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Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘cheek augmentation’

Understanding Cheek Implant Augmentation

Monday, December 31st, 2012


Implant augmentation of the cheeks provides a valuable facial structural enhancement as well as is useful for an anti-aging effect. For many women, it may be the most critical aesthetic facial prominence (short of the nose) in contrast to men where it is the chin and the jawline. The cheek in both genders, however, can make the face more bold, defined and attractive. But cheek augmentation is a procedure that is harder to predict the  implant’s effect on males or females because it is a curved facial feature that defies any exact mathematical measurement like most other facial features.

When one factors in the many different styles and sizes of cheek implants, not to mention the different manufacturers and materials, there may be upwards of near100 different cheek implants to choose from. How does one know what is the best cheek implant to choose for this midfacial area? There are numerous factors to consider but the first is to recognize the gender differences in desired cheek shapes. Men desire and look better with a more chiseled cheek appearance that is often described as angular . This is a high more sharply defined cheek look. Conversely, women usually desire and look better with a less angular fuller cheek. This round cheek creates a softer more feminine appearance.

Because the cheek is not seen at its best in either a frontal or a profile view, it defies any exact measuring system. The influence of the cheek is best seen in a quarter or oblique profile view which is how most people see your face anyway. It is possible to isolate the most optimal area of cheek enhancement by the intersection of an oblique line drawn from the corner of the mouth to the corner of the eye and a horizontal line drawn outward from the top of the nostrils. Higher up from this intersection is where male cheek prominence should be while more near the intersection is where female cheek prominence should be. But no measurement can tell one about the best cheek implant size. This is where the role of intraoperative implant sizers and the aesthetic judgment of the surgeon comes into play.

Cheek implants are used for four types of aesthetic facial issues. The most common indication is for inadequate cheek volume or an underdeveloped cheek area. The cheeks simply did not develop with the desired amount of aesthetic projection.  Asymmetry of the cheeks is another indication which can occur from mild to more severe forms of facial hypoplasia or from cheekbone fractures that were not adequately treated or not diagnosed at the time of the injury. Ethnic cheek augmentation is a third use of implants that represent a form of cheek ‘underdevelopment’ but is really more of an effort to change one’s basic facial shape.This is most commonly seen in Asian and African-American patients where improved cheek projection is desired as one of the maneuvers to change their facial shape. Lastly, which is not really a bone-problem, are the effects of aging. The soft tissues of the cheek are pulled downward towards the mouth area, revealing what appears to be a cheek deficiency. Pushing the soft tissue upwards with an implant is more important here than pure bone augmentation.

When selecting the style of cheek implants, it is important to realize what area of the cheek bone needs to be augmented. If it is a high angular look that one wants, then the cheek implant should be more narrow so that it does not augment the lower or front edge of the cheek bone. For rounder fuller cheeks, the implant needs to be wider to cover the entire cheek bone including its lower edge. To widen the face, which means the posterior edge of the cheek bone and onto the zygomatic arch, the implant design needs to extend further back or be positioned further back on the cheek bone. If the soft tissue of the cheek needs to be lifted, then the implant should have its greatest prominence on the bottom of the cheek bone or the submalar area. Thinking about how the shape of the cheek bone needs to be changed is how the style of cheek implant is selected and one can then easily work their way through the maze of implant options.

One cheek implant issue that is chronically debated is the choice of implant material, which is fundamentally either silicone or Medpor. While there are advocates of either material, what really matters is whether it have the right shape for the area of desired cheek augmentation. Your body does not really care which material is implanted. It will react the same by enveloping it a capsule of scar. The only real difference is that a Medpor implant will be harder to remove or adjust its position but not impossible. Regardless of the material, it is always best to secure the cheek implant into permanent position with a self-tapping 1.5mm screw, one for each side.

Dr. Barry Eppley

Indianapolis, Indiana

Shaping The Male Face

Monday, October 17th, 2011

Superman has been an American cultural icon since he first appeared in comic books back in 1938. His appearance is absolutely distinctive, most notably that of his red, white and blue colors and the stylized S shield on his chest. The shield is so symbolic of his character than its appearance alone immediately brings image of the comic character.

But beyond the colors and the symbol, many of his other features are particularly iconic of what masculinity and attractiveness is supposed to be. His face is absolutely chiseled and proportioned and exudes strength and power. Such Man of Steel facial features appear to have galvanized one male fan to undergo numerous plastic surgery procedures to try and look like this popular superhero.

Hebert Chavez, a superfan of Superman from the Phillipines, has dramatically altered his face to look more like Superman. New agencies have reported that he has undergone a series of operations since 1995. These have included a chin implant to get a strong chin with a cleft, nose reshaping, injections for fuller lips, cheek and jaw implants and eyelid surgery. As bizarre as this sounds, his surgical results actually look pretty good and not as unnatural as one would think.

Such a plastic surgery story brings to mind another face changer, Michael Jackson, and there is no doubt that they both share the similar malady of Body Dysmorphic Disorder. In this mental illness, a person can’t stop thinking about how their appearance is flawed and that perfection is just a surgery away.

But beneath these extreme cases of facial plastic surgery lies some basic truths about what makes a male face more appealing. It starts with an overall facial shape that has more definition and a square to inverted triangular shape. The three bony highlights of the male face are the chin, cheeks and jaw angles. Some degree of prominence in all of them is important to create a sense of overall angularity. Therein lies the frequent use of chin, cheek and jaw angle implants to create those prominences if they are weak, flat or recessed.

In the more lean male face, creating these prominences with implants alone may be adequate. As the chin, cheek and jaw angles become more visible, the non-bony supported areas (submalar and lateral face and neck) will appear more concave as the amount of subcutaneous facial fat in these areas is thin. In the rounder or fuller face, however, some fat removal will need to be considered. This could include procedures such as buccal lipectomies, lateral face and neck liposuction to try and change a convex shape in these areas to at least one that is flat or ideally a little bit concave.

Not every male face can be made more ‘super’. These facial plastic surgery techniques work best in a face that is not too overly round or thick. Such facial shapes are the kryptonite for obtaining the well defined male face that is deemed in both comic books and in real life as desireable.

Dr. Barry Eppley

Indianapolis, Indiana

Cheek Augmentation and Facial Attractiveness in Men and Women

Saturday, July 23rd, 2011

It is well known that one of the major contributors towards the perception of an attractive face, albeit a man or a woman, is the proportion of certain features. Known as indicators of facial beauty, disproportionate and asymmetric features are the main reasons many patients seek plastic surgery procedures. One can debate endlessly why this is so, but we are fundamentally driven to an attractive face from an innate drive of evolution and the desire to procreate. Attractiveness is desireable because it is perceived, right or wrong, to be associated with better genes.

But what are some of these features and can they really be changed by plastic surgery? For women it is bigger eyes, a rounder forehead, a smaller nose, well defined cheeks, larger lips and a chin that is not too prominent. For men, slightly prominent brows, a nose with a high dorsal line, well-defined cheeks, and a strong chin and jaw angles are associated with more masculinity. Short of the size of the eyes, all of these facial features can be modified by differing plastic surgery techniques.

The one desireable facial feature that both men and women share is the value of high and well-defined cheek bones. It is probably the only facial feature whose size and prominence is considered attractive for both sexes. It is also the one facial feature that I never receive requests to be reduced. (short of Asian patients and this more about the zygomatic arch width not anterior cheek projection) Few patients, if any, really want smaller cheeks.

What is it about high cheekbones that makes them some desireable? Many say that they feminize a face. If high cheek bones contribute to greater femininity, then why would it be attractive on men? The caveat is that it is only an aesthetically desireable facial feature in a man when it coexists with a stronger jawline as well. Strong cheekbones on a man with a small jaw or chin does not make for an attractive face. It is the angularity of the three defining points of a male face, the cheeks, chin and jaw angles, that makes for its aesthetic desireability. Such well-defined facial skeletal highlights equates with a strong and virile personal character. (and maybe the chance to pass along some good genes)

The benefits of cheek augmentation in either a man or a woman must take into consideration these aesthetic and gender differences. While cheek enhancement can be done with injectable fillers, I am reserving my comments here to the insertion of implants. Injectable fillers are largely a good trial method to determine the merits of proceeding to a permanent cheek augmentation in my opinion. Cheek implants in women should be softer and more round to provide volume but they usually don’t need to be angular or cross onto the zygomatic arch or encroach upon the lateral orbital rim area. This can add too much width which is not usually feminizing. Cheek implants in men often need to be more angular and add more height. They are beneficial to help balance out a strong jawline or should be done in conjunction with chin and jaw angle augmentation.

The cheeks can contribute significantly to one’s facial attractiveness. But it needs to be considered within the context of the whole face. The balance of one’s facial features is what makes for gender-specific facial beauty.

Dr. Barry Eppley

Indianapolis, Indiana

Surgical Options for the Chubby Face (Fat Face)

Monday, February 15th, 2010

It is not uncommon to hear a patient’s concern about their chubby or ‘fat face’. For some of these patients their face matches their body habitus and some significant weight loss will do wonders for those concerns. But there are people who do have a chubby face that are not necessarily significantly overweight and they may seek a plastic surgery consult to see what their options are.

 The chubby face differs from other facial types in that the entire face appears full. From the cheeks down to the neck, the face assumes a definite round shape. Patients with a chubby face will often complain that the shape of their face makes them appear heavier than their body really is.

There are numerous non-surgical facial fat reduction methods that are marketed and sold. I can not comment on whether these work or are effective as they are not used in my Indianapolis plastic surgery practice. But should you try them and find them unsatisfactory, you can consider the following surgical options.

Almost all chubby face patients have thicker and elastic skin. This is a double-edged anatomic consideration. Such skin has the ability to shrink and contract (snapback if you will) which is good for getting better contours, particularly in the neck. Conversely, thick skin is also heavy and is prone to prolonged swelling.

The strategy for the chubby face is not one of overall fat reduction through liposuction. This is not possible in the face contrary to the perception of many. Select or spot fat reduction must be done instead. This would include submental and neck liposuction and buccal (cheek) lipectomies. These are very consistent procedures that are effective but patients should not expect them alone to produce a dramatic facial change. Fat pockets around the eyes and excessive skin can also be helpful if they exist but these are complementary procedures, not a primary modification maneuver.

There are no other fat areas of the face that can be effectively reduced. While significant changes can be made, for example, through a superficial parotidectomy and submandibular gland removals, these are extreme procedures which are not justifiable for cosmetic changes. Attention must be turned to bringing out facial prominences to aesthetically work in the opposite direction.

The cheeks, chin and nose must be carefully look at to see if their accentuation would be beneficial. The chin is the easiest one to assess as a weak chin is readily seen. Chin augmentation, even if it is only a minor amount, can complement the contour pullback from the neck liposuction. Cheek augmentation is more difficult to determine its potential benefits as it is not a profile structure. Unlike the chin, cheek augmentation in some patients may actually make their face look fuller or heavier. A cheek implant to help make a face look thinner must be placed high on the cheekbone and not be overdone in amount and location of projection. Too much anterior or too much lateral projection creates undesired midfacial fullness.

A rhinoplasty with dorsal augmentation and tip narrowing can help make the face look thinner by an optical illusion effect. Thinning of the nose is the one procedure that affects the central face whose appearance is not based on how much fat is present. Patients with chubby faces rarely have a narrow nose or a nose with a high dorsum. Usually they have a broader dorsum with a wider tip to their noses.

To change the appearance of the chubby face, multiple soft and hard tissues procedures are needed. These can include neck and cheek fat removal, blepharoplasty, and facial bone prominence highlighting. Piecing together these procedures into an effective facial surgery plan is as much an art form as any definitive science.   

Dr. Barry Eppley

Indianapolis, Indiana

Common Questions about Cheek Augmentation (Implants)

Saturday, January 16th, 2010

The appearance of a well-defined cheekbone helps provide a sculpted and youthful look as it provides midfacial prominence and give the appearance of a thinner lower face. Flat cheekbones can make a large nose look larger and a receding chin smaller. The cheekbones are one of the three convex prominences that help define your face, highlighting the eyes and adding balance to your features.

Cheek augmentation (also known as malar augmentation or malar implants) is a surgical method to bring the cheeks into better balance with your other facial features.

  1. How do I know I am a good candidate for cheek augmentation?

People who benefit by cheek implants have smaller or flatter cheek bones naturally and/or have sagging of the cheek soft tissues due to normal aging. With aging can also come deflation, or loss of healthy fat which normally lies just under the cheek bones. This can give a gaunt look to one’s face.

A cheek implant can build out the flat cheek bone, provided a lifting effect to sagging cheek skin, and can partially fill out a sunken in look. Think of it as adding substance which may just make the cheekbone bigger or help hold up sagging or collapsed tissues.

That being said, whether anyone would benefit by a cheek implant is as much an  artistic feel as a facial feature that can be precisely defined. Unlike other facial implants, such as chins or jaw angles which can be measured and morphed with computer imaging, cheek implants defy such analytical evaluation as the area is not a clean profile or silhouette. This is an area that requires a good evaluation and discussion with your plastic surgeon using a mirror and finger technique.

2. What are cheek implants made of?

The vast majority of cheek implants are made of solid silicone rubber that is very flexible. While there are a few other materials of which they are made, they are not very popular. What material they are made of is not as important as two other critical issues; what styles and sizes are available and how easy are they to insert. This is where silicone rubber has a huge advantage over other materials.

One type or style of cheek implant is not right for everyone. The cheek bone shape and geometry and the soft tissue overlying them is different for each patient. Just like the obvious benefits of different sizes, style or shape of the implant needs to be individualized. That is why there are nearly a half-dozen different cheek implant styles. Only a silicone rubber material can offer this diversity of selection.

The flexibility of silicone rubber and the ability to have feathered edges allows it to be the easiest material to position on the bone without having an edge that can be felt or seen.

3. How is cheek augmentation surgery done?

There are two approachs to placing the implant, from inside the mouth and through the lower eyelid. By far, the intraoral method from a small incision up high under the lip is preferred. The only reason to use the eyelid approach is if a midface lift or suspension is being done at the same time.

From inside the mouth, a path is made up onto the cheek bone. It can be extended out onto the zygomatic arch if necessary. Sizers are used to determine what will look the best. The final implant is then inserted. Some plastic surgeons secure the implant in place with a small titanium screw, others do not. Closure of the incision is done with dissolveable sutures.

4. Is cheek implant surgery painful? How long does the swelling last?

I would not call it painful, rather it is more uncomfortable due to the swelling. Often there is some numbness of the cheek skin  which goes away in the first month after surgery. There rarely is any bruising because the surgery is very deep on the surface of the bone. Any bruising that occurs will not be seen on the skin but will present only as swelling. While remnants of swelling take six to eight weeks to completely go away, you will look fairly normal within two to three weeks. The initial abnormal fullness will have go away by then.

5. What are the risks and complications that can occur?

The standard surgical risks of bleeding and infection apply but they are very uncommon. The risk that is more significant and probably accounts for most instances of revision or secondary surgery is implant asymmetry or sizing issues. Because the cheeks have two sides, the placement of the implants must be perfectly symmetrical. That may seem easy but even slight changes in orientation of the implant may be able to be seen. Implants can also shift or slide downward towards the direction in which they were placed. Oversized cheek implants are especially noticeable because they can make the face look very unnatural. Cheek implants are always best done smaller than bigger.

One risk of having cheek implants is delayed infection, even many years later. This is caused by one specific event…dental injections. This can happen when your dentist is numbing your upper teeth. The needle can tract bacteria near or onto the implant. Advise your dentist if you have cheek implants.

6. I’d like higher cheekbones but I don’t want them to look fake. How can this be avoided?

There are many well known examples of famous people that look strange and overdone after facial rejuvenation surgery. In some of these cases, it is obvious they had cheek implants and it is because they are too big. This ‘error’ is most likely to occur when cheek augmentation for anti-aging purposes and are being used to fill out sagging cheek tissues. A cheek implant is not the same as a breast implant…its size should not be pushed to do too much.

7. I have very flat cheeks that extend down below my eyes. It makes me look sad. Will cheek implants help?

Having flat cheekbones can give the face a long drawn look that many may describe as sad. In the facial expression of smiling, we naturally see more prominence in the cheek area. When it is flatter it adversely affects how one’s smile looks. More fullness in the cheek allows a more  youthful look, whether one is smiling or not.

Dr. Barry Eppley

Indianapolis, Indiana 

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

Cheek Augmentation – Preventing Complications and Improving Outcomes

Thursday, November 19th, 2009

Cheek augmentation is done for a variety of different aesthetic reasons. Besides the obvious need to fill out a sunken in cheek appearance and improve facial balance, they are just as commonly used for an anti-aging effect. By augmenting the soft submalar tissue to fill midfacial hollows, the lifting of this tissue provides a facial rejuvenating effect and may even soften the depth of the nasolabial fold beneath it. This tissue lifting or anti-aging effect is unique amongst facial implants.

The shape of the cheekbone and its location between the convex orbital rim and the concave maxillary wall make it the most complex facial area to augment from an aesthetic standpoint. Where along the cheekbone should the implant be positioned and what shape and size of implant should be used are what the plastic surgeon ponders. There really are no guidelines as to how to exactly to make these selections. Artistic technique is as important as any type of scientific approach. This high degree of variability lends to revision rates that are higher than any other facial implant currently used.

Cheek implant complications usually are of two types, undesired aesthetic outcome and implant shifting or migration. Unhappy outcomes come from either an implant that is too big or positioned in the wrong location. Either way, an unnatural appearance often results. Because of where cheek implants are located, they catch attention almost as much as one’s nose or eyes. Cheek implants come in a variety of sizes and shapes but can fundamentally be divided into malar and submalar implants. Malar implants being placed on top of the zygomatic bone and submalar implant highlighting the underside of the bone. (submalar hollow or buccal space) Malar implants have different extension that either go back further onto the zygomatic arch, up around the lateral orbital wall , or anteriorly along the underside of the orbital rim. Because of these variable implant shapes, it takes a good aesthetic eye and communication with a patient beforehand to get a good result.

Cheek implants are also unique because of where they are positioned on the zygomatic bone. They often are sort of hanging from the side of the cliff, which makes them prone to shifting. Shifting will usually occur in a downward direction from whence they were initially inserted, which is usually through the mouth. For this reason, it is possible for cheek implants to shift around and end up with asymmetry. This is particularly true if the implant is made from silicone which is very smooth and slippery. Other implant composition have a much greater frictional grip on the bone and will not move as easily.

One interesting silicone cheek implant design which can effectively address the shifting problem is that of the Conform midfacial implant. Its undersurface is not smooth silicone but rather a pebbly or nubbed surface. The many little ‘’fingers’ of silicone allow it to develop some degree of frictional gripping to the bone surface. Also when soft tissue grows around it, the capsule will absolutely lock it into place. This is very similar to the concept of placing a textured surface on a breast implant which was developed nearly twenty years ago. Its shape also allows it to be trimmed and used as either a malar or submalar implant. 

Dr. Barry Eppley

Indianapolis, Indiana




Cheek Implants in Patients with Dentures

Thursday, October 15th, 2009

Cheek implants are a fairly simple and effective method for adding projection of various areas of the zygomatic midface. Because they are various shapes of cheek implants that are available, there is a fair amount of art as opposed to science in selecting style and size of implant to get the patient’s desired effect. Because these implants are placed on the side or underside of a bony surface, they are also prone to postoperative migration in an inferior direction of they are not secured.

Cheek implants are typically shown in textbooks, journals, and patient results in patients who have teeth. By having teeth, the vertical distance from a positioned implant to the maxillary vestibule (highest area under the upper lip) is maximized. There will always be a good soft tissue buffer between the implant and the inside of the mouth. This lessens the long-term likelihood of implant exposure should it ever migrate downward. (if one secures the implant with screws, this will not happen)

In the patient without teeth, however, the use of cheek implants can be more problematic as the facial anatomy has changed…unfavorably. The loss of upper teeth changes the structural integrity of the face. The vertical dimension of one’s occlusion (bite), or the height of the bite formed by the contact of the upper and lower rows of teeth, determines the shape and length of the cheeks. When a patient becomes edentulous, the mouth closes too fully with no teeth to separate the jaws, thus contributing to a sunken in appearance of the cheeks. Without teeth, the cheeks tend to wrinkle, the angle between the nose and the lips changes, the ridges that hold the teeth flatten, and the tongue may splay out to fill the open mouth space. These changed features often make the edentulous patient seek midface volume replacement.

The fundamental concern in placing cheek implants in a patient who wears an upper denture is two-fold. First, the distance between the cheek bone and the maxillary vestibule has shortened considerably. There is less soft tissue coverage between the implant and the oral mucosa. This makes the use of certain types of cheek implants, the submalar implant specifically, more risky. Because it sits on the underside of the zygomatic bone, it is even closer to the lining of the mouth. Secondly, the flange of an upper denture can be an erosive source causing implant exposure. A high-riding denture flange may eventually cause pressure necrosis of the thin soft tissue between it and the implant. At the least, it can be a source of irritation and discomfort.

Cheek implant selection is critical in the edentulous maxilla. The implant should be placed on the zygomatic prominence and its maxillary extension trimmed if necessary to keep it from hanging too low. The implant should absolutely be secured in place by a screw. If the implant needs to be extended for midface volume, it should go as close to the infraorbital nerve (without compression) as possible. The canine fossa area should be avoided, as tempting as it is to help this volume deficient area. Lastly, the patient’s dentist should be consulted to shorten the posterior flange of the maxillary denture before surgery. The broad palatal surface provides enough surface area for retention that the flanges can be shortened without sacrificing denture stability.

Cheek implants can work effectively in the typical older edentulous patient who usually suffers midfacial volume depletion and sag. Several alterations in surgical technique are necessary to avoid the increased risk of eventual implant problems caused by vertical maxillary shortening.

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

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

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

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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