Can secondary malar implant surgery be done under twilight or local anesthesia?

Question

With so many malar (cheek) implant surgeries revised due to malplacement why aren’t more done under twighlight or local so the patient can provide input as to the placement of the implants intraoperatively? Are there doctors that would do secondary malar implants this way?

Zoran Potparic, MD · Answer

In our practice this procedure is done in twilight or local anesthesia in particular when it involves replacement of implants. Unfortunately, in twilight anesthesia it is very hard to count on patient cooperation and input regarding the size and position of implant due to swelling and sedation. Implant displacement and other complications are not that frequently seen in our practice and based on recent literature reports they are in a range of 5-7% altogether. Detailed in person evaluation and discussion about your options with a board certified plastic surgeon with expertise in facial implants is recommended. Good luck.

Richard G. Reish, MD, FACS · Answer

Hello and thank you for your question. I perform malar augmentation with either conscious sedation or general anesthesia, both of which would be administered by a board-certified MD anesthesiologist.   I always use
medpor implants with screw fixation.  Therefore, local anesthesia is not possible due to the screw fixation.  Silicone malar implants tend to
have a high rate of malrotation over time.  The most important
aspect is to find a surgeon you are comfortable with. I recommend that you seek
consultation with a qualified board-certified plastic surgeon who can evaluate
you in person.
Best wishes and good luck.
Richard G. Reish, M.D.  FACS
Harvard-trained plastic surgeon

Francis R. Palmer, III, MD (retired) · Answer

Hi, I have performed many facial shaping procedures using dermal fillers, facial silastic implants (for the cheeks, chin and lips), liposuction and/or facelifts for over 30 years.  While I have seen patients from all over the world that had their initial cheek implant surgery done elsewhere who required removal and replacement because the  silastic cheek implants were either aesthetically the incorrect shape, size or placement...I'm not sure that I would call it a "common" occurrence.  In the hands of an experienced cheek implant surgeon, this should be quite rare of an event.  It does however, require the proper aesthetic judgement and experience in selecting the correct implant and knowing how to place that I'm implant properly.   
 Following my beauty principles, women look the most feminine, youthful and attractive with heart shaped faces.  Heart shaped faces have cheeks that are full and round in the front.  Cheek augmentation with a dermal filler or using cheek implants for a permanent enhancement will create full, round cheeks that will feminize the entire face.  Conversely, men look chiseled and handsome with angularity in the cheeks, chin and mandibular angles.  This knowledge leads to the proper selection and implant placement.
 There are many faces that have excess fat over the cheek area which hides the "true" shape of the cheeks below.  In addition to obstructing the cheek shape, this excess fat will sag prematurely as it is pulled by gravity at an accelerated rate versus a face without excess fat in the mid face.  Removal of the excess fat, with liposuction, is key when properly shaping the cheeks with cheek implants.  I have used this in combination with cheek implant surgery for 30 years.  In my experience these procedures when combined in a face with excess fat in the mid face are extremely safe, effective and reliable in the aesthetic results they produce.  I prefer augmenting the cheek with silastic malar implants that are placed over the "malar" or cheek bone thus creating the desired aesthetic shape to the cheek.  In contrast, sub malar cheek implants are as the name "sub malar" or below the malar (cheek bone) implies are not placed over the cheek bone itself but below it in a potential tissue space.  As such sub malar implants might elongate the cheeks inferiorly (below the cheek) but can't actually change or shape the cheek itself.  For this reason, I do not use sub malar implants for cheek augmentation.
 The procedure is performed under a general anesthetic in about 30 minutes using a small incision on the inside of the mouth.  I have used silastic cheek implants for 30 years and do not find it necessary to use screws or sutures to hold the implants in place.  Proper creation of the implant pocket combined with complete closure of the surgical area, in multiple layers, prevents the implant from moving.  We do ask that our cheek implant and chin implant patients sleep using a U-shaped airline pillow for 1 month following the procedure.  After that, the implant is secure and will not move.  Full healing can be expected between 3-4 months post-op however, full activity can be resumed at 1 month.  Out of town or international patients are cleared to fly home in one week following the procedure. Using "twilight" anesthesia does not allow adequate protection of the airway and as such is dangerous.  Local anesthesia can be used however, the best method of cheek implant placement uses an incision on the inside of the mouth which most patients do not tolerate well under local.  In my humble opinion, the patient would not be able to provide any meaningful feedback to the cheek implant surgeon as they would not be able to feel the implant on top of the cheek bone as well as the surgeon can visualize the actual position as the surgery is being performed.  While I do most on my chin implant placements (through an incision under the chin) using a local anesthetic alone....I do not find that a local anesthetic provides the best patient experience when placing cheek implants.Hope this helps.

Gerald Wittenberg, MSc, DMD (retired) · Answer

Yes. Most patients prefer some form of light sedation by choice. One can do with Local anesthetic alone but the surgeon has to be detailed about how much solution of the anesthetic used since it can distort the contours once placed. As to 'patient input', that is not usually necessary either due to good pre operative communcation about what you prefer; or the surgeon having an artistic eye to ensure proper balance with the rest of the face structures.

Can secondary malar implant surgery be done under twilight or local anesthesia?

Answers (4)

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