Q: Dr. Eppley, I am a 25 year old man and I want to fix the sunken look I have in my midface area. Below my cheeks it is very hollow. In addition, there are indented lines which I call railroad track lines in my midface? I have read about filler injections but I know they are only temporary and may leave a plump, round shape which I don’t want. I would like to have a more narrow/angular look. Do you think cheek implants will work?
A: Hollowing below the cheeks, known as submalar hollowing, is the result of the cheek soft tissue not being supported by bone. Without a large buccal fat pad or thick subcutaneous fat being there, this area will become a concavity and not a convexity. Injectable fillers can certainly be used as a temporary augmentation method but I would agree that it lacks the ability to create sharp definition. Cheek implants are the only other options and they do provide a permanent change. But there are numerous types of cheek implants and it would be very important to get the right implant shape to achieve the desired result. Submalar cheek implants would theoretically be the best choice but they do add some cheek width and lateral fullness.. It may be better to use a combined malar and submalar implant, known as a malar shell, and modify the submalar edge to create medial augmentation of the submalar hollow but not lateral fullness.
Dr. Barry Eppley
Q: I have lipoatrophy and would like to perhaps have my face lifted and cheeks implants placed in order to achieve a fuller, rounder appearance so I am able to appear the age that I am which is age18. I sent in earlier pictures and I was smiling in them and was told they were unusable so I sent these.
A: Thank you for sending your additional pctures. You probably have the most severe case of facial lipoatrophy that I have ever seen in someone your age. Facial lipoatrophy is classified on a scale of 1 to 5 based on its severity. You are clearly at least a 4 if not a 5. You face is completely skeletonized with essentially no fat, thus resulting in hollowing of the temporal, submalar, maxillary and lateral facial areas. This problem is not treated by any form of facelifting. Rather it requires volume addition, most of whcih must be fat not implant. Submalar implants would be helpful in the cheek area but most of the volume addition must come from fat injections due to the size and location of the hollowed areas. The important question is….do you have enough fat to harvest and transfer? Most medically-sound people with severe facial lipoatrophy are also thin in their bodies, thus having little fat to harvest for the procedure. At a minimum, you need about 30 to 35 cc of concentrated fat per facial side (in addition to the submalar implants), which means that 150cc to 200cc needs to be harvested from somewhere, usually the abdomen or thighs. While that is not much and easy to get from most people, your body may be a different matter.
The pictures you sent are not easy to show the results of volume addition, which is virtually impossible to image from the side view. The front view imaging is not great but it demonstrates what happens when your facial hollows are filled in or expanded. Just think of your concave facial regions becoming more even with the surrounding bone structure.
Dr. Barry Eppley
Q: Hello, I have severe facial wasting. I am not an HIV patient, I had a normal plump face as a young child and by about the third grade my cheeks had completely sunken in and has given me a much older and skull-like appearance. I am only eighteen years old. I would like to have a procedure to correct this done this summer before I begin college in the fall. I would like to know if you handle this sort of procedure and what you would suggest to be done. I have attached some pictures with this e-mail inquiry.
A: Thank you for your inquiry and sending your pictures. You have a classic case of facial lipatrophy, type IV (type V is more consistent with HIV related facial lipoatrophy) Your history is classic for it as most patients convert from the plump face of childhood to a thinner more gaunt facial look during grade or intermediate school. Of the augmentation methods for treatment (implants and fat injections), I think you need a combination approach. I would place submalar cheek implants that specifically builds up the area right under the cheekbone known as the buccal area. This implant is placed through the mouth under the upper lip. Then I would do fat injections with Acell collagen particles to the area below the implants out into the side of the face and down to opposite the corners of the mouth. The goal is to add some fullness to the sides of your face and help reduce your more skeletonized appearance.
Dr. Barry Eppley