Your Questions
Your Questions
Q: Dr. Eppley, Can I benefit from cheek implants? I have a long thin face that has always bothered me. I don’t know what if anything can be done to add fullness or reduce length? I always look like I am scowling and as I age…it gets worse. The first picture attached us awful I know but it at least gives you an idea of my situation. The second pic is simply one I have played with to widen my features and wish were possible. Thanks for your time.
A: There are improvements that can be made to a long thin face in terms of both length and width. Facial height reduction options are more limited than those of width and are often relegated to the considerations of vertical chin reduction, upper lip lift (shortening) and in some cases rhinoplasty. Numerous facial width increase options include jawline and jaw angle widening, cheek implants and fat injections between these two skeletal area. (the trampoline facial zone) Which one(s) of these might be most beneficial to your face depends on a computer imaging analysis. Unfortunately your one picture is not adequate to much of anything with due to the poor picture quality. If you could send me a front, quarter and profile views of your face (non-smiling) I would be happy to do that assessment for you. Based on this one picture it does seem that cheek implants may be helpful for more facial width and that could be combined with fat injections for a more blended transition from the implants into the thinner and non-bony supported areas outside of the cheek zone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very sorry to disturb you, I live in a remote area of Russia, and my grandson was born with craniofacial distortions of his face and skull. My friend found your contact details in the Internet. I have a few questions to you:
1) Is it possible to enhance at the same time (by one surgery) my grandson’s forehead and back of his head? They are both too flat and the maximum distance between his eyebrow line and the back of the head is 14.7 cm only. By how much is it possible to make this length longer?
2) What should it be done with his medium face? Will it be the treatment by implants, or it is possible to put there human grease/fat?
3) What else could you recommend on him ? We know that he also needs the surgeries on his jaws.
4) How much will it cost us to get the above mentioned treatments ( 1) and 2) points) at your clinic in the USA?
Thank you so much for your reply.
A: Thank you for your inquiry. In looking at your grandson’s pictures, it is clear that he was born with some form of craniofacial deformity, most likely one of the craniosynostoses. (Crouzon’s etc) It also appears based on the scars on his forehead that he may have had some initial efforts at craniofacial surgery when he was younger.
While you did not state his age, he appears to be a mid-teenager at least. I will separate his craniofacial concerns for this discussion into cranial (skull/forehead) and face.
From a skull standpoint he has a short front to back distance typical of many congenital craniosynostoses. He is shorter in the back than in the front in my assessment. The back (occiput) can be augmented significantly (up to 2 cms.) and the forehead smoothed out for a better contour. The most relevant issue here is where is his previous coronal (scalp) incision as that will determine how to approach is skull augmentation reshaping.
From a face standpoint there are two directions to go. Ideally he needs pre- and postsurgical orthodontics and a LeFort I midface advancement with a sliding chin genioplasty. The key there is orthodontic preparation. If this is not possible, the second approach is to camouflage the bony deformities by a combination of orbital, cheek and paranasal implants combined with a sliding genioplasty. (see attached imaging) That could be done at the same time as skull augmentation.
The key in any complex craniofacial problem in a mid- to late adolescent is to identify those craniofacial surgery procedures that are most practical to do that provide the greatest physical and psychological change for the patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had all my stiches break open (only left side) 1 week after my cheek implant surgery so my left cheek got infected. I was in pain with swelling. The Dr .chose to do revisional surgery in his office where he took the implant out, sterilized it and flushed my cheek out with a liquid then put it back in and stitched it up again. I was on two antibiotics and right away the pain stopped and some swelling came down. My problem is that at 4 months out I noticed my cheeks were not matching up! From the top were the malar implant was put is fine but the bottom looks swollen on that problematic left side. The right side is thin and slender but the left looks like a ball especially when I smile. I talked to the Dr and all he offered was some lipo and acted like I always had that there. I know my face and it was never there before. My question is what test would you recomended to figure out why the tissue on one side of my face different from the other. The tissue is soft and squishy not hard. I’m worried this still has something to do with it being infected.
A: The two possibilitues are that this is excessive scar tissue that would commonly form after an infection. I doubt that it is an infection now since you know what that feels like. The other possibility is that the implant on the infected/revised left side is sitting lower or in a different position than that on the uncomplicated right side. I would suspect it is the latter and not the former. The definitive answer would be to get a 3D CT scan which would show the exact location and symmetry between the two cheek implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheekbone reduction using the L method. Now cheeks are really low. I want to ask can you put an implant on top of the cheekbones which have been cut and screwed in a lower position? Or is this not possible as it may make the already cut cheekbones move position or fall off??
A: Your cheek bone prominence can be restored by the placement of an implant on the cheekbone. Even though the face of the cheekbone has changed, cheek implants are screwed into position so there is no chance of shifting or falling off of the face of the cheekbone. Having a prior cheekbone reduction does not preclude the placement of cheek implants later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my husband had maxillofacial surgery for an under bite and put cheek implants in to balance his facial features about five years ago. He has had problems with the left cheek implant moving slightly and when he blows his nose his left cheek gets swollen and you can feel bubble like things moving around implant. It has caused him a lot of pressure and pain and this happens more often. I have begged him to go to the Dr but the entire experience of the surgery has traumatized him and so I’m trying to figure out what’s wrong. Please help me try to help my husband.
A: Undoubtably what your husband is experiencing is what one may call a ‘blowhole’ in the simplest of terms. When a maxillary osteotomy (LeFort I osteotomy) is done, the bone cut across the upepr jaw exposes the entire maxillary sinus. While most osteotomy lines experience complete bony healing afterwards, some do not particularly larger maxillary advancements and those that may have been vertically elongated. Any large unhealed bony openings allows air to escape from the maxillary sinus up into the cheek facial area, particularly when the air is forced such as blowing one’s nose. A cheek implant may be laying right next to or even over the original osteotomy line. This air being forced into and around a cheek implant (if it is not secured with a screw) make make it move slightly from the air pressure. Air into the subcutaneous tissues of the face is known as crepitus, which you more commonly call ‘bubbles’.
Thus there is a bony hole right next to the cheek implant as the culprit of all of these symptoms. This is a relatively easy problem to fix by covering the bone hole (sealing the sinus from the face) and stabilizing the implant to the bone with a screw. This is a simple outpatient procedure done under general anesthesia with minimal recovery. The only question is what to use to seal the bone hole as a variety of materials can be used to accomplish that end.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m considering cheek implants to address the following problem. I have a wide round face with a flat midface and I want to avoid implants that make my face look wider or rounder. Should I go for malars without edges (so ones that only address the cheekbone) what part of the cheek contributes the most at creating forward projection? My main goal is to achieve a less wide face with more projection. Thank you so much!
A: When it comes to increasing midface projection without making the face wider, all implants have to remain inside of a vertical line drawn down from outside of the lateral orbital rim. This means the options of using orbital rim implants with small malar extensions relegated to the anterior cheekbone surface, paranasal, and premaxillary implants. These are the implants that can increase midfacial projection without creating width.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in cheek augmentation and an African-American rhinoplasty. I have fat cheeks and I want them smaller. I also want a more refined and less fat nose. I have attached a picture of me so you can see what needs to be done.
A: Thank you for sending your picture. This one view is not the best picture to judge the result but it is helpful. I believe you are looking for a buccal lipectomy to reduce the fullness under your relatively flat cheek bones. Or you could leave the buccal fat alone and augment the cheekbones which I think is a better alternative. (maybe just a little buccal fat removal. Your nose shows many of the typical ethnic features and that could be improved by an open rhinoplasty in which the nasal bridge is built up with an implant, the tip lengthened and narrowed and the nostril flaring/width reduced. I have just imaged the buccal lipectomy and the rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in having the following procedures done:
* Ear surgery – ear pinning + fix right ear that sits lower than left ear or fix left ear that sits higher than right ear + improve general appearance of ear cartilage
* Blepharoplasty – lower eyelid of my left eye (when I smile, it creates a prominent bag under the eye – not the case with my right eye though)
* Septoplasty – nose veers a little bit to right (possibly due to deviated septum)
* Rhinoplasty – remove slight bump & also looking to have a thinner nose
* Lip augmentation – improve general appearance
* Liposuction under chin – just to get rid of dreaded dubble chin
* Other possible procedures (if doctor recommend them): cheek implants, jaw implants and chin implant – I would like to have more masculine facial structure
Other possible procedures, if you offer them: tear trough implants, cheek lift
PICTURES:
First pic: how I actually look
Second pic: alterations I made to my face on your website (not perfect, just played around).
A: In answer to the facial procedures:
1) It is possible to raise an ear .5 to .75 cms but it is not possible to lower an ear. Ear pinning or antihelical fold setback can effectively reshape the outer ear cartilage.
2) The ‘bag’ of the left lower eyelid is hard to appreciate in your non-smiling views so I am not sure if it is a skin issue or a fat issue.
3 and 4) A septorhinoplasty is needed to straighten the nose, reduce the bump and have a thinner tip.
5) To make that amount of lip augmentation change, you would have to think about fat injections even though their survival in the lips is anything but assured.
6) Submental liposuction can be done but, more importantly, significant chin augmentation will eliminate that concern on its own. Cheek and jaw angle implants would be complementary to the chin and, in your thin face, would make it very sculpted and angular.
7) Cheek implants will obviate the need for a cheek lift. Tear trough implants can be done to fill out the under eye hollows.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Are malar cheek implants considered soft tissue augmentation? Are porous implants mainly used for submalar or malar cheek implants? Do malar cheek implants sag with time if not screwed in? Sorry if I am asking so many questions! Thanks!
A: Malar or cheek implants are onlay bone implants that create overlying soft tissue augmentation by pushing from beneath it. Porous or Medpor implants are one type of facial implant (silicone being the other) that can be used for facial augmentation. The material has certain advantages and disadvantage compared to silicone, which neither makes it better or worse than silicone in overall implant characteristics. Malar implants may shift or move from their original implanted position over time if not secured into position by screw fixation. (I would not call that sag but implant displacement)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had Medpor midface rim implants placed a year ago and have had no issues so far. However, I have been considering getting a malar shell or combination submalar implant to add more contour and definition to my cheeks and midface. My only concern is that having the medpor implant would preclude this procedure. Would the cheek implants overlap the existing Medpor implant and can they be secured and screwed in over the Medpor implant? Also, would the surgery be much more difficult as I hear that Medpor implants are hard to remove, and I assume that this difficulty in removal might make it harder to create a pocket. Thank you for taking the time to read this!
A: The simple answer to your question is that is no problem on any of those issues. The silicone malar implants can be placed and overlap the Medpor material and then secured by screw fixation into place. The pocket dissection over the top of the Medpor implants is minimally more difficult and that also is not a concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m now thinking I want to move forward with doing cheek implants and picked out the style of implant I want but need to know it the implant is falls into the category of small, medium or large. It’s by spectrum design and is called( malar profile ) the nominal dimensions are 5.4×3.2×0.5. But it doesn’t say if its a medium implant or large and this is something that is important for me to know. Pls help. Thank You.
A: To help answer your question, here is the schematic on that particular cheek implant style.
| Profile Malar Implants | ||||
 | Catalog Number | NOMINAL DIMENSIONS | ||
| A | B | C | ||
| S140-414S | 4.6 cm | 2.3 cm | 0.4 cm | |
| S140-424S | 5.1 cm | 2.7 cm | 0.5 cm | |
| S140-434S | 5.4 cm | 3.2 cm | 0.5 cm | |
| S140-444S | 5.7 cm | 3.5 cm | 0.5 cm | |
| Sizer set 900-014 | Designed to enhance the entire malar region, this implant features thin tapered edges and provides a smooth transition to the malar prominence. | |||
You can think of the four options as Small, Medium, Large, and Extra Large. Therefore what you inquiring about is S140-434S which would be considered a large implant. As you can see by this dimensional chart on cheek implants is that the thicknesses don’t differ that much but the surface area that they cover do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in silicone malar cheek implants and wanted a dramatic look to change the shape of my flat face. I for sure want to get a medium size implant and was wondering if a 3mm falls in that category or if a 4mm is considered a medium? Thank you.
A: The determination of size is but one consideration in the selection of a cheek implant. It would be equally important to select the style or shape of cheek implant that works best for your face and could create the look you are after. But back to size, a cheek implant’s size has numerous dimensions of which thickness is but just one of them. Generally as the thickness of the implant increases so does the height and width of it as well. (total surface area that it covers) Whether a 3mm thick cheek implant would be considered a ‘medium’ would depend on what cheek implant style you are talking about. For some silicone cheek implants such as the malar shell, 3mms in thickness would be considered an intermediate sized implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 25 year old male and I am interested in facial cosmetic surgery. My previous history of cosmetic surgery is otoplasty, rhinoplasty and a chin implant. I would like a more balanced face and more of an oval/square shape.
Frontal/anterior view:
-Is it possible to augment more on the weaker side (jaw and cheeks) to balance asymmetry?
-On the cheekbone I would like to augment both the temporal process and the zygomatic bone, augmenting both the sides and front of the cheek bone (particular more augmentation on the right side to balance the weakness)
-On the mandible, i would like the Ramus more laterally augmented (a more square jaw) (also particularly more augmentation to balance the weakness on the right side)
-On the nose, a narrower and more defined tip
Left and right profile views:
-augmentation of the cheekbone (both the temporal process and the zygomatic bone)
-more square mandible angle
-slight de-projection of the nasal tip, lower and upper cartilage*
*Tip projection is more pronounced in the photos of the oblique smiling views.
I am sending pictures of anterior view and right oblique smiling view. If you could please send me altered photos with your expected results explaining the procedures you have added and why you feel so.
Thank you for your time and consideration
A: Thank you for your inquiry. Unfortunately the images you have sent me are inadequate for imaging. Only the front view is useful. A NON-SMILING oblique and side views are needed to get a more complete analysis.
Other issues:
1) It is not clear if the images are flipped or not. As I see them, the left side of your face is the smaller or weaker side.
2) The concept of oval and a square face are contradictory. As a male I will assume you mean more of a square facial shape is what you desire.
3) While the temporal hollows can be augmented, the bony zygomatic arch and its temporal process which lies below it can not.
4) Correction of facial asymmetries is difficult even using differently sized implants for each side. Improvement may be obtained but do not expect perfect symmetry as that will not happen.
5) Since you have already have a rhinoplasty, what was done to the tip of the nose initially? What tip changes ere already done and didn’t achieve your goals? It is now a scarred tip and a review of the previous operative note would be helpful to know what now lies underneath and whether cartilage grafts were harvested from your septum. You also have a right middle vault collapse, a step-off at the osteocartilaginous junction, significant nasal deviation and nostril retraction/asymmetry. These and the desire for tip de-projection are going to require cartilage grafts.
All this being said, I have done some imaging based on the one useful frontal view that you have provided with jaw angle, cheek and temporal implants as well as revisional rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, it’s been exactly 2 months since my cheek implants were inserted and I cannot move my upper right lip & have numbness in the lower cheek area. My upper lip movement has SLIGHTLY increased since the surgery but I’m very concerned that I have permanent nerve damage or lip upper paralysis. In your experience, have you seen any cases where patients get permanent lip/facial paralysis as a result of cheek implant surgery?
A: The intraoral insertion of cheek implants is a subperiosteal pathway to the zygomatic body that lies way below where the buccal branches of the facial nerve lie in the more superficial overlying muscles. The dissection does expose the large infraorbital nerve (2nd division of the trigeminal nerve) which is a sensory nerve that exits the bone below the infraorbital rim and usually transects the small zygomatico-orbital nerve branch (sensory nerve branch) as the dissection crosses the zygomatic body. Thus it is very common to have some temporary numbness to the cheek area and even the upper lip which can take several months to resolve. It is very difficult to get motor weakness/paralysis of the buccal facial nerve branches which supply movement to the upper lip given where the nerve lies and where the deeper dissection is done. If weakness is present, it is likely due to a traction injury rather than nerve branch transection. In addition, there are numerous branches of the buccal nerve which have some cross-innervation. This means that eventual return of full lip function is assured. The return of nerve function may be slow and the fact that you are seeing some upper lip movement indicates that the recovery process is ongoing. It may take up to six months or more for complete function to return.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have a couple of questions and I have included a photo of me now (right side) and when I was younger (left side). I’m currently overweight and intend to lose that weight but what interests me the most is if it is possible to look like my younger and fresher self again, like the left side of the picture. I have seen surgery that make people look at least 5 years younger. Is it realistically possible to make me look like that younger me again? And if so, what are my options? What procedure would suit me best? I would say that my cheekbones, used to be wider, the cheek pads were higher, there is a lot of sagging in my cheeks. Also the area around my eyes has become hollow. The bone is more visible and my eyes look deeper placed. If I would be my own surgeon I would probably suggest to lose that weight. And maybe then turn to possible cheek implants and fillers to reduce the hollow look. I’m not sure because I’m no expert. I could be totally wrong?
A: The first question you have to asked yourself is what has changed that makes you look older. By identifying the changes then you can see what may be able to be done. Thus I would first ask you what you see. I have my thoughts but what do you identify that you see has changed? What changes do you think would make you look more refreshed? You have done that and I feel that you are totally right. That is exactly what I would recommend and what I see as beneficial…small cheek implants and fat injections to the lower eyelid hollows.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have had two cheek implant surgeries. Initially I had 4mm malar shell implants which were barely noticeable. Then I switched to 6mms implants which are now too big. I have a question regarding projection size. I’ve attached two photos showing my face with Conform Terino Malar Shell medium implants with 4mm projection. As you can see, I didn’t feel that these 4mm implants gave me enough definition in my cheekbones or enough outward projection. Therefore, I just had these implants exchanged with Terino Malar Shell 6 mm, but I now feel that the 6mm projection sticks out way too much. I’ve heard that a 1 mm difference in implant thickness (projection) is equivalent to about 1/2 inch difference in actual cheek shape. So, looking at the attached photos (and now that I know through trial and error that 6 mm projection is too large), do you think the same implant with a 5mm projection would still look too large, so I should go with a 4.5mm implant when I exchange the implants next month?
A: It is not true that 1mm of cheek augmentation equals a half inch difference in how the cheek looks. What I can tell you is that it can be striking how a few millimeters in the cheek area can make a big difference. So I think the statement that a little augmentation goes a long way in the cheek area. You case illustrates that in particular. If 4mms is too small and 6mms is too big, one would logically assume that 5mms would be the right size for you. Be aware, however, that in any cheek implant style and size that not just the thickness changes but overall size of the implant (height and width) as well. It is unfortunate that you will have had to go through three surgeries to finally get the right size implant. But there remains no quantitative way before surgery to determine how any amount of cheek implant augmentation will look
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, two months ago I got 6 mm silicone malar shell implants put in. I have flat cheekbones and full cheeks so the goal was to achieve higher, chiseled cheekbones (without placing them too laterally because I didn’t want the overall width of my face to look wider). To be clear, I do not have a combined malar/submalar implant because I did not want to augment my submalar region. Is the malar shell the implant you would have used or would the Medpor RZ malar implant work better to achieve prominent, high cheekbones? Thanks so much.
A: Quite frankly I would have used neither. All silicone malar shell implant styles are fairly wide which are going to give a round look to the cheek more than a high angular look. The medpor RZ implant is a lower projecting cheek implant style that will not give a high lateral look either. In reality, there is no really one good cheek implants style that will give that highly placed chiseled look in many patients. The best cheek implant that I have found is to either cut the silicone malar shell implants in half so that only the highest part stays or to use a so-called anatomical (style 1) implant that only imparts fullness to the high malar region.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m currently 30 years old and after a long career of modeling I see that I’m not longer as popular as when I was younger. Since I have seen good plastic surgery turn people 5 to 10 years younger, I was wondering if the same thing could be done for me. Could implants help me to retrieve a more youthful look. I’m not expecting to look any younger then 25, I am realistic about the possibilities. What would you suggest? What would help me the most to fight the “aging”. Even though I’m still young, it is important to me to know what my options are. From what I have understood. Elasticity of the skin declines and the cheeks start to sag, so will an implant help with that? I also have a bit hollowness under my eyes. What could be done against that? People have advised me to get some kind of fillers, or fat transfer to create that younger look again. But what is your opinion? Is it surgically possible to make even a fairly young person look younger? Thanks.
A: Most likely at your age the initial changes that you see are best treated by some skin rejuvenation techniques and fat injections. The quality of your skin can be improved, at any age, by such techniques as light fractional laser resurfacing. Loss of some facial volume, particularly over the cheeks, is very amenable to improvement by fat injections as is the infraorbital hollowing. Depending upon your natural skeletal anatomy of the infraorbital-malar area, the concept of cheek implants is also an option. But I would have to see pictures of your face for further assessment as to the benefits of fat injections vs cheek implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek implants in 1991…through the years they have shifted upward….more on the right, the right also is sore when applied pressure on it. I’m interested in having a revision.
A: All facial implants when placed ultimately form a layer of scar around them known as a capsule. This capsule not only envelopes the implant to separate it from the rest of the body but also serves to anchor or maintain the implant in its location. It is interesting as to why, years later, that the capsule somehow changes and allows the implant to change location even if it is only slightly. This is not unique to facial implants as it is seen in some breast implants as well as they bottom out or move too far to the side over time in some patients. What this indicates is that the interaction between implants and the body’s tissues is not just a static one. This is why I feel it is important to screw all facial implants into place when possible so implant micromotion and sliding around is not possible.
The question with your current indwelling cheek implants is whether they should be merely repositioned and secured with screws or replaced with new ones. That would depend on how you feel they look now and whether you have had any significant facial tissue sagging over them over their twenty years of implantation. Seeing some pictures of your face would be very helpful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had both buccal fat pad removal (10+ years ago) and cheek implants (6 mos ago). I'm now considering fat transfer to go over my cheek implants since that didn't seem to add enough volume. I was also considering perioral mound lipo, but I have a concern that I hope you can advise me on. Ever since my buccal fat pad removal (10+ years ago) I've felt a constant throbbing in my cheeks, the Dr. that did my cheek implants said it was likely due to nerve damage. Do I face a higher risk (than the typical person) of further nerve damage because of this? If further nerve damage did occur, what would be the extent of it? i.e., do I run the risk of paralyzing all the nerves in my face, or having thick scar tissue, or…?? Also, do you think with the fat transfer that I could look like I did before? My goal is to not only look like before, but also go back into modeling and acting. I very much like your website and it seems you have a lot of experience.
A: Knowing your prior facial surgery history explains your younger appearance with the indentation in the submalar/buccal fat pad space from an earlier picture. Since you had cheek implants just six months ago, that explains several current findings. First, the throbbing that you feel in your face is not likely nerve damage. The nerve that runs around the buccal fat pad is a branch of the facial nerve which is partially responsible for upper lip and nostril movement. If that nerve was damaged you would have some observable facial weakness not a throbbing sensation. The most likely reason you feel a throbbing sensation is the loss of the buccal fat pad which helps buffer the pulsations from a large branch of the facial artery that crosses around it. You always have to remember that the buccal fat pad was there serving some purpose. Thus your face is not at any higher risk of further nerve damage no matter what additional procedures that you may undergo. Second, if the cheek implants didn't give enough volumetric addition that would indicate that the style or size of your current cheek implants is inadequate. When considering additional cheek augmentation, your options would be an exchange to cheek implants that have more projection (much easier the second time around because of the existing pockets) or fat injections. Each of these has their own advantages and disadvantages. While you can certainly put fat injections above cheek implants (not actually on the implants) there is always the unpredictability of how much fat will survive. But certainly fat injections are easier with next to no recovery other than the temporary acceptance that they will be a little too big, compensating for some injected fat absorption in the first 6 weeks after the procedure. That combined with perioral mound liposuction creates a complementary cheek effect.
In terms of can you get back to exactly to how you were when you were younger, I would say no not exactly. At best I would anticipate you would get closer but never exactly that exact look again as you are now older.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 52 year old white male 5'9″, 165 pounds. I have had a hair transplant and ears pinned back in 2002 and nose job way back in the in mid '80s. I have a very strict diet and workout extensively and have developed a very msucular physique, particularly for someone my age. I am concerned with my face as I am interested in male model look. What do you think could be done to make my face more aesthetically pleasing, proportional, etc. more in line with a male model type of look? I am very curious to see a computer projection of your proposed procedures. Thank you.
A: The first thing that I observe is that you have a body physique and msucular definition (to your credit) but the face doesn’t match it. While age never helps any face, your facial proportions and skeletal structure is not as robust/proportioned/chiseled as that of your body. Thus there is a mismatch and I can see why this has become an area of interest to you.
When it comes to the so-called male model look, what that means is defined facial skeletal structures or highlights of the facial triangle, the cheek, jaw angles and chin. Augmenting these three areas is what is usually done to create a more defined masculine facial structure. While your chin has reasonable projection, your jawline and face is narrow. I have done some imaging based on jaw angle augmentation, cheek implants and a square chin implant. None of your pictures are really great for imaging due to their quality, angles, lighting and facial expressions but at least they give a general idea of the effect. Be aware that computer imaging is really just a point of discussion and communication of the desired effects and reflects only one variation of the potential effects. There are magnitudes of potential change and this first set is just a starting point.
When it comes to your eyebrows, you have all of the issues that must be considered for any male browlift patient. Because of the absence of a hairline, none of the traditional browllift approaches can be used. (through the scalp) Thus most men need an upper eyelid approach (transpalpebral) with release of the medial muscle around the nerves to get sosme inner lift and relaxation of the glabellar musculature and a lateral brow lift using an endotine device. The ‘below the brow’ approach, which by necessity must be done in most men, only produces a modest brow elevation. But that usually turns out to be a good thing as one of the most unnatural and peculair looks in a man is an over elevated browlift. (e.g., Kenny Rogers, Bruce Jenner)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was looking into orthognathic surgery as I have a receding chin and asymmetrical jaw. I was wondering if this procedure helps shorten the length of the face? Also does it have any type of effect on the cheekbones? I have flat cheekbones and was wondering if this surgery would have any type of affect on them.
A: Depending upon the type of orthognathic surgery done and the bony movements, it may well improve jaw asymmetry and a shorter chin, although often a separate chin osteotomy needs to be combined with it. But it would be uncommon that orthognathic surgery will shorten the vertical length of the face. It may make no significant vertical change or may even lengthen it but vertical shortening will only occur if the maxilla is being impacted as part of the treatment plan. What is for absolute certainty is that the cheek bones will not be affected in any way, positive or negatively, with orthognathic surgery. The horizontal bony cut at the LeFort 1 level goes below the cheek bones just above the roots of the upper teeth. Cheek augmentation can be achieved at the time of orthognathic surgery, however, by the simultaneous placement of cheek implants above the level of the osteotomy cut on the flatter cheek prominence.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Let me say right off the bat that I've had rhinoplasty 3 times. The first one, done in 1999, was kind of silly because the change was so minute that I felt I wasted my time and money. My complaint was that I wanted my bridge to be higher. The doctor took a bone off my hip, and placed it on top my nose. Basically it looked the same. Yet, I dealt with it and moved on but the feeling that the surgery was a failure never went away. I did a second rhinoplasty in 2005. The doctor placed Gortex on top my nose towards the bridge, which made my nose look a little dented in at the middle part of the nose. For a few years, I tried to convince myself of a positive change, but to no avail. Lastly, the third surgery was done in 2009 to address the dent. The surgery was successful in removing the slight dent but it didn't remove how I felt about my profile. All the doctors made conservative changes to my nose which I am fine with since my intention was not to change the racial characteristics of my nose. Again, I did it with the hope that it would improve my facial profile.
None of these surgeries addressed my main concern which is to make my profile at the midface less pushed in looking when I am expressive with my face. When I do this my profile looks ape-like, so I try not to make expressive facial profile which is really hard to do. It is not easy to walk around stoned face. I also had Invisilign work done last year. This was not done to correct crooked or misaligned teeth, as I have relatively straight teeth. It was to hopefully undo the imperfection I see in my profile while at the same time maintaining my facial identity. My teeth still flares out. The results were not a major difference from what I started with. So basically my teeth is the same way. The orthodontic treatment was done by filing in between the teeth to create space for the teeth to move back. I did this because I absolutely didn't want to loose four teeth to create space. I didn't see any noticeable change.
All the above doctors I visited were never aware of my underlining concern which is that I am not please with my profile because it make me look ape-like, due to how the mid part of my face is position with respect to the lower part, especially when I make facial expressions. This is not an easy issue for me to talk about so I kept it to myself instead of disclosing my feelings to the doctors. The orthodontist I visited last year told me that I have a large lower jaw and a smaller upper jaw which is the reason he was having trouble getting my teeth in the position he wanted, which was more vertical. Hence, the teeth moved backed, but not much. The change was so imperceptible (honestly I don't think It made any difference what so ever to my face) that no one ever commented to me of any change.
That is pretty much my situation in a nutshell. I am not happy with my profile, and as you would expect it is hurting my ability to live a happy, social life because of the way I feel about myself. I've attached pictures for you to look at. Pictures are of me after all procedures.
A: Thank you for sharing your surgical history, concerns and pictures. Your fundamental underlying problem is maxillary alveolar prognathism, which is common with your ethnicity. I am not surprised that orthodontics alone, of any form, did not improve that problem., It never had a chance to, its movements are too small for your problem. Ultimately you would have to have upper teeth extracted and the entire cant of the maxillary incisors brought back in to make a visible difference. Your rhinoplasty using a bone graft was a poor choice because that type of nasal augmentation will end up just resorbing, even if you get enough dorsal augmentation. A cartilage rib graft would have been much better. You had had three inadequate dorsal augmentation approaches because the materials and their volumes used were insufficient. You need a combined dorsal onlay with a columellar strut approach to get a much higher dorsal profile.
There are other midfacial procedures that can be used to help change your profile at rest or in expression but their effectiveness is uncertain. These include augmentations of the paranasal and cheek bones. And perhaps a good nasal augmentation with paranasal implant enhancement may be beneficial. I have attached a computer imaging prediction of that potential outcome.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I want to create dimension to my face by making bony features more prominent. I would like to correct my flat midface, drooped nasal tip, recessed chin, flat cheeks and forehead, and create a more prominent bridge to my nose. What procedures would you use and how would you make these changes?
A: To make those facial changes, I would perform forehead augmentation with PMMA, a rhinoplasty using either a synthetic implant or rib cartilage grafts, and cheek and chin implants. I have done a side imaging photo to illustrate what I believe you are after with this compilation of procedures, to pull your face out and provide projection to a face that is naturally flatter and more wide. The only thing that I couldn't properly illustrate in the imaging is the bridge of the projection that would be achieved. Your natural bridge is hidden behind the eye so its profile can not be pulled based on this one photo. Always remember that computer imaging is just a visual way to start the discussion about what changes one wants and how much they want those changes to be. All of these facial changes can be done in varying degrees. Finding the correct amounts when multiple facial areas is being done is the key to a successful result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been reading for quite some time on your website and I found a lot of terrific information. I am looking for what you describe as the “Male Model Look”. Could you please tell by the enclosed photos what procedures you would suggest for my face in order to achieve this look. I have been reading about jaw angle, jaw, implants and cheek implants but would like to know what you suggest for my particular face. What else would you suggest? I am 38 years old. I have already had my ears pinned one month ago. Could you also do a custom facial imaging so that I have an idea how I will look (more or less).
A: Thank you for your inquiry. The so called Male Model Look is really about accentuating some or all of the skeletal highlights of the face. These include the brow bones, nose, cheeks, chin and jaw angles/jawline. One has to not have too thick of facial soft tissues to see the effects of the augmentations. When analyzing your face, you have the right amount of soft tissue cover to show these effects well. You are most deficient in the jawline area (chin and jaw angles) and secondarily in the cheeks. For starters, I have just focused on these three areas as you can see in the attached computer imaging. There would be the 'best value' procedures for your face. The only other thought would be some nasal thinning in the tip area. (but I have not done that so you can focus on the more important areas for now)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek implants and fat grafting 3 weeks ago. The left implant is sitting too close to the lower eyelid and the end of the implant can be seen and felt at the end of the eye. I have numbness in the upper lip and teeth. Is this normal? Implant was silicone and attached with screws.
A: Cheek implant asymmetry is not a rare problem. As the swelling subsides, usually about the three week time period after surgery, the position and symmetry of the implants becomes apparent. The most common form of cheek implant asymmetry is that one of the implants is sitting too high as evidenced by the lateral wing of the implant being palpable close to the corner of the eye. While it is something that you can tell now, the question is whether it is an aesthetic issue that ultimately you will want improved. If it is not seen or causes a visible lump, then it is an issue that most patients can live with. If the end of the implant is visible, you likely will wanted it adjusted for better symmetry. Intraoral placement of cheek implants almost always cause some temporary numbness of the infraorbital nerve with decreased feeling of the upper lip and teeth. This is a temporary issue, which is expected, and should resolve over the next month or so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in the process of correcting my jaw. I have had SARPE for my first phase. My main concern for the second phase of the surgery is to correct my flat under eye region. I would like implants to corrects this region of my face. I have a negative vector, flat upper cheeks, however I have moderate submalar projection. I have been told that my cheeks will fill out and the cheek fat of the submalar region will be pushed upward creating a fuller cheek effect, which I am seeking. I was also told, if I am still unsatisfied with my cheeks, it’s best to wait a year after orthognathic surgery to augment my cheeks. I have been reading that these procedures can be done at the same time and that orthognathic Lefort I osteotomy will not provide the same results as cheek implants/augmentation. I keep reading mixed reviews, Please help.
A: Let me answer your two questions directly and unequivocally.
1) A LeFort osteotomy, no matter how it is done, will not create a cheek augmentation effect. Based on where the bone cuts are and the how the bone is moved, this is simply not possible. Anyone that would suggest otherwise does not understand cheek augmentation.
2) Cheek implants can be done at the same time as a LeFort osteotomy. I have done it many times without any problems. It is as good combined procedure for the right patient. Just because someone had not done it before or is unwilling to do it does not mean it can not be done.
I hope this is helpful,
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m going to ask you a question you probably heard 10000 times. What procedures do I need to perform in order to get “the male model look” and look handsome? I think(I may be wrong) I need: Skull Reshaping, Cheek Augmentation, Chin Advancement, cheek and chin;jaw/mandibular Implants, nose rhinoplasty; lip reduction; Neck Contouring; I’ve attached a few photos of me. My face looks fat. That’s because i have about 20 pounds of excess fat.
A: You are correct in assuming that I have been asked that question a lot….and have subsequently done a lot of male facial sculpting surgery. In getting a better balanced and more defined facial shape in a male, there is a list of procedures to consider most of whom you have mentioned. But each face is different and therefore has different needs to improve its proportions and get closer to a more sculpted look. There is also the issue of priority and the associated cost to do them so making the proper diagnosis as to the anatomic problems is extremely important in surgical procedure selection.
Your most glaring anatomic problem is your severe lower jaw/chin deficiency. A short lower jaw makes the entire lower face both horizontally and vertically short. This is what contributes to your impression that your fat is fat…it is not. It is just that the lower 1/3 of your face is overpowered by the upper 2/3s. This is further accentuated in profile by a moderate nasal hump which makes the facial convexity worse.
Your most important procedure is to get the lower 1/3 of your face in proportion. This is beyond what a chin implant alone can do. You really need a chin osteotomy (sliding genioplasty) combined with a small square chin implant placed in front of it. Removing your nasal dorsal hump would then complement your facial profile. (see attached side profile prediction) These are the two most important procedures. Secondary consideration could also be given to cheek implants. (see attached front view prediction)
While some other procedures may be complementary, this is the foundation for helping you get closer to more of a ‘male model look’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want more angularity to my face. I want high cheekbones, a stronger jaw, an enhanced chin, and possibly removing fat from around my mouth. Do you this will give me what I want? I have attached pictures so you can show me what this may look like after.
A:I have done some imaging on the photos you have sent. Your photos are not the best quality for imaging (poor resolution, fuzzy) but I think they will illustrate the point.
To improve your facial shape, I believe you have correctly identified the structures to consider changing. Your face is somewhat vertically short and lacks keys points of angular definition. From a chin standpoint, you need vertical lengthening as well as increased horizontal projection. Unless one uses a custom implant, the chin can only be lengthened by a sliding genioplasty, it can be brought forward at the same time. I am estimating that you need 7mms of vertical lengthening and up to 9mms of horizontal projection increase. You may also benefit from jaw angle augmentation but your pictures are not good enough to do useful imaging for that evaluation. You would also benefit my higher cheekbones using implants and some perioral liposuction to remove some fat around your mouth area. I Have attached some imaging of these potential results, keeping in mind the limited nature of the quality of the original photographs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What I am most interested in is the cheek enhancement. I feel like creating volume there will help balance everything else out. If I still want to make other enhancements after, I suppose we can do them at separate times. My question at this point is, considering how many different variations for cheek shapes there are, is how do we determine the best shape for me. I know what I like, but I’m not sure what the materials are that would achieve that result. I seem to remember several different options for custom implants and fillers on your site based on the patients face structure. I was seen my someone who gave the option of three sizes of Gore- tex implants and I am looking for a more custom and personal approach which is what drew me to your site. I could show you some photos of shapes I like or even photoshop my image myself to indicate what I’m looking to achieve.
A: When it comes to cheek implant options, the number of different types depends on the manufacturer. For most patients, there are enough styles and sizes to produce a satisfactory outcome. Furthermore, it is easy and very common to take an existing off-the-shelf cheek implant and modify to make what I call a ‘semi-custom’ implant. True custom implants can be made off of a 3-D model of the patient and obviously this is as custom as it gets. Which one of these three implant options, stock, semi-custom and custom, is best for you is yet to be determined based on your exact aesthetic needs. You doing some Photoshop to illustrate what you are after would be very helpful.
Dr. Barry Eppley
Indianapolis, Indiana
