Q: Dr. Eppley, I am asking you to ask about your experience with midface Medpor implants. How often do you use them, especially in men and is this your preferred material to work with? Do you have much experience in customizing the standard implants offered by the company that produces them?

I was wondering if you could take a minute or two and look at the pictures I’ve attached.

The first picture is of someone else that shows the area I’m trying to augment. This is not the malar or submalar area as such, but rather the cheekbone area high and laterally – my goal is augmenting laterally as much as possible along the zygomatic arch. The cheeks in attractive men are almost always perfectly flat or even hollow, as is the case with most/all fashion models.

The second picture is of me – I apologize for the low quality. I saw a plastic surgeon locally who said that I’m exactly the opposite of the man in the first picture. The area I marked in green is my main problem. This area (please notice the same at the opposite cheek) is very, very prominent, bulging, and very not-masculine, worsening the problem with my under-eye hollows and nasolabial folds. Someone recommended buccal fat removal, however, I don’t think this is at all right for me, as buccal fat will remove the area I marked in red, and that has little if any overlap with the problematic area on my face. Am I right in this? Or is there a way to remove the fat from the marked green area? I thought the best solution for me, instead of removing anything, would be building the upper-mid face, as I discussed above using the example of the man in the picture I’ve attached. I marked that area in black in my picture. This particular area looks depressed on my face (as you can see on the opposite, unmarked cheek), and the prominence of that diagonal strip on the cheeks (the green area) makes it much worse. Most people think i’m older than I actually am and I look tired all the time. Another surgeon suggested some sort of mid-face vertical lift, but I don’t think there is any effective way to do this. Most techniques result in short-term results and awfully lot of swelling for months. 

So, I concluded my best option is building that area marked in black with medpor implants. This would balance the prominent bulging cheeks. I attach here their catalogue (please see pdf file). On page 6, I noticed the “extended malar shape” type that the company says extends laterally along the zygomatic arch. I think it also captures the infraorbital rim area, if I’m not mistaken, and I could really benefit from it, as the existing hollows under my eyes are also a problem.

If I could please ask you: Having seen my picture, would you say this implant is the right for me, or would there be a better type? As it is extremely important for me that the implant does not add to the problematic, already prominent diagonal stripe in the submalar area of my face (marked in green), can this part be cut off from the standard implant? Or will there be no need for that? I can’t judge at all how much vertically the implant drops, but the part below the infraorbital rim is where the bulk of it is. The more vertically it drops, the worse would the outcome be for me, because it will make the cheeks even more bulging. 

I find it hard to believe that there aren’t any standard mid-face implants on the market that would cater to the needs of men. Even in this “extended” type, the extended part looks thin and stops prematurely, while the remaining malar part is quite bulky. I would probably have to go for the largest size and cut off much of the unwanted part to benefit the best. For illustration, I’ve attached here some pictures of models – in any beautiful male face the cheeks are always perfectly flat (most of malar and definitely submalar parts) and even hollow (the exact opposite of what 90% of the malar and submalar implant do!!!), but the cheekbones are high and the whole area is always built naturally well laterally along the zygomatic arch, all the way to the temporal process. 

Yet another surgeon recommended the use of hydroxyappatite instead of implants to build the area of the face I’m interested in augmenting. However, I don’t think HA can achieve that much as implants can and I wonder if it does give so much flexibility and is safe, why more surgeon are not using it?

A: To answer your questions succinctly:

1)      I use both silicone and Medpor facial extensively and have a lot of experience with both of them. I have no preferred fondness for either material as the body does not care what is implanted…it treats them all the same from a biologic response standpoint. I choose the implant material based on which one offers the best shape and size for what I am trying to achieve for the patient. In many cases the implants have to be modified during surgery to create the desired shape. In other cases, I make the implants before surgery (true custom designed implants) based on modifying existing implant styles or design my own shapes for a specific patient.

2)      You are correct in that there is no current facial implant style, regardless of the manufacturer, that is designed to create the effect you are after. This will require a modified malar implant design to achieve.

3)      The Medpor extended malar implant is the closest preformed shape but there is way too much material in the submalar area.

4)      Hydroxyapatite granules are never going to create the look you are after as they will be flattened by the pressure of the overlying cheek tissues.

5)      The cost of your malar implant surgery would be influenced by the material you want it composed (Medpor vs silicone) and how you want it prepared (intraoperative modification or custom premade).

Dr. Barry Eppley

Indianapolis, Indiana