Cheek (Malar) Implants & Other Augmentation Options

Once upon a time only silicone implants and bone grafts were used, now there are many options.  Believe it or not, cheek implants have been around since about 1956.  Here is a list of the most popular methods and products for cheek augmentation, including autologous (from your own body) mediums, injectable fillers and implants as well as the material type and manufacturer information.

Bone Grafts: There is a degree of resorption.  There may be a longer recovery time with bone grafts and an increased risk of bone infection as well as excessive calcifications.  The donor site, if using your own bone, is also an issue which can be subject to a secondary site infection or other complications.  Below is an explanation of how bone grafts are incorporated: 

  • "1) Induction:  Activation of host osteoblasts and differentiation of primitive mesenchymal cells into chondroblasts and osteoblasts.

  • 2) Inflammation:  Graft invaded by PMN's and its cellular elements are degraded.  Neurovascularization and mesenchymal proliferation follow.  Small avascular autografts can become vascularized within 4-5 days.

  • 3) Soft tissue callous formation:  The cellular matrix of the invading granulation tissue becomes more dense and the vascularity increases.  Osteoclasts continue to remove dead bone, while chondroblasts deposit a new matrix of chondroid on the old bone; this begins to calcify.  In cortical bone there is a preferential removal of necrotic Haversian systems rather than lamellae leading to an increased porosity of the graft.

  • 4) Hard callus formation:  Osteoclasts continue to remove dead bone and also begin degrading calcified cartilage, while osteoblasts lay down membranous bone to replace it.

  • 5) Remodeling:  Graft is remodeled into lamellar bone and a medullar canal is established".  credit: Yale Medical University Core Curriculum

Cadaveric Bone Grafts: These bone grafts come from cadavers (from deceased donors) and are used the same way as your own.  The chance of rejection is slightly higher but very rare.  The way a cadaveric bone graft is incorporated is the same as above but without, of course, the donor site risks and complications. 

Autologous Tissue Grafts (excluding fat): This is the use of your own tissue from elsewhere on your body and is usually not the best choice for cheek augmentation.  Although there is no chance of rejection as it is your own tissue, there is a high degree of absorption as well as the risk of an additional site infection or contour irregularities at the donor site.  

Autologous Fat Transfer (Fat Grafting):  Fat transfer, more commonly known as Fat Grafting, is also referred to as free fat transfer, autologous fat grafting/transfer/transplantation, liposculpture, lipostructure, volume restoration, micro-lipoinjection, fat injections, f/g and even the "Space Lift(R)".  For Simplicity, Fat Grafting will be used from here on. 

Fat Grafting or Fat Transfer is the procedure to remove surplus fat cells with meticulous extraction methods and to re-implant where needed - to the cheek and other places such as the lips, nasolabials (mouth to nose folds), undereyes, cheeks, temples, etc.   This is a very exciting procedure as it is not incredibly invasive, produces natural results, but does create a moderate amount of swelling.

However, fat can be resorbed by the body and sometimes only a certain percentage is permanent although newer techniques are resulting in increased longevity.  Although it seems the longevity of fat in the cheeks is actually pretty good if performed correctly.  If you would like to know more please visit the Fat Grafting page on www.FacialPlasticSurgery.net.

Cadaveric Tissue Grafts & Cultured Tissue:  Cadaveric tissue grafts are derived from deceased donors.  Although most of this tissue was "donated", some companies have chosen to profit by their donations and sell the tissue at exorbitant costs to patients who desperately need it.  In a 2 billion dollar a year market, many times these tissue grafts are not available to or are too expensive for burn patients -- yet find their way in plastic surgery operating rooms.  On the other hand, companies such as Advanced Tissue Sciences, BioSurface Technology, Dermagraft-TC, Genzyme, and Organogenesis (Graftskin(TM)) extract cells from purchased foreskins which have been excised and sold by hospitals to culture skin in petri dishes and large trays.  These products were originally processed and approved for skin replacement in patients with large burns or diabetic ulcers.

AlloDerm (Lifecell Corp.): (technically: Acellular human cadaveric dermis) AlloDerm is made by LifeCell Corporation in Palo Alto, California.  The Tissue Banks surgically remove a thin layer of skin tissue (an allograft) from the 'donor' at the time of death, place it into an antibiotic solution and transport it to LifeCell Corp.  There, the allograft is processed by removing the epidermis and all of the cells in the dermis which may cause rejection.  The resulting AlloDerm graft is the protein framework without any of the donor's DNA.  This material is also used for dermal augmentation, to cover implants on the cheek, chin and nose, as well as augmentation of the lips (mobile soft tissue).  It reportedly lasts up to two years and in some instances, indefinitely if proper collagenation of the scaffold occurs.
Website: LifeCell Corp.

AlloGraft:  Also provided by both cadaveric and family donors. This product is typically used for skin replacement and "slings" for patients suffering from a "falling bladder" or injectable form for urinary incontinence. Has been used for soft tissue augmentation.

Apligraft: This product is cultured from infant foreskin cells and bovine (cow) collagen.  The tissue is primarily used for the replacement of skin in patients needing reconstruction.  Although, it has been used for soft tissue augmentation.

Silicone Implants: Solid silicone has been used as a material for facial implants since about 1956.  The silicone facial implants are solid, yet flexible and very durable.  They are manufactured in different durometers (degrees of hardness) to be soft or quite hard.  These implants are designed to enhance soft tissue areas and not the underlying bone structure.   They are usually easily removed as they are quickly encapsulated by scar tissue.  Some surgeons affix cheek implants to the bone by way of one or several titanium screws per implant. When used for cosmetic purposes this implant rarely exhibits a biochemical reaction.  However, when used in functional surgeries such as TMJ disorder or hip replacement, fragments can rub off of the implant and cause inflammation within the joints.

  • Popular Manufacturers Of Silicone Implants:

    • Surgiform: Surgiform Technology, Ltd. is an Ohio based bio-medical company that specializes in developing, manufacturing and distributing polymer based aesthetic surgical implants and devices for plastic, cosmetic and reconstructive surgery. Surgiform offers a complete line of pre-formed silicone facial implants including nasals, chins and malars. We also offer a full range of custom implants for body contouring such as pectus, calf, carving blocks, and cranial plates. Surgiform can work from a sketch, plaster moulage, or CT scan data to create a custom implant for your patients' specific requirements.
      Website: Surgiform Technology, Ltd.

    • Implantech: Implantech has over 140 sizes and shapes of facial implants in stock at all times.  They produce a few new models often and offer a custom 3D scan by using the patient's MRI scan.  The result is a fully customized fit.
      Website: ImplantTech Associates

    • Inamed Aesthetics (formerly McGhan Medical): These implants are made from a standard implant grade silicone elastomer and are available in soft, medium, and firm durometers.  They have several pre-formed configurations but not to the extent of some manufacturers.
      Website:  Inamed Spectrum Facial Implants

    • Advanced Bio-Technologies, Inc.: This company has limited types but does offer carvable blocks (unsterile) like the other companies.  Silicone carving blocks and pre-made implants are made of implant grade silicone elastomer and are available in soft, medium, and firm durometers.
      Website:  Advanced Bio-Technologies, Inc.

    • Allied Biomedical: These implants are made of a carvable, solid silicone elastomer designed for permanent implantation.  Facial implants are provided sterile in a sealed packaged until ready for use or for customization. Implants may be trimmed with a scalpel or scissors to meet the individual patient's needs.
      Website:  Allied Biomedical

Expanded Polytetrafluoroethylene (ePTFE): These implants are porous and utilize the benefits of tissue integration as well to keep it in place.  Not as firm as the more harder silicone implants.  There is less bone resorption underneath (ePTFE) implants as opposed to silicone implants.  When used for cosmetic purposes this implant rarely exhibits a biochemical reaction.  However, when used in functional surgeries such as TMJ disorder or hip replacement, fragments can rub off of the implant and cause inflammation within the joints.

  • Popular Manufacturers (ePTFE) Implants:

    • Gore-Tex (Gore Industries Worldwide): This material is made from expanded polytetrafluoroethylene (ePTFE).  It is known as Gore S.A.M. (Gore subcutaneous augmentation material) and is made of biocompatible, micro-porous ePTFE which supports rapid tissue incorporation.  It is flexible, soft and yet very strong, Gore S.A.M. is available in pre-formed configurations (facial implants and the like) as well as sheets and blocks.  The pre-formed Trimensional 3-D shapes improve the outcome of malar, chin and nasal reconstructions or other cosmetic augmentations.  An added bonus is that it can also be easily carved for further customization. 
      Website:  Gore Medical Products

    • SoftForm: The SoftForm implant is also made of ePTFE (expanded polytetrafluoroethylene) and can also be carved.  This implant is flexible, soft yet very strong and rarely causes inflammation when used for cosmetic purposes such as cheek augmentation.

Polyethylene Implants: These implants are bio-compatible and reportedly place no extra stress on the body or effect it whatsoever.  Not saying that Silicone does, it's just another option for your cheek augmentation.  They are porous and rely on tissue integration instead of titanium screws for stability. These are more difficult to remove but do produce excellent results if placed correctly. 

  • Popular Manufacturers Polyethylene Implants:

    • MEDPOR Biomaterial (Porex): MEDPOR is made of a lightweight, porous form of high-density polyethylene. This material has a long history of medical applications without any reported harmful effects. This implant's porous texture allows tissue to incorporate into the implant, to prohibit "shifting". The shape and size can be customized by your surgeon to fit your individual needs. MEDPOR is also widely used for facial repair following trauma and for corrections of congenital defects. Although its porous feature can be its downfall, for a porous implant, after tissue incorporation, is more difficult to remove without destruction of tissues. 

Hydroxyapatite Implants: Medical Science has come up with a way to alter coral into an even closure match to bone and that is called Hydroxyapatite or simply, HA.  It has both the porous structure and chemical make-up of bone so that the body accepts it wholeheartedly and even incorporates normal tissue integration and not capsulization like synthetic implants.  A patented process converts Calcium Carbonate into hydroxyapatite while maintaining the three-dimensional integrity of the coral yielding Coralline Hydroxyapatite (CH). All the proteins are removed by intense heat. This renders the structure totally non-immunogenic so it becomes a nearly perfect bone lattice. Closest to bone grafts but without the bone. 

So how exactly is HA made? "The synthetic material is prepared by heating the coral-which is essentially calcium carbonate with ammonium phosphate at more than 200º C for 24 to 60 hours to obtain about 95% Hydroxyapatite. The material is processed into block or granular form and sterilized by gamma radiation". (American Chemical Society)

How long does it last you ask? "The natural porosity of the material does have the drawback of reducing its strength, notes David C. Mercer, Interpore's president and chief executive officer. But the porous structure provides room for bone tissue to immediately grow into the pores of the implant. However, the material is only partially resorbed and replaced by natural bone. The company is now evaluating in pre-clinical studies a related new product that has a higher resorption rate". (American Chemical Society) 

*Also available in an injectable or spreadable, non-porous paste. See below.

Injectable Tissue Augmentation Products: These products offer ease of placement with less downtime although the permanent micro-implants are not easily removed.  Some products are temporary and could be used to "try on" what cheek augmentation would look like although asymmetry is possible as the injectable solution is, of course, not pre-formed and subject to migration within the first few minutes to days.

  • Popular Injectable Products:

    • Collagen (technically: suspended bovine collagen):  The most commonly used injectable bovine collagen product in the Unites States is Zyderm and Zyplast.  This product is an injectable bovine-derivative (made from cow collagen) and you will need to have a skin test prior to any treatments.  To determine if you are eligible for collagen treatments your doctor will inject a small amount of collagen usually into your forearm just below the skin's surface.  You should watch the injection site closely for at least 4 weeks for signs of inflammation (red, swelling, itchiness, etc.)  The majority of test reactions occur within the first 3 days, but it CAN happen anytime within this time frame.  About 1 in every 100 tested patients have a negative reaction and cannot be treated with injectable collagen. 

      Collagen injections do cause discomfort without a prior injection of regional anesthesia.  Although there is lidocaine inside of the syringe the initial injections do cause slight to moderate pain.  Especially that not only are they injecting the local anesthetic, they are injecting the thick collagen.  After a bit of collagen is injected into your lip the doctor/nurse has about a 3-7 second window to "massage" your lip and smooth out the collagen within before it firms up.  Half of the injection consists of the saline carrier so you will look very swollen for about 1 to 3 hours until your body absorbs the saline. You may have a few minor bruises at the injection sites.

      • Allergy Test: Required

      • Longevity: 1to 5 months. This is a temporary solution and is not recommended for long term cheek augmentation.

      • Approximate Costs: $325.00 for 1.0 cc, $425.00 for 1.5 cc, and $525.00 for 2.0 cc

      • Special Note: Is injected into the dermis, not the muscle.  Injectable bovine collagen is a cream color and patients report a blanching effect which can be visible under the skin.

    • Hyaluronic Acid: There are now many manufacturers of hyaluronic acid products (namely Q-Med Laboratories of Sweden which makes Restylane & Perlane).  Q-Med's products' chemical make up is based on a non-animal hyaluronic acid.  Hyaluronic acid gels are injected into the dermis or lips.  No pre-test in necessary is needed as one of it's main components, Hyaluronic acid, occurs naturally in the body.  Hyaluronic acid is a substance found in all living organisms.  If injected within wrinkles, it lessens the appearance of such.  Once injected it works together with your body's own hyaluronic acid and lasts longer than bovine-derived collagen.  The entire Q-Med hyaluronic line is based on the same type gel from highly concentrated (20mg/ml) stabilized hyaluronic acid - the different "grades", or versions, just vary in particulate size.  There are other companies which have begun marketed non-animal and animal-based products so be sure to inquire if you choose to use these products.

      • Allergy Test: reportedly not necessary, although some offices suggest it just to be safe.

      • Longevity: Hyaluronic Acid Gel is not permanent, it eventually absorbs into the body. Hyaluronic Acid Gel typically lasts 3-6 months in most patients. Hyaluronic Acid is a temporary solution and is not recommended for long term cheek augmentation.

      • Approximate Cost: 1cc  $250 to $500. Prices are approximate.

      • Special Note:  Some allergic reactions have been reported by a few visitors to our website, but are still considered very rare.

    • Injectable Hydroxyapatite Paste:  There are also injectable paste forms of HA.  Some surgeons have suggested separating the periosteum [: the membrane of connective tissue that closely invests all bones except at the articular surfaces] from the facial bones as proper incorporation and osteoinduction (integration of bone) is not compromised.  However, HA paste is not porous and usually osteoinduction is not possible. Resorption is very possible.

    • Poly-methyl (methacrylate) (PMMA): This product is best described as Microscopic polymethyl-methacrylate beads suspended in a vector such as bovine collagen, hyaluronic acid and the like.  PMMA was discovered in Germany in the early 1900's.  PMMA in conjunction with medical implantation usage dates back to 1936.  Common usage for PMMA include bone cement (like Palacos), dentures, artificial eye lenses, pacemakers (like Lucite, Palavit and other brands). The PMMA is formulated into microspheres (extremely small round bits) and blended with 0.3% lidocaine for comfort and collagen (3.5%) (or hyaluronic acid) as well.  

      It is injected deep within your skin (the Dermal level) through a tunneling technique with a hypodermic needle. Your injector inserts the needle and pushes the plunger to deposit the the PMMA at the same time pulling the needle out. Thereby leaving a little cylindrical deposit of PMMA left in place of the injection tunnel. There are only a few individuals (0.1%) that may have a reaction to PMMA; PMMA reportedly, is an inert substance and reported as well-tolerated by the body. Of course if the products vector (delivery agent) is bovine collagen, it will degrade within 2-5 months and the microspheres of PMMA are encapsulated (surrounded) by your body's own collagen in about 2-4 months. Thus networking added tissue augmentation without migration of the microspheres. 

      • Popular PMMA Manufacturers

        • Artecoll Artecoll is marketed in Canada by CANDERM, INC. and in Mexico by Grupo Venta International of Guadalajara (1-800-368-4600). In the US it will be distributed by Artes Medical, Inc. in San Diego, California. The inventor can be reached at Artes Medical. The first use for tissue augmentation was in 1989 and it is reported that in the last 10 years, more than 100,000 men and women have been successfully treated with Artecoll. This product can be used successfully for injectable augmentation however, any considerable augmentation problems would best be corrected with an implant. Please see their Artecoll website at  www.artecoll-usa.com for more information

          • Allergy test: Required, due to the collagen carrier

          • Longevity: permanent

          • Approximate Cost: $400.-$900 per cc. The cost for Artecoll in Alberta,

          • Canada $800.00cdn per syringe 

        • MetaCrill: "MetaCrill is an implant composed with microspheres of polymethyl-methacrylate (PMMA) 20 to 80 Mc micra diameter-- suspended in a chemical coloid, biological inert, composed of carboxi-gluconate-hidro-lactic of magnesium.  The proportion microspheres x coloid is 30%. It is stable in normal temperatures and does not need to be kept refrigerated. It is bio-compatible, non-absorbable and provides permanent correction of any depression in any part of organism introduced."  This product can be used successfully for injectable augmentation however, any considerable augmentation problems would best be corrected with an implant. MetaCrill Bio-Implante

          • Allergy test: reportedly not necessary
            Longevity: permanent
            Approximate Cost: The cost for MetaCrill in Mexico, is $500. to $1,000. per treatment 

    • Hydrophilic Polyacrylamide Gel: Also known as "acrylic hydrogel",  "Hydrogel" or "HPG". Hydrophilc means "having an attraction to water". This product is usually a combinations of polyacrylamide (5%), a synthetic polymer, suspended within apyrogenous water (95%).  Unlike all of the other injectables, this one stays soft. After it is injected and after the water is absorbed by the body, the HPG remains pliable and plump like your own soft tissue, not hard like bone. The hydrophilic polyacrylamide retains fluid - so your own fluids keep it plump.

      • Popular Hydrophilic Polyacrylamide Products:

        • Interfal Gel: Interfal was the original Ukrainian product and had many problems with inflammation. It is no longer available.

        • Formacryl: This is a Russian first generation product made by (Bioform) that you made have heard about.  This product is no longer being manufactured and has been replaced by the next product, Argiform.

        • Argiform: This is the second generation product by Bioform of Russia with less residual unpolymerized acrylamide and also has an added antibacterial property due to the addition of silver ions.

        • Bioformacryl: This is an Italian-made chemical replica of Formacryl.

        • DermaLive: This is a French Product which is also similar to Formacryl.

        • Aquamid: This is also another polyacrylamide product.

        • Bio-Alcamid: Reportedly an exact chemical replica of Formacryl.

        • Amazing Gel: Reportedly an exact chemical replica of Interfal.

    • Injectable Silicone (polydimethylsiloxane oil): Liquid silicone injections are NOT FDA approved for cosmetic applications. In fact, it is illegal to advertise silicone injections for cosmetic applications (except for clinicals with SilSkin) in the US. However there is a loophole which allows any approved medical device to be used by any physician on any patient as he or she sees fit.  Injectable silicone is reported as being very unpredictable and having quite a few inflammatory responses.  

      • Popular Injectable Silicone Products:

        • Adatosil: This product is NOT approved for cosmetic use and is only FDA approved as a retinal tamponade in ophthalmic use.  This product has been used off-label for wrinkles, soft tissue augmentation and more and has resulted in tissue necrosis, infection, fibrosis and more.  We can not recommend it for soft tissue augmentation.

        • Silikon 1000: This product is NOT approved for cosmetic use and is only FDA approved as a retinal tamponade in ophthalmic use.  This product has been used off-label for wrinkles, soft tissue augmentation and more and has resulted in tissue necrosis, infection, fibrosis and more.  We can not recommend it for soft tissue augmentation.

        • SilSkin: This product is also an injectable form of liquid silicone oil.  It is considered "medical grade" or "pure silicone" and may still cause granulomas, migrate into surrounding tissues and cause tissue necrosis. SilSkin is entering clinical trials for cosmetic applications.  Although we can not recommend any injectable silicone oil for cosmetic use, SilSkin believes that the completed clinicals will eventually show their product has the upperhand in the market of over any other silicone products. 

 

References
Photo:  Surgiform Technology, Ltd.
Paul Sabini, MD; Anthony P. Sclafani, MD; Thomas Romo III, MD; Steven A. McCormick, MD; Rubina Cocker, MD - Modulation of Tissue Ingrowth Into Porous High-Density Polyethylene Implants With Basic Fibroblast Growth Factor and Autologous Blood Clot 
Yale Medical University Core Curriculum
Dept. of Otolaryngology, UTMB, Grand Rounds, Chin and Malar Implants, September 6, 1995 Resident physician, Michael Bryan, M.D. faculty, Karen Calhoun, M.D. 
Dept. of Otolaryngology, UTMB, Grand Rounds, Chin and Malar Implants, April 17, 2000; Ravi Pachigolla, M.D. faculty, Karen Calhoun, M.D. 
Merriam-Webster Medical Dictionary
American Chemical Society
Silver, WE, Malar augmentation. Facial Plast Surg 1992 Jul;8(3):133-9.
Constantino PD; Freidman CD Synthetic Bone Graft Substitutes. Otolaryngologic Clinics of North America 1994 Oct; 27(5):1037- 1074.

 


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