Cheek Reshaping Specialist
As one of the leading cheek reshaping specialists in America, Dr. Barry L. Eppley, has years of experience helping his patients achieve a more defined facial profile. Please read on to learn more about the procedure. To see results from our previous patients, visit our cheek before and after photo gallery .
Well defined and distinct cheeks are part of an aesthetic and well balanced face. They help highlight the middle part of the face, promote a more youthful appearance, and can contribute to making the nose and chin smaller in certain patients. Women know this facial characteristic well by the common method of applying darker make-up underneath the cheekbone area and lighter make-up above it in an effort to highlight its location and shape. Cheeks appear in a variety of undesired aesthetic shapes from being too flat/lacking structure, being too prominent or wide, having fallen over time due to aging or prior surgery and having different cheek shapes between the two sides. (asymmetry)
When considering cheek reshaping surgery, particularly that of cheek augmentation, it is extremely important to appreciate the differences between the female and male cheekbone structures and what makes them look aesthetically better. Such cheekbone differences are well depicted in the art world with males having a higher and extended cheek prominences while women will have a lower and more anterior cheek fullness with a more angulated sweep backwards. This is a general statement about gender differences and in contemporary times these historic distinctions are becoming more blurred.
Injectable Cheek Enhancement
By far the most common form of cheek augmentation done is through the use of injectable synthetic fillers and fat. These minimally invasive methods offer immediate results without any downtime of significance and exacting placement of the augmentation materials. Synthetic fillers offer good results and are completely reversible when using hyaluron-based fillers. Fat injections can also be effective but their results are not always predictable (how much will survive) and are difficult to reverse. For many people synthetic fillers are a good starting point into cheek augmentation as a trial to determine whether they like it and where is the best augmentation location. Fat injections are often done as a matter of surgical convenience when performed along with other surgical procedures and if one is doing fat injections elsewhere on the face or body. The cheeks usually have one of the highest take rates in the face with the exception of thinner faces in younger people.
The cheek area can be permanently enhanced by the placement of an implant that sits either entirely on its bone surface and/or partially extends beneath it. While the concept of placing a cheek implant can seem simple, it is much more challenging than most think because of the 3D shape of the cheek and how it is positioned on the face to get a satisfying aesthetic result. This is illustrated by the wide range of contemporary cheek implant styles which selectively highlight specific portions or all of the cheek area.
To help select the cheek implant that best creates the patient’s desired look, it is important to know which of the zones of cheek enhancement (malar, submalar, and zygomatic tail) needs to be covered. Such standard cheek implant options include the following:
Malar Cheek Implants
This cheek implant style provides complete coverage of the front and sides of the main body of the cheekbone. (zygomatic proper) It is designed to sit completely on the bone and provides anterolateral cheek fullness. It is most commonly used in patients seeking cheek augmentation for their flatter cheeks.
Submalar Cheek Implants
This unique cheek implant sits mainly on the underside of the cheekbone and was originally designed to correct submalar hollowness from aging or in facial lipoatrophy. As a result it is the implant alternative to a soft tissue midface lift and creates a very similar and often more effective midface lift result. It is also used in conjunction with facelift surgery as the alternative to a deep plane cheeklift.
Malar-Submalar Shell Cheek Implants
As the name implies this cheek implant styles adds a lower extension that allows the implant to fill out the submalar hollows as well as well as creates increased bony projection above it.
Midface Cheek Implant
This cheek implant style provides broader coverage than the malar-submalar shell style but with less projection.
Regardless of the cheek implant style (with the exception of the submalar) cheek implants are usually placed from an incision inside the mouth up under the upper lip. Cheek implants can also be placed through a lower eyelid incision which may be part of an overall midface lifting strategy. There is a certain risk of asymmetry in cheek implants for two reasons. It is hard to see if they are positioned evenly because one can not see the placement of both implants at the same time. The use of bone landmarks is used and the implant is positioned by them. This is not always completely accurate however. Secondly, if the implants are not firmly secured onto their placed position on the bone they may shift after surgery. Their position is best assured by using self-tapping microscrews through the cheek implants to the underlying bone or an external bolster for a few days after surgery.
CHEEK (Midface) LIFTS
Sagging cheeks (bags below the lower eyelids and under the cheekbones) from aging is due to the skin and underlying soft tissue ‘falling off of the bone’ as the ligaments weaken over time. These cheek tissues at one time were higher up on the bone but can fall with time and the effects of gravity. These are often called malar bags or sagging cheeks. These are particularly seen in those people who naturally have weaker or less prominent cheek bones.
This cheek condition may be helped by two surgical options, a submalar cheek implant or a cheek lift. A submalar cheek implant not only adds volume to the underside of the cheekbone but also has a slight lifting effect on weak or sagging cheek tissues. A cheek or midface lift, done through a lower eyelid incision, lifts the sagging cheek tissues back up on the bone and resuspends them. The resuspension by sutures may be done to a temporal fixation point (fascia) or more superiorly to a point high on the forehead behind the hairline. (skull bone) In some cases of midface lifting a combination of a cheek implant and tissue resuspension is done for a more profound effect.
MIDFACE/CHEEK SAGGING AS PART OF AGING
Aging affects all regions of the face from the forehead down to the neck. While facelifts improve the neck and jawline and browlifts improve the forehead, the central third of the face has fewer surgical options for aging improvement besides eyelid surgery. It is often neglected or overlooked in facial rejuvenation approaches. The cheek tissue is well known to descend downward with time and gravity, creating a roll of tissue below the cheek bones (malar descent) and making a significant contribution to the deepening of the nasolabial folds.
WEAK CHEEKBONES CONTRIBUTE TO MIDFACE AGING
Some patients are highly susceptible to developing sagging cheeks because they have a weak or underdeveloped bone structure. Their cheekbones are flatter and more recessed and do not provide much of a ‘ledge’ for which the cheek tissues can be supported. Thus, when the ligaments holding the skin and soft tissues to the bone weakens they are especially prone to drifting ‘south’.
DIFFERENT TYPES OF MIDFACE LIFTS/CHEEK LIFTS
The concept of a cheeklift is to reposition the fallen soft tissues back up onto the cheek bone. This can be done one of two ways, soft tissue resuspension or bone implant augmentation. In some cases, both cheeklift approaches may be used.
MIDFACE LIFT/CHEEK LIFT – SOFT TISSUE RESUSPENSION
A soft tissue cheeklift is done through a lower eyelid (blepharoplasty) incision where the fallen cheek tissues are lifted back up onto the bone. At the same time, a lower blepharoplasty is also performed which most facial aging patients need as well. A soft tissue resuspension midface lift may also be done through a temporal incision (temporal suspenion), a scalp incision (cranial suspension) or combined with the Endotine device to help hold up the cheek tissues. Almost every approach, however, uses a lower eyelid incision as part of the procedure.
MIDFACE LIFT/CHEEK LIFT – IMPLANT AUGMENTATION
A bony cheeklift is done by placing a specially designed cheek implant (submalar or combined submalar/malar shell) onto the bone through an incision inside the mouth. By adding bone support, the fallen cheek tissues are lifted up. The size of the submalar or shell implant will determine how effective this type of cheeklift is. For some patients this is all the midface lifting effect they will need.
The Cheeklift Operation
All cheek lifts are done under general anesthesia. A soft tissue re-suspension is done through a lower eyelid incision, often combined with an intraoral incision as well. This allows the cheek tissues to be completely freed up and lifted. The key to this type of cheeklift is in how to lift and maintain support to the bone as it heals. (where and how to the tissues) While many different methods have been described, my preferred approach is a cranial suspension technique where the sutures lifting the cheek tissues are passed under the temporal and forehead skin and sewn high up onto the skull bone directly above the outer corner of the eye. Malar shell or submalar cheek implants are introduced from inside the mouth and placed on top of the cheek bone. The implants are secured into position by a small titanium screw to the bone to prevent the risk of displacement.
Due to a broad or wide face, some people desire a facial narrowing surgery. The widest part of most people’s faces is in the cheek area, with the widest part at the midportion of the zygomatic arch. This thin sliver of bone is a bowed structure that connects the larger cheek or zygomatic bone with the temporal bone above the ear. Underneath the zygomatic arch passes the large temporalis muscle which attached the upper portion of the lower jaw.
The cheekbones can be reduced by moving the zygoma and the zygomatic arch inward, as a combined unit, through osteotomies or bone cuts. From inside the mouth an L-shaped osteotomy is done through the main body of the zygoma and from a small temporal incision the attachment of the tail of the zygomatic arch is cut. This allows a cheekbone reduction to be done by moving these bone segments inward and fixing them there with tiny plates and screws. These types of osteotomies are the primary method of cheekbone reduction surgery and produce the greatest amount of facial narrowing. In rare cases, simple burring of the zygoma may be done for very subtle narrowing effects.
CHEEK SLIMMING (BUCCAL LIPECTOMY)
Chubby cheeks can occasionally be the result of too much fat right below the cheekbone. This fatty area is know as the buccal pad fat. This is a discrete encapsulated ball of fat that can be quite large in some people. The removal of part of this fad pad is known as a buccal lipectomy and can reduce facial fullness right below the cheekbone. This is done from an incision inside the mouth and is a very straightforward procedure. While effective for cheek fullness reduction in the properly selected patient, it can have long-term adverse effects (gaunt face) if overly done or done for the wrong reason. The wrong reason is the misunderstanding that the effects of a buccal lipectomy are right under the cheekbone (high cheek area) not down by the corner of the mouth. (lower cheek area)
Dr. Eppley not only performs cheek augmentation to help his facial aesthetic patients. He also performs facelift, Botox, in addition to helping rhinoplasty patients achieve their desired facial profile. He also offers custom implants patients facial implant procedures that are specifically tailored to their aesthetic or reconstructive needs.
Cheek Reshaping – Before Surgery
Evaluation of the face and how cheek augmentation and/or lifting may fit in the overall shape of the face is important for the patient to visually see. Often times, cheek augmentation is part of other facial procedures (e.g., nasal or eyelid surgery) to improve facial proportions and overall facial balance. This may be helped by computer predictions, although this is one of the harder areas to demonstrate by digital imaging. Choosing from amongst the different cheek implant styles is important as different areas of the cheek may be highlighted in different patients. Cheek or midface lifting is often part of other anti-aging facial plastic surgery such as a facelift or browlift and eyelid surgery.
Cheek Reshaping – Operation
Cheek implants are done as an outpatient procedure under general anesthesia in most cases. They are most commonly placed through the mouth through a small incision high above the molar (upper back) teeth. They may be secured to the bone by a small screw to prevent them from moving after surgery. In some cases, they may be placed through a lower eyelid incision if a lower eyelid procedure is also being performed at the same time. Cheek (midface) lifting is done through a lower eyelid incision and is often part of eyelid and browlifting surgery. The cheek tissues are elevated and sutured back up onto the bone, restoring fullness to the cheek area and eliminating bags below the cheekbone.
Cheekbone Reshaping Recovery
No specific dressing or bandages are needed. Mild swelling of the cheek and middle part of the face will be seen but usually there is no bruising. Pain is very minimal. The final result is usually seen in about three weeks when most of the swelling has subsided.
Complications are very infrequent with facial implants due to the good tolerance of the face to synthetic materials, particularly at the bone level. Infection is very rare. Implant location and size (too much or too little) is the most common complication that may require revisional surgery. The only significant complication from cheek lifting is alteration of the lower eyelid position (pulled down) due to scar contracture. While rare, it may require a touch-up procedure to readjust the lower eyelid.
A detailed description and pictures of your concerns allows for the most informed response.