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Archive for the ‘cheek implants’ Category

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

Combining Facelift, Cheek Implants and Laser Resurfacing for Total Facial Rejuvenation

Monday, November 3rd, 2014


When most people think of facial rejuvenation undertandably the thought a facelift emerges. But contrary to popular perception, a facelift only addresses the lower third of the face. While smoothing out the neck and the jawline provides a youthful improvement, it does not address the middle of the face. Even if it could pulling the middle of the face outward would produce an unnatural distortion and is rarely the answer to midface rejuvenation.

Loss of facial volume and removal of tissue support is a well recognized mechanism of facial aging. Thus volume restoration is a very useful approach to helping to reverse midface deflation. This can be done by either malar/submalar implants or fat injections and there are advocates for each approach. Implants tend to produce a more consistent augmentation method that is stable long-term.

Neither a facelift or the addition of volume restoration to the midface will improve the texture of the skin. Chemical peels and laser resurfacing are the known effective approaches for smoothing out fine wrinkles and improving the look of the skin.

A more complete facial rejuvenation approach would include all of these elements from a facelift, midface augmentation and skin resurfacing. In the September 2014 issue of the American Journal of Cosmetic Surgery, an article appeared entitled ‘Total Face Rejuvenation: Simultaneous 3-Plane Surgical Approach Combined With Ablative Laser Resurfacing’. In this paper, a retrospective review of 21 female patients (age 58 to 71 years old) undergoing combined extended-SMAS facelift, mid-ace augmentation with implants, and full-face ablative laser resurfacing by a single surgeon was done. None of the facelift skin flaps suffered any healing problems. The skin healed (re-epitheliazed) within ten days and makeup was able to be worn again within two weeks. One hematoma occurred as well as one implant infection. This study showed that all three facial procedures can be performed at the same time.

It has been historically thought that combing certain procedures, such as laser resurfacing and a facelift, runs the risk of skin loss and other healing problems. But this study shows what has been known now for some time that combining multiple facial rejuvenation procedures is not only safe but necessary in most cases to have the best results. As long as the laser resurfacing is not done too deep over the raised skin flaps of the facelift, a negative effect of skin and incisional healing does not occur.

Dr. Barry Eppley

Indianapolis, Indiana

Correction Of Cheek Implant Asymmetry

Saturday, July 26th, 2014


Cheek Implants Indianapolis Dr Barry Eppley IndianapolisWhile cheek augmentation can be done by synthetic injectable fillers or fat injections, the only assured permanent method is through the use of preformed implants. Cheek implants come in a variety of styles and sizes and it is critical to make these implant choices thoughtfully to get the desired midface result. The most common aesthetic cheek implant complication, however, is that of asymmetry.

Cheek implants are the second most commonly performed facial implant used behind those used for the chin. But unlike chin implants, cheek augmentation requires the use of two implants that must be placed with their symmetry in mind. But cheek implantation sites can be difficult to see simultaneously and their symmetry is usually assessed by external evaluation of how the cheeks look. But swelling and other tissue distortions can mar the accuracy of this comparative assessment. This external view is complemented by also assessing how the implants rest on the bone between the two sides.

Cheek Implant Shift and Asymmetry Dr Barry Eppley IndianapolisBut despite the best placement efforts, cheek implant asymmetry can occur. This could be due to initial asymmetric implant placement or a migration/shift of the implant afterwards. Due to the size of the implant pocket initially, unsecured cheek implants can shift move right after surgery. (early displacement) It is very rare to have a cheek implant change position months or years later (late displacement) although it can happen. Why a cheek implant would have such a delayed shift in position long after the enveloping capsule (scar) around it has been created and healed could be infection or a reactive seroma formation. Surgery performed near the implant can also cause an implant  reaction and subsequent shift. (picture shows a CT scan with cheek implants at two different positions and a reactive fluid collection around the left cheek implant as it moves its way towards the mouth incision)

Cheek Implant Repositioning Dr Barry Eppley IndianapolisCheek implant reposition surgery can be performed but is rarely as simple as just ‘moving the implant around’. Because scar tissue forms around all synthetic materials, repositioning of implants usually requires some form of capsulectomy/capsulotomy. (releasing or excising portions of the existing implant’s pocket) In addition, it is critically important to secure the cheek implant into the new position and this is most reliably done by screw fixation with self-tapping titanium 1.5mm microscrews. A layered closure over the implant consisting of muscle and mucosa is also important to keep as much soft tissue between the intraoral cavity and the implant pocket.

Because of the path of cheek implant insertion, asymmetry or migration of the implant is usually downward towards the location of the incision. This occurs also because the cheek bone is sloped downward and the maxillary bone underneath it is concave, making movement in that direction easy. Thus , most cheek implant repositioning is moving the implant back up over the bone.

Dr. Barry Eppley

Indianapolis, Indiana

A Facial Implant Approach To Volume Restoration in Facial Wasting (Severe Lipoatrophy)

Sunday, June 29th, 2014


Fat loss in the face is referred to as facial lipoatrophy. While some people have it occur naturally with aging or weight loss, for others it is a medication side effect. While retroviral drugs have extended the lives of patients with human immunodeficiency virus (HIV), one of its well know side effects is the loss of the facial fat compartments. This has become known as facial wasting since it is an abnormal and active process. In facial lipoatrophy terms, there are various degrees of it classified as I through V. Many HIV positive patients have advanced type IV and V facial lipoatrophy appearances.

While facial wasting affects all fat layers in the face, its biggest impact is on the buccal fat pad. With its numerous fingers of fat that extend throughout the face and up into the temple region, loss of the buccal fat pad creates a skeletonized and hollow facial appearance. In its fullest extent, it makes one look ill and unhealthy and carries the social stigmata of someone who has the disease.

It has been shown that thymidine analogue drugs are the cause of this facial lipoatrophy effect. Recovery of some of the lost fat can be achieved with a switch to nucleoside reverse transcriptase inhibitor-sparing therapies but it is slow and never complete.Various forms of plastic surgery are needed to create a more dramatic and immediate facial change.

Facial rejuvenation procedures for facial wasting is focused on volume restoration around  the periorbital region (eyes), specifically that of the cheeks and temple regions. The temple hollowing is a pure soft tissue deficit while that of the cheek area is a combined bone and soft tissue deficit. This is not to say that the cheek has lost bone but that it has become very skeletonized adn looks withered, thus cheek (malar = bone) and the area below the cheek (submalar = soft tissue) needs building back up.

While there are injectable treatments available to treat facial wasting, synthetic (Sculptra) and natural (fat), they have favorable degrees of effectiveness. Sculptra injections are for those patients who are definitely opposed to surgery and have the patience to wait until their fill effect is seen…and then have it repeated 18 to 24 months later. Fat injections are problematic both in harvest and persistence. Many facial wasting have little fat to harvest and its ability to survive in tissue beds with very little subcutaneous fat is precarious at best.

Temple Implants in Facial Wasting result front view Dr Barry Eppley Indianapolis_edited-1A facial implant approach can be very successful and create an immediate volume restoration with long-term stability. The temple hollowing is treated with new soft silicone elastomer temple implants that are placed below the fascia but on top of the muscle. This camouflages the implant edges and is a remarkably simple procedure to insert them with no postoperative pain, little swelling and a very quick recovery. They are far superior to any injectable filler because they are so effective. They key in using them is to not pout in a size that is too big which is very easy to do in a very skeletonized temporal region.

Cheek Implants for Facial Wasting Dr Barry Eppley IndianapolisThe cheek area requires a very broad-based implant, part of which is placed below the cheek bone on the masseter muscle. Proper implant placement actually puts at least half if not more of the implant below the bone. While once submalar cheek implants were exclusively used, I have found that larger combined malar-submalar shell implants do a better job of midface volume restoration. Because these type of cheek implants are substantative in size, screw fixation is useful to keep them in the desired location as they heal.

One area that is left out with temple and malar-submalar shell implants is the intervening area over the zygomatic arch and immediately beneath it into the lower face. A complete facial wasting surgery includes implantation of this area as well but has to be done with either fat injections or preferably a dermal-fat graft placed through a limited facelift approach. Without filling in this area there can be a step-off in the face behind where the malar-submalar shell implant ends.

Facial wasting treatment is one specialized form of facial reshaping surgery. These procedures allowing for volume restoration of the face hopefully to a level that is close to what they looked like before starting their anti-viral drugs. With a more ‘plump’ face, one self-confidence is improved, they look healthier and they will be encouraged to stick with their long-term drug therapy.

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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