Q: Dr. Eppley, I am a 32 year old female who underwent several facial procedures last year. I had a vertical chin shortening and a midface lift. I know feel that my chin is too short for my face. Also the midface lift has caused my eyes to look worse than before with too much scleral show. What can be done for these problems now? Wouldn’t you agree that I really do not look better than before?
A: Whether an aesthetic operation produces a pleasing outcome is for the patient to judge not me. What I can say is that you obviously have concerns/questions about the chin and eye areas so I will make some comments about them. If you just showed me the after result of your chin, I would not say it is too short. But given where you started I could understand why you may feel that it is. The good news is that chin lengthening is more reliable than chin shortening whether it be done by an opening bony genioplasty or a vertical lengthening chin implant.
Your eyes clearly have lower lid retraction, a sequelae of the midface lift, which is unclear to me why that was ever done. Given how your eyes looked and your young age, undergoing a midface lift runs a very high risk of lid retraction because you have no extra skin. Such lower lid retraction most likely will require posterior lamellar reconstruction with palatal grafts to get the lid margins up a few millimeters. Lower lid retraction is a far more challenging problem than vertical chin lengthening.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 29 year old female and I am interested in a midface lift in hopes of achieving a cat eye look. I love how my hair looks when pulled back into a tight high pony tail. It gives me Asian eyes and lifts my cheeks.
I notice celebrities are having this look, people refer as the PILLOW… I read they have a lot of fillers and botox but i want something that will last longer.
I once had a temple lift with Endotine and done by endoscopic. I loved the results. It gave me exactly what I wanted…slanted eyes and my cheeks raised. But unfortunately it lasted no more than a month. My skin, just went back to it’s pre-surgery state.
So will a midface lift help achieve this for me? I see other questions you answered involving lateral canthoplasty, would that help as well? Which is preferred? Thank you so much for your time Dr. Eppley!
A: What you have learned from your midface lifting experience is that simply pulling on the skin up and back, like a tight ponytail, is not going to create a sustained result. It simply is not that easy. Such endoscopic temporal lifts alone always fail because skin pulling/shifting alone is not the answer for raising the corner of the eye and keeping the cheek tissue lifted. A direct approach to the corner of the eye (lateral canthopexy vs canthoplasty) is needed in conjunction with a high placed cheek implant and and an excisional temporal lift. Like a strair step approach, lifting and support needs to be added at three levels to get a better and more sustained result.
Dr. Barry Eppley
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?
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
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
Q: Dr. Eppley, I’m currently 26 and I had large silicone cheek implants placed two years ago together with a buccal fat pad extraction. I had them removed two months ago as I just felt they were too big for my face. The issues I have now is that there seems to be a small degree of mid-facial sagging. I’m looking to get smaller malar implants later in the year, but I’m concerned that that will not be able to proper address this sag. Out of curiosity, since I’ll be undergoing a cheek implant procedure again, could a mini-lift help address this sag? I don’t think I’ll require anything too aggressive – do you know of any midface lifts that could help me out?
A: It is no surprise that once cheek implants are removed that some degree of midfacial sag will result. This is not just due to the stretched overlying tissues but because the soft tissue attachments to the bone have been permanently detached. Once the implants are out, the overlying midface soft tissue can not reattach to the bone (due to the slick surface of the residual capsule) and it thus slides ‘south’.
With your new cheek implants you consider a temporal suspension midface lift which can simply and easily pull back up the midface tissues over the new implants.
Dr. Barry Eppley
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
Q: Dr. Eppley, I had malar and para-nasal implants, also infra-orbital porex placed in 2006, and six months ago removed because the malar increased my gaunt look, provided only lateral projection, and started to show through my thin skin. The paranasal implants didn’t really do much for me in terms of anterior volume, since they were placed so low on my long face. Also, right infra-orbital implant became infected during removal of the malar implant and was also removed. Now I’ve got the left one still in there and, without the malars, the edges are poking through and it’s too small for my face. I trust my original surgeon and he wasn’t the one who removed the malar implants for financial and geographic reasons. Although the malars were kind of cool and from some angles gave me an “actor” look butI don’t want to replace them alone.
But, I do want to explore all options. That said, his idea is: 1) larger medpor tear trough plus midface lift. I realize the right eye is drooping. I also think there is some scar tissue where the paranasal was on right side that makes that cheek droop more and look puffy. I know that midface lift means basically 2-month initial recovery and can leave one funky-looking, and seems to not really last that long. I was thinking of the blepharoplasty to reposition the eye, instead??? (less invasive??) I like the idea of tear trough improvement , now that I can compare left vs. right, I see that my face needs it.
The groove and shadows beneath eyes are my biggest complaint. Because I realistically, with my long and gaunt face because of exercise, it would take a lot to fill it out. So I think a compromise of concentrating on eye area is the best option at this point. But I don’t want to go thru that recovery time and cost of the midface lift if it is going to fall in a year and the tear trough won’t be big enough and will start poking through….2) another surgeon I have worked with in past suggested malar-submalar combo, goretex. But is worried that any implant will just show through. I am also open to this, to give some structure to my flatness, lower healing time, lower cost. 3) This second surgeon prefers just to use injectables. I won’t do fat transfer because I will burn it off and it’s a waste of money and time. It would just leave the left infraorbital implant in and try to compensate on right and in lower cheeks with filler under eye. At this point, though, I would be looking at minimum $6000 in filler.
I had noticed the medpor porex tear trough implant and that, based on the brochure, seems to be what I’m looking for in terms of volume. But, I don’t think my present surgeon would go for something this big,and he had mentioned the Hoenig model. Again, anything anterior he is against in order to avoid hitting the nerve.
I’m not against the midface lift, but at this point would prefer to save any lifting for a mini-lift 5 years down the road, perhaps with submalar added…. with skin excision not just suspension, when I really need it. And for the massive recovery time. But, I have seen some awesome B & A of tear trough shadow improvement.
I don’t know…???? I started on this porex implant road and maybe just have to continue in this direction.
A: In answer to your questions:
1) Don’t do a midface lift. This is a longer recovery than most patients realize and with your facial skeletal structure you are at an increased risk of creating lower eyelid ectropion or an unusual look. With your thin facial tissues, you are always going to be at risk of tear trough implant palpability, visibility or asymmetry. But I can get more enthused about tear trough implants in you though than a midface lift.
2) A small thin malar shell implant for the cheeks is reasonable and far preferable to a midface lift. With your thin tissues there is not much room for error about implant size as it is easy to end up in you with a visible implant look as you have had in the past.
3) Injectable fillers or fat in your thin face will not only not work well but has a poor return on investment over time.
4) There should be no concern about ‘hitting’ the infraorbital nerve going over the edge of the infraorbital rim. The nerve is well below it. That appreciation is just a function of having placed implants there before.
Dr. Barry Eppley
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
Q: Dr. Eppley, I really need your advice, I have a problems with my eyes. There are very round, there are always dry and the corner of my eyes there is no fullness. (no arch shape) . My questions is are infraorbital rim implants right for me? Should a midface lift be done with the infraorbital implants? Please send info to my email please get back to me if you can.
A: To best answer your questions, I would need to see some pictures of your orbital/facial area. Round eyes with too much scleral show can be improved by tightening procedures at the corners (canthopexy) which may alone offer an improvement. In some cases of round eyes, there is laxity and/or a lower eyelid malposition contributed to by a lack of underlying skeletal support. That is where infraorbital rim implants can be helpful. By providing skeletal augmentation and a push upward to the lower eyelids, lower eyelid tightening procedures can be more effective and the lower eyelid position better maintained in its new position. This is also the role of a midface lift, to provide soft tissue support to the lower eyelid. By definition, infraorbital-malar implants produce a midface lift by the displacement of the soft tissues.
Dr. Barry Eppley
Q: Dr. Eppley, I have a midface deficiency which is causing the skin of my midface to sag alot causing it to look pigmented, I have been told I am more suitable for orbital rim implants (after many consultations for standard cheekbone implants) but it seem a subtle implant is all that can be used due to my skin not being very hefty. What I want to know is how far around from the nasion area around to the malar lateral area does the implant reach? Will it fill out the area on outer corner of eyes where a normal persons cheekbones would normally be located? I generally have good projection on the sides of my head, but I have developed a fat face appearance and I’m only 24, this is giving a pigmented look to the unsupported skin. It’s like I’ve lost a lot of weight which I haven’t as I’m only 150lbs.I have been told I could go with fat transfer after implants if I wanted a more drastic change later on down the road. Will subtle rim implants be enough to lift the sagging skin as it feels like there is a lot? My face has no angles like it used to and has become very doughy. I’m depressed over this as I simply don’t know what to do.
A: While I will have to see pictures of you, I can make some general comments in regards to infraorbital-malar implants. There are numerous styles and designs of orbital rim, malar and combined infraorbital-malar implants. Some do reach the whole way from the medial orbital rim around and onto the malar region and up on the lateral orbital rim. How much midfacial tissue lifting these implant styles do is limited. Some malar tissue elevation is obtained but more significant amounts will likely need some form of a midface lift done concurrently with implant placement.
Dr. Barry Eppley
Q: Dr. Eppley, I have read recently about a procedure that lifts up the cheeks using an implantable device. It is supposed to go away after it is implanted. This sounds appealing but I don’t understand how it works and what happens to it after it is put in. How can something create a permanent effect when it goes away? Since it is used and put in by plastic surgeons and is sold commercially, it obviously is legitimate but I am confused as to how it works. Can you explain it to me?
A: What you are specifically referring to is the Endotine Midface Lift Device. This is a small platform with small angled spikes on its outer surface that is made of a well known resorbable material known as poly-lactic acid. Many dissolveable sutures are made of the same material. The concept is that the sagging cheek tissues are lifted up back onto the cheek bones and are held there by this device. The device is attached to the bone and the small spikes face upward. The cheek tissues are lifted up on top of the device and are held in place by the angle of the small spikes. This repositions/resuspends sagging cheek tissues back up higher on the bone. The procedure is done through a small incision from inside the mouth. The device resorbs within a year after surgery and is replaced by scar tissue. In theory, the scar tissue then acts to hold the cheek tissues in place.
The nice thing about this device approach to a midface lift is that is fairly simple to perform and is done without scar from inside the mouth. Unlike a traditional midface lift, it does not disrupt the lower eyelid tissues and eliminates the risk of ectropion or lower eyelid sag. For the right patient if performed well, it can be a good midface lift operation. Understand, however, that no form of facelifting is permanent. As the device goes away and with time and aging, some cheek sagging will return.
Dr. Barry Eppley
Q: I had inferior orbital rim implants done with a midface lift about 6 weeks ago. It has left me with upper lips on the right side that I cannot purse and numbness in my top front teeth and extending up my nose to my eyes. I am also numb above the implant on the right side. I also had a blepharoplasty. My muscles of my lip don’t function right so my lip hangs down a bit and I have to be careful not to bite it. I can’t spit or whistle right. The muscles that lift the right side of my nose and face don’t work right so one side goes up higher than the other. The implant was put in so that part of it sticks up like the screw wasn’t seated well so i can feel the edge and see its edge in the mirror. The surgeon says he’ll fix it but there is still so much trauma in my face that I don’t know if it will ever resolve and I don’t want to make it worse! I know you don’t know me but I need advice on how to proceed and if this teeth numbness, etc. is normal. Should I wait until my face settles down?
A: The combination of a midface lift, lower blepharoplasties, and orbital rim implants does impose a fair amount of trauma to the midfacial area. It does take more than a few weeks for the feeling and lip and nose movement to return to normal. If this was done in the usual fashion, the lower blepharoplasties was the route through which the orbital rim implants were placed and incisions were done inside the mouth under the upper lip to assist with the midface lift.
The combination of orbital rim implants and the intraoral dissection works around the infraorbital nerves which comes out just under the lower orbital rim. This nerve supplies the feeling to your lip, nose and cheek. It is normal for some temporary numbness to occur afterwards due to the trauma around it. It should be gradually improving and I would expect less numbness each and every week at this point. It should take no longer than three months or so to completely return. If the numbness is not improving by the week, there is the possibility that the implant may be impinging on the nerve. If the other side is completely different in the recovery and much further along, this becomes a real possibility.
Feeling the edge of the implant or the screw is not likely to become less noticeable with time. I believe this is the implant on the same side as the lip and nose numbness and movement concerns. The combination of the above suggests that orbital rim implant adjustment may be needed. Since this is done through the lower blepharoplasty incision, there would be no added trauma to the recovering area below the implant.
As a general philosophy, you wait on a revision when it appears that time is continuing to make progress. When time no longer is making any difference, and the operated area still has problems, then revisional surgery can proceed.
Dr. Barry Eppley
Q: I am impressed with the results I saw of yours on a patient that I ran accross on the internet while doing plastic surgery research. The patient had cheek implants and I think removal of buccal pads. I am 57 years old and have a lean face. I think this procedure is what I would need to achieve the results I am looking for. My buccal pads are more prominent with age and above the buccal pad area my cheeks are flat. I am not interested in filler because the buccal pad area, I believe, still needs to be addressed. Did you remove the buccal pads in this patient and insert cheek implants? I am thin so I do not think liposuction would be in order. I once asked a plastic surgeon about removing the buccal pads and he told me that would make me look dreadful. Please advise. Thank you for your time.
A: Cheek or midface augmentation can include several procedures depending upon the make-up of the anatomic problem. Implants for cheek and submalar augmentation, submalar or buccal fat removal OR augmentation, and cheek or midface lifts for sagging skin are all potential options. These procedures can be done alone or some combination thereof may be more ideal. But it all depends on an appreciation of the cheek bone anatomy and the soft tissue make-up around the cheek bones. Only through a pictorial analysis could I provide you with what may be beneficial for you.
That being said, a thin face almost never aesthetically benefits from a buccal lipectomy. I have a suspicion that what you may be seeing as buccal fat may be cheek tissue ptosis or sag. Rather than a buccal lipectomy, you may need a midface lift which resuspends the sagging cheek tissues which have fallen into the buccal triangle up back onto the bone. A midface lift may or may not be complemented by small cheek implants.
Dr. Barry Eppley
Q: I am interested in getting some facial implant work done and was wondering if I can have wisdom teeth extraction done at the same time? I want to get orbital rim implants with a possible midface lift. Is there any reason why these two can not be done together? Will one potentially cause problems with the other or is it better to have them done separately, like a decreased risk of infection?
A: I see no reason why these two facial bone procedures can not be done at the same time. It is quite common to do multiple hard and soft tissue procedures of the face together. The face is tremendously well vascularized and very resistant to infection. (I didn’t say impossible just very resistant) While such a combination (facial implants and 3rd molar extraction) is unusual, it is by no means contraindicated. The hardest part is not the operation, but finding someone who is well qualified to do both at the same time.
Orbital rim augmentation and a midface lift is done from the outside through a lower blepharoplasty incision. Wisdom tooth or 3rd molar extraction is done intraorally from inside the mouth. The two areas are not anatomically contiguous and would not connect, thus ensuring no risk of oral bacterial contamination coming in contact with any implanted material. Because of this risk, the orbital/midface procedure is done first so cross-contamination from instruments does not cause any inadvertent oral bacterial inoculation on the implant.
Dr. Barry Eppley