Your Questions
Your Questions
Q: Dr. Eppley, After perusing your blog extensively (thank you for it, it has been a tremendous help!), I’ve finally decided to get cheek implants. My issue is that I had a sinus infection 2 weeks ago,and my doctor put me on antibiotics for a week. It has since cleared up and I don’t have any symptoms of sinusitis anymore. As I will be getting my cheek implants in two weeks, will enough time have passed for me to get the implants safely, or will I be an increased risk of infection due to the prior sinusitis?
A: It would be logical to assume that there could be a correlation between cheek implants and maxillary sinusitis. And certainly one should not undergo any elective cosmetic procedure if any active head and neck infection is ongoing. While they are anatomically very close, the placement of cheek implants on top of the zygomatic bones and the sinuses located below and behind the front wall of the maxilla are distinctly separate areas that do not connect. Even an active maxillary sinus infection does not contaminate the tissues where a cheek implant would be placed.
But having a two week period where the maxillary sinusitis is cleared would be prudent. But the typical antibiotics given for facial implants (usually Keflex) is not the type of antibiotics that should be prescribed for maxillary sinusitis since it does not provide adequate antimicrobial coverage.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek implants recently and developed right after a weakness of my right upper lip and nostril. I was reading up on people that have had similar issues like mine and what other doctors have recommended and can across this (read below). I’ve also read the longer you wait to get the issue checked out the worse the outcome will be if your trying to fix it. So I’m torn on waiting if it lowers my chances of resolving the problem. I’m terrified this is permanent and was wondering if conducting a nerve test would be a smart thing to do. Maybe the nerve just needs to be decompressed, or if it was damaged or cut then nerve grafting would be the way to go. But the longer I wait the less my chances are to fully recuperate to the way I was before.
What do you think?
‘The usual risks have been well presented by the other physicians. However, based on observed cases, there is a risk for temporary weakness of a cheek or upper lip especially with the larger implants which have to be placed beneath a branch of the facial nerve which is stretched. When and if this happens , Botox therapy can be used for symmetry until the nerve function returns.’
A: Facial nerve injury is a very rare occurrence after cheek implants as the dissection is done under the muscle where the nerves supply them. But it can happen. In almost all cases complete nerve recovery would be expected.
I would be very careful about what you read and try to interpret about facial nerves injuries…as they are quite different based on where the injury to the nerve occurs and what type of injury that it is. Most of what you are reading refers to a proximal injury to a facial nerve branch, whereas what you have is a distal or terminal branch type of nerve injury. In essence if you draw a line between the corner of your eye and the corner of your mouth what lies towards the ear would be considered proximal and what lies on the nose side of that line is distal. Distal facial nerve injuries, where the nerve fibers are smaller than a human hair, are not treatable by any surgery or other therapy. Time and healing is all that can be done for them. This is particularly true for the distal branches of the buccal nerve which supply the upper lip and nostril. The buccal branch has a particular propensity to recover, unlike many other facial nerve branches, because there is considerable cross connections between these terminal nerve fibers. So even if one little branch is injured, the cross connections will allow other signals to supply what has been lost. This is particularly true in stretch injuries. (which is the only type of injury you could have) Thus it is not true that the longer you wait the worse the chances of recovery are. Waiting is the treatment and the longer you wait (there is nothing else to do) the better the chances of recovery will be. This is a process which is unknown as to how long it will take…it could be days, weeks or even months. Although I would guess some improvement will start within four to six weeks, it could take longer and complete nerve recoveries have been seen out to even a year after the event.
Botox injections can be done on the opposite side for facial symmetry, although if recovery on the affected side starts weeks later, the facial asymmetry will persist until the Botox wears off. (around 4 months) Since facial nerve recovery is usually progressive (starts working a little at a time), I would wait a few weeks or month to see if the nerve will slowly start coming to life. If not, then you can get Botox on the opposite to provide some temporary improvement in facial symmetry with smiling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am getting cheek implants next week but I became worried because my surgeon says he does not use any screws to secure the implants to the bone…just uses a pocket and wait for the scar tissue to hold implant in plance. Should I find another surgeon?
A: Just because your surgeon does not use screw fixation for cheek implants, that does not mean it will not be a successful surgery and outcome. Surgeons do use different techniques in facial implant placement and, as long as it works successfully in their experience, then that technique is adequate. I would say that those surgeons who secure their cheek implants with screw fixation is far fewer than those who don’t. The most common type of cheek implant fixation is pocket positioning that may be combined with sutures or even an external cotton bolster into which the sutures around the implant is passed. (this is generally removed in one to two days after surgery)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 21 years old and I have average sized cheekbones. I’ve always dreamed of having very prominent and chiseled cheekbones, such as those of Mads Mikkelsen (even though I’m a girl) that have more projection on the outer corners of the zygomatic bone as opposed to the classic apples in the area below the eyes. I would like to augment a good part of the bone, yet pay much more attention to the area adjacent to the zygomatic arch. Many people would recommend me to aim at a natural and light outcome, but I want a very noticeable difference. I’m also a bit confused about the procedures. So far I’ve read a fair few articles regarding PMMA bone cement as well as Kryptonite and something about Medpor, still I have no clues whatsoever which one would suit my needs best. I would like something that is permanent, that endures time, that is at least as strong as the bone itself and that doesn’t get loose. As to the volume to be added, would it at all possible to have a 7mm or over projection.
A: When it comes to cheek augmentation, it is very important in any patient that the correct zone (s) of the cheek or zygomatic bone is augmented or highlighted. You have described exactly where you want the maximal augmentation to be done (posterior malar) as opposed to anteriior submalar which, as you have corrected stated, is the usual highlight augmentation zone for a female. That is is very helpful as then the correct cheek implant style can be chosen.
When it comes to cheek implant augmentatation material, no form of bone cement would be appropriate. What is used are preformed implants made of either silicone or Medpor material. Both are permanent materials that will never degrade or change shape and when fixed to the bone will be just as strong as the bone underneath it. Their ability to stay in place is more about how the pocket is made and how they are secured than it is about the material. There are advanatges and disadvantages to either solid silicone elastomer ot medpor, but my preference is for silicone as there are many more styles and size options and it is far easier to revise should that ever need to be done.
As for size of the cheek implant, 7mms would be a very strong change and may or may not be too much. Such thickness numbers may seem small but when it comes to putting an implant on your face, it can easily end up being much larger than one would have initually predicted. When it comes to facial implants, a slightly too small change is always better than one that is too big…as that will always lead to revisional surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been an admirer of your work for some time & consider your website an invaluable resource for patients seeking to inform themselves in regard to cosmetic procedures.
I am a young male in my late twenties. My question relates to cheek implants. Specifically, I am looking to address two issues and I am hoping you might offer me some insight & the benefit of your expertise to provide advice as to what might be suitable choices. I have some asymmetry, my right cheekbone is less pronounced and has less anterior projection than my left side. I prefer the left side. I have also lost some weight & this has contributed to a loss of mid-face volume and deepened nasolabial folds. I do however have fairly good malar projection laterally, especially on my left side.
Would you advise me to address these issues with submalar implants of differing sizes or perhaps a combination implant on one side or both? I wish to avoid feminising my face through excessive lower cheek volume, but I am very keen to mitigate the asymmetry and restore lost volume in the midface. I would like to achieve the classic “v†shape model look if at all possible, but addressing the two issues I described is my priority.
Thank you for your time and attention.
A: In regards to your cheek asymmetry, the issue is whether you should just correct the right side to better match the left or do both sides with differing size and shaped cheek implants. The issue with either approach is how to best obtain symmetry. To do so you have to have a stable target so to speak. It is more predictable with standard preformed implants to just do the right side to try and match the left. But when it comes to implanting both cheeks that are already very different, it is pure guesswork with preformed implants. And such guesswork will undoubtably lead to improved cheek and midface volume but persistent asymmetry of some degree. If you are going to both cheeks, it is probably best to consider custom designed implants to get the best coverage and volume with the best shot at achieving much improved symmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to get cheek implants soon. I am also interested in having a hair transplant about 6 months after I have cheek implant surgery. My question to you is do you think it is safe to have a hair transplant after cheek implants? …. Is there any risk of infection to my cheeks implants? … during the hair transplant they will poke the front of my hairline hundreds of times. Can this in any way effect my cheek implants ??
A: This is a thoughtful question that speaks to the potential of bacterial seeding of any implant in the body due to bacteremia (release of bacteria in the bloodstream) after any invasive procedure. I think as long as your cheek implants are well healed and have an intact mature capsule, this potential risk is very low to negligible. It can easily be compared to having a dental cleaning in which one has any implant in their body. This is clearly not a problem of any magnitude given the millions of people who get their teeth cleaned or undergo any dental work and have surgical implants of many varieties and anatomic locations. But to be safe, and this would be done anyway, take an antibiotic starting one hour before the surgery and then for a few days after.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Just wondering what i could do about my midface deficiency. I had a cross bite and underbite correct by braces and now feel like I should have had jaw surgery …Just wondering your views on my situation.
A: I could not tell you based on your current pictures alone whether you should or should not have had maxillary advancement and whether that degree of movement forward would have made a noticeable aesthetic improvement. But after having been orthodontically corrected, that is an irrelevant issue now. The more relevant question now is whether any form of midfacial onlay augmentation will create the aesthetic improvement you seek. Paranasal implants do replicate in some ways at the nasal base level what a mild to moderate maxillary advancement would do in terms of horizontal projection. The next relevant question is whether any augmentation above that level (which is not what a maxillary advancement achieves) would also provide aesthetic improvement (malar vs malar-infraorbital augmentation) with the paranasal augmentation. I will do some computer imaging and get that back to you on both paranasal and cheek augmentation. It is a question of whether paranasal implants alone are adequate or whether a more complete mid facial augmentation is a better approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I lost of a lot of weight and my face is asymmetrical. I have small jowls and not sure if I need a facelift or just a necklift and if face implants would be an alternative to a facelift. I want to look prettier and have a long, narrow face with high cheek bones but hollow cheeks underneath and nasolabial folds. I have tried to have my own fat injected into the nasolabial folds but it does not last very long. I also have very thin skin. Would you recommend a regular face lift or a smart lift? Thank you
A: In looking at your face and objectives, I see three procedures that would be simultaneously beneficial. Higher cheekbones are only going to be obtained by cheek implants. While chin or chin-prejowl augmentation is not a substitute for what some form of a facelift can do, a small vertically lengthening chin implant can help the jowls somewhat but more importantly contribute towards a longer more narrow face. Facelifts go by many names and their name sometimes indicates the extent of the procedure. You need more of a jowl lift type procedure which often carries the name of short scar facelift, Lifestyle Lift, Smartlift etc. Regardless of the name it is designed primarily to lift and eliminate the jowls. When done together with the chin augmentation your jawline should be fairly smooth.
Improving the nasolabial folds is difficult and fat injections, while worth a try, are rarely successful. The only technique that I have found consistently effective are dermal-fat grafts which are essentially autologous implants but they require a harvest site to use.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I had cheek implants done 6 months ago, but they have unfortunately have become infected with a low-grade infection. My surgeon has advised that I get them removed, and has given me the option of either local or general anesthesia. I’m trying to save on this if possible, but I have a few concerns about going the local anesthesia route. Anyway, here are my questions:
1) Is it safe to get them removed via local? Is this something that you’ve done for your patients?
2) More importantly, how comfortable is it? Will it be a very painful experience, or just some mild discomfort at worst?
A: In answer to your questions:
1) The use of local anesthesia to remove your cheek implants is certainly safe. Fortunately I have never had a cheek implant infection so I have never had to do it. But if I did and that is the way the patient wanted to remove them, I would. Are your cheek implants silicone or Medpor. Are they screwed in? That would affect the question of whether local anesthesia is a good option or not.
2) With good local infiltration and infraorbital nerve blocks, it should be able to be done comfortably. But that would depend on the skill and experience of the surgeon in doing the local anesthetic injections.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had two facial problems my entire life, dark circles and retracted lower eyelids. I have always hated my look when I am not squinting and because of that I think that my ower eyelid muscles have become overdeveloped. I have attached pictures of when I squint and when I don’t. This will give you an idea of my orbital/cheek area.
The area circled in the picture was filled with Juvederm already as suggested by a local plastic surgeon to improve lower eyelid projection but it didn’t help at all. Though I do like my cheeks now and I am also thinking about making this permanent with cheek implants to give even better support to lower eyelid. What do you think about this idea? The local plastic surgeon seemed to think that cheek implants were a bad idea.
What procedures would you recommend? Also would canthopexy/canthoplasty address problem with overdeveloped muscle, or would it need to be trimmed with another procedure ? Could all procedures be done together?
A: Your pictures show a large orbicularis muscle roll of the lower eyelid (when squinting), cheek bone hypoplasia and lower eyelid hollows. (with some slight scleral show) I would recommend medium submalar shell cheek implants, a pinch lower blepharoplasty with excision of redundant muscle and fat injections for undereye hollows, all of which could be done as a single procedure. When done locally this is an outpatient procedure but, if from afar, most patients would return home in 48 hours. It would take about 10 to 14 days to look very acceptable without obvious signs of surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had rhinoplasty, Medpor jaw angle implants (11mm projection) and silicone chin implant (medium 7mm). But I want a stronger look that is more masculine. I also want cheek augmentation and I want a stronger chin. But the biggest chin implant I can find only gives 8mm horizontal projection so I’m considering a sliding genioplasy to have both horizontal and vertical augmentation. For the cheek implants iIm considering Design M Malar Implants from Medpor, I think they’re more anatomic than silicone ones, and also Medpor ones augment from zygomatic arch to the cheek bone which I think will give a stronger and masculine look. I would like to know which size would you recommend me to use. (4.5mm or 7mm) so they would look proportional to my jaw angle implants (11mm) I read in the internet that when you use facial implants, you have to consider the soft tissue augmentation that is different from the size of the implant… for example if you have a chin implant with 10mm projection…you’ll end up only with 7mm in soft tissue projection. So if I have cheek implants size of 4.5mm I’ll end up with 3mm augmentation, but if I have the 7mm ones,, I’ll end up with 4.9mm, So i don’t know which ones to use. I read in your blog that when it comes to cheek augmentation you should not over do this specific part because you will look unnatural. I definitely don’t want that. But also I have read that the cheek or zygomatic bone should be bigger than jaw angle.
A: I would take exception with your supposition that there is not a 1:1 correlation with the translation of implant thickness to how much change is seen on the outside. When it comes to any form of jawline augmentation, it is pretty much a 1:1 correlation. In the cheeks it is most commonly a 0.8:1 ratio. However the thickness of the soft tissues in any patient is so variable that no absolute implant size to external change seen can be generalized. Thus I would always assume it is a 1:1 relationship through the skeletal structure of the face. This would be true in my opinion given your relatively thin face.
I would also point out that a little bit in the cheeks goes a long way so I would be careful about going too big here. It is very easy to end up with cheek implants that are too big. Thus, I would lean towards the 4.5mm implants as opposed to the 7mm thick cheek implants.
Lastly, you can certainly do a sliding genioplasty using/keeping the existing chin implant in place getting the dual benefits of both techniques. However be aware as the slidinjg genioplasty moves forward and down there will be a slimming.narrowing effect on the chin. Thus if you want to end with a more square chin look than you have now, the chin implant should be switched to a square design or even a more square one and not a rounder anatomic style.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very interested in getting cheek implants. I have some questions and infection concerns that I need answers to.
1) Will using Rogaine(Minoxidil) on my head twice a day increase the chance of my implants becoming infected? Minoxidil is absorbed through the skin, thats why I ask.
2) If I opt to have Micro Scalp Pigmentation (MSP), This is a procedure where they basically tattoo your scalp with little black dots , to make it look like you shave your head. Do you think tattooing your scalp can cause your cheek implants to become infected?
3) I have had numerous dental problems. If I were to have cheek implants, how can I avoid the risk of infection? Should I take an antibiotic before and after the dentist for a couple days?
4) Can I use acne medication on my face after I’ve healed? Can this cause infection?
A: In answer to your questions about cheek implants and their infection risk:
1) There is no correlation between Minoxidil on the scalp and an increased risk of cheek implant infection.
2) The issue is the same with scalp tattoos as that of topical Minoxidil for cheek implant infection.
3) The real risk of getting cheek implants infected with dental treatments is the risk of the dentist inadvertently sticking a needle into the implant while injecting local anesthetic for maxillary vestibular infiltration. It would be important to tell your dentist that you have cheek implants should any upper teeth (premolar and molar) dental work be needed. This would be particularly important should any root canal work be done on these same teeth.
4) Topical acne medication does not increase the risk of cheek implant infection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to achieve more definition and masculine features. I want a more defined jawline, neck and cheekbones. I actually am even more dissatisfied with how my face looks from the side or profile view. Do you think that liposuction of any area of the neck or cheeks would be beneficial? Or just all implants? I’m slightly hesitant to do implants other than the chin and wondering if you yourself would be able to use fillers instead of something permanent. I have attached some front and side pictures for your assessment.
A: Your side picture clearly shows a more recessed chin that would benefit from a chin augmentation. I think this combined with small jaw angle and cheek implants would provide much better facial definition. But it is clear that you are only comfortable with a chin implant at this time.
When it comes to fat removal, many chin/jawline enhancement patients will benefit from sub mental/neck/liposuction as a complementary procedure. For the cheeks, fat removal is done by a buccal lipectomy procedure which help define or skeletonize the cheek bones better. There is certainly nothing wrong with using injected fat for cheek augmentation. It does not create a sharper or mored defined cheek augmentation effect because it is a soft material and its survival is anything but assured. But for those patients who are a bit skiddish about cheek implants and want to do an initial trial with something more natural (albeit with its own drawbacks), injected fat for cheek augmentation is a good treatment approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was told in a consultation with a local plastic surgeon that I needed cheek implants, chin reduction (just shaving the bone down and removing some fat/skin), and a little off the hump in my nose. That is the basis for my inquiry. Even though those were his suggestions, I still wanted to keep looking because I didn’t see that he had a very extensive client base where he had performed all of those at once…or more than one procedure at the same time.
I normally pose differently and make myself look better in pictures, but my profile is very flat in the cheek area and prominent in the chin. I’d like to get this corrected somehow, but I think with so many things to address at once, I get concerned that the surgery would be very noticeable and I would look like a different person all together…
A: In reviewing your pictures, I could make the following comments:
Your vertically long but non-projecting chin would be best treated by an extra oral vertical reduction ostectomy. (submental chin reduction) A burring technique would not remove nearly enough. You need at least 8mms or more off to really make a difference.
Your flat mid facial profile is ideally treated by a combination of paranasal and malar shell cheek implants. This will help pull out the entire midface. (both the nasal base and the cheeks)
You do have some significant facial asymmetry that actually affects the whole left side of the face. (which is shorter) The chin reduction will help with the lower facial asymmetry. The eye asymmetry, however, will not be improved.
One realization is that these changes will make a facial difference with much better balance…but it will likely be noticeable as your face gets vertically shorter and more horizontally projected.
Dr. Barry Eppley
Indianapolis, Indianapolis
Q: Dr. Eppley, I would like to know if the following facial surgery results are possible.
1) With a custom cheek/orbital implant can I augment all of the inferior, lateral, and superior orbital rims along with a small portion of the malar bone?
2) Can off-the-shelf jaw angle implants guarantee that my jaw angles will look more squared/pointed rather than U shaped and heavy?
3) With a rhinoplasty do you believe you can achieve an aesthetically pleasing nose job that keeps a lot of masculinity to my nose. (i.e., keeping a majority of the nasal bone projection and width while still projecting the tip out a slight bit and straightening the nasal bone and cartilage from a frontal view?
A: In answer to your questions:
- While any design can be made for custom cheek and orbital implants, there are limitations to the surgical access to place them. Through a lower eyelid incision, a custom implant can be placed to cover the inferior and lower lateral orbital rim and cheek, but not the upper lateral orbital rim or superior orbital rim. (those require a coronal scalp incision for placement)
- A preformed off-the-shelf jaw angle implant that I commonly use has a more flared and square jaw angle point to it that does not usually cause a rounded jaw angle look. (that patient undoubtably has the traditional rounded style of silicone jaw angle implant that is what is available to most surgeons)
- I believe your thinoplasty goals are achieveable as you have defined them and as we have looked at them with computer imaging in the past.
With that being said, let me make some general statements based on a lot of experience with male facial structural surgery. (of which all your procedures would qualify) It is important to understand that there are no guarantees in surgery. No surgeon can guarantee that any specific outcome will be obtained no matter how much thought goes into it beforehand. Aesthetic surgery involves risk of which the biggest one is less than the desired result. I mention this as you have used the term ‘guaranteed’, this is not an assurance I can give you. In the same vein, it is important to also understand that male facial restructuring is associated with a notoriously high rate of revisional surgery, probably approximating 25% to 33%. This is of paramount note in the young male patient who often is very difficult to please in their search for an optimal result. A good rule of thumb is that the patient will put twice the amount of time assessing their result after surgery than what they spent beforehand…hence leading to such high revisional rates. Slight asymmetries and imperfections are very poorly tolerated in the young male patient.
I mention these issues as you need to factor these considerations also into whether the facial surgeries we have discussed are for you, your expectations and your level of risk tolerance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some type of cheek implant I think. I am not sure whether I have weak cheekbones or whether they are average or it is really a lack of fat or a lack of orbital rim development that gives me those lines under my eyes near the cheekbone. (Not tear trough) I have gotten comments on having a sunken/droopy “eyes” look when I’m cutting body fat and I’d prefer to have a much more healthy looking eye area when I’m at a lean fat %, just not too feminine either. I just wasn’t sure if that was primarily due to the cheekbone, orbital rims, or an odd lack of fat storage in that area of the face. So if am just to augment my orbital rims (lateral, inferior) and perhaps a bit of the anterior cheek (not too feminine) don’t you think fat transfer is my best option rather than a cheek implant, since a cheek implant doesn’t really touch those areas?
A: Cheek implants are your best treatment option but not the way you currently think of them. You do have a ‘weak’ orbitomalar area which is the result of infraorbital rim and cheekbone deficiency/underdevelopment and a thin soft tissue cover. Fat injection grafting will not work to create any sustained desired augmentation as it will be absorbed completely in less than 4 to 6 weeks after placement. The only effective approach is a combined infraorbital rim-cheek implant, probably only about 4mms thick, which will completely and permanently augment this area. While this is ideal, it will require a custom fabrication (thin tissues have no tolerance for anything less than a perfect fit that feathers on all edges) and that it will require an eyelid (subciliary) incisions to place them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have done further research on cheek implants and have a few question on them.
1) I have spoken to a few men who hated their cheek implants because they said it made them look feminine and gave the face more of a heart shape. Is it true that flat cheekbones are masculine? if so, in what circumstances can cheek implants be beneficial for a man? What’s the trick for a man? Is it too match the cheek prominence to the brow and jaw and not go over?
2) I was hoping for a subtle change in the under/lateral eye area, just to provide a bit more strength and less of that droopy look. Would fat transfer be better for this than cheek implants in my face? I very much do not want any apple look to the cheeks or even a rounded appearance.
A: The aesthetics of the cheek area when it comes to cheek implants is different for men vs. women. The proper fullness in the cheek for females is more in the anterior submalar area which creates the ‘apple cheek’ look and more of a softer heart-shaped face. In men, however, the proper cheek fullness is higher and slightly more posterior with the goal being to create a more defined and stronger cheeks. There are differences, of course, between what some men and women want but submalar augmentation in a man can definitely feminize the face. Flat cheekbones, however, would not be viewed as masculinizing feature. What you are showing in your attached picture is a very small amount of cheek augmentation but at least it is in the right place for a man. Cheek implants are always superior to injectable fillers and fat because they offer a one-time permanent solution that produces a predictable result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting jaw and cheek implants, but I am waiting until there is a more natural choice. I want implants that integrate with the bone so I won’t have to worry about shifting. I’ve read online that some doctors have been able to 3D print bones that integrate with the bone. How long until this is applied to cosmetic surgery?
A: If your primary concern about cheek and jaw implants is that they will shift, there is a far simpler technique available today that ensures that will not happen…known as screw fixation. Securing the implant to the bone with small titanium screws ensures that it will never move and is a technique of implant fixation that I do to just about every facial implant that I place. I have used that implant technique for over twenty years and I have yet to see a facial implant that has yet moved from where I placed it.
When it comes to 3D printing of any human tissue, this topic has been in the news of late and is a technology that is quite early in its development. All the recent press releases demonstrate that it can technically be done. But that is far cry from being able to do it in humans for real surgery. I do believe that one day such technology will be available for surgical use but, at a minimum, it will be 10 to 15 years due to FDA regulations and the clinical approval process which is involved in getting it through those hurdles. This does not take into account the economics of the process in which a company has to invest millions (or tens of millions) to get it through that regulatory process. And a company will only do that if the market in which they are developing their product for justifies that expense. The facial implant market would not be considered such a market by today’s standards.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, in seeking online consultations I have spoken to several plastic surgeons ti get their cheek implant choice opinions. Most have recommended a 3 to 4mm cheek implant for me. I understand that a small amount of augmentation goes a long way, but even so, 4mm and especially 3mm just seems a little too small, even though I don’t have much in the way of a deficiency. Do you often find a need for bigger cheek implants in men?
A: The reason that no greater than 4mm cheek implants were recommended to you is that 4mms is the thickest or largest in commercially available malar shell implants…the most popular cheek implant used today. While it is true that a few millimeters of augmentation go a long way in the face, you will likely find that inadequate for the cheek look you are after. I have designed custom cheek implants that are as much as 8 to 9mms thick for men seeking that male model look.
But cheek implants for most men can use several of the available styles and sizes that are commercially available. The male model look is a unique and often an extreme variant of what many men and women want for their cheek augmentation results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing because I have a quick question regarding cheek implants, which we had briefly discussed, vs fillers. I may have rheumatoid arthritis and I’ve heard that injectable fillers aren’t the best route with autoimmune disorders. I’m curious to know if cheekbone implants would be any better, and if you offer any that are non-silicone. I would be grateful to read your thoughts on this topic.
A: The use of injectable fillers in patients with known autoimmune diseases is a bit of a mix bag. Historically the thought was that only collagen fillers should be avoided since they are a foreign collagen processed from a bovine source, hence the understandable apprehension when the body is injected by that material. But more recent anectodal reports have come out that indicates even the very popular and well tolerated hyaluronic acid-based fillers may pose some concern. This has not been definitely proven and it may just represent the general ‘reactivity’ of the autoimmune patient to any stimulus, but the safest route would be to avoid any injectable fillers and lower the risk of that concern to zero.
This, of course, raises the question of whether any cheek implant, regardless of the material, might not pose the same risk…although they have not been to my knowledge in the medical literature or experience. Your concerns about silicone cheek implants is understandable although that feeling undoubtably comes from fluid-filled silicone breast implants of yesteryear and not solid preformed silicone facial implants. But alternative materials for cheek implants include PTFE-coated silicone, Medpor (porous polyethylene), pure PTFE and mersilene mesh. Whether these are all chemically and structurally different than silicone, whether one is better in the automimune patient is not known.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering facial implants to rejuvenate my youthful face. I am 27 years old and underwent gastric bypass surgery 4 years ago and it seems all the volume in my face went away. I hate the excess skin under and above the eye and the deep grove under the eye..I use to have chubby cheeks that went away after the surgery. I tried Radiesse a year ago that didn’t give me the cheek volume I desired and didn’t address the hollow grove under the eye and my face went back flat in about eight months. I have always hated my nose. I hate that the bridge is flat but have a big round tip and my nostrils are huge. I always wanted a small nose that lined up with my eyebrows..I shaved my eyebrows and draw them on until I find the perfect surgeon for a forehead/brow lift to address the hanging/excess skin. I am aware that some people want a subtle change..not me I want a drastic change. I lost over 160 pounds so I feel like a new person but I look like a old person. I have searched high and low for the perfect facial surgeon please let me know if you can help.
A: Facial implants can be beneficial for all three areas that you have mentioned, tear trough, cheeks and the nose. But in applying facial implants to these areas, it is important to realize what they can and can not do. Tear trough implants, which have to be placed through a lower eyelid incision, will help fill in the depressions along the infraorbital rim but they will not get rid of loose skin on the lower eyelids. In many cases skin removal may be simultaneously done but you seem to have little room for loose skin removal even though you are demonstrating the laxity of the skin by pulling on it. Cheek implants, which are placed through the mouth, can be used to build up overall cheek area although your cheeks already seem full. (but then I have no idea what you looked like before your weight loss) Nasal implants are commonly used in rhinoplasty to build up the bridge of the nose. When combined with tip narrowing and elevation and nostril narrowing, significant changes can be achieved in the shape of the nose. Although the thickness of one’s skin will control how much narrowing of the tip can be obtained so one has to be realistic with these type of rhinoplasty outcomes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been looking into getting facial implants, specifically chin, cheek and jaw angle implants, now for quite some time. During my time researching these procedures I have come across many reputable sources of information, like yourself, and millions of internet experts professing to know the ‘truth’ of some sort of another regarding facial implants. Nowhere amongst all this are clear and unambiguous answers to some of the most basic questions. Hopefully you can provide these for me. My questions are as follows:
1. If a chin, cheek or jaw angle implant is placed, the surgical wound heals, all is well and the patient loves the result several months after the operation, what is the likelihood that the implant will become infected years or decades later.
2. In your experience, if an implant is placed uneventfully can the patient then go on to live for decades having ‘forgotten’ about the implant, so to speak? I don’t want to have to come back to any implants later in life, I want to have my first cosmetic surgery and then forget about it forever.
3. Is the removal of an integrated Medpor jaw angle implant as difficult as it is said to be? Also, is there a silicone jaw angle implant that can provide the so called drop down effect?
4. There is a lot of confusion regarding cheek implants for men who want their cheekbones to flare out laterally. Do you think it is a deficiency in zones 1 and 2 of the malar-zygomatico complex that needs to be corrected in order to achieve the male model look? If so, are custom cheek implants capable of achieving this in the right individuals
5. Individual implants will not make a person look radically different. Is this something that can happen, for good or ill, when several implants are placed at once?
A: In regards to your questions about facial implants ( cheek, chin and jaw angle implants), my answers are as follows:
1) The risk of implant infection is greatest in the perioperative period (first month or two after surgery) usually as a result of implant contamination during placement. Delayed facial implant infections are very rare. not impossible, but it would require contamination into the implant capsule like from a dental local anesthetic injection. Delayed infection risks are so rare that they are almost case reports for the literature.
2) If one has uncomplicated healing and is pleased with the size and symmetry of the facial implant result, having them will quickly become a ‘natural’ part of one’s anatomy and they will be forgotten as being a synthetic extension of one’s face.
3) Medpor implants,including those of the jaw angle, can be removed and I have removed many of them. They are much more difficult to remove than silicone implants but that is an issue of relativity. Silicone facial implants are so easy to remove that anything that is more adherent seems difficult.
New styles of vertical lengthening silicone jaw angle implants are now available. I designed them to provide a better implant material to that of Medpor. They are much easier to insert and replace/modify if necessary.
4) The concept of getting cheek implants to achieve any type of facial look is more ambiguous and harder to achieve that most would think. The cheek area is a complex four-dimensional structure and the interpretation of what is a pleasing shape is as variable as the anatomy of each person’s cheek bones. It frequently is not as simple as just pulling an implant off the shelf, regardless of its style and size, and the desired look is achieved. Even using custom designed implants is not a guarantee that the desired look can be achieved as the ability to translate a design to what it makes the outside of the face look like is not a mathematical one. Many men seek the so called ‘male model’ look which often but not always means a high angular skeletonized cheek look. You would have to define what cheek look you are after by using model pictures as examples. While all of them are models, many of their cheek shapes are quite different.
5) The more facial implants that are placed, if they are not properly sized, the more different one can look.
The one caveat I would add to all of this is a basic fact based on my very extensive experience with male (almost always young) facial skeletal augmentation surgery…such patients have a remarkably high revisional surgery rate which approximates 50% or greater in the first six months after surgery. These revisions are almost never because the implants have any medical problems but because many young men are impatient of the healing process and often are uncertain if they like the aesthetic outcomes of their procedures even if it is exactly what they thought they wanted. Thus, when you think about getting facial implants this revisional surgery issue is what you need to consider, not all the other concerns that you have mentioned which are fairly irrelevant compared to this consideration.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 22 year old man who is interested in custom facial implants. I have taken an interest in your practice because of your really detailed and informative website and photos and because of the experience you have with the particular facial implants I want done. I am interested in getting cheek and wraparound jawline/chin implants. I want the cheeks implants because my cheeks are quite small and I would like to have implants put in to make them larger and have a more sculpted face. As for my jawline and chin, it is quite small and narrow and I would like a wraparound jawline implant to give me a stronger wider jawline, a sharper jaw angle in the back, and a larger chin that are seamlessly connected together. I know this will require a custom implant approach to get the best implant symmetry and shape, provide a faster operating time, and provide me with a better chance of obtaining the results I am looking for. I want to know if these two surgeries could be done at the same time? I am really looking for a more masculine sculpted jawline and chin and cheekbones that provide a youthful face as well. I am really interested in you performing the surgery since so far you seem to be the only surgeon I have searched online who has a blog devoted to helping answer clients questions and you have an extremely thorough website.
A: You are correct in assuming that a custom facial implants is the best way to go when one seeks a wrap around jawline implant that is seamless from front to back. While off-the-shelf cheek implants could probably be used, one might as well make the cheek implants custom as well since that would add little cost as the 3D CT scan and software design process is already in place. It would be very common to do cheek, chin and jawline implants together to achieve a comprehensive overall facial enhancement result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheek implants. Please find my two photos. First one is my face, which is ok I think but it is the second photo which kills me. You can see the nasolablial fold and the cheek skin/fat falling down my face, making me look fat and old. I need to fix this and want to know my best options. Is it cheek implants? Paranasal implants? (whenever I push my top lip forward with my tongue from inside the mouth, my nasolabial folds and falling cheek fat disappear. Please let me know my best option sir. I don’t want to look like a fat guy even though I’m skinny. It’s just like my face is falling. I think I lack the bone structure to hold up my face. As my jaw and cheek bones are non existent. I am 32 years old. Thanks!
A: At your age I don’t know that your face is truly falling but I would not disagree that you have weak cheekbone structure. Pushing the lip out is not a practical approach to improving your facial structure. The only way to get some tissue lift is through cheek implants which will create a bit of a midface lift using malar shell implants. This will not eliminate the nasolabial folds completely but it will provide better facial balance and make your face look less fat. In addition I would do fat injections into the nasolabial folds and the paranasal areas to provide some augmentation to them as well. This in combination with the cheek implants will likely create the overall facial improvement you seek.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m an Asian American and I’ve been thinking of a few cosmetic procedures to enhance my flat face and that is rhinoplasty and midface augmentation.I’ve decided to go with the midface first. Being that, I’d like to know your inputs on the area of my midface that needs to be augmented for a more chiselled, three-dimensional look. I know that there a few parts to the midface – premaxillary and maxillary area for the anterior cheek ( I may be wrong on that ). So with that being said, what would you say about having both paranasal and malar implants done together? (for the case that I may need both) Would that cause a great incremental change in my facial projection compared to just one procedure done?
A: In looking at your face, which is not atypical for many Asian males, you might consider a somewhat different approach. The best procedures for ‘pulling your face out’ (increasing midfacial projection is a rhinoplasty combinjed with paranasal implants. It is very difficult to give much definition to broad wide cheeks without burying the rest of the midface behind them. (making the nose look even smaller) Look at the imaging I have attached to see what effect is created by initially pulling the nose and its base out. With your specific facial shape, this is where the real value is in any plastic surgery for you. The cheeks can be enhanced by probably not in the ideal chiselled fashion that you seek, I don’t think that is realistic for your face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheek augmentation but am not sure which option to pursue. Can you help me decide between fillers and cheek implants?
A: Cheek augmentation can be done with a variety of methods because the cheek is a rather indistinct structure that does not have sharp contours. Thus cheek augmentation usually only requires a mass effect which rarely has to have very distinct contours. Fillers and implants make up the two categories of treatment options that can have similar effects but different methodologies and short and long-term effects.
Synthetic injectable fillers are the easiest approach as they can be done in the office and can be placed anywhere on the cheek. Their effects are instantaneous and there is little swelling and no recovery. Their downside is that they will not be permanent and must be repeated to have a sustained result, regardless of the filler type used. For many this can be a good test or trial if one is uncertain about whether cheek augmentation is for them.
The natural injectable filler of fat offers the potential of longevity but its complete survival is not assured. This is why cheek fat injections are often overdone to some degree building into the result some amount of postoperative fat resorption. Because this requires the harvest of fat, it is usually done in the operating room and usually as part of other face or body procedures.
Cheek implants offer a reliable method of permanent volume augmentation that can be placed in a variety of cheek locations due to the different implant styles and sizes available. This is the most invasive approach and is done from an incision inside the mouth under the upper lip. If the implants are properly selected and placed, potential complications such as cheek asymmetry or an unaesthetic shape can be avoided.
When all put together, one should do synthetic fillers if one is uncertain about the benefits of cheek augmentation, use fat if doing other surgery and want a natural cheek augmentation effect or use implants if one is certain about their desire for cheek augmentation and/or want a permanent and/or dramatic effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek and jaw angle implants four months ago. I see that you are ubiquitous on the Internet for cheek and jaw angle implants. My question: my right jaw has been very swollen to the point where I had an MRI that shows unusual swelling. As a result I’m scheduled to have that jaw area opened up and cleaned out with hopes of immediate replacement of implant. I was hopeful that during this same procedure I would have the cheek implants replaced with smaller ones and located a bit higher in my cheek area with more emphasis on the enhancement of the upper cheekbone. My surgeon said its not a good idea to work on the cheeks because of the inflammation in the right jaw. Is this true? If I’m going to be under sedation I would prefer to have the cheek implants adjusted. It would save me a third flight and money for sedation in the future. Your thoughts?
A: In regards to the simultaneous management of your cheek and jaw angle implants, I see no problem with doing them together. The ‘cleaner’ cheek implants should be downsized first and then the presumably infected right jaw angle implant should be opened and managed. I do not necessarily believe that one infected implant will affect unaffected ones of the sequencing in surgery is done in the right order.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek implants placed over 25 years I have lost weight and would like to know if facial fillers can be used close to the implant. Is there and increased chance of infection? Thank You
A: Cheek implants that have been in place for 25 years had to have been some of the first cheek implants every put in, usually of a small ovoid shape that were positioned on the anterior end of the cheekbone. This location creates that ‘apple cheek’ look that is very appropriate for many women. While the bony augmentation has remained stable, over the years the soft tissue around the implants has undoubtably changed becoming thinner and developing some malar sag. Thus the impetus for injectable fillers to recreate some lost cheek highlights due to aging. Generally it should be no problem to place injectable fillers in the tissues overlying such ‘old’ cheek implants. Having removed several cheek implants of a similar age, the scar capsule that surrounds them can be incredibly tough and even partially calcified. It would be probably be unlikely that a needle could even penetrate the capsule should it inadvertently come into contact with it. This is also a good use of the microcannula method of injectable filler placement which has a blunt tip and would have zero chance of breaking through the cheek implant capsule and inadvertently injecting into the implant itself.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting facial implants and am gathering information about getting plastic surgery. My intention is to improve my facial features with facial implants and cosmetic plastic surgery. I would like to get your professional impression and advice to enhance my look.
The areas that I would like to improve are:
– Jawline. I think I have an elongated face. So, I am looking for a more square and strong jaw.
– Cheeks and Eye Hollows. I am starting to notice some eye hollows. I think I do not have a strong features in this area, they are somehow “flat”. At this time, it is not bad, but I believe with time they will get more pronounced.
– Upper Eyelids. I notice that I have extra skin on my eyes lids, especially on my left eye.
– Any suggestions to make the face more aesthetically balanced and harmonious with the rest of the face.
Concerns:
– I am concerned about the scars and the surgery around the eyes. I do not mind internal scars but external incisions concern me.
– What is the material used for the facial implants? I read about Silicone, Medpor and Gore-Tex. I would like to know your impressions about these materials, and their pros and cons, and why you use ones over the others.
– Asymmetry, implant shifting and/or misplacement (due to position, scarring, etc.)
– Final look. I would like to look natural and not “done”.
– Revisions. What is your policy in case of revisions?
– Complications during and/or after surgery. What is your policy in case of complications during the surgery and/or after the surgery? nerve damage?, secondary effects?, responsibility, cost, etc.
– Bone erosion with implants over time. What is going to happen with the implants when I get older. I am 30 years old at this time. What is going to happen with the implants and the bones when I am 85-90 years old? the implant, the screw, the bone. Is there any research done about this?
Ideal:
– I can imagine you have heard this before, but I would like to get the “model” look. Strong, symmetrical, pleasing features. I attached some photos of some ideal looks, by all means I don’t want to look exactly like a specific “celebrity” or “model”, it is just an idea of the look I am looking for.
Questions:
– Could you provide me with your professional impressions about the surgery/ies that I will be benefiting from, their related costs and results?
– Do you provide any imaging about the possible results. I attached photos of my face in different angles.
– What are the difference between conventional and custom designed implants? what are their costs?
– How long will I have to stay in Indianapolis after the surgery?
– When would I be able to return to my normal life work, exercise, being in public, etc?
– How much discomfort should I be expecting in the surgery?
A: I have done some computer imaging on your face for the various facial implants for the following procedures:
1) Square chin augmentation
2) Vertical lengthening as a well as width expansion jaw angle implants
3) Cheek implants
4) Fat injections to the lower eye hollows/tear troughs
In answer to your questions:
CONCERNS
– there would be no external incision with fat injections
– implants would be silicone, best because of better shapes and easily reversible or modifieable
– all implants would be screwed into place
– natural comes from not using too big of implants, particularly when multiple implants are being used.
– we have a complete page of the revision policy which you would get to read before surgery.
– bone erosion is a non-issue. The implants will look the same decades from now as they will one year after surgery.
IDEAL
– you are correct in assuming that every male who wants this kind of surgery wants the ‘male model’ look. Those who have a chance to come close to that look have to have thinner faces and some decent underlying facial bone structure…you are the uncommon one that actually fulfills these criteria.
QUESTIONS
– I have attached some imaging predictions for your review. I will have my assistant pass along the costs to you in a day or two.
– you should be fine with standard implants. Custom implants are always ideal but at the additional costs of $7500 they had better provide a real difference…which in your case they do not.
– 2 to 3 days, all based on how you feel.
– that is based on how you feel and look, somewhere between 10 and 21 days after surgery.
– jaw angle implants provide the most discomfort, the other procedures are much less.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting cheek and paranasal implants. What is the best procedure to correct a deficient (flat) mid face? I’ve always hated my facial profile. I have attached some photos which I realize probably are not the quality needed for computer imaging but I was hoping you would be able to gauge if and how you might be able to correct my facial features.
A: The photos you have sent show you smiling in both of them so they not only are not useful for computer imaging but have distorted the midface due to the soft tissues changes. Unfortunately if I can’t image them to see the visual change then it is difficult to say such procedures are aesthetically productive…because what ultimately counts is what you think not what I think about the potential facial look change.
Having said that, cheek and paranasal implants are useful for improving the facial profile that has some midface deficiency…which may apply to you but smiling photos pull the soft tissue up (at least on the cheeks) and make them look fuller than they really might be. I can see the paranasal deficiency which smiling actually accentuates rather than improves.
So my incomplete assessment at this point suggests that you may be correct that your midface profile could be improved by these types of implant augmentations.
Dr. Barry Eppley
Indianapolis, Indiana
