Achieving Facial Balance

Facial aesthetics depends on facial balance. The interrelationship of the volume-mass elements of the face constitutes the basis for attractiveness or beauty. The most major volume-mass elements of the face are the upper one third forehead segment, the malar mid face middle-third segment, the nose volume prominence, and the lower third mandibular jaw line segment.

When one or more of these predominates, the others appear less significant. When one or more of these are reduced in size, the others attain appear larger.

Now in aesthetic facial surgery alterations of volume and mass can be successfully produced with alloplastic augmentation that has permanent long-term efficacy. Although autologous techniques i.e. fat (fascia, muscle, etc.) are used and can achieve some degree of permanence, controversy still exists as to whether or not these autologous tissue changes can be permanent. Such autologous techniques need multiple treatments and donor site operations and the percentage of successful volume augmentation with each technique is unpredictable from patient to patient. These procedures do not blend themselves to the desires of today's cosmetic surgery patients who are oriented towards minimally invasive techniques, which do not remove them repeatedly from the mainstream of either their social or professional life or for very long. Autologous fat injection techniques produce extensive and extreme swelling and discoloration which persists for months. It is a well known fact that edema of the midface requires much longer to subside than that of the chin or jaw line region.

The periorbital region has traditionally been of great concern to plastic surgeons. Operations which remove skin and fat from the upper and lower eyelids have been demonstrated to produce more of an aging unattractive effect because the orbit becomes more depleted of volume from both the surgery and the aging process. Moreover, highly unattractive and deforming alterations of the lower lid are quite common with traditional blepharoplasty techniques.

It is for these reasons that the author abandoned any skin and extensive fat removal from the lower eyelid and fat removal from the upper eyelid over 10 years ago. Only minimal amounts of skin are necessary to bring about a more youthful change to the upper eyelid without drastic resection of the orbicularis muscle and fat.

In 1983, the author prompted by complaints of patients about the increased hollowness of their orbital region from traditional blepharoplasty began transplanting autogenous tissues such as fat, temporalis fascia, temporalis muscle, and galea in and around the suborbital region below the orbital rim, now recognized as the true area of deficiency that produces the aging, tired appearance due to fat atrophy from aging. These transplanted tissues were quite successful in that they improved most people while in others they left something to be desired. Overall, this experience proved to the author that something better was necessary for more permanent augmentation of this region.

Dr Sam Hamra reported transposing fat over the orbital rim from inside the orbit to fill this Suborbital (5) deficiency. He gave credit to Dr. Raol Loeb for pioneering fat translocation techniques (6). This author had satisfied his interest in improving the area by autologous tissues early in the 1980s. Due to his interest in alloplastic materials, he felt that an implant could be designed to fit the suborbital region and improve the contour from either aging or heredity that gave an unattractive appearance.

Dr. Glen Jelks reported that a recessive orbital rim which he called a “negative vector” suborbital deficiency accentuated the appearance of the protrusion of both the fat of the lower eyelid as well as the ocular globe itself creating nonattractive and tired-aging appearance(7). Many, if not, most of the patients with a suborbital maxillary deficiency have an associated malar zygomatic deficiency. This has been defined as a Type 1 face. A Type-1 face has regional volume deficiency in the malar-zygomatic region but has adequate fullness in the submalar lower mid face cheek region. This upper malar zygomatic deficiency is a skeletal deficiency, and therefore, augmentation of the entire suborbital malar-zygomatic region with an anatomic alloplastic implant became an obvious solution for resolving the deficiency.

The natural junction between the cheek and a thicker skin and subcutaneous fat of the cheek with the thinner lower eyelid skin where subcutaneous fat is sparse creates the abrupt change in the lid-cheek junction along the entire suborbital region. This has been recently described as a tear trough or a suborbital lid-cheek dysjunction. Therefore, the obvious solution would be to volume fill this region and alleviate this cosmetic deficiency while simulteneosly providing augmentation to the zygomatic-malar area in the many patients where this is also indicated.

The suborbital valley at the junction of the cheek skin and eyelid skin typically occurs 7 to 10 mm below the orbital rim. Therefore, the aim of a cosmetic surgical intervention naturally would be to augment that region and permanently. A popular recent two pronged approach is to perform a subperiosteal mid face elevation to bring the thicker subcutaneous tissues and skin up into that area while transposing fat over the orbital rim to provide a second deeper layer. The two procedures in combination provide excellent volume filling. Once again, however, it must be understood that such surgeries are technically rather sophisticated and have greater risks of undesirable lower lid sequelae especially in the hands of inexperienced surgeons.

By utilizing a volume fill 4-mm suborbital implant or an extended suborbital malar tear trough implant, the volume can be restored without the use of an upper mid face suspension. Protruding infraorbital fat which creates the tired “bags” can simply be sutured to the external surface of the implant, a very simple solution to the entire problem of suborbital unattractive aging that is currently being intensively explored by the aesthetic facial surgery community.

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