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    Experts weigh in on how to avoid pitfalls with malar enhancement

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    58-year-old man before (left) and after (right) an endoscopic forehead lift, a vertical midface lift with ePTFE orbital rim implant and a full-face chemical peel.
    NATIONAL REPORT Cosmetic surgeons might shy away from malar implant surgery because a lot can — and does — go wrong with the complex surgery. The result: a higher-than-usual potential for unhappy primary patients, many of whom are left with the dim prospect of an even more difficult secondary procedure.

    COMMON PITFALLS A fundamental problem with malar implant surgery, according to Michael J. Yaremchuk, M.D., plastic surgeon, professor of surgery at Harvard Medical School and chief of craniofacial surgery, Massachusetts General Hospital, is that it is difficult to know exactly where to put the implants because there is no defined landmark of malar prominence. As a result, surgeons rely largely on clinical judgment. Another issue: cosmetic surgeons have to place the implants symmetrically, working in an area of limited exposure, to augment a complex three-dimensional curvature, according to Dr. Yaremchuk.

    "In addition to the problem of asymmetry, there is a tendency to put the implants too far laterally, making the face too wide," says Dr. Yaremchuk, who published a paper on secondary malar implant surgery this past Spring in Plastic and Reconstructive Surgery. "Often, surgeons make the implants too large; so, rather than augmenting the skeletal contour, they are creating a new implant contour.


    52-year-old man with profound under eye hollows before (left) and after (right) deep filling the under eye areas with a total of 4 mL Restylane without the necessity of surgery. He also had a lower face liposuction prior to the after photograph. All photos credit: Kenneth Steinsapir, M.D.
    Still other surgical approaches that lead to less-than-desirable outcomes, according to Dr. Yaremchuk, include augmenting beneath the malar area, which results in an unnaturally low cheek contour, or placing implants through the eyelids, which leads to capsular contracture and pulled lower lids.

    IMPLANT OPTIONS Not surprisingly, the implants that surgeons use can significantly impact results. Cosmetic surgeons often turn to premade malar implants, which, when inserted through the mouth, sit on the eminence of the malar prominence.

    "It's my opinion that the premade implants are placed in far too many patients, where they are not appropriate," Los Angeles ophthalmic plastic surgeon and fellowship-trained cosmetic surgeon Kenneth Steinsapir, M.D., tells Cosmetic Surgery Times.

    Implant material is also critical. Dr. Yaremchuk does not use silicone implants, for example, because the smooth implants, he says, cause capsule formation, and ultimately a relief of the implant in the soft tissue. Instead, he uses porous polyethylene implants, which do not result in the same capsular formation, he says.

    "I also fix the implant to the skeleton with titanium screws, so the implant cannot move," he explains.

    "The screws also work to apply the implant to the skeleton, which is important because it is very unlikely that the posterior surface of the implant is going to be congruent with the anterior surface of the skeleton."

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    Lisette Hilton
    Lisette Hilton is a writer in Boca Raton, Fla., who heads up her company, Words Come Alive.

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