Your Questions

Q: Dr. Eppley, I want to get cheek implants, a sliding genioplasty and jaw angle reduction.My question is that I have just had maxilla advancement jaw surgery (LeFort 1 osteotomy) one months ago. Only the maxilla was moved forward. The mandible was not moved. How long is necessary to wait before I can come see you to get these surgery procedures done? I worry the maxilla may be banged in the surgery or after 4 weeks is this not a problem?

A: Since you just had a LeFort 1 osteotomy just four weeks ago, I would wait a full 8 weeks before doing any surgery that would involve re-entering the surgical site (cheek implants) This is not because the maxilla has any change to be displaced. (it is undoubtably rigidly secured into place with plates and screws) but because you want all the swelling to get out of the cheeks so you have a good idea when placing cheek implants so that the style and size of the implants could be best judged. As it relates to the mandibular procedures (sliding genioplasty and jaw angle reduction) the previous LeFort 1 osteotomy has no impact on their execution and vice versa. But waiting until all facial swelling has resolved is still worthy of the wait.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wondering how augmentation of the zygomatic arch is done. Is it possible and is it safe to do? It seems that it would not be much different than getting cheek implants.

A: Zygomatic arch augmentation is permanently done by placing an implant from inside the mouth, very much like a cheek implant. (only further back to the temporal bone in front of the ear. This is easiest and most consistently done using a remade implant as opposed to filler, fat or any other type of material injections. Zygomatic arch augmentation can be done alone or in conjunction with the cheek as an extended cheek implant. It is ideally done using a custom made implant for an exacting fit but in some cases may be able to be done using a ‘semi-custom’ approach. (semi-custom means using a custom zygomatic arch design already created for another patient) There is not that much variation in the shape or curve of the zygomatic arch amongst most people.  As you may know there is no specific zygomatic arch implant available off the shelf or premade. So zygomatic arch augmentation must be done by making the implants for each patient. (custom vs semi-custom)

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek implant replacements. I had cheek implants placed two years ago. As a result, my cheeks are uneven and prominent in the wrong place. I want high cheekbones and also the uneveness of the current submalars makes one cheek look higher and more prominent and throws my jawline off making it look wider on one side. I want to correct this and obtain higher cheekbones instead of the cartoon character look. That’s why I want to swap them out for other cheek implants, either malars only or combo implants. Can you look at my pictures and give your recommendation?

A: Thank you for sending your pictures and questions about cheek implant replacements. It is very clear that the large submalar cheek implants is really not the right cheek implant style for you. It creates too much fullneess below the cheek bone which does not work well in your face. I would recommend the following:

1) Remove existing submalar cheek implants.

2) Your new cheek implant style would be any form of a combo or one that has no submalar component at all.

3) You need ‘high’ malar augmentation style implants that also go back further onto the zygomatic arch. No such standard malar cheek implants exists, even amongst the standard malar options. Ideally a custom cheek implant style is made that would fit your face precisely and create the augmentation exactly where it is needed. Because your current implants have created loose cheek tissues, the new cheek implants really need to help lift up this tissue.

4) If I was ‘forced’ to use a standard cheek implant I would use the malar shell style and modify it during surgery.

5) I would consider doing subtotal buccal lipectomies and perioral mound liposuction to contour in the area below the new higher malar augmentation to maximize the effect.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implants placed two years ago. As a result, my cheeks are uneven and prominent in the wrong place. I want high cheekbones and also the uneveness of the current submalars makes one cheek look higher and more prominent and throws my jawline off making it look wider on one side. I want to correct this and obtain higher cheekbones instead of the cartoon character look. That’s why I want to swap them out for other cheek implants, either malars only or combo implants. Can you look at my pictures and give your recommendation?

A: Thank you for sending your pictures. It is very clear that the large submalar cheek implants is really not the right cheek implant style for you. It creates too much fullness below the cheek bone which does not work well in your face. I would recommend the following:

1) Remove existing submalar cheek implants.

2) Your new cheek implant style would be any form of a combo or one that has any submalar component at all.

3) You need ‘high’ malaria augmentation  styles implant that also go back further onto the zygomatiuc arch. No such standard malar cheek implants exists, even amongst the standard malaria options. Ideally a custom cheek implant style is made that would fir your face precisely and create the augmentation exactly where it is needed. because your current implants have created loose cheek tissues, the new cheek implants really need to help lift up this tissue.

4) If I was ‘forced’ to use a standard cheek implant I would the malar shell style and modify it during surgery.

5) I would consider doing subtotal buccal lipectomies and perioral mound liposuction to contour in the area below the new higher malar augmentation to maximize the effect.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw angle implants and cheek implants. I’m 31 years old  and I’ve always felt my cheeks and jawline have been a bit “soft” and chubby despite me being rather skinny, so I was hoping you could give me your opinion. I’ve attached a couple images to the post but I’ve also uploaded a file here which includes multiple angles of my face: I wanted to discuss whether surgery might be appropriate on the following areas, given I’m not at all overweight and I don’t think I could address them via weight loss:

1) You can see there is some fat under my chin towards the back of my neck in the first picture when the camera is tilted upwards (I’m 6’1″ tall so it’s fairly visible in everyday life).

2) You can see from the side views that my jawline is quite “soft” and not well defined in general, particularly towards the back.

3) What I assume is the jowl area (labelled in red on one of the images) also seems quite “chubby” and both hangs down below my jawline and makes my lower face wider and less defined than it would otherwise be. There’s also a pre-jowl “hole” in my jawline in the 3/4 view that may or may not be connected with this.

4) My cheek area as a whole just seems quite flat and undefined when seen from the front. There doesn’t seem to be much shape there, it’s kinda just a large empty space.

I’ve had a chin implant in the past (Implantech Anatomical Chin sized large) and I’m generally content with the new position of my chin, but I was told I had an underdeveloped jaw and I assume that is contributing to these issues. However, as the surgery to fix that issue is such a major undertaking I was hoping it would be possible to address these issues via other methods. 

I’m curious as to whether these issues are caused by excess fat or by skeletal deficiency? Would liposuction be a good idea? Are cheek implants a possibility to give my cheeks a bit more structure?

I had cheek implants placed roughly 18 months ago, but I had them removed again 6 months ago as I felt they made my face too wide (and a little feminine), particularly when I was smiling. However, we never really discussed the different areas of the cheek that could be enhanced via an implant before the surgery, so I’m unsure if I was unsuitable for implants in general or if the type of implant was simply poorly chosen.

Thanks for your time and apologies for the long email!

A: Thank you for your inquiry and sending your pictures. For our jawline, I think the fundamental problem is that of skeletal deficiency. By your own admission you had a naturally shorter and underdeveloped jawline that ideally should be treated by orthognathic surgery. But, understandably, you do not want to purse that amount of effort. The chin implant has now provided adequate anterior jawline projection but the rest of the jawline behind it remains deficient and actually now has become more apparent with the chin being corrected. Your jaw angles are high and deficient. This creates a relative soft tissue excess/looseness. While liposuction can be done around the jaw angles and along the jawline, it is not really going to reshape these areas. This is an issue of volume deficiency particularly at the jaw angles. Either preformed or custom jaw angle implants are what you really need to complete the total jawline augmentation effect.

Since you have had cheek implants that were not successful, any reconsideration of them should be done more thoughtfully. I would need to see before and after pictures of your initial cheek implant results and to know exactly what style and size of cheek implants that were used. It is certainly true that a cheek implant is not just a cheek implant. There are different styles of cheek implants and, in my experience, most of the available cheek implant styles are not really made for men. (just like most chin implants do not really work well for most women)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few questions about faclal implants. Can cheek implants be done with local or non general anesthesia? Also I have a short face and need to add lateral width and height but I worry about the big wrap around jaw implants involving the masseter muscle. So can we do a custom chin implant with wide wings extending laterally and vertically as far back posteriorly as possible but not hitting the masseter muscle. I realize there would be a major step off somewhere further down the jaw and the rest all the way around the ramus I would fill in with fat or radiesse. Also could that be done without general anesthesia too?

A: In regards to facial implants, certainly cheek and an extended chin implant can be done under IV sedation or MAC. (monitored anesthesia care) The use of local anesthesia for most facial implants alone would likely be inadequate and that would be doubly true if both cheek and chin implants are done at the same time. Be aware that the use of local or IV sedation does not save any money as the intraoperative time to do facial implants takes twice as long as when done under general anesthesia. So your motivation for the selection of anesthesia for these facial implant surgeries should not be one of saving money.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had so much filler, including volume (five vials of Sculptra and Juvederm within the past year) and I still feel that my cheeks are not full enough. I had very high cheek bones when younger and I am now 52 years old. I used to do the IPL laser years ago and this thinned my face very much due to fat loss. I would like to have a consistently full face rather than be dependent on these costly fillers. When I do the filler the swelling makes me look fantastic, but once the swelling is over it is deflation all the way. I thought that cheek implants, even the smallest, would give me a foundation that I could be happy with. 

A: injectable fillers play a major role in facial voluminization, particularly in the cheek area. But the reality is that it is not a long-term solution to one’s desire for fuller cheeks. Fillers are great long enough until one’s decides that they either want to ‘graduate’ to more permanent solutions or to stop their cheek augmentation efforts. While fat injections are one of the two more permanent options, cheek implants provide an assured method of permanent cheek augmentation. With the wide variety of cheek implants style and sizes, patients and plastic surgeons have a lot of good options to choose from for permanent cheek augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have rather under defined but wide cheeks. I’m interested in undergoing both Cheekbone Reduction and Cheek Implant surgeries. I saw your answers on RealSelf and wanted to know more about your experiences in these surgeries. Also, how much would it cost to perform both surgeries? Thank you a lot in advance.

A: You have the classic wide cheekbones (technically zygomatic arches) that do not have much anterior projection over the body of the zygoma. (malar prominence) Hence your description of ‘underdefined but wide cheeks’. As you already know improving this type of cheekbone anatomy requires cheekbone reduction surgery (technically inward respositioning of the zygomatic arches) and implant augmentation. (anterior cheek augmentation) The most challenging aspect of this surgery is in the cheek implant design. There is no standard cheek implant made that achieves the type of cheek augmentation that you need. Fortunately I have treated enough Asian patients who desire this exact type of cheek change that I have designed specific cheek implants to achieve this anterior projection but which create no lateral projection or width increase.

I will have my assistant pass along the cost of the surgery to you on Monday.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had injectable fillers in my cheeks with injections of several popular products over the course of three years now. It is costing a fortune since I metabolize it quickly. (so I’ve been told) I have used Radiesse, Juvederm, and most recently Voluma and love the results for correcting diagonal mid cheek lines and loss of fullness but they do not last more than 4 months. How do I find a surgeon who has sufficient experience in cheek implants ? What is cheek implant surgery downtime? Longevity? Any other cheek augmentation alternatives?

A: Your injectable filler story is not uncommon and many patients will be in your same situation in the years ahead. Injectable fillers are great at doing what they are intended to do most of the time. But despite the good results they provide, many patients have or will find out that the long-term costs of injectable filler ‘maintenance’ will become prohibitive for some patients. Thus seeking a permanent cheek augmentation solution has merits.

Cheek implants can provide a very satisfactory solution provided the proper implant style and size is chosen. Because the cheek area and the cheek implants chosen to augment it defy any exact method of measurement (unlike chin implants for example where the amount of horizontal augmentation needed can be measured) it takes a surgeon with a lot of cheek augmentation experience to get it right the first time. While the concept of cheek implants is simple, it can be difficult to get their placement anatomically correct with good symmetry. This difficulty is imposed on top of how to select the best cheek implant style and size for the patient.

Cheek implant recovery is largely about facial swelling and the time it takes for it to look acceptable. In reality expect that to be longer than one really wants. It takes about ten days to look socially acceptable, three weeks to ‘normal’ and really three months to judge the final result and how one feels about the facial change.

The intermediate step between injectable fillers and implants for cheek augmentation is fat injections. While far simpler and with a very quick recovery compared to cheek implants its issue is how well the fat will survive and how long it will persist. These are unpredictable and can be different for each patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what is the difference between the effects of cheek implants and a cheek lift? In looking at pictures cheek implants looked more subtle than the lifting of the  cheek tissues. The cheek implants themselves looked more obvious than the cheek lift, however. The cheek lift appears to pull on the face and make the nose a bit wider and even lift the lip. So the overall change to other facial features with implants seemssubtle while there were more changes to other facial features with the cheek lift,despite the cheeks themselves looking more natural. Am I correct in this assessment?

A: You are quite accurate in your assessment of the influence of the cheek lift vs cheek implants and their effects on the face. Cheek implants push the tissues more out and forward while a cheek lift pulls the tissues more up and back. Thus their effects on the cheeks are different. A cheek lift can widen the nose and pull upward on the lips. Conversely cheek implants have no effect on the nose and the lips.

This is why a cheek lift often creates a bigger change on one’s face while cheek implants have a isolated effect on just the cheeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I contacted you six months ago about cheek implants. I had gotten cheek implants placed, removed, and then a cheek lift. I promised a six month update. Wow, what a difference six months post op can make. My desire for to have implants reinserted (in this present moment) has vanished along with all of the swelling that previously existed. Swelling can play serious tricks on the mind, and it’s unfortunate that many people don’t realize this. I had mentioned that I wished I had waited the full 6 months to see the cheek implant result, and that still rings true, but not much can be done about that now. I’m sure as a plastic surgeon you must go batty trying to help people understand what is just swelling and to wait out the full six months before judging the final result.

Anyway, things are great for now, but moving forward, if several years from now I am interested in getting implants reinserted, I will definitely keep you in mind. Thank you very much for your help regarding my cheek implant issue.

A: One of the hardest things for facial reshaping patients to understand is the time it takes for all swelling to subside, soft tissue contraction to occur and one to psychologically adjust to the new facial look. The patience it takes to go through these phases is highly variable and some patients are more tolerant if it than others. There definitely is a tendency for some patients to want to reverse their result in the early phases of healing  for the comfort of what they used to look like.

Cheek implants are no different in this regard and the tendency is to think they are too big early after surgery. When months later had they waited it out it may be just fine…or in some cases not enough of a cheek augmentation effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a healthy 32 yr old man who previously had a successful rhinoplasty one yr ago. One week ago I had Radiesse (1,5 ml x 2) injected in my cheeks and I loved the results immediately after. But since the inflammation has gone away, I lost that chiseled male model look I am going for. It still looks good but not as good and not that chiseled look anymore. I can’t afford to inject my cheeks with Radiesse every week so I need a permanent result. The problem with off the shelf cheek implants is that they only provide a 4 mm thickness and the post op pictures look too subtle for me. (because I want to be a model). I have low body fat and a narrow face with thin cheeks so I feel that I have the anatomical prerequisites to achieve that attractive look with the help of a skilled surgeon like yourself. What is your opinion on this? I have attached 2 photos from before and immediately after my Radiesse injections. I also attached photos of three male celebrities with the chiseled look that I am looking for.

A: Injectable filler treatments can be a good test to see the effects of cheek augmentation but are clearly not suitable for a sustained and repeated cheek augmentation approach over time. If an injectable filler treatment gave you very pleasing results then I am certain that a bone-based cheek implant can do the same if not better. Cheek implants do come in thicknesses greater than 4mms so I am not certain that a preformed standard cheek implant of the right style and size would not work for you. There is, of course, always the option to make custom cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my facial problem is that I am very skinny. I have no volume in my face with flat cheekbones. The doctors say my maxilla is also very small and is retrusive by 6mms.has a reduction of 8mm. Even though my body is not skinny, I have talked with surgeons because I want more volume as my face is very flat/skinny. They placed implants in my maxilla on both side of the nose. Even tough my profile is good, my face still looks skinny and I cannot smile because the implants change my smile completely.

I want to remove these implants. I want to have my smile back and more volume in my face, but I’m afraid if I put new ones in, the result will be exactly the same. I want to talk with a new surgeon so I can get a more satisfactory facial profile result. I have attached numerous pictures of my face so you can see my deficient midface profile.

A: Thank you for sending all of your pictures. If I understand your surgical history correctly, you currently have in certain types of midface implants. (malar and paranasal implants – four total implants) You mentioned malar but I wanted to be certain that you also have in paranasal (side of the nose) implants. Paranasal implants would be the culprit of affecting your smile, not the malar implants. Overall facial volume enhancement could be improved by fat injections which would provide a more global effect. Although I would not want to see you remove your existing malar implants as they are undoubtably providing some facial volume effect. I would have to know more about your paranasal implants as the style and size in place may be the problem not just paranasal implants per se.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, I am looking for temporal implants due to significant thinning of my face with age and weight loss. I would also be interested in possible fat transfer or other procedures to fill my cheeks in some. Would like to consult on what my options are. Here is one old photo of me 30 years ago, I don’t ever expect to look that young again, but I would like my face to be plump or full looking again like it used to be. I’ve lost a lot of weight and my face now looks sunken and sickly. Please help me. I am embarrassed by my appearance.

A: Thank you for sending your pictures. You have very classic panfacial soft tissue volume loss which is very common in significant weight loss particularly in an older person. It affects some individuals more so than others. This is most manifest in your temporal region where it has turned into a complete concavity from the zygomatic arch all the way up to the anterior temporal line on the forehead. It is seen less severely in the cheek area only because your naturally high cheek bones have preserved some of the volume. (there is no bone protecting the temple areas) For your temporal areas there is no question that an extended temporal implant is the preferred procedure as it will create a permanent volume solution to that problem. It requires an extended temporal implant as opposed to the standard one given that it needs to reach all the way up to the forehead. For the cheeks your options are submalar cheek implants or fat injections. Each one has their own merits. (fat is better at total area volume addition but its survival may not do well given your age and lack of natural fat in the area…an implant has assured permanent volume but only provides volume to one specific area) In facial volume lose cases like yours I will often combine submalar cheek implants with fat injections to get the best of what each has to offer.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial reshaping surgery. Can I get a longer and slimmer face with strong jawline and cheekbone through the facial reshaping procedures? If no, what type of procedure will I need and how much will the total cost be . I feel like I can trust Dr Eppley for these life changing procedures.

A: In looking at your pictures, I can recommend several facial reshaping procedures that would make your face longer and slimmer. These procedures include vertical chin lengthening (vertical lengthening chin implant vs. open sliding genioplasty), cheek implants, buccal lipectomies and perioral mound liposuction. The effect of these procedures is created because multiple hard and soft tissue changes are occurring in different dimensions. When all are combined the effect of increased vertical facial height (real facial change) and decreased facial width (more of a visual facial) occurs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, awhile ago you helped answer my questions about cheek lifts, as I was getting one to correct sagging from malar implant removal. Well, I had the cheek lift, and while it made some major improvements, I still have some sagging. 

Now I probably should just accept the remaining sagging at this point, but since I had NO sagging on my face while the implants were in, I am of course beginning to wonder if I should have just kept them or should replace them or get some sort of filler to fill out the loose skin at some point. 

My reason for removing the cheek implants was that unfortunately I felt they were not proportionate and looked a bit obvious –  but in retrospect I wish I had just waited for more swelling to subside and embraced the new look rather than removing them and making myself look older.

The issue remaining seems to be mostly skin (with a tiny bit of tissue). The pocket of looser skin is still in the shape of a malar implant.

Is it possible that replacing the malar implants in the future would help fill out this looser skin  –  or after all of these surgeries should I just give up on having tight  mid face skin again?  You can be honest, I know it’s a lot

Would replacing the malar implants after placement, removal, and a lift just be too much scar tissue and way too complicated? How long should I wait before making this decision?

I regret removing the implants, as they made me look much younger and I had no idea I’d have sagging if I removed them.

I just keep wondering if re-inserting the malar implants would lift that tiny bit of excess skin that is looser since removing them. Perhaps filler might do the trick too?

Also,  I forgot to mention that if you do think reinserting the malar implants would lift the skin a bit how long would I need to wait after the cheek lift. I was told that the sutures dissolve in 6 months. Would it be safe for the implants to be in there theoretically even if the sutures had not dissolved?

Any other suggestions about how to lift that sagging mid face skin are greatly appreciated, or if you think i should throw in the towel and quit and just accept the sagging skin now as it’s just too much surgery and scarring that’s understandable as well.

A: I think given your past history of cheek implants in and then out, any further efforts at cheek lifting should be done by either injectable fillers or fat injections.They both will provide more upper cheek fullness and will do some cheek lifting. Ultimately cheek implants could be redone now that you know their benefits. But you need to wait a full year after the cheek lift before replacing them with fillers or fat if they turn out to be inadequate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have questions about temporal augmentation. I just got cheek implants and am modestly happy with them. I wanted to know if temple implants can co-exist with cheek implant. My surgeon has explained to me that temple implants are not safe due to a sensitive nerve in that area, and something he does not practice, nor advises. 

A: I am afraid to say that what your surgeon is telling is inaccurate and anatomically incorrect about temporal augmentation. Temporal implants are placed in a subfascial pocket through a small incision in the temporal hairline. There are no nerves in the subfascial temporal plane which is directly on top of the temporalis muscle. Your surgeon is likely referring to the subcutaneous temporal location where the frontal branch of the facial nerve runs. The subfascial is below that location and is perfectly safe.

Cheek and temporal implants can co-exist because they are in completely different tissue pockets even though they are right next to each other. Cheek implants can make the temporal region above it look hollow/deficient and it is not rare in my experience that the cheek implant patient subsequently goes on to have temporal implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am thinking of getting orbital rim implants to improve my lower eye hollows socket area and mainly to raise my lower eyelids so less scleral show is showing…

Can cheek implants placed very high have the same effect of pushing up lower eyelids? Give a less round eye look?

Also will there be lower eyelid retraction after orbital rim implants?

A: It is important to understand that neither orbital rim or cheek implants is going to drive up the lower eyelids to improve scleral show and give the eye less of a rounded eye look. In fact, one of the potential side effects of these implant procedures when done through a lower eyelid approach is lower eyelid retraction. If technically done well and orbicularis muscle resuspension and lateral canthopexies are performed with closure, lower eyelid retraction can be prevented and may even help with less scleral show. But bone-based implants can not push up on the lower eyelid and improve the level of the lash line across the eyeball. The bone levels lie well below the lash line of the eyelid. This is a common misconception which can be verified by pushing up on he cheek tissues and you will see that it does not change the position of the lower eyelid. (unless you really push up far which is not a realistic surgical effect)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, if one has cheek implants (malar implants) placed high up and towards the lower orbital rim can this raise the lower eyelids a bit? Or result in decreased scleral show? I am hoping this is true.

A: I would never count on any any type of malar/cheek implants or orbital rim augmentation being able to raise the lower eyelids or decrease scleral show. Logically that would seem like it would work but that has not been my experience. What drives up the position of the lower eyelid from a scleral show standpoint is the support that lies within the eyelid itself  (adequate vertical tissue support) combined with medial and lateral canthal positioning.

While cheek implants push up the overlying cheek tissue that does not translate to the lower eyelid. The lower eyelids can usually only be vertically elevated by the use of spacer grafts placed within the lower eyelid or reattaching the outer corner of the eye up higher in the lateral orbital rim. That is not to say there might not be some supportive effect from elevation of the cheek tissues but it is just not a major one or one that can work completely on its own.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had cheek implants for four months now and dislike them and want cheek implant removal. I’m sure this is a common story. The implants are Design M Malar by Medpor and I would like them removed by yourself. I had a bad experience with my surgeon and don’t want to return. Would removal be straightforward and would recovery be minimal? Thanks so much for your help.

A: It is certainly not the first time I have seen ‘buyer’s remorse’ after cheek implant surgery. That does not make cheek implants a bad procedure, just one that may not have oived up to one’s expectations for a variety of reasons. Removal of Medpor cheek implants, like any type of cheek implants, can be done. But unlike silicone cheek implants, whose removal would be very easy, quick and with minimal recovery, the removal of Medpor cheek implants is more difficult due to the tissue ingrowth. The ‘difficulty’ of their removal is a relative one given that silicone facial implant removal is so easy. While Medpor cheek implant removal procedure is straightforward, I would not necessarily call the recovery ‘minimal’. It is best to think of it as about 75% of the original cheek implantation procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to install cheekbone implants while wearing braces? And if so, is it recommended? To be more specific, it’s reasonable to think that, once the braces will be removed and the teeth aligned, my face would appear different from now. Would it be unwise then, to undergo a surgery while not taking into consideration the aesthetic changes brought by the braces?

A: The question you are asking is whether braces distort the face so that it makes it more difficult to judge the effects of intraoperative sizing of cheek implants…or maybe whether cheek implants are even needed at all when the braces come off. The answer is no. Braces do create some lip distortion/protrusion but not above the dedntoalveolar facial level. They cause no facial changes at the cheek level. Only if the braces are in preparation for orthognathic (jaw) surgery with major jaw repositioning anticipated should the consideration of delaying cheek implants until afterward be considered.

From a technical aspect, braces do not impede or make the placement of cheek implants any more difficult than if they were not there. Cheek implants are placed through high maxillary vestibular mucosal incisions which are well away from the location of the orthodontic brackets and wires on the teeth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m sure a surgeon at your level is capable of the best possible cheek augmentation results. However, for cheek implants performed in general, I am a little concerned about having found an average self-reported procedure satisfaction rating of only about 60% from this site called Realself. Could you tell me more about satisfaction-levels and potential complications for these procedures? Could they affect the shape of the nose?

A: It does not surprise me that the satisfaction rating for cheek implants is around 60% or roughly two-thirds of the patients that took the time to register their experience. While it is an apparently ‘simple’ procedure, it can be plaqued by problems of implant asymmetry and an inability to have achieved the desired cheek augmentation effects. It is important to remember that all facial implants, cheek implants included, are based on styles that presumably fit the average person. Often these implant styles, in my opinion, are dated and may not reflect contemporary aesthetic objectives. Thus surgeons are relegated to using cheek implant styles that are not really specific to the patient’s anatomy and may not always have a realistic chance to achieve the patient’s cheek augmentation goals. But plastic surgeons may due with what they are provided and try to get the result with the cheek implants that are available.

It is also important to note that cheek implants are paired unlike a chin implant which is singular. Since they must be placed independently and without full view of either one at the same time, the potential risks of implant asymmetry are increased.

Lastly, there is no training manual or intuitive aesthetic ability for plastic surgeons to knowing how to pick a cheek implant style and size. Cheeks, unlike chins, are more than just a single horizontal measurement seen in just one profile view. (which is how most plastic surgeons simplistically see the chin…unfortunately) Rather the shape of the cheeks is truly a three-dimensional structure (with four different aesthetic zones) where number and measurements do not help in knowing how to make a successful cheek augmentation change.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am aware of the custom cheek implants option and am actually looking to get those done. But before I get in to the questions I have a little disclaimer- the photos I’ve attached are merely for reference purpose. I know that these women have been photoshopped and what not and/or are genetically blessed with great cheekbones. I don’t look like them, nor do I intend do. Please don’t mistake the photos for me trying to get cheeks exactly like the celebrity. In your honest opinion, looking at the attached photos of the cheeks on these women- I’m talking about the placement on the face, the shape, the definition of the zygomatic tail etc. All of those factors put in, what cheek implants would give me a result closest to these photos. Malar implants? Or combined submalar implants? 

A: For many women, combined malar-submalar shell cheek implants would work the best as an off-the-shelf style. These can be placed high on the cheek bone and come forward to cover the submalar area. Probably the implant would have to be modified a bit (the tail and posterior submalar areas narrowed) to make sure that the arch portion does not get too wide in a superior-inferior direction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been looking into getting cheek implants for a while now, and I came across your helpful blog on my numerous exhaustive searches on the Internet for cheek implants. I was hoping I could get your opinion on one big question that I have- what kind of implants will give me the high prominent cheeks look, but with some fullness in the front of the face too. (The pictures show the look that I’m after) (I’d also like to point out that those pictures are just for reference, I do know that cheek implants won’t turn me into Rosie Huntington-Whiteley) want both, the definition from the side, the high placement and also some frontal fullness. Thank you.

A: While there are many different styles of cheek implants, it is important to realize that the look you are after is not likely to be achieved by standard stock implants. If you translate the look you are after to the type of cheek implants available, it is fairly easy to see that no such cheek implant style exists. (at least none that I would feel comfortable placing hoping to achieve that type of cheek augmentation effect) In my opinion, only custom designing cheek implants can create the style and size you seek. Then there is also the factor of your own cheek bone anatomy and how it may help or hurt the desired look…hence the benefits of a custom designed cheek implant style.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in possibly getting cheek and chin implants (or starting out with dermal filler) to attain a more chiseled & angular look. I would like to get a well-defined, hollowed-out appearance similar to what many actors have.
I am especially interested in seeing if I can obtain not just the hollowed-out cheeks, but also the well-defined line that seems to run from the cheeks to the chin on both sides of his face (this effect is especially noticeable in the last picture).
I have also submitted two photos of myself; please excuse the eye asymmetry, which occurs occasionally due to an outdoor allergic reaction (I run/jog outside a lot).
Generally speaking, do you think the goals I am trying to achieve are realistic?

A: Based in these pictures and your face, I do not find your facial goals especially realistic. While cheek and chin implants will help create more prominent facial structures, they will not necessarily cause that hollowed look you are seeking. That is caused as much by the lack of any subcutaneous fat over the trampoline area of the face and prominent jaw angles as it is caused by any prominent cheek and chin structure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m currently 26 and I had large silicone cheek implants placed two  years ago together with a buccal fat pad extraction. I had them removed two months ago as I just felt they were too big for my face. The issues I have now is that there seems to be a small degree of mid-facial sagging. I’m looking to get smaller malar implants later in the year, but I’m concerned that that will not be able to proper address this sag. Out of curiosity, since I’ll be undergoing a cheek implant procedure again, could a mini-lift help address this sag? I don’t think I’ll require anything too aggressive – do you know of any midface lifts that could help me out?

A: It is no surprise that once cheek implants are removed that some degree of midfacial sag will result. This is not just due to the stretched overlying tissues but because the soft tissue attachments to the bone have been permanently detached. Once the implants are out, the overlying midface soft tissue can not reattach to the bone (due to the slick surface of the residual capsule) and it thus slides ‘south’.

With your new cheek implants you consider a temporal suspension midface lift which can simply and easily pull back up the midface tissues over the new implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implants and paranasal implants placed overseas two months ago, but it appears that the ones on the left side have been infected (yellow drainage, mild swelling). My issue is that I do not have the time to get them removed right now. I’m thinking of going to a local doctor to get antibiotics to try and control the infection in the interim. If I do that and wait till year’s end to remove them, will it cause any permanent issues (excessive tissue scarring)? 

As for the removal, have you ever had any cases whereby you only removed the infected implants? I understand that this will cause asymmetry, but could I use fillers for the side where the implants were removed to compensate (at least until I get the implants reinserted)? 

Finally, would waiting 6 months before reinsertion be enough time for the tissues to heal and for the infection to clear? Or, would you recommend waiting even longer?

Sorry for these questions, but I can’t seem to contact my original surgeon right now, and I was hoping you could just help assuage some of my concerns.

A: This is disappointing that you trusted a doctor to do the surgery and now you can not get a hold of him to answer the most basic of questions when you have a problem that he created.

In short, antibiotics will only keep the problem at bay temporarily with infected cheek implants. Leaving them in, if infected, is just going to cause a lot of scar tissue that could make future surgery problematic. If infected it is in your best interest to have them removed, let it heal and then reinsert 3 to 6 months later. Injectable fillers or fat injections should not be placed into the cheeks after implant removal for a minimum of 6 to 8 weeks after the infection has cleared.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implants and facial liposuction two weeks ago. Since my procedure I can’t feel my upper lip and it still doesn’t move like its supposed to with no improvement since the first day after surgery. Is it highly likely something was transected or the fat closer to my lip was removed along with the nerves? The doctor did it through the same incision used for my cheek implants implants rather than one further back and it concerns me both sensory and motor function are absent from the same spot and there has been no recovery in more than two weeks.

A: It is not rare that numbness and facial muscle movement are temporarily impaired after cheek implants, particularly when it is combined with facial liposuction. It would be highly unlikely that any nerves were transected. But it could easily take up to three months or longer after the procedure for both normal facial feeling and lip movement to return. Two weeks is way to early for these small facial nerves to ‘wake up’ and begin functioning. Your sense of what is normal and how nerve recovers is understandably limited to this present experience. But it takes much longer to return to normal that most patients think after any form of midface surgery including cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had cheek implants done and I look terrible. I’ve never been this hideously ugly, and other people seem to instantly love their results, so I’m really scared and really depressed. I hope to eventually move my face normally and that sensation will return. I don’t know why he augmented one side such that the two sides will be off balance butI could see from day one before the swelling set in that the two sides were not even.

A: With time and healing your face will move again normally but that will be a process of up to three weeks or more. Feeling will also return normally but that will take a little longer.

I have done this type of facial implant work (cheek implants) for a long time and I can tell you that not everyone instantly loves their results.  Swelling and bruising causes a lot of facial distortions and it can be unnerving to see your face this way. But what you see now is not necessarily what it will be four to six weeks from now. But that is understandably hard for many patients to see. There are many patients who feel just like you do at this point so what you are experiencing is not unusual at all.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial reshaping surgery. I can not figure out what my face needs to look better. I’d really appreciate you taking your time for this. I have been given different surgery options from doctors here in Australia. However my opinion is that the best doctors are located in America, especially for facial surgery. It has been recommended to me that I have cheek implants, buccal lipectomy and a chin implant. But I want to know your opinion since you are regarded as one of the best surgeons in the world for facial reshaping surgery.

A: In looking at your pictures, your facial reshaping/restructuring goal would be to shorten your longer face and provide some more central projection. You have a more flat paranasal/midface and thus you have to be careful with how you change things to not look worse. I would recommend the following:

1) Chin augmentation but by sliding genioplasty as your chin needs to come forward but should become vertically shorter not longer. (implants tend to make the chin longer or at least neutral in vertical length)

2) Malar/Submalar implant augmentation with emphasis on providing with anterior projection not so much width

3) Avoid a buccal lipectomy. That would be one of the worst things you can do to a face that already lacks projection and could easily end up looking gaunt.

4) Paranasal augmentation to build out the base of the nose and the maxilla. This complements what the dimensional changes of the cheeks and chin and avoids ‘leaving the area between the two behind’.

Dr. Barry Eppley

Indianapolis, Indiana