Your Questions
Your Questions
Q: Dr. Eppley, what is the difference between the effects of cheek implants and a cheek lift? In looking at pictures cheek implants looked more subtle than the lifting of the cheek tissues. The cheek implants themselves looked more obvious than the cheek lift, however. The cheek lift appears to pull on the face and make the nose a bit wider and even lift the lip. So the overall change to other facial features with implants seemssubtle while there were more changes to other facial features with the cheek lift,despite the cheeks themselves looking more natural. Am I correct in this assessment?
A: You are quite accurate in your assessment of the influence of the cheek lift vs cheek implants and their effects on the face. Cheek implants push the tissues more out and forward while a cheek lift pulls the tissues more up and back. Thus their effects on the cheeks are different. A cheek lift can widen the nose and pull upward on the lips. Conversely cheek implants have no effect on the nose and the lips.
This is why a cheek lift often creates a bigger change on one’s face while cheek implants have a isolated effect on just the cheeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, awhile ago you helped answer my questions about cheek lifts, as I was getting one to correct sagging from malar implant removal. Well, I had the cheek lift, and while it made some major improvements, I still have some sagging.
Now I probably should just accept the remaining sagging at this point, but since I had NO sagging on my face while the implants were in, I am of course beginning to wonder if I should have just kept them or should replace them or get some sort of filler to fill out the loose skin at some point.
My reason for removing the cheek implants was that unfortunately I felt they were not proportionate and looked a bit obvious – but in retrospect I wish I had just waited for more swelling to subside and embraced the new look rather than removing them and making myself look older.
The issue remaining seems to be mostly skin (with a tiny bit of tissue). The pocket of looser skin is still in the shape of a malar implant.
Is it possible that replacing the malar implants in the future would help fill out this looser skin – or after all of these surgeries should I just give up on having tight mid face skin again? You can be honest, I know it’s a lot
Would replacing the malar implants after placement, removal, and a lift just be too much scar tissue and way too complicated? How long should I wait before making this decision?
I regret removing the implants, as they made me look much younger and I had no idea I’d have sagging if I removed them.
I just keep wondering if re-inserting the malar implants would lift that tiny bit of excess skin that is looser since removing them. Perhaps filler might do the trick too?
Also, I forgot to mention that if you do think reinserting the malar implants would lift the skin a bit how long would I need to wait after the cheek lift. I was told that the sutures dissolve in 6 months. Would it be safe for the implants to be in there theoretically even if the sutures had not dissolved?
Any other suggestions about how to lift that sagging mid face skin are greatly appreciated, or if you think i should throw in the towel and quit and just accept the sagging skin now as it’s just too much surgery and scarring that’s understandable as well.
A: I think given your past history of cheek implants in and then out, any further efforts at cheek lifting should be done by either injectable fillers or fat injections.They both will provide more upper cheek fullness and will do some cheek lifting. Ultimately cheek implants could be redone now that you know their benefits. But you need to wait a full year after the cheek lift before replacing them with fillers or fat if they turn out to be inadequate.
Dr. Barry Eppley
Indianapolis, Indiana
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 wanted to restore my cheekbones and the saggy soft tissue with an endoscopic midface lift after cheekbone reduction. I found a very good maxillofacial surgeon and a plastic surgeon who worked together to bring my zygomatic bone to the old anatomic position and lifted the sagging soft tissue. That surgery was exactly six weeks ago. I know that swelling from jaw surgeries are extreme and lasts a long time but I am very afraid because I still can’t see the Ogee curve and high cheekbones that I had before the zygoma reduction. There is an improvement but not so much. I don’t know if it is because of the swelling that are all around my mouth, nasolabial folds and upper lip or if he didn’t lift enough or what could be the reason for that? I know I have to wait six months until one year to see the result but what can I do if my surgeon didn’t lift enough. ( I trust him but I know that my case was difficult because of the cheekbone restoration at the same time) Is it possible to lift the fat pad again after one or two years or is it too difficult? Otherwise I don’t know what to do, it still look a little bit saggy (maybe because of swelling)
A: With the scarred tissue from these two surgeries (cheek bone reduction and cheek bone elevation and fixation), it is highly unlikely you will get significant improvement with any type of attempts at midface or cheek lift. The tissues are both scarred and atrophic and their elevation will be both difficult and limited. While you need to let the swelling subside so you can judge the final result, I doubt it will be much different than before surgery. (remember the result is going to look worse as all swelling subsides.
Any effort at cheek sagging improvement in the future can only use the approach of adding volume to lift the sagging tissues…but that is exactly what you were looking to avoid from the beginning. (too much cheek fullness) I am afraid you have reached the point where the cheek result you have is as good as it is going to get unless you are willing to acccept other trade-offs.
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 had an endoscopic mid face lift two months ago. Actually I had minimal problem but I decided to go through this surgery. Actually it did not help me that much. I did not have any complication but it just was not very helpful for me. As my swelling went down I do not see any noticeable changes at all. Now the problem is that my upper lip is very stiff and it is hard for me to move it. I am at 2 months post surgery and it has only improved by about 30%. The approach was through my mouth. Is this caused by the Endotine device or because the dissection was through my mouth and temple. Is it normal to have a stiff upper lip after midface lift? Your answer will be very highly appreciated.
A: Most effective midface (cheek) lifts do involve a combined temple/scalp and mouth approach. While this does create some temporary mouth soreness and upper lip stiffness, it has not been my experience that the upper lip stiffness is prolonged out to months after surgery. The Endotine device is positioned up on the zygomatic bone so that device is not the source of prolonged upper lip stiffness…or should not be. It is the path of dissection and how much tissue was released in doing so that is the cause. This is an issue for which only time and further healing can provide a resolution.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about a cheek lift procedure. I had cheek implants placed four years ago. The right cheek had to be redone less than a month after placement because the implant had gotten loose and falling. Now that same cheek is loose and detached and sags and I also have a deep jowl. What are my options? Are you familiar with this? What kind of surgery would be involved?
A: The cheek sag you have now is probably not caused by your cheek implant being loose or fallen. I will have to assume that it is a true soft tissue sag. Why that would be just on one side and with an indwelling cheek implant in place is not clear. Usually a cheek implant actually helps protect against soft tissue sag as it has it own lifting effect by creating more support.
But that issue aside, a cheek lift is needed to reposition the sagging tissues over the cheek bone/implant prominence. There are multiple ways to do cheek lifts which have to consider the following variables; incision location, vector of the lift and type of suture suspension. If you don’t have any lower eyelid skin excess concerns, a combined temporal intraoral approach can be used. If there are lower eyelid skin concerns, then a lower eyelid incisional approach can be with a more superior cranial suture suspension done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in eye reshaping surgery. I am 26 years old and interested to have slanted/exotic/cat eyes. I’m not sure if canthoplasty alone will achieve my goals.
I don’t know if canthoplasty alone or canthoplasty combined with a cheek lift would work better. Will the canthoplasty and/or cheek lift fail in the short run due to gravity? such as lasting no more than a few months?
A: Changing one’s eyes to a look that is more ‘exotic’ almost always means the lateral canthus (corner of the eye) needs to be elevated and be substantially higher than the inner corner. (hence the out to inner ward downward slant. Certainly the basis of doing requires a canthoplasty procedure of which the most secure would be what is known as a drill hole lateral canthoplasty which can really pull up and maintain a new lateral canthal position. This would be far more effective and secure than a canthopexy or even a standard lateral canthoplasty procedure where the tendons is sewn onto itself or to the periosteum of the inner orbital wall. Whether that would be enough depends on the tightness of your lower eyelid and the cheek skin which can really only be determined by a physical examination. The concept of a cheek lift is a supportive one to the corner of eye and/or providing more of an upward and outer sweep to the cheek and outer eye area. At your young age it would seem a cheek lift would most likely be excessive.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a fat transfer to remedy malar crest. Now there is still a prominent dent across the upper line. What do I do now?
A: I would have to see some pictures of your concern, which I assume is a residual malar crease that was unlikely to be improved by fat grafting alone. Malar crescents are rarely completely eliminated by fat grafting alone because there is a tissue sag component to it. It is not just a volume depletion issue alone.. Ballooning the crescent up with fat may be helpful in some cases but often can lead to a fuller crescent but one that still has a visible crease or dent. If you are more than 3 months after your fat grafting procedure, you may need to consider a cheek lift which can be done multiple ways depending on the aging condition of the lower eyelid. Cheek lifts are most effective in middle-aged to older patients who have a more significant aging component to their midface. A combined lower blepharoplasty with cheek suspension can work well in these patients. Cheek lifts in younger patients are more problematic because the lower eyelid is tighter and less aged. This leaves little eyelid skin to be removed with the cheek lift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a lower face lift done along with neck liposuction. The doctor did a skin only lift and pulled it to the side and incisions were made by ears and in back of hairline. He redid 4 months later because it was not correct. It is better but I think my cheeks need pulled up, more like a vertical lift. I feel like my cheeks are hanging down by bottom of face. I have already invested $8,000 into this and wondered if I could now just have some vertical pull in cheek area?
A: A facelift (aka neck-jowl lift) never changes or rejuvenates the cheek area on its own in most cases unless a more extensive procedure was done. A neck-jowl lift moves sagging tissues obliquely back towards the ear while sagging cheeks require a more vertical lift as you are aware. However, in looking at your pictures I can not see a great benefit for such a procedure in you. A cheek or midface lift is a very technique-sensitive procedure to do since it often involves incisions along the lower eyelid and there is always the risk of lower eyelid malposition/sagging afterwards. Therefore, one should have a compelling reason to do the procedure. Cheek lifts can also be done endoscopically with a combined incision in the mouth and in the temples in more mild cheek sagging cases.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 33 years old and my cheeks are coming forward creating deep folds around mouth. I hate fillers as they don’t help, they make the cheeks look worse. I like the look of the cheeks slightly pulled back giving me a more youthful look. Is this something you could do on someone my age and how much would you charge to do this procedure. Thanks!
A: With aging, the soft tissues of the cheek do slide off of the bone and fall downward towards the mouth area. This is the source of the deepening nasolabial fold (lip-cheek groove), the cheeks tissues from above falling downward into the fixed tissues of the upper lip. The amount of falling tissue can be appreciated at the corners of the mouth where a roll of skin ends up hanging over the corner driving it downward creating a frowning effect. Some younger people have full cheek tissue that naturally sits lower but do not have a downturned corner of the mouth because the tissues are not really falling…yet. At the age of 33, I doubt if you have significant tissue falling or sagging and I will assume that this is really part of your natural facial anatomy.
A cheek or midface lift can lift these tissues and there are different versions of it. These include a traditional transcutaneous lower eyelid approach, a temporal endoscopic approach and a purely intraoral approach pinning the tissues up on the bone with a resorbable device. (endotine) The real question is how mobile your cheek tissues are and how much they can be lifted. At your young age, those cheek tissues may not be very mobile. That would be the determining factor in whether any form of a cheek lift would be aesthetically beneficial for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my cheeks are very low and I would like them to be higher. When I pull upwards on them, my face looks better. That also helps soften the lines around my mouth. Will cheek implants create this effect or so I need some form of a facelift to get that look?
A:The question you are asking is an important one because there are clear differences between what cheek implants and a cheek lift achieve. Cheek implants are about creating a bony highlight for improved facial contours purposes. While there may be some cheek lifting effect, it will be relatively minor and one should not think of cheek implants as a soft tissue lifting method. (even though it can complement cheek or midface lifting surgery) A cheek lift is about lifting and resuspending sagging soft tissues that have fallen off of the cheek bone. This does create an effect sometimes similar to a cheek implant but it is more similar to what most patients thinik that a ‘facelift’ does in that area. This will help soften the nasolabial folds because it is pulling upward the soft tissues that lie above it. Based on your description, I suspect you would benefit more by a cheek lift than cheek implants. Whether that is a worthwhile surgery for you depends on numerous factors including your age, your cheek bone and lower eyelid anatomy and how much malar soft tissue ptosis you have.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, A friend of mine just had her upper and lower eyelids done. She said that on her lower eyelid, besides removing fat and pinching some skin out, that she also had her cheek muscles repositioned. Is it true that cheek muscle can be lifted with a lower eyelid procedure? If so, what is the cosmetic benefit for doing so?
A: What you are referring to is known as lifting the sagging cheek at the same time as a lower blepharoplasty. Some call this a midface lift or malar resuspension. It is not a true muscle lifting procedure but rather that of sagging cheek fat and skin. As the midface ages, the cheek tissues will slide off the cheek bone particularly if the cheek bone is naturally flat or not that prominent. This creates malar pads that can be seen as an additional fold of tissue below the lower eyelids. This sagging cheek tissue can be lifted through a standard open lower eyelid incision for a full lower blepharoplasty. This is convenient since both the lower eyelid and cheek issue can be addressed through the same incision. The operation you describing that your friend had was a more limited blepharoplasty known as a pinch lower blepharoplasty. Through this limited approach it would not be possible to do a true midface lift or malar resuspension.
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