Q: Dr. Eppley, I have been diagnosed with a mild midface deficiency. I would like to have this corrected to end up with the most aesthetic appearance possible. I have been reading about facial implants and the work you have done with them. I would like to achieve a reduction of the depressions on either side of the nose, reduction of the heavy creases going down to the corners of my mouth and better projections of my face to make it look less wide and flat. In addition I am also interested in lip implants. I already have some lip implants placed. They were the type that look like spaghetti and the size was 4mm top and bottom. I would like to add to these to make my lips bigger. Specifically I would like to show more of the pink lipstick area rather than just make them stick out more. I would also like to bring the implants out to the edges of my mouth to make the lips and mouth appear wider.
A: When it comes to facial implants, there are a lot of facial changes that they can make…and there some changes that they can not. For a mild midface deficiency, consideration can be given to paranasal implants to bring out the base of the nose and anterior submalar implants to provide some upper midface projection. The lower nasolabial folds as they approach the corners of the mouth will not be affected by any bone-based implant. This area is best treated by fat injections.
In regards to the lips, you either have more recent Permalip silicone implants or older style Advanta lip implants. Either way it is not a good idea to double stack lip implants as there will be a great tendencey to have them roll or twist on one another. You may exchange them for the largest 5mm implants but, for the sake of a 1mm increase, that is not likely to make much of a difference. Furthermore, some of the lip changes you desire can not be achieved by lip implants. No implant will increase the vertical height of the vermilion (pink lipstick area) nor will they make the corners of the lip appear fuller or wider, they are too thin in this area. To make these kind of lip changes, you will need to consider a vermilion or lip advancement procedure which directly changes the location of the vermilion…which is what is needed to make the type of lip changes you desire.
Dr. Barry Eppley
Q: Dr. Eppley, I recently read your blog about malar and submalar implants. I just have one question since there doesn’t seem to be much information on these implants, but where exactly are the malar and submalar regions?
If I’m looking at implants to provide a swoop from the nose to the cheeks (sorry, not sure how to describe it, but think of Bradley Cooper’s midface), which implant would actually provide that kind of volumetric augmentation?
A: The difference between malar and submalar implants is subtle but very different. As shown in the attached drawings on a person’s face, the malar region is the cheek bone itself while the submalar region is actually below that off of the bone.
There is no preformed or standard shaped implant that provides fullness (a swope) from the nose to the cheek because directly in its path is the large infraorbital nerve. An implant can be fashioned with notching of the nerve to avoid compression (maxillomalar implant) of the nerve using either a 3D model of the patient or pre making it off of a basic skull shape.
Dr. Barry Eppley
Q: Dr. Eppley, I understand that malar and sub-malar facial implants can be used to add volume, 3-dimension and contour to the face. Initially the imaging you provided showed the malar implants only, I think? I am interested to know if the sub-malar implants can be added as well, and more laterally, to camoflauge the slighly hollow buccal area of my face.
Can you please also explain to me the use of paranasal implants? I understand these are largely popular in Asia.
In your opinion, would they assist in the roundening and softening of my face as a whole?
You mentioned the chin augmentation I did may have produced an extreme result, compared to what is actually achievable? Do you think I would notice a measurable reduction in both the width and length of my chin with the sliding genioplasty?
A: What I previously showed was the use of malar implants in your face. The combination of malar and submalar implants is known as malar shells. That would extend the fullness into the underlying buccal space right below the prominence of the cheek bone.
Paranasal implants are designed to add fullness to the base of the nose or push it out further. They are common in Asians because they naturally have a flatter mid face throughout. I can not tell if they would be of benefit to you without looking at picture of your face from different angles, like the side view and the three-quarter or oblique. Midface augmentation in general requires a more 3D type assessment not just a flat 2D picture from the front view.
As for our chin reduction/narrowing, what you had demonstrated was a bit too sharp and extreme which is not surgically possible. But an osseous genioplasty (not a sliding one) can reduce the height of the chin as well as make it more narrow through vertical and midline bone removal.
Dr. Barry Eppley
Q: Dr. Eppley, I would like to get rid of my facial wasting due to HIV. I am interested in cheek implants and fat fillers for lipodystrophy. I have attached a picture of my face for your evaluation.
A: In looking at the one picture you sent, your greatest area of lipoatrophy is in the temples and secondarily in the submalar regions. Compared to many patients that I see, your degree of facial lipoatrophy is fortunately more moderate in severity. Given that you have existing lipoatrophy, and I assume you are on antiviral medication, this makes the use of injectable fat survival precarious at best. For this reason, I make an effort to use permanent synthetic implants when possible for its treatment. These would be applicable to the temporal, submalar and even the nasolabial fold areas. But facial implants do not cover all facial lipoatrophy areas and are at best thought of as building blocks from which to fill around with fat injections as needed. Even though fat injection survival is unpredictable, it is the best filler to use for broader facial areas. And since it is not the only method of treatment that is being done, any survival that is achieved is a bonus to the underlying implants.
Dr. Barry Eppley
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: Dr. Eppley, I am interested in neck liposuction, revision rhinoplasty, and cheek augmentation. I want to get rid of neck fat, define my jaw and neck line, straighten nose-one side of nose is bigger, and add volume in mid- and lower cheeks and under eyes. I have attached pictures for your review and assessment.
A: In looking at your pictures and your areas of interest, I can make the following comments/recommendations:
1) You jawline is ill-defined because your chin is both horizontally and vertically short. This makes your lower face look very deficient and creates a lack of any jawline definition. What you would ideally benefit from is a vertical-lengthening chin osteotomy which adds lower facial height and creates a more obvious jawline. This will also improve the appearance of a fuller/fatter neck although some submental liposuction done with the chin procedure would complement that improvement.
2) Your nose shows numerous secondary rhinoplasty issues. I do not have the benefit of knowing what you looked like before but I see issues relating to lack of upper dorsal height, tip asymmetry/thickness, nostril asymmetry and a deviated columella.
3) The need for volume in your cheeks and lower eyes is a bit perplexing to me. I see no benefit to lower eyelid volume augmentation. Perhaps with the chin lengthening, more volume in the lower cheeks (submalar implants) may be aesthetically beneficial to you. I have left those areas unimaged so you can see the other more important areas of facial change first.
Dr. Barry Eppley
Q: Dr. Eppley, I had submalar implants (Binder silicone submalar implants) done one year ago, large size. I could not smile fully, corners of my upper lip did not go high enough, so I had them removed 3 months ago. Now, everything is fine with my smile, and I would like to have submalar implants again, may be smaller size.I would like to ask few questions: Is it common that patients which use submalar implants have difficulties with smiling or that smile looks different that before? Can it be due to too large size used in my case or…?
A: While this is not a problem that I have ever seen from submalar implants, it is theoretically possible. Unlike malar implants, a significant portion of the submalar implant hangs down off of the bone. Given that the levator anguli oris muscle runs from the corner of the mouth up to the cheek bone and its contraction is responsible for lip elevation, it is easy to see how a large submalar implant could interfere with its action. It is either that or the sheer size of the implant simply interfered with mass tissue movement. (more likely) Either way, your experience demonstrates that it happened as proven by a return to a normal smile with their removal. While I have no idea what size submalar implant you had or exactly where on the bone it was placed, I suspect that a smaller size implant would be less likely for this problem to recur.
Dr. Barry Eppley
Q: Dr. Eppley, I had implants for submalar augmentation placed through mouth on September 2nd and then had them removed one month later. I also had a small premaxillary implant put in through the nose. I removed them because they were too big and the premaxillary implant changed the way my nose looked. The implants have been out for one week. I know that some of the undesirable effects were swelling and that I didn’t give them a real chance. But the anxiety they were causing me on a daily basis was too much. I can’t find any information as to why my nose looks different still after removal, it is wider and the nostrils look rounder and slightly more upturned. Is it possible it won’t go back to pre op look? Could scar tissue have formed that quickly or is it just swelling and if so when should I expect it to truly resolve. The cheeks and lower face are still very swollen also, will this eventually return to pre op look also given that they were in and out so quickly? When can I expect to look like me again? My muscles are a bit tight but overall seem to be functioning without any issues to the nerves and I can smile. Thanks and I look forward to your response.
A: Certainly one week after implant removal, there will be residual swelling and facial distortions. By your own admission you know this and it will take several months before you can judge the final outcome. I would have no doubt that the cheeks area will return completely to normal. Whether the nasal base will is unknown. In placing premaxillary implants the attachments to the nose around the pyriform aperture and the anterior nasals spine are disrupted. This may cause the nostrils to end up slightly wide than before but this is a possibility not a certainty.You must wait three months after facial implant surgery, either after their placement or removal, before seeing the final results.
Dr. Barry Eppley
Q: Dr. Eppley, My cheek bones come down just past the nostril base of my nose and from what I’ve read, that is supposed to be ideal. However, to me, it appears that I am lacking some volume and “flatness” in the submalar region. My chin is also slightly weak but the idea of a chin implant concerns me since it can be easily overdone and too prominent. If possible, I’d like the chin not to look wider from the front or longer from the profile…just creating outward volume. My goal is to maintain a feminine look with naturally done contours.
A: In looking at your face and in conjunction with your stated goals, I would recommend a small submalar implant and a small central chin implant style. Your cheekbones actually are quite nice and ideally positioned and full. The submalar area could stand a little volume as you have surmised but the key is subtle or small. This is why I suggest one of the smallest submalar implants. The malar and submalar areas are very easy to overdo and too large a size is a common problem in implant selection. From a chin standpoint, females needs a more central chin implant with very limited lateral wings. Women need a more tapered chin appearance, more pointy if you will, which is more feminine as opposed to a more square chin look for men. The combination of small submalar and chin implants should provide highlights and natural contours to your already good facial bone structure rather than overpowering it or being obvious.
Dr. Barry Eppley
Q: I am HIV positive as well as a diabetic with deflated cheeks. Do you think transferring fat from my own body to my face will work?
A: Facial lipoatrophy is a common sequelae from the antiviral medications used in the treatment of HIV. Often this loss of fat is quite severe with the skin literally be right down on the bone with loss not only of the buccal fat but loss of the subcutaneous fat as well. When the condition is this severe, the concept of injectable fillers must be looked at very carefully. While fat injection transfer can clearly be done, the question is will it work long-term. How much of the injected fat will survive? The HIV patient on antivirals poses an additional variable to the biology of injected fat which is already challenged in the variability of its survival. Will the same medications that caused the fat atrophy to begin with do the same to the injected fat? No one knows with absolute certainity.
For these reasons, I prefer an additional approach to just injected fat for this cheek lipoatrophy. I like to place a submalar implant on the lower edge of the cheekbone and then cover this with an internally placed dermal-fat graft. Then injected fat can be placed subcutaneously throughout the cheek and lateral facial areas as an additional outer layer. This is a good way to hedge your bet so to speak by at least having some type of cheek augmentation that you can be assured will have stable volume preservation.
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
How Can The Area Below My Cheeks Be Built Out To Add Some Slight Fullness And Get Rid Of My Smile Lines?
Q: I am unhappy with the mid- and lower cheek area of my face. My cheeks are sunken in below the cheek bone causing a hollow/gaunt appearance. I have smile lines that are becoming heavier and more visible all the time. I had fat injections in the area of the smile lines about 3 months ago. I would estimate that about half remains at this point. I saw your videos on Youtube and would like your opinion on whether a submalar implant would fully correct, partially correct, or have minimal effect in this area of my face. I would like to understand your recommendations on improving this area. My objective is to create a permanent and fuller looking face in the cheek area and pull out the smile lines without creating a chubby or fat face.
A: The key to answering your question is to understand the anatomy of the submalar triangle area. This is an inverted triangle facial zone that lies below the cheek bone in which the apex of the inverted triangle goes down below the corner of the mouth. Almost all of this area is not supported by bone, but by soft tissue only. As a result, a submalar implant will only help create fullness in the upper region of the submalar triangle. The smile lines lies in the lower end of this triangle and will not be changed by a submalar implant. Soft tissue augmentation must be done in the smile line area. Fat injections is one method but is fraught with unreliable take as you have experienced. But its simplicity remains its appeal and another effort at it may produce even better results. The other option, which I currently prefer due to its better effect and longevity, is interpositional dermal grafting. By placing layers of allogeneic dermal grafts in this area, the skin and the underlying tissues are released and separated by the grafts. They add an eventual well-vascularized tissue layer that can be from 2 to 5mms thick which is not unduly bulky. They must be placed through a limited facelift (preauricular) incision. Their longevity is much more assured than injectable fat grafts in this facial area.
Dr. Barry Eppley
Q: I want to get implants to have higher looking cheekbones. What is the difference between malar and submalar cheek implants? Which would be better for me?
A: In considering cheek augmentation, or enhancement of the midface, there are a wide variety of cheek implant styles from which to choose. Gone are the days when only a single design of a cheek implant existed. One of the different style designs is between malar and submalar implants. Malar is another word meaning cheek. So a malar implant sits on top of the existing cheekbone, providing more cheek projection. A submalar implant, however, sites on the cheekbone’s bottom edge providing increased fullness to the area below the cheekbone.
Submalar cheek implants have actually been around for some time and were developed to help with midface sagging from aging. As we age, cheek tissue slides or falls off of the cheekbone. One way to help lift it and restore more youthful fullness is with the submalar implant. The other option would be a midface lift, a more extensive operation with an increased risk of complications.
When most patients are considering cheek enhancement, they are usually thinking of higher cheekbones and more fullness to the bone right beneath the eye. Cheek implants come in a variety of designs to achieve this fullness and they differ in whether the most fullness in the implant is anterior, central, or posterior along the cheekbone. To choose the best implant style for you, you need to go over carefully with your plastic surgeon your exact concerns and what areas of the cheek you would like to be bigger. Most dissatisfaction with cheek implants occur because of style and size selections.
Dr. Barry Eppley