Cheek augmentation is most commonly done by onlay augmentation. A wide variety of cheek implants exist to achieve almost every type of cheek dimensional in increase. And if a standard cheek implant cam meet the patient’s aesthetic midface needs, custom cheek implants can be designed for even the most exotic cheek augmentation change.
But some patients do not prefer the use of implants in the face and seek a more natural or autologous cheek augmentation method. Cutting and repositioning portions or all of the cheek bone can be done but its effects are more dimensionally limited. Just like the cheek bone osteotomy used to narrow the cheeks, it can be similarly done to done to widen.
A sagittal cut through the main body of the zygoma can be done from an intraoral approach. This maintains the anterior attachment of the zygomatic arch to the outer cortex of the zygomatic body. This cantilevered cheekbone segment can then be pushed out to increase zygomatic width and help there with a plate and screws. An interpositional autologous or cadaveric bone graft can be used between the segments if desired.
This cheekbone osteotomy method is used to widen or lateralize the outer cortex of the cheeks. It is a two-dimensional cheek augmentation technique that increases facial or bizygomatic width. However, it can not increase anterior cheek projection. It has its value in certain aesthetic midfacial needs as well as in partial secondary correction of certain types of healed displaced cheekbone fractures.
While one does not see their face in a profile view naturally (only in pictures), the world sees your face in three-quarter view or in profile. Thus the perception of one’s own facial profile is important and it is stressed in many plastic surgery procedures. The two most important hard structures that make up the profile is the nose and the chin. As such the combination of a rhinoplasty and genioplasty is often done together. When done simultaneously, this combination has even been called a profileplasty.
These two profile structures influence each other even if only one is surgically changed. It is well acknowledged that reducing a large nose makes the chin look bigger and chin augmentation can make the nose look smaller. Certainly it can be a very powerful profile changer when a larger nose and a smaller chin are simultaneously corrected.
While a reduction rhinoplasty can be done by various methods based on the actual deformity, these represent relatively minor technical differences in the manipulation of the bone and cartilages. In contrast, a genioplasty can be done by fundamentally different techniques…an implant or an osteotomy. (sliding genioplasty) There are advantages and disadvantages to either type of genioplasty but most patients undergo the ‘simpler’ implant augmentation. Only a minority of chin augmentations are done by a sliding genioplasty although this is often the common chin augmentation technique for oral and maxillofacial surgeons.
Long-term outcomes of combined rhinoplasty and genioplasty patients are rarely reported probably because most plastic surgeons correctly assume that patients are very happy and there is little to gain by looking at the long-term results. But no studies to my knowledge have ever been reported looking at combined rhinoplasty and sliding genioplasty augmentation.
In the July 2013 issue of the Archives of Facial Plastic Surgery, a study was published entitled ‘Combined Rhinoplasty and Genioplasty: Long-term Follow-up’. In this paper, a total of 90 cases of combined open rhinoplasty and augmentation/reduction genioplasty over a three year period were reviewed to assess the stability of the aesthetic results. Specifically the chin was studied by anthropometric measurements. Soft tissue pogonion projection to the true vertical line and mandibular height (incisor to menton) were measured. The average horizontal augmentation genioplasty had 7mms advancement and the average vertical lengthening genioplasty had 5mms increased height. The measurements shows a 100% stability after three years. In reduction genioplasty, half of the patients had 100% stability after three years. The results of this study showed that there is minimal change (less than 1mm) in the chin position as part of a profileplasty.
While rhinoplasty and genioplasty is common, doing the genioplasty portion by a sliding osteotomy rather than an implant is very uncommon. The only advantage that a bony genioplasty has over an implant in most typical aesthetic patients is when a vertical chin change is needed. Given the average amount of horizontal advancement in this study that movement alone is well within the range of what an implant can do. The stability of the bony movements of a sliding genioplasty has been extensively studied before without being done at the same time as a rhinoplasty. This study corroborates what many studies have shown before, bony chin changes are fairly stable and any relapse or bone resorption is not clinically observable or significant.
Background: Chin augmentation is the most common implant enhancement procedure of the face. It is usually highly successful as long as the chin is not horizontally too short. Once horizontal chin deficiences approach 10mms or more, it will also have other dimensional issues as well being also vertically short.Trying to make a chin implant correct an overall short chin will leave the patient with a suboptimal result.
Once a chin implant augmentation procedure is deemed inadequate, one has to consider whether a new implant or a sliding genioplasty would be better. With greater than a 10mm horizontal deficiency, only a custom computer-designed implant will suffice. Besides that no existing commercially-made chin implants do not exceed 11mms, none provide any vertical lengthening at all. The other option is a sliding genioplasty. The downfractured chin segment can be moved as far forward as the thickness of the chin bone which almost always is more than 10mms. The other benefit that a sliding genioplasty provides is that the chin can be vertically lengthened by opening up the chin segment as it is brought forward.
While a sliding genioplasty can provide significant horizontal and vertical chin changes, it is not always a perfect chin augmentation procedure either. The amount of horizontal projection increase can not exceed the thickness of the chin bone so very short chins may still be left aesthetically deficient. In addition as the u-shaped chin segment is brought forward, the chin shape will actually become more narrow as the projection is increased. This may be an aesthetic disadvantage for some men who prefer or desire a more square or wider chin appearance in the frontal view.
Case Study: This 50 year-old male wanted to make one final effort at improving his chin shape. He had a prior history of two chin augmentation procedures using implants. He originally had an original 7mm anatomic silicone chin implant that was subsequently replaced by a 9mm Medpor two-piece chin implant that had been separated in the middle to give more of a square chin look. While he was improved with each procedure, he felt his chin was still too short. In addition, his chin felt tight and mildly uncomfortable even years after the second procedure.
Under general anesthesia, an intraoral anterior mandibular incision was made. The indwelling Medpor implant was exposed, unscrewed and removed. Contrary to popular perception the Medpor material did not have any bone ingrowth and, although the surrounding tissues were adherent, was not unduly difficult to remove. A horizontal chin osteotomy (sliding genioplasty) was done with the back end just beyond where the tails of the removed implant were. The downfractured chin segment was brought forward 12mms and secured into placed with a titanium step plate and two screws above and below the osteotomy line. To make the chin have more width, a small square silicone chin implant was placed in front of the chin segment and secured to it with screws. The mentalis muscle was then resuspended over the implant and advanced bone in layers.
His recovery showed the typical swelling and bruising down into the neck that commonly occurs with sliding genioplasties. It took almost three weeks until all swelling and bruising had resolved.
Significant chin deficiencies that do not achieve good results with implants may achieve better results with a sliding genioplasty, particularly when a vertical chin deficiency exists. Contrary to common perception, an implant can be used in front of a sliding genioplasty if more horizontal projection or greater width is needed.
1) Once a horizontal chin deficiency exceeds 10mms, standard chin implants will not produce an ideal result.
The facial aging process is one that is well known as everyone will eventually see it on their face. The eyes get heavy, the brows descend, the cheek fall, jowls develop and the neck sags. Women become concerned earlier in the aging process and proceed to do procedures to treat or slow it down in an overall more comprehensive manner. Men take a much more delayed approach to it often waiting until one facial area becomes a major concern or until the facial aging process is fairly advanced.
While the face ages largely similar in both men and women, the facial procedures used to treat them are often done differently. Not as many men have facelifts as their aging neck and jowls are more tolerated. But in men that have facelifts they must be done very carefully, respecting the natural hairlines of the temples and behind the ears and being careful not to displace the beard skin into the ear canal. Incisions must be placed very inconspicously and often less of a tightening result must be accepted to keep the scars hidden. That is not a bad thing as men look better underdone than having their faces pulled too tight anyway.
While men also develop heavy upper eyelid skin and lower eyelid bags just like women, their eyelid lifts (blepharoplasties) need to be done more conservatively. Browlift options in men are more limited due to the frequent lack of adequate scalp hair and a well defined frontal hairline. The most common male browlift method is through the upper eyelid (transpalpebral browlift) using the endotine device to accomplish the lift. This produces a very modest browlift but creates no visible scars and with more conservative eyelid skin and fat removals can avoid overfeminizing the male face and creating an unnatural overdone look.
Men do not engage in as many Botox and injectable fillers treatments as women as some wrinkles and signs of aging are more tolerated. A more natural result for men is one that reduces the worst of the wrinkles but does not eliminate all of them. This is the same reason men, at best, will only do a bare minimum of facial skin care. Many men would rather seek more definitive surgical procedures, or do nothing at all, that engage in non-surgical procedures that require frequent efforts to maintain.
Facial reshaping surgery is vastly different in men than women. Male rhinoplasties must keep a high and straight dorsal line and avoid an overly upturned tip while most women desire a smaller less projecting tip and lower dorsal lines. The shape of the face in men is dominated by a strong jaw and requests for chin, jaw angle and even total jawline enhancements are not uncommon to pursue a more masculine appearance and even the so called ‘male model’ look. Men favor higher more angular cheek augmentations while women prefer a lower more anterior rounded cheek prominence. Men pursue brow bone surgery for either reduction of an overlying prominent one or for augmentation to create a more masculine brow prominence and a more backward sloping forehead profile.
Plastic surgery for men has its own unique requirements both in the type of surgeries and the demeanor of the patients. One should not assume that every plastic surgeon or plastic surgery practice is equally adept about meeting the needs of the male patient. Just like breast reconstruction for women or body contouring after massive weight loss, the male patient presents unique challenges for a satisfying surgical outcome.
One of the key features of an attractive and youthful face is the cheek area. The desire for fuller cheeks, however, is driven more than just by that of model and celebrity faces. Part of the aging process is losing volume (fat) in the cheeks and temple areas, creating more hollowed or gaunt type look. For those that start out with thinner faces, this process is more accentuated even earlier in the aging process. This form of facial aging can not be treated by any form of a facelift or tissue shifting approach. It requires restoration of facial volume.
So it is no surprise that plastic surgeons over the years have used every available option in their armamentarium to reshape and lift the cheek area. While once only able to be treated by synthetic implants up to the early 1990s, injectable fillers of differing compositions for cheek enhancement became a dominant force over the past two decades as they have surged in popularity. The use of autologous fat in just a few short years has also become now a major tool for use in the cheek.
The single greatest advantage to synthetic injectable fillers for cheek enhancement is its immediate result. The hyaluronic acid-based fillers, such as Restylane or Juvederm, offer the greatest margin of safety because of their lack of inflammatory response and assured resorption profiles. Other fillers such as Radiesse and Sculptra offer longer results but a somewhat higher risk of soft tissue reactions to their particulated content. Composition aside, the biggest disadvantage to fillers is that they are temporary. (which is also their advantage) This makes them expensive to maintain over time if one likes the result. But they are actually a low cost approach to doing a trial cheek enhancement that is completely reversal. Using a microcannula delivery technique, injectable fillers can now be delivered painlessly and without bruising.
On the surface, fat carries with it many of the same features as synthetic materials because it is injected. But beyond being injectable, it is a very different filler material. Because it is harvested from each individual patient, there is no chance of any inflammatory reaction and a very low risk of infection. It’s other tremendous advantage is that there is no limit on the volume that can be injected (in the small face) and its inherent composition of stem cells has its own list of theoretical advantages. In addition, it is done for a set procedure price rather than by a cc cost for synthetic fillers. It is similarly injected by small cannulas so placement can be very exact without bruising. The best fat placement is down at the bone level and in the muscle, where survival is better. But with all these advantages comes two distinct disadvantages…it is a minor surgical procedure and there is no assurance as to how much fat will survive. For these reasons, fat grafting is often advocated when the patient is in surgery for other procedures (e.g., facelift, lkipsouction etc) or the patient has been previously qualified by having had successful cheek augmentation with synthetic fillers.
Implants offer the one permanent method of cheek enhancement. With no external scarring as a result of being placed from inside the mouth, implants are not only permanent but can provide the most dramatic of cheek augmentation effects. The most difficult aspect of using cheek implants is selecting the proper style and size. With dozens of implant options the choices can be overwhelming and there is no clear-cut quantitative way to know what effect the implant will create in any particular patient. It can also be surprising how much change can occur in the cheeks from what appears to be a relatively small implant.The cheek is a very volume-sensitive area. So it is always better to ‘undersize’ or choose a size below what you think you should use in many cases. The disadvantages to cheek implants are infection, displacement and asymmetry. Fortunately infections are very uncommon and displacement can be circumvented by securing the implant position with small self-tapping screw fixation. Avoiding asymmetry is a matter of experience and matching carefully the position of the implant in reference to various bony landmarks.
With three cheek augmentation options available, how does any patient know what is best for them? Cheek augmentation is a lot more art than it is science and appreciating the underlying bony anatomy, the overall facial shape and what look the patient is after is key. But you have to take the whole patient into analysis not just the cheeks. Thin people with low body fat may do poorly with fat grafting, the devout non-surgery patient can only have synthetic fillers, or those seeking the most efficient and long-term method may opt for implants. Good cheek results defy a cookie-cutter approach and the most natural outcomes come from knowing how to use all three…occasionally even blending two of the techniques together.
Almost anyone in the world is aware of the recent tragedy in Norway with the mass killings of an incomprehensible number of Norwegian teens and young adults. The murderer Anders Breivik appears to have acted alone, driven by his white supremacist and anti-Muslin views. What has caught my attention as a plastic surgeon, however, is comments that have been written about his facial appearance.
According to the head of Norway’s intelligence agency, it is believed that he had undergone plastic surgery in the past to look more “Aryan.” The agency’s head has stated that “You do not have that Aryan look naturally in Norway”…”Hitler would have had him on posters. He has the perfect, classic Aryan face. He must have had a facelift.”
While I am not an expert on Norwegian facial structure, I do know that he would not have had a facelift to change his facial appearance. That is not what a facelift does. A facelift is what I call ‘anti-aging facial surgery’, where one is trying to return to one’s prior appearance. This does not change your face but rather makes it look rejuvenated and less tired like it did 10 or 15 years ago. But you still look like you, just a better you.
Rather he would have undergone ‘structural facial surgery’, where the foundational components of the face are altered. That can and often does change one’s appearance. Foundational facial procedures are done at the bone or cartilage level, not just the skin and soft tissues. This includes plastic surgery procedures such as rhinoplasty and facial bone augmentations. (forehead, brow, cheek, chins and jaw angles) According to reports, he supposedly underwent nose and chin surgery at age 21. This would make more sense as these can change the structure of the face and definitely can make one more Aryan in facial appearance, particularly if certain elements of the face are already there.
This raises the question of what is an Aryan facial appearance and why does it look so? The word Aryan, at least as it was perceived and used in Nazi Germany, specifically refers to being white, blond-haired and blue-eyed. But there is not necessarily a specific set or arrangement of facial features that are ascribed to an Aryan face. People talk about it and one would know if they saw it but may not be able to describe the details of it. But what it undoubtably refers to is a strong and well-chiseled face. For a male this would be highlighted by well-defined facial bony prominences of the brows, cheeks, chin and jaw angles. The nose would have a strong and high dorsal line with a balanced ratio between the three nasal thirds.
The concept of an Aryan face continues to exist today but it is better known as the ‘Male Model Face’. Most young male models in any advertisement today almost all have this type of facial appearance. Whether they have it by genetics, plastic surgery or the use of good lighting and/or Photoshop, the strong and desireable male face has these consistent features.
Plastic surgery techniques today can help many men undergo these type of structural facial changes. Rhinoplasty, anatomical cheek implants, square chin implants, vertical lengthening jaw angle implants and occasionally select fat removal below the cheeks and in the neck can create a face that has more well-defined angles and is more masculine in appearance. For some men, this ‘Male Model Surgery’ can be very effective provided they don’t have a lot of facial fat and not an overly round face.
It is well known that one of the major contributors towards the perception of an attractive face, albeit a man or a woman, is the proportion of certain features. Known as indicators of facial beauty, disproportionate and asymmetric features are the main reasons many patients seek plastic surgery procedures. One can debate endlessly why this is so, but we are fundamentally driven to an attractive face from an innate drive of evolution and the desire to procreate. Attractiveness is desireable because it is perceived, right or wrong, to be associated with better genes.
But what are some of these features and can they really be changed by plastic surgery? For women it is bigger eyes, a rounder forehead, a smaller nose, well defined cheeks, larger lips and a chin that is not too prominent. For men, slightly prominent brows, a nose with a high dorsal line, well-defined cheeks, and a strong chin and jaw angles are associated with more masculinity. Short of the size of the eyes, all of these facial features can be modified by differing plastic surgery techniques.
The one desireable facial feature that both men and women share is the value of high and well-defined cheek bones. It is probably the only facial feature whose size and prominence is considered attractive for both sexes. It is also the one facial feature that I never receive requests to be reduced. (short of Asian patients and this more about the zygomatic arch width not anterior cheek projection) Few patients, if any, really want smaller cheeks.
What is it about high cheekbones that makes them some desireable? Many say that they feminize a face. If high cheek bones contribute to greater femininity, then why would it be attractive on men? The caveat is that it is only an aesthetically desireable facial feature in a man when it coexists with a stronger jawline as well. Strong cheekbones on a man with a small jaw or chin does not make for an attractive face. It is the angularity of the three defining points of a male face, the cheeks, chin and jaw angles, that makes for its aesthetic desireability. Such well-defined facial skeletal highlights equates with a strong and virile personal character. (and maybe the chance to pass along some good genes)
The benefits of cheek augmentation in either a man or a woman must take into consideration these aesthetic and gender differences. While cheek enhancement can be done with injectable fillers, I am reserving my comments here to the insertion of implants. Injectable fillers are largely a good trial method to determine the merits of proceeding to a permanent cheek augmentation in my opinion. Cheek implants in women should be softer and more round to provide volume but they usually don’t need to be angular or cross onto the zygomatic arch or encroach upon the lateral orbital rim area. This can add too much width which is not usually feminizing. Cheek implants in men often need to be more angular and add more height. They are beneficial to help balance out a strong jawline or should be done in conjunction with chin and jaw angle augmentation.
The cheeks can contribute significantly to one’s facial attractiveness. But it needs to be considered within the context of the whole face. The balance of one’s facial features is what makes for gender-specific facial beauty.
The appearance of a well-defined cheekbone helps provide a sculpted and youthful look as it provides midfacial prominence and give the appearance of a thinner lower face. Flat cheekbones can make a large nose look larger and a receding chin smaller. The cheekbones are one of the three convex prominences that help define your face, highlighting the eyes and adding balance to your features.
Cheek augmentation (also known as malar augmentation or malar implants) is a surgical method to bring the cheeks into better balance with your other facial features.
How do I know I am a good candidate for cheek augmentation?
People who benefit by cheek implants have smaller or flatter cheek bones naturally and/or have sagging of the cheek soft tissues due to normal aging. With aging can also come deflation, or loss of healthy fat which normally lies just under the cheek bones. This can give a gaunt look to one’s face.
A cheek implant can build out the flat cheek bone, provided a lifting effect to sagging cheek skin, and can partially fill out a sunken in look. Think of it as adding substance which may just make the cheekbone bigger or help hold up sagging or collapsed tissues.
That being said, whether anyone would benefit by a cheek implant is as much anartistic feel as a facial feature that can be precisely defined. Unlike other facial implants, such as chins or jaw angles which can be measured and morphed with computer imaging, cheek implants defy such analytical evaluation as the area is not a clean profile or silhouette. This is an area that requires a good evaluation and discussion with your plastic surgeon using a mirror and finger technique.
2. What are cheek implants made of?
The vast majority of cheek implants are made of solid silicone rubber that is very flexible. While there are a few other materials of which they are made, they are not very popular. What material they are made of is not as important as two other critical issues; what styles and sizes are available and how easy are they to insert. This is where silicone rubber has a huge advantage over other materials.
One type or style of cheek implant is not right for everyone. The cheek bone shape and geometry and the soft tissue overlying them is different for each patient. Just like the obvious benefits of different sizes, style or shape of the implant needs to be individualized. That is why there are nearly a half-dozen different cheek implant styles. Only a silicone rubber material can offer this diversity of selection.
The flexibility of silicone rubber and the ability to have feathered edges allows it to be the easiest material to position on the bone without having an edge that can be felt or seen.
3. How is cheek augmentation surgery done?
There are two approachs to placing the implant, from inside the mouth and through the lower eyelid. By far, the intraoral method from a small incision up high under the lip is preferred. The only reason to use the eyelid approach is if a midface lift or suspension is being done at the same time.
From inside the mouth, a path is made up onto the cheek bone. It can be extended out onto the zygomatic arch if necessary. Sizers are used to determine what will look the best. The final implant is then inserted. Some plastic surgeons secure the implant in place with a small titanium screw, others do not. Closure of the incision is done with dissolveable sutures.
4. Is cheek implant surgery painful? How long does the swelling last?
I would not call it painful, rather it is more uncomfortable due to the swelling. Often there is some numbness of the cheek skinwhich goes away in the first month after surgery. There rarely is any bruising because the surgery is very deep on the surface of the bone. Any bruising that occurs will not be seen on the skin but will present only as swelling. While remnants of swelling take six to eight weeks to completely go away, you will look fairly normal within two to three weeks. The initial abnormal fullness will have go away by then.
5. What are the risks and complications that can occur?
The standard surgical risks of bleeding and infection apply but they are very uncommon. The risk that is more significant and probably accounts for most instances of revision or secondary surgery is implant asymmetry or sizing issues. Because the cheeks have two sides, the placement of the implants must be perfectly symmetrical. That may seem easy but even slight changes in orientation of the implant may be able to be seen. Implants can also shift or slide downward towards the direction in which they were placed. Oversized cheek implants are especially noticeable because they can make the face look very unnatural. Cheek implants are always best done smaller than bigger.
One risk of having cheek implants is delayed infection, even many years later. This is caused by one specific event…dental injections. This can happen when your dentist is numbing your upper teeth. The needle can tract bacteria near or onto the implant. Advise your dentist if you have cheek implants.
6. I’d like higher cheekbones but I don’t want them to look fake. How can this be avoided?
There are many well known examples of famous people that look strange and overdone after facial rejuvenation surgery. In some of these cases, it is obvious they had cheek implants and it is because they are too big. This ‘error’ is most likely to occur when cheek augmentation for anti-aging purposes and are being used to fill out sagging cheek tissues. A cheek implant is not the same as a breast implant…its size should not be pushed to do too much.
7. I have very flat cheeks that extend down below my eyes. It makes me look sad. Will cheek implants help?
Having flat cheekbones can give the face a long drawn look that many may describe as sad. In the facial expression of smiling, we naturally see more prominence in the cheek area. When it is flatter it adversely affects how one’s smile looks. More fullness in the cheek allows a moreyouthful look, whether one is smiling or not.
A face that has good skeletal contours, which some would call sculpted, is desired by many young men and women. The appearance of high cheekbones is one important element of achieving such a look. Cheekbones create a well-defined face by creating an upper facial prominence which makes the lower face look thinner. Such a facial look is seen as ‘model-like’ as is reflected in much of our society’s advertising.
In performing cheek augmentation, there are numerous typical questions that prospective patients may have about the procedure. In my Indianapolis plastic surgery practice, here are some of the most common.
Q: I am afraid if I get cheek implants that it may look unnatural. I have seen some Hollywood people that supposedly have them and they look fake. Will this happen to me?
A: That is an avoidable result. In choosing the right cheek implant for any patient, three factors are considered…the selection of the patient, the size and shape of the implant, and properly positioning them during surgery. Not every person will benefit from cheek implants, the whole face must be considered. Rounder and fuller faces are not usually good candidates. There are different styles and sizes of implants available. As a general rule, it is always best to not overdo them. A subtle enhancement is more aesthetically pleasing than being too big. The implant must be positioned and secured over the curve of the cheekbone that is most deficient.
Q:I want higher cheekbones but do I need to have a scar to get that look?
A:All facial implants need an incision to be placed into the bone site. Surgical access to the cheek is done from inside the mouth high up under the upper lip so there is no visible scar.
Q: My face looks very flat. Do I need more than just cheek augmentation?
A: Some patients have more significant flattening of the middle part of their face that involves the upper jaw (maxilla) as well. While increasing cheek projection is helpful, that alone may not be enough. In this case, another set of implants can be placed along the paranasal area. (base of the nose) These two sets of implants can help bring out the entire middle part of the face into better balance with the lower jawline.
Q: What is the most common complication that occurs with this type of cheek surgery?
A: Implant asymmetry. Because cheek augmentation is a ‘paired’ surgery, both implants must be placed exactly the same. That sounds simple but slight differences in angulation and orientation of the implant may be able to be seen when the swelling subsides after surgery. This may require adjustment secondarily.
Q: How much time will I need off work to recover from cheek enhancement surgery?
A: Cheek implants will cause some obvious swelling but it is not significantly painful. Once can return to any type of work in one week but the cheeks will still be noticeably swollen. It will take at least two weeks before the cheeks will not temporarily unnatural.
Cheek augmentation is done for a variety of different aesthetic reasons. Besides the obvious need to fill out a sunken in cheek appearance and improve facial balance, they are just as commonly used for an anti-aging effect. By augmenting the soft submalar tissue to fill midfacial hollows, the lifting of this tissue provides a facial rejuvenating effect and may even soften the depth of the nasolabial fold beneath it. This tissue lifting or anti-aging effect is unique amongst facial implants.
The shape of the cheekbone and its location between the convex orbital rim and the concave maxillary wall make it the most complex facial area to augment from an aesthetic standpoint. Where along the cheekbone should the implant be positioned and what shape and size of implant should be used are what the plastic surgeon ponders. There really are no guidelines as to how to exactly to make these selections. Artistic technique is as important as any type of scientific approach. This high degree of variability lends to revision rates that are higher than any other facial implant currently used.
Cheek implant complications usually are of two types, undesired aesthetic outcome and implant shifting or migration. Unhappy outcomes come from either an implant that is too big or positioned in the wrong location. Either way, an unnatural appearance often results. Because of where cheek implants are located, they catch attention almost as much as one’s nose or eyes. Cheek implants come in a variety of sizes and shapes but can fundamentally be divided into malar and submalar implants. Malar implants being placed on top of the zygomatic bone and submalar implant highlighting the underside of the bone. (submalar hollow or buccal space) Malar implants have different extension that either go back further onto the zygomatic arch, up around the lateral orbital wall , or anteriorly along the underside of the orbital rim. Because of these variable implant shapes, it takes a good aesthetic eye and communication with a patient beforehand to get a good result.
Cheek implants are also unique because of where they are positioned on the zygomatic bone. They often are sort of hanging from the side of the cliff, which makes them prone to shifting. Shifting will usually occur in a downward direction from whence they were initially inserted, which is usually through the mouth. For this reason, it is possible for cheek implants to shift around and end up with asymmetry. This is particularly true if the implant is made from silicone which is very smooth and slippery. Other implant composition have a much greater frictional grip on the bone and will not move as easily.
One interesting silicone cheek implant design which can effectively address the shifting problem is that of the Conform midfacial implant. Its undersurface is not smooth silicone but rather a pebbly or nubbed surface. The many little ‘’fingers’ of silicone allow it to develop some degree of frictional gripping to the bone surface. Also when soft tissue grows around it, the capsule will absolutely lock it into place. This is very similar to the concept of placing a textured surface on a breast implant which was developed nearly twenty years ago. Its shape also allows it to be trimmed and used as either a malar or submalar implant.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.