Your Questions

Q: I`m considering having some plastic surgery and that`s the reason I`m writing to you. I am 28 years old and I`ve got a very rounded face with lot of babyfat and I want to make it more sharp/angled and more masculine looking. I have had a rhinoplasty done on my nose when I was 18 and it looks great from the profile, the only thing is that from up front one of the sides is indented and I was thinking that either an injectable filler to build up that side up or a silicone implant to make that side more fuller and match the other side. I don`t need a major or new nose job, just to fill up one side of my nose. I`ve got a double chin and even when I was thinner I still didn`t have a 90 degree angel between my neck and chin. So I want a liposuction and tightening of the neck muscles. I think this will also help to make my jawline stand up a bit more. I have a very round and big chin. It`s not too big but it`s very round so I was thinking that the liposuction of the double chin and platysmaplasty will also help to give my chin more angles but I`d also like to have a small dimple there. This will give me that masculine clefted chin look. I`d also like to have liposuction of my lower face (removal of buccal fat) to give it more angles and make it less rounded and more masculine. I think some cheek implants will give my face more bone structure. I want to remove the bags under my eyes. I`d like the procedure where the incision is from the inside of my eyelid. My upper lip is a bit uneven. One side is more rounded than the other, so I`d like to correct and get more symmetry to my lips. It`ll be nice to get them a bit bigger too. I have attached some photographs for you to review and await your comments/recommendations.

A: In reviewing your photographs and your concerns, I can make the following suggestions/recommendations:

1) Nose. Your nose is asymmetric because you have left upper cartilage/middle vault collapse. That is why it appears deviated due to the inward turning of the dorsal line. This is the result of your prior rhinoplasty. That is best corrected not by an implant or an injectable filler, but by cartilage grafting. The use of a left spreader graft and a crushed cartilage onlay graft over the indented area is the treatment of choice.

2) Lips. Fat injection grafting would be best. Although a vermilion advancement would perfectly correct the left upper lip asymmetry (lack of vertical height), that fine line scar in a male would be unacceptable.

3) Lower Eyelids. The lower eyelid bags could be removed by a transconjunctival lower blepharoplasty with fat removal only.

4) Cheeks. Cheek implants would be a good choice for your malar-infraorbital hypoplasia. I would also add fat injections above the cheek implants along the infraorbital rims.

5) Cheeks. Buccal lipectomies are needed to get rid of the fullness below the cheek bones which are going to be highlighted with the implants.

6)  Chin. A square-shaped chin implant is needed with the placement of a central dimple or cleft, whichever is your preference. The chin implant would have minimal forward projection but is more to create fullness on each side.

7) Neck. it could be improved by some liposuction  and a corset muscle plication (platysmaplasty ) to maximize the cervicofacial angle.

Lastly the Jaw Angle. A would do some liposuction around the jaw angle area to try and make it a little more distinct although the result would be fairly subtle.

Most of these procedures you had already surmised but here is what can be realistically done in an effort to achieve more of a sculpted masculine facial appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I feel like my cheeks are flat and that makes my face very non-descript and uninteresting. I think cheek implants would help but I have also read that you get get better cheeks with injectable fillers also. Which do you think is better? I have attached two pictures of my face as well as two examples of what I think are good-looking cheeks.  Will cheek implants or injectable fillers worko better to reach these goasl based on the structure and limitations of my facial bones?

A:  Your pictures do show malar or cheek flatness. Based on your desired goals by the pictures, cheek augmentation would definitely offer a big improvement towards improved facial balance and attractiveness. For ideal cheek augmentation and a better overall effect, an implant is the best choice in my opinion. Besides its permanent effect, it has a better economic value long-term. . If you are uncertain as to whether cheek implant surgery is for you, however, then initially have an injectable filler treatment done. Be aware that injectable fillers will not create exactly the same look as implants which have a very well defined shape. Injectable fillers create more of a less-defined mass effect although that will still be helpful to prove that cheek augmentation is or is not for you. When considering cheek implant surgery it is important to realize that there are different styles of cheek implants that accentuate subtle but different areas of the cheek. Selecting the right cheek implant  and size is critical as the main reasons for cheek implant revision is improper implant selection and inadequate sizing.

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like to ask you some questions concerning cheek implants. I am a 23 years old male, my eyes have an outer tilt to them, there is no scleral show between the iris and the margin of the lower eyelid, my eyes are rather slightly deep set and i have already high lateral cheek bones. Although my cheek bones are already high, they are not very well defined and for this reason I want to get them bigger and to get a more dramatic and contoured look. I managed to get me samples of all cheek implant designs from Porex Surgical. I think the implant, that would provide the look, that i am desiring, could be the Extended Malar Shapes with a 5 mm augmentation that is shown in the picture. Recently I heard that such an implant that is placed near the infraorbital rim could pull down the lower eyelids. I like the shape of my eyes and if there is any risk of lower eyelid distortion downwards, I would rather go without these cheek implants. What is your opinion on this? Do you think there is any risk of lower eyelid distortion downwards with these kind of implants? Have you noticed such changes on the lower eyelid with this high and lateral cheek implants, yet? Thank you in advance for your reply.

A: The simple answer is no. The longer detailed answer is that there is no chance of any lower lid effects when placed through the mouth as the implant actually pushes up on the lid. There is a chance of lower eyelid ectropion if a cheek implant is placed through a lower eyelid approach however. This is a function of the incisional approach and how it is closed, not because of the position of the cheek implant.

In addition, the size of the cheek implant you have shown is way too big and positioned too far back on the zygomatic arch. One can do anything on a skull model as there is no soft tissue to go through and there is no appreciation of how it will look from outside later. I find that many of Porex’s midface implants are designed too big. There is a big difference between designing them on a skull model and actually putting them in and using them in real patients. The other issue is that small augmentations in the midface and cheek area can look more dramatic than you would think by just looking at the skull model. A little goes a long way in the cheek area. Oversized cheek implants is a common complication that I see from this type of facial implant and is due to this effect.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in rhinoplasty and cheek implants and have had a consultation done which included computer imaging. The profile images show a nice improvement but in the front view I can see very little change around the cheeks and eyes. Will the actual surgery fill out these areas nicer than what I see in the imaging? What about the nasolabial folds, don’t they also diminish with cheek implants? Do you think larger cheek implants are better for me? (I heard small ones are unnoticeable)

A: While I have no idea as to the quality of the computer imaging that was done, it is difficult to show much cheek improvement from a front view. Computer imaging works best on facial structures that are not overlapped or in profile. That is the problem in the cheek area, it is not a profile structure unless it is imaged in the oblique or three-quarter view. Most likely, cheek implants will produce a much better result than what those images show…particularly if the cheek implants are a size beyond the very smallest. You are correct in that small cheek implants in most patients ones can barely be seen or are very subtle.

Cheek implants may create some lessening of the nasolabial folds but it will not be substantial. That is not an intended or known effect from cheek implants. However, paranasal implants can make a bigger difference as they are placed right behind the nasolabial folds so they create more of a push outward, thus lessening the deepest upper portion of the nasolabial fold.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Is a cheek implant that is placed high (near the orbital rim) and lateral, that extends to the orbital rim and that provides a significant augmentation (5 mm or more), able to lift the portion between the iris and the lateral canthus (not the lateral canthus itself) of the lower eyelid a little bit? I noticed this feature of the lower eyelids in people who have naturally very high and prominent cheek bones.

A:  The simple answer is that it is unlikely. While it seems logical that the lower eyelid can be pushed upwards, and it is easy to do with one’s finger, try it by pushing up on the cheek tissue. You will notice the lower eyelid does not really move upward but just creates bunching of tissue right beneath the lid line. This is because the lateral lid line is fixed by the lateral canthal tendon. The only way to change the lateral lid line is by repositioning or tightening the lateral canthus. I suspect that putting in a cheek implant as you have described may seem to work during surgery, only to be disappointed later when no change is seen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Six years ago I had a mandibular implant placed as well as malar implants.  I am unhappy with the end result and do not feel  the result was what I requested.  I think, as I did then, that a geniomandibular groove implant with extended malar implants would provide my desired results.

A: I am assuming when you say mandibular implant you are referring to a chin implant.  Since you feel that a geniomandibular groove implant is better, it appears that you feel that the transition between the chin and jowl area is not a smooth or confluent one or that the jowl area needs to be more enhanced as well. Do you know what type of chin implant you have in now?

From a cheek standpoint, the desire for further malar extension suggests that either you desire more fullness out across the zygoma to the zygomatioc arch or that your desire more fullness in the submalar area suggesting more of a malar shell design. Do you know what type of malar implants you have in now?

Please send me some photographs of your face and let me know, if you can, what type of implants you have in place. A copy of your original operative note can also be very helpful as often the type of implants used are described there. Once I have this information, I can offer a more qualified response as to the best replacement facial implants for you.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr.Eppley, will you look at patients that had cheek implants performed by another surgeon? The surgery was performed a month ago and they are asymmetrical and one side is more swollen then the other. They don’t look right. I would like them revised or removed.

A: Thank you for your inquiry. The first thing to realize about cheek implants is that the swelling between the two sides is never exactly symmetrical. Even though you do exactly the same thing to both sides, they will have differential amounts of swelling. Secondly, it really takes almost three months to see the final results from the procedure. It takes this long to have almost all of the swelling gone and to see if true cheek implant asymmetry exists. Since you are only one month from surgery (which does seem like forever when you are the patient), it is too early in my opinion to yet assume that the cheek implant placements have been asymmetrical. That being said, I would be happy to assist you. Please send me some pictures and any information about your surgery (when, type of implants if you know etc) that you know. Let us assume that after three months, this cheek asymmetry persists. Since there is asymmetry, I am assuming that there is one good side and one unhappy asymmetric side. That raises the question about whether the off side should be adjusted to better symmetry, changing the styles and position of the implants on the cheeks (there was a good reason you have it done to begin with) or simply having them removed altogether. At that point, we can delve into what your original objectives were for getting the cheek implants and see if that effort can be salvaged.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  For most of my life I have considered myself ugly. I avoid having pictures taken and I most certainly don’t look at them if they have to be taken. I have a total lack of confidence and this has definitely poses problems in my personal relationships. I don’t know what it is about my face but it just doesn’t look right. I am only 29 but I look much older. My eye area looks droopy and old and may face looks thin and distorted. I have attached some pictures for you to see and review. What would you recommend to help me look better ?

A: When someone doesn’t like their face, particularly at a young age, this indicates that the problems are with how it is put together (structural components) not that it is has early aging. This means the underlying structures that make up the shape and highlights of the face which are largely bone and cartilage. In reviewing your pictures, I can see that your face has unbalanced structures which include low hanging brows, a broad and prominent nose, hollow cheeks, and a wide and long chin. The combination of these features creates an overall facial look that you do not like. Procedures such as an endoscopic browlift, rhinoplasty, cheek implants and chin reduction collectively would make a major change in how your face looks. It would lend a softer and more youthful due to a better balance of your facial features. Computer imaging with these changes would demonstrate their potential benefit in changing the shape of your face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have read that paranasal implants can be done in local anesthesia. Is this right? Is local anesthesia possible also with malar implants which are placed right next to paranasal implants? Does not the lifting of the periosteum from the bone hurt in spite of the local anesthesia? Thank you very much for your information.

A:  Cheek and paranasal implants are placed from an incision inside the upper lip. Besides the mucosal incision, muscles and the periosteum covering the maxillary and zygomatic bone must be lifted up and a pocket made to place the implants. Given the proximity of the paranasal area to the upper lip compared to the cheek area, it would be ‘easier’ to position paranasal implants under local anesthesia as opposed to cheek implants where greater dissection is needed and the feeling in this area has more contributing nerve endings. You are correct in that it is the periosteum that is the most sensitive part of the surgical dissection. I also prefer to us screw fixation for the implants that I place in the midface which can cause more discomfort from the bone drilling.

 While just about any surgery can be done under local anesthesia, I am not sure if I was a patient that I would ever do it that way. (particularly cheek implants) Unless there is some compelling medical reason why IV or general anesthesia could not be used, it would be more comfortable and slightly less costly to use some form of anesthesia for this type of facial implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in learning about the cosmetic effectiveness of doing both zygomatic osteotomies with orthognathic surgery. I have seen some plastic and oral surgeons and I am told I have what they call a class 2 malocclusion with a restrusive mandible and maxilla, low sunken zygomas and mid-face with the outer edges of my eyes drooping. I am going to have orthognathic surgery in near future for functional reasons, sleep apnea, tmj problems, snoring, and to improve breathing while I am awake by enlarging the air ways. But cosmetically my cheeks and drooping eyes I would also like to improve. There are multiple modified LeFort osteotomies that help with filling in the face, but I am looking for something that will address the drooping outer edges of the eyes. What are the risks involved for a zygomatic osteotomy? (like double vision) How do you feel about the procedure being performed with orthognathic surgery? How cosmeticly effective is it when both done together? (other opinions suggesting best done separately) Can you achieve symmetric cosmetic pleasing effect? Not too interested in implants due to risks of dislodging and erosion, very active lifestyle, feel it would get in the way.

A: Let me give you some general thoughts about your questions with the caveat that I have never seen your photographs or x-rays and am only working off of your description of your face.

Your orbitozygomatic facial skeletal arrangement is such that the cheek bones are flat and recessed and the lateral orbits may have a little downslanting orientation. (tilted horizontal orbital axis) That problem alone, which occurs commonly in more severe deformities such as Treacher-Collins, requires a combination of  a C-shaped orbitozygomatic osteotomy with bone grafts to improve the total three-dimensional bone problem. Yours may not be as severe but the 3-D problem is likely the same. Beyond the fact that this requires a coronal (scalp) incision to do the bone cuts properly, it would be very difficult to do this simultaneously with any form of a LeFort I osteotomy. Between the scalp scar and the type of osteotonies needed, this treatment is likely too severe for correcting a more mild orbitozygomatic bone problem.

While there are some high modifications of a LeFort I osteotomy, they are restricted in how the zygoma moves and will only bring it forward but not out. (no width improvement) These are interesting operations on paper and in surgical diagrams but have never proven very practical or effective. That is why they simply are not done or rarely attempted.

The conclusion is that any form of an orbitozygomatic osteotomy is too big of an operation, will leaves palpable (able to be felt) bone edges, and also requires bone grafts. This is why the best approach, even if you don’t desire it, is to do some form of a cheek implant with lateral canthal repositioning of the eye. These are far simpler, much more cosmetic effective, have less complications (both short and long term) and can be combined with orthognathic surgery.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am impressed with the results I saw of yours on a patient that I ran accross on the internet while doing plastic surgery research. The patient had cheek implants and I think removal of buccal pads. I am 57 years old and have a lean face. I think this procedure is what I would need to achieve the results I am looking for. My buccal pads are more prominent with age and above the buccal pad area my cheeks are flat. I am not interested in filler because the buccal pad area, I believe, still needs to be addressed. Did you remove the buccal pads in this patient and insert cheek implants? I am thin so I do not think liposuction would be in order. I once asked a plastic surgeon about removing the buccal pads and he told me that would make me look dreadful. Please advise. Thank you for your time.

A: Cheek or midface augmentation can include several procedures depending upon the make-up of the anatomic problem. Implants for cheek and submalar augmentation, submalar or buccal fat removal OR augmentation, and cheek or midface lifts for sagging skin are all potential options. These procedures can be done alone or some combination thereof may be more ideal. But it all depends on an appreciation of the cheek bone anatomy and the soft tissue make-up around the cheek bones. Only through a pictorial analysis could I provide you with what may be beneficial for you.

That being said, a thin face almost never aesthetically benefits from a buccal lipectomy. I have a suspicion that what you may be seeing as buccal fat may be cheek tissue ptosis or sag. Rather than a buccal lipectomy, you may need a midface lift which resuspends the sagging cheek tissues which have fallen into the buccal triangle up back onto the bone. A midface lift may or may not be complemented by small cheek implants.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am very unhappy with the appearence of my jaw and cheek areas. I had ptosis surgery and forehead lift ten years ago. The eyelids are not symmetric but that’s not why I refer to you now. The profile of my face is very long and in my opinion the middle of the face is too far backwards.  I’m interested in what you would propose to make my appearance more harmonic.

A: In reviewing your pictures, you do indeed have a longer vertical length to our face. This is magnified by the short or more posteriorly (backward) position of your chin point and your midface. The cheek and nasal base is very flat and your chin is significantly behind the upper lip, giving your face a more convex profile.

While you can not really shorten the vertical length of your face, you can change how it appears. By bringing forward the midface and chin through bony augmentation, you can achieve better facial balance which will make it appear ‘shorter’. This can be done with cheek and paranasal implants to the midface as well as chin augmentation through either an implant or an osteotomy. I would also recommend comsidering a rhinoplasty as well. Very frequently, long faces have an increased nasal length with a small dorsal hump. This long nose contributes to making the face look longer as well. A small change in the shape of the nose through rhinoplasty can also help change the visual effect to a shorter and more balanced face.

Dr. Barry Eppley

Indianapolis Indiana

Q: Nearly 15 years ago I was assaulted and punched repeatedly while unconscious. This resulted in broken bones in my face which were never fixed at the time. I have a sunken cheek and I believe my eye has dropped slightly with it. Can my cheek be repaired being that it was so long ago?

A: It sounds like your original facial fracture was of the zygomatic-orbital complex variety which displaced in its classic manner, downward and into the maxillary sinus. When this ‘cheekbone complex’ falls down like this it creates a depressed or sunken cheek (lack of cheek projection/prominence) as well as moving the floor of the eye down with it. (eyeball moves downward)

Just because it has been allowed to heal and needs secondary correction does not preclude that it can be treated. But the type of treatment changes when the injury is old like yours as opposed to when it was a freshly broken. Depending upon the degree of bone displacement, there are two options. If the cheek displaccement is fairly mild, it can be treated with a cheek implant and possibly an orbital floor implant and repositioning of the corner of the eye tendon. (lateral canthoplasty) If the bone displacement is more severe, however, it is better to cut the cheekbone complex (osteotomy) and do bone grafting. Simply trying to build up bone with implants that is way out of position does not produce a result that looks very natural.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am exploring cheek implants as a solution to my flat cheekbones which i was born with.sunken cheeks (genetic). I live in Pennsylvania and wanted to find out if Dr. Eppley would initially review emailed photos before making an appointment.

A: The concept of  ‘consults from afar’ in plastic surgery was once inconceivable and impractical. But the internet and the ease of photographic acquisition and transfer has changed that perception. Since almost all of plastic is external and very visible, physical and cosmetic issues can now be seen from great distances by simply sending pictures. In fact, the reach of the internet and its virtual no cost has made it possible to connect any two places in the world, at the very least by e-mail.

I regularly (daily ) do internet plastic surgery consultations. Many are from various U.S. states and provinces of Canada but some are from countries around the world ranging from the United Kingdom to China. There are two types of internet consultations. The first type is of an e-mail nature only. Inquiries are initially done by e-mail from which I request photographs for review and possible computer imaging. That may then proceed onto an actual phone call for the next level of more indepth discussion. The other type is a Skype video consultation. Its origin may be from an initial e-mail or from Skype itself. If a video Skype consultation is arranged, then photographs may be bypassed due to actually seeing the patient. However, due to the poorer resolution of many Skype video connections, photographs are recommended to be sent first.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello Dr Eppley. I have several issues about my face that I would like changed. I am a 21 year old female with prominent eyes along with an oblong face shape. My eyes are not bulging out but they are just prominent. I have no cheek bones. It must just come with having a longer face shape I guess and I lack fat below lower eyelids. I was considering a mini face lift to make my eyes less prominent and my face look less tired. But as I have researched it’s too early to get it done at my age. What options do I have? What would you recommend in order to make my eyes look less prominent and get some volume on my face to get rid of the tired look and make my face look fuller (rounder).

I’m sorry for the long question but I’m so excited to come across your site since I see that you are experienced in almost all areas of cosmetic surgeries.

A: By your description, it appears that you have a longer but flatter face. Flatter in the face refers to a recessed development of the midface, particularly the zygomatic-orbital skeletal areas. (midface, cheek and lower eye socket bones) This lack of anterior projection makes a face appear longer, particularly if the vertical height of the face is long to start with. This also accounts for the lack of fullness in the lower eyelids (sunken in appearance) and the apparent big size of the eyes.

While your eyes may be big in size and your face long, the lack of cheek and lower orbital rim bones can really accentuate that appearance. Improvement of midface deficiency at this level is done by the use of cheek and orbital implants, specifically a combined infraorbital rim-malar implant. This provides fullness across this deficient bony area and provides some horizontal projection. (fullness) This helps balance the face better, make it look a little shorter and can help make the eyes look a little less prominent. These implants are placed through a lower eyelid incision.

Any form of a facelift is exactly what you don’t want to do. This is not a skin problem but a bone-based issue.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am 18 years old and cheek enhancement seems to have caught my interest.  I’ve been rolling the thought of having a procedure in my head for quite some time now, so here I am asking for information. People say there is nothing wrong with my face but what I want is more defined cheekbones, like the male model look. There is this heart shape the cheeks do along with the jaw angle if you understand what I mean. What effects might the procedure have on my face in a long term period of time? I mean, when I get to 50, will there be any undesirable changes on my face? Thank you for your time. I look forward to receiving an answer from you.

A: High cheek bones are a frequent aesthetic desire. In a male the triangular effect of prominent cheeks, chin and jaw angles makes for that chiseled or angular face look. That particular male facial look is certainly one that is evident in many male models in magazines and advertisements.

While strong cheek bones may be desireable, they are not achieveable in every male face. While cheek implants can make the cheek area bigger, that doesn’t necessarily mean that effect makes for a more sculpted facial look. One has to look at the other facial features and the overall facial shape to see if cheek augmentation offers an aesthetic improvement. If cheek implants are put in just any face, some of those faces will just look like they have big or puffy cheeks and may not become more angular.

One positive long-term effect that cheek implants do is help maintain cheek tissues from sliding off the bone, so to speak, with age. In fact,  they are occasionally placed in older patients for a midface rejuvenative effect to help lift sagging cheek tissues. Unfortunately, when done to an extreme, they can make the older face look odd or have an ‘apple cheek’ effect. There are numerous famous male celebrities that have this look.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am a 40 year old male with medium acne scars over my cheeks While I have acne scars other places, these are the most bothersome to me. Will cheek implants help lessen the acne scars and be a good anti-aging step?

A: Acne scars come in a variety of shapes which determines what procedures may be helpful for them. Surgery by excision is the preferred approach, for example, of the classic ‘ice-pick’ acne scar because of its depth. No superficial treatment of a deep acne scar, such as laser resurfacing, will work.

Many of the most troubling acne scars over the cheek area tend to be the ‘saucer-shaped’ variety. These are larger, less deep, acne scars that do resemble a saucer or a moon crater. They still are too deep to respond well to laser resurfacing (taking down the edges will not usually work) and their larger surface area causes a noticeable contour deformity. These are the type of acne scars that can respond well to injectable fillers as the problem is loss of skin dermis (thickness) and some subcutaneous fat. They represent a true volume deficient problem.

While injectable fillers can work for cheek acne scars, it is not unreasonable to consider the push of an underlying cheek implant. By pushing out from the bone, the expanded underlying tissues can help ‘fill out’ some of the saucer-shaped skin depression. I have done this a few times and do find it helpful. The existing size of the cheek area should be considered as the trade-off of a flatter acne scar for an overbuilt cheek may not be worth that trade-off.

Dr. Barry Eppley

Indianapolis Indiana

Q : I am interested in cheek implants but am not looking for a drastic change, just enhancement. I want to look better but have people not be able to tell what is different. I have a few questions. What is the recovery time from work and  physical activity (running and cross training/weight lifting)? Are the implants inserted from the mouth and fixed to the jaw? Do cheek implants inhibit ability to smile? Approximately what  % of patients are happy with the cheek implant procedure?

A: Cheek implants are done as a simple 1 hour outpatient procedure. They are inserted through the mouth and secured to the bone with a screw. There are no restrictions of any kind after surgery. While you will have some cheek swelling (but no bruising), there is nothing you can do from an activity standpoint that will hurt the implant or their position on the bone. One can eat and drink right after surgery. Pain is very minimal although usually there will be some temporary numbness of the cheek skin and a little bit of the upper lip. Cheek implants will not change your ability to smile or how your smile will look. Initially, your smile will feel a little stiff but that is due to the swelling. The vast majority of patients who receive cheek implants are happy but I also feel that it is the one facial implant that undergoes higher revision rates than all others due to inexperience in placing them, size and position selection, and style of implant used. It is a simple procedure to do but there is definitely an artistic flair to doing them well.

 Dr. Barry Eppley

Indianapolis, Indiana

Q: Four years ago, I was injured and sustained a fractured zygomatic arch from a blow to the side of my face from a punch. I did not get it treated at the time because I had no medical insurance. After the swelling went down, I noticed an indentation over the side of my face which has remained ever since. Recently I visited a local plastic surgeon and he suggested to inject Artefill into the cheek area to  lift  up the dent. It is about the size of a dime or larger in diameter, a little less than an inch maybe. I had a CT scan which showed the zygomatic arch in the form of a U shape and it goes impressed in towards my skull. Please give me your opinion about  his idea and yours.

A: The zygomatic arch is a very thin piece of bone that runs between the cheek bone (zygoma) in the front of the face back to the temple bone near the temporomandibular joint. It has a true arch shape as the large temporalis muscle runs underneath it. This arch shape provides fullness to the transition zone of the temple above to the rest of the face below.

Because of its thinness, it can be easily fractured with a direct blow. Once fractured, it changes from a convex arch to a V-shape as the fractured ends bow inward. This will create an indentation in the overly cheek skin. While easily repaired near the time of injury, it is very difficult to fix once it has healed in this position. If one has difficulty with opening one’s mouth because of the bone edges impinging on the masseter muscle, then some form of bony repair should be attempted.

If the zygomatic arch fracture is causing an external cosmetic deformity (indentation), there are multiple ways to fill out this bony deformity. Using an injectable filler is a simple and very reasonable method. While Artefill is a long-lasting filler, it is not permanent. Repeated injections may make it so however. Another method is to place a custom-shaped arch implant over the bone from an intraoral (inside the mouth) approach. This is easily done and would provide a permanent solution with a single procedure.  

Dr. Barry Eppley

Indianapolis Indiana

Q: I had cheek implants 3 yrs ago which I am looking at having revised. I am tall and athletic and they are just giving me a bony gaunt look to my face which also makes my eyes appear too far apart. What I really wanted in the beginning were midface implants, but wasn’t able to make this clear with the doctor. They are screwed in and I am wondering if they can simply be reduced or shaven down? Also I have jaw implants and am not happy with the square shape that has resulted from their outcome .

A: Facial implants today come in a wide variety of styles and sizes. They are far more versatile than just augmenting the chin, cheeks or jaw angle in a single way. Frequently, I have patients come to my Indianapolis plastic surgery practice that have existing facial implants but did not end up with the result that they wanted. Communication and computer imaging is key in facial bone augmentation with implants.

Both cheek and jaw angle implants can certainly be modified, exchanged, or simply removed. The question for both areas is what is the best strategy to achieve your goals. From a cheek standpoint, you may have been more interested in submalar implants (on the underside of the cheek bone) rather than malar implants which sit on top. They create different looks. With the objective of improving a gaunt looking face, submalar augmentation is preferred. Malar implants will actually make that appearance worse. In jaw angle implants, the size may be too big or their position on the bone may be too high or too low. The style and shape of the implant can also affect how square or sharp the mandibular angle is.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have an old indented fracture of my left cheekbone. I fell several years ago on my face and was diagnosed with an ‘infracture of my zygoma’.  It didn’t seem to bad at the time but maybe the swelling made it look better than it was. Now that side of my cheek is flatter and asymmetric to the opposite cheek. Can it be repaired?

A: Zygomatic, or cheekbone fractures, are common facial injuries. When fractured, the cheekbone rotates downward and inward, causing loss of prominence of the cheek. While the swelling may camouflage the ultimate degree of cheek flattening, eventually an asymmetric cheek will result if not repaired as the swelling goes away and the overlying soft tissue contracts.

Secondary correction of the cheek flattening can be done by one of two approaches. A cheek implant can be placed through the mouth to build the depressed part of the cheek back out. With some many different styles and sizes of cheek implants available today, a lot of cheek reshaping can be done with an implant alone. The other more extensive alternative is to re-fracture the cheekbone and move it back into its original position. (cheek osteotomy) Generally, a cheek osteotomy is reserved for those cheek deformities where the amount of cheek flattening is severe, the position of the corner of the eye is pulled down, and/or there is numbness of the lip and nose from the infraorbital nerve being impinged from the bone displacement.

I suspect your cheek deformity is more modest, since it was not initially repaired, and an implant would be the simplest and less complicated treatment approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I recently had cheek implants but now one side of my face has hollowed out and both sides of my mouth have developed drooping pouches of tissue .  It looks very uneven and has  distressed me greatly.  I would like your opinion  about this.

A: This is certainly a very unusual type of mouth result from cheek augmentation. The reason it is unusual is that cheek implants add volume to an otherwise prominent facial bone area. If anything it may cause a very mild cheek tissue lifting effect but not dropping of tissues as you state around your mouth. Early after surgery, in the first few weeks or month, one could have swelling and some bruising which drifts downward along the mouth and even into the neck. But if this is would not be the case more than a month after surgery. If other facial procedures were done at the same time, which would be common, then this could still be residual swelling which may yet go away.

Uneveness of cheek implants, however, is not rare and is probably the number one complication of cheek augmentation. It is more difficult than it looks to place cheek implants in the identical position on both sides of the face. The thickness of the cheek tissues do not make it easy to see minor differences in position during the actual surgery. I would wait at least three months after surgery to let everything settle before making a final judgment about cheek symmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Q : I have broken my cheekbone 2 times and never had surgery. Now my face is assymetrical and I have frequent headaches and can’t breath thru one side of my nose. People close to me say that my face looks caved in. It also affects my vision and I sometimes have localized pain in my cheek. Do you think my insurance will pay for reconstructive surgery? How would this be fixed?

A: Cheekbone, or zyomatic or malar, fractures are common facial bone injuries. They are second in frequency to the most common facial fracture, that of the nose. When a cheek bone fractures, a classic set of problems results from the bone rotating downward into the maxillary sinus. The cheek prominence will become flatter (caved in), one may develop sinus congestion, and numbness or pain may occur from the infraorbital nerve being bruised or pinched. (the fracture line usually goes through the nerve foramen) It does not usually cause any vision problems.

If not repaired early, the secondary cosmetic deformity is that of an asymmetrical face with a flatter cheekbone prominence. There are two ways for its correction after the bone has healed. Building out the depressed cheekbone with a cheek implant is often very successful and is certainly the easiest. The other approach is to re-cut the cheekbone and move it back into its proper place. This is obviously more complicated with a longer recovery but can also be successfully done. Which approach is best is largely determined by the magnitude of the cheekbone depression and whether it extends into the surrounding orbital (eye) area.

Typically, reconstructive surgery from a facial bone fracture should be covered by one’s medical insurance. However, this must be determined by a written pre-determination process before proceeding to surgery.  

Dr. Barry Eppley

Q: I am interested in having small cheek implants and was wondering who you would recommend I see in the Washington-Baltimore metropolitan area. I have spoken to several plastic surgeons who say they remove more cheek implants than they put in. I am wondering who has had good results with this procedure?

A: I wish I could answer your question in regards to plastic surgery referral in your geographic area. But, unfortunately, I could not tell you with any assurance who gets good results with cheek implants. While I am certain all plastic surgeons say that they do them, who would be better than other is impossible for me to know. (just like you)

What I can tell you about cheek implants is that what you have heard about them are true. Even though it is a very simple operation, they are the most revised and/or removed implant of all the facial implants. The reason that exists, in my experience, is that they are often oversized for the patient. Cheek implants are much better to be done in moderation or ‘underdone’. Cheek augmentation should be subtle, not dramatic. It is not like a breast implant, where many times bigger may be better. That is never true with a cheek implant. The second reason they are revised is that the cheek implant is unique in its position. It is the only facial implant that is literally ‘hanging on the side of the cliff’ in where it is placed on the cheek bone. So they are prone to movement and asymmetry between the two sides afterwards. That is why I prefer to secure them with a screw to the underlying bone to prevent that problem. Lastly, there are at least 5 different styles (not to mention sizes) of the implants, so matching the unique anatomy and patient desires with the right style and size of cheek implant is certainly more art than it is science.

Dr. Barry Eppley

Q: Can facial implants help to fill in a cheek region, where collagen injections have been beneficial? I have a large depressed scar from dermabrasion and laser treatments on an acne scarred region of my face. I would be glad to email pictures of the region to assist in the answer. 

A: Facial implants work by pushing out from the underlying bone on the overlying soft tissue. This how they create more highlights or volume to specific facial bony prominences. While a facial implant can be placed anywhere on the facial bones, they work best on convex or flat surfaces such as the chin, cheeks, and jaw angles.

The treatment of most depressed scars would be either some form of surgical scar revision (cut out and re-closure) or skin resurfacing. In some select cases, such as yours, actually filling in the underlying soft tissue helps flatten the outer appearance of the scarred area. Injectable fillers can work well for that type of depressed scar but they are not permanent and must be repeated.

You have correctly pointed a very uncommon but potentially beneficial approach to depressed cheek scars. Having proven that soft tissue expansion makes the scar look better, it is insightful to ask about whether a cheek implant can create the same effect. Since the cheek bone is convex, an implant will definitely push outward on the skin, helping flatten a depressed scar. I have done such an approach twice in my Indianapolis plastic surgery practice and it can work well as you have surmised.

The key to the successful use of an implant for a depressed cheek scar is two-fold. The acne or traumatic scars must be directly over the prominence of the cheekbone to get the most benefit from the underlying push of the implant. And you must consider the opposite cheek prominence as well from the perspective of balance. (one-sided or both sides for cheek augmentation)

Dr. Barry Eppley

Q: I want to get implants to have higher looking cheekbones. What is the difference between malar and submalar cheek implants? Which would be better for me?

A: In considering cheek augmentation, or enhancement of the midface, there are a wide variety of cheek implant styles from which to choose. Gone are the days when only a single design of a cheek implant existed. One of the different style designs is between malar and submalar implants. Malar is another word meaning cheek. So a malar implant sits on top of the existing cheekbone, providing more cheek projection. A submalar implant, however, sites on the cheekbone’s bottom edge providing increased fullness to the area below the cheekbone.

Submalar cheek implants have actually been around for some time and were developed to help with midface sagging from aging. As we age, cheek tissue slides or falls off of the cheekbone. One way to help lift it and restore more youthful fullness is with the submalar implant. The other option would be a midface lift, a more extensive operation with an increased risk of complications.

When most patients are considering cheek enhancement, they are usually thinking of higher cheekbones and more fullness to the bone right beneath the eye. Cheek implants come in a variety of designs to achieve this fullness and they differ in whether the most fullness in the implant is anterior, central, or posterior along the cheekbone. To choose the best implant style for you, you need to go over carefully with your plastic surgeon your exact concerns and what areas of the cheek you would like to be bigger. Most dissatisfaction with cheek implants occur because of style and size selections.

Dr. Barry Eppley