients, since malar augmentation does increase the visibility of the tear trough, a complementary action on this crease may need to be considered in order to avoid any ageing effect to the surgery (either some filling component injection or a Concentric Malar lift).
Practical recommendations prior to the operation
If malar implants are to be put in place via the mouth, make sure that you have a dental check-up far enough in advance in order to be able to have the appropriate cleaning care if necessary.
Do not arrive too morally or physically tired to the operation. Let us know about any change in your state of physical or mental health and do not forget that there is never any urgency to carry out an aesthetic operation.
The operation will be cancelled if you are ill, or for women, if you are pregnant on the day of the operation.
Due to the risk of necroses it is imperative that the patient stops smoking. Medicines that cause bleeding are prohibited during the days leading up to the operation: Aspirin, Anti-inflammatory medicines, Anticoagulants, Vitamin E…. Also, no progestin treatments (contraceptive pill) should be taken during the month before and after the operation to limit the risk of embolisms and scar inflammations.
It is imperative that you neither drink nor eat for the 6 hours prior to the operation.
The operation will be cancelled if preoperative recommendations are not adhered to : assessment, fast, stopping smoking…
When preparing your belongings DO NOT FORGET YOUR MEDICAL FILE. Where possible, do not bring any valuable jewellery with you (or put it in the safe at the clinic with your other valuables during the operation.)
Have a shower or bath before coming to the clinic and make sure your hair is clean; women should obviously not wear nail varnish or make-up.
Prior to the anaesthetic contact lenses, dentures and hearing aids must imperatively be removed.
Anaesthetic and hospitalisation
The operation is always performed at the clinic. It is usually performed without hospitalisation, under assisted local anaesthetic and lasts for approximately one hour.
You will usually be discharged a few hours after the operation. However, in certain cases (nausea, stress…) it can be preferable to spend the night at the hospital. Ask an ABLE-BODIED AND RESPONSIBLE person to take you home. Since anaesthetics are euphoriants do not make any plans to do anything requiring concentration or the use of potentially dangerous equipment. If you are going home by car YOU WILL NOT BE ABLE TO DRIVE UNDER ANY CIRCUMSTANCES.
You should arrange for someone to be with you at home. In fact, you should not get up during the night following the operation without being accompanied, even to go to the toilet and even if you feel perfectly fine (anaesthetic products can produce effects identical to those of alcohol abuse).
Before leaving home prior to the operation, ensure that you have prepared everything for your return:
– Prepare a light meal
– Put Arnica 5CH, paracetamol-based painkillers (Dafalgan, Doliprane..) and a bottle of mineral water on your bedside table.
For the first few days at home you must relax as much as possible and avoid all over exertion. However, you should walk a little several times a day to prevent the risk of embolisms and should eat enough to enable healing.
It is important that you do not smoke for 15 days after the operation to facilitate the healing process and to reduce the risk of necroses.
After an implant has been added, one should at all cost, avoid direct trauma for one month after surgery, since it could lead to the implant displacement and thus required further surgical readjustment.
You should not experience any pain, only discomfort, notably when chewing.
Antiseptic mouthwashes are prescribed for malar implants.
Bruises continue usually 8 to 15 days and can be concealed by make-up. Swelling is at its height on the 3 rd to 4 th day post-op then fades progressively, but the face will take several months to reach its definitive shape. Just like the bruises, the swelling and possible hardening vary from one side to the other. It is normal that there should be an asymmetry after the operation, but this in no way negatively affects the final result.
Common products, such as Arnica or Auriderm, and cold compresses calm bruises and swelling, helping them to heal more quickly. The face can also be drained by temporarily adopting a sleeping position with the chest slightly raised.
Note down the telephone number of the office (01 45 53 27 17 from France, 33 1 45 53 27 17 for international call), and of the number clinic near your home telephone and in your mobile phone. Do not hesitate to call us if you are worried. Call us if you have a temperature, experience weeping, pain or other symptoms that give you cause to worry.
Leave from work: 1 to 2 weeks depending on your professional activity
Bruises 8 to 15 days
Swelling very visible for 15 days
Exercise – combat sports that can lead to direct trauma can be practised after one month, but you should be aware that a violent blow, even long-term, can harm the result (displacement of implant may require surgery)
In most cases, operations run smoothly and patients are happy with the result. However, before deciding to go ahead with an operation, you should be aware of the risks and possible complications.
General risks of all surgical operations: infections, haematomas, healing problems and risks from anaesthetics
Infections are rare; however, they may require the temporary ablation of the implant. As such, it is very important after the operation to respect antiseptic and antibiotic prescriptions. In case of infection, surgical draining may be necessary. Oral infections are rare if the dental assessment is carried out correctly.
Haematomas are very rare complications, but need to be evacuated rapidly. They tend to occur in the hours following the operation. The risk of haematoma rises considerably when medicines that can cause bleeding are taken pre and post-op.
In the first hours after the operation there is generally moderate bleeding. Exceptionally, a haemorrhage can occur needing treatment in the operating theatre.
As in any plastic surgery operation, the quality of healing is not known in advance. Immediately after the operation a scar can inflame or weep, requiring specific local treatments that can often be long. Respect of advice concerning cleanliness, stopping smoking and attendance of monitoring sessions will be decisive. In the mid-term, in case of a temple implant, a scar can sometimes develop poorly: thicken, expand, form keloids. This principally depends on the type of skin (red or black skins experience more problems) and health behaviour (cigarettes and the contraceptive pill increase this risk.)
Risks from anaesthetics
Anaesthetic techniques and monitoring methods have improved immensely and safety is high when an operation is performed in non-emergency conditions on a person in good health, when the anaesthetist is competent and working in a recognised establishment. However, the effect of anaesthetics on the body can be difficult to predict and treat. Therefore there are still risks and hazards inherent to all anaesthetics before and after the operation. This is why it is imperative that you consult the anaesthetist prior to the operation and fully inform him of the state of your health. In function of your health and the planned operation, he will assess the risks related to anaesthetics and tell you of any potential precautions to take. If the anaesthetist objects to the operation, this decision is final.
(see in chapter ” Before surgery ” section “Check up and anaesthetic consultation“)
Risks during any aesthetic operation: asymmetry, a result judged as insufficient or excessive, need to touch up results, sensitivity issues
The way in which tissues react to an operation is always specific and, to a certain extent, unpredictable. It depends on the patient correctly following the doctor’s recommendations, but luck also plays a role. This is why all risks of asymmetry, unsatisfactory or excessive results and the need to touch up results are evoked prior to any aesthetic operation.
Malar and temple – specific issues:
Imperfections of the result
Certain problems linked to results stem from misunderstandings between the patient and surgeon concerning the aim of surgery or from decisions taken without due consideration. This risk can be limited by good reflection prior to the operation.
Other problems are caused by unexpected tissue reactions specific to the patient that can lead to an excessive, insufficient or asymmetric result. This risk especially concerns patients with a poor quality of skin, but retractile fibroses are always possible. If resulting imperfections are not easy to bear, they can potentially be surgically touched up, generally much less intense than the first operation. But it is necessary to wait until the end of the healing process before proceeding to a second operation.
Cheek bone operations can lead to generally temporary problems (3 to 6 months) of sensitivity in the upper lip and cheek bone areas.
Necroses and skin seizure
These are rare but still possible. Simple wounds or erosions usually heal without leaving marks, whilst necroses, also rare, require specific care that is often long and leaves a small scar. The risk increases greatly if a patient smokes or through traumatisms.
The operation of the malar area requires that the surgeon work very near the mouth’s nerve hub; this can mean that there is an exceptional yet generally transitional change in the mouth’s expression.
The operation in the temple area requires that the surgeon work near the forehead’s nerve hub; there can be an exceptional and generally temporary change in the elevation of the eyebrows.
It is possible to make a first evaluation of the results two or three months after the operation . However, scars and tissues can experience an inflammatory peak at that moment, which is why it is often necessary to wait for nine to twelve months to see a final result.
Usually an appreciable aesthetic result is achieved with real psychological benefits.
By way of conclusion, we remind you that precise and detailed information, an in-depth analysis of the reasons for the operation, teamwork between the patient and the surgeon during the preparatory phase, the search for surgical excellence coupled with a good analysis of benefits and risks, the respect of pre-op and post-op advice and regular monitoring of the patient are all key elements for aesthetic surgery to be a success.
Specific information delivered on this website is based on Doctor Le Louarn’s practice. The following publications and works can also be listed (this list is obviously not exhaustive and may be amended) :
1 – YAREMCHUK M.J. : Secondary malar implant surgery
Plast. Reconstr. Surg. 2008 Feb ; 121(2):620-8
2 – LOWE N.J., GROVER R. : Injectable hyaluronic acid implant for malar and mental enhancement
Dermatol Surg. 2006 Jul ; 32(7):881-5
3 – TESSIER P., KAWAMOTO H., MATTHEWS D., POSNICK J., RAULO Y., TULASNE J.F., WOLFE S.A. :
Autogenous bone grafts and bone substitutes-tools and techniques: I. A 20,000-case experience in maxillofacial and craniofacial surgery
Plast Reconstr Surg. 2005 Oct ; 116 (5 Suppl) : 6S-24S
4 – TERINO E.O. : Chin and malar augmentation
Chapter 6 in Complications and Problems in Aesthetic Plastic Surgery
Edited by George C. PECK – Gower Medical Publishing 1992 : ISBN 0-397-44613-6