Your Questions

Q: Dr. Eppley, I had my upper and lower jaw advancement done 7 months ago and was not too happy with the results. I recently had chin and jaw implants together with a rhinoplasty done. I have also had some facial fillers placed under the lower eyelids and on the upper cheeks. Regardless, I still feel like my mid-face is flat and would like to know what can be done (if any) to make it more convex.

A: While I do not have the advantage of seeing any pictures of your face, I will assume by your description that you have either a malar or a combined orbito-malar skeletal deficiency from an aesthetic standpoint. This may or may not include a maxillary-paranasal deficiency as well although your recent maxillary advancement surgery may have improved that concern. Knowing which of these areas needs augmented is obviously important. But for the sake of completeness let me review all three areas.

Cheek implants are probably very familiar to you but there are four basic styles to consider that augment different areas of the cheek. To improve facial convexity, the cheek implant must provide anterolateral projection, with more anterior than lateral. This can be placed through the mouth like most traditional cheek implants. If a concomitant infraorbital deficiency exists, an orbito-malar implant can be used which is placed through a lower eyelid (blepharoplasty) incision. When a deficiency around the nasal base exists, paranasal or a premaxillary implant can be used. The difference is that one pushes out the base of the nose on the sides (paranasal) while the other pushes on the base of the columella (premaxillary) to open up the nasolabial angle.

Without seeing pictures, I could not tell you which type of midfacial implant(s) would be appropriate for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you feel it is possible to create an aesthetic male face even with my Class 1 hypertelorism? I understand that it can be found to be an attractive feature in women (such as Jackie Kennedy), but I can’t really seem to find any examples of good looking male face with hypertelorism. Do you know of any? Thanks!

A: First degree hypertelorism, as you have been mentioned, can be attractive in females. You have mentioned Jackie Kennedy as an historic example but Uma Thurman would be a more recent illustration. When it comes to men, however, I have never heard it so described and can not think of any example where it is.

The spacing between the eyes can be improved by several facial camouflage strategies. I have not seen a side view of you so I can not say how successful they would be in your case. Building up the bridge of the nose, usually with an implant,  is a classic example of decreasing the distance between the eyes. This is best done in patients that have a low or wide nasal bridge. The higher the nasal bridge, the less the eyes look far apart. In addition, widening the lower face can also help camouflage it. Cheek and jaw angle implants in particular help widen a the lower 2/3 s of the face.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, there is an overall lack of definition to my face (flat cheeks and very prominent and long chin) which you will notice here.  It’s my belief that with some cheek contouring and possibly jaw as well, I may look as beautiful as I feel.  When I smile and when the lighting is even I have a much more appealing appearance as it seems to round out my face if you know what I mean. When I’m not smiling and when the light is harsh (as it usually is unless one is in a photography studi0 and manipulating light!) I feel like my face is a sliver- very long with nothing to break it up or draw the eye up.  I look forward to hearing what you think!

A: In looking carefully at your facial features, there are three areas that could be altered to help make the transition from a long flatter face to one with better proportion and angularity. As you have mentioned, your cheeks/infraorbital areas are flat, your chin is long and slightly retruded and your nose is slightly prominent and a little deviated. Changing all three would make the greatest change but I just want to focus on your cheeks and chin for now. Cheek implants with anterolateral augmentation and a chin osteotomy that vertically shortens the chin and brings it forward is the best way to help vertically shorten your face and ‘pull’ it outward. I have demonstrated that on the attached imaging pictures in the side and front views. I think a reductive rhinoplasty would also be very helpful to shorten and deproject the nose, which would make the midface look more full, but the pictures you have sent are not of good enough quality to do the rhinoplasty imaging justice. But these initial images will give you some good material to think about.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get some facial cheek implants done and I have heard there is silicone and Gore tex. Do you have an idea of which one is better? And does Gore tex  implants get smaller after time passes? Thanks alot.

A: What is commercially available as preformed off-the shelf cheek implants are the materials, silicone and Medpor. Each of these materials has advantages and disadvantages and neither one is perfect. So it is not an issue that one is better than the other. Both can work very successfully and they are non-resorbable so they are permanent and do not change in size with time. Goretex is available as a block material which can be carved into a cheek implant shape during surgery but is a softer material and more deformable than either silicone or Medpor. What matters a lot more than the material is the right shape and size for your desired cheek look and a surgeon who has both the artistic skill to make that selection and then insert them properly.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 38 year-old female that has chubby cheeks. They make me look ten years older than I am and I just hate them. I have been to several plastic surgeons and they have uniformly said there is nothing to do about them. I have tried injectable fillers around them but that just makes me look puffy and is not an improvement. What do you recommend? I have attached pictures so you can see what they look like in different lighting.

A: Thank you for sending your pictures. I can clearly see your concerns of the ‘fatty or chubby cheeks’. The first question is always what is the diagnosis. Why do your cheeks look chubby? Is it because they are chubby or is what is around has become indented or atrophic? I am going to assume that they did not look like this originally ten or fifteen years ago. Many people with aging will develop malar festoons. These occur because the cheek pad falls off of the bone (ptosis) and in much later years can even become chronically swollen. While your cheek problem initially may appear as festoons, on close examination of the pictures they are not. Your cheek tissues are up high on the bone as would be commensurate with your still young age. It is easy to see that you have little aging around the eyelid area. In short, I do not feel that your chubby cheeks are from soft tissue laxity or ptosis. You clearly have tear troughs and a descending infraorbital groove which goes below the cheek area. This is what I think makes your cheeks look chubby, it is what is around them either from the early signs of aging or genetic predisposition that makes them look fat.

In theory, the correct treatment would not be cheek reduction but augmentation of the tear troughs and infraorbital groove. Having had this done through injectable fillers with an unsatisfactory result, this appears to not be a good option for you. It may be that the injectable fillers were not placed correctly or overdone, but I will assume for now they were and the look from that approach was not an improvement.

This raises the next question of what can be done with the cheek pad tissue. Simple ‘removal’ is not a realistic treatment as you can not liposuction the cheek pads or perform direct excision. Even if that was technically possible, it would leave the cheek skin deflated, possibly wrinkled, and thus create an alternative problem that would not be viewed as an improvement. Treatment possibilities include some higher malar suspension through a transcutaneous lower eyelid incision, possibly combined with a small cheek implant that would augment the lower cheek groove. Even though you don’t have true malar ptosis, lifting and repositioning this cheek tissue slightly higher would help to efface the lower malar groove. One way you can get a feel if this approach might be effective is to push up on the skin by the corner of the eye and see what happens to the appearance of the chubby cheeks.

Another option to consider before surgery is non-invasive skin tightening and fat shrinking devices. There are numerous device options out there. My current favorite is that of Exilis. It is a radiofrequency device that has the ability to perform some small amounts of fat reduction and skin tightening. It always takes a series of treatments, usually four, to get the final result. But I would be very interested in seeing you have this done before any surgical efforts are made. Whether it would solve your cheek issues is unknown, but it would be more reassuring that you tried every less invasive option before you came to the conclusion that surgery was warranted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to have a well defined face shape, so I am thinking of doing buccal fat removal but at the same time I want high cheek bones. Is it possible for me to do buccal fat removal and at the same time still put Juvederm fillers in right under my eyes? Does that make sense?

A: That does make sense with the exception of it is unclear how that will give you high cheek bones. Buccal fat reduction provides some submalar ccontouring which helps in some small amount of facial thinning in that area but will not, by itself, give you high cheek bones. The Juvederm filler will help with tear trough filling but also will give not give you any cheek bone augmentation effect. Those two procedures make sense for what they are intended to improve but neither one will create the illusion of high cheek bones. For that result, you should consider a small cheek implant which can be placed through the same incision as tha of buccal fat removal. That combination will create a more shapely cheek look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, does cheek bone augmentation work?

A: On the surface this seems like an unusual question. Cheek bone augmentation with implants has been around for nearly thirty years. Next to chin implants, cheek implants are the most common facial implant performed. (this has a lot to do with that there are two cheeks but one chin) It is a very straightforward procedure to do because they are placed through a small incision high up under the lip. There is very little muscle and tissues to dissect through and there are no important structures, such as nerves, that are in the path of implant placement up across the zygomatic prominence and onto the zygomatic arch. . From that standpoint, it is a very successful facial augmentation procedure. But cheek implants are prone to complications, most of which are aesthetic in nature. Getting the right style and size of cheek implant can be challenging and their symmetrical placement is not always easy or assured. This can lead to the need for cheek implant revision…which could lead one to believe that they don’t ‘work well’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting implants for my flat cheeks but am not sure what type of implant I really need. I have attached 4 images of three different individuals cheeks I really appreciate and believe to be prominent and masculine. They are Lars Burmeister, Fernando Torres, and Ben Affleck. All seem to have the prominence up on the side of the eyes and they wrap around to the front of the eye a bit. They all look more chiseled, narrow, and angular though, relative to the other examples of cheekbones I have attached. The other examples are of cheekbone structures that I would prefer to avoid. They are Zac Efron, Cilian Murphy, and Peter Facinelli. Their cheeks just cover too much surface area and look like an enlarged cheek mass, rather than finely chiseled cheekbones. They are prominent but look too feminine and bulky. Perhaps you can enlighten me more on what it is I both desire and do not desire in the above referenced cheeks.

Also, will I be getting the inferior orbital rim augmented as well? Reason being that my eye does indeed pass over this bone. Besides creating a better angular appearance to my face, I’m hoping the midface implants rejuvenate my face a bit and help me look less sickly when I get down to 10% body fat percentage or so. Would I need some kind of midface lift along with the implants to give myself this appearance? I am apprehensive to undergo a procedure that is often only discussed with people in their 40s or above.

Lastly I have attached a crude approximation of the area on my cheek I want to be augmented. The black marks denote areas I would prefer to see little to no enhancement on. They include the zygomatic arch, the base of the zygomatic bone, and underneath the front of the zygomatic bone beside my nose. Let me know if this is realistic.

A: Thank you for the detailed information about the desired cheek augmentation result. That is very helpful.

The first comment that I would make is that their is no standard or off-the-shelf ‘cheek’ implant that has exactly those dimensions that you have well outlined in your own photo. I would agree completely that the best aesthetic midface result for you is exactly what you have described, as you have a true combined anterior zygoma-lateral orbital wall-inferior orbital rim deficiency which is a reflection of the overall underdevelopment/flattening of the zygomatico-orbital complexes. Your issue is a bone problem not a soft tissue one so the concept of any form of a midface lift is not a consideration.

So it is not a question as to what you need but how to get there. In an ideal world from a bone standpoint, I would use Kryptionite bone cement/putty to intraoperatively fashion the implant exactly the way I want it and place it from above through a lower eyelid incision. This is most ideal not only because of the ability to create a truly custom implant but the area of augmentation needs to extend across the orbital rim (at least laterally). This infraorbital rim area is the ‘rate-limiting’ step in getting the ideal implant shape as it can not be accessed from below. (inside the mouth…the big infraorbital nerve is in the way) But due to cost considerations and that I nor you would be thrilled with making a lower eyelid incision, this ideal approach may not a good option for you. The other option is to pre-make a custom implant off of a 3-D scan and model, but again cost becomes a consideration with that approach as well.

With the ideal approach off the table, then we must look for using/modifying existing stock implants to achieve most of the cheek augmentation goals. One style of cheek implant, sometimes called the Malar II, augments the lateral orbital wall as well as cheek bone. It does not extend out onto the infraorbital rim to any degree which is its one limitation.

The other issue I would mention is that the use of these celebrity faces and pictures serve only as a direction that you want to go and that no cheek implant, even one custom made, will make you look exactly like them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in correcting the asymmetry of my face. The right side of it, particularly in the jaw angle area, is tilted upwards and shorter. I have read that a jaw angle implant may be able to correct this tilt.Would this implant make the right side look closer to the left and would I feel the difference? Would a cheek implant help along with the mandibular angle implant to even out the balance? I don’t want the right looking more full and balanced then the left.  Would braces help fix or improve the jaw tilt/angle?

A: In the ideal correction of facial asymmetry, it rarely is just one facial area that is shorter or asymmetric. In most cases of facial asymmetry, the entire side of that face is shorter. For this reason, jaw angle and cheek implants together are often done and produce the greatest amount of facial lengthening and correction of the shorter side.

Braces change how the teeth fit together but will not change the tilt of the jawline.

The goal of facial asymmetry correction with facial implants, the most common treatment method, is to try and get the best match between the two sides as possible. While perfect symmetry is never possible, the closer the two match the better. In the spirit of that goal, it is always better to be slightly less full than too full when deciding about implant sizes.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I plan on getting a rhinoplasty, chin, cheek and jaw angle implants this summer. It makes sense to me to have them all done at once. I have limited time off from work and only have a few weeks to recover at this time of the year. The one plastic surgeon I saw said he wouldn’t do them all at once as it would be too hard on me. I am not sure what he is talking about as I am young and healthy. I am aware that doing more surgery increases the overall risk of potential problems such as infection, but are there other risks to be taken into consideration, such as blood loss, that I am not aware of? Do you think it is safe and reasonable to have all of these facial procedures done at the same time?

A: In my experience and practice, I routinuely perform three, four, five or more facial procedures at the same time. For the reasons you have mentioned, such as recovery and other considerations such as cost, it is desirous to do a ‘facial makeover’ as a single stage procedure. There are no increased health risks for doing combination facial surgery in an otherwise healthy person. Blood loss is not a concern. With that being said, there is one risk that occurs in multiple facial restructuring procedures particularly those that involve facial implants…an increased aesthetic risk of implant asymmetries and the need for revisional surgery. The more procedures you do, the more risk there is for less than perfect results. Each individual procedure comes with its own aesthetic risks which are increased as more procedures are combined. Patients need to appreciate that the likelihood of the need/desire for revisional surgery is multipled as procedures are combined.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I don’t like the idea of losing consciousness under general anesthesia or IV sedation. Would it be possible to undergo cheek augmentation with malar cheek implants with only local anesthesia? I am very tough and I am not afraid of surgery or the sounds of surgical instruments at all, but I don’t want to feel any pain during the procedure. Is it possible to numb the midface area completely? Would you do cheek augmentation under local anesthesia if the patient is aware of the fact that this might be very uncomfortable?

A: While any type of procedure can theoretically be done under local anesthesia, that does not mean it is always a good idea. I have never done cheek implants under straight local anesthesia since it is a bone-based operation. I am sure one could get through it, but I could not promise that it would be completely pain-free. In addition, the most important aspect of the procedure is to get the implants into the correct position. You would not want anything to limit that objective. Always remember the purpose of the operation is about getting the best surgical result, not about how little anesthesia is needed. There are no rewards for seeing one ‘tough;’ one can be. In short, this would not be something I would advise or do… as I know well how this story would play out. To quote an anesthesiologist whose skill and experience I admire…‘the patient who states that will be just just fine under local anesthesia is exactly the patient who won’t be’. I would recommend that you do not have this operation unless you can come to the acceptance of doing it under sedation or general anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my buccal fat pads removed nearly fifteen years  ago at age 31 for some facial sculpting. Now that I am older, I look completely different. My face is very flat and not as attractive. What can I do to look like before? What are my choices for making my face now a little fuller?

A: As you have aged, your face likely has lost overall fat and the prior removal of the buccal fat pads has only accentuated this natural fat involution process. There are several options available to consider for facial volume restoration. The first approach is fat injections which focuses on replacing like with like. The only question is how much fat will survive after transplantation. This is an overall facial volume approach. The next approach is focal or spot treatment, just adding volume to the buccal or submalar area. This could dbe done with either submalar cheek implants or injectable fillers. The real value of injectable fillers in your case, in my opinion, is to be an initial test to determine if augmentation of this area is what you are looking for. It serves as a test to determine if more formal augmentation (implant) is worthwhile.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my cheeks are very low and I would like them to be higher. When I pull upwards on them, my face looks better. That also helps soften the lines around my mouth. Will cheek implants create this effect or so I need some form of a facelift to get that look?

A:The question you are asking is an important one because there are clear differences between what cheek implants and a cheek lift achieve. Cheek implants are about creating a bony highlight for improved facial contours purposes. While there may be some cheek lifting effect, it will be relatively minor and one should not think of cheek implants as a soft tissue lifting method. (even though it can complement cheek or midface lifting surgery) A cheek lift is about lifting and resuspending sagging soft tissues that have fallen off of the cheek bone. This does create an effect sometimes similar to a cheek implant but it is more similar to what most patients thinik that a ‘facelift’ does in that area. This will help soften the nasolabial folds because it is pulling upward the soft tissues that lie above it. Based on your description, I suspect you would benefit more by a cheek lift than cheek implants. Whether that is a worthwhile surgery for you depends on numerous factors including your age, your cheek bone and lower eyelid anatomy and how much malar soft tissue ptosis you have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want cheek implants to help balance out my face. I have a strong jawline but no cheekbone definition whatsoever. I think that some type of a cheek implant would help balance out my face a bit more. However, I don’t want the implants on the apples of my cheeks but just on the top of my cheekbones to give me a more defined face. Is this possible? I’ve seen some awful examples of cheek implants where the apples of the cheeks have ended up looking way too large for the face they were on.

 A: Choosing the placement and size of cheek implants is critically important in obtaining an improved but natural looking result. It would be essential to know exactly what part of the cheek you want augmented and a feel for how much volume you like. If in doubt, you should first try an injectable filler to get the exact location identified and make sure you like the result. The cheek area is one of the aesthetically sensitive facial areas and quite frequently poor results happen because of improper implant style and/or size selection. Cheek implants are a good example where a little volume goes a long way.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am thinking that I need something to make my face look better. I realize that I am young to be thinking about surgery, but I’ve never liked the way I looked. I thought maybe cheek implants might help, but I was wondering if you had any other suggestions of how I could make myself look better.

A:  In looking at your pictures, I can see that you have some mild cheek flattening or hypoplasia. Higher cheekbones may be an accent to your facial appearance. Should you be so motivated, I would suggest you initially pursue injectable fillers for cheek augmentation. This would be a good temporary test to determine if the placement of permanent cheek implants would be aesthetically beneficial.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I would like to start by saying your website and blog have been so helpful as both a research tool and making me feel so much more comfortable in approaching this issue. It is one of the few sources I have found that really takes the time to properly explain things, that most people in plastic surgery don’t understand. I would like to have more balanced facial features and to improve my asymmetries to improve my facial appearance. I feel that I have a long lower face and chin compared to my forehead, which is very low and slopping. I can’t wear hats and have to spike up my hair all the time so I don’t get teased. I recently lost a lot of weight and with it my cheeks, with used to be very full. But I guess what bothers me the most is my nose – I have a deviated septum which makes me look crooked and my nose is very romanesque in appearance. I think that a rhinoplasty and cheek augmentation would help me best but I’m open to suggestions. I just want to be the most attractive me I can be. From my photos can cosmetic surgery help me?

A: Facial symmetry and proportion are the two most important components of facial attractiveness. In looking at your photos, I would agree that the deviated and dorsal convexity of the nose combined with flat cheeks are the two main areas to try and improve. I would propose a rhinoplasty whose objectives are to straighten the nose in the frontal view and bring down the dorsal line to one that is straight between the frontal-nasal junction and the nasal tip. The tip could also tolerate a bit of thinning as well. For your cheeks, anatomical style cheek implants secured high up along the flat malar prominence will bring some highlights to your midface and more angularity to your face.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley,  I have lost a lot of the fat in my face particularly in the cheeks which has left them very hollow and sunken in. The area below my cheeks looks too full because it is indented above it. I havhe been told that fat injections would be the way to go even though fat transfer may not always stay. I know that cheek implants are permanent becuase they can not be absorbed. But I didn’t know of they come big enough to fill out the entire depressed cheek area. What sizes do they come in and do you think they are big enough to fill out the whole cheek area?

A:Your concept of considering cheek implants for helping restore facial volume loss is only partially correct. Cheek implants are not a substitute for fat injections when it comes to facial fat volume loss. The submalar style of cheek implant can help fill out the buccal area of the cheek (right below the cheekbone) but this represents only part of a larger surface area of the cheek and surrounding tissues which makeup the gaunt or skeletal facial look. Therefore, the use of this type of cheek implant may be a companion strategy with fat injections but is not a stand alone treatment for refilling out the deflated or fat-depleted face. Fat injections are more versatile because they can be placed anywhere. Cheek implants, even the submalar style, can not go very far from the edges of the bone and are more limited as to the facial area that they can cover.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want your advise on getting suitable cheek implants. I currently have a Medpor midface contour implant. They were placed six months ago. My implants were placed  unmodified. Although I have achieved a decent level of midface augmentation, I feel the implant is too large, surface area wise. It is too close to my eyes and is also too low and close to the top of my teeth. I also have visible edges on both the left and right side near my eyes.I did previously have a Lefort 1 osteotomy for my bad bite in the past but the central part of my face wasn’t really improved. What I was looking for in cheek implants was something to improve my midface. The current implants have alleviated midface flatness but I do still feel I look at bit gaunt but less so. However they are just too big, so looking for opinion of porex alternatives which might be appropriate. I was looking at either RZ 5m, or the 4mm extended malar, basically something to emulate the middle third or so of my current implant. I have attached pictures for you to see my face and what my current implants have done.

A: What you are showing is the problems with stock midfacial/cheek implants which are now, by your own illustrations, demonstrating that their shape is not adequate in multiple dimensions. This leaves you with three implant options:

 1) Modify your existing indwelling implants by tapering the bothersome edges and adding/removing the areas to create better convexity.

2) Remove and replace your existing implants with new implants that would likely need a combination of infraorbital rim and cheek implants. The medpor RZ4 or the 4mm extended malar are reasonable options but they will need intraoperative modifications.

3) Remove your existing implants and replace with custom-made implants that are designed off of your own skull model.

While all of these are possible, they each have their own advanatages and disadvantages. Modifiying what you have in, while seemingly simple and easy, will not likely make a significant or the desired changes that you want. (but it is always worth a try) Replacing them with new stock implants I suspect will put you in the same position you are now, better in some areas but inadequate in others. There simply are not stock implants that can fully meet your aesthetic goals. Custom-designed cheek/midface implants are the most likely to really meet all of your aesthetic midfacial goals as all of the planning and adjustments of them are thought out before surgery. The only downside is the increased cost to do so. 

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I’m interested in cheek implants and a few other things that might be needed depending on your recommendation. My goal is to have a defined cheek/jaw line like some male model pictures that I have attached. I will get the buccal fat removed also if that is required. The 1st model model might have the cheek implants because the cheek area is not as pronounced as in the 2nd picture. I have attached pictures of myself from different angles so you can see the shape of my face. I look forward to your recommendations.

A:  I have done an analysis on the photos that you have sent. The frontal photo is of excellent quality, the side view is not good quality but useable. I have also looked at the model photos that you have shown, and while they illustrate a facial shape goal, I hope you realize you can never look quite like them as you have a completely different facial shape.

Where I think your face can be improved is in multiple areas including vertical chin lengthening with some horizontal advancement (chin osteotomy), cheek augmentation with implants, buccal lipectomies, rhinoplasty with tip thinning and nostril narrowing and earlobe reductions. I have attached some computer imaging to show you a realistic potential outcome.

With your thick skin and existing facial shape, there are limits as to what can be achieved. I thinik this is the best approach to obtain some increased facial angularity.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley I am 34 years old and in the past several years I have noticed quite a lot of sagging in my mid and lower face along with  volume loss. Cheeks have gravitated downward, neck sagging and my eyes have hollows under and around them. I see much of the same in my mother.  I have researched many plastic surgeons this past year and have heard only great things about you online! I am most concerned with sagging in my lower face, neck and around cheeks. I also would maybe like to add some volume to lips especially from a profile view. And one more thing, my ear lobes tore several years ago from scabbing due to hypersensitivity to earrings so I would like to have ear lobes repaired as well.

A:  I have taken a careful look at the pictures you have sent me. As you know you are fairly young for any major procedures and you really don’t need anything too drastic. But I can see your concerns about having an overall tired appearance. There are several things I might consider for some structural improvement. These would be the following: small cheek implants to lift the midface and fill out some hollowing, small chin implant for more chin projection and to improve the jawline, and liposuction of the jowl and neck for a little contouring and skin tightening. I think if you can just ‘slenderize’ your face a bit and give it some more structure or angularity, it will look more youthful and rested. You most certainly don’t need anything done around your eye area.

As you know, you already have excellent lips with good vermilion show so increasing their size is a matter of adding some more volume. This could be done with fat injections as you can take advantage of a surgical opportunity since this is not a traditional office procedure. Obviously the earlobe repair can be done at the same time with any of the aforementioned procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, I’m writing to you in regards to plastic surgery options. You were recommended to me as a highly qualified professional. I’m a 24 year old and I wish to transform my face for it to be more balanced and more aesthetic in general. Enclosed please find pictures for my face from various angles and a picture that I did in Photoshop which outlines how I would like my face to look. Is this realistic? Here are things that concern me by order of importance:

1) Jaw/chin is too prominent, protruding and simply too large. I would like bit smaller jaw and chin, making my face look more compact, yet remaining sharp and angular.

2) Cheek bones. As you see, mine are quite flat. Cheek implants would probably benefit here.

3)Nosejob – make my nose more prominent and fill the radix.

4) Eyebrow transplant

I would like to know my facial surgery options. This is very important for me so I would kindly ask you to provide me with a professional and honest opinion.

Thank you in advance.

A: Thank you for sending your pictures. As you have already done a nice job with Photoshop on your face, and I think all those changes are both possible and realistic, my task is to comment on how to accomplish those potential changes.

The reduction in the chin is of a horizontal nature. There are two ways to accomplish that task, either a setback genioplasty or an open submental burring reduction. I would feel more confident with the open submental approach so there are no irregular bony edges and an excess soft tissues can be excised and tightened. That is done from an under the chin (submental) incision. The other alternative is to do a setback chin osteotomy with the possible need of a submental tuck-up later is needed.

I agree about the need for cheek enhancement and stronger cheek bones using implants would be beneficial, particularly to balance out the stronger chin. (a ying and yang effect if you will)

Your ‘deficient’ nose is part of the overall flatter or less well developed midface. A dorsal augmentation rhinoplasty, in combination with cheek augmentation, would put the middle third of the face in better balance with your jawline. The real debate here is what material tio use to build-up the nose. My prerference would be your own cartilage.

Eyebrow hair transplants are the only other choice besides tattooing for improving congenitally deficient eyebrow hair density.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in getting cheek and jaw angle implants. My jaw angles are very steep which got worse after jaw surgery for a bad bite several years ago. My cheeks have always been flat and I get Radiesse in them which makes them look better. Can you tell me what types of implants I should get and what are some of the complications that could happen that I should be aware of. I have attached some pictures for you to see what my face looks like.

A: Thank you for sending your pictures. I have reviewed all of them. The key to your successful facial implant surgery is to have appropriately-sized implant selections. For the cheek area, you would benefit by implants but they must be small to not overwhelm your feminine face. Small malar shell style would work well for your face. For your jaw angles, you need implants that provide some vertical lengthening but minimal width increase, otherwise you will create a wider fatter face and not a nice jawline enhancement that fits your face. Small Medpor RZ angle implants (3mms width and 10mms length) should work nicely, but no bigger.

Implants should be placed that fit the face. As it turns out cheek and jaw angle implants are the most highly revised of all facial implants. The problem with many cheek implants is that they are too big. The problem with many jaw angle implants is that they are improperly positioned and/or secured.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for an opinion regarding correction of my steep jaw line. I had orthognathic jaw surgery in 1998 to correct an underbite, but over the years I feel that the angle of my jaw has gotten steeper, giving my profile a “harsh” look. A doctor has suggested jaw angle and cheek implants to balance out my chin and soften my face. I am hesitant to go under general anesthesia and am concerned with the risks of the procedure and, most importantly, whether it will improve my look. I was told that another option is filler in the jaw line, but that an implant would provide more correction.What would you recommend for me? Do you think that jaw angle implants would improve my look? Do you think I could achieve good results with just filler? After going through orthognathic surgery, I was hoping to have achieved a better result and I feel self conscious about my jaw line. I have attached some pictures for you to review.

A: Based on the viewing of your side profile, your jawline is characteristic for someone who has had a mandibular setback osteotomy for a Class III malocclusion due to an original mandibular prognathism. This can adversely shorten the jaw angle and increase its plane angle. I can understand the proposal of jaw angle and cheek implants to give your face more skeletal balance. The real questions are, however, will it make a positive change and is it worth undergoing surgery for it.

There are two ways to provide insight to those questions. First, computer imaging should be done with jaw angle implants alone and then combined with cheek implants. While computer imaging is an estimate and not a guarantee, I have always found it very helpful for prospective patients. I have done that for you and it is attached. These are based only on a side view. The front view you have provided is not good for imaging because you are smiling and it doesn’t show the jawline/angle all that well. The three-quarter or oblique view is the next most helpful view to evaluate. Secondly, injectable fillers can be an alternative to see if the concept of implants would be appropriate. When placed next to the bone they can provide some bone augmentation. But they will never produce the same effect as adding implants because of the sheer volume differences. Injectable fillers are never a comparative substitute for facial implants but they may provide some insight into whether bony augmentation is the right concept. If one is not absolutely certain that implants are the right answer, try fillers first.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I would like to get Medpor cheek implants for higher and more defined cheekbones. My question is, since I am relatively young (25), will Medpor implants hold throughout my entire life if they don´t get infected or damaged by an accident? Could I be, let’s say 100 years old, with a Medpor implant in my midface since I was 25 years old? Do Medpor implants show any tendency to dissolve over time? Is it true that Medpor becomes more like a part of your body due to its porous nature that allows blood vessels grow into the implant?

A: Medpor facial implants are composed of a porous polyethylene (PPE) material. This is a well known medical implantable synthetic material that is most commonly used on orthopedic implants as the lining of joint surfaces. (high molecular weight PPE) As a facial implant, it is a lower molecular weight which gives it some flexibility. Pertinent to your question, it is a stable material that does not degrade. There is no enzyme in the body that can break it down…ever. Your facial implants will be found on your skeleton thousands of years from now. Medpor does have surface porosity so there is some tissue growth into the outside of the implant.  This property is often touted as being a superior implant feature but its main benefit is that it helps fix and secure the implant into place. Screw fixation obviates the need for that material feature. This material property does make the implants more difficult to remove should that be necessary so it is a double-edged feature.

Rather than getting hung up on the material composition of a facial implant, one should focus more on does it have the right shape and size for the desired result. Medpor cheek implants do have less options for styles and sizes than silicone-based cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, I recently read, that a revision on a chin implant that has been inserted through an intraoral incision, can lead to distortion of the chin muscle because this muscle would be cut through twice. I don´t have a chin implant, but porex cheek implants (inserted through an intraoral incision) that need to be shaved down on the left side. Now I would like to know if an intraoral performed cheek implant surgery also involves cutting through a muscle what eventually could lead to distortion of the soft tissue if this muscle is cut through twice.Thank you in advance for your reply!

A: When it comes to surgical access in the face for the placement of implants, they must be placed down at the bone level below the periosteum. This always requires cutting through attached muscle to get to the proper placement level. But there are significant differences between the lower jaw (mandible) and the rest of the face. The lower jaw is the only bone of the face that actually moves, the rest of the facial bones are fixed. This makes for significantly different types of muscular attachments.

The mentalis muscle of the lower jaw, while having no function in its opening and closing, covers the chin bone and affects the lower lip and soft tissue movements. When it becomes detached or scarred, one can develop lower lip and chin soft tissue sagging. While good soft tissue closure will avoid this problem it is always a risk. While there is  nothing wrong with secondary intraoral chin surgery, the upper attachments of the mentalis muscle are being severed and reattached twice. This does increase the potential for secondary mentalis muscle problems.

The intraoral placement of cheek implants does not cut through any muscles of jaw motion or those responsible for any soft tissue support. There are no risks, therefore, for muscle scarring that would affect any facial function or appearance. The muscle issues of intraoral chin implant surgery do not apply to intraoral cheek implant surgery.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Dear Dr. Eppley, I would like to have those chiseled high cheekbones. I have looked at some implant styles online and it seems that the Medpor extended malar implant may work for me. The picture on the website product catalog shows the implant in a high and lateral position and the implant is described to augment the malar region. My surgeon told me that this kind of implant can only be placed under the cheekbone (submalar) and more towards the nose than towards the zygomatic arch and that the picture on this website shows the wrong placement of this implant design. I really don´t want submalar augmentation! Is it true that this implant design is actually a submalar implant and therefore not used for malar augmentation or can it be used for both malar and submalar augmentation? What is your experience with this kind of implant design?

A:  Choosing the correct implant design and size is obviously critical for any type of facial implant procedure. This is particularly true in the cheek or malar region as this area has the most complex three-dimensional anatomy to it. It contains five zones of potential augmentation including anterior, lateral, oblique, orbital rim and submalar. Any cheek implant will affect at least three of these zones in any single design. For those interested in more ‘chiseled’ cheeks, by definition this means that the oblique and lateral zones are most important. The submalar zone should absolutely not be augmented as part of this type of cheek implant because it will create more of a rounded full cheek look rather than making higher and more ‘chiseled’ cheekbones. The type of cheek implant to which you refer will not help create the look you are after. That type of cheek implant design creates fullness on the lower or submalar cheek zone and will not achieve that higher angular cheek look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in getting cheek implants as I think they would help my facial appearance. But I don’t really know if that is true. If it is, what type of cheek implant would be best? I know there are different types, like malar, submalar and shell styles, so which would be best for me? I have attached some pictures of my face for your opinion. Thanks and looking forward to your recommendations.

A: When looking at cheek augmentation, you must first determine whether and where any cheek bone (zygomatic or malar) deficiency exists. This requires looking for obvious bony deficiences of the midface, the relationship of the eye to the brow and cheek bones and the thickness of the overlying soft tissues. This must all be taken in context of the overall facial shape as well.

In looking at your face, you have a longer face that is fairly skeletonized. Your eyes do not have a lot of fat around them which makes them more deep-set. This is magnified by prominent brow bones and heavy eyebrow hair density. Your malar area shows good width but there is anterior malar and infraorbital rim deficiency. This is why your cheeks appear flat to you in a side or three-quarter view. When considering cheek implants, therefore, it is important that you avoid submalar and any malar implant that adds much zygomatic arch width. Augmenting these areas are not helpful to your face. Malar implants that add some anterior fullness along the suborbital groove and front end of the cheek is where your augmentation needs to be. This cold be done with either a modified malar shell implant or an extended tear trough style. Either way the volume should not be much greater than about 5mms. Too big of a cheek implant size will make the eyes even more deep-set or hollow in appearance.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have been researching how to make my cheek area look better as it seems to be kind of flat and has no cheek highlights, plus my face is a little round. It seems I have two choices, cheek implants, buccal fat removal or some combination. In my research I have reading that cheek augmentation would be better than the buccal fat removal as far as years down the road as I may not like it and it may look like I am older than I really am. Just doing some research on this subject. What is your opinion? Thanks for your help.

A: Both cheek implants and biccal lipectomies do impact on the appearance of the midface. While they are in close proximity, they create different midface effects. Buccal fat removal decreases the fullness below the cheekbone area. If the complete buccal fat pad is removed then a gaunt look may eventually appear is some patients. The key is subtotal reduction, particularly in someone who does not have a ‘fat’ or round face. Cheek implants create a different effect as it brings out the prominence of the bone above the buccal fat area. These can be not so subtle differences and you have to look and play with your own face to see whether more cheek or less fullness below it is better. They are not necessarily interchangeable procedures. Whether one is better than the other, or whether a combination of both is best, is determined by one’s facial shape and must be decided on an individual basis

Dr. Barry Eppley

Indianapolis Indiana

Q: I am thinking about getting numerous facial procedures and I have a few questions. I am wondering if getting a chin implant will stop hair growth on my chin? Whatever I have done I want a natural look, will too much facial surgery ruin this or make me look unnatural? Last question,what are some alternatives to cheek implants?

A: A chin implant will not stop beard growth on the chin. It is put in through an incision under the chin so it is very far away from the hair follicles of the chin skin.

Getting a natural result in facial surgery is based on doing whatever procedures are done in balance with the rest of the face and not overdoing any one procedure. Facial surgery, whether it is a rhinoplasty, chin implant or forehead recontouring, is making the structural change to look ike it belongs to the rest of the face.

The only alternative to cheek implants is fat injections. While I think cheek implants and their numerous styles and sizes offer more versatility for cheek changes, fat injections can definitely add volume to the cheek and submalar (below the cheek) areas. With today’s more concentrated methods of fat preparation, fat injections to the face also work better in terms of maintaining volume to the injected facial area.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in correcting some asymmetry in my face and creating more harmony to the lower third of my face. The back of my lower jaw area (masseter muscle) is bigger on my right side. There is also some soft tissue asymmetry with the right side being fuller in my mid cheek area, and my chin is off center. I have been to different cosmetic surgeons but have not come across anyone who has a real solution for this. Orthognatic surgery was recommended, however I believe there is a way to correct this without such invasive surgery. I have had trouble locating a doctor in my town that does jaw implants, that’s why I was happy to find your site because it seems jaw angle implants and dealing with facial asymmetry and the jaw area in general is something you have extensive experience. I have done some research, and the solution I came up with would be jaw angle implants, with the one on the right side being bigger to account for the asymmetry. However, even without the asymmetry I would still be considering jaw implants, just because I feel that my jawline is more narrow/less defined than I would like. For the soft tissue asymmetry I would like to do removal of the buccal fat pad/or facial liposuction to thin out the lower cheek area of my face and make that area more defined. Please let me know what you think. I look forward to hearing from you and getting an idea of what you think is best from the imaging. Thanks!

A:  Thank you for your inquiry and sending your photos. As you have astutely pointed out, you have overall lower facial asymmetry marked by a very high left mandibular angle (steep mandibular plane) compared to the right side and chin bone asymmetry. This could be improved by jaw angle implants (3mm lateral style on right and 3mm inferolateral style on left) and chin bony contouring. (right chin tubercle reduction) For the midface, I would look at not only buccal lipectomies but the addition of small cheek implants as well. When you have a long face that is flatter in profile (malar hypoplasia), some anterior projection of the cheeks is helpful. Otherwise, buccal lipectomies alone may just make you look a little more sallow or gaunt and not provide the facial highlighting that you desire. 

Dr. Barry Eppley

Indianapolis, Indiana