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Dr. Barry Eppley

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Archive for the ‘cheek implant’ Category

Common Concerns about Cheek Implant Surgery

Sunday, December 20th, 2009

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

Indianapolis, Indiana

Facial Implant Surgery on Indianapolis Doc Chat Radio Show

Saturday, June 20th, 2009

On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 1:00 – 2:00PM on Saturday afternoon, hosted by Dr. Barry Eppley Indianapolis plastic surgeon,  todays’s topic was facial augmentation.  The topic of facial implant surgery including what they are used for, how they are surgically placed, recovery from the procedures, and complications were reviewed. Chin, jawline, jaw angle and cheek implant types of surgery were covered. How one can tell if they would benefit from facial implant surgery and how such implants may enhance the overall appearance of the face were interesting topics of discussion.

Free plastic surgery consultations can be arranged by calling Dr. Eppley at IU Health North or IU Health West Hospital at 317.706.4444 or send an inquiry by e-mail to: info@eppleyplasticsurgery.com.

Important Concepts of Chin Augmentation in Women

Tuesday, June 2nd, 2009

Chin augmentation is a simple and successful plastic surgery procedure for bringing the lower face into better balance with the neck and upper face. How far to bring the chin forward and how to determine that prior to surgery are important questions. But an equally important question is the difference between men and women and the chin augmentation goals between the two. While no exact statistics are known, it is fair to say that at least one-half of chin augmentation patients are female.

The traditional approach (male) to chin augmentation is to bring the most anterior chin point to a vertical line dropped down from the Frankfort horizontal line. This essentially is like dropping down a line from one’s brow prominence. While this may look quite pleasing in profile in men, such an anterior point is often too strong for many women. It is usually not aesthetically pleasing to masculinize a woman’s profile too much. I have found a few woman that felt such a chin position was too much and their implants had to be downsized slightly.

While the profile position is the most commonly viewed in computer imaging and in before after photographs, it is not how most patients see themselves. While the profile view is relevant, it is the frontal or three-quarter view from which they see themselves far more frequently. Therefore, the shape of the chin is almost as important as how far forward it comes. It is perfectly acceptable in men to develop a broader or more square chin which can happen with extended or more wrap-around chin implants. In women, however, the use of less extended or more central implants should be considered. These will allow the width of the chin to remain much narrower than the body and angle of the jaw. In other words, keeping a more narrow chin which is consistent with a more feminine appearance.

The projection and shape of the chin are especially important considerations in female chin augmentation. A chin point that lies slightly behind the ideal vertical facial line and a more centrally-shaped chin implant will keep the chin more gender specific.

 Dr. Barry Eppley

Indianapolis, Indiana

Midfacial Implants – Different Styles for Cheek, Orbital, and Maxillary Augmentation

Friday, May 29th, 2009

Facial implants are a common and assured method of building out skeletally deficient areas such as the chin, cheeks, and jaw angles. While many are aware of these popular locations for esthetic facial enhancement, there are many more implant styles and locations than most envision. This is particularly true in the midfacial area.

The midface (between the lower eye sockets and the upper teeth)has the most complex external anatomical shape of any area on the craniofacial skeleton. From the prominences of the cheek bone to the concave surface of the pyriform aperture, no one single-shaped implant can be adapted to all of them. For this reason there are at least nine (9) different midfacial implant styles.

Cheek implants are the most commonly used midfacial implant. But there are four (4) different styles to choose from for the differing areas of esthetic deficiency on this bone. The standard cheek implant, also known as a malar implant, fits on top of the cheek bone and has a broad surface area that covers most of its surface area. The two (2) styles of this standard cheek implant differ in that the more extended version has a portion that goes up higher to make a smooth transition into the lateral orbital bone. For flat cheek bones, these implants styles will generally work well.

The submalar cheek implant, however, is indicated when the cheek soft tissues are a little droopy and the area under the cheek prominence is a little sunken in. This implant fits on the bottom or underside of the cheek bone which helps lift up sagging cheek tissues, fills out the submalar space and may even soften the deep nasolabial fold a little. The submalar cheek implant comes in two styles which differ in how much fullness is added to the submalar space.

The tear trough midfacial implant is a specialized lower orbital rim (eye socket) implant. It augments the depressed suborbital groove that some people have naturally or develops from aging and tissue atrophy. This groove runs between the inside of the eye across the lower orbital rim often ending below the cheek. While some use fat injections for augmentation of this area, a carefully placed tear trough implant provides permanency to this contour problem.

The pyriform aperture implant fits along the bone which forms the side rim of the nasal cavity. It is designed to build out the base of the nose where the side of the nostril meets the lower cheek tissues. I have most commonly used this implant in secondary cleft surgery to build out the deficient bone area where the cleft went through. While bone grafts are commonly used for this problem, the pyriform aperture may still remain depressed even with a well done bone graft.

The premaxillary or peri-pyriform implant builds out the entire base of the nose from one side of the pyriform aperture to the other. This includes anterior nasal spine area as well. For very flat midfaces, this implant can really help provide augmentation to the nose and upper lip.

The nasolabial or melo-labial groove implant fits onto the bone to the side of the nose and helps soften or build-out the very deep nasolabial fold or groove. Rather than using temporary injectable fillers placed beneath the skin, this implant placed on the underlying bone serves to provide the same push.

The Lefort or maxillary implant, the least common of all midfacial implants, is designed to be used during or after a LeFort I osteotomy. This implant would fit above the osteotomy line so that the midface would not look more deficient as the maxillary teeth come forward.

All midfacial implants, while being very different in shape and indication, share two common features. First, they are all placed from an incision inside the mouth so no skin incision is ever needed. Secondly, they are all best secured into position with a screw as their position is critical in getting the desired esthetic result.

Dr. Barry Eppley

Indianapolis, Indiana

Cheek Implants for the Aging Face

Wednesday, April 8th, 2009

One of the common facial aging changes for some people is the loss of fullness in the middle of the face and a longer distance between the height of the lower eyelid and the prominence of the cheek. This is most apparent when you look in the mirror and notice a flattening of the cheek area and a hollowed out look around your eyes.  This occurs as the soft tissue of the cheeks, much like the jowls and neck skin, goes south due to gravity and skin loosening. The specific anatomic reason is that the ligaments that attach the skin to the bone weakens  or stretches out and the skin that is stretched out over the cheek bone falls. This can also appears as folds or festoons of skin that hang down from the lower eyelid to below the cheek.

 To improve  this cheek ‘deflation’, adding volume through cheek implants is one approach. By ‘re-inflating the cheek by putting an implant underneath it, the cheek tissue is lifted back up and the cheek highlight or prominence is restored…or even made more evident. In my Indianapolis plastic surgery practice, I perform cheek implantation by making small incisions inside the mouth above the gum line with no visible external incisions and this is my preferred approach in my Indianapolis plastic surgery practice. Cheek implants can also be placed through a lower eyelid incision but this is prone to placing the implant too high. There is no evidence in the medical literature or in my experience that an increased infection risk exists by going through the mouth.

This relatively simple surgery gives a notable richness to the face resulting in a more rejuvenated look. The face also seems to age better after cheek augmentation as the implant helps lessen the potential for future sagging. Cheek enhancement can be done at the same time as a facelift, resulting in a dual change that can be more significant.

In the use of cheek implants in the aging face, it is common to see it overdone. Too much cheek enhancement can look unnatural and be apparent that something was done. A subtle change is more natural and less obvious. Cheek implants come in a variety of sizes and shapes and it is far better to use a small or the smallest size. Because it is done on both cheeks, the after surgery effect can be more than one would expect. Unlike the naturally deficient (underdeveloped) cheek patient, who usually needs a bigger size, the aging face does not usually have a bone deficiency but a much thinner soft tissue prolapse.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Correction of Chin Ptosis

Saturday, April 4th, 2009

A chin that sags over the line of the jaw (chin bone) is called chin ptosis. (ptosis is medically defined as a sagging of a body part) While some people have this naturally, most of the time it is due to the soft tissues of the chin sliding downward for a reason. This can occur from simple aging, loss of one’s lower front teeth, and due to different surgical procedures of the chin. A few people actually have pseudo- or perceived chin ptosis which occurs as a result of a natural deep crease below the lower lip (submental crease) which makes the chin look ptotic (particularly when smiling) even though it is not.

Successful correction of chin ptosis can usually be done for those problems caused by prior surgeries. Chin surgeries that are well known to cause soft tissue sagging include the intraoral placement of implants, removal of an overly large implant and bony reductions. Other less common causes include intraoral access for repair of mandibular symphysis and parasymphyseal fractures and vestibular lowering procedures (preprosthetic surgery) in preparation for improved lower denture fit.

Treatment is  based primarily on resuspension or tightening of the mentalis muscles  with or without hard tissue chin expansion. For sagging caused by intraoral access to the chin, the mentalis muscles must be brought back up into their original anatomic position. The intraoral route of access to the chin always divides the upper attachments of the mentalis muscles. (some surgeons put them back well while others do not) This is why the submental (under the chin) skin approach for chin implants is always better with a very acceptable scar and why I use it in my Indianapolis plastic surgery prasctice.  It is not always easy to find good muscle to sew to and this is why a bone-anchoring technique with titanium screws or Mitek suture anchors is my preferred method for a ‘high’ reattachment.

If chin implant removal is the cause of sagging, replacement with a new implant alone may be satisfactory. Or if the patient no longer wants an implant but still desires an augmentation, moving the chin bone forward as a natural ‘implant’ may create enough expansion to fill out and elevate the sagging chin tissues. A chin osteotomy is an excellent opportunity to elevate the muscles as well as the plates and screws used to hold it in its new place are good anchoring points for the muscle.

Chin reduction procedures are especially prone to chin sagging problems after. The lower attachments of the mentalis muscle must be divided to access the chin bone. Once the bone is reduced by burring, the muscle and sometimes skin must be shortened and reattached. Usually tightening the muscle across the reduced bone and reattaching it to the muscle on the underside of the chin is adequate. If not, bone holes can be made on the inferior ledge of the chin bone onto which the muscle can be reattached.

 he chin is unique in that the mentalis muscle is attached and suspended across it  both above and below the chin prominence. The skin and fat are attached to the underlying muscle and follow its position on the bone. If the muscle sags, so does the appearance of the chin. The key to correction of chin ptosis is management of the mentalis muscle attachments in most cases.

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

The Use of Infra-Orbital Rim and Cheek Implants

Friday, November 14th, 2008

Deficiencies of the lower rim of the eye socket and cheek create a hollowed-out appearance. Some call this a tear-trough deformity although this is not really accurate. A tear trough deformity is a depression between the eye and nose, technically known as the nasojugal fold. Underdevelopment or underprojection of the lower orbital rim and cheek is part of a more global midface issue, with a flatter bone profile across this area. This can be evidenced in a profile photo by dropping a vertical line from the lens of the eyeball downward. If the cheek and orbital rim is behind this line, the bone is deficient. Correction of combined orbital rim and cheek deficiencies is most predictably done with implants.


There are several types of implants for the orbital rim. Some extend from the orbital rim towards the nose and down into the tear trough, some extend out from the rim to the cheeks, and others connect the orbital rim to the outer corner of the eye. Pre-formed orbital rim implants are currently available in solid silicone as well as polyethylene. (Medpor) Implants can also be hand carved out of a block or sheet of Gore-tex. (PTFE) I do not believe that the material used makes any difference. It is more important to have the right shape implant in good position than anything else.


Orbital rim implants are best placed through a lower eyelid incision directly onto the bone. This is an obvious way to go if the patient needs skin removed from the lower eyelid as well. It is possible to place them through the inside of the eyelid (transconjunctival approach) but this is more difficult. Lifting up the periosteum of the bone is important so that a cuff of tissue can be used to cover a part or all of the implant. Bringing tissue back up over the implant is important to prevent the edges of the implant from being visible. This is particularly important in those people with thin lower eyelid skin, which seems to be most people who have bone deficiencies in this area. I always secure the implant to the bone with small tiny screws so that it will never move. You will always be able to feel where the implant is as there is little tissue between the implant and the skin in the eyelid area. Most importantly, you just don’t want to be able to see them through the skin. Often I will place a strip of fat or transpose lower orbital fat over the implant to get better coverage.


The key to a good result with orbital rim implants, with or without a cheek extension, is to not overdo it. The improvement is better to be subtle and not dramatic. It doesn’t take very much implant thickness, just a few millimeters, to make a real visible change in the eye area. Large orbital rim implants, while producing better correction, are often visually detectable and, at the least, very palpable.


Because adjusting an orbital rim implant is like repeating the original surgery in its entirety (reopening the whole lower eyelid), I prefer a dual implant approach to the orbital rim. One implant across the orbital rim (placed through the lower eyelid) and a cheek implant placed high up to the orbital rim, touching its edges. This way adjustment of the implants may be easier, particularly when they become scarred into place.

Dr. Barry Eppley

Indianapolis, Indiana

Improving the Shape of the Face by Bony Augmentation and Fat Reduction

Thursday, October 9th, 2008

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

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

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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