Quantitative Assessment of Midface Feminization Using Custom-Designed Malar Implants

Malar prominence is a key sexually dimorphic landmark. Although malar augmentation is frequently incorporated into facial feminization surgery (FFS), no standardized methodology exists for its quantitative assessment, limiting systematic planning and outcome evaluation.

The authors retrospectively reviewed 35 consecutive transfeminine patients who underwent FFS, including 33 who received custom polyetheretherketone malar implants between February 2023 and August 2025. Preoperative maxillofacial computed tomography scans were obtained, and malar complex measurements were assessed for both baseline skeletal landmarks and projected postoperative landmarks with implants. Cephalometric landmarks were systematically evaluated to identify the most effective and reproducible reference points for quantifying changes in malar projection. Complications, revision rates, and patient-reported satisfaction were recorded.

Mean patient age was 38.9 ± 2.2 years, and median implant volume was 1.8 (interquartile range, 1.55-2.13) cm3. The malar apex-to-clivus distance increased by 5.5 mm (P < 0.0001), and the malar apex-to-temporomandibular joint distance increased by 4.9 mm (P < 0.0001). The nasion-clivus-malar apex angle decreased by 5.4 degrees (P < 0.0001), intermalar distance decreased by 9.8 mm (P < 0.0001), and malar apex-to-menton distance decreased by 2.9 mm (P < 0.0001). One patient required postoperative antibiotics for self-resolving erythema. No explants or revision procedures were required over a median follow-up of 8 months (interquartile range, 4.3-13).

Custom malar implants provide reliable augmentation with low complication rates and excellent patient-reported satisfaction in FFS. The quantitative metrics identified here appear to be effective, objective, and reproducible tools for assessing midface feminization and may support future implant optimization and surgical planning.