What Are The Potential Complications From Cheek Implants?

Q: Dr. Eppley, I’m sure a surgeon at your level is capable of the best possible cheek augmentation results. However, for cheek implants performed in general, I am a little concerned about having found an average self-reported procedure satisfaction rating of only about 60% from this site called Realself. Could you tell me more about satisfaction-levels and potential complications for these procedures? Could they affect the shape of the nose?

A: It does not surprise me that the satisfaction rating for cheek implants is around 60% or roughly two-thirds of the patients that took the time to register their experience. While it is an apparently ‘simple’ procedure, it can be plaqued by problems of implant asymmetry and an inability to have achieved the desired cheek augmentation effects. It is important to remember that all facial implants, cheek implants included, are based on styles that presumably fit the average person. Often these implant styles, in my opinion, are dated and may not reflect contemporary aesthetic objectives. Thus surgeons are relegated to using cheek implant styles that are not really specific to the patient’s anatomy and may not always have a realistic chance to achieve the patient’s cheek augmentation goals. But plastic surgeons may due with what they are provided and try to get the result with the cheek implants that are available.

It is also important to note that cheek implants are paired unlike a chin implant which is singular. Since they must be placed independently and without full view of either one at the same time, the potential risks of implant asymmetry are increased.

Lastly, there is no training manual or intuitive aesthetic ability for plastic surgeons to knowing how to pick a cheek implant style and size. Cheeks, unlike chins, are more than just a single horizontal measurement seen in just one profile view. (which is how most plastic surgeons simplistically see the chin…unfortunately) Rather the shape of the cheeks is truly a three-dimensional structure (with four different aesthetic zones) where number and measurements do not help in knowing how to make a successful cheek augmentation change.

Dr. Barry Eppley

Indianapolis, Indiana

Can Thick Skin Prevent A Good Rhinoplasty Result?

Q: Dr. Eppley, I am interested in a rhinoplasty. I have consulted with a plastic surgeon who said I had thick skin and results would be minimal. I can accept this, however, I do believe that at least suturing the tip cartilage together would minimize the width. My goal is a narrower nose in general, but particular attention to the tip. Perhaps narrow the bone structure? I have always kind of wiggled my nose down which elongated it and made the tip smaller and less noticeable. Of course it manipulated my upper lip. Is it possible to take a pie shape of skin out of the side of each nostril to bring it down and narrow it? I do always seem to have a congested nose. If I pull outwards beneath my eyes I can breathe significantly better. My profile is acceptable. I appreciate your consultation greatly! 

A: By your description, it sounds like a rhinoplasty that includes tip width reduction by cartilage reduction and suturing, nostril narrowing and possible middle vault spreader grafts (although this would widen the middle third of your nose) and/or inferior turbinate reduction would help improve your nasal appearance and function. While it is true that thick skin does not a limiting effect on rhinoplasty results, I would not say that the results would necessarily be ‘minimal’ and that the desired tip changes seem achievable.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Best Cheek Implants For Women Who Want A Model Cheek Look?

Q: Dr. Eppley, I am aware of the custom cheek implants option and am actually looking to get those done. But before I get in to the questions I have a little disclaimer- the photos I’ve attached are merely for reference purpose. I know that these women have been photoshopped and what not and/or are genetically blessed with great cheekbones. I don’t look like them, nor do I intend do. Please don’t mistake the photos for me trying to get cheeks exactly like the celebrity. In your honest opinion, looking at the attached photos of the cheeks on these women- I’m talking about the placement on the face, the shape, the definition of the zygomatic tail etc. All of those factors put in, what cheek implants would give me a result closest to these photos. Malar implants? Or combined submalar implants? 

Malar Shell Cheek Implants Dr Barry Eppley IndianapolisA: For many women, combined malar-submalar shell cheek implants would work the best as an off-the-shelf style. These can be placed high on the cheek bone and come forward to cover the submalar area. Probably the implant would have to be modified a bit (the tail and posterior submalar areas narrowed) to make sure that the arch portion does not get too wide in a superior-inferior direction.

 

Dr. Barry Eppley

Indianapolis, Indiana

Can I Achieve A High Cheek Bone Look With Cheek Implants?

Q: Dr. Eppley, I’ve been looking into getting cheek implants for a while now, and I came across your helpful blog on my numerous exhaustive searches on the Internet for cheek implants. I was hoping I could get your opinion on one big question that I have- what kind of implants will give me the high prominent cheeks look, but with some fullness in the front of the face too. (The pictures show the look that I’m after) (I’d also like to point out that those pictures are just for reference, I do know that cheek implants won’t turn me into Rosie Huntington-Whiteley) want both, the definition from the side, the high placement and also some frontal fullness. Thank you.

High Cheek Implant Look Dr Barry Eppley IndianapolisA: While there are many different styles of cheek implants, it is important to realize that the look you are after is not likely to be achieved by standard stock implants. If you translate the look you are after to the type of cheek implants available, it is fairly easy to see that no such cheek implant style exists. (at least none that I would feel comfortable placing hoping to achieve that type of cheek augmentation effect) In my opinion, only custom designing cheek implants can create the style and size you seek. Then there is also the factor of your own cheek bone anatomy and how it may help or hurt the desired look…hence the benefits of a custom designed cheek implant style.

Dr. Barry Eppley

Indianapolis, Indiana

Will Abdominal Liposuction Help With Back Pain And A Spinal Deformity?

Q: Dr. Eppley, I am a male that has Scheuermann’s Disease and would like to know if having abdominal liposuction may help relieve some of the discomfort and strain from my back and neck? It makes sense to me since less fat would mean less strain Your thoughts on this?

A: I know of no medical evidence that supports abdominal liposuction as providing symptomatic or preventative benefits with this form of spinal issue. (kyphosis) Having said that perhaps if the abdomen was big enough and the liposuction of sufficient volume that there could be some potential benefit. However, most of abdominal fat in men is intraperitoneal and is not treatable by liposuction extraction. That is a fundamental difference between men and women in their abdominal fat distribution and shape.

Thus I am not sure if liposuction alone would produce an adequate relief of the abdominal ‘load’ that would translate into some form of back pain relief or prevention of further spinal kyphosis. It would make more sense to me that an abdominal panniculectomy would have such back benefits since removing an overhanging and heavy pannus is known to reduce lower back strain due to its size and the pulling on the trunk from hanging down below the waistline.

Dr. Barry Eppley

Indianapolis, Indiana

Do I Need A Browlift Or An Upper Blepharoplasty?

Q: Dr. Eppley, I have very heavy looking eyelids. Would I be a good candidate for an endoscopic browlift or an eyelid lift? I have some concerns about making my forehead higher.

A: Your question is not an uncommon one as many people with ‘heavy’ upper eyes do have a combination of some degree of brow ptosis and redundant upper eyelid skin. In looking at your pictures, I think your heavy upper eyelids do fall into this ‘combo’ category and are caused by a combination of slightly low brows and upper eyelids that have too much fat and just a touch of extra skin. The question is whether a browlift alone (pretrichial not endoscopic so your hairline will not only not get longer but can even be lowered if desired), some upper eyelid skin removal and defatting or both would be optimally beneficial.

This type of periorbital decision can be difficult as you do not want to over operate but, by the same token, you do not want to under treat either.

Dr. Barry Eppley

Indianapolis, Indiana

How Do I Correct Cheek Sagging After Cheek Implant Removal?

Q: Dr. Eppley, Earlier this year I had my cheek implants removed and I feel a lot better that I did. The only thing is the hollowness that it created under eyes and lower cheek area. I feel that that this is due to the loss of cheek attachments and you have even mentioned so in one of your blogs. Do you know of any method to reattach the tissues to cheek and under eyes?

A: You are correct in that I have written in the past about your exact situation. Like breast implants once the cheek tissues are detached and stretched out for implant placement, they may not recover their original position after cheek implant removal. It is not so much from the tissue stretching but all of the cheek tissue attachments have been stripped off from the bone. Unless there was some specific method to reattach these tissues or lift them at the time of cheek implant removal, they may develop some sag off the cheek.

There are several methods to resuspend sagging cheek tissues. This can include a mitek suture anchor resuspension done intraorally or a suture suspension done through a combined temporal and intraoral approach. It is important to realize that this will help with cheek sagging and will have no effect on undereye hollowness.

An alternative approach is to simply have fat injections done to restore cheek volume and  fill in the under eye hollows at the same time. Or resuspend the cheek tissues and save the fat injections just for the under eye hollows.

Dr. Barry Eppley

Indianapolis, Indiana

Can A Premaxillary Cartilage Implant Cause A Smile Deformity?

Q: Dr. Eppley, I had a rhinoplasty done about a year ago to extend and derotate my tip and columnella. In the process I also had a premaxillary implant which was inserted in the nasal spine area through an incision through the inside of my upper lip. All of these were rib cartilages.

Whatever the cause, my smile has been warped for the worst. Before surgery, when I smiled, my upper lip used to be mobile, flip up, and thick and my columnella and tip would also droop down resulting in a nice natural smile that wasn’t tense. Now my smile is frozen looking. My upper lip is thin, tense and my nose tip and columnellar are also wooden looking and do not move with my smile the way it used to. It looks off and disturbing according to many of my friends. I am very upset with this. Is this my tip and columnella rib work that is doing this or is it a result of my premaxillary graft? I would certainly like to remove my premax graft if this will fix my smile. Thank you very much.

A: When you add a lot of rib cartilage grafts to the tip of the nose and the underlying pyriform aperture/nasal spine area, there is the possibility of stiffening how the upper lip moves. While it is possible that it is the combination of the effects of all the cartilage grafts (I have no idea as to teh details of where they were placed exactly and their size), the most likely culprit is the premaxillary graft. Its removal would be a good place to start and would also not affect to any significant degree the rhinoplasty result. Whether it will produce a complete normalization of your smile can not be predicted and it is not known if that could ever be achieved even with removal of all of the rib cartilage grafts.

Dr. Barry Eppley

Indianapolis, Indiana

Can An Occipital (Back of the Head) Implant Augmentation Be Revised For More Projection?

Q: Dr. Eppley, I wanted to thank you for the kind and professional treatment by you and your staff during my stay in Indianapolis for my occipital augmentation surgery. My scar on the back of my head is healing nicely! I almost can’t see it when I use a mirror to see the back of my head. Overall, in terms of the shape of the back of my head, I’d say there’s a 60% to 70 per cent improvement. However, as you correctly noted during our visit the day after my surgery, my head is/was really flat in certain areas, and the implant may have not been created with sufficient thickness/volume to create a “rounder” effect. It’s funny, with the CT scan, I’d have thought the outer implant shape would be super-precise. So I am wondering about the possibility of doing a revision. I am grateful for the improvement so far, but I sometimes think that the back could be a bit “rounder”, and hence, I start pondering my options. Do you think it would be worth doing a revision for more occipital projection?

custom occipital implant design side view jmA: Let me provide with some insight as it it relates to a result that has ’60% to 70% improvement and what a ‘revision’ really means.

First, the computer design process did a very precise job of making the implant perfectly. What the computer can do is to make it fit the bone perfectly, make the implant symmetric based on differences of the shape of the underlying bone and make its outer surface and edging as smooth as possible. That is has done wonderfully. What the computer can not do is to inherently know what the shape and thickness of the implant should be based on aesthetic goals. That is the role that I play and it will only follow the design that I instruct it to do. My job is to design an implant that will fit given the tolerances of the overlying scalp and be able to be placed through the smallest incision possible. Occipital implants that are too big can cause catastrophic problems, such as scalp and incisional tissue necrosis, hair fall out, non healing wounds, infection and the need to do a lot of ‘wittling’ on the implant trying to make it fit. (resulting in irregularities and asymmetries) It is my experience and judgment that allows for these type of problems to be avoided. That is why your implant, like many patients, is not designed to be thicker than 9 to 10mms as this is what I have learned to be a safe implant thickness that will always avoid any of these concerns. Most of the time patients will say down the road that they wish it was a little fuller after they get past the initial euphoria of having some augmentation effect. But it is always better to have a 70% result that has never experienced any complications vs. having the perfect volumetric result that has developed a complication.

When it comes to a ‘revision’, this is often a poor term to use and the incorrect way to think about it. Understandably patients think that ‘just adding a little more’ or ‘making an adjustment secondarily’ is easier than the first time. But the reality is that it is exactly the opposite. It is now harder because the tissue are more scarred and the scalp is less flexible. You may be able to place an implant that is 4 to 5mm thicker but it will likely require a bigger incision, a whole new implant, and will increase the potential for any of the complications that I have previously described. (the risk may be still fairly low but it is higher than the first time). Thus one has to weigh the risk vs. benefit for that extra 20% to 30% gain of improvement that could be achieved.

While I am happy to place a whole new implant, and I have done it many times for patients with many different kinds of skull and facial structural surgeries, it is important to understand that every surgery has risks. Just because it worked perfectly the first time is not a guarantee that it will be so the next time. Manipulating otherwise uncomplicated aesthetic results should be considered carefully if not more so than the first time.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Cheek Bone Reduction Results Be Fixed?

Q: Dr. Eppley, I had cheekbone reduction surgery done five years ago and I felt it left me with asymmetric cheeks. CT scan pictures after the surgery show that the cheekbones were probably removed too much and they were placed in different positions vertically. There are ‘gaps’ in the cheekbone area. I wonder if this can be fixed.

A: It is not rare to have some asymmetry in the position of the bones after cheek bone reduction surgery. Besides the fact that most people’s cheek bones are not really symmetric initially, there are always going to be differences in the angle of the cuts and the bone fixation points  between the sides since they are not independent of each and can not be view intraoperatively in a simultaneous fashion. That being said you do have external cheek bone asymmetry with the right side being more medial or moved inward that the left. I will assume by your comments that your ‘good’ side is the left one and the side you seek improvement is the right side. That could be improved by either repositioning the anterior end of the right cheek bone or adding a small implant over the osteotomy site.

In regards to the cheek bone gaps seen on the CT scan, that is an early after surgery x-ray. At this point years later, those bone gaps have likely filled in and healed with bone. If not, they have a fibrous union and there is no aesthetic benefit to having those bony gaps ‘fixed’.

Dr. Barry Eppley

Indianapolis, Indiana