What Is The Best Method For A Midface Lift After Cheek Implant Removal?

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

Indianapolis, Indiana