Malar implant surgery and the science of malar augmentation

A dome-like shape with an absence of easily defined landmarks that are projected to the surface of the skin precludes anthropometric or cephalometric analysis of the malar area. Several landmarks lie adjacent to, or involve portions of the malar bone, but there are none defining an area of maximum malar prominence. The resultant paucity of objective data describing the malar area has inevitably made implant augmentation of this area more subjective. Because it is difficult to define what is average or normal for the malar area, selection of implant shape, implant size and implant position for malar augmentation can be problematic.

Several surgeons, working without quantitative data, have suggested techniques to identify the malar prominence as a guide to malar augmentation. Their techniques use fixed relations to various anatomic landmarks to determine an ideal position of malar prominence.

The lack of consensus regarding the most projecting point of the malar prominence reflects the plastic surgeon’s dilemma.

After analyzing many attractive faces, three dimensional facial CT scans and anatomic specimens, I have concluded that the most projecting part of the malar area bone is relatively high – “high and near the eye”. I have found that the point intersecting a vertical line through the lateral canthus with a horizontal line through the infraorbital foramen to be a useful reference point when positioning or designing malar implants.

As the most prominent and surgically accessible portion of the midface and, until recently, the only area of the midface for which implants were available, many patients receive malar implants when the entire midface or another midface area is deficient. This may exaggerate the facial imbalance. For example, malar augmentation, particularly when it extends far onto the zygomatic arch, may exaggerate the appearance of prominent eyes due to midface hypoplasia. These patients are better served with augmentation of the infraorbital rim alone or, in combination with malar augmentation and other soft tissue manipulations.

Since full cheeks are associated with youth, malar augmentation is often performed to provide a youthful appearance. This may provide an aesthetic benefit if there is a relative malar hypoplasia or if the implants are of modest size and projection. This skeletal augmentation is not equivalent to a soft tissue augmentation or resuspension. Similarly, malar implants are often advocated as a means to obliterate lower eyelid wrinkles or secondary bags. Malar augmentation impacts poorly on these surface irregularities. More often, they detract from periorbital aesthetics by contributing to lower lid malposition, particularly when placed through an eyelid approach.

Certain implant designs do not mimic the contours of the midface skeleton. For example, submalar implants are designed to be placed over and below the origin of the masseter muscle - a location where there is no midface skeleton - in an attempt to provide cheek fullness. It is often performed as an adjunct to, or as an alternative to a facelift. The result is an unnatural midface – one with too much lower midface fullness which actually detracts from malar definition and projection.

In summary, the lack of anthropometric and cephalometric landmarks precludes the availability of normative data making analysis and augmentation of the malar area largely subjective. Malar deficiency is often part of a generalized midface deficiency for which malar augmentation alone may be inadequate or, even, inappropriate. Clinical experience has shown that when malar projection is deemed inadequate, malar augmentation is most effective when it recreates the contours of a normal skeleton with prominent anterior projection.

typical position and shape of a malar implant
This figure shows a typical position and shape of a malar implant