The cheek or the midface region plays an important role in facial appearance. As one

of the five facial bony prominences (brow, nose, chin, and jaw angles are the others),

it is actually the most complex. It lacks any sharp angles, is made up of several bones that

intersect together and is surrounded by three distinctly different soft tissue regions. While

everyone appreciates that a high and strong cheekbone is desireable, it is not easy to

quantitate what that should look like unlike chin projection or jaw angle width which can

be actually be measured.

Rather than some absolute number, the cheek region is better recognized for what it does

for facial shape and width. As part of understanding cheek morphology, one should not

forget how the soft tissue below it affects how the bone looks above. Known as the

submalar (below the cheek) region, it is affected by the size and prominence of the buccal

fat pad. This golfball-sized fat collection can be surprisingly large and it helps make for a

rounder and fuller cheek region appearance. If the buccal fat pad is very large, it can

make this area protrude or be quite ‘cheeky’. If this and other facial areas are small or

atrophic, the facial shape may assume a more gaunt appearance.

Therefore when assessing the cheek area, the consideration of both bone (malar) and

buccal fat (submalar) areas should be done. Implant manufacturers have recently showed

an appreciation for this concept by expanding traditional cheek implants to include either

(malar and submalar) or both. (combined submalar shells) Combinations of malar

and submalar changes can often make for a better cheek result than just a ‘simple cheek’

implant’ alone. In some cases, cheek bone enhancement and some submalar reduction

(buccal fat removal) may produce better cheek highlights. In other cases, submalar

augmentation or a combined malar-submalar augmentation may be aesthetically better.

The uniqueness of  each person’s face and their desired cosmetic outcome must be taken

into consideration when planning changes in this area.

Removal, or more accurately, reduction of the buccal fat pad (buccal lipectomy) is a

surgically simple procedure but it’s decision to do so is more aesthetically complex.

Through a very small incision inside the mouth opposite the maxillary first or second

molars, the buccal fat pad can be gently teased out. When doing at the same time as some

type of midfacial implant, it can be done through the same incision. How much one

removes is a matter of judgment. As a general rule, it is not a good idea to try and

remove all of it. Not only may that be undesireable in facial appearance in the long-term,

but there are several buccal branches of the facial nerve which interlace with the multi-

lobed buccal fat pad. They exist most commonly on the superficial (outer) aspect of the

buccal lobe, away from the area of intraoral manipulation. For this reason, aggressive

buccal lipectomies may inadvertently damage these branches. I have never observed

facial nerve injury from a buccal lipectomy procedure but this attests to a more

conservative resection philosophy. In uncommon cases with a very full and ‘fat’ face, a

more complete buccal lipectomy may be justified. Such an approach works well when

‘fat-reducing or facial thinning’ procedures are being done such as neck liposuction

and/or chin or cheek implants.

Conversely, submalar augmentation rather than reduction may be needed to help fill out a thin or

gaunt facial appearance. While initially developed for lifting sagging cheek tissues over ten years

ago, the submalar implant is much more commonly used to add soft tissue fullness rather than a

lifting effect. If the cheek prominence is adequate but the underlying submalar region is thin or

‘sucked inward’ (indented), than an isolated submalar implant may suffice. If the overall cheek

(malar and submalar) is too flat or deficient, then a combined malar-submalar implant may be

needed.

When considering cheek enhancement as part of an overall facial improvement plan, both the

malar and submalar regions must be considered together. Between expanded submalar implant

designs and buccal lipectomies,  a more comprehensive approach with satisfying surgical results

is now available.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

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

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

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
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis