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Archive for the ‘cheek implants’ Category

OR Snapshots – Extended Arch Cheek Implants Replacement

Sunday, July 16th, 2017


Cheek implants can be the most difficult to decide preoperatively as to their style and size. Because the cheek is an oblique structure and not a profile one, it defies any exact measured target to achieve. The cheek does have very specific zones of augmentation, four to be exact, and it becomes important to consider these cheek zones when selecting the implant style that can achieve the patient’s desired midface look.

Most cheek implant styles focus on augmenting either the malar body and/or the submalar region underneath it. These are the central zones of the cheek. While effective for some patients, they are prone to creating a bulge or bump effect particularly if the size of the implant is too big. This is because the cheek, also known as the ZMC (zygomatico-maxillary) complex, is a bony structure that has three visible legs or extensions to it that emanate out from its main body. To look more natural many cheek implants should flow into these extensions more fully.

One newer cheek implant option is the malar-arch style. As the name implies it is a midface implant that augments the malar body but has a long posterior tail to it that goes back along the zygomatic arch. It extends back along the curved arch and stops before it reaches its temporal attachment. This provides a gentle sweeping augmentation across the cheek area and achieves a more complete and natural cheek enhancement. It is also the type of cheek look seen in many models, for example, whether that is their natural look or has been created by makeup or photo editing.

It has not uncommon that I see a ‘standard’ cheek implant patient who is dissatisfied with just augmentation of the malar-submalar cheek area. Exchanging these standard implants for an extended arch style usually provides a more desired midface enhancement effect. It is the creation of a more horizontal line across the side of the face that is often sought out today.

Dr. Barry Eppley

Indianapolis, Indiana

The Model Cheek Implant (Malar-Arch Design) for the High Cheekbone Look

Thursday, June 22nd, 2017


Cheek implants have been around for decades and have undergone an evolution of design changes. While initially developed as small oblong shapes to sit on top of the malar eminence, newer designs have incorporated the area under the malar eminence as well known as the submalar region. This has led to a variety of current shapes that include malar, submalar and combined malar-submalar (shell) styles, creating up to five different cheek implant options. (not to mention the various sizes of each style)

But careful analysis of the actual anatomy of the zygomatic complex (aka cheekbone) reveals that it does not match the shape of any current cheek implant. Structurally the cheekbone is fairly complex with a main body and three processes that articulate with other bones (frontal, temporal and maxillary) and has four borders. When the term ‘high cheekbones’ is used from an attractive and desirous facial beauty standpoint, this usually refers to more pronounced zygomatic arches or its posterior process. This causes a raised line along the sides of the face to appear which creates a distinct facial skeletal feature. This is often seen in fashion models in both men and women.

No performed cheek implant today truly creates the ‘model cheek’ look as they do not incorporate the zygomatic arch process as part of their design. To achieve this effect a special designed cheek implant is needed.  It can have various anterior shapes but the key element in the extended posterior zygomatic arch process. This extension can go back all the way to the temporal region if desired. Besides creating the raised line back from the cheek it also creates a smoother and more blended flow up across the cheeks  and back along the face rather than just a raised ‘bump’ over the cheekbone.

This malar-arch cheek implant design is placed in the standard intraoral fashion through the mouth. Subperiosteal dissection is carried way back along the zygomatic arch. As long as one is right on the bone there is no danger of injury to the frontal branch of the facial nerve that crosses in the tissues above the posterior zygomatic arch. The length of the tail of the implant can be shortened based on the patient’s anatomy and aesthetic goals. Because the implant has a long surface area contact with the bone in a more horizontal orientation the risks of intraoperative implant malposition and postoperative migration (if screw fixation is not used) is greatly reduced.

The model cheek implant is a malar-arch design that adds a skeletal coverage area not previously seen in any previous midface implant. It creates the high cheekbone look that many younger patients today seek in with contemporary fashion and beauty trends.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Cheek Implant Asymmetry Correction

Saturday, May 20th, 2017


Background: Augmentation of the cheeks is a frequently performed aesthetic facial reshaping procedure. While once only capable of being performed with implants, it is now more commonly done with synthetic fillers and fat. But the only assured permanent cheek augmentation result from a single effort is with the use of implants.

Like all implants placed anywhere in the body, cheek implants have the traditional medical risks of infection. Fortunately this is very low even though the intraoral route is a common incisional method of insertion. The most common risks with their use is aesthetic with an undesired outcome due to implant style, size or positioning on the bone.

In my experience cheek implant asymmetry is its most common aesthetic risk. This is a risk that is shared by any facial implant in which it is bilateral. (has a right and left side) While not commonly appreciated it is very difficult to get perfect facial implant symmetry when they have to be placed in pairs. There are a variety of reasons why implant asymmetry occurs but the fundamental reason is that the limited incisions do not allow for bilateral implant positioning assessment by direct vision.

Case Study: This 35 year male had cheek implants placed five years ago to improve flatter cheeks. He knew right after surgery that the implants were asymmetric and it had always bothered him since. He liked the right side but felt the left side was flatter. He finally decided to seek a solution and a 3D CT scan showed that the left implant was more anteriorly positioned and its shape was different from the right side.

Under general anesthesia and through his existing left maxillary vestibular scar, the left cheek implant was located. It was above the periosteum in a more superficial location and close to the infraorbital nerve. On its removal it could be seen that it had been modified in an irregular fashion. The purpose of the implant modification was unclear. The cheek implant was reshaped to a smoother upper contour and re-inserted and positioned as per the right side of the 3D CT scan. Double screw fixation was used through the implant to ensure its new position on the bone.

In comparing the implant with the preoperative 3D CT scan, it could be appreciated how accurate the scan was in both identifying the implant shape and its anatomic position in the patient. In addition without an exact knowledge of how the right cheek implant was positioned, it would have been impossible with any accuracy to know what the matched position was to the opposite ‘good’ side.


  1. Cheek implant asymmetry is common regardless of implant style and size.
  2. A 3D CT scan is essential when considering cheek implant asymmetry correction.
  3. Repositioning of one or both cheek implants is guided by the the 3D CT scan of the good side.

Dr. Barry Eppley

Indianapolis, Indiana

Cheek Implants for High Cheekbone Look

Monday, January 30th, 2017


Cheek implants come in a variety of styles and sizes to create slightly different midface augmentation effects. Many of the styles of cheek implants have surgeon names attached to them which does not help in understanding exactly what cheek effect they create. But fundamentally cheek implants effect either the malar or submalar regions.

Cheek Bone Anatomy Dr Barry Eppley IndianapolisThe malar region of the cheek refers to augmentation of the zygomatic body proper. This is the convex outer surface of the larger portion of the cheekbone. On its outer central surface is the small foramen for the zygomaticoforamen neurovascular bundle and an elevated area for the origin of the zygomaticus muscle. This central bony area serves as the historic placement for an implant and thus comes the name of malar implants. The submalar region of the cheek refers to the lower edge of the zygomatic body as well as off the bone onto the masseteric fascia. It is really a combined bone and soft tissue augmentation implant.

Cheek implants today come in either malar, submalatr or combined malar-submalat styles. It is easy to see in any of their designs that their effects are over the main portion of the zygomatic bone which is effective for some but not all patients seeks cheek augmentation.

One cheek augmentation effect that some patients seek is the ‘high cheekbone look’. While this seemingly would be created by a malar cheek implant style, it does not usually create that exact desired effect. It is important to appreciate that creating a more prominent malar eminence must include the infraorbital processes in front of it and the zygomatic arch extensions in back of it. If not it will just look like a bump placed on the side of the cheeks. There is a limit as to how the zygoma can be augmented outward until it looks unnatural.

Malar-Arch Cheek Implant Desigtn Dr Barry Eppley IndianapolisMalar-Arch Cheek Implant Design views 2 Dr Barry Eppley IndianapolisThe cheek implant design for the high cheekbone look is an infraorbital-malar-arch design. This actually covers all the zygomatic bone area that would be needed to create a wider (and higher) cheek augmentation effect in a more blended harmonious fashion. Its anterior and posterior extensions feather down onto the bony extension areas for smooth and impalpable transitions of the implant.

Malar-Arch Cheek Implant design color mapping Ddr Barry Eppley IndianapolisWhat is important to appreciate when seeking the augmented high cheekbone look is that the maximum thickness of the implant can not get too close to the eye. It still must remain located centrally on the zygomatic body or it will create an unnatural ridge along the orbital rim. The red portion in the color mapping of the implant design shows the area of greatest augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Zygomatic Arch Implants and the High Cheekbone Look

Sunday, January 8th, 2017


zygomatic-arch-sumental-viewThe zygomatic arch is the part of the cheekbone that extends back to the temporal bone in front of the ear. It is a thin bone and serves and looks like a bridge, allowing the temporalis muscle to pass underneath it. It can be thought of as the side of the cheekbone.  While it looks like a solid bone close inspection reveals a suture line in its middle, signifying it is formed by the union of the temporal process of the zygomatic bone and the temporal process of the zygomatic bone.

The word, ‘zygomatic’ is derived from the Greek word zygoma meaning bolt or bar….to join. The term has been used since ancient times and the arch part of the zygoma certainly joins the cheek to the temporal bone.

female-high-cheekbone-lookmale-high-cheekbone-lookWhile this facial bony anatomy is interesting, it is relevant in aesthetics to the structural basis of the high cheekbone look. This often exaggerated look to the cheeks creates a distinct line along the sides of the face. It is often seen in many male and female models and is a desirous facial feature for many patients seeking an improved and more symmetric facial appearance.

While numerous styles of cheek implants are available, none of them are designed to actually create the complete high cheek bone look. While they all add increased volume to the zygomatic body, none has any extension back along the zygomatic arch…which is the key to high cheekbone look.

large-zygomatic-arch-implants-design-dr-barry-eppley-indianapoliszygomatic-arch-implant-dr-barry-eppley-indianapolisZygomatic arch implants are designed to be used alone or in conjunction with standard cheek implants to create the high cheekbone look. These implants help to create an augmentation ridge from the cheekbone below the side of the eye back to in front of the temporal bone in front of the ear. Their posterior lengths can be adjusted to either stop in front of the temporal hairline or go back further into it.

When placing zygomatic arch implants it often takes more implant size than one would think. More than a few millimeters in height and width are needed in most cases.

Dr. Barry Eppley

Indianapolis, Indiana

Model Cheek Implants

Tuesday, December 6th, 2016


Cheek implants are the third most commonly performed facial implant procedure. Trailing behind nasal and chin implants, cheek implants provide augmentation to a lateral facial structure and not a midline one. As a result most cheek augmentations are bilateral or paired and that poses a unique challenge in their surgical placement.

But prior to having them surgically placed is one of preoperative implant selection. While the cheek or zygomatic bone seems like a relatively simple convex structure, it actually has multiple aesthetic zones (malar, submalar, anterior infraorbital and posterior arch zones) that must be considered. Not every patient wants exactly the same area of the cheek augmented let alone be the same size. This helps to explain why there are so many different cheek implant styles from which to choose. From one manufacturer alone (Implantech) there are seven (7) different cheek implant style options.

While these current and commonly uses styles of cheek implants work for most patients, they are not aesthetically ideal for some patients and the facial change they hope to achieve. One type of cheek augmentation look for which standard cheek implants usually fail to achieve is that of the ‘high cheekbone’ look. This is also commonly referred to as the ‘model look’.

model-cheeksWhether it be a man or women the model look refers to high cheekbones. These are cheeks that would be considered highly placed and robust. It is not that they as so big or protrude a lot to the sides. Rather their location and shape have the ability to add some angularity to the face by creating submalar hollows beneath the cheekbones.  This is also a type of facial look which is not just located over the malar eminence but also creates a horizontal ridge along the entire length of the zygomatic process. Not such cheek implant style today can create that type of midface effect.

high-cheek-implant-design-side-views-dr-barry-eppley-indianapolismodel-cheek-implant-design-front-views-dr-barry-eppley-indianapolisThe high cheekbone or model cheek implant has its high point higher up on the cheekbone with a long posterior zygomatic arch extension. This helps to create an augmentation ridge from the cheekbone below the side of the eye back close to the temporal bone in front of the ear. This also gives a bit of vertical facial lengthening between the cheeks and the jawline helping to thin the face and give it some added angularity if one is thin enough.

extended-high-cheek-implant-design-dr-barry-eppley-indianapolisPlacement of the high cheek or model cheek implants largely differs only in the extent of the zygomatic arch dissection. It is needed to go all the way back along the zygomatic arch until it meets the temporal process just in front the temporomandibular joint. In this dissection it is important to stay right on the bone in the subperiosteal plane to avoid injuring the crossing frontal branch of the facial nerve.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Zygomatic Arch Implants

Saturday, October 29th, 2016


Cheek implants are a well recognized form of facial augmentation that has been used for decades. By placing an implant on the cheekbones a permanent midfacial augmentation effect can be achieved. But cheek implants are not just one style or size fits all. There are over a half dozen styles of cheek implants designed to augment different parts of the cheek bone in various ways. These are most commonly seen as malar, submalar and shell (combined malar and submalar) style cheek implants.

But all forms of cheek implants augment the largest bony area of the cheek, the zygomatic body. No implant style extends more posteriorly across the thinner and more curved zygomatic arch. The zygomatic arch adds lateral projection to the midface as evidenced by its bowed convex shape. For those patients seeking a wider or a stronger arch cheek look, as often seen on male and female model faces, augmentation of the zygomatic arch is needed.

zygomatic-arch-implant-extension-off-of-cheek-implant-dr-barry-eppley-indianapolisThere are no standard preformed zygomatic arch cheek implants. They have to be individually made for each patient either through computer design or hand carving the implant shape from a solid block of silicone material. Zygomatic arch implants can be used in conjunction with standard cheek implants (as seen in this picture) or a combined cheek-arch implant can be custom made from the patient’s 3D CT scan.

For male or female patients seeking a high cheek augmentation look, or that ‘model cheek look’, a zygomatic arch component needs to be part of the cheek augmentation. Zygomatic arch implants can be done alone add facial width if sufficient anterior cheekbone projection already exists.

Dr. Barry Eppley

Indianapolis, Indiana

Volume Comparison of Cheek Implants and Injectable Fillers

Wednesday, June 1st, 2016

Cheek augmentation is a common facial reshaping procedure that is done for both aesthetic enhancement and volume restoration due to aging. It is the one facial procedure that, while historically only done with cheek implants, is now done more often by injection methods using synthetic fillers or fat.

The emergence of injectable methods is now the most common approach for cheek augmentation. Any of the synthetic fillers can be used since the cheek is a broad area and is spread out over the cheekbone as well as below it in the submalar region.While no synthetic injectable filler provides a permanent result, it does provide an instantaneous result and the opportunity for the patient to determine if this type of facial enhancement is appealing to them.

Cheek implants offer the only guaranteed permanent method  for cheek augmentation. But this requires a surgical commitment to an invasive procedure and has certain risks and complications. Injectable fillers can also be placed over a broader surface area greater than that which most cheek implants can.

An interesting but relevant issue when using injectable fillers for cheek augmentation is how do they compare volumetrically to that of cheek implants. To create an injectable cheek augmentation effect, what volume of injectable filler is needed to compare to what a cheek implant does? An injectable method is only a fair test in facial augmentation if similar volumes of material are placed that compares to what an implant does.

Conform Submalar Implants Dr Barry Eppley IndianapolisConform Midfacial Implant Dr Barry Eppley IndianapolisComparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would equal to the volume of the implant. (provided that they sink in water and cheek implants do) Using the most commonly used style of cheek implants (Conform Submalar and Conform Malar Shells from Implantech) of all available sizes, their weights in grams and volume displacement were as follows:


Small        1.89 grams     0.7ml

Medium   2.13 grams     0.8ml

Large        2.36 grams     1.1ml

Large        2.58 grams     1.3ml


Extra Small  1.47 grams   0.6ml

Small             1.71  grams   0.7ml

Medium        1.96 grams    0.8ml

Large              2.43 grams   1.1ml

Extra Large   2.62 grams   1.3 ml

Volume Displacement of Facial Implants Dr Barry Eppley IndianapolisThe volume displacement of all injectable fillers is on the syringe so the comparison to cheek implants can be directly compared. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be equal to small and medium sized styles of cheek implants.ess than even a small chin implant. Larger cheek implants more directly compare to a 1.5cc syringe of Radiesse.

Volume alone, however, is not the complete story of any material’s external facial augmentation effect. Besides volume there is the issue of how well the material pushes on the overlying soft tissues to create their effect. This is known as G Prime Force or the elastic modulus. By feel it is obvious that cheek implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) It is therefore probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to implants.

The comparison between injectable fillers and implants in the cheeks may be different than in many other facial enhancement sites. Because the cheeks cover a significant soft tissue area not supported by bone the direct volumetric comparison may be more similar despite its lower elastic modulus.

Dr. Barry Eppley

Indianapolis, Indiana

Extended Cheek Implants for High Cheekbone Look

Sunday, April 10th, 2016


High Cheekbone Look Indianapolis Dr Barry EppleyHjgh cheekbones, whether it is in women or men, is an often desired facial feature. Careful inspection of what constitutes the ‘high’ or ‘strong’ cheekbone look reveals that it has several anatomic components. The main portion of the cheekbone is indeed high but the prominence extends back along the zygomatic arch, stopping just short of the temporal region. A prominent zygomatic arch creates both a strong cheek line but also contributes to a submalar hollow or concavity.

Cheek implants are commonly used to try and achieve it but often are inadequate due to the implant’s shape. No cheek implant provides any zygomatic arch extension which is critical in helping to achieve this type of cheekbone augmentation result.  (extended cheek implants) Fabricating  custom cheek implants from the patient’s 3D CT scan is the ideal method to achieve this implant design and look but adds a significant amount to the cost of surgery.

Facial Implant silicone carving blocks Dr Barry Eppley IndianapolisCustom Carved Extended Cheek Zygomatic Arch Implants Shape Dr Barry Eppley IndianapolisAngel Wings Extended Cheek Zygomatic Arch Implants block carving Dr Barry Eppley IndianapolisAn alternative method to fabricate extended cheek implants is to make them during surgery by hand carving. This is done using a silicone carving block. These are available as rectangular carving blocks of the dimensions of 12 cms x 7 cms and being 1.5cm thick.  They are available in three durometers (hardness) which I prefer the medium or 20 durometer. Measurements and a paper template are made from the patient and then transferred to the block where their outlines are traced onto it. A large scalpel blade is used to cut out the design from the blocks  and it is finished with small scissors. The image left behind in the carving block resembles that of ‘angel wings’.

Extended Cheek Zygomatic Arch Implants intraop placement Dr Barry Eppley IndianapolisThe extended cheek implants are fashioned so that the portion over the zygomatic prominence is curved downward to add anterior cheek fullness. Wedges are taken on the underside to allow it to make the bend down onto the maxilla. Perfusion holes with 3mm punches are made to allow tissue ingrowth over the maxillary portion of the implant.

Extended cheek implants provide a zygomatic arch extension that is critical to create the elongated midfacial line for the high cheekbone look. Such a facial implant design can be handmade during surgery from silicone carving blocks.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Male Cheek Implants

Thursday, January 21st, 2016


Cheek augmentation is a popular facial enhancement procedure that can be done by a variety of methods. The most approach today is that of an injectable technique using either synthetic fillers or the patient’s own fat. The injectable cheek augmentation material is often highly influenced by whether any other surgery is being done, fillers in the office and fat in the operating room.

But the historic and only true one-time permanent cheek augmentation method is that of implants. Cheek implants have been around for over three decades and have evolved into a wide variety of styles and sizes. Cheek implants today definitely have far better choices for surgeons and patients to select. But careful assessment of almost all current cheek implants styles can be seen to be geared more towards women than men. Creating submalar and more anterior zones of augmentation creates more of a full rounder or ‘apple‘ cheek effect. In my experience this is really not what most men are interested in achieving, particularly that of the younger male.

male model cheek s2Many men seek a cheek augmentation effect that can only be described as the ‘male model look’. In essence this is a very angular facial look characterized by high strong cheek bones and a well defined jawline. The cheeks have a unique shape that creates a strong skeletal contour along the main zygomatic bone the whole way back along the zygomatic arch to the temporal region. As a result of the bone shape an underlying facial concavity is created beneath it. There is no cheek implant today that can come close to making the cheek bones have this look.

Custom Male Cheek Implants Dr Barry Eppley IndianapolisCustom Male Cheek Implants Indianapolis Dr Barry EppleyWhile this type of male cheek look may be exaggerated through the use of lighting, makeup and Photoshop, the point remains that current cheek implants are not designed to remotely achieve this type of facial skeletal augmentation. For these more exaggerated male cheek looks that some men desire, I have found that a special custom cheek implants design can help achieve this facial look. The difference in this implant design is the anterior zygomatic prominence is high and the augmentation goes the whole way back along the zygomatic arch to just in front of the ear in a tapering fashion.

Custom Male Cheek Implant Thicknesses Dr Barry Eppley IndianapolisThis type of cheek implants does not achieve its effect because it is necessarily thicker. Rather it achieves a powerful cheek augmentation effect because of the surface area that it covers in a better bony location.

Such a custom cheek implant design works best in men with leaner or thinner faces. This is the type of face where the skeletal augmentation is best seen. This is well illustrated in male model faces where it can be seen that they all have an overall thinner face with little subcutaneous fat.

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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