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

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.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Making a face more square or angular can be done through bone augmentation, fat reduction, or both. I have found that there are two types of patients who come because they want a more defined facial look. First is the male patient (usually younger)who does not necessarily have a full or fat face but wants more definition at the defining points of the face. In some cases, I call this seeking the ‘male model look’. The second type of patient is male or female who does have a fuller face and simply wants to be ‘less round’. Their goals are not quite so precise as the first patient. Usually they are younger as well but can be middle-aged also.

The defining bony points of the face are the cheeks, chin, and jaw angles. Facial fat points are the cheeks and neck. Those searching for the ‘male model look’ are usually looking at the trio or combination of cheek, chin and jaw angle implants.  The thinner the face is, the more profound the result will be with this triple implant approach. When you are placing three implants, or simultaneously changing three facial prominences, it is always best to not to overdo it. Large implants in all three places can create a very unnatural or artificial look. Cheek implants never look too good if they are too large.  Subtle cheek changes are more natural.The proper size of a chin implant is easier to know because the amount of chin deficiency can be measured in profile. Most men should consider a more square chin implant style as that is often what this type of patient is trying to achieve. Jaw angle implants can rarely be too large as they are manufactured small anyway and the jaw muscles and thickness of tissue over the jaw angles can camouflage a great deal of the implant.

Those trying to deround a face must use a different approach. Fat removal in the neck (liposuction) and in the cheeks (buccal lipectomies) are an important element of derounding and is often done with a chin implant. In rare cases, cheek implants may be considered but they should be small as buccal fat removal will create the visual impression of some minor cheek augmentation as the area below the cheek moves inward. This type of facial derounding is more subtle than squaring a face with the most dramatic changes occurring in the neck and less in the cheek and side areas of the face.

Careful analysis of the face prior to surgery through computer imaging can be invaluable in this type of surgery. Changing multiple areas of the face at one time, with the objective of changing one’s facial look, requires good insight and understanding between the patient and their plastic surgeon.

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

Not infrequently I get requests from patients for the desire to transform a round face into a more shapelier one. One cause of a round face is that the patient is overweight. A full neck, round cheeks, and a lot of subcutaneous fat throughout the face creates a generalized fullness that creates a fat and round face. These patients know full well that they are overweight and some liposuction of the neck and buccal lipectomies may make some difference. But weight loss will probably make the most difference in these cases. And these procedures should not be performed until some weight loss has been achieved.

 
But the overweight patient is not what usually makes up the ’round face’ patient. Most commonly these are younger patients that are not significantly overweight and are usually closer to being more height and weight porportionate. They may have some mild fullness in the cheeks and neck but often their bony prominences (cheeks, chin, or jaw angles) may be somewhat deficient. The approach to these patients must deal with both hard and soft tissues issues to be effective at improving the face’s angularity and definition.

 
In addition to the fullness of the cheeks and neck, the next most important consideration in facial shape improvement should look at the chin. Often it may only be midly short in the horizontal dimension but the width of the chin is also important, particularly in the male patient. Chin implants today can provide more projection as well as width in many different sizes. Placed through a small incision under the chin bone, a chin implant can lend more definition and squareness to the lower face from subtle to dramatic results.

 
Upper facial fullness, more specifically midfacial fullness, can be achieved through cheek implants. Placed into position by incisions inside the mouth under the upper lip, cheek implants can provide good highlights through three-dimensional enhancement of the bone as it wraps around the area below the eye. An amazing aray of cheek and midface implants is available to provide a lot of enhancements around this important facial landmark. When paired cheek implants are combined with a chin implant, an upside down triangle of change is created that directly opposes a more round or oval facial shape.

 
Jaw angle implants are always a possibility but these are rarely needed in most really round faces. They can produce some lateral facial fullness but this is not usually helpful in ‘de-rounding’ the face.
The procedures of buccal lipectomies, neck and jowl liposuction, chin and cheel implants make up the usual plastic surgery tools for facial rehaping. Which one or combination of procedures is most helpful for improving facial definition is best determined by careful computer imaging study between the patient and their plastic surgeon.

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

Chin, Cheek, and Jaw Implants for Facial Augmentation in Indianapolis

In the pursuit of improved facial balance and shape, the use of solid facial implants is a simple and proven method. While there are facial implants made from different materials that can be used, the use of solid silicone (rubber) chin, cheek, nose and jaw implants are by far the most commonly used. They are soft, flexible, and slide easily into place on top of facial bones. These type of facial implants are placed deep to the skin down at the bone level. Since they are solid, not gel-filled, there is no risk of implant leakage or breaking. All facial implants can be inserted through very discrete incisions that often leave no visible scars on the face. While any implant (foreign-body) has some risk of infection, facial implants infection is quite uncommon.

Enhancing the chin with an implant is the most commonly performed facial implant procedure. With a small incision under the chin, a chin implant can be easily put into place, bringing the chin forward so that it is in balance to the nose and lips. Unlike the old style ‘button’ chin implant, there are many different styles of chin implants today. From curved styles to a more box shape, to those chin implants with a central dimple, there are many options to custom tailor a chin implant to fit most patient’s faces. Usually the chin implant is sutured into place, a metal screw can be driven through the implant to the bone. This screw fixation method can eliminate one of the very few complications of chin implants, that of shifting or changing position after surgery causing chin asymmetry. Chin implants are commonly in conjunction with other facial procedures including rhinoplasty, neck liposuction, and facelifts.

Cheek implants also have a variety of styles, allowing fullness to be gained over the prominence of the cheekbone, filling out the hollow underneath the cheekbone, or allowing more fullness to be gained up to the side of the nose. By going through the mouth under the upper lip, there is no facial scarring. Cheek implants help bring fullness to a flat cheeks, help camouflage a prominent nose, or restore facial fat atrophy lost in HIV disease. Metal screw fixation seems to be of particular importance as the cheek implant is really sitting ‘on the side of the cliff’ so to speak and, therefore, is more prone to the risk of moving out of place after surgery.

Jaw implants of the mandibular (jaw) angle are relatively new. Jaw implants are designed to ‘square’ the face at the jaw angle for a more masculine look or to correct facial asymmetry if jaw development is different between the two sides of the face. Swelling and recovery after jaw angle implant placement is greater than with chin and cheek implants as the big chewing muscles must be lifted up to put the jaw angle implant in place. This causes some soreness in opening the mouth for several weeks after surgery.

In some cases, the use of different implants in the same patient, such as a chin and jaw angle implants in a male, can provide dramatic changes in one’s facial appearance. Facial implants are a powerful tool, that is simple and usually uncomplicated, to achieve facial enhancement.

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