Your Questions

Q: Dr. Eppley, I recently read your blog about malar and submalar implants. I just have one question since there doesn’t seem to be much information on these implants, but where exactly are the malar and submalar regions?

If I’m looking at implants to provide a swoop from the nose to the cheeks (sorry, not sure how to describe it, but think of Bradley Cooper’s midface), which implant would actually provide that kind of volumetric augmentation?

A: The difference between malar and submalar implants is subtle but very different. As shown in the attached drawings on a person’s face, the malar region is the cheek bone itself while the submalar region is actually below that off of the bone.

There is no preformed or standard shaped implant that provides fullness (a swope) from the nose to the cheek because directly in its path is the large infraorbital nerve. An implant can be fashioned with notching of the nerve to avoid compression (maxillomalar implant) of the nerve using either a 3D model of the patient or pre making it off of a basic skull shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I understand that malar and sub-malar facial implants can be used to add volume, 3-dimension and contour to the face. Initially the imaging you provided showed the malar implants only, I think? I am interested to know if the sub-malar implants can be added as well, and more laterally, to camoflauge the slighly hollow buccal area of my face.

Can you please also explain to me the use of paranasal implants? I understand these are largely popular in Asia.

In your opinion, would they assist in the roundening and softening of my face as a whole?

You mentioned the chin augmentation I did may have produced an extreme result, compared to what is actually achievable? Do you think I would notice a measurable reduction in both the width and length of my chin with the sliding genioplasty?

A: What I previously showed was the use of malar implants in your face. The combination of malar and submalar implants is known as malar shells. That would extend the fullness into the underlying buccal space right below the prominence of the cheek bone.

Paranasal implants are designed to add fullness to the base of the nose or push it out further. They are common in Asians because they naturally have a flatter mid face throughout. I can not tell if they would be of benefit to you without looking at picture of your face from different angles, like the side view and the three-quarter or oblique. Midface augmentation in general requires a more 3D type assessment not just a flat 2D picture from the front view.

As for our chin reduction/narrowing, what you had demonstrated was a bit too sharp and extreme which is not surgically possible. But an osseous genioplasty (not a sliding one) can reduce the height of the chin as well as make it more narrow through vertical and midline bone removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Are malar cheek implants considered soft tissue augmentation? Are porous implants mainly used for submalar or malar cheek implants? Do malar cheek implants sag with time if not screwed in? Sorry if I am asking so many questions! Thanks!

A: Malar or cheek implants are onlay bone implants that create overlying soft tissue augmentation by pushing from beneath it. Porous or Medpor implants are one type of facial implant (silicone being the other) that can be used for facial augmentation. The material has certain advantages and disadvantage compared to silicone, which neither makes it better or worse than silicone in overall implant characteristics. Malar implants may shift or move from their original implanted position over time if not secured into position by screw fixation. (I would not call that sag but implant displacement)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, two months ago I got 6 mm silicone malar shell implants put in. I have flat cheekbones and full cheeks so the goal was to achieve higher, chiseled cheekbones (without placing them too laterally because I didn’t want the overall width of my face to look wider). To be clear, I do not have a combined malar/submalar implant because I did not want to augment my submalar region. Is the malar shell the implant you would have used or would the Medpor RZ malar implant work better to achieve prominent, high cheekbones? Thanks so much.

A: Quite frankly I would have used neither. All silicone malar shell implant styles are fairly wide which are going to give a round look to the cheek more than a high angular look. The medpor RZ implant is a lower projecting cheek implant style that will not give a high lateral look either. In reality, there is no really one good cheek implants style that will give that highly placed chiseled look in many patients. The best cheek implant that I have found is to either cut the silicone malar shell implants in half so that only the highest part stays or to use a so-called anatomical (style 1) implant that only imparts fullness to the high malar region.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have what I would consider a significant amount of lipoatrophy in my face (and I’m HIV positive for almost 4 years).  I also unfortunately had a small amount of buccal fat removed when I was younger.  That, combined with the lipoatrophy, has left my cheeks, buccal, and temporal areas looking quite thin (and in my view, gaunt).  What do you feel is the best way of treating this fat loss?  I’m not really interested in an implant due to cost and I really am interested in restoring volume.  I have had Sculptra treatments previously, but the results were not long lasting and did not restore an adequate amount of volume in my view.  I have considered facial fat grafting, but am concerned about the reliability of whether that fat would survive (especially in someone with HIV).  I am interested in your thoughts as to what the best course of treatment may be for something that is not short lasting and not outrageously expensive.

A: The only reliable permanent method of restoring volume in the malar, submalar and temporal regions are with implants. Malr shell and temporal implants will do well in those areas. Injectable fat grafting is another alternative, and the least costly one, but its reliability on someone on antiviral medication is very suspect. Even in a patient not on such medication, fat grafting is not always reliable anyway. Unfortunately, there are no treatment options that combine the concepts of ‘not short lasting and not expensive’ when it comes to facial volume restoration. Your best choice under these circumstances is fat grafting and one has to accept that it is unknown what will happen with volume persistence. Another option is to combine temporal implants with malar/submalar fat grafting. Temporal implants are the easiest and least costly of all facial implants to put in and can easily be done under IV sedation as can fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a tear trough and orbital deformity. One year ago I had surgery in which malar implants were placed. But it is too big and was the wrong choice for me. I only wanted to make my midface look healthy. I want make another surgery in 3 months and I now think an orbital rim implant is the right choice for me. Do you have experience with this type of facial implant and what are your feelings about it? Are the risks for an orbital rim implant surgery higher than a malar implant which I have now? Thank you very much.

A:  The use of malar vs. orbital rim implants are for completely different facial problems or concerns. Even though they are anatomically close and contiguous, what effects they have on facial structure is completely different. If a malar implant was used in the treatment of a tear trough (orbital) deformity, it would have likely made it look even worse.

The midface has  six structural components to it including the orbital rim, malar, lateral malar, submalar, paranasal and maxillary regions. The tear trough deformity represents a central and medial soft tissue recession even though the underlying bone deficiency may extend out into the malar area. Tear trough, also known as orbital rim, implants come in several different shapes and sizes which differ in the extent of the orbital rim that they cover and in how much projection they provide. It requires a careful assessment of the lower orbit and cheek to see which implant is best. Even with good implant selection, tailoring and shaping for fit is almost always required.

Unlike malar (cheek) implants, orbital rim implants must be placed through a lower eyelid (blepharoplasty) incision. This induces one potential risk that does not exist with an intraoral approach for malar implants, that of ectropion or lower eyelid retraction. Careful handling of the eyelid tissues and orbicularis muscle and canthal suspension are needed to avoid this potential problem.

Of all available facial implants, orbital rim implants are the most sensitive to size, placement and incisional access. To those with a lot of experience in maxillofacial trauma and craniofacial surgery, orbital manipulations is a comfortable place to work.  

Dr. Barry Eppley

Indianapolis, Indiana

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