The cheek or the midface region plays an important role in facial appearance. As one

of the five facial bony prominences (brow, nose, chin, and jaw angles are the others),

it is actually the most complex. It lacks any sharp angles, is made up of several bones that

intersect together and is surrounded by three distinctly different soft tissue regions. While

everyone appreciates that a high and strong cheekbone is desireable, it is not easy to

quantitate what that should look like unlike chin projection or jaw angle width which can

be actually be measured.

Rather than some absolute number, the cheek region is better recognized for what it does

for facial shape and width. As part of understanding cheek morphology, one should not

forget how the soft tissue below it affects how the bone looks above. Known as the

submalar (below the cheek) region, it is affected by the size and prominence of the buccal

fat pad. This golfball-sized fat collection can be surprisingly large and it helps make for a

rounder and fuller cheek region appearance. If the buccal fat pad is very large, it can

make this area protrude or be quite ‘cheeky’. If this and other facial areas are small or

atrophic, the facial shape may assume a more gaunt appearance.

Therefore when assessing the cheek area, the consideration of both bone (malar) and

buccal fat (submalar) areas should be done. Implant manufacturers have recently showed

an appreciation for this concept by expanding traditional cheek implants to include either

(malar and submalar) or both. (combined submalar shells) Combinations of malar

and submalar changes can often make for a better cheek result than just a ‘simple cheek’

implant’ alone. In some cases, cheek bone enhancement and some submalar reduction

(buccal fat removal) may produce better cheek highlights. In other cases, submalar

augmentation or a combined malar-submalar augmentation may be aesthetically better.

The uniqueness of  each person’s face and their desired cosmetic outcome must be taken

into consideration when planning changes in this area.

Removal, or more accurately, reduction of the buccal fat pad (buccal lipectomy) is a

surgically simple procedure but it’s decision to do so is more aesthetically complex.

Through a very small incision inside the mouth opposite the maxillary first or second

molars, the buccal fat pad can be gently teased out. When doing at the same time as some

type of midfacial implant, it can be done through the same incision. How much one

removes is a matter of judgment. As a general rule, it is not a good idea to try and

remove all of it. Not only may that be undesireable in facial appearance in the long-term,

but there are several buccal branches of the facial nerve which interlace with the multi-

lobed buccal fat pad. They exist most commonly on the superficial (outer) aspect of the

buccal lobe, away from the area of intraoral manipulation. For this reason, aggressive

buccal lipectomies may inadvertently damage these branches. I have never observed

facial nerve injury from a buccal lipectomy procedure but this attests to a more

conservative resection philosophy. In uncommon cases with a very full and ‘fat’ face, a

more complete buccal lipectomy may be justified. Such an approach works well when

‘fat-reducing or facial thinning’ procedures are being done such as neck liposuction

and/or chin or cheek implants.

Conversely, submalar augmentation rather than reduction may be needed to help fill out a thin or

gaunt facial appearance. While initially developed for lifting sagging cheek tissues over ten years

ago, the submalar implant is much more commonly used to add soft tissue fullness rather than a

lifting effect. If the cheek prominence is adequate but the underlying submalar region is thin or

‘sucked inward’ (indented), than an isolated submalar implant may suffice. If the overall cheek

(malar and submalar) is too flat or deficient, then a combined malar-submalar implant may be

needed.

When considering cheek enhancement as part of an overall facial improvement plan, both the

malar and submalar regions must be considered together. Between expanded submalar implant

designs and buccal lipectomies,  a more comprehensive approach with satisfying surgical results

is now available.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

Facial lipoatrophy is a not uncommon facial condition that all of us have seen but didn’t know exactly what to call it. Some people call it ‘gaunt looking’, others may refer to it as ‘hollowing’ of the face. No matter what you call it, it is the result of loss of the buccal (cheek) fat pad that lies directly under the cheekbone (zygoma) prominence. The fatty layer immediately underneath the skin throughout the fat thins as well but the dominant feature is the sunken or dented in area immediately beneath the cheek.

 
There are numerous causes of facial lipoatrophy but the most common are aging in an alreadly thin person, advanced cancer or immune disease with significant weight loss, and loss of the buccal fat pad due to medications. (such as in the HIV patient who is on antiviral medication) The facial appearance is classic with the loss of roundness in the middle part of the face and an actual indentation where th cheek fat used to be. This gaunt look creates an unfavorable appearance that appears old or unhealthy.

 
There are two distinctly different methods in plastic surgery to treat facial lipoatrophy and rebuilt this area up andout, either using injectable fillers (including fat) or a special type of cheek implant. Both obviously attempt to fill the cheek void left by the vacated fat pad but approach it differently. Injectable fillers replace it either with a viscous liquid component which may or may not be permanent. Most injectable fillers are not permanent. Inject fat could be permanent but is unpredictable. I have not been a big fan of the injectable fillers for the cheek deficiency of facial lipoatrophy simply due to the volume of the filler needed and the subsequent cost. It doesn’t take long before one can approximate the cost of a surgery. For a more assured result, albeit a surgical one but it provides the best value, is the use of a submalar cheek implant.

 
Submalar cheek implants are a variation of the traditional cheek implant. They are not designed to build out the cheekbone prominence but fill out the submalar area where the buccal fat pad partially lies. They are surgically placed through a small incision underneath the upper lip. Different sizes are available dependent upon how much of a deficiency exists in the submalar area. Submalar cheek implants are placed on the underside of the cheek bone and are secured into position with s small screw to hold their precarious but important position. The effect of the submalar cheek implant is immediate. There is really no recovery other than mild soreness and some swelling for a few days.
The treatment of facial lipoatrophy with a submalar cheek implant is easy, satrightforward, and effective. While it only treats one component of facial lipoatrophy, the buccal fat pad area in the midface, this is often the most recognized and disfiguring component of the problem. The material that the submalar cheek implant is made out of is not of particular importance, whether it be silicone rubber, gore-tex, or other well-tolerated facial implant material. An artistic eye for proper cheek implant style and selection and accurate placement on the underside of the cheek bone are the keys to a pleasing outcome that can make the face appear more healthy and youthful.

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

I have seen numerous patients over the years who are positive with the HIV virus, otherwise known as the acquired immunodeficiency syndrome (AIDS) and probably some that had the virus but it was unknown to them or they did not disclose it. Thesd patients fall into two categories of procedural requests; those patients seeking typical cosmetic procedures and those patients who have the adverse effects of antiretroviral therapies known as the lipodystrophy syndrome. In either case, there is always the question of the adviseability of performing elective plastic surgery. Are the patients healthy enough so that they are not at increased infection and complication risks?….and….What is the real risk to the operative team in terms of potential disease transmission?

 
In an excellent article in Plastic and Reconstructive Surgery (May 2008), Dr. Steve Davison of Georgetown University reviews these basic issues. In HIV positive patients, they can safely undergo elective plastic surgery provided that a thorough preoperative workup has been performed. Patients with CD4 counts greater than 200 and low viral loads have surgical risks that are similar to the general population. There is no evidence to support the historic contention that they have poor or compromised wound healing. Increased surgical risks are in those patients whose CD4 counts are less than 200 or have viral loads greater than 10,000. The risk of disease transmission to the surgical team is not precisely known but is estimated to be around 0.3% for penetrating injuries from surgical sharps, a rate that is less than 10% that of hepatitic C exposure which is far more dangerous.

 
In my practice, I generally see known HIV-positive patients for facial lipoatrophy of the cheek and temple areas and fat accumulation of the back of the neck (buffalo hump). Both of these can be managed by non-surgical options although I find the surgical alternatives to give superior results. Injectable fillers, such as Scuptra, Radiesse, and ArteFill can be used to correct the typical patterns of facial wasting but they do require large volumes of injectate and numerous sessions. They quickly become as costly as surgery. A surgical alternative are submalar implants and fat grafting which I have found quite satisfying even if 100% of the fat does not survive. Buffalo hump reduction (dorsocervical fat accumulation) can be treated by LipoDissolve injections if the area is not too large but it usually takes at least 3 sessions over a greater number of months to get a reasonable result. Ultrasonic liposuction is far more efficient and can take away a larger amount of excess fat in an obviously shorter time.

 
I have found performing plastic surgery on HIV positive patients to be rewarding and well appreciated. They often suffer the stigmata of their disease and wish its improvement to improve their self-esteem and improved social acceptance. I have seen no greater incidence of complications in this patients than any other types of patients.

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

Facial lipoatrophy, sometimes referred to as facial wasting, is the loss of fat in the face usually in the cheek and temple areas. It is not necessarily loss of fat in all cases, in some it is simply that it was never there to start. It really represents a failure of adequate development of the buccal fat pad and all its extensions or a loss of this fat pad over time due to aging or certain medications. Facial lipoatrophy presents itself in five degrees of severity from the subtle type I, which usually represents as a mild congenital or natural gauntness to the face to the most severe type 5 which is best illustrated in the HIV patient where total loss of the buccal fat pad occurs due to the antiviral medications.

 
While a mild type 1 facial lipoatrophy appearance can be quite attractive when one is young (due to the appearance of high cheekbones), ongoing aging in one’s later years creates more of an unhealthy aged appearance. In severe facial lipoastrophy cases of the HIV patient, treatment of this facial appearance helps mask the stigmata of the disease. Various treatment options exist for the treatment of facial lipoatrophy and they can be tailored to how sunken the face appears. Most of the treatment approaches focus on the cheek or midface areas for enhancement or volume addition.
In miinor cases of submalar or cheek deficiency, many of the injectable fillers can be used. They are costly, require fairly large volumes, and are only temporary. Sculptra is the one injectable filler that has been specifically approved for facial lipoatrophy. It is essentially liquid ‘plastic’ and must be injected in layers over time. While it can be effective in the short-term, its development was based on its use in HIV patients who may not always be immunocompetent. Whether healthy patients with a normal imune system will adversely react to this filler more so than HIV patients remains to be seen. Such volumes of injectate for aesthetic applications make me a little nervous so I prefer other treatment approaches.

 
My preferred approach is the use of cheek, or to be more specific submalar, implants that sit below the cheek bone. This effectively pushes out the area where the buccal fat pad once was. The implants are placed through an incision inside the mouth and secured to the bone with screws. Additional implants can be placed over the upper jaw itself slightly in front of the submalar area. I have not seen any increase in infections or complications with the use of these implants, even in the HIV patient. Fat injections, using the patient’s own fat as a donor source, can then be done over the sides of the face where the implants do not create an effect. The entire facial enhancement could be done by fat injections alone but a lot of fat placed in not predictable in terms of survival in all cases.
While this combined implant and fat grafting approach does not treat all the areas of facial deficiency, it does focus on the most aesthetic area of the midface.

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