Q: Dr. Eppley, I bite down on my cheeks sometime when chewing my food which makes it uncomfortable and sore. Sometimes I can barely eat they are so sore. My cheeks are also sunken in. What are your recommendations for submalar surgery to correct this problem and get it covered by insurance.
A: Biting down on one’s intraoral cheek mucosa is not rare but occurs more frequently in some people. This can occur because of the cant of the occlusion, broken teeth, a swollen cheek lining and particularly if one is wearing hardware on their teeth such as braces. Once the cheek lining gets swollen, it is bigger and creates a protruding ridge which is a viscous cycle for recurrent biting on it.
Having a sunken cheek, however, is not an anatomic reason why one would bite their cheeks. This make seem like a logical explanation but the fat atrophy of the buccal fat pad occurs on the outside of the buccinator muscle and does not effect the shape of the inside of the cheek lining. The buccinators muscle is like a stretched trampoline and what occurs on the outside (visible submalar area) does not effect what lies on its opposite side inside of the mouth. (buccal mucosa) Thus performing submalar augmentation by injecting fat or placing an implant will not improve the shape of the lining inside the mouth…or improve the cheek biting problem.
Submalar augmentation can be performed to improve the aesthetics of the face and would not be covered by insurance under any circumstances. If a palpable ridge of mucosa exists along the occlusal level inside the mouth, its excision may remove the cheek mucosa that is getting in the way of the upper and lower teeth biting together.
Dr. Barry Eppley
Q: What are the options to put volume back to buccal area underneath the cheek bone? I am in my mid 30s.
A: A buccal or submalar indentation or concavity can occur for a variety of reasons including a congenital facial concern (developmental), after a buccal lipectomy (iatrogenic), or medication-induced. (retroviral drugs) This area extends from underneath the prominence of the cheek bone down to the end of the nasolabial fold and out into the lateral face. In many patients the outline of this area resembles a triangle, hence its common referral as the submalar triangle.
The easiest approach for submalar facial augmentation is the injectable route. The most common agents used are the synthetic material Sculptra or your own fat. Sculptra was specifically developed for exactly this facial problem with its initial FDA-approval for facial lipoatrophy in the HIV patient. It is not permanent, however, and it requires a series of three injections a month apart to build up a result that may last up to 2 years. Fat injections are more of a surgical injectable method as they require a fat harvest which is then processed and injected into the submalar area. The fat of fat injections is not always consistent but the submalar does better than many other facially injected areas.
The other submalar augmentation method is the use of implants. A synthetic implant, known as a submalar implant, can be placed on the underside of the cheekbone to provide fullness to the upper submalar area. The other implant option is the use of a dermal-fat graft which can be placed into the buccal space. In a few cases, I have done a combination of a submalar implant with a dermal-fat graft to get a more complete submalar augmentation.
Dr. Barry Eppley
Q: Hi Dr. Eppley, I have a question regarding my face since it has gotten thinner after a facelift. I had a facelift last summer after losing 45 pounds. My plastic surgeon said he took four inches of skin out of my neck. However I did lose my round face because my cheeks are more sculpted now due to loss of volume. While I like the change it is a weird look for me because I have always had a round face since I was just a kid. I never had sculpted cheeks even at a normal weight. I used to get carded well in my 30’s because of my baby face. So there is some merit to having volume. It is weird for me to see my cheekbones as opposed to my puffy cheeks. I almost feel like I look older without my round face. So my question to you is it possible to add some volume in my lower cheeks BELOW the cheek bone to get my “baby face” back. What would you suggest? I can send pix if you want me to. Thanks for your advice.
A: There is no doubt that between having a facelift and undergoing considerable weight loss, one can end up with less facial volume. This is usually most manifest around the cheek areas when it occurs, specifically in the area below the cheeks known as the submalar area. I prefer to call this area the submalar triangle as it is a soft tissue area that has the configuration of an inverted triangle and has no underlying bony support. That is why it suffers the greatest indentation or hollowing on the face with fat loss…it has no underlying bony support so it sinks in.
There are several ways to build out the submalar triangle. The simplest is to replace what is lost through fat injections. Fat is both natural and easy to harvest through liposuction and its injection is not ‘invasive surgery’. Its downside is that its survival is not always predictable. The other is to use a specific submalar implant which sits on the underside of the cheek bone. This will build out the upper part of the submalar triangle but not the lower area near the corner of the mouth. The total submalar area can also be built out by the insertion of onlay dermal grafts. Using part of your old facelift incision, allogeneic dermal grafts (human dermis out of a box) can be cut and laid underneath the skin to add a soft natural volumetric fill. The dermal grafts will integrate and become part of your natural tissues.
As you can see there are a variety of submalar augmentation options. Which one is right for you depends on which approach offers the simplest, most natural, and predictable outcome.
Dr. Barry Eppley
Q: Hi Dr. Eppley, I am interested in filling in my lower cheeks. They are sunken in and I have had multiple fillers from Radiesse, Juvederm etc for years. I am tired of it looking really good for 2 weeks due to swelling and then having it all disappear and look the same within the month. Do you ever do a tissue fill on the lower cheeks? I had one doctor do filler one time on the upper cheeks and I hated it. I looked like cat woman and I don’t like that look. I just want to fill in the bottom cheeks. I’m afraid to put in an implant because of the risk of crooked smiling. What do you suggest?
A: The area below the cheeks is known as the submalar triangle which extends from below the cheekbone down (in an upside down triangle) to below the side of the mouth. It is important to appreciate that this area is not supported by underlying bone. This is why anyone with a thin face or fat loss will show an indentation in this area and create a ‘gaunt’ look. This also means that there is no type of a bone-based facial implant providing any fullness to this area.
While synthetic injectable fillers will produce some temporary fullness, they are not a long-term solution to this area of soft tissue facial deficiency. The next logical approach is that of fat injections. While they offer at least the potential for some long-term retention, they are also plagued by potential resorption. I have mixed these fat injections with PRP (platelet-rich plasma) for facial injections and feel that this combination does offer better results. But the risk of near to complete resorption still exists. No one can predict how well fat injections will persist in any particular patient.
The remaining good alternative is that of dermal grafts. Using allogeneic dermal grafts, they can be put it in sheets and layers. They can nicely built up an area and are very soft. They are human collagen which will eventually be replaced by your own tissue. They can be put in through a limited facelift incision. Their long-term volume retention is much more assured than fat injections.
Dr. Barry Eppley