Q: Dr. Eppley, I have some questions about facial implants. I want to improve the narrowness of my face. You have posted many articles on face widening, but it seems there are so many options. I am hesitant to simply stuff my face with implants to solve this problem. Particularly, I feel my temple area and zygomatic arch should go more laterally than they do, which may contribute to the narrowness. Would fat injections be a viable option here? Does the fat just reabsorb like many people say? I looked into submalar implants, but, again, I would hate to go down that road unless I had do. It also worries me that they are placed through the mouth when I’ve had issues with the chin already. Are they at least screwed in? Because my chin implant is not.
A: The options for facial widening are only facial implants, fat injections and injectable fillers. While fat injections can be done to create a facial widening effect, and there is certainly no harm in doing so, one has to be prepared to accept the unpredictability of both its survival and persistence.
Even compared to fat, temporal facial implants are so simple and effective that I would not even consider fat in that area as a first option.
Any cheek facial implants placed through the mouth are always secured into place with small microscrews so they will never be dislocated from their optimal placement.
Q: Dr. Eppley, I am interested in chin, cheek and jaw augmentation. Like others, I am looking for exceptionally square, strong and masculine jawline to bring my facial aesthetics to the next level. I already have a fairly low body fat percentage (around 7-8%) but have always had slight TMJ on my right side and for as long as I can remember wanted to really strengthen my face.
Would I be a good candidate for a jaw, cheek, chin augmentation, and/or rhinoplasty to strengthen and balance my face? Or should I address the slight TMJ issue first? Which procedure or combination of the aforementioned would lead to the highly coveted male model facial look? I’ve attached a photo with the front and both sides of my face as well as a goal photo for reference.
A: I have done some imaging looking at rhinoplasty, cheek, and total jaw augmentation for your review. You have a good face for these type of changes because your face is already skeletonized, just disproportionate. The jawline change will require a custom wrap around jawline implant. Whether this would achieve the male model look that you desire is open to one’s interpretation
Q: Dr. Eppley, I have a few questions about faclal implants. Can cheek implants be done with local or non general anesthesia? Also I have a short face and need to add lateral width and height but I worry about the big wrap around jaw implants involving the masseter muscle. So can we do a custom chin implant with wide wings extending laterally and vertically as far back posteriorly as possible but not hitting the masseter muscle. I realize there would be a major step off somewhere further down the jaw and the rest all the way around the ramus I would fill in with fat or radiesse. Also could that be done without general anesthesia too?
A: In regards to facial implants, certainly cheek and an extended chin implant can be done under IV sedation or MAC. (monitored anesthesia care) The use of local anesthesia for most facial implants alone would likely be inadequate and that would be doubly true if both cheek and chin implants are done at the same time. Be aware that the use of local or IV sedation does not save any money as the intraoperative time to do facial implants takes twice as long as when done under general anesthesia. So your motivation for the selection of anesthesia for these facial implant surgeries should not be one of saving money.
Q: Dr. Eppley, I am interested in orthognathic surgery even though my bite (Class 1) normal. Thus any orthognactic surgery would be cosmetic and not functionally beneficial. It just appears to me that my face and the bones in it did not grow in an optimal aesthetic direction. It seems that my face is too long and has dropped to a gaunt look with a flat midface. Could this be due to a downwards grown maxilla or other bones? Can it be fixed with a maxillary impaction?
A: Your malocclusion is modest and within the confines of a general Class I occlusion. The point being is that it is not the source of your aesthetic facial concerns. The difference between your child face and your adult one is the relatively standard change between the 2/3s dominance of the upper face in childhood to the completion of facial growth in early adulthood with a reversal in that proportionate relationship. Whether your face is too long is a personal assessment and not a function of actual facial structure disproportions.
Changing your facial proportions is done by decreasing the vertical length and improving the midface projection width. This is usually best done by a vertical wedge reduction genioplasty (chin) and malar-submalar implant augmentation. Doing a maxillary impaction would bury your upper teeth under your upper lip and would also require a concurrent mandibular osteotomy to keep your bite relationship from changing unfavorably.
Q: Dr. Eppley, I want to know if there is a difference in the appearance between silicone cheek and jaw implants and medpor cheek and jaw implants. From pictures and my own knowledge I think it is clear that the Medpor looks and feels more like real bone. But I don’t know if this has an effect on the appearance outside the face. Does Medpor give a more chiselled appearance? I am concerned maybe silicone will give a softer, less angular look (even if customized to be angular). Is this true? I know the silicone is made in to harder material, but I have felt it and it is quite easy to cut (with scalpel). I also notice it can be bendy, and be twisted etc. I don’t think Medpor can bend like elastic, can it? I want a very sharp angle jaw and also cheek implants (sharper than angelina jolie even). Thanks in advance.
A: What creates an outer facial appearance is the shape of the implant that lies underneath. What composition facial implants are made of makes no difference at all. So that is a misconception. Do not get caught up in what the material feels or does outside the body. When any material is overlaid on bone it will feel as form and inflexible as bone.
Quite frankly Medpor is not a very good facial implant material that turns into a major problem if you ever have to revise it. And the potential revision of any type of facial implant should not be underestimated. Removing or revising a Medpor implant is very traumatic and destructive to the tissues. I take them out frequently from other surgeon’s work and I shake my head every time wondering why this material is ever put in.
Q: Dr. Eppley, I have a few questions about facial implants. Do tear trough, cheek implants, and orbital rim implants become visible as the skin ages? If I need to get them removed will it leave obvious scars? If I get the facial implants but later decide to get a cheekbone reduction would it affect the implants? Thank you!
A: This is a good question about facial implants and is not the first time I have heard it. I have not seen increased visibility of midface implants with aging but that does not mean it does not exist. It would depend on the patient’s face and whether they suffer significant fat loss in the face as they age. It would also depend on how much fat one has in their face and the number and size of midface implants placed.
The removal of implants does not usually any more scars than those that were used to place them. If you get cheek implants and then elect later to have cheekbone reduction, the implants may or may be in the way based on how far back the tail of the cheek implant goes. Usually the implant would be in the way but it could easily be displaced so that the cheekbone osteotomies could be done.
Q: Dr. Eppley, I am interested in temporal and jaw angle implants. But when I get really old would it look like this if I have implants in my face? See the attached picture of breast implants where one is able to see all the edges of the implants. This is a scary picture.
A: It is important to separate what can happen with facial implants vs that of breast implants with aging. The show of breast implants can become more obvious when one loses weight or has very little subcutaneous fat cover from aging. Breast implants are ultimately only covered by the thickness of the breast tissue and if they are partially under the muscle. (which the lady’s implants in the pictures are not) Facial implants are placed next to the bone with a soft tissue cover that is not as influenced by fat loss. (more muscle cover) Thus, facial implants will never get as skeletonized or develop implant edge show as breast implants can. Facial implants are bone implants while breast implants are soft tissue implants. That is a fundamental anatomic difference. Because facial implants add support to the overlying soft tissues they often are a positive additive feature rather than a detraction from aging.
Q: Dr. Eppley, I am interested in fat augmentation around my facial implants. My biggest concern is how much fat will survive as the plastic surgeon I saw mentioned that the presence of the implants will make it less likely the injected fat cells will be able to develop their own blood supply and grow. This gives me pause as I’m not too keen on another procedure that might just be an expensive temporary natural filler. I would appreciate your thoughts on this and how to maximize the survival of any grafted fat. Are there any other options to reduce the noticeability of the implants and fill/round out the cheeks more?
A: Your plastic surgeon did reach out to me and I have discussed your case with him. Fat injections are the only treatment that can be used as the ‘missing’ piece of your face is now not what is on the bone but is where the bone/implants aren’t. It is true that the final take of injected fat is both variable and not completely predictable. But I know of no scientific evidence that supports the supposition that fat grafts take less well over or around facial implants. And where you need the fat is to fill in the areas around and between the implants which is only soft tissue anyway.
One technique that can be done to improve fat graft survival is the use of platelet-rich plasma. (PRP) By mixing PRP with the fat grafts, it optimally enhances fat cell survival through its growth factor effects. It may also have an inducing effect on the stem cells that naturally reside in fat. Given that it is an extract from your own blood, there is no reason not to use this natural fat ‘booster’.
Q: Dr. Eppley, I would like to make a few enquiries regarding facial implants. My plan is to have bespoke implants fitted precisely over my current facial skeletal bone structure to adjust the appearance. I am interested in various different locations on the face, and I know fairly precisely the dimensions of the facial appearance I would like to have. I was wondering if you have an information pack for new patients for this procedure and some advice on getting started?
My second questions is in regards to the materials used for the implants. On your website, you mention two materials – silicone and Medpor. I was wondering if you ever work with, or would consider working with 3D printed titanium implants. the reason I am particularly interested in this material is the strength advantage it has over others.
A: The best way to get started is to send me some pictures of your face and a detailed list of what you want to achieve and where you envision the augmentations to be done. Using that information, custom implant designs can be done on a 3D CT scan which you would need to get. That CT scan can be done in your local community.
As for custom facial implant materials, only silicone is currently available for use as a custom facial implant material for 3D CT fabrication. While I am certainly not opposed to using any other material, such as titanium, you have to factor in other important considerations such as cost and access. Very stiff materials, such as titanium, require much larger incisions to place dependent on their size and location. This is an issue that patients never think about but can be a very limiting issue. In addition, there is no advantage to a stiff metallic material as an implant. Since bone is the backing for all implant materials, they all become firm and ‘bone-like- once in place.
Q: Dr. Eppley, I had jaw surgery just over a year ago and it left me with some irregularities. This led me to get chin and paranasal implants a month ago. While they have provided some improvement and there is still some swelling, they still have not completely solved the appearance of nasolabial folds and pre-jowls.
I now suspect that this may be a soft-tissue problem. However, because I am only 25 years old such soft tissue deficiencies seem unusual. Anyway, I’ve googled facial fat grafting and this image really pinpoints the areas I would like to build up and bring forward (the direction of the arrows). My biggest questions are as follows:
1) Could my soft tissue issues have been caused by my previous underbite (thereby affecting soft tissue development) or the jaw surgery itself?
2) Given my age, can fat grafting be done for these regions? If so, how much volume of fat is usually required?
3) Instead of fat grafting, are permanent fillers an option? Alternatively, are there any different implants that can be placed in these regions?
4) I have implants near these areas. Can fat grafting be done safely without infecting my implants?
Anyway, I also had some fat grafting done to my brow ridge and central forehead to make it look masculine. My surgeon did a decent job, but I’m noticing that insufficient fat was placed in the central forehead (the area between the two eyebrows and just above the nose), which means that my outer/lateral brow ridges are more augmented than the inner portion, causing it to look like I’m constantly frowning. I’m looking to add more fat to the central forehead, but I understand that a revision should only be done a few months later. Regarding this, I have a couple of questions:
5) It has only been 4 weeks since the fat grafting, can I use temporary fillers to augment the deficient areas in the meantime?
6) If so, will fillers affect how my fat graft survives at this stage?
A: I am going to assume that your jaw surgery was orthognathic surgery, possibly a mandibular advancement osteotomy. But that issue aside, let me address your specific facial fat grafting questions.
The cause of your nasolabial folds and prejowls is impossible for me to comment on since I don’t know what you looked before your jaw surgery or your most recent facial implant surgery.
While injectable fat grafting can be done for these areas, how retentive it will be is somewhat dependent on your body habitus. Thin young people usually have a poor rate of fat graft survival and retention. The fat graft volumes needed for the nasolabial folds are 3 to 5ccs per side. The prejowls usually require a similar amount of injectate.
There are few permanent fillers available in the U.S. and, even if there were more, I would not use them. All of the so-called permanent fillers run the risk of lump and nodules. While more often these do not occur, but if they do they are problematic to treat. Other styles of facial implants may indeed be more effective than what you have such as a true maxillary implant. (combined medial and lateral maxillary coverage which is much ore comprehensive than a simple paranasal style which I find archaic and inadequate for many midfacial hypoplasia needs)
Fat grafting is done above the level of the bone where the implants reside so they are not in danger of being accidentally injected.
I would probably wait another month before placing synthetic fillers into the fat grafted areas. The fat grafts are still healing and there is an increased risk of causing an infection by introducing another material into these areas.
At 8 weeks after fat grafting, injectable fillers will not have any adverse effects on the outcome of the fat grafting.