The course of the operation when implanting the face

It should be understood that to adapt to a narrow face or thin skin, it is necessary to reduce the size and thickness of implants of standard shape and size. Since all persons are different, it is necessary to take as a rule that implants require a modification. Therefore, the surgeon must prepare all the expected designs, shapes and materials and be ready for an improvisational change in the implant. The absence of a proper implant for a particular patient can lead to an inferior result.

The day before the surgery, the patient begins to take a broad-spectrum antibiotic, the course of which will be prolonged up to 5 days after the operation. Immediately before the intervention, the antibiotic and dexamethasone are injected intravenously. The marking of the areas of expected increase is made in the vertical position of the patient. This is the primary contour that is drawn on the skin, and then the patient is explained that the final definition of the implant will be made so as to correspond to the representations of the surgeon and the patient about its shape, size and position.

General surgical technique of implantation on the face

The basic principles of an increase in the middle part of the face, in the area of the cheekbone elevation, the space in front of the lower jaw or nose are identical. The final common contour of the face will be determined by the shape, size and location of the implant.

Surgical technique of magnification in the area of the lower jaw

• Anterior mandibular implants

Access to the space in front of the lower jaw is performed either through the oral cavity, or from the outside. In the latter case, a 1-1.5-cm incision is made in the sub-chordial fold. Advantages of external access are that it does not contaminate the oral cavity with bacteria; it allows you to directly extend to the lower edge of the mandibular bone, where there is a powerful cortical layer; it does not require a strong stretching of the chin nerves; and it allows you to fix the implant to the periosteum along the lower edge of the bone with simple sutures. This helps prevent lateral or vertical displacement. The relative advantage of intra-oral access is that it does not leave a scar. Access is through a transverse incision of the mucosa. The chin muscle is divided vertically along the median suture without crossing its abdomen and attachments to the bone. This median incision provides adequate access down to the bone of the central part of the chin, and is not accompanied by a weakening of the muscle, which can occur in the case of crossing. Separation in the sides requires the allocation and retraction of the chin nerves.

The basic rules for a safe and accurate corrective procedure on the lower jaw should be as follows. Separation should go along the bone. Subperiostal implant placement creates a dense fixation to the bone. A dense growth of the periosteum along the anterior margin of the jaw is present in the region of the anterior chin ligament, which defines the anterior margin groove in the lower part of the fold of the puppet arising with age. Often it is necessary to dissect this ligamentous attachment in order to continue excision along the lower part of the mandibular bone. Separation of this space should be spread enough to comfortably place the prosthesis. In the center, sharp separation can be used, but only blunt dissection should be performed around nerves and adjacent soft tissues. The chin nerve must be preserved. To secure the fabric around the chin opening, they are pressed with an inoperative hand, which helps to guide the elevator from the nerve and along the lower edge of the jaw. For accurate visualization, dissection and proper implant placement, as well as for the prevention of postoperative hematoma or seromy, careful hemostasis must be performed.

For dissection along the lower edge of the jaw, a 4 mm Joseph periosteal elevator is used. When the pocket becomes large enough, one shoulder of the implant is inserted into the corresponding lateral part of the pocket and then bent to hold the other shoulder in the opposite side of the pocket. The implant is placed in place. If the implant material is not flexible, either a larger incision is required, or the operation is performed through the intraoral cut. Implants that reach the mid-lateral, or near-symphysis zone, give the front extension of the lower third of the face. The required average protrusion in the center is 6-9 mm for men and 4-7 mm for women. Occasionally, patients with severe micro-genesis may need implants to produce a normal profile and a wider jaw line, giving a protrusion of 10-12 mm or more.

• Implants for the angle of the lower jaw

Access to the angle of the lower jaw is made through a 2-3 cm incision of the mucosa in the retro-molar triangle. This gives a direct approach to the angle of the lower jaw. Dissection is performed on the bone and under the chewing muscle, with the periosteum up, along the branch, and then anterior, along the body of the bone. A curved (90 °) dissector is used to separate the periosteum along the posterior part of the angle and the branch of the lower jaw. This allows precise placement of implants that are specially made to fit the posterior bone edge of the ascending branch and better contour the angle of the lower jaw. Implants are fixed with titanium screws.

Surgical technique of correction of contour of cheekbones and middle part of face

The main way to access the tissues of the zygomatic area and the middle part of the face is intraoral. Other accesses include a submental (in conjunction with the plasty of the lower eyelids), transconjunctival, rhytidectomic, temporal-malar and coronary.

Intraoral access

Intraoral access is the most frequent and preferred access for the introduction of most implants into the middle part of the face, with the exception of implants for correction of gnawing deformity (V type). After infiltration of the anesthetic solution, a 1-centimeter cut is made through the mucosa, which is directed to the bone in a co-curved direction above the buccal-gumline line and over the lateral support. Since the mucosa stretches and allows you to fully examine the structure of the middle part of the face, a long incision through the mucous and submucosal layers is not required and even hinders. The incision should be made high enough to leave a minimum of 1 cm of the mucosa of the gingival cuff. If the patient wears dentures, the incision should be placed above the upper edge of the prosthesis. After the operation, the prosthesis can be left in place, which, in our experience, does not lead to dislocation of the implant and does not increase the incidence of complications. A wide elevator of the Tessier type (about 10 mm wide) is guided through the incision to the bone in the same direction as the incision. A wide elevator increases the safety of dissection, and it is relatively easy for them to work under the periosteum. Working with an elevator, directly along the bone, soft tissues separate obliquely upward from the jugular process of the upper jaw and bilious rise. The elevator moves along the lower edge of the zygomatic elevation and zygomatic arch. A free hand from the outside helps to guide the elevator in the right direction. With the usual correction of the zygomatic and subcutaneous areas, no attempt is made to see or isolate the infraorbital nerve unless the implant is required to be installed into this area. If necessary, the infraorbital nerve can easily be seen more medially. The subclavian cavity is created by separating the soft tissues down, below the malar bone and over the masticatory muscle. The correctness of the plane of dissection can be recognized by visualizing the white shiny fibers of the tendon of the masticatory muscle. It is important to note that these masticatory attachments do not intersect and remain completely intact to provide a supporting framework on which the implant can lie. As you move along the zygomatic arc posteriorly, space becomes narrower, and it is not so easy to expand as in the medial part. However, in part this space can be opened by gently separating and lifting the tissue with a powerful blunt periosteal elevator. For the passive placement of the implant in the pocket, it is extremely important that the dissection be sufficiently wide. Too small a pocket will push the implant in the opposite direction, leading to its displacement or dislocation. It is established that, in a normal situation, the pocket collapses, and most of the space around the implant closes within 24-48 hours after the operation. Precise selection of the implant is facilitated by observing the changes caused by the installation of various "calibrators" in the pocket.

The final placement of the implant must correspond to the outer contours of the area of the defect circled on the face before the operation. With a subculture increase, the implant may be located under the malar bone and the zygomatic arch, over the tendon of the masticatory muscle; it can cover both the bone and the tendon. Cheeky implants such as shells of a larger size are located mainly on bones with large lateral lateral displacement and can partially enter the subculus space. The combined implant will occupy both areas. Any implant that can be placed on patients with marked facial asymmetry, thin skin, or very noticeable osseous protrusions, may require modification with a reduction in thickness or length to prevent contouring. One of the advantages of silicone elastomer implants is their flexibility, which allows them to push through small holes, followed by volume and shape restoration in accordance with the created pockets. This makes it unnecessary to perform the large incisions necessary for the introduction of more rigid implants, and allows multiple replacement of implants during the selection of sizes and configurations.

• Asymmetry of the face

The most difficult task in improving the contours of the face is to correct the asymmetry of the face. During the pre-operative consultation, a detailed discussion of this problem is required, since most patients are usually unaware of the qualitative and quantitative expression of their facial asymmetry. To identify, understand and choose the type of correction of spatial disturbances, careful attention to detail is required. It is often possible to find adequate development of cheekbones and well-maintained soft tissue cushions with a satisfactory external contour on one side of the face and an underdeveloped cheek-like elevation with relative atrophy of soft tissues and significant skin wrinkles on the other hand. In such cases it is necessary to select adequately the available standard implants and to prepare for their individual adaptation to eliminate differences in contours from both sides. Unusual asymmetry may also require the use of different implants on each side or individual pads cut from the silicone block and sewn to the back surface of the implant to increase the protrusion of one of the segments.

• Fixation of the implant

After the implant is installed, it is usually necessary to fix it. This can be done in various ways. Fixation by internal seams implies the presence of an adjacent stable segment of the periosteum or tendon structure, to which the implant is to be sewn. You can also use stainless steel wire or titanium screws. There are two methods for fixing implants from the outside. The technique of indirect lateral fixation involves the use of Ethilon 2-0 threads on large Keith needles, with which the implant is stitched through the end. Then the needles are pierced from the inside through the pocket, in the rearward direction, and are punctured through the skin backward from the border of hair growth on the temple. The seams are tightened on the roller, creating tension at the end of the implant. This technique is more suitable for zygomatic implants. A direct method of external fixation is often used in patients with severe asymmetry or when using subculture or combined implants. In such situations, a direct method of external fixation prevents slipping in the early postoperative period. When using this technique, the implants are placed in direct correspondence with the marks on the skin, which coincide with the two most medial fenestration in the implant. The symmetry of the placement of both implants is controlled by measuring the distance from the midline to the right and left medial mark. Then the implants are removed and placed on the skin so that the medial fenestration coincides with the corresponding labels. The position of the lateral part of the implant is determined by the second label applied in accordance with the neighboring fenestration in the implant. Then, through two medial fenestrations of the implant in the direction of the posterior anteriorly, a thread with straight 2.5-cm needles is carried out at each end. Needles are pierced from the inside into the front wall of the pocket, perpendicular to the skin through the skin and punctured through the appropriate tags. On this thread, an implant is inserted into the pocket, which is fixed in place by tying the threads on the rolls, consisting of two gauze balls.

Access under the eyelashes (for plastics of the lower eyelid)

To introduce a large implant through a subliminal access is much more difficult. However, this access is preferred for the introduction of a "gum implant". Access, as with blepharoplasty, can be acceptable with an isolated increase in the cheekbones, when the introduction of a smaller zygomatic implant into the 1 or 2 zone is required to obtain high cheekbones. Advantages of sagittal access are the absence of contamination by the flora of the oral cavity and soft-tissue support from below, which reduces the likelihood of the implant dropping. However, in the presence of a weak cartilaginous basis of the eyelids, this technique can force the formation of ectropion.

Transco-cumulative access

Chronoconjunctival access is used to insert implants into the middle of the face, but it also requires the separation of the tendon of the lateral corner of the eye gap. This makes necessary subsequent cantoplasty, accompanied by a risk of asymmetry in the lower eyelid.

Rhytidectomy access

In the zygomatic space, it is safe to enter through zone I. Penetration of the subcutaneous musculo-aponeurotic system (SMAS) is medial to the zygomatic elevation, and then the bone is bluntly reached. In this area, there are no important nerve branches. The skull pocket is created, mainly, by retrograde dissection. However, the introduction of an implant through this access may encounter technical difficulties in the dissection and separation of SMAS, which limits the use of extended implants.

Chest / temporal and coronal approaches

The techniques of the subperiosteal facelift give quick access to the zygomatic area. However, endoscopic accesses, for the most part, limit the exposure and visualization needed to work with larger implants.