Your Questions

Q: Dr. Eppley, I am an Asian male interested in custom cheek implants. Is it possible through custom implants to add lateral projection to the zygomas? What would be the maximum lateral projection the implants could give? (Iam hoping for at least 1.5cm to each zygomatic, but 2cm each would be ideal). I am after a look of very prominent cheeks to go with a very prominent jawline (also through implants) similar to the guy in this picture (note his flanged and very prominent cheekbones) Thank you for your assistance.

A: When it comes to designing custom cheek implants, any size or dimensions of the implant can be done. In making these designs and in looking for an ‘extreme’ facial look, one only has to be vigilant of two issues. First, one must make sure that the size of the implant does not preclude a good and competent intramural soft tissue closure over them. The stretch on the cheek tissues in very large implants can theoretically cause such an issue which would be disastrous if wound breakdown occurs postoperatively. Fortunately the cheek soft tissues are fairly elastic and have a lot of give to them. Secondly, one must avoid making an implant that is too big and thus creating the need for revisional surgery. The actual site and thickness of a cheek implant to create the look you are desiring is probably less than what you think. I have placed cheek implants up to 1 cm in thickness on each side and it can be impressive as to how much change that creates. I would doubt that you need 1.5 cm to 2cms of width on each side to achieve that cheek augmentation look. Dimensions such as those does run the risk of oversizing and the potential need for a revisional surgery to downsize the implants.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom cheek implants. I have sent in a picture of the design I want and where I want it to cover over my cheeks. I appreciate your comments that you think the design is too big and I understahd what you’re saying. But given the cheek implants I currently in place now, and it is a strength that works for a look of health, that is a strength I would hope to keep. Is it that you object to the look of it, the safety of it, or simply that is has not been customary in your practice?

A: I never professionally care what shape or size the custom implant design that a patient wants.  Custom cheek implants would be no different. What I care about with custom facial implants and what I look at carefully in the planning are only two things. First, can I safely make the implants fit into the tissues and close the incisional entrance. Secondly will the implants be too big and the patient will then have a 100% probability of needing a revision to downsize it. Having performed more computer designed custom skull and facial implants that probably any surgeon in the world, of almost every conceivable shape and size, I have a acute awareness of what will work and what will turn into a problem. I am merely trying to guide you in avoiding the latter. The single greatest error when patients provide their design layouts is that they have no understanding of the powerful effect of a custom implant that covers a large surface area over that of what a traditional implant shape does. Custom cheek implants are very powerful in the size you are envisioning and it would be very easy to make them too big, particularly in a more lean face like yours.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a healthy 32 yr old man who previously had a successful rhinoplasty one yr ago. One week ago I had Radiesse (1,5 ml x 2) injected in my cheeks and I loved the results immediately after. But since the inflammation has gone away, I lost that chiseled male model look I am going for. It still looks good but not as good and not that chiseled look anymore. I can’t afford to inject my cheeks with Radiesse every week so I need a permanent result. The problem with off the shelf cheek implants is that they only provide a 4 mm thickness and the post op pictures look too subtle for me. (because I want to be a model). I have low body fat and a narrow face with thin cheeks so I feel that I have the anatomical prerequisites to achieve that attractive look with the help of a skilled surgeon like yourself. What is your opinion on this? I have attached 2 photos from before and immediately after my Radiesse injections. I also attached photos of three male celebrities with the chiseled look that I am looking for.

A: Injectable filler treatments can be a good test to see the effects of cheek augmentation but are clearly not suitable for a sustained and repeated cheek augmentation approach over time. If an injectable filler treatment gave you very pleasing results then I am certain that a bone-based cheek implant can do the same if not better. Cheek implants do come in thicknesses greater than 4mms so I am not certain that a preformed standard cheek implant of the right style and size would not work for you. There is, of course, always the option to make custom cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is the material used to widen my face at all areas. (especially the area at side from zygoma to lower jaw) Will silicone material be the best ? I have tried fat transfer but it was little volume and only had a temporary effect. I wish to widen my face with permanent and semisolid material. I have attached my photo. Thanks a lot.

A: The best way to permanently widen your face is by using a combined custom facial implants approach with jawline and zygomatic arch designs made from a solid silicone implant material. They will provide an immediate and lifetime change. With a custom design they can be made to match in their upper and lower facial width increases so one is not wider than the other.

Fat injections in you was never going to work. And even if the fat took it would look soft and ill-defined. But most importantly your face is too thin to ever have any fat graft take very well. Fat grafts always work better when there is some natural subcutaneous fat into which they are placed.

The only issue here is that there will be a concavity between the mid- and lower facial widths increases where there is no bone support. I assume this is one of the areas where the fat injections were placed that did not work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom cheek implants.  I has severe sleep obstructive apnea and it took maxillomandibular advancement surgery where both jaws were advanced about 8 MM) to finally cure me.  As you can from the attached photos the maxillomandibular advancement surgery changed my face for the worse. Some people do not recognize me, others say I really aged and others say I look totally different. Other people on the internet that had maxillomandibular advancement surgery for sleep apnea say that they got there face back by having cheek implants put in. I would like to augment my cheeks in the best way and have other procedures and/or fillers to get me looking at least as good as I was before the sleep apnea and maxillomandibular advancement surgery.

A: The current state of your facial skeleton/appearance is rather classic when the upper and lower jaws are significantly moved forward when there is no natural malocclusion. These osteotomies are done below the level of zygomas (cheeks) and thus they create a relative state of upper midface/cheek deficiency as there is now a big forward step off between the zygoma and the maxilla as opposed to the reverse step off that normally exists. Cheek and/or cheek-infraorbital rim implants are the logical solution for this induced facial skeletal deformity. There are arguments to be made for either using preformed or custom cheek implants for your midface restoration. But the very altered bing anatomy does make an argument for the custom approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some type of cheek implant I think. I am not sure whether I have weak cheekbones or whether they are average or it is really a lack of fat or a lack of orbital rim development that gives me those lines under my eyes near the cheekbone. (Not tear trough) I have gotten comments on having a sunken/droopy “eyes” look when I’m cutting body fat and I’d prefer to have a much more healthy looking eye area when I’m at a lean fat %, just not too feminine either. I just wasn’t sure if that was primarily due to the cheekbone, orbital rims, or an odd lack of fat storage in that area of the face. So if am just to augment my orbital rims (lateral, inferior) and perhaps a bit of the anterior cheek (not too feminine) don’t you think fat transfer is my best option rather than a cheek implant, since a cheek implant doesn’t really touch those areas?

A: Cheek implants are your best treatment option but not the way you currently think of them. You do have a ‘weak’ orbitomalar area which is the result of infraorbital rim and cheekbone deficiency/underdevelopment and a thin soft tissue cover. Fat injection grafting will not work to create any sustained desired augmentation as it will be absorbed completely in less than 4 to 6 weeks after placement. The only effective approach is a combined infraorbital rim-cheek implant, probably only about 4mms thick, which will completely and permanently augment this area. While this is ideal, it will require a custom fabrication (thin tissues have no tolerance for anything less than a perfect fit that feathers on all edges) and that it will require an eyelid (subciliary) incisions to place them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am asking you to ask about your experience with midface Medpor implants. How often do you use them, especially in men and is this your preferred material to work with? Do you have much experience in customizing the standard implants offered by the company that produces them?

I was wondering if you could take a minute or two and look at the pictures I’ve attached.

The first picture is of someone else that shows the area I’m trying to augment. This is not the malar or submalar area as such, but rather the cheekbone area high and laterally – my goal is augmenting laterally as much as possible along the zygomatic arch. The cheeks in attractive men are almost always perfectly flat or even hollow, as is the case with most/all fashion models.

The second picture is of me – I apologize for the low quality. I saw a plastic surgeon locally who said that I’m exactly the opposite of the man in the first picture. The area I marked in green is my main problem. This area (please notice the same at the opposite cheek) is very, very prominent, bulging, and very not-masculine, worsening the problem with my under-eye hollows and nasolabial folds. Someone recommended buccal fat removal, however, I don’t think this is at all right for me, as buccal fat will remove the area I marked in red, and that has little if any overlap with the problematic area on my face. Am I right in this? Or is there a way to remove the fat from the marked green area? I thought the best solution for me, instead of removing anything, would be building the upper-mid face, as I discussed above using the example of the man in the picture I’ve attached. I marked that area in black in my picture. This particular area looks depressed on my face (as you can see on the opposite, unmarked cheek), and the prominence of that diagonal strip on the cheeks (the green area) makes it much worse. Most people think i’m older than I actually am and I look tired all the time. Another surgeon suggested some sort of mid-face vertical lift, but I don’t think there is any effective way to do this. Most techniques result in short-term results and awfully lot of swelling for months. 

So, I concluded my best option is building that area marked in black with medpor implants. This would balance the prominent bulging cheeks. I attach here their catalogue (please see pdf file). On page 6, I noticed the “extended malar shape” type that the company says extends laterally along the zygomatic arch. I think it also captures the infraorbital rim area, if I’m not mistaken, and I could really benefit from it, as the existing hollows under my eyes are also a problem.

If I could please ask you: Having seen my picture, would you say this implant is the right for me, or would there be a better type? As it is extremely important for me that the implant does not add to the problematic, already prominent diagonal stripe in the submalar area of my face (marked in green), can this part be cut off from the standard implant? Or will there be no need for that? I can’t judge at all how much vertically the implant drops, but the part below the infraorbital rim is where the bulk of it is. The more vertically it drops, the worse would the outcome be for me, because it will make the cheeks even more bulging. 

I find it hard to believe that there aren’t any standard mid-face implants on the market that would cater to the needs of men. Even in this “extended” type, the extended part looks thin and stops prematurely, while the remaining malar part is quite bulky. I would probably have to go for the largest size and cut off much of the unwanted part to benefit the best. For illustration, I’ve attached here some pictures of models – in any beautiful male face the cheeks are always perfectly flat (most of malar and definitely submalar parts) and even hollow (the exact opposite of what 90% of the malar and submalar implant do!!!), but the cheekbones are high and the whole area is always built naturally well laterally along the zygomatic arch, all the way to the temporal process. 

Yet another surgeon recommended the use of hydroxyappatite instead of implants to build the area of the face I’m interested in augmenting. However, I don’t think HA can achieve that much as implants can and I wonder if it does give so much flexibility and is safe, why more surgeon are not using it?

A: To answer your questions succinctly:

1)      I use both silicone and Medpor facial extensively and have a lot of experience with both of them. I have no preferred fondness for either material as the body does not care what is implanted…it treats them all the same from a biologic response standpoint. I choose the implant material based on which one offers the best shape and size for what I am trying to achieve for the patient. In many cases the implants have to be modified during surgery to create the desired shape. In other cases, I make the implants before surgery (true custom designed implants) based on modifying existing implant styles or design my own shapes for a specific patient.

2)      You are correct in that there is no current facial implant style, regardless of the manufacturer, that is designed to create the effect you are after. This will require a modified malar implant design to achieve.

3)      The Medpor extended malar implant is the closest preformed shape but there is way too much material in the submalar area.

4)      Hydroxyapatite granules are never going to create the look you are after as they will be flattened by the pressure of the overlying cheek tissues.

5)      The cost of your malar implant surgery would be influenced by the material you want it composed (Medpor vs silicone) and how you want it prepared (intraoperative modification or custom premade).

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting implants for my flat cheeks but am not sure what type of implant I really need. I have attached 4 images of three different individuals cheeks I really appreciate and believe to be prominent and masculine. They are Lars Burmeister, Fernando Torres, and Ben Affleck. All seem to have the prominence up on the side of the eyes and they wrap around to the front of the eye a bit. They all look more chiseled, narrow, and angular though, relative to the other examples of cheekbones I have attached. The other examples are of cheekbone structures that I would prefer to avoid. They are Zac Efron, Cilian Murphy, and Peter Facinelli. Their cheeks just cover too much surface area and look like an enlarged cheek mass, rather than finely chiseled cheekbones. They are prominent but look too feminine and bulky. Perhaps you can enlighten me more on what it is I both desire and do not desire in the above referenced cheeks.

Also, will I be getting the inferior orbital rim augmented as well? Reason being that my eye does indeed pass over this bone. Besides creating a better angular appearance to my face, I’m hoping the midface implants rejuvenate my face a bit and help me look less sickly when I get down to 10% body fat percentage or so. Would I need some kind of midface lift along with the implants to give myself this appearance? I am apprehensive to undergo a procedure that is often only discussed with people in their 40s or above.

Lastly I have attached a crude approximation of the area on my cheek I want to be augmented. The black marks denote areas I would prefer to see little to no enhancement on. They include the zygomatic arch, the base of the zygomatic bone, and underneath the front of the zygomatic bone beside my nose. Let me know if this is realistic.

A: Thank you for the detailed information about the desired cheek augmentation result. That is very helpful.

The first comment that I would make is that their is no standard or off-the-shelf ‘cheek’ implant that has exactly those dimensions that you have well outlined in your own photo. I would agree completely that the best aesthetic midface result for you is exactly what you have described, as you have a true combined anterior zygoma-lateral orbital wall-inferior orbital rim deficiency which is a reflection of the overall underdevelopment/flattening of the zygomatico-orbital complexes. Your issue is a bone problem not a soft tissue one so the concept of any form of a midface lift is not a consideration.

So it is not a question as to what you need but how to get there. In an ideal world from a bone standpoint, I would use Kryptionite bone cement/putty to intraoperatively fashion the implant exactly the way I want it and place it from above through a lower eyelid incision. This is most ideal not only because of the ability to create a truly custom implant but the area of augmentation needs to extend across the orbital rim (at least laterally). This infraorbital rim area is the ‘rate-limiting’ step in getting the ideal implant shape as it can not be accessed from below. (inside the mouth…the big infraorbital nerve is in the way) But due to cost considerations and that I nor you would be thrilled with making a lower eyelid incision, this ideal approach may not a good option for you. The other option is to pre-make a custom implant off of a 3-D scan and model, but again cost becomes a consideration with that approach as well.

With the ideal approach off the table, then we must look for using/modifying existing stock implants to achieve most of the cheek augmentation goals. One style of cheek implant, sometimes called the Malar II, augments the lateral orbital wall as well as cheek bone. It does not extend out onto the infraorbital rim to any degree which is its one limitation.

The other issue I would mention is that the use of these celebrity faces and pictures serve only as a direction that you want to go and that no cheek implant, even one custom made, will make you look exactly like them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want your advise on getting suitable cheek implants. I currently have a Medpor midface contour implant. They were placed six months ago. My implants were placed  unmodified. Although I have achieved a decent level of midface augmentation, I feel the implant is too large, surface area wise. It is too close to my eyes and is also too low and close to the top of my teeth. I also have visible edges on both the left and right side near my eyes.I did previously have a Lefort 1 osteotomy for my bad bite in the past but the central part of my face wasn’t really improved. What I was looking for in cheek implants was something to improve my midface. The current implants have alleviated midface flatness but I do still feel I look at bit gaunt but less so. However they are just too big, so looking for opinion of porex alternatives which might be appropriate. I was looking at either RZ 5m, or the 4mm extended malar, basically something to emulate the middle third or so of my current implant. I have attached pictures for you to see my face and what my current implants have done.

A: What you are showing is the problems with stock midfacial/cheek implants which are now, by your own illustrations, demonstrating that their shape is not adequate in multiple dimensions. This leaves you with three implant options:

 1) Modify your existing indwelling implants by tapering the bothersome edges and adding/removing the areas to create better convexity.

2) Remove and replace your existing implants with new implants that would likely need a combination of infraorbital rim and cheek implants. The medpor RZ4 or the 4mm extended malar are reasonable options but they will need intraoperative modifications.

3) Remove your existing implants and replace with custom-made implants that are designed off of your own skull model.

While all of these are possible, they each have their own advanatages and disadvantages. Modifiying what you have in, while seemingly simple and easy, will not likely make a significant or the desired changes that you want. (but it is always worth a try) Replacing them with new stock implants I suspect will put you in the same position you are now, better in some areas but inadequate in others. There simply are not stock implants that can fully meet your aesthetic goals. Custom-designed cheek/midface implants are the most likely to really meet all of your aesthetic midfacial goals as all of the planning and adjustments of them are thought out before surgery. The only downside is the increased cost to do so. 

Dr. Barry Eppley

Indianapolis, Indiana