In this edition of Inside Cosmetic Surgery, we speak with American Academy of Cosmetic Surgery member, Dr. Bruce Chisholm. He specializes in above the neck procedures, and gives us great info on facial implants of the cheek, chin, and jaw areas.
Give the interview a listen, or read through the transcript.
Sharon Odom (SO): Hi everybody, this is Sharon Odom from Cosmetic Surgery Today and welcome to another episode of our continuing series Inside Cosmetic Surgery. Our special guest today is Dr. Bruce Chisholm, also known as the Facelift Specialist, who is quadruple board-certified, and he has offices in Rancho Mirage, California. Hi Dr. Chisholm, how are you?
Dr. Bruce Chisholm (DBC): Hi, how are you?
SO: I’m great. I just couldn’t help, but say quadruple board certified because I have never seen so many boards on one doctor’s website. Thanks for joining us to discuss facial implants, and that is of the jaw, cheek and chin, correct?
DBC: That’s right.
SO: First of all, what are facial implants made of?
DBC: The facial implants that I use, a hundred percent are made of silicone, solid silicone material, called silastic. It’s a molded silicone made by silicone manufacturers into the shape and size for support in the region you are trying the treat, whether it’s the chin or the midface or any other area.
SO: So they are all made of silicone. There are no other options?
DBC: There are other options. There is Gore-Tex, which is also used. It’s probably the second most common material and then there are some of the older materials like Medpor and such and there is also polymethylmethacrylate. You can actually custom make an implant, but for the most part, it’s solid silicone.
SO: What keeps them in place? How do you secure it to the face?
DBC: There are actually three options. You can make an exact pocket, whether it’s in the chin or the midface, and you don’t have to fixate in all circumstances, particularly with the newer implant with a broader base. If it’s a smaller implant, then you will want to secure the implant either with several resorbable sutures or with small micro screws into the malar buttress region.
DBC: That’s correct. Yeah, the cheek would be the malar buttress region. With the chin, you could use a small screw. Generally, the chin implant does not require a screw. Occasionally, the midface implants do, and the angle implants almost always.
SO: Now, I was trying to visualize before I got on the call the cheek and the jaw. What is the difference? Where do they separate?
DBC: Well, with the cheek, we are generally talking about the upper part or the mid-part of the face, the upper jaw. The most common area to augment in a cheek is actually what we call the midface region area right below the eyeball itself and that is the area that’s lost most frequently almost on everybody as they get older.
The actual cheek area, the malar region, which is just outside of the eye socket, outside the lower canthus, that area doesn’t loses as much volume. If you put an implant, such as a cheek implant in that area, it tends to change in appearance versus restoring your appearance if you placed an implant toward the nasal region and in the midface region. So most of the time, we are doing midface implants.
The jaw line itself would either be the chin, which would the actual chin area, put in through a small incision out of the chin. The angle area is back by the angle of the jaw just below and in front of the ear and that’s the augmented lateral projection that sometimes lent to the jaw itself.
SO: Are the implants permanent? Are touchups or maintenance required?
DBC: The implants are permanent. They are there forever. They will last forever and ever.
SO: So it’s nice to hear that something is really permanent.
DBC: It’s the most significant benefit. The benefit of the implant is that we age, we all lose volume, projection and support, and these [facial implants] replace it permanently.
SO: I’ve seen on women, especially the area right around the eye with a sort of, I don’t know, it’s felt like a little hollow area. Is this something that addresses that or is that some other procedure?
DBC: Well, this is a procedure that addresses that hollow region. It does not correct it completely, but it improves it dramatically and is the single most effective thing in the long term that’s particularly permanent treatments. In that particular area, as people get older, even if you augment that area with an implant, you often find yourself having to do a little bit of injectable fillers as the hyaluronic acid, the Juvéderm, and things like that to augment it maybe once a year to keep the area looking really good. But the implant itself will take care most of the problem, but generally not all of it.
SO: That sort of answers my next question, which is what are the benefits of facial implants over other methods like injectable fillers.
DBC: Well, the implants are permanent. That’s the big thing. You can do just about everything with fillers than you can do with facial implants. But it’s going to resorb and go away, and people do that, but after several times or several years, they get a little bit tired of it. As we get older, we lose more and more volume, more and more support, so you are having to do more and more fillers.
It’s nice to have something permanent done that provides a very natural cosmetic aesthetic restoration of volume and support in the cheek area, the chin area, the angle area. Then even if you need a little bit of filler as time goes on, it will be a lot less and in between fillers you will maintain most of the projections and support that would not have been there if you are just doing fillers alone.
So there is an excellent way to reestablish a baseline, and sometimes correct it completely and then if you need a little bit later on with fillers, you can always augment [facial implants] with that.
SO: So it sounds like you used them in combination?
DBC: Yes, in combination. I think most of the time most people are happy with just the implants, but with the one exception being around the eyes. The medial tear trough region is very difficult to augment with implants correctly because the skin is so thin. So that area is one area we do touch up maybe once a year with a little bit of filler.
SO: I’ve heard that facial implants are a sort of unsung hero in facelift. Can you talk a little bit about that?
DBC: They are. The facelift procedure has changed so much. Years ago, maybe 10 or 15 or 20 years ago we thought of it as a tightening, pulling procedure, and it just isn’t that anymore. It’s considered more of restoration of tension, restoration of volume, and restoration of support, and so much volume and support is lost.
It cannot be replaced with a facial surgical procedure that’s pulling and repositioning the native tissues. The facial implants have come along and provided that 50% that was missing and that’s the support and volume that is just naturally lost in the chin, and mostly the midface, it’s the number one area. Second would the chin and third would the angle of the jaw.
SO: As far as chin implants, how do people usually choose those? I mean, what type of person would want a chin implant?
DBC: Well, there are two different types of reasons we use chin implants. One is the person who is born with a small chin, or microgenia, and an excellent way to give them a balanced facial appearance is just to put in a small anatomic chin implant. It’s an excellent way to do it because it’s permanent; it’s simple; it’s easy. It doesn’t really require cutting the bone or anything like that.
The second is the aging chin. Some individuals, or actually a significant number of individuals, like with the rest of the face lose support, lose projection, and lose volume. A very small anatomic chin implant placed in there can restore their natural appearance without giving them the appearance of a bigger chin.
Those are the two most common reasons. Sometimes it’s in combination where some people are older and have a small chin and lose volume. But for the most part, it’s someone who is born with a small chin or just the natural aging chin process we restore with a chin implant.
SO: Can you feel the implants?
DBC: Can you feel the implant? No, the midface implant, the chin implant, and the angle implant, you can’t, but we can feel them. As surgeons, we can feel the edges of them and such, but the patient can’t feel them as long as you keep them under the more supportive muscular regions.
SO: That means if someone has an implant and they try to touch it and rub it, they can’t feel it with their hands?
DBC: Most people can’t feel it, no. Cheek implants are a bit different. It’s what we call the malar or cheek implant. That is not very well covered. I personally don’t do a lot of cheek implants. You can feel those because the coverage is very thin, but the midface implants, the medial cheek implants, chin and angles, you generally cannot feel them. Patients aren’t aware and are unable to feel them.
SO: They can’t even feel them inside of their face, and not with their hands, or they just aren’t aware of them like a hair in the eye or anything like that.
DBC: They are not aware.
SO: What board certifications should patients look for in a facial implant surgeon? I imagine that a surgeon should be specialized in this kind of surgery?
DBC: They should. Board certifications are very important and that’s something you should ask your surgeon each time. Then look for hospital privileges and experience and then results. All of them are very, very important. I wouldn’t skip any one.
The thing about facial implants is it’s a bit of a niche area and lots of, or a fair number of, people don’t do it and a fair number of people do do it. So when you are thinking about facial implants, you do want to check the person’s training, the board certification, hospital affiliation, and then you will really find out if this is a procedure they are doing a lot.
SO: Who would be a good candidate for facial implants?
DBC: It’s anybody who has a congenital atrophy or missing volume such as a small chin, cheeks or such. But in today’s practice, what we mostly see is the person getting into their 40s, 50s, 60s, and above who are just naturally losing the volume and support in their midface.
Well, the midface is number one, and then some in their chin, and then some people lose not quite as much, but in some groups of individuals, more so in the jaw area. So what we really see is a lot of people, the vast majority of people as they age normally could benefit from a midface implant. A smaller percentage would benefit from the chin implants, just from the natural aging process to restore real balance and support so it’s natural looking.
SO: Is it considered reconstructive surgery?
DBC: In those circumstances, no. It would be considered cosmetic, but we do do it for reconstructive surgery. People who’ve had cancer, tumor removals, gunshot trauma, and/or there are people who’ve had cancer who have ended up paralyze one side of the other or for any other reason, they tend to get atrophied in the area and the implants can provided a very nice balance back to the face.
SO: So do you get many people seeking reconstructive surgery or most of them cosmetic?
DBC: Most cosmetic, but we have a fair amount seeking reconstructive.
SO: What are the potential risks and side effects?
DBC: The implants are really a tried and true procedure at this time. Infection is almost unheard of. It’s as close to zero as you can get. For most people, it’s a little bit of an altered sensation that resolves over a few weeks, then there is the occasional person that might feel that they want more or less, that’s a very small amount, and then you’d have to look for movement of the implants, which again with a new anatomic implant is very rare. So the problems with the implants are very, very, very minimal.
SO: What about anesthesia? Are they under local or general?
DBC: They are very simple to place once you gain the experience and you can place them with local anesthetic, a little bit of light sedation or general. I, most of the time, use a very light sedation with a little bit of augmentation of local anesthetic.
Some people do it. We have a fair number of particularly busy, the professionals, that don’t have a lot of time and they will do them on a Friday. We do it under local anesthetic. It’s a very brief and quick procedure and they can go home and resume most of the normal activities the next day.
SO: Does their face look different? Does it look bruised? Like what’s the downtime?
DBC: The downtime physically, if it’s just a facial implant you are doing, is you would limit it to a day or two. The visual downtime is different. There is swelling. There is going to be a bit of swelling, more swelling than bruising, but definitely swelling, and they may experience a small amount of bruising that’s going to take a week or so to go away. So it’s more of a visual downtime than it is a physical downtime.
And that is a very individual subjective thing. Some people don’t mind it with people knowing, and some people don’t want anybody to know.
So that really depends on the patient.
SO: Right. Can you share a patient success story with us? No names, of course, but just an idea.
DBC: Okay. One of the things I really enjoy with the implants that we didn’t have in the past or what we weren’t using as much as today or using fillers that disappeared, was the person who has a very imbalanced face. Maybe a large nose or a bump, a deficient midface and a small chin. They are pretty, they are confident, they like the way they look, but there is just a significant balance that’s missing.
When you combine a midface implant that’s very, very aesthetic, very small, very natural with a small chin implant and then just a very, very conservative reduction of the nose, it’s just amazing the balance that returns to the face from a very, very simple procedure. From a cosmetic standpoint, that’s one of the most rewarding.
From a reconstructive standpoint, the reconstruction of the jaw is much more complicated issue. I’m going to talk more about maybe the midface, particularly with people who have had previous cancer surgery with tissue removal or people who were paralyzed on one side of their face, whether it’s a neurological problem or cancer surgery, there is a very significant imbalance that occur that’s difficult to return them to normal and do normal function.
What you can do is give them an initial appearance of balance that nothing else will do that for them, and the midface implants have been very successful in restoring people who has had a stroke, weakness in the neuromuscular complex from whatever reason and giving them just more. They are happy with their appearance and it just puts a little a bit of joy in their life.
SO: It’s interesting what you said about balance, because I remember reading somewhere that beautiful people, if you study their face, that that is the number one thing, that they are symmetrical.
DBC: It is. I’ve been doing facelifts now for over 20 years. The first part of my facelift experience was technical and getting results, and the second half was the other stuff, which is balance and support and volume restoration. It is the key to a really long lasting balanced pretty facelift, and that’s where implants come in.
SO: Would you like to tell our listeners about your practice in sunny Southern California?
DBC: Well, the vast majority of my practice is cosmetic multi-facelift. It’s what I enjoy the most. One of the fun things about facelifts today are the implants that I use in just about every patient. I know a lot of people think implants change your look, not aesthetic looking, but it’s actually the opposite.
It gives them a very balanced, very natural look as long as all you replace is what they have lost. In the American Academy of Cosmetic Surgery (AACS) meetings, there has been a real push to talk about the natural restoration of balance and support, and I could not agree more with them.
SO: And you specialize in above the neck surgeries, correct?
DBC: Yeah, and most of my practice is facelift.
SO: What is your website?
DBC: My website is bchisholmmd.com
SO: Great. Thank you very much. I really appreciate your time.
DBC: Thank you for you time.