Q: Dr. Eppley,I had cheek implants done 6 months ago, but they have unfortunately have become infected with a low-grade infection. My surgeon has advised that I get them removed, and has given me the option of either local or general anesthesia. I’m trying to save on this if possible, but I have a few concerns about going the local anesthesia route. Anyway, here are my questions:
1) Is it safe to get them removed via local? Is this something that you’ve done for your patients?
2) More importantly, how comfortable is it? Will it be a very painful experience, or just some mild discomfort at worst?
A: In answer to your questions:
1) The use of local anesthesia to remove your cheek implants is certainly safe. Fortunately I have never had a cheek implant infection so I have never had to do it. But if I did and that is the way the patient wanted to remove them, I would. Are your cheek implants silicone or Medpor. Are they screwed in? That would affect the question of whether local anesthesia is a good option or not.
2) With good local infiltration and infraorbital nerve blocks, it should be able to be done comfortably. But that would depend on the skill and experience of the surgeon in doing the local anesthetic injections.
Dr. Barry Eppley
Q: Dr. Eppley, I had two facial problems my entire life, dark circles and retracted lower eyelids. I have always hated my look when I am not squinting and because of that I think that my ower eyelid muscles have become overdeveloped. I have attached pictures of when I squint and when I don’t. This will give you an idea of my orbital/cheek area.
The area circled in the picture was filled with Juvederm already as suggested by a local plastic surgeon to improve lower eyelid projection but it didn’t help at all. Though I do like my cheeks now and I am also thinking about making this permanent with cheek implants to give even better support to lower eyelid. What do you think about this idea? The local plastic surgeon seemed to think that cheek implants were a bad idea.
What procedures would you recommend? Also would canthopexy/canthoplasty address problem with overdeveloped muscle, or would it need to be trimmed with another procedure ? Could all procedures be done together?
A: Your pictures show a large orbicularis muscle roll of the lower eyelid (when squinting), cheek bone hypoplasia and lower eyelid hollows. (with some slight scleral show) I would recommend medium submalar shell cheek implants, a pinch lower blepharoplasty with excision of redundant muscle and fat injections for undereye hollows, all of which could be done as a single procedure. When done locally this is an outpatient procedure but, if from afar, most patients would return home in 48 hours. It would take about 10 to 14 days to look very acceptable without obvious signs of surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I have had rhinoplasty, Medpor jaw angle implants (11mm projection) and silicone chin implant (medium 7mm). But I want a stronger look that is more masculine. I also want cheek augmentation and I want a stronger chin. But the biggest chin implant I can find only gives 8mm horizontal projection so I’m considering a sliding genioplasy to have both horizontal and vertical augmentation. For the cheek implants iIm considering Design M Malar Implants from Medpor, I think they’re more anatomic than silicone ones, and also Medpor ones augment from zygomatic arch to the cheek bone which I think will give a stronger and masculine look. I would like to know which size would you recommend me to use. (4.5mm or 7mm) so they would look proportional to my jaw angle implants (11mm) I read in the internet that when you use facial implants, you have to consider the soft tissue augmentation that is different from the size of the implant… for example if you have a chin implant with 10mm projection…you’ll end up only with 7mm in soft tissue projection. So if I have cheek implants size of 4.5mm I’ll end up with 3mm augmentation, but if I have the 7mm ones,, I’ll end up with 4.9mm, So i don’t know which ones to use. I read in your blog that when it comes to cheek augmentation you should not over do this specific part because you will look unnatural. I definitely don’t want that. But also I have read that the cheek or zygomatic bone should be bigger than jaw angle.
A: I would take exception with your supposition that there is not a 1:1 correlation with the translation of implant thickness to how much change is seen on the outside. When it comes to any form of jawline augmentation, it is pretty much a 1:1 correlation. In the cheeks it is most commonly a 0.8:1 ratio. However the thickness of the soft tissues in any patient is so variable that no absolute implant size to external change seen can be generalized. Thus I would always assume it is a 1:1 relationship through the skeletal structure of the face. This would be true in my opinion given your relatively thin face.
I would also point out that a little bit in the cheeks goes a long way so I would be careful about going too big here. It is very easy to end up with cheek implants that are too big. Thus, I would lean towards the 4.5mm implants as opposed to the 7mm thick cheek implants.
Lastly, you can certainly do a sliding genioplasty using/keeping the existing chin implant in place getting the dual benefits of both techniques. However be aware as the slidinjg genioplasty moves forward and down there will be a slimming.narrowing effect on the chin. Thus if you want to end with a more square chin look than you have now, the chin implant should be switched to a square design or even a more square one and not a rounder anatomic style.
Dr. Barry Eppley
Q: Dr. Eppley, I am very interested in getting cheek implants. I have some questions and infection concerns that I need answers to.
1) Will using Rogaine(Minoxidil) on my head twice a day increase the chance of my implants becoming infected? Minoxidil is absorbed through the skin, thats why I ask.
2) If I opt to have Micro Scalp Pigmentation (MSP), This is a procedure where they basically tattoo your scalp with little black dots , to make it look like you shave your head. Do you think tattooing your scalp can cause your cheek implants to become infected?
3) I have had numerous dental problems. If I were to have cheek implants, how can I avoid the risk of infection? Should I take an antibiotic before and after the dentist for a couple days?
4) Can I use acne medication on my face after I’ve healed? Can this cause infection?
A: In answer to your questions about cheek implants and their infection risk:
1) There is no correlation between Minoxidil on the scalp and an increased risk of cheek implant infection.
2) The issue is the same with scalp tattoos as that of topical Minoxidil for cheek implant infection.
3) The real risk of getting cheek implants infected with dental treatments is the risk of the dentist inadvertently sticking a needle into the implant while injecting local anesthetic for maxillary vestibular infiltration. It would be important to tell your dentist that you have cheek implants should any upper teeth (premolar and molar) dental work be needed. This would be particularly important should any root canal work be done on these same teeth.
4) Topical acne medication does not increase the risk of cheek implant infection.
Dr. Barry Eppley
Q: Dr. Eppley, I am looking to achieve more definition and masculine features. I want a more defined jawline, neck and cheekbones. I actually am even more dissatisfied with how my face looks from the side or profile view. Do you think that liposuction of any area of the neck or cheeks would be beneficial? Or just all implants? I’m slightly hesitant to do implants other than the chin and wondering if you yourself would be able to use fillers instead of something permanent. I have attached some front and side pictures for your assessment.
A: Your side picture clearly shows a more recessed chin that would benefit from a chin augmentation. I think this combined with small jaw angle and cheek implants would provide much better facial definition. But it is clear that you are only comfortable with a chin implant at this time.
When it comes to fat removal, many chin/jawline enhancement patients will benefit from sub mental/neck/liposuction as a complementary procedure. For the cheeks, fat removal is done by a buccal lipectomy procedure which help define or skeletonize the cheek bones better. There is certainly nothing wrong with using injected fat for cheek augmentation. It does not create a sharper or mored defined cheek augmentation effect because it is a soft material and its survival is anything but assured. But for those patients who are a bit skiddish about cheek implants and want to do an initial trial with something more natural (albeit with its own drawbacks), injected fat for cheek augmentation is a good treatment approach.
Dr. Barry Eppley
Q: Dr. Eppley, I was told in a consultation with a local plastic surgeon that I needed cheek implants, chin reduction (just shaving the bone down and removing some fat/skin), and a little off the hump in my nose. That is the basis for my inquiry. Even though those were his suggestions, I still wanted to keep looking because I didn’t see that he had a very extensive client base where he had performed all of those at once…or more than one procedure at the same time.
I normally pose differently and make myself look better in pictures, but my profile is very flat in the cheek area and prominent in the chin. I’d like to get this corrected somehow, but I think with so many things to address at once, I get concerned that the surgery would be very noticeable and I would look like a different person all together…
A: In reviewing your pictures, I could make the following comments:
Your vertically long but non-projecting chin would be best treated by an extra oral vertical reduction ostectomy. (submental chin reduction) A burring technique would not remove nearly enough. You need at least 8mms or more off to really make a difference.
Your flat mid facial profile is ideally treated by a combination of paranasal and malar shell cheek implants. This will help pull out the entire midface. (both the nasal base and the cheeks)
You do have some significant facial asymmetry that actually affects the whole left side of the face. (which is shorter) The chin reduction will help with the lower facial asymmetry. The eye asymmetry, however, will not be improved.
One realization is that these changes will make a facial difference with much better balance…but it will likely be noticeable as your face gets vertically shorter and more horizontally projected.
Dr. Barry Eppley
Q: Dr. Eppley, I would like to know if the following facial surgery results are possible.
1) With a custom cheek/orbital implant can I augment all of the inferior, lateral, and superior orbital rims along with a small portion of the malar bone?
2) Can off-the-shelf jaw angle implants guarantee that my jaw angles will look more squared/pointed rather than U shaped and heavy?
3) With a rhinoplasty do you believe you can achieve an aesthetically pleasing nose job that keeps a lot of masculinity to my nose. (i.e., keeping a majority of the nasal bone projection and width while still projecting the tip out a slight bit and straightening the nasal bone and cartilage from a frontal view?
A: In answer to your questions:
- While any design can be made for custom cheek and orbital implants, there are limitations to the surgical access to place them. Through a lower eyelid incision, a custom implant can be placed to cover the inferior and lower lateral orbital rim and cheek, but not the upper lateral orbital rim or superior orbital rim. (those require a coronal scalp incision for placement)
- A preformed off-the-shelf jaw angle implant that I commonly use has a more flared and square jaw angle point to it that does not usually cause a rounded jaw angle look. (that patient undoubtably has the traditional rounded style of silicone jaw angle implant that is what is available to most surgeons)
- I believe your thinoplasty goals are achieveable as you have defined them and as we have looked at them with computer imaging in the past.
With that being said, let me make some general statements based on a lot of experience with male facial structural surgery. (of which all your procedures would qualify) It is important to understand that there are no guarantees in surgery. No surgeon can guarantee that any specific outcome will be obtained no matter how much thought goes into it beforehand. Aesthetic surgery involves risk of which the biggest one is less than the desired result. I mention this as you have used the term ‘guaranteed’, this is not an assurance I can give you. In the same vein, it is important to also understand that male facial restructuring is associated with a notoriously high rate of revisional surgery, probably approximating 25% to 33%. This is of paramount note in the young male patient who often is very difficult to please in their search for an optimal result. A good rule of thumb is that the patient will put twice the amount of time assessing their result after surgery than what they spent beforehand…hence leading to such high revisional rates. Slight asymmetries and imperfections are very poorly tolerated in the young male patient.
I mention these issues as you need to factor these considerations also into whether the facial surgeries we have discussed are for you, your expectations and your level of risk tolerance.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in some type of cheek implant I think. I am not sure whether I have weak cheekbones or whether they are average or it is really a lack of fat or a lack of orbital rim development that gives me those lines under my eyes near the cheekbone. (Not tear trough) I have gotten comments on having a sunken/droopy “eyes” look when I’m cutting body fat and I’d prefer to have a much more healthy looking eye area when I’m at a lean fat %, just not too feminine either. I just wasn’t sure if that was primarily due to the cheekbone, orbital rims, or an odd lack of fat storage in that area of the face. So if am just to augment my orbital rims (lateral, inferior) and perhaps a bit of the anterior cheek (not too feminine) don’t you think fat transfer is my best option rather than a cheek implant, since a cheek implant doesn’t really touch those areas?
A: Cheek implants are your best treatment option but not the way you currently think of them. You do have a ‘weak’ orbitomalar area which is the result of infraorbital rim and cheekbone deficiency/underdevelopment and a thin soft tissue cover. Fat injection grafting will not work to create any sustained desired augmentation as it will be absorbed completely in less than 4 to 6 weeks after placement. The only effective approach is a combined infraorbital rim-cheek implant, probably only about 4mms thick, which will completely and permanently augment this area. While this is ideal, it will require a custom fabrication (thin tissues have no tolerance for anything less than a perfect fit that feathers on all edges) and that it will require an eyelid (subciliary) incisions to place them.
Dr. Barry Eppley
Q: Dr. Eppley, I have done further research on cheek implants and have a few question on them.
1) I have spoken to a few men who hated their cheek implants because they said it made them look feminine and gave the face more of a heart shape. Is it true that flat cheekbones are masculine? if so, in what circumstances can cheek implants be beneficial for a man? What’s the trick for a man? Is it too match the cheek prominence to the brow and jaw and not go over?
2) I was hoping for a subtle change in the under/lateral eye area, just to provide a bit more strength and less of that droopy look. Would fat transfer be better for this than cheek implants in my face? I very much do not want any apple look to the cheeks or even a rounded appearance.
A: The aesthetics of the cheek area when it comes to cheek implants is different for men vs. women. The proper fullness in the cheek for females is more in the anterior submalar area which creates the ‘apple cheek’ look and more of a softer heart-shaped face. In men, however, the proper cheek fullness is higher and slightly more posterior with the goal being to create a more defined and stronger cheeks. There are differences, of course, between what some men and women want but submalar augmentation in a man can definitely feminize the face. Flat cheekbones, however, would not be viewed as masculinizing feature. What you are showing in your attached picture is a very small amount of cheek augmentation but at least it is in the right place for a man. Cheek implants are always superior to injectable fillers and fat because they offer a one-time permanent solution that produces a predictable result.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in getting jaw and cheek implants, but I am waiting until there is a more natural choice. I want implants that integrate with the bone so I won’t have to worry about shifting. I’ve read online that some doctors have been able to 3D print bones that integrate with the bone. How long until this is applied to cosmetic surgery?
A: If your primary concern about cheek and jaw implants is that they will shift, there is a far simpler technique available today that ensures that will not happen…known as screw fixation. Securing the implant to the bone with small titanium screws ensures that it will never move and is a technique of implant fixation that I do to just about every facial implant that I place. I have used that implant technique for over twenty years and I have yet to see a facial implant that has yet moved from where I placed it.
When it comes to 3D printing of any human tissue, this topic has been in the news of late and is a technology that is quite early in its development. All the recent press releases demonstrate that it can technically be done. But that is far cry from being able to do it in humans for real surgery. I do believe that one day such technology will be available for surgical use but, at a minimum, it will be 10 to 15 years due to FDA regulations and the clinical approval process which is involved in getting it through those hurdles. This does not take into account the economics of the process in which a company has to invest millions (or tens of millions) to get it through that regulatory process. And a company will only do that if the market in which they are developing their product for justifies that expense. The facial implant market would not be considered such a market by today’s standards.
Dr. Barry Eppley