Although the achievement of beauty is the fundamental goal of facial cosmetic surgery, the concept of beauty is quite abstract and difficult to define. We define facial beauty as the perception that a face is proportionate and demonstrates a harmonious relationship among its various anatomic components, highlighted finally by the delicacy of the facial details. Moreover, it is the face that defines our unique identity and at the same time differentiates us unequivocally from our fellow human beings.The anthropometric proportions, structural architecture, and spatial relationships among the various anatomic components of the maxillofacial skeleton generate a visual impact that creates a phenotype that ultimately projects our own very personal visual and perceptual image. It is then probably true to state that it is this facial architectural disposition that is the pillar on which the perceived facial beauty of any given individual depends. If we can surgically modify these spatial relationships, we can generate truly profound cosmetic changes that can yield a new image, a new phenotype. Facial aesthetic surgery is therefore the art and science of creating such balance, proportion and harmony.

The pioneering work of Dr. Paul Tessier and the many others who followed him has demonstrated the effectiveness of craniofacial surgery in modifying the spatial proportions of the maxillofacial skeleton. These modifications produce a range of changes, all of which influence the final cosmetic outcome. Although there are innumerable variations among the common structural anatomic components of the maxillofacial skeleton that yield a vast number of different and distinct phenotypes, a particular series of features and characteristics is common to a large part of the population. Structural osseous hypoplasia, which can be expressed as a deficient midmaxillary-paranasal projection or retrusive labio-columellar angle, is frequently associated with microgenia and mandibular retrusion. Together these findings may result in a “deflated” or “sad-looking,” prematurely aged face.

In my experience, many patients, ranging from their early teens to late thirties or even early forties, seek facial improvement without a firm understanding of their wants or needs. Most of these patients are not yet candidates for a full face lift. They often focus on the nose or eyelids. However, I have found that many demonstrate some degree of maxillofacial hypoplasia, which must be addressed for the overall harmony and proportion of the face to be improved. The purpose of this article is to demonstrate how the plastic surgeon can enhance the maxillofacial skeleton with the use of multiple alloplastic implants placed simultaneously in the adult who presents with a degree of structural hypoplasia.

In my early years of surgery, I offered just the rhinoplasty and blepharoplasty the patient thought he or she needed. After years of practice and many “halfway good” results, I learned to perceive the face as an integral unit. This was largely a result of the influence of many outstanding colleagues, with Terino the unequivocal leader. I believe it is the task of the plastic surgeon to take an integral approach to aesthetic surgery to obtain excellent, not merely “halfway good,” results.

Materials and methods

The authors of previous studies have tried to measure and standardize the “ideal” anthropometric relations of the human face. This ideal, of course, does not exist. It is only a general guide and a changing trend modified by a series of variables such as time, age, sex, race, culture, and, above all, subjective judgment.

In this study, I have used my own perception of beauty and proportion when evaluating the need for cosmetic enhancement or modification of the contour or structural architecture of the face. No preoperative radiologic studies or cephalometric analysis or measurements were performed in patients, other than preoperative and postoperative photography.

I have been using alloplastic implants since September 1989. At first such implants were used only selectively. Today, placement of Medpore (Porex Surgical, Newman, GA) alloplastic implants has become a routine means of treatment in young adult patients seeking facial enhancement who present with variable degrees of structural hypoplasia of the maxillofacial skeleton, be it a sole treatment, a complement to a previous cosmetic procedure, or in association with a concomitant aesthetic procedures. To date, some 500 implants have been placed in some 258 patients of both sexes, ranging in age between 14 and 85 years. A diverse combination of implants has been used, including chin, malar, and paranasal implants, ranging from 1 to 5 implants placed in a single procedure.