Your Questions

Q: I want to get implants to have higher looking cheekbones. What is the difference between malar and submalar cheek implants? Which would be better for me?

A: In considering cheek augmentation, or enhancement of the midface, there are a wide variety of cheek implant styles from which to choose. Gone are the days when only a single design of a cheek implant existed. One of the different style designs is between malar and submalar implants. Malar is another word meaning cheek. So a malar implant sits on top of the existing cheekbone, providing more cheek projection. A submalar implant, however, sites on the cheekbone’s bottom edge providing increased fullness to the area below the cheekbone.

Submalar cheek implants have actually been around for some time and were developed to help with midface sagging from aging. As we age, cheek tissue slides or falls off of the cheekbone. One way to help lift it and restore more youthful fullness is with the submalar implant. The other option would be a midface lift, a more extensive operation with an increased risk of complications.

When most patients are considering cheek enhancement, they are usually thinking of higher cheekbones and more fullness to the bone right beneath the eye. Cheek implants come in a variety of designs to achieve this fullness and they differ in whether the most fullness in the implant is anterior, central, or posterior along the cheekbone. To choose the best implant style for you, you need to go over carefully with your plastic surgeon your exact concerns and what areas of the cheek you would like to be bigger. Most dissatisfaction with cheek implants occur because of style and size selections.

Dr. Barry Eppley

Q: I’ve lost about 90 lbs and now I have excess skin that hangs on my upper arms that I want to have fixed.

A: One of the many skin problems that develops after large amounts of weight loss is that of loose hanging arms. The skin on the back of the upper arm in the triceps area hangs down, creating what is often called ‘bat wings’.  The excess skin frequently extends into the armpit (axillary) area and down into the side of the chest wall. Such large amounts of upper arm skin are a unique finding amongst extreme weight loss patients, particularly after bariatric surgery. Interestingly, this arm problem occurs overwhelmingly in women and not usually in men. (I have never performed an armlift in men) It may be that men’s skin shrinks down better after weight loss.

An armlift, known in plastic surgery as a brachioplasty, is an extremely effective procedure for reducing the size of the upper arms and getting rid of this loose floppy skin. While it accomplishes this result with the trade-off of a long arm scar, patients with this amount of loose arm skin consider that scar better than the excess skin. Armlifts are one of the most satisfying of all weight loss body contouring surgeries.

Armlifts traditionally have either placed the scar running down the middle of the inside of the arm or on the back of the arm. Recently, I am using a new technique during surgery that places the scar between the middle and the back of the arm with significantly better results.  The scar is not only better hidden but the common postoperative wound healing problems that used to occur (particularly when using the inside of the arm location) have been largely eliminated.

Dr. Barry Eppley

Q: I have been infected with HIV for nearly 15 years. While he medications have been invaluable and have saved my life I suffer from some of their cosmetic side effects including a very gaunt face and a  non-existant butt. For my face which is better, fillers or iimplants. Can anything be done to my butt bigger?

A: One of the well known side effects of the medications to treat HIV is lipoatrophy or fat loss. The fat loss is quite specific, however, and has a predilection for facial and buttock fat. Loss of the buccal fat pads and, in severe cases, much of the subcutaneous fat results in a sunken in or very gaunt look to the face. It is such a classic presentation that it can be socially stigmatizing has having the underlying medical problem. In the buttocks, fat is lost so they become very flat appearing. Other parts of the body, for unknown reasons, undergo fat hypertrophy (excessive growth) most commonly in the back of the neck (buffalo hump) and in the abdominal area.

Facial lipoatrophy can be successfully improved with a variety of approaches including synthetic cheek implants, fat injections, or synthetic fillers. (e.g., Sculptra) Which one is best must be determined on an individual basis considering the extent of the fat loss and whether one prefers to avoid actual surgery or not. Fat grafting is probably best avoided as its persistence in the face of the medications is unlikely.

Treatment of buttock lipoatrophy is a different matter with no good options. Fat injections are not adviseable due to likely complete resorption and a result which will be underwhelming. This leaves buttock implants as the only option which carries with it a significant recovery and risks of infection and seroma complications.

No type of plastic surgery should be performed in an HIV patient unless their cell counts have been normalized and medical clearance is obtained from their treating physician. According to recent studies, the infection rate for plastic surgery procedures is not different in HIV vs non-HIV patient populations if good cell counts exist.

Dr. Barry Eppley