Lifting of aging and sagging facial tissues is often perceived as a facelift. In reality, a traditional facelift only affects the lower third of the face…the neck and jowls. That leaves out the two other major facial areas which can be lifted, the forehead (brows) and cheeks. Browlifts are well known and very effective facial rejuvenation procedures whose numerous techniques and methods are well established. Browlifts are often done in combination with a facelift. The cheek area, while aging as much as the brows and the neck, does not have a simple  and consistently effective  surgical lifting procedure.

Cheek lifts, also known as midface lifts, are intended to lift sagging tissues that were once on top of the cheeks. When the soft tissue falls off of the bony cheek due to loosening of its ligamentous attachments to the skin, it creates what are known as malar festoons. These are bags or bunching of tissue that often creates a ‘double bubble’ look to the midface. Or the midface can look like wax melting off of candle. Most people think that a facelift or a browlift will somehow correct this cheek sagging but it will not.

Midface lifts are relatively new compared to facelifts and numerous techniques have been used. The fundamental midface lift approach can be ascertained based on the vector of pull and incisional access. The traditional midface lifts is done through a lower eyelid incision and pull the cheek tissues directly upward. When using this technique, I will fix the cheek tissues to a cranial fixation point directly above a vertical line up from the cheek. This is a very powerful method for lifting sagging cheek tissues but involves manipulation around and through the eyelid. The eyelid is very unforgiving and numerous complications can result. Eyelid deformities, particularly ectropion, is not rare with this type of midface lift. This cheek lift requires absolute precision and is very unforgiving of any slight technical deviation.

An alternative and less problematic approach is that of the temporal cheek lift. The incision is right at the junction of the  preauricular and temporal hairline. By placing it here, the hairline will not be shifted upward and the delicate lateral eyelid area is completely avoided. Skin flaps elevated for about an inch or inch and a half downward so that its pull lifts the cheek tissues. This is then combined with the use of barbed sutures or threads which are inserted underneath the skin flaps. They are directly toward the sagging cheeks and then tied together to further lift the cheeks. The combination of the skin pull and the barbed sutures creates a very nice cheek tuck-up. The excess raised skin, now lying over the incision is trimmed and closed.

This temporal cheek tuck-up has numerous advantages including ease of execution, lack of any problems in the eye area, and very minimal recovery. It can be performed in the office under local anesthesia. Its disadvantage is that it is not as powerful as the cranially-directed midface lift so patient selection and expectations are critical. I have found it useful for those patients with more mild forms of cheek sagging, after a facelift procedure, and when a conventional midface lift needs further improvement.      

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

As one ages, the entire face changes. Some parts of facial aging are more obvious than others as the face does differentially age. The forehead, brows, eyes, mouth, jawline and neck are all areas whose aging is well recognized. The aging of the midface and cheek areas, however, has only become more recently recognized.

With the aging process, the fatty tissue that normally drapes over the cheekbones can begin to sag. The result is less prominent cheekbones, and a droopy fold of skin and fat between the nose and the cheek (the nasolabial fold). The sagging cheek fat can also alter the appearance of the lower cheek. For example, bagginess of the lower eyelids often becomes more apparent after the fat of the upper cheek begins to sag. This in essence ‘unveils’ the bagginess of the lower lids, which have always been there. In addition to sagging of the skin and fat of the midface, there is also volume loss in the cheek due to loss of fat and muscle.

A number of cheek lift or midface lift procedures exist to address this aging area. The goal of all of them is to lift up droopy cheek tissue over the cheekbone restoring the more prominent youthful contour, improving the tear trough and bagginess of the lower lids, and softening the undesirable cheek fold. Fundamentally, they may be divided into lifting approaches vs volumetric addition. In some cases, they may even be done together.

Lifting approaches aim to reposition the sagging fat of the cheek over the cheekbone to restore the youthful fullness of the cheeks. Such midface lifts use differing access including the lower eyelid, scalp, and temporal incisions using open incisional or endoscopic instrumentation. Implants have also been devised to provide less invasive options including suspension sutures and bone-anchored lift devices. The plethora of differing lifting approaches suggests that no one of them is universally successful.

Contrarily, cheek implants have also been used to help create a degree of cheek lifting. By placing an implant through the mouth onto the cheek bone, some fullness is added to the volume-depleted cheek and the cheek tissue on top of the implant is pushed upward. While not creating as dramatic effect as a lifting procedure, it is far simpler and with fewer complications. This cheek lift approach, using a specially designed submalar implant which fits on the underside of the cheek bone, has been around for nearly two decades. When used in the right patient and properly sized, it can have a good cheek enhancement effect. But it is also easily overused and overdone (too large a size) as older celebrity faces are rife with examples of odd-looking and peculiar cheek prominences due to oversized implants.

Given the choices between cheek lifts and cheek implants, which is the most helpful for cheek rejuvenation? The answer is no one of them is best for all patients. Over the years, I have used almost of all of them in my Indianapolis plastic surgery practice….and have also seen and learned the downsides to each of them. Midface or cheek rejuvenation is as much an art form as almost any area of anti-aging facial surgery. Given the potential complications that can occur with lifting procedures, most specifically lower eyelid ectropion, their use should be reserved for the most severe sagging cheek problems. More moderate cases with less prominent cheekbones may benefit with a small to moderate-sized implant. In all cases, moderation is the key…not too much lift or too big of an implant. The midface is one area that does not look good overdone and is easy to do.  

Barry L. Eppley, M.D., D.M.D.

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The cheek lift is a plastic surgery procedure designed to lift and tighten the cheek and a little of the jowl area. It is also referred to as numerous other names such as a short scar facelift, S-lift, J-lift, and trademarked names such as Lifestyle Lift and Quick Lift which are variations of the basic cheek lift procedure. It is suited for those who are looking for just a perk-up or light facial lift rather than a full facelift.

The cheek lift is best suited for younger patients (< 50 years of age) who have adequate or strong cheek bones, not a lot of loose skin, minimal jowling and maybe a little excess fat in the central neck area. This procedure is not a replacement for a cheek-neck lift or facelift if there is a lot of excess neck and jowl skin and fat.

For the cheek lift, thin incisions are made inside of the ear for women or in front of the ear for men . The incision is then carried up into the hairline, well back of the sideburn or temporal hairline. These incisions do, of course, result in scars although they are well-concealed within the hairline and inside of or in front of the ear. The skin in front of the incision is lifted after dissecting deep near the cheek area. This enables the loose cheek skin to be lifted up and back. I usually perform some SMAS elevation and imbrications as I don’t want to the long-term results to rely exclusively on the skin closure. These maneuvers provide for a long-lasting, natural results without a “pulled-back” look. Liposuction of the neck and other procedures such as blepharoplasty are often performed at the same time for a more complete rejuvenation or anti-aging effect. The cheek lift alone takes about an hour or so to complete.

Recovery after a cheek lift takes about a week at which time one can look fairly ‘non-surgical’.Swelling and bruising are quite minor. Showering is permitted the very next day with washing and blowdrying of hair. One can return to work in about one week but should wait for about two weeks before undertaking strenuous activities and exercise. The stitches are often dissolveable and require no removal.

The cheek lift is a nice gentle procedure that really is easier to go through and recover from than most would think. Do not confuse it with how most people envision as a facelift, which is a neck procedure primarily. It works best when it is combined with other facial procedures of which the list could be numerous nips and tucks, injectable fillers, or facial implants. In my Indianapolis plastic surgery practice, I find that it works well with a lot of other facial rejuvenation procedures and its effect is enhanced by doing so.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The facial features most associated with masculinity is the chin and jawline. A stronger chin and jawline conveys increased masculinity, smaller chins and ill-defined jawlines convey timidity and weakness. While this perceptions may not always be true (and often aren’t), they certainly help create a first impression by their appearance. In today’s plastic surgery, newer generation implants and fillers make this look possible more than ever before.

 
Chin implants have really evolved over the past decade with many new styles and sizes. The most important change has been that they have been extended in their shape rather than small ‘buttons’. The idea is to have an enhanced chin that flows better into the surrounding jaw. This requires an implant that ‘extends’ back from the chin to create a smooth transition from the augmented chin to the back of the jaw. These newer implants are longer and more tapered at the ends, although they can still be placed through a small incision right under the chin. Because they extend back further they give an enhanced but natural appearance to the chin. This is achieved by filling in the jawline between the chin and the back of the jaw, slightly widening the anterior jawline making the overall look more balanced. In addition to jawline width, chin and jawline height can also be lengthened by having a ‘wrap-around’ implant that extends lower than the existing edge of the bone. Prior to these type of implants, only cutting the bone or bone grafting could have achieved this look. This increases the height of the lower third of the face, a very male-enhancing effect.

 
New implant options also exist for bolder cheekbones and more square jaw angles. Small cheekbones generally are not as obvious as a smaller chin but the effect on the appearance of the face is just as real. Small cheek bones create a flatter facial appearance or even a longer thin face look. Several styles of cheek implants exist to fill out different areas of the midface, from creating higher cheekbones to improving that sunken cheek look. Cheek implants are placed through an incision in the mouth so there is no scarring. A more square and well-defined jaw angle is a very masculinizing look and can only be created with implants. Jaw angle implants can eitehr widen the back of the jaw, make it more longer and more square, or both. Like cheek implants they are placed inside the mouth so scarring is never any issue.

 
It would not be uncommon to perform several areas of facial enhancement in the male to get the overall look that they want. Since an appreciation of facial shape and how the different areas can be changed and how they would look from implants mandates that computer-imaging be used. I find it usually takes at least two consultations to thoroughly cover all the options and make sure the patient has complete understanding of the facial look that they desire.

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

One of the most overlooked areas of facial aging is that of the cheek region. Most think of facial aging in the neck, jowls, or eyes, and while these certainly exist, the midfacial cheek region often sags as well. In those patients with weak cheekbones and a flatter face, the cheek tissue can especially sag as one ages. This appears as a ‘double bag’ under the eyes with deepening of the lip-cheek grooves. Like ‘wax dripping from a candle’, the cheek soft tissues can be seen as falling off of the cheek bone.

Such midfacial aging has created two basic approaches to addressing this facial aging concern. Historically, a special type of cheek implant has been used, a submalar implant. This type of facial implant sits on the underside of the cheekbone. Because it is placed on the underside of the cheek, it does not accentuate the cheekbone, but rather helps push up fallen cheek tissues. The implant is placed through the mouth through a small incision and is either screwed or sutured to the underside of the cheekbone to hold it in place. As a result of its position, it also helps add fullness to the triangle area under the cheekbone, restoring a subtle and youthful fullness to the midface. This is a simple approach, with few complications, and is a good alternative for those patients that have a minor problem of midfacial aging and can accept a synthetic implant.

An alternative, and more recent approach, has been the midface lift. With this technique, the sagging cheek tissues are actually lifted and resuspended by sutures into a more lifted position. This is done through a lower eyelid approach (and is often done simultaneously with a lower eyelid procedure (blepharoplasty) where the sagging cheek tissues are lifted off of the bone from above. Sutures are then placed through the loosened tissues and are passed underneath the skin and sutures high onto the fascia or bone of the temples. The sutures can be adjusted to control how much lift is achieved. This method restores fullness to the midface by using the patient’s own tissues rather than implant. This is a more complex procedure, with the risk of lower eyelid malpositioning, and is a good choice for those patients with more severe midfacial aging who can accept a longer period of swelling around the eyes after surgery. In the midface lift, make sure you have a plastic surgeon experienced in the procedure due to its higher rate of complications.

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