Dr Terino - Cheeks

People meet you by looking directly at your face, eyes, and nose. Of course, the remainder of the features makes a difference as well, such as the chin, the lips and the eyebrows. But, the shape of a cheek is the major structure which forms an attractive foundation for the face. The other features such as eyebrows, eyelashes, lips, skin and hair are of secondary importance. Finally, the chin and jaw line, as well as an attractive nose, puts the finishing touches on an excellent basic foundation of facial structure to have a face be called attractive and more beautiful.

Implants of various materials, from bone to plastic to paraffin wax, oils, liquid silicone, jellies, and other substances have never worked in the face and indeed have created nothing but very serious problems with infections and permanent deformities of all kinds that cause ugliness. Current facial implants used by The Hospital Group plastic surgeons are made exclusively of silicone rubber which has been proven harmless through extensive scientific research over the past 60 years. It does not stimulate cancer and other diseases at all. There are very small chances of infections around the silicone rubber implants that mostly have everything to do with the technique of surgeons. Excellent facial implant surgeons have only a very small (less than 3%) incidence of infections. Moreover, over 90-95% of infections around silicone rubber implants can be cured and resolved without removing the implants.

Other substances such as Medpor, Porex, hydroxyapatite, Bio-Alcamid, and a host of others that are still being used outside the United States, are not approved by the Food and Drug Administration, because significant infection problems which occur from their implantations even months to years into the future. Facial implants such as cheek implants are very short procedures requiring only 30-45 minutes of time to perform. They are inserted through small openings of approximately ½ - 1 inch inside the mouth or under the chin for chin implants. Cheek implants have no pain following surgery, although the swelling is significant and may last for several weeks and even a month or two. The final definition that comes from these implants, which are uniquely anatomically designed to imitate Mother Nature by Dr. Edward O. Terino, the international pioneer in this field, are not fully evident for perhaps 6 months or 1 year. An excellent improvement, however, is noticed immediately within a week or 2. The chin and the jaw line are also very special parts of the face which also create attractiveness or beauty.

Standards of beauty change over decades and centuries. Currently in this time period, faces with very marked structural foundations and overlying structures in the chin and jaw line, as well as the cheeks and the nose have become highly sought after and appreciated by both the observer and the owner of these facial characteristics.

Shapes of chins and jaw lines come in many varieties and sizes from a round chin, to a pointy chin, to varieties of square chins. Also, the angle of the jaw in the back comes in many different sizes and shapes as well, and that are tremendously important along with the cheeks and the nose in establishing the overall appearance of both men and women’s faces.

Today, people are attracted to and personally desire to have more definition of the chin, the jaw line, and the cheekbone areas. Strong classic noses are now preferred over small, turned up, cute “button” noses by most people.

The size of the chin, jaw, cheeks and nose all interact together so that when one or more is larger the other one will appear smaller. This of course also works in reverse. A chin and nose can appear too strong when cheeks are very weak or flat.

Chin and jaw operations, again, are minimally invasive. The implants are placed directly on the bone and there is no interference with the tissues that are above the bony foundation, which consists of muscles, nerves, and fat in the face.

Facial implants placed in the cheek and mid face stay in position when they are placed on bone. The body forms a layer of scar tissue over them that compresses them against the bone so that they are not able to move. They look and feel like the patient’s own natural anatomy. Once again, this is because of the anatomical designs created by Dr. Edward O. Terino as a pioneer in this art form in the 1970s and 1980s.

Today’s minimally invasive facial implant improvements are entirely due to the unique anatomical designs in all these areas of the face created by Dr. Edward O. Terino, who pioneered this art form in the 1970s and 1980s.

Throughout the centuries man has bestowed admiration and power to the possessors of beautiful faces. Although the standards of beauty substantially change from time period to time period, decade to decade, and generation to generation beauty has profound effects upon both those who perceive it and those who possess it. Facial beauty represents the most desirable goal because communication with other people is mutually directed at the eyes and facial region. The rest of the body is camouflaged with clothing most of the time.

Facial aesthetics, therefore, is important in today's society where anatomical surgical operations to improve attractiveness have become a reality rather than a science fiction fantasy. The sculptural "shape" of a face has been appreciated by artists forever. A sculptural face by definition means it's three dimensional form, which includes the many anatomic parts which have volume and mass and interrelate through their neighboring position to each other. The location, relative size and shape of these parts create the topographic contours of the face. Therefore, to sculpt a face the contours have to be altered by manipulating the specific anatomic elements in specific locations to create or enhance facial attractiveness. This involves working with both the skeletal foundation of the face and its more external soft tissue layered covering.

The skeletal foundation gives definition and structure to faces. In today's world definition and structure in faces is considered attractive or beautiful, both in youth, and even more so during the aging process. It is the shape of the facial skeleton that determines the contours which are reflected through the overlying soft tissues.

Plastic surgery techniques today provide plastic surgeons with the ability to augment the facial skeleton with materials, such as silicone rubber. These techniques are the essence of sculpturing faces aesthetically in three dimensions. There are a number of other ways to alter the soft tissue covering of the face with cosmetic surgery procedures, such as autologous fat injections, but in the opinion of this author these methods are less predictable, less precise, and less lasting than alloplastic augmentation.

Our own technique for alloplastic augmentations originated from Dr. Terino’s experiences in reconstructive surgery. Traumatic injuries to the facial skeleton, such as those that are encountered in severe automobile accidents and cancers of the head and neck, had severe technical limitations twenty-five years ago. The ability of plastic surgeons to repair and reconstruct both the soft tissues and the skeletal foundation accurately and precisely with maxillofacial techniques present at that time was less than desirable. Crude alloplastic materials were applied to the surface of the bones in the cheeks and jaw line to attempt adequate reconstruction. It was my opinion that then alloplastic materials could provide great benefit, except for problems from both the crude shapes , as well as from the techniques themselves. Complications such as infections, extrusions, and malpositional deformities were not infrequent.

As a young practitioner starting practice Dr. Terino believed there was a great need for alloplastic implants that could provide a greater aesthetic benefit to people's faces. Dr. Terino’s own personal perception since youth was that strong and bone structure and defined contours in both the cheeks and jawline area gave actors, actresses, models, etc. a more attractive appearance. A human skull and some molding clay were all that were necessary to create natural anatomic shaped implants designed to contour and fit snugly to the facial bone structure. This simple idea was the beginning of a new era of facial sculpting and contouring using alloplastic materials. This brief history of how extended anatomic chin implants were born in 1982, was followed quickly by the Terino malar shell design in 1984. However, ten years of careful observation and cautious and judicious "experimentation" were necessary to slowly modify shapes for the malar mid-face and chin jaw line that have resulted in today’s final and best shapes .

Only the details of technical execution (i.e. shape, size and positioning), needed to be worked out through experience, to provide the plastic surgery specialty with this new and final frontier for facial cosmetic surgery. Because standard facial tightening and lifting procedures are two-dimensional, permanent alloplastic implants which are the last chapter in 21st century aesthetic facial surgery contour faces in three-dimensions.

Alloplastic facial sculpting also allows compensation for facial asymmetries, which are extremely common, if not universal. These asymmetries become particulary evident in the aging process, secondary to the thinning and shifting of the soft tissue facial coverings of the face which aging products. Different size and shape implants can be used on one side to the other to improve facial asymmetries. The techniques of selecting the appropriate implants and positioning them properly is very creative art form, but not one that is impossible to learn.

In alloplastic facial contouring there is a need to analyze subtleties of facial contours. In the future one hopes that computer software will be able to simulate changes in facial contours and produce specific data that will enable surgeons to select implant sizes, shapes and positions with scientific precision and accuracy. At the present time, however, these decisions can only be made by devoting substantial time preoperatively with patients to analyze their faces and communicate intimately with them about their specific wishes for a desired outcome.

A scientific and precise method for analyzing the bone structure of the malar mid face, chin and jaw line, is necessary helpful for the surgeon when he selects the best therapeutic approach. The malar mid-face is devided into five zones: Zone 1, the major body of the malar bone extending to the middle of the zygomatic arch; Zone 2, the middle third of the zygomatic arch; Zone 3, the perinasal zone including the tear trough suborbital area; Zone 4, the posterior zygomatic zone overlying the temporal mandibular joint; and Zone 5, the extremely important submalar zone, which contributes significantly to giving an aesthetic convex mid-face curve in the submalar area just beneath the lower border of the malar bone.

Similarly fashion, the lower third premandibular segment can be characterized by four zones: 1) the central mentum extending to the mental foramen (CM), which is the traditional site for a traditional limited central chin implant; 2) the mid-lateral zone (ML), extending from the mental foramen to the oblique ridge of the lateral mandibular ramus. This is an area which when augmented expands the width of the lower jawline; 3) the posterior lateral zone (PL), contains the posterior angle of the mandible as well as the ascending ramus. This segment produces definition and expansion of the posterior aspect of the facial jawline; and 4) the very special submandibular zone (SM), which exists beneath the central mentum and the mid-lateral zone. This area can be expanded in two directions to benefit and balance a face in a vertical dimension by increasing its height as well as its projection.

Webster's dictionary defines aesthetics as “the study of beauty and the emotional responses to it”. Facial aesthetics constitutes the study of how to apply cosmetic surgery techniques to enhance the attractiveness of a human face, to even being considered beautiful. Creating a harmonious facial balance is of major importance in determining aesthetic facial beauty. Facial balance involves the expansion or contraction, that is the increase or decrease in size, form, shape and volume of several major segments of facial anatomy that have been long recognized by artists as having the greatest contribution to overall facial form. These major elements of volume and mass are 1) the malar mid-face; 2) the nose size, width, and projection; 3) and the lower third facial segment volume and size, specifically that of the chin and the mandible, which comprise the “jawline”.

Changing the size, shape and volume of any one or more of these areas, affects the appearance of the third area. An alteration (increase or decrease) of size in volume of one area makes the other two areas greater or lesser in significance. Therefore, the art of sculpting faces in three dimensions necessitates analyzing the elements of facial balance and being able to adjust sizes, volumes and masses favorably by using of alloplastic facial implants.

Further analysis, easy for surgeons to learn, consists of evaluating of faces by regional types, each type having a specific volume deficiency in a specific anatomic location.

For example, a Type I regional volume deficiency is characterized by a flatness in the malar zygomatic bone region, while at the same time there is a relative fullness in the mid-face submalar zone region (SM 5). Such an observed deficiency is corrcetable by placing an appropriately sized Terino malar shell into the zone 1 and zone 2 regions. This provides a stronger high cheekbone contour with some widening of the upper part of the face.

A Type II face is characterized by a submalar deficiency. These patients have adequate malar bone prominence with a relative deficiency of soft tissues in the submalar mid-face region that may be an inherited weakness or an aging change due to shrinkage of fat in the face. In aging patients, shrinkage can produce a tired, drawn or emaciated look. If there is an extreme sunken appearance in the submalar region, it is characterized as a Type III deficiency. Both Type II and Type III faces are corrected with Terino malar shell implants placed in the submalar region.

The average thickness for a malar mid-face implant is 4 mm. This provides an excellent contour for 98% of faces. The only other parameter to be mastered by the surgeon is the size of the implant. Small, medium, large, and extra large sizes, all have a larger surface area that also possess a 4 mm. projection. Implants measuring 5, 6 and 7 mm. in thickness are also available in all sizes for augmenting greater volume deficiencies and the very common facial asymmetries.

The above facial types constitute only three of the half a dozen or more volume deficiencies of the face which can be corrected by alloplastic implants which have been designed by plastic surgeons. They are all commercially available from, IMPLANTECH Corporation, located in Ventura, California.

Similar to the midface, there are a variety of implants specifically designed to augment the premandible zones. This includes a posterior angle implant and an assortment of implant shapes to augment the central mentum (CM) and mid-lateral(ML) zone. These can produce greater or lesser squaring of the anterior jawline as well as increasing forward projection. There is also the previously mentioned submandibular implant, which increases the vertical dimension of the face.

Another critical factor in selecting an implant is the coice of an alloplastic material. For example, silicone rubber is a variable and flexible implant material that is smooth on the surface, and is therefore relatively easy to insert through a small incision either external or internal onto the facial bones. The design of anatomic implants consists of creating a posterior curvature which conforms to the shape of the bony skeleton. The margins or borders of the implants are tapered finely so they blend onto the surface of the skeleton. This minimizes or eliminates any obvious visibility or palpability. Silicone rubber implants are easy to carve, shape, and modify during surgery. They can be changed with relative ease at a later date because they do not become fixated onto the facial skeleton. They are only held in place by an external fibrotic capsule.

Other materials such as Porex and MedPore are much more difficult to shape. They are of a porous nature, which inherently has greater risk for the penetration of bacteria that might predispose to infection. Reports from experienced investigators deny the fact that medpore implants have a higher risk of infection than silicone rubber. However, it is also reported that these harder, rougher materials necessitate larger openings and more extensive dissections to place them accurately into an anatomic zone. Medpore implants are fastened to the skeleton by small titanium screws. Silicone rubber implants are only secured to the skeleton by a few plastic surgeons.

A major advantage of silicone rubber implants is that they readily accommodate in facial contouring procedures, because patients who may be dissatisfied with their result and desire either a removal or a revision.

With careful surgical technique implant risks and complications using facial implants and especially with silicone rubber, are less than 1%. This includes such sequelae as infections, extrusions, contour abnormalities, hematomas and permanent nerve damage.

Malar implant malpositions may exist in about 5 % of surgical patients, depending upon the anatomic asymmetries of a patient's face and the experience of the surgeon. Malpositions are generally not difficult to correct and require only minor adjustments. Infections, while potentially dangerous, can almost always be resolved quickly with prompt and aggressive treatment, and without the need for removing the device.

The era of facial contouring has only just begun. The demand for improvements in facial contour with alloplastic implants is rapidly increasing. However, the number of surgeons who are experienced and trained in these techniques is few. Because of the expanding demand, there are, out of necessity, more plastic surgeons who wish to learn and use these valuable aesthetic facial three-dimensional techniques.

The business of facial contouring with alloplastic implants is unique because it is almost exclusively patient driven. As mentioned before the techniques are not yet well understood by most plastic surgeons. Patients who desire facial contouring with implants are usually extremely particular and precise in their descriptions and needs. They are generally have extremely high standards, which certainly does not encourage average plastic surgeons to take on the challenge.

The business of facial implants is steadily growing and at a rapid rate. Patients are thoroughly investigating the subject, often exploring the Internet as well as the medical literature. This includes "chat rooms," in which they can communicate extensively with other patients who have had these procedures.

Marketing and public relations about facial implant procedures has not been done on a regular visible basis, other than an occasional article about the subject in some women's magazine. The general subject of plastic facial augmentation has not been exported by the media as so many other cosmetic surgery procedures have. The recent "makeover" television shows, have not looked for procedures of this type to be presented. It is the author's view that the contour of faces which now prevail in magazines, print, advertising, television, soap operas, and in the cinema, will continue to stimulate the facial implant market. This in turn will enhance patients’ requests so until all plastic surgeons who have an interest in facial surgery will want to be interested in mastering these procedures.

At the present time, the only major medical surgical text book, which describes alloplastic techniques in detail is “The Art of Alloplastic Facial Contouring” published by Elsevier Medical Publishing Co. Dr. Terino is developing a series of thorough weekend teaching seminars to comprehensively educate and teach plastic surgeon attendees the nuances and pitfalls of these alloplastic surgical procedures which he has learned well from twenty-five years of extensive experience.

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