Your Questions
Your Questions
Q: Dr. Eppley, I am interested in numerous facial reshaping procedures including cheek augmentation. I think my chin is too big, my cheeks are flat and my nose could have a better shape. I have attached some pictures for your review. What do you think about these three facial areas in me?
A: Thank you for sending your pictures. From a chin reduction standpoint, it appears you have too much horizontal projection. Your chin can be reshaped by a submental approach where it is horizontally reduced and the sides tapered in so it does not end up looking wider. The cheek look you seek is a classic ‘apple cheek’ look that many females want. You have a very visible submalar concavity, probably due to buccal fat atrophy/deficiency, which gives yours cheeks an hourglass appearance as opposed to a fuller more convex anterior shape. You need a combined malar-submalar shell type cheek implant for your cheek augmentation which places the implants anteriorly to help achieve that type of cheek augmentation look. As to your nose, I would need more information as to what changes you seek as I see no obvious or glaring nasal shape deficiencies.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to know if there was any way to make my mouth smaller. I am 22 years old and I have always been self-conscious about my mouth. It has become a major problem in my life. I want to know what kind of recommendations you might have.
A: To some degree you have a bit of bimaxillary alveolar protrusion which makes your overall mouth area project further out from the frontal plane of your face. This makes your overall mouth look big. Also, by pure measurements, the horizontal width of your mouth from one corner to the other is wide as it exceeds a vertical line drawn down from the pupil of your eyes.
One method to make a mouth look smaller is to narrow its width by bringing in the corners of the mouth. While this can be down, it does leave scars at the corners of the mouth which with your natural skin pigment will probably not be very good scars. Eve if they were good and acceptable scars I do not think that would help that much as your problem is as much a protrusive issue as it is about its width.
An alternative strategy to dealing with a protrusive mouth is to increase projection of other areas of your face to better balance the mouth. You do have a retrusive chin and flat cheek bones. Increasing their projection through chin and cheek augmentation will probably help make the mouth look less protrusive and create better overall facial balance. This is a scarless and safer approach to smaller mouth surgery. The potential benefits of improving these facial areas on the appearance of the mouth could be demonstrated by computer imaging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I really need an opinion on what I should do to correct facial sagging or ‘bulging’ around my perioral area. I had upper jaw surgery six months ago which was a maxillary impaction. Since then, the left side of my face looks normal but the right side looks ‘pouchy’ and droopy to me. I’m glad I did the jaw surgery for my bite, but the way the right side of my mouth looks makes me feel old and ugly. I had a tiny bit of Juvederm injected in my cheeks and near the corner if my right lip a few weeks ago, but it hasn’t made any difference whatsoever to the problem. What do you recommend?
A: When you think about the mechanics of this type of facial skeletal surgery, it is perhaps no surprise that some facial sagging can occur in a few patients. When the maxilla is vertically shortened and the lower jaw rotates more upward in a new bite relationship, the overlying soft tissues have not changed. Thus there may be a relative ‘excess’ of soft tissue to bone. (bone is removed but the soft tissue is the same amount) While this is theoretically true, it rarely poses an aesthetic problem. But this can be a source of the tissue sagging…a relative soft tissue excess compared to the vertical length of the facial bones.
The options for improvement could be simple perioral mound liposuction on the fuller/sagging side or attempt to lift the sagging tissues by a variety of cheek augmentation methods. Which one may be best for you I can not say based on just this one picture and how you feel about the rest of your midface.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
Q: Dr. Eppley, thank you for the great fat grafting done to my cheeks a few weeks ago. It has helped a lot and I know that it is too early to tell how much fat will survve. But should a significant or at least enough fat go way that I want more at the three month time after the surgery, would you be able to go in and get more fat to put into that cheek? I was looking at some publications by Coleman and it appears that it is OK to inject more into the face after a three month waiting period. Also, is it true that you can extract a lot of fat and then freeze it for use in future treatments? What does the literature say about this type of procedure?
A: Secondary fat grafting can be done anytime after the initial procedure. The reason that the three month time period is given is so that one has enough time to fully appreciate how much fat has taken. Three months is the generally accepted time period to see the balance between what fat has died and been absorbed and how much has survived…thus making the final achieved contour change visible. Harvested fat can be stored in a frozen state for future use. Despite its appeal, however, the medical literature indicates that the thawed and re-injected fat quickly undergoes complete resorption. While not completely understood, the freezing and thawing process apparently is very detrimental to fat cells. (adipocytes)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheek implants. Please find my two photos. First one is my face, which is ok I think but it is the second photo which kills me. You can see the nasolablial fold and the cheek skin/fat falling down my face, making me look fat and old. I need to fix this and want to know my best options. Is it cheek implants? Paranasal implants? (whenever I push my top lip forward with my tongue from inside the mouth, my nasolabial folds and falling cheek fat disappear. Please let me know my best option sir. I don’t want to look like a fat guy even though I’m skinny. It’s just like my face is falling. I think I lack the bone structure to hold up my face. As my jaw and cheek bones are non existent. I am 32 years old. Thanks!
A: At your age I don’t know that your face is truly falling but I would not disagree that you have weak cheekbone structure. Pushing the lip out is not a practical approach to improving your facial structure. The only way to get some tissue lift is through cheek implants which will create a bit of a midface lift using malar shell implants. This will not eliminate the nasolabial folds completely but it will provide better facial balance and make your face look less fat. In addition I would do fat injections into the nasolabial folds and the paranasal areas to provide some augmentation to them as well. This in combination with the cheek implants will likely create the overall facial improvement you seek.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheek augmentation but am not sure which option to pursue. Can you help me decide between fillers and cheek implants?
A: Cheek augmentation can be done with a variety of methods because the cheek is a rather indistinct structure that does not have sharp contours. Thus cheek augmentation usually only requires a mass effect which rarely has to have very distinct contours. Fillers and implants make up the two categories of treatment options that can have similar effects but different methodologies and short and long-term effects.
Synthetic injectable fillers are the easiest approach as they can be done in the office and can be placed anywhere on the cheek. Their effects are instantaneous and there is little swelling and no recovery. Their downside is that they will not be permanent and must be repeated to have a sustained result, regardless of the filler type used. For many this can be a good test or trial if one is uncertain about whether cheek augmentation is for them.
The natural injectable filler of fat offers the potential of longevity but its complete survival is not assured. This is why cheek fat injections are often overdone to some degree building into the result some amount of postoperative fat resorption. Because this requires the harvest of fat, it is usually done in the operating room and usually as part of other face or body procedures.
Cheek implants offer a reliable method of permanent volume augmentation that can be placed in a variety of cheek locations due to the different implant styles and sizes available. This is the most invasive approach and is done from an incision inside the mouth under the upper lip. If the implants are properly selected and placed, potential complications such as cheek asymmetry or an unaesthetic shape can be avoided.
When all put together, one should do synthetic fillers if one is uncertain about the benefits of cheek augmentation, use fat if doing other surgery and want a natural cheek augmentation effect or use implants if one is certain about their desire for cheek augmentation and/or want a permanent and/or dramatic effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am really interested in one of the facial procedures (cheek augmentation I think) to improve my smile. I make an effort to smile only to find out that people don’t find it compelling. I am confused and this makes my self-esteem very low. I have small(weak) cheek bones which some how make me look like I am frowning all the time. It was after me noticing my self-consciousness that I started being aware of all the people I found very approachable or had friendly faces, in other words their cheek bones were gently protruding and noticeable from a profile(side view of the face). This, them having strong cheek bones, really made them appear to be ‘ever smiling’ and smile effortlessly even when it is just a grin their evoking. I looked at myself talking in the mirror lately and was evidently stunned, because I would say things but my facial expression was not corresponding with what I say or the way in which I respond to things I said to myself. For instance, when I am surprised my eyebrows don’t rise and no lines on my forehead show, because my eyebrow bone is also flat and I seem not to send my messages across to others other than verbally. A stronger cheek bone with lines on the corners of my lips and bigger eyebrow bones will make my smile sensible.
A: It sounds like you have a good grasp on how to improve your facial appearance. By your own description you know that cheek augmentation by implants, possibly combined with brow bone augmentation, would help your smile both outside and in.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know I need rhinoplasty but am not sure what else I need. I would like you to analyze the attached photos in order to determine the ideal procedures to bring better balance to my face. These are my own assumptions about my facial appearance, both what I see as out of proportion and how to go about fixing it along with the objectives I hope to achieve
1. Droopy asymmetrical nose – It would be optimal to both straighten the entire nose and strengthen the tip (add cartilage). The tip would look best projecting forward more. I would still want to keep a high strong nasal bridge, so little shaving should be done there. Tip should still be turned down slightly a few degrees further than perpendicular to the face.
2. My eyes are too prominent relative to my other features and I would like a stronger, masculine look to eyes. I have looked at everything from malar to inferior, lateral, and superior orbital rim implants. I am less sure what would prove ideal for this issue, so your own suggestions here would be much appreciated (though if you think it is a bad area for me to augment please let me know as I want your complete objective opinion). Be as specific as possible, referencing both the individual anatomy and procedures that are possible.
A: Based on the one side view picture that you have provided, I did some imaging for the rhinoplasty based exclusively on tip rotation and elongation with minimal reduction of the middle vault height and no reduction of the nasal bridge bone. With this change I see no reason for chin augmentation which is the first other facial feature to think of when the nose becomes derotated.
From an eye standpoint, the only consideration you want to make is for infraorbital rim-malar augmentation. While superior and lateral orbital rim augmentation can be done, the effort to do does not justify the minimal benefits and risks. The focus for making the eyes less prominent should be on the recessed infraorbital-malar complex. I have factored this into the imaging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of facial freshaping. I have some issues regarding a long face, and more importantly a long midface. It’s just been seriously bothering me for years to the point where it is causing problems. If you could take a look at these pics and just figure out what is so wrong with it, i would really appreciate it.
A: While I would not disagree that your face is a little long and the guilty component is your midface, there are other facial structural issues that are magnifing that impression. A horizontally short chin and a long nose with an acute nasolabial angle make the midface loo longer than it already. When you combine that with a very skeletonized face (little facial fat), the effect becomes even more so. There really are no true midface shortening procedures other than a maxillary impaction which is only used for vertical maxillary excess that has a gumkmy smile. (which does not apply to you) But what you can do is change some of the other factors that are accentuating the midface elongation effect. This includes a sliding genioplasty to bring the chin forward, a rhinoplasty to rotate the tip and decrease its length and submalar cheek augmentation to procide some more width to the midface. Together, these facial structural procedures can help shorten a long midface appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My concern is my facial asymmetry. My one side of my face did not develop normally, my left eye sets lower than the right. Also my left cheek bone is under developed. I want to know if it can be corrected. I have attached some pictures so you can see what I mean by one side of my face being different than the other.
A: Thank you for sending your pictures. You have a left-sided form of facial asymmetry due to some underdevelopment of various facial structures. This is probably a minor variant of hemifacial microsomia. I can see in looking at your pictures you have some orbital dystopia (lower eye socket) with malar (cheekbone) hypoplasia as well as some chin asymmetry. (shift towards the underdeveloped left side) The best treatment approach would be orbital floor augmentation, medial z-plasty canthoplasty, cheek augmentation and a chin straightening genioplasty. But probably what bothers you the most is the cheek-eye area which is what you see and look at the most.
I believe the eye and cheek area could be significantly improved but I wouldn’t use the term ‘correction’ as that implies they could be made perfectly normal which they can’t can’t. It is just a question of how close to normal can they be made.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had two cheek implant surgeries. Initially I had 4mm malar shell implants which were barely noticeable. Then I switched to 6mms implants which are now too big. I have a question regarding projection size. I’ve attached two photos showing my face with Conform Terino Malar Shell medium implants with 4mm projection. As you can see, I didn’t feel that these 4mm implants gave me enough definition in my cheekbones or enough outward projection. Therefore, I just had these implants exchanged with Terino Malar Shell 6 mm, but I now feel that the 6mm projection sticks out way too much. I’ve heard that a 1 mm difference in implant thickness (projection) is equivalent to about 1/2 inch difference in actual cheek shape. So, looking at the attached photos (and now that I know through trial and error that 6 mm projection is too large), do you think the same implant with a 5mm projection would still look too large, so I should go with a 4.5mm implant when I exchange the implants next month?
A: It is not true that 1mm of cheek augmentation equals a half inch difference in how the cheek looks. What I can tell you is that it can be striking how a few millimeters in the cheek area can make a big difference. So I think the statement that a little augmentation goes a long way in the cheek area. You case illustrates that in particular. If 4mms is too small and 6mms is too big, one would logically assume that 5mms would be the right size for you. Be aware, however, that in any cheek implant style and size that not just the thickness changes but overall size of the implant (height and width) as well. It is unfortunate that you will have had to go through three surgeries to finally get the right size implant. But there remains no quantitative way before surgery to determine how any amount of cheek implant augmentation will look
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What I am most interested in is the cheek enhancement. I feel like creating volume there will help balance everything else out. If I still want to make other enhancements after, I suppose we can do them at separate times. My question at this point is, considering how many different variations for cheek shapes there are, is how do we determine the best shape for me. I know what I like, but I’m not sure what the materials are that would achieve that result. I seem to remember several different options for custom implants and fillers on your site based on the patients face structure. I was seen my someone who gave the option of three sizes of Gore- tex implants and I am looking for a more custom and personal approach which is what drew me to your site. I could show you some photos of shapes I like or even photoshop my image myself to indicate what I’m looking to achieve.
A: When it comes to cheek implant options, the number of different types depends on the manufacturer. For most patients, there are enough styles and sizes to produce a satisfactory outcome. Furthermore, it is easy and very common to take an existing off-the-shelf cheek implant and modify to make what I call a ‘semi-custom’ implant. True custom implants can be made off of a 3-D model of the patient and obviously this is as custom as it gets. Which one of these three implant options, stock, semi-custom and custom, is best for you is yet to be determined based on your exact aesthetic needs. You doing some Photoshop to illustrate what you are after would be very helpful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Doctor Eppley, can the type of cheekbone and jaw angle advancement be done without implants but with the patients own bone? Such as with a cheekbone osteotomy? Also, do you have any before and after pics of this kind of procedure. I would like the male model look, but I have relatively flat and narrow cheekbones and a weak chin. I am currently undergoing orthodontic treatment and will eventually have a rotational advancement of my jaw, but this will not necessarily improve my cheekbones –do you perform cheekbone advancement widening? And could you send me some before/after pics of such results? Thank you very much for any help! I would certainly be willing to travel to consult with you.
A: Most facial bone augmentations can only be done using synthetic implants on top of the bone. The one exception to that is the chin where the option exists of either a chin osteotomy or chin implant. This is because there is enough bone to cut and move and the direction needed is a favorable one from a bone movement and blood supply concern. Such is not the case with the cheek. While the cheekbone can be cut and moved, it will only produce a widening effect and not a forward or anterolateral effect which is what most patients need and want when they undergo cheek augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I would like to have those chiseled high cheekbones. I have looked at some implant styles online and it seems that the Medpor extended malar implant may work for me. The picture on the website product catalog shows the implant in a high and lateral position and the implant is described to augment the malar region. My surgeon told me that this kind of implant can only be placed under the cheekbone (submalar) and more towards the nose than towards the zygomatic arch and that the picture on this website shows the wrong placement of this implant design. I really don´t want submalar augmentation! Is it true that this implant design is actually a submalar implant and therefore not used for malar augmentation or can it be used for both malar and submalar augmentation? What is your experience with this kind of implant design?
A: Choosing the correct implant design and size is obviously critical for any type of facial implant procedure. This is particularly true in the cheek or malar region as this area has the most complex three-dimensional anatomy to it. It contains five zones of potential augmentation including anterior, lateral, oblique, orbital rim and submalar. Any cheek implant will affect at least three of these zones in any single design. For those interested in more ‘chiseled’ cheeks, by definition this means that the oblique and lateral zones are most important. The submalar zone should absolutely not be augmented as part of this type of cheek implant because it will create more of a rounded full cheek look rather than making higher and more ‘chiseled’ cheekbones. The type of cheek implant to which you refer will not help create the look you are after. That type of cheek implant design creates fullness on the lower or submalar cheek zone and will not achieve that higher angular cheek look.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Several years ago I was involved in a cycling accident in which I landed on my face and broke a lot of my facial bones, including my jaw, nose and cheeks. My face was initially reconstructed and looked quite good, almost like it was before the accident. But after 6 months, I began to notice that my cheeks looked a little flat. This appears to have gotten worse and now they look even flatter than a year ago. I don’t like to look at myself in pictures because I look so flat in my face. I know that swelling does take many months to go away but this seems more than just swelling. Why has this happened and what can I do about it? Do you think cheek implants would be a good idea? Wouldn’t they be hard to get due to scar and the metal plates that were used to fix the bones back together?
A: It is not uncommon after extensive facial fracture repair that particularly involves the cheeks, that there is cheek flattening with time. This can happen due to the cheeks not being put back to their original projection or can even happen with the most accurate realignment of the fractured bone segments. This is the result of underlying soft tissue atrophy, particularly the fat which is very sensitive to trauma. As a result fat dies (atrophies) over time. This may make the cheek prominence, which initially looked good, become flatter as the face heals up to a year or so after the injury. Cheek implants can be a good secondary reconstructive procedure. It is important to get the right style and size of cheek implants to get a good result. It would be expected that there would be scar and even some plates and screws in the path of re-entry over the cheeks but this does not prevent the secondary placement of cheek implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I feel like my cheeks are flat and that makes my face very non-descript and uninteresting. I think cheek implants would help but I have also read that you get get better cheeks with injectable fillers also. Which do you think is better? I have attached two pictures of my face as well as two examples of what I think are good-looking cheeks. Will cheek implants or injectable fillers worko better to reach these goasl based on the structure and limitations of my facial bones?
A: Your pictures do show malar or cheek flatness. Based on your desired goals by the pictures, cheek augmentation would definitely offer a big improvement towards improved facial balance and attractiveness. For ideal cheek augmentation and a better overall effect, an implant is the best choice in my opinion. Besides its permanent effect, it has a better economic value long-term. . If you are uncertain as to whether cheek implant surgery is for you, however, then initially have an injectable filler treatment done. Be aware that injectable fillers will not create exactly the same look as implants which have a very well defined shape. Injectable fillers create more of a less-defined mass effect although that will still be helpful to prove that cheek augmentation is or is not for you. When considering cheek implant surgery it is important to realize that there are different styles of cheek implants that accentuate subtle but different areas of the cheek. Selecting the right cheek implant and size is critical as the main reasons for cheek implant revision is improper implant selection and inadequate sizing.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am going to get cheek implants but am concerned about them moving around afterwards. I am an extremely athletic person who works out a lot. This involves running and jumping around a lot. I do participate in conatct sports such as basketball and flag football. However, I don’t do boxing and am not planning to get punched in the face. (who does really?) My cheek implants will be the Conform malar shell type so they are not small. Do you think just suturing them in is enough or should they be secured with screws. Which method is best for me?
A: What makes cheek implants different from other facial implants is their bony position. Sitting on the side of the cheek bone, with no bone support underneath them, makes them more prone than many other facial implants to shifting or malpositioning. This risk is magnified by their path of insertion from inside the mouth which opens up the southern avenue for shifting. While most cheek implants do not experience these problems, the risk is not zero. Because of this concern, it is my preference to almost always screw fixation for cheek implants. This makes me feel the most comfortable that the postoperative risk of implant shifting is virtually eliminated. the appeal to me of screw fixation is that it is also easy to do, involves no risk, is done at minimal extra cost, and adds essentially no extra time to complete the procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: All my life I have had depressions under my eyes. It’s a hereditary thing as I have no cheekbones at all. It makes me extremely self-conscious. Although I don’t need glasses, I wear them all the time to hide this problem. I have been thinking about getting cheek implants. Do you think that will help me? I have seen some cheek implant results and they look really fake to me. How do you avoid cheek implants from looking unnatural and even making my eyes look too sunken in?
A: There is no doubt that well-defined cheekbones are an important facial component of what can make a man or a women good looking. Cheekbones help define the face by highlighting the eyes, adding balance to the other facial prominences and contributing to a look of youth and vitality.
Cheek implants can really help those whose midface is deficient. But cheek implants come in different styles and sizes. There is more to cheek implants than just choosing a size. The cheekbone is a curved structure that has dimensions of a frontal, central, posterior and inferior considerations. Different styles of cheek implants highlight these areas differently. Patients have different types of cheekbone deficiencies and that is the reason so many cheek implant styles exist. In addition, how the implant is placed along the bone and what size is chosen will influence how it will look after surgery.
Probably the biggest consideration in avoiding an unnatural cheek implant result is to not use too big of an implant. The cheek area is very aesthetically sensitive and trying to make too big of a change or use the implant to lift sagging cheek tissues can quickly make for a peculiar looking result. There are some good celebrity illustrations of this exact problem.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi Dr. Eppley, I am interested in filling in my lower cheeks. They are sunken in and I have had multiple fillers from Radiesse, Juvederm etc for years. I am tired of it looking really good for 2 weeks due to swelling and then having it all disappear and look the same within the month. Do you ever do a tissue fill on the lower cheeks? I had one doctor do filler one time on the upper cheeks and I hated it. I looked like cat woman and I don’t like that look. I just want to fill in the bottom cheeks. I’m afraid to put in an implant because of the risk of crooked smiling. What do you suggest?
A: The area below the cheeks is known as the submalar triangle which extends from below the cheekbone down (in an upside down triangle) to below the side of the mouth. It is important to appreciate that this area is not supported by underlying bone. This is why anyone with a thin face or fat loss will show an indentation in this area and create a ‘gaunt’ look. This also means that there is no type of a bone-based facial implant providing any fullness to this area.
While synthetic injectable fillers will produce some temporary fullness, they are not a long-term solution to this area of soft tissue facial deficiency. The next logical approach is that of fat injections. While they offer at least the potential for some long-term retention, they are also plagued by potential resorption. I have mixed these fat injections with PRP (platelet-rich plasma) for facial injections and feel that this combination does offer better results. But the risk of near to complete resorption still exists. No one can predict how well fat injections will persist in any particular patient.
The remaining good alternative is that of dermal grafts. Using allogeneic dermal grafts, they can be put it in sheets and layers. They can nicely built up an area and are very soft. They are human collagen which will eventually be replaced by your own tissue. They can be put in through a limited facelift incision. Their long-term volume retention is much more assured than fat injections.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am 18 years old and cheek enhancement seems to have caught my interest. I’ve been rolling the thought of having a procedure in my head for quite some time now, so here I am asking for information. People say there is nothing wrong with my face but what I want is more defined cheekbones, like the male model look. There is this heart shape the cheeks do along with the jaw angle if you understand what I mean. What effects might the procedure have on my face in a long term period of time? I mean, when I get to 50, will there be any undesirable changes on my face? Thank you for your time. I look forward to receiving an answer from you.
A: High cheek bones are a frequent aesthetic desire. In a male the triangular effect of prominent cheeks, chin and jaw angles makes for that chiseled or angular face look. That particular male facial look is certainly one that is evident in many male models in magazines and advertisements.
While strong cheek bones may be desireable, they are not achieveable in every male face. While cheek implants can make the cheek area bigger, that doesn’t necessarily mean that effect makes for a more sculpted facial look. One has to look at the other facial features and the overall facial shape to see if cheek augmentation offers an aesthetic improvement. If cheek implants are put in just any face, some of those faces will just look like they have big or puffy cheeks and may not become more angular.
One positive long-term effect that cheek implants do is help maintain cheek tissues from sliding off the bone, so to speak, with age. In fact, they are occasionally placed in older patients for a midface rejuvenative effect to help lift sagging cheek tissues. Unfortunately, when done to an extreme, they can make the older face look odd or have an ‘apple cheek’ effect. There are numerous famous male celebrities that have this look.
Dr. Barry Eppley
Indianapolis Indiana
Q : I am interested in cheek implants but am not looking for a drastic change, just enhancement. I want to look better but have people not be able to tell what is different. I have a few questions. What is the recovery time from work and physical activity (running and cross training/weight lifting)? Are the implants inserted from the mouth and fixed to the jaw? Do cheek implants inhibit ability to smile? Approximately what % of patients are happy with the cheek implant procedure?
A: Cheek implants are done as a simple 1 hour outpatient procedure. They are inserted through the mouth and secured to the bone with a screw. There are no restrictions of any kind after surgery. While you will have some cheek swelling (but no bruising), there is nothing you can do from an activity standpoint that will hurt the implant or their position on the bone. One can eat and drink right after surgery. Pain is very minimal although usually there will be some temporary numbness of the cheek skin and a little bit of the upper lip. Cheek implants will not change your ability to smile or how your smile will look. Initially, your smile will feel a little stiff but that is due to the swelling. The vast majority of patients who receive cheek implants are happy but I also feel that it is the one facial implant that undergoes higher revision rates than all others due to inexperience in placing them, size and position selection, and style of implant used. It is a simple procedure to do but there is definitely an artistic flair to doing them well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I recently had cheek implants but now one side of my face has hollowed out and both sides of my mouth have developed drooping pouches of tissue . It looks very uneven and has distressed me greatly. I would like your opinion about this.
A: This is certainly a very unusual type of mouth result from cheek augmentation. The reason it is unusual is that cheek implants add volume to an otherwise prominent facial bone area. If anything it may cause a very mild cheek tissue lifting effect but not dropping of tissues as you state around your mouth. Early after surgery, in the first few weeks or month, one could have swelling and some bruising which drifts downward along the mouth and even into the neck. But if this is would not be the case more than a month after surgery. If other facial procedures were done at the same time, which would be common, then this could still be residual swelling which may yet go away.
Uneveness of cheek implants, however, is not rare and is probably the number one complication of cheek augmentation. It is more difficult than it looks to place cheek implants in the identical position on both sides of the face. The thickness of the cheek tissues do not make it easy to see minor differences in position during the actual surgery. I would wait at least three months after surgery to let everything settle before making a final judgment about cheek symmetry.
Indianapolis, Indiana
Q: I am interested in having small cheek implants and was wondering who you would recommend I see in the Washington-Baltimore metropolitan area. I have spoken to several plastic surgeons who say they remove more cheek implants than they put in. I am wondering who has had good results with this procedure?
A: I wish I could answer your question in regards to plastic surgery referral in your geographic area. But, unfortunately, I could not tell you with any assurance who gets good results with cheek implants. While I am certain all plastic surgeons say that they do them, who would be better than other is impossible for me to know. (just like you)
What I can tell you about cheek implants is that what you have heard about them are true. Even though it is a very simple operation, they are the most revised and/or removed implant of all the facial implants. The reason that exists, in my experience, is that they are often oversized for the patient. Cheek implants are much better to be done in moderation or ‘underdone’. Cheek augmentation should be subtle, not dramatic. It is not like a breast implant, where many times bigger may be better. That is never true with a cheek implant. The second reason they are revised is that the cheek implant is unique in its position. It is the only facial implant that is literally ‘hanging on the side of the cliff’ in where it is placed on the cheek bone. So they are prone to movement and asymmetry between the two sides afterwards. That is why I prefer to secure them with a screw to the underlying bone to prevent that problem. Lastly, there are at least 5 different styles (not to mention sizes) of the implants, so matching the unique anatomy and patient desires with the right style and size of cheek implant is certainly more art than it is science.
Dr. Barry Eppley
Q: Can facial implants help to fill in a cheek region, where collagen injections have been beneficial? I have a large depressed scar from dermabrasion and laser treatments on an acne scarred region of my face. I would be glad to email pictures of the region to assist in the answer.
A: Facial implants work by pushing out from the underlying bone on the overlying soft tissue. This how they create more highlights or volume to specific facial bony prominences. While a facial implant can be placed anywhere on the facial bones, they work best on convex or flat surfaces such as the chin, cheeks, and jaw angles.
The treatment of most depressed scars would be either some form of surgical scar revision (cut out and re-closure) or skin resurfacing. In some select cases, such as yours, actually filling in the underlying soft tissue helps flatten the outer appearance of the scarred area. Injectable fillers can work well for that type of depressed scar but they are not permanent and must be repeated.
You have correctly pointed a very uncommon but potentially beneficial approach to depressed cheek scars. Having proven that soft tissue expansion makes the scar look better, it is insightful to ask about whether a cheek implant can create the same effect. Since the cheek bone is convex, an implant will definitely push outward on the skin, helping flatten a depressed scar. I have done such an approach twice in my Indianapolis plastic surgery practice and it can work well as you have surmised.
The key to the successful use of an implant for a depressed cheek scar is two-fold. The acne or traumatic scars must be directly over the prominence of the cheekbone to get the most benefit from the underlying push of the implant. And you must consider the opposite cheek prominence as well from the perspective of balance. (one-sided or both sides for cheek augmentation)
Dr. Barry Eppley
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