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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Archive for the ‘cheek augmentation’ Category

Cheek Implants in Patients with Dentures

Thursday, October 15th, 2009

Cheek implants are a fairly simple and effective method for adding projection of various areas of the zygomatic midface. Because they are various shapes of cheek implants that are available, there is a fair amount of art as opposed to science in selecting style and size of implant to get the patient’s desired effect. Because these implants are placed on the side or underside of a bony surface, they are also prone to postoperative migration in an inferior direction of they are not secured.

Cheek implants are typically shown in textbooks, journals, and patient results in patients who have teeth. By having teeth, the vertical distance from a positioned implant to the maxillary vestibule (highest area under the upper lip) is maximized. There will always be a good soft tissue buffer between the implant and the inside of the mouth. This lessens the long-term likelihood of implant exposure should it ever migrate downward. (if one secures the implant with screws, this will not happen)

In the patient without teeth, however, the use of cheek implants can be more problematic as the facial anatomy has changed…unfavorably. The loss of upper teeth changes the structural integrity of the face. The vertical dimension of one’s occlusion (bite), or the height of the bite formed by the contact of the upper and lower rows of teeth, determines the shape and length of the cheeks. When a patient becomes edentulous, the mouth closes too fully with no teeth to separate the jaws, thus contributing to a sunken in appearance of the cheeks. Without teeth, the cheeks tend to wrinkle, the angle between the nose and the lips changes, the ridges that hold the teeth flatten, and the tongue may splay out to fill the open mouth space. These changed features often make the edentulous patient seek midface volume replacement.

The fundamental concern in placing cheek implants in a patient who wears an upper denture is two-fold. First, the distance between the cheek bone and the maxillary vestibule has shortened considerably. There is less soft tissue coverage between the implant and the oral mucosa. This makes the use of certain types of cheek implants, the submalar implant specifically, more risky. Because it sits on the underside of the zygomatic bone, it is even closer to the lining of the mouth. Secondly, the flange of an upper denture can be an erosive source causing implant exposure. A high-riding denture flange may eventually cause pressure necrosis of the thin soft tissue between it and the implant. At the least, it can be a source of irritation and discomfort.

Cheek implant selection is critical in the edentulous maxilla. The implant should be placed on the zygomatic prominence and its maxillary extension trimmed if necessary to keep it from hanging too low. The implant should absolutely be secured in place by a screw. If the implant needs to be extended for midface volume, it should go as close to the infraorbital nerve (without compression) as possible. The canine fossa area should be avoided, as tempting as it is to help this volume deficient area. Lastly, the patient’s dentist should be consulted to shorten the posterior flange of the maxillary denture before surgery. The broad palatal surface provides enough surface area for retention that the flanges can be shortened without sacrificing denture stability.

Cheek implants can work effectively in the typical older edentulous patient who usually suffers midfacial volume depletion and sag. Several alterations in surgical technique are necessary to avoid the increased risk of eventual implant problems caused by vertical maxillary shortening.

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

A New Technique for Reduction Malarplasty for Prominent Cheekbones

Friday, October 2nd, 2009

The cheekbone or zygoma is one of the highlights of the midface area. Most Caucasians prefer a well-defined and prominent cheekbone which can be weak from congenital development or an injury. This is why cheek implants are a common cosmetic procedure in this population. Conversely, by comparison, Orientals prefer a softer facial contour but usually have more prominent zygomas  by development. As a result, reduction of the cheekbone or malarplasty is a common cosmetic procedure for them.

Cheek bone reduction is a well described operation for which a variety of bone cutting and reducing approaches have been described. In my Indianapolis plastic surgery experience, an osteotomy at the front and back of the long zygomatic arch using a combined intraoral and perauricular incision has been a common successful approach.

To make the reduction malarplasty operation simpler but still effective, a variation of the osteotomy has been described. In the October 2009 issue of the journal Plastic and Reconstructive Surgery, a new L-shaped osteotomy through an intraoral approach is described. In an impressive 418 cases, the frontal L-shaped zygomatic body included two parallel vertical osteotomies (with bone removal) and one oblique osteotomy. This was then combined with a greenstick fracture at the root of the zygomatic arch from an inside approach. The vertical osteotomies allow good control of the reduction which is then secured with small plates and screws. It offers the advantages of being done completely inside the mouth with very controlled bone cuts and secure stabilization of the repositioned segments. They had a very high satisfaction rate of 96% with the potential for late complications of cheek asymmetry and soft tissue sagging (ptosis) due to over stripping of the attached soft tissues.

Reducing prominent cheekbones can and should be a fairly simple procedure with very predictable results.This new modified technique appears to offer advantages that make that a reality. White this technique may expose the maxillary sinus that is of no consequence as we know from a lot of experience in LeFort osteotomies and cheek bone fracture repair. The design of this new zygoma osteotomy even makes it theoretically possible to be used for lateral cheekbone expansion in cases of post traumatic infracture repair.  

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

Zygomatic Osteotomies in Cheek Augmentation and Cheek Reduction

Thursday, August 27th, 2009

The cheek bone (zygoma) is a very valuable part of one’s appearance as it provides a prominent highlight and a width dimension to the face. It also provides support to the eyeball and serves as an attachment point to the tendons of the upper and lower eyelids.

Some people have naturally broad or narrow cheek widths, of which one component is caused by the development and shape of the dimensionally complex zygoma. The curvature of the zygomatic body and attached arch bone is responsible for some of this width.

The normal position of the zygoma cam also be altered through injury, with cheek or ‘tripod’ fractures being frequent. When the bone is fractured, it almost always is displaced downward and inward into the maxillary sinus cavity. As the pillar or support of it is lost, it can only fall in this direction. Technically, it rotates  (tilts, not just falls) and the cheek prominence is lost and the corner of the eye may be pulled down slightly also. While most of these zygoma fractures are repaired immediately, some never get fixed for a variety of reasons creating a secondary zygomatic deformity marked by a flatter cheek.

Zygomatic osteotomies are one potential method to improve these bone malpositions. Depending on the facial objective, the type of zygomatic osteotomy can differ which also influences the incisional approach.

In a purely cosmetic application, the zygomatic body (not arch) can have a wedge of bone removed for reduction or can be cut and expanded. (with or without grafting) By so doing, one can moderately help change the width of the face in this area. Because it is usually done on both sides of the face for cosmetic change, the total amount of change (by bone measurement) may be as much as 10 to 15 mms. Almost all cosmetic zygomatic osteotomies are done through an intraoral approach.

For reconstructive purposes, most zygomatic osteotomies are usually done on one side only. The objective being to match the opposite uninjured side. Deoending on how the bone must change position will determine what incisions are used. Usually the intraoral approach alone is not adequate as the zygomatic complex must be freed and rotated, not just changing one dimension of the zygomatic body. Thus two incisions are used, most commonly intraoral and lower eyelid. (blepharoplasty) Extensive three-dimensional complex movements may need a coronal (scalp) incision as well to fully mobilize the bone at each pillar of support. In my Indianapolis plastic surgery practice, I usually try to avoid the scalp approach as this is undesired by most patients and is reserved for those few patients who have had a more significant midface ‘crush-type- injury.

Zygomatic osteotomies will need bone fixation, using very small titanium plates and screws. These almost never need to be removed later and they rarely cause any problems.

When contemplating reconstructive zygomatic osteotmies, there is often an orbital component to the deformity that may require orbital floor reconstruction and repositioning of the lateral canthus to change the level of the corner of the eye as well.


Dr. Barry Eppley

Indianapolis, Indiana 

Cheek Implant Complications and Their Revisions

Sunday, December 14th, 2008

Cheek implants are one of the more common types of facial implants used for esthetic or reconstructive enhancement of the malar area. They are second in use only behind chin implants which are the most common implant placed on the facial bones. Like all implants, they have the potential for some complications such as infection, shifting and asymmetry, and poor sizing and positioning. Cheek implants also have a few unique complications as well.

Infection from any type of facial implant is possible but it is very uncommon. The extensive blood supply of the face and the implant’s position at the bone under a muscle layer make infection uncommon. In the very few that I have seen, reopening the implant pocket, cleaning off the implant thoroughly and immediately reinserting it has always worked with smooth silicone rubber implants. Porous type implants are another story because it is not possible to rid the bacteria which are embedded in the irregular deep channels of a porous surface. Cheek implants made of these materials should be removed and replaced at a later date.

Cheek implants are unique from many other facial implants because they are positioned ‘on the side of a cliff’ so to speak, with no natural resting place. Only the soft tissue pocket developed on the bone becomes their containment method. Because a pocket must be developed that is bigger than the implant to allow it to slide into place without folding or bending of its edges, it is possible for cheek implants to slip around and be different between the two facial sides. This is probably the number one complication related to them….asymmetry. Persistent asymmetry over time can also lead to eventual migration of the implant down to and through the mouth incision which is commonly used for their placement. To prevent shifting of the implant after surgery, I prefer to ‘nail’ the implants into place with a small screw through them into the underlying cheek bone once the position I want is assured.

Aesthetically, cheek implants are often oversized in my opinion. What makes a significant change on the operative table can often be too dramatic to the patient later. The cheek is a unique three-dimensional facial unit that defies a precise measurement or method of implant selection. (the chin is very straightforward in this way) Computer imaging of the cheek, unlike the chin or nose, is more artistic than scientific and does not help in selecting a size or shape of a cheek implant. A subtle augmentation or increase in cheek size is almost always better. Don’t try and make a cheek implant do too much. Fortunately, downsizing of a cheek implant is a simple replacement surgery that is much less traumatic than the original surgery. Re-entering the same pocket without extra dissection makes adjustment surgery usually easier.

Revisions of problematic cheek implants with a satisfactory outcome can usually be done by changing the size and shape of the implant or repositioning it with more secure fixation to the bone. Cheek implants, however, are highly critically assessed by most patients and meeting their aesthetic demands of size, shape, and symmetry make them one of the most challenging of all the facial implants for a satisfactory outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Cheek Implants – Different Styles for Different Problems

Wednesday, November 5th, 2008

The cheek area is a central and critical element of one’s facial appearance. Situated between the pyramidal landmarks of the eye, mouth, and jaw angle, its prominence (or lack thereof) provides projection to the middle of the face. In today’s society, the perception of high or prominent cheekbones is one that is a positive statement about attractiveness and beauty. It is not clear why high cheekbones cast this image, but we all know the emotional response when we see it.

Today’s plastic surgery techniques and modern facial implants now make it possible to provide a wide range of cheek enhancements. Highlighting different areas of the cheek complex is made possible because of the many different styles of cheek implants that are available. Different cheek implant shapes are available that can enhance the front, side, underside, as well as the bone underneath the eye in front of the cheek. Because of these different style options, it is critical that a plastic surgeon look carefully at the anatomy of the cheek to determine which parts of it should be improved.

The ‘traditional’ cheek implant is really like a shell which covers all aspects of the curved cheek, adding volume to the front and sides of it in equal amounts. For those patients with really flat cheeks, this is usually a good choice. The implant can be slid further forward or further to the back of the cheek to customize its effects. Submalar cheek implants sit more on the underside of the cheek bone. They push up loose overhanging cheek tissue and , as a result, are more ideal for the aging patient with loose or sagging cheek skin. They also are good for patients who have had loss of the buccal fat pad and hollowing of this area. (facial lipoatrophy, e.g.,  HIV disease)  Because the submalar implant fills the upper part of the buccal space as well as the underside of the bone, a dual effect is achieved. Tear trough implants are not really cheek implants per se. They fill underneath the eye area which is in front of the cheek. For those patients with some good cheek width but flattening of the bone in front of the cheek, this is the only facial implant made for that use. Sometimes it can be used in combination with a traditional cheek implant for greater fill of a flat midface.

To get the best effect from these different cheek implant styles, their position on the bone is critical. For this reason, I always secure any style of cheek implants to the bone with screws. This is the only way to be certain of their long-term position after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Osteotomies for Cheek Augmentation/Widening

Wednesday, October 1st, 2008

People with a narrow-appearing face have often a deficiency in the width of where the upper jaw and cheek meet, known as the cheek or malar complex. The most common and simple method to improve the amount of cheek that one has is to place a cheek implant. There are some patients who do not want a synthetic implant in their face and may ask if there are any other ways to have ‘more cheek’.


There is one bone-moving alternative. Like the reverse of the bone cut used to make the cheek area more narrower, the cheek can similarly be made wider. Rather than removing a wedge of bone when the cheek cut is made, a single cut is made and the cheek complex pushed out. Because moving the cheek bone out creates a bone gap, the separated edges of bone need to be held apart with a small plate and screws. It is thought best to fill this bone gap with some material but a bone graft is unappealing for a cosmetic procedure. Filling this gap with synthetic bone particles or blocks is one option. I actually prefer not to fill this bone gap at all with the exception of the very top area which can be felt on the outside of the face by the eye. A small piece of ceramic bone substitute can be wedged up high near the top of the bone gap. The rest of the bone gap will fill in and heal over time on its own.


The use of this cheek expansion technique is for a very small number of patients. Cheek expansion builds out the side of the cheek but will not bring it forward or add forward projection, which many patients need more than they do width. Having adequate cheek projection but with a narrow face is a very rare cosmetic problem. Furthermore, there are fewer still that want to go through an operation to correct it. For this reason, cheek bone expansion is an operation of more theoretical than practical significance.

Dr. Barry Eppley

Indianapolis, Indiana

Cheek Enhancement – A Missing Part of Facial Rejuvenation

Tuesday, September 2nd, 2008

When one thinks of facial aging, they inevitably look to the jowl and neck area.While this lower facial area is of big concern to many and is the foundation of facial rejuvenation surgery (usually through a facelift-type procedure), the underlooked area is the midface or cheek. As one ages, the cheek area sinks in and sags for many as it loses volume through fat atrophy. This is partly why a heavy person with a full face may still look somewhat youthful as they age. (known as the Santa Claus effect) A gaunter, thinner face, while interesting when one is young, can really show age when one is older.


Adding volume to the cheek has been recently shown to to help make a more youthful face. Based on cadaver work by Dr. Joel Pessa at the University of Texas at Southwestern, a deep fat compartment was identified in the cheek. When this fat compartment was enhanced through implants or fillers, there was an immediate improvement in the hollowing of the face. Not only does restoring volume to this cheek compartment make the cheek/midface area more youthful, it also helps improves the look under the eyes as well as around the nose and upper lip area.


The jury is still out, however, on the best method to do this cheek volume addition. Fat injections would be the simplest and the most versatile, but fat survival remains unpredictable particularly in the older patient. I currently add PRP (platelet-rich plasma extract from the patient) to the injections and isolate the fat through a unique centrifguation method. Early results are encouraging but only one year results count when it comes to fat grafting. Cheek implants are simple to do, remain stable in volume over time, and come in a few styles to add volume to some different areas around the cheek. Unfortunately, the more lateral cheek area, which is not over bone is not affected by the introduction of an implant. And there is always the risk of infection or malpositioning. Injectable fillers are as versatile as fat injections and don’t involve an operating room experience. But their effects are only temporary and, when adding up the cost per volume injected, can potentially rival surgery fees if a large cheek area needs to be treated.
Not every aging face patient needs cheek enhancement nor is it the mainstay treatment of most aging faces. But it can be a good complement to more conventional facelifting procedures and is a ‘missing component’ of some patient’s treatment plans whether they are young or old.
Dr. Barry Eppley

Indianapolis, Indiana

Cheek Augmentation with Injectable Fillers

Wednesday, May 28th, 2008

As we age, one of the many facial changes is the loss of volume in the cheek area. This is most apparent in patients that are thin or have a normal age-appropriate weight. The cheek prominences become less and more saggy. In addition, the area below the cheek bone known as the submalar or buccal cheek area will often become more indented. In some patients, this can create a ‘gaunt’ or aged look. People who are heavy rarely develop this sign of facial aging as their cheeks remain fuller and more rounded, creating the ‘Santa Claus’ effect. (round and jolly but vibrant)
While the most effective long-term solution to cheek volume loss is surgical (midface lift, cheek implants, submalar implants, or fat injections), injectable fillers offer a quick and effective method of a subtle cheek enhancement. By injecting volume into the cheeks or below in the buccal area, the face can appear more youthful and ‘uplifted’. The effect is not designed to be dramatic, nor should it be, but a subtle improvement that looks natural. This is a quick solution that has immediate effects without the swelling and potential bruising from surgery.
While the effect injectable cheek augmentation is only temporary, how long it lasts will be influenced by what type of injectable filler is used. The hyalurons, such as JuvaDerm and Restylane, will last in the range of 4 to 6 months, in some cases maybe a few months longer. When using the particulated fillers, such as Radiesse or ArteFill, I would expect the effect to last longer in the range of 9 to 12 months. (or basically double that of the hyalurons)
Injectable cheek augmentation can be enhanced by the simultaneous use of Botox injections in the crow’s feet and cheek areas. The objective being to weaked the expression lines around the eyes so that the amount of wrinkling with smiling is less. The combination of these injectable midface treatments makes for a nice rejuvenation of the middle third of the face that looks very natural and relaxed. All done in less than 30 minutes and you are on your way back to work or home for the evening without anyone being the wiser!
Dr. Barry Eppley

Indianapolis, Indiana

The Role of Cheek Implants in Facial Enhancement

Monday, December 31st, 2007

Cheek Implants for Facial Enhancement


In the pursuit of a more balanced and shapely facial appearance, the cheek is an often overlooked facial feature. Even though strong or ‘high cheekbones’ is frequently commented on as desireable, the cheek is not as visible as that of its more protruding cousins, the nose and the chin. The cheek area is more subtle but an integral facial element that must be in balance with the nose, chin, and overall facial shape. With the cheek bones are diminished, the face will have a flatter appearance which  may make the nose look bigger than what it is. In the aging face, the cheek tissues are more probe to sag off of smaller cheek bones, creating bags below the cheeks and deepening of the lip-cheek groove. It is extremely rare to have cheekbones that are too big in Caucasians. I have done cheek bone reductions only in Asians, where this is more of a cosmetic problem.


In my practice here in Indianapolis, I discuss cheek bone enhancement through the use of implants. There are no practical bone-moving procedures for cosmetic purposes for the cheek area, so implants are always used. While cheek implants are available in different materials, I prefer the use of solid silicone (rubber) cheek implants, which are by far the most commonly used. They are soft, flexible, and slide easily into place along the upper jaw and cheek bones. A cheek implant is inserted through a small incision hidden underneath the upper lip. This leaves no visible scar. Usually the cheek implant is sutured into place, however, I sometimes use a metal screw to secure the implant to the bone. This screw fixation method can eliminate one of the very few complications of cheek implants, that of shifting position after surgery causing cheek asymmetry and loss of the desired cheek projection.While any implant (foreign-body) has some risk of infection, cheek implant infections are quite uncommon.


Enhancing the cheek with an implant is not as commonly performed as that of a chin implant. The goal of a cheek implant is to provide a subtle fullness to the cheekbone area. The key to cheek augmentation is not to overdo it. It is not a facial feature in which a dramatic enhancement usually results in a better aesthetic change. There are several different styles of cheek implants today. The most basic differences in cheek implants styles are whether they are malar or submalar-type designs. Submalar (below the cheek or on its lower edge) cheek implants add fullness to the buccal area which lies below the cheekbone. This style of cheek implant is good in the aging face (where it can pick up sagging cheek soft tissues) or in the face with too much hollowing in the buccal area. The different sizes and styles of cheek implants makes it possible to make a subtle or a dramatic facial change, dependent upon the patient’s cosmetic needs.


Cheek implants are commonly in conjunction with other facial procedures including rhinoplasty, facelifts, and chin augmentation.


Dr Barry Eppley

Indianapolis, Indianapolis

Dr. Barry EppleyDr. Barry Eppley

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.

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