Your Questions
Your Questions
Q: Dr. Eppley, I had combination malar submalar implants placed a year ago, but they were too big and I had them removed. I later decided to go with malar implants only, but they got infected and I had to remove them too. I guess you can say that I haven’t had the best of luck with these implants.
Anyway, what I’ve noticed is that there seems to be some sagging in the mid-face from the cheek implant removal, and I seem to have deeper nasolabial folds and some droopiness at the corners of my eyes too. I’m not too happy with this, and would like it fixed.
Would it be possible to explain to me what my options are? Are there any minimally invasive lifting procedures that can be done? I’m still young (mid-20s), so I would preferably like to avoid anything too extensive or invasive.
A: With cheeks implant removal of any style and size, tissue sag is inevitable due to loss of anchoring attachments of the overlying cheek tissues to the zygomatic bone. The only potentially effective treatment would be cheek soft tissue resuspension. There are multiple ways that cheek resuspension can be done from using intraoral, lower eyelid and temporal suspension points of anchorage. One can debate whether any of these techniques are less invasive or extensive than the other, but I would not make much of a distinction between them. It can also be debated as to which of these cheek resuspension techniques is more effective than the other. But that is probably more surgeon dependent than technique dependent per se. Lastly whether they can create the more complete improvement that you seek (midface sagging, nasolabial fold reduction and corner of eye droopiness correction) is asking a lot of them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheek implant removal surgery.What techniques are used in Medpor removal to avoid any tissue sag? Does Medpor hinder the face returning to normal after removal.
A: Any cheek implant removal has the potential for a soft tissue sag thereafter, regardless of the material composition of the cheek implant. It is a simple function of tissue expansion of the overlying tissues and release of the soft tissue attachments. The likelihood of this happening in any cheek implant removal patient can not be precisely predicted and is a function of implant size, implant location and the patient’s inherent anatomy. This raises the question then of whether any type of cheek resuspension/tissue reattachment method should be done at the same time as their removal. This is not an easy decision and there is no method to accurately know if it is really needed. But I think one has to recognize that the face is not going to return completely to its preoperative state. (any more than removing breast implants will return the breasts exactly back to what they were before surgery to make a comparative tissue expansion analogy) If in doubt the best method is to do a soft tissue cheek resuspension through a remote temporal incision. The other more limited option is to use a bone anchoring method through the intraoral incision alone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had cheek implants for four months now and dislike them and want cheek implant removal. I’m sure this is a common story. The implants are Design M Malar by Medpor and I would like them removed by yourself. I had a bad experience with my surgeon and don’t want to return. Would removal be straightforward and would recovery be minimal? Thanks so much for your help.
A: It is certainly not the first time I have seen ‘buyer’s remorse’ after cheek implant surgery. That does not make cheek implants a bad procedure, just one that may not have oived up to one’s expectations for a variety of reasons. Removal of Medpor cheek implants, like any type of cheek implants, can be done. But unlike silicone cheek implants, whose removal would be very easy, quick and with minimal recovery, the removal of Medpor cheek implants is more difficult due to the tissue ingrowth. The ‘difficulty’ of their removal is a relative one given that silicone facial implant removal is so easy. While Medpor cheek implant removal procedure is straightforward, I would not necessarily call the recovery ‘minimal’. It is best to think of it as about 75% of the original cheek implantation procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Earlier this year I had my cheek implants removed and I feel a lot better that I did. The only thing is the hollowness that it created under eyes and lower cheek area. I feel that that this is due to the loss of cheek attachments and you have even mentioned so in one of your blogs. Do you know of any method to reattach the tissues to cheek and under eyes?
A: You are correct in that I have written in the past about your exact situation. Like breast implants once the cheek tissues are detached and stretched out for implant placement, they may not recover their original position after cheek implant removal. It is not so much from the tissue stretching but all of the cheek tissue attachments have been stripped off from the bone. Unless there was some specific method to reattach these tissues or lift them at the time of cheek implant removal, they may develop some sag off the cheek.
There are several methods to resuspend sagging cheek tissues. This can include a mitek suture anchor resuspension done intraorally or a suture suspension done through a combined temporal and intraoral approach. It is important to realize that this will help with cheek sagging and will have no effect on undereye hollowness.
An alternative approach is to simply have fat injections done to restore cheek volume and fill in the under eye hollows at the same time. Or resuspend the cheek tissues and save the fat injections just for the under eye hollows.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek implants placed 4 months ago together with a buccal lipectomy. However, they got infected 2 weeks post-op, but I’ve only managed to get time off to remove them in 2 weeks. I’ve been taking antibiotics to control the infection in the meantime.
Anyway, I’ve read that removing these implants can cause some sag, and I’m particular worried because I’ve also had my buccal fat pads removed. I have read that a temporal mid-face lift can help. However, I have a few questions:
1) Should I do the lift during the removal? Or, should I wait till I get the implants replaced? Will getting the mid-face lift during the removal limit my options should I decide to get more implants in the future?
2) If I wait to get the temporal mid-face lift, is there anything I can do to help minimize the sagging after removing the implants? Would taping my face during recovery help prevent sagging?
Thank you!
A: In getting cheek implants removed, no everyone will get a midface sag. It depends on how large the cheek implants were, their location on the bone, and how long they have been in place. Thus by having your cheek implants removed you do not know if you will develop this problem or whether it will be problematic even if it does occur. It would then make the most sense to remove the cheek implants and not commit to another invasive procedure that is done to treat a problem you do not know if you will even get.
The best approach to ‘hedging the bet’ against midface sagging with cheek implant removal is to do an immediate reattachment of the cheek tissue back to the bone. This is done by placing a small resorbable bone anchor or screw into the midbody of the cheek bone onto whoch the cheek tissues are reattached to. This would be far better than any form of external taping or dressings.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hope you don’t mind but I have a plastic surgery related question I was wondering if you could answer. I would like to explain my unique case and see if you have any recommendations. Any advice at all would be helpful.
Earlier this year I had a cheek augmentation to fill out my flat mid-face with cheek implants. I had great malar prominence but was lacking in the submalar region. There was unfortunately some miscommunication between my surgeon and I on what I wanted. I believe that this miscommunication occurred because I did not have a consultation with the surgeon until a day before the surgery due to long distance. I had wanted the inner, lower area of the cheeks (submalar region) augmented, but instead was given medium malar shell implants. The malar implants did not flatter my feminine face like I believe the submalar implants would have done due to their outer location and also perhaps their size and projection. I had the malar implants removed after 3 months which left me with mid-face ptosis than I never had before.
I am now debating on what to do in order to correct this mid-face ptosis and restore my cheeks to their original lifted position. I had not expected this to happen as I was prepared to be satisfied with my cheek implants had they been the right type and size. However, since I now have this sag, I assume that it is not best to get the submalar implants I had originally wanted because they will simply “augment the sag” so to speak. Also, on the off chance I again did not like them, I would end up back where I started. In general I don’t think that re-inserting submalar implants is the answer.
I have assumed that the answer to this mid-face ptosis is a cheek lift. There seems to be many different kinds. I am most worried because in all of my research it seems as though all of the procedures to lift the mid face are fairly new and mid-face ptosis is a relatively difficult area to correct. In many of the before and after photos I have seen from various doctors, there isn’t much of a difference in the after photos. Basically it seems like the results are subtle and barely noticeable. It also seems as though perhaps the results do not last very long either. Please let me know your thoughts and whether you agree or disagree with these concepts.
So far, I have only contacted two doctors regarding my case. Unfortunately one of the two doctors refused to consider my case due to my young age, which I am completely understanding of. However, I was disappointed as his mid-face lift results were astounding. He not only lifts the sagging fat and tissue but he also does skin removal from the mid face in order to ensure that it’s tight again. This eliminates the nasolabial fold completely. I personally feel that my skin was significantly stretched from the implants and swelling twice both upon placement and removal and I know that a tiny bit of skin removal might be beneficial however considering my young age it is highly possible that just simply elevating the tissues will do the trick.
The second doctor I contacted did agree to consider my case and upon examination in my consultation he recommended a cheek lift without skin removal and perhaps a minor correction of the lower eyelids following my healing from the cheek lift. I’m not sure of exactly his technique but I will try to get more information. All l I know that he uses sutures that dissolve in 6 months. According to him he has never re-done a patient in 10 years, which to me implies that it lasts, however there’s no guarantee and perhaps these patients just did not feel like going through the stress and swelling again in order to have it redone.
I was wondering your own personal thoughts on the cheek lift techniques because I have seen many of your answers on Realself as well as your videos regarding submalar cheek implants. I am trying to figure out what the best option is for me that will not only give me the most optimal result but will also have longevity.
What is the best method in your opinion? Any advice you can give me on what is the best course of action to correct mid-face ptosis after cheek implant removal would be helpful. Thank you in advance.
A: There is no doubt that the entire concept of cheek or midface lifts are muddied with a wide variety of techniques, many of which the doctors claim their approach works the best. Any time you see so many different ways to treat an aesthetic problem should tell you that there is no one single way to do the procedure…or that there is no one best way. This does not mean that midface lifts can not be effective or long lasting but each patient must be looked at individually and the advantages and disadvantages of the different techniques considered.
What makes midface lifts unique is that it involves surgery around the eye and the sensitivity to any changes of the eyelids is highly visible. This is quite different than a facelift where the changes around the ear and hairline are more obscure from a high level of scrutiny. In essence, a midface lift is a more ‘risky’ surgery and can be unforgiving of even a minor technical error. Thus undergoing a midface lift must be considered carefully in terms risk vs. reward.
I fundamentally divid midface lifts into either an endoscopic temporal or open eyelid approach. There are numerous variations amongst each subset and there can even be cross over between the two. All midface lifts rely on subperiosteal tissue mobilization and suture suspension. The vector of that suspension highly influences how effective or powerful the midface tissues can be lifted. In simplicity, endoscopic temporal suspensions produce more moderate results but have little risk in doing so. A midface that incorporates an open eyelid incision, particularly with cranial suspension, produces the most significant lifting that lasts the longest. But it involves the risk of a lower eyelid malposition and visible lateral canthal scar.
For cheek sagging that has resulted from the removal of cheek implants in a younger patient, I would lean towards the endoscopic temporal approach. But that is based on no idea of what you look like now or before or cheek implant surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m having my cheek implants removed later in the week due to an infection. Just wondering, will there be an excessive amount of swelling like when I had them placed in or will the amount of swelling be more limited this time round? Also, I’ve had them in for a year and will be replacing them in 6 months. In the meantime though, should I expect any damage or deformity from their removal? Lastly, I will be having some fat grafting done to my brow ridge. Will there be a lot of swelling associated with fat grafts to that region? Thanks for taking the time to answer my queries and it is much appreciated!
A: Removal of cheek implants is associated with far less swelling than their initial placement. Letting the tissues settle down and replacing the implants months later is not associated with any damage or deformity issues. Fat injections to anywhere on the face do not cause much tissue swelling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had porex cheek implants implanted then removed a year later. It has been about 8 months since the removal and I look ok and do not have any sagging, however, I do have excess scar tissue that is built up on the bone of the cheek. It is not that bad (meaning hard to see without feeling the face) but it is quite lumpy in some spots (especially on the one side) and I would like it reduced if possible. I heard steroid injections work well, but not sure. Your opinions? I am a 27 year old male. No other plastic surgery or intention for future surgery. Thanks!
A: What you are referring to as scar tissue is the residual capsule left after removal of the cheek implants. In most cases, much of that capsular scar tissue will resorb over time but it may well over a year for maximal absorption. While steroids are commonly used for scar issues, most of that is done at the more superficial skin level where control of placement of the steroids can be visually done. While steroids could be injected deep into your cheeks, I would not do it because you have no assurance as to exactly where it is being placed. Indiscriminate use of steroids can be associated with fat tissue loss and tissue thinning. Given that your scar problem is not visible, I would not risk potentially creating another problem that may turn out to be just as bothersome or worse than what you have now. You are better off to live with what you have, no matter how it eventually turns out.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am now 10 weeks after cheek implant removal. Implants were removed because of infection and incorrect asymmetry. I am now thinking of getting Sculptra, Radiesse or Juvederm but am getting different answers as to how long I should wait to get the injections after removal. I still have some fluid, swelling and lip numbness after 10 weeks post op. My implants were put in October 2 and removed November 2, so they were only in for one month. I am very concerned about my health and healing from this and want to wait long enough to make sure the filler injections are safe. But my face looks worse than it did before the implants. Your expertise is very much appreciated!!
A: I would agree that complete healing should take place before you place any injectable fillers, even though the tissue plane where they will be placed is differngt from that were the implants were. That would be a minimum of three months. But a better barometer rather than just raw time is when the cheeks are no longer tender and any signs of numbness has completely dissipated. In short, don’t do fillers until your cheeks feel completely normal again.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, How long does it take for the tissues to shrink back down and stick to the bone after cheek implant removal? I had anatomical malar shell implants placed three months ago and then had them removed after being in for just six weeks. I think all of the swelling is now gone but my cheeks don’t look like they did before. I have more cheek sagging and my nasolabial folds are deeper than before. I thought the stretching caused by the cheek implants was reversible and would just shrink back down. What can be done now? I want my old cheeks back!
A: When undergoing any form of facial implants, it takes time to see the final results as the tissues settle down around the implant and you adapt to your new facial look. Removing your cheek implants just six weeks after having them placed may have been premature. One of the reasons you do not want to be quick about reversing facial implant surgery is because of tissue deformation. There is no guarantee that the tissues will return to their pre-implant state. In placing cheek implants, the tissues must be stripped off of the bone over a wide area to get the implants into proper position. This not only stretches the tissues (actually a relatively minor effect) but, more importantly, the tissue attachments to the bone is forever altered. It would be natural after implant removal that the cheek tissues can sag somewhat since these tissue attachments will not jump back up into their original position. Once can see that the bigger the implant and size, the more significant that this cheek sagging problem can be. With more cheek sagging, the deeper the nasolabial folds can be. Improvement would either require implant augmentation or some form of a cheek lift or resuspension.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am planning on removing silicone malar implants without replacement that I had done 8 years ago. I am hoping that my skin will contract down once the imlant is removed. However, I realize that sagging is a possibility due to the stretching of my soft tissues from the cheek implants. I do not want any kind of implant again and a subperiosteal resuspension surgery is something that I would want to avoid at my age. Therefore, I was wondering if surgical adhesives, like a fibrin glue sealant would be useful in preventing or at least minimizing sagging and would help the tissues to better redrape the face. Would there be any potential complications from using surgical adhesives?
A: Your concern and questions about cheek implant removal are good ones. Like all implants in the body that push off of the underlying bone, their effects are seen by the stretching of the overlying tissues. Whether this soft tissue stretch is significant, and would result in malar tissue sagging after their removal, depends on how large an implant was originally used and how much elastic deformation of the skin was created. For some patients with smaller cheek implants, no significant malar sagging will occur. For other patients with larger implants and more significant cheek hypoplasia to begin with, the sagging may very well be noticeable.
Regardless of the size of the implant, the question is whether any surgical manuever (from the intraoral approach) during cheek implant removal surgery can prevent sagging and maintain a better soft tissue position on the underlying cheek bones. I think there are two options. As you have mentioned, tissue adhesives can be used. Whether they can really glue the outer capsular lining to the inner capsular lining on the bone is debatable (the surrounding cheek implant capsule is not removed so these two layers are present) But there are no risks to doing so. I would use an autologous tissue adhesive made from the patients’s own blood, like that obtained from the GPS III system. (Biomet) Another option is to place several sutures between the capsular layers to prevent the outer capsular lining, of which the cheek soft tissue are attached, from sliding off of the inner capsular lining and bone below. This is, in reality, a subperiosteal suspension done from below. That is a more likely effective manuever that would be more secure than tissue adhesives.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, you have mentioned your experiences with porex facial implant removals. I am looking to get my pair of porex cheek implants removed that were placed about a year ago. I am 26 years old and hoping my face will be able to return to its pre-surgical state, but given the scar tissue must be removed am I setting my expectations too high? I am worried that if they are removed my cheeks could be even more depressed than before my original surgery.
A: I have heard and read about the ‘scar tissue’ that must be taken with Medpor facial implant removals numerous times. From my perspective, it is largely a myth and not reality. It is very similar to them being hard to remove as well. Both those issues stem from a comparative experience with that of silicone facial implants. Compared to the very easy removal of any silicone-based implant (it is very smooth so it slides in and out easily), the porous outer surface of Medpor does make it more ‘difficult’ but then anything would be hard compared to silicone. Medpor implants can be removed with just a little more effort and there is no reason to be taking out any scar tissue (known as the surrounding capsule) with them.
Therefore, when it comes to removing your Medpor cheek implants, a potential loss of volume in the cheeks will not come from having had scar tissue removed. But it is likely that it will occur due to a common implant sequelae known as tissue expansion. Depending upon the size of the implants you have in, there will likely be some cheek volume loss and/or sagging due to the stretching of the overlying tissues and the separation of the attachments of the tissues to the bone. Once the implants are removed, these tissues may not stick back down just the way they were before surgery. This potential problem can be countered by either inserting a smaller replacement implant, performing soft tissue resuspension, or inserting a dermal graft into the implant space to act as a ‘natural’ implant volume replacement. Whether any of these are appropriate for you is impossible me to tell based on the information that you have provided.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I recently had small cheek implants but they don’t seem to have made much of a difference. No one has really noticed. In addition, I have pain on my left side, it is more swollen, and my teeth and upper lip are numb. I think they should just be removed. Do you think implants should be removed sooner rather than later? What sort of time frame would you suggest -one week, two weeks etc? At this point I am taking Oxycodone just to get through work due to the pain. My plastic surgeon does not seem overly helpful at this point. I cannot get in to see him until the end of this month. The pain was so great over the weekend I was thinking of going to the ER but I did not think an ER doc could do a whole lot to help. Also, if the implants are removed will there be any permanent structural change to my cheeks, from the pockets that were created for the implants?
A: I would only suggest getting them removed sooner rather than later given your pain issues. If they weren’t painful, then there would be as much urgency to it. Such pain after cheek implants is uncommon…plus if the implant on the numb side is sitting up against the nerve (don’t know whether it is or isn’t but the numbness on just one side is a concern) the sooner it is removed the better for nerve recovery. With such small implants, there should not be any residual effects from having them in there. The pockets will just shrink down and go away and will leave no residual structural or scar issues.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have cheek implants that I would like to have taken out. What can I expect after they are taken out? Also, my right side of my face is a little higher then my left. Is their anything that can be done about that?
A: While cheek implants can certainly be removed, is it important to look and consider several factors before doing so. First and foremost, why did you have them put in in the first place? Was it a primary procedure (the only one done) or where the implants a secondary procedure or a throw-in? (while we are there….why not?) Second, what is it about them that you do not like? Too big, creating an unusual look, not the look you wanted? Lastly, what size can style are these cheek implants?
The amalgamation of all of these factors can help one determine whether removal or replacement/adjusting the cheek implants is the best choice. Usually when someone wants their cheek implants removed, it is because they are creating a look that they do not like….and often they were put in not as a primary procedure. Whether the undesired look is a result of cheek implant style or size must be determined on an individual patient basis.
All of that being said, the removal of any facial implant will likely leave behind the potential of soft tissue sag as a result of soft tissue expansion. Whether the soft tissue expansion will be significant depends on the size of the implant used. A small cheek implant will likely not cause this potential problem. But a bigger cheek implant might. If this is a real potential problem with removal, one may consider some form of a cheek or midface soft tissue lift at the time of their removal.
Dr. Barry Eppley
Indianapolis Indiana