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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘cheek implant’

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

The Endoscopic Midface Lift With Malar Augmentation – Rejuvenation Of The Aging Cheeks

Sunday, March 20th, 2011

The midface is the most difficult part of the face in which to reverse the effects of aging. While the upper face (forehead) can be very successfully treated by different forms of a browlift and the lower face (neck and jowl) with facelift variations, improving sagging cheeks poses different challenges. The presences of the eyes and the bony orbit prevents a straightforward upward vector for soft tissue re-suspension and easy incisional access.

While the cheek tissues sag and falls vertically, any method of soft tissue re-suspension must be in an oblique and not vertical vector because of the eye above it. In addition, the lower eyelid and its rather delicate suspension system holds it uptightly against the eye. While eyelid incisions are commonly used for midface lifts, they definitely pose risks for lower eyelid sag problems if any tension is placed upon them or they are not meticulously put back together.

This is why the endoscopic approach for midface lifts can often be the best and safest approach. Through a combination of a temporal hairline incision and a mucosal incision inside the mouth, an uncomplicated dissection can be done in the subperiosteal plane. Such an approach avoids the problems associated with eyelid incisions and potential postoperative ectropion. Dissection between these two points is joined over the body of the zygoma. The wide connection between the temporal and intraoral pockets allows for tissues to be lifted for a volumetric change at the zygomaticomaxillary point.

One complement to a midface lift is cheek or malar augmentation. There are two approaches, synthetic or a natural source of cheek augmentation. Before suspension, a small cheek implant can be used to add further volume at the height of the existing cheekbone. It would be important to screw this implant into position given the wide open tunnel from the endoscopic dissection. The other option that I have used in some cases would be to use the buccal fat pad as the implant. By mobilizing it from its submalar location, it can be draped up over the cheek by an additional suture passed up to the temporal region.

In the world of facelifting, emphasis has been finally placed on rejuvenating the midface and improving the eyelid-cheek interface. Unlike other areas of facial rejuvenation, however, there are real risks from problems caused by incisions to do the procedure. This makes doing a midface lift using non-eyelid incisions appealing if possible. A lower blepharoplasty can be done with the midface lift and often some skin removal may be necessary as the cheek tissues are pushed upward.

Dr. Barry Eppley

Indianapolis, Indiana

Midfacial Implants – Different Styles for Cheek, Orbital, and Maxillary Augmentation

Friday, May 29th, 2009

Facial implants are a common and assured method of building out skeletally deficient areas such as the chin, cheeks, and jaw angles. While many are aware of these popular locations for esthetic facial enhancement, there are many more implant styles and locations than most envision. This is particularly true in the midfacial area.

The midface (between the lower eye sockets and the upper teeth)has the most complex external anatomical shape of any area on the craniofacial skeleton. From the prominences of the cheek bone to the concave surface of the pyriform aperture, no one single-shaped implant can be adapted to all of them. For this reason there are at least nine (9) different midfacial implant styles.

Cheek implants are the most commonly used midfacial implant. But there are four (4) different styles to choose from for the differing areas of esthetic deficiency on this bone. The standard cheek implant, also known as a malar implant, fits on top of the cheek bone and has a broad surface area that covers most of its surface area. The two (2) styles of this standard cheek implant differ in that the more extended version has a portion that goes up higher to make a smooth transition into the lateral orbital bone. For flat cheek bones, these implants styles will generally work well.

The submalar cheek implant, however, is indicated when the cheek soft tissues are a little droopy and the area under the cheek prominence is a little sunken in. This implant fits on the bottom or underside of the cheek bone which helps lift up sagging cheek tissues, fills out the submalar space and may even soften the deep nasolabial fold a little. The submalar cheek implant comes in two styles which differ in how much fullness is added to the submalar space.

The tear trough midfacial implant is a specialized lower orbital rim (eye socket) implant. It augments the depressed suborbital groove that some people have naturally or develops from aging and tissue atrophy. This groove runs between the inside of the eye across the lower orbital rim often ending below the cheek. While some use fat injections for augmentation of this area, a carefully placed tear trough implant provides permanency to this contour problem.

The pyriform aperture implant fits along the bone which forms the side rim of the nasal cavity. It is designed to build out the base of the nose where the side of the nostril meets the lower cheek tissues. I have most commonly used this implant in secondary cleft surgery to build out the deficient bone area where the cleft went through. While bone grafts are commonly used for this problem, the pyriform aperture may still remain depressed even with a well done bone graft.

The premaxillary or peri-pyriform implant builds out the entire base of the nose from one side of the pyriform aperture to the other. This includes anterior nasal spine area as well. For very flat midfaces, this implant can really help provide augmentation to the nose and upper lip.

The nasolabial or melo-labial groove implant fits onto the bone to the side of the nose and helps soften or build-out the very deep nasolabial fold or groove. Rather than using temporary injectable fillers placed beneath the skin, this implant placed on the underlying bone serves to provide the same push.

The Lefort or maxillary implant, the least common of all midfacial implants, is designed to be used during or after a LeFort I osteotomy. This implant would fit above the osteotomy line so that the midface would not look more deficient as the maxillary teeth come forward.

All midfacial implants, while being very different in shape and indication, share two common features. First, they are all placed from an incision inside the mouth so no skin incision is ever needed. Secondly, they are all best secured into position with a screw as their position is critical in getting the desired esthetic result.

Dr. Barry Eppley

Indianapolis, Indiana

Improving the Shape of the Face by Bony Augmentation and Fat Reduction

Thursday, October 9th, 2008

Making a face more square or angular can be done through bone augmentation, fat reduction, or both. I have found that there are two types of patients who come because they want a more defined facial look. First is the male patient (usually younger)who does not necessarily have a full or fat face but wants more definition at the defining points of the face. In some cases, I call this seeking the ‘male model look’. The second type of patient is male or female who does have a fuller face and simply wants to be ‘less round’. Their goals are not quite so precise as the first patient. Usually they are younger as well but can be middle-aged also.

The defining bony points of the face are the cheeks, chin, and jaw angles. Facial fat points are the cheeks and neck. Those searching for the ‘male model look’ are usually looking at the trio or combination of cheek, chin and jaw angle implants.  The thinner the face is, the more profound the result will be with this triple implant approach. When you are placing three implants, or simultaneously changing three facial prominences, it is always best to not to overdo it. Large implants in all three places can create a very unnatural or artificial look. Cheek implants never look too good if they are too large.  Subtle cheek changes are more natural.The proper size of a chin implant is easier to know because the amount of chin deficiency can be measured in profile. Most men should consider a more square chin implant style as that is often what this type of patient is trying to achieve. Jaw angle implants can rarely be too large as they are manufactured small anyway and the jaw muscles and thickness of tissue over the jaw angles can camouflage a great deal of the implant.

Those trying to deround a face must use a different approach. Fat removal in the neck (liposuction) and in the cheeks (buccal lipectomies) are an important element of derounding and is often done with a chin implant. In rare cases, cheek implants may be considered but they should be small as buccal fat removal will create the visual impression of some minor cheek augmentation as the area below the cheek moves inward. This type of facial derounding is more subtle than squaring a face with the most dramatic changes occurring in the neck and less in the cheek and side areas of the face.

Careful analysis of the face prior to surgery through computer imaging can be invaluable in this type of surgery. Changing multiple areas of the face at one time, with the objective of changing one’s facial look, requires good insight and understanding between the patient and their plastic surgeon.

Dr. Barry Eppley

Indianapolis, Indiana






Facial Reshaping Techniques for Improving The Round Face

Thursday, July 10th, 2008

Not infrequently I get requests from patients for the desire to transform a round face into a more shapelier one. One cause of a round face is that the patient is overweight. A full neck, round cheeks, and a lot of subcutaneous fat throughout the face creates a generalized fullness that creates a fat and round face. These patients know full well that they are overweight and some liposuction of the neck and buccal lipectomies may make some difference. But weight loss will probably make the most difference in these cases. And these procedures should not be performed until some weight loss has been achieved.
But the overweight patient is not what usually makes up the ’round face’ patient. Most commonly these are younger patients that are not significantly overweight and are usually closer to being more height and weight porportionate. They may have some mild fullness in the cheeks and neck but often their bony prominences (cheeks, chin, or jaw angles) may be somewhat deficient. The approach to these patients must deal with both hard and soft tissues issues to be effective at improving the face’s angularity and definition.
In addition to the fullness of the cheeks and neck, the next most important consideration in facial shape improvement should look at the chin. Often it may only be midly short in the horizontal dimension but the width of the chin is also important, particularly in the male patient. Chin implants today can provide more projection as well as width in many different sizes. Placed through a small incision under the chin bone, a chin implant can lend more definition and squareness to the lower face from subtle to dramatic results.
Upper facial fullness, more specifically midfacial fullness, can be achieved through cheek implants. Placed into position by incisions inside the mouth under the upper lip, cheek implants can provide good highlights through three-dimensional enhancement of the bone as it wraps around the area below the eye. An amazing aray of cheek and midface implants is available to provide a lot of enhancements around this important facial landmark. When paired cheek implants are combined with a chin implant, an upside down triangle of change is created that directly opposes a more round or oval facial shape.
Jaw angle implants are always a possibility but these are rarely needed in most really round faces. They can produce some lateral facial fullness but this is not usually helpful in ‘de-rounding’ the face.
The procedures of buccal lipectomies, neck and jowl liposuction, chin and cheek implants make up the usual plastic surgery tools for facial rehaping. Which one or combination of procedures is most helpful for improving facial definition is best determined by careful computer imaging study between the patient and their plastic surgeon.

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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