The facial aging process is one that is well known as everyone will eventually see it on their face. The eyes get heavy, the brows descend, the cheek fall, jowls develop and the neck sags. Women become concerned earlier in the aging process and proceed to do procedures to treat or slow it down in an overall more comprehensive manner. Men take a much more delayed approach to it often waiting until one facial area becomes a major concern or until the facial aging process is fairly advanced.

While the face ages largely similar in both men and women, the facial procedures used to treat them are often done differently. Not as many men have facelifts as their aging neck and jowls are more tolerated. But in men that have facelifts they must be done very carefully, respecting the natural hairlines of the temples and behind the ears and being careful not to displace the beard skin into the ear canal. Incisions must be placed very inconspicously and often less of a tightening result must be accepted to keep the scars hidden. That is not a bad thing as men look better underdone than having their faces pulled too tight anyway.

While men also develop heavy upper eyelid skin and lower eyelid bags just like women, their eyelid lifts (blepharoplasties) need to be done more conservatively. Browlift options in men are more limited due to the frequent lack of adequate scalp hair and a well defined frontal hairline. The most common male browlift method is through the upper eyelid (transpalpebral browlift) using the endotine device to accomplish the lift. This produces a very modest browlift but creates no visible scars and with more conservative eyelid skin and fat removals can avoid overfeminizing the male face and creating an unnatural overdone look.

Men do not engage in as many Botox and injectable fillers treatments as women as some wrinkles and signs of aging are more tolerated. A more natural result for men is one that reduces the worst of the wrinkles but does not eliminate all of them. This is the same reason men, at best, will only do a bare minimum of facial skin care. Many men would rather seek more definitive surgical procedures, or do nothing at all, that engage in non-surgical procedures that require frequent efforts to maintain.

Facial reshaping surgery is vastly different in men than women. Male rhinoplasties must keep a high and straight dorsal line and avoid an overly upturned tip while most women desire a smaller less projecting tip and lower dorsal lines. The shape of the face in men is dominated by a strong jaw and requests for chin, jaw angle and even total jawline enhancements are not uncommon to pursue a more masculine appearance and even the so called ‘male model’ look. Men favor higher more angular cheek augmentations while women prefer a lower more anterior rounded cheek prominence. Men pursue brow bone surgery for either reduction of an overlying prominent one or for augmentation to create a more masculine brow prominence and a more backward sloping forehead profile.

Plastic surgery for men has its own unique requirements both in the type of surgeries and the demeanor of the patients. One should not assume that every plastic surgeon or plastic surgery practice is equally adept about meeting the needs of the male patient. Just like breast reconstruction for women or body contouring after massive weight loss, the male patient presents unique challenges for a satisfying surgical outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Rejuvenation of the aging face has well established methods for correcting the upper (browlift) and lower face (lower facelift/necklift) that produces consistent and satisfying results. But the face does not age in just individual subunits and the midface has similar aging issues that are uniquely different. Sagging cheeks, lower eyelid hollowness and lines and folds under the eyes present challenges for successful rejuvenation.

The development of midface rejuvenation techniques has historically lagged behind that of the upper and lower face. Only in the past decade has the concept of midface lifting emerged. The vector of the midface lift is different than that of a facelift being more vertical than oblique in orientation and more closely resembles the direction of a browlift. But it has been associated with significantly more complications and dissatisfaction than either browlifts or facelifts.

The factors that contribute to midface rejuvenation complications are several fold. First, most midface lifting techniques go through the lower eyelid and require resuspension after the tissues are lifted. This places the lower eyelid at risk for sagging or ectropion due to the tension placed on it and the very delicate suspension system of the lower eyelid which is easily disrupted. Secondly, where to attach the lifted cheek tissues to is limited and adequate bony support may be lacking.

As a result of this midface conundrum, a wide variety of open and endoscopic midface lifting techniques has developed. There is no consistent midface rejuvenation technique and this has lead to a lot of confusion on the part of both surgeons and patients alike.

To aid surgeons in midface analysis and in the selection of the most successful rejuvenation strategy, a paper on this topic published in the March 2013 issue of the journal of Facial Plastic and Reconstructive Surgery. A retrospective review was done on 150 patients who had midface rejuvenation procedures done by a single surgeon. The procedures included cheek implants, fat injections, limited and full midface lifts and facelifts. The vast majority were women (93%) with an average age of 51 years as would be expected. About one-third of patients had more than one treatment for their midface aging. Patient dissatisfaction in this study was 14%. Fat grafting alone had the highest rate of dissatisfaction of all treatments. The rate of patient dissatisfaction was associated with malar hypoplasia (skeletal deficiency) and loss of skin elasticity.

What makes midface rejuvenation unique from a facelift is that the degree of skeletal support is significant. No matter how well the cheke tissues are lifted, failure to achieve an aesthetically pleasing or a sustained result is doomed if the cheek bone does not have adequate projection to support it. The use of cheek volumizing through implants is needed in such cases. When the cheek skin has poor elasticity, pulling up alone again is inadequate and adding skeletal support needs to be considered.

Dr. Barry Eppley

Indianapolis, Indiana

Almost anyone in the world is aware of the recent tragedy in Norway with the mass killings of an incomprehensible number of Norwegian teens and young adults. The murderer Anders Breivik appears to have acted alone, driven by his white supremacist and anti-Muslin views. What has caught my attention as a plastic surgeon, however, is comments that have been written about his facial appearance.

According to the head of Norway’s intelligence agency, it is believed that he had undergone plastic surgery in the past to look more “Aryan.” The agency’s head has stated that “You do not have that Aryan look naturally in Norway”…”Hitler would have had him on posters. He has the perfect, classic Aryan face. He must have had a facelift.”

While I am not an expert on Norwegian facial structure, I do know that he would not have had a facelift to change his facial appearance. That is not what a facelift does. A facelift is what I call ‘anti-aging facial surgery’, where one is trying to return to one’s prior appearance. This does not change your face but rather makes it look rejuvenated and less tired like it did 10 or 15 years ago. But you still look like you, just a better you.

Rather he would have undergone ‘structural facial surgery’, where the foundational components of the face are altered. That can and often does change one’s appearance. Foundational facial procedures are done at the bone or cartilage level, not just the skin and soft tissues. This includes plastic surgery procedures such as rhinoplasty and facial bone augmentations. (forehead, brow, cheek, chins and jaw angles) According to reports, he supposedly underwent nose and chin surgery at age 21. This would make more sense as these can change the structure of the face and definitely can make one more Aryan in facial appearance, particularly if certain elements of the face are already there.

This raises the question of what is an Aryan facial appearance and why does it look so? The word Aryan, at least as it was perceived and used in Nazi Germany, specifically refers to being white, blond-haired and blue-eyed. But there is not necessarily a specific set or arrangement of facial features that are ascribed to an Aryan face. People talk about it and one would know if they saw it but may not be able to describe the details of it.  But what it undoubtably refers to is a strong and well-chiseled face. For a male this would be highlighted by well-defined facial bony prominences of the brows, cheeks, chin and jaw angles. The nose would have a strong and high dorsal line with a balanced ratio between the three nasal thirds.

The concept of an Aryan face continues to exist today but it is better known as the ‘Male Model Face’. Most young male models in any advertisement today almost all have this type of facial appearance. Whether they have it by genetics, plastic surgery or the use of good lighting and/or Photoshop, the strong and desireable male face has these consistent features.

Plastic surgery techniques today can help many men undergo these type of structural facial changes. Rhinoplasty, anatomical cheek implants, square chin implants, vertical lengthening jaw angle implants and occasionally select fat removal below the cheeks and in the neck can create a face that has more well-defined angles and is more masculine in appearance. For some men, this ‘Male Model Surgery’ can be very effective provided they don’t have a lot of facial fat and not an overly round face.  

Dr. Barry Eppley

Indianapolis, Indiana

It is well known that one of the major contributors towards the perception of an attractive face, albeit a man or a woman, is the proportion of certain features. Known as indicators of facial beauty, disproportionate and asymmetric features are the main reasons many patients seek plastic surgery procedures. One can debate endlessly why this is so, but we are fundamentally driven to an attractive face from an innate drive of evolution and the desire to procreate. Attractiveness is desireable because it is perceived, right or wrong, to be associated with better genes.

But what are some of these features and can they really be changed by plastic surgery? For women it is bigger eyes, a rounder forehead, a smaller nose, well defined cheeks, larger lips and a chin that is not too prominent. For men, slightly prominent brows, a nose with a high dorsal line, well-defined cheeks, and a strong chin and jaw angles are associated with more masculinity. Short of the size of the eyes, all of these facial features can be modified by differing plastic surgery techniques.

The one desireable facial feature that both men and women share is the value of high and well-defined cheek bones. It is probably the only facial feature whose size and prominence is considered attractive for both sexes. It is also the one facial feature that I never receive requests to be reduced. (short of Asian patients and this more about the zygomatic arch width not anterior cheek projection) Few patients, if any, really want smaller cheeks.

What is it about high cheekbones that makes them some desireable? Many say that they feminize a face. If high cheek bones contribute to greater femininity, then why would it be attractive on men? The caveat is that it is only an aesthetically desireable facial feature in a man when it coexists with a stronger jawline as well. Strong cheekbones on a man with a small jaw or chin does not make for an attractive face. It is the angularity of the three defining points of a male face, the cheeks, chin and jaw angles, that makes for its aesthetic desireability. Such well-defined facial skeletal highlights equates with a strong and virile personal character. (and maybe the chance to pass along some good genes)

The benefits of cheek augmentation in either a man or a woman must take into consideration these aesthetic and gender differences. While cheek enhancement can be done with injectable fillers, I am reserving my comments here to the insertion of implants. Injectable fillers are largely a good trial method to determine the merits of proceeding to a permanent cheek augmentation in my opinion. Cheek implants in women should be softer and more round to provide volume but they usually don’t need to be angular or cross onto the zygomatic arch or encroach upon the lateral orbital rim area. This can add too much width which is not usually feminizing. Cheek implants in men often need to be more angular and add more height. They are beneficial to help balance out a strong jawline or should be done in conjunction with chin and jaw angle augmentation.

The cheeks can contribute significantly to one’s facial attractiveness. But it needs to be considered within the context of the whole face. The balance of one’s facial features is what makes for gender-specific facial beauty.

Dr. Barry Eppley

Indianapolis, Indiana

Facial implants have come a long way in the past two decades with the introduction of dozens of different styles. One of the expanding facial implant areas is that of the midface. Known commonly as the cheek, it has become recognized that its anatomy is more complex than a single implant design can adequately treat. With the numerous midface implants now available, more patients than ever are being implanted. With increasing numbers of midface augmentations comes complications. The vast majority of these complications are cosmetic in nature, meaning the final result was not what the patient had hoped.

Undesired midface implant results are usually the result of a mismatch between the patient’s aesthetic concerns and the implant type and size. The large number of implant options may seem confusing, but midface augmentation can be thought of as three zones or implant locations. These include the malar, submalar, and suborbital tear trough malar regions. There are more anatomic zones to the midface, but based on desireable facial changes, these three areas can be effectively enhanced.

The malar area is the most midface zone enhanced and makes up the major aspect of the zygomatic or malar bone. This extends from the infraorbital nerve to the middle third of the zygomatic arch. Malar implants create a high, strong cheekbone which is for men who want a more sculpted facial appearance or by younger women who want more of an exotic look.

The submalar area lies below the zygomatic bone. It actually sits on the top portion of the masseter muscle where it comes up and attaches to the underside of the zygomatic bone. This facial area has become recognized as significant because fat is lost in this area with aging. Submalar hollowing can also be created in the younger person with a fuller face by buccal fat pad removal. Augmenting the submalar area can help reestablish a more youthful appearance by building it out again. When introduced over a decade ago, the submalar implant was touted as a substitute for a midface lift by being able to lift up sagging cheek tissues. This probably overstates the effect that it actually does create.

The newest midface zone to be effectively implanted is the suborbital tear trough area. Extending from the medial canthus, over the top of the infraorbital nerve, and along the lateral orbital rim extending into the malar area, this implant fills out suborbital flattening and tear trough depressions. Because of its location, this implant must be inserted from a different direction than all midfacial implants…from above (through the eyelid) rather than from below. (through the mouth)

While these three types of midfacial implants augment areas in close proximity, their effects can produce dramatically different facial changes. Subtle changes in the midface are easily detectable because of their proximity to the eye, a visual focal point in all conversations. The rise in the number of midfacial implants has led to, not surprisingly, an increased rate of complications. Many times the correct zone is augmented but the implant is too big. It is always best to undersize a midfacial implant in most cases. Unless there is a significant facial bone deficiency (e.g., maxillary hypoplasia), large midfacial implants should not be used. What make look like a significant improvement on the operating table can look dramatic in real life afterwards. Other times, the effect the implant created was different than the patient expected. This is most commonly seen with the submalar implant when it is used for a cheek tissue lifting effect and all the patient sees afterwards is unnatural fullness.

The three primary midfacial implants add an effective arsenal to a variety of congenital and age-related midfacial changes. Complications can be avoided by an implant size and type that is suited to the patient’s aesthetic concern. While the midface is one of the hardest facial areas to accurately computer image, such analysis furthers the dialogue between patient and plastic surgeon.  

Dr. Barry Eppley

Indianapolis, Indiana

The use of injectable fillers has been revolutionary in the augmentation of facial soft tissues. The wide array of different filler compositions and their immediate results with a minimal complication rate has enabled patients to enjoy facial enhancements that could not be envisioned just over a decade ago.

But like all good things, injectable fillers can also be overused or injected for ill-advised purposes. Their simplicity of use makes them easy to place anywhere, literally right down to the bone. As filler techniques are taught to an ever-widening array of injector backgrounds, I have seen an increasing number of patients in whom they are being used for facial bone augmentation purposes. Cheek, chin or jaw angle augmentation are the most common areas of facial filler use.

While there is no physical harm that is likely to ever come from using fillers for facial bone augmentation, it offers a poor value as facial aesthetic procedures go. While it is obvious that injectable fillers are temporary and must be repeated, they end up being much more costly than using a facial implant. This is because of the volume of material needed to create the same effect. I just saw a patient recently who had his jaw angles injected with Radiesse. While he was pleased with the effect, it took over 7 millimeters of volume to do so. At that cost, he was well on his way to two-thirds of the cost of having jaw angle implants which are permanent!

For bone augmentation, injectable fillers are at a disadvantage compared to facial implants. It is much more difficult to get a smooth and confluent layering that can match that of the shape of any facial implant. Because an injection method can not get into a consistent and widespread subperiosteal layer, uneven material deposition is the norm not the exception. Some injectors get around this issue by placing it above the periosteum in the deep soft tissues which is more likely to result in a more consistent layering of material.   

With the increasing recognition of the value of a stable platform onto which to resuspend aging and sagging facial soft tissues, solid implants are superior to injectable fillers. They are not only permanent, but they will feel more like natural bone structure and are much more likely to be symmetrical in cheek and jaw angle augmentation.

Both injectable fillers and solid implants offers excellent options for facial enhancement, but they are not interchangeable. Injectable fillers are for soft tissue volume improvement while implants are for bony augmentation. On the surface, some patients not may see that as not much different. But the facial results of each will make that distinction more clear. Just like trying to use solid implants for soft tissue augmentation, the use of injectable fillers for bone enhancement is likewise limited.  

Dr. Barry Eppley

Indianapolis, Indiana

The cheek or the midface region plays an important role in facial appearance. As one of the five facial bony prominences (brow, nose, chin, and jaw angles are the others), it is actually the most complex. It lacks any sharp angles, is made up of several bones that intersect together and is surrounded by three distinctly different soft tissue regions. While everyone appreciates that a high and strong cheekbone is desireable, it is not easy to quantitate what that should look like unlike chin projection or jaw angle width which can be actually be measured.

Rather than some absolute number, the cheek region is better recognized for what it does for facial shape and width. As part of understanding cheek morphology, one should not forget how the soft tissue below it affects how the bone looks above. Known as the submalar (below the cheek) region, it is affected by the size and prominence of the buccal fat pad. This golf ball-sized fat collection can be surprisingly large and it helps make for a rounder and fuller cheek region appearance. If the buccal fat pad is very large, it can make this area protrude or be quite ‘cheeky’. If this and other facial areas are small or atrophic, the facial shape may assume a more gaunt appearance.

Therefore when assessing the cheek area, the consideration of both bone (malar) and buccal fat (submalar) areas should be done. Implant manufacturers have recently showed an appreciation for this concept by expanding traditional cheek implants to include either (malar and submalar) or both. (combined submalar shells) Combinations of malar and submalar changes can often make for a better cheek result than just a ‘simple cheek’ implant alone. In some cases, cheek bone enhancement and some submalar reduction (buccal fat removal) may produce better cheek highlights. In other cases, submalar augmentation or a combined malar-submalar augmentation may be aesthetically better.

The uniqueness of  each person’s face and their desired cosmetic outcome must be taken into consideration when planning changes in this area. Removal, or more accurately, reduction of the buccal fat pad (buccal lipectomy) is a surgically simple procedure but it’s decision to do so is more aesthetically complex. Through a very small incision inside the mouth opposite the maxillary first or second molars, the buccal fat pad can be gently teased out. When doing at the same time as some type of midfacial implant, it can be done through the same incision. How much one removes is a matter of judgment. As a general rule, it is not a good idea to try and remove all of it. Not only may that be undesireable in facial appearance in the long-term, but there are several buccal branches of the facial nerve which interlace with the multi-lobed buccal fat pad. They exist most commonly on the superficial (outer) aspect of the buccal lobe, away from the area of intraoral manipulation. For this reason, aggressive buccal lipectomies may inadvertently damage these branches. I have never observedfacial nerve injury from a buccal lipectomy procedure but this attests to a more conservative resection philosophy. In uncommon cases with a very full and ‘fat’ face, a more complete buccal lipectomy may be justified. Such an approach works well when ‘fat-reducing or facial thinning’ procedures are being done such as neck liposuction and/or chin or cheek implants.

Conversely, submalar augmentation rather than reduction may be needed to help fill out a thin or gaunt facial appearance. While initially developed for lifting sagging cheek tissues over ten years ago, the submalar implant is much more commonly used to add soft tissue fullness rather than a lifting effect. If the cheek prominence is adequate but the underlying submalar region is thin or ‘sucked inward’ (indented), than an isolated submalar implant may suffice. If the overall cheek (malar and submalar) is too flat or deficient, then a combined malar-submalar implant may be needed.

When considering cheek augmentation as part of an overall facial improvement plan, both the malar and submalar regions must be considered together. Between expanded submalar implant designs and buccal lipectomies,  a more comprehensive approach with satisfying surgical results is now available.

Dr. Barry Eppley

Indianapolis, Indiana

A face that has good skeletal contours, which some would call sculpted, is desired by many young men and women. The appearance of high cheekbones is one important element of achieving such a look. Cheekbones create a well-defined face by creating an upper facial prominence which makes the lower face look thinner. Such a facial look is seen as ‘model-like’ as is reflected in much of our society’s advertising.

In performing cheek augmentation, there are numerous typical questions that prospective patients may have about the procedure. In my Indianapolis plastic surgery practice, here are some of the most common.

Q: I am afraid if I get cheek implants that it may look unnatural. I have seen some Hollywood people that supposedly have them and they look fake. Will this happen to me?

A: That is an avoidable result. In choosing the right cheek implant for any patient, three factors are considered…the selection of the patient, the size and shape of the implant, and properly positioning them  during surgery. Not every person will benefit from cheek implants, the whole face must be considered. Rounder and fuller faces are not usually good candidates. There are different styles and sizes of implants available. As a general rule, it is always best to not overdo them. A subtle enhancement is more aesthetically pleasing than being too big. The implant must be positioned and secured over the curve of the cheekbone that is most deficient.

Q:  I want higher cheekbones but do I need to have a scar to get that look?

A:  All facial implants need an incision to be placed into the bone site. Surgical access to the cheek is done from inside the mouth high up under the upper lip so there is no visible scar.

Q: My face looks very flat. Do I need more than just cheek augmentation?

A: Some patients have more significant flattening of the middle part of their face that involves the upper jaw (maxilla) as well. While increasing cheek projection is helpful, that alone may not be enough. In this case, another set of implants can be placed along the paranasal area. (base of the nose) These two sets of implants can help bring out the entire middle part of the face into better balance with the lower jawline.

Q: What is the most common complication that occurs with this type of cheek surgery?

A: Implant asymmetry. Because cheek augmentation is a ‘paired’ surgery, both implants must be placed exactly the same. That sounds simple but slight differences in angulation and orientation of the implant may be able to be seen when the swelling subsides after surgery. This may require adjustment secondarily.

Q: How much time will I need off work to recover from cheek enhancement surgery?

A: Cheek implants will cause some obvious swelling but it is not significantly painful. Once can return to any type of work in one week but the cheeks will still be noticeably swollen. It will take at least two weeks before the cheeks will not temporarily unnatural.

Dr. Barry Eppley

Indianapolis, Indiana

On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 1:00 – 2:00PM on Saturday afternoon, hosted by Dr. Barry Eppley Indianapolis plastic surgeon,  todays’s topic was facial augmentation.  The topic of facial implant surgery including what they are used for, how they are surgically placed, recovery from the procedures, and complications were reviewed. Chin, jawline, jaw angle and cheek implant types of surgery were covered. How one can tell if they would benefit from facial implant surgery and how such implants may enhance the overall appearance of the face were interesting topics of discussion.

Free plastic surgery consultations can be arranged by calling Dr. Eppley at IU Health North or IU Health West Hospital at 317.706.4444 or send an inquiry by e-mail to: info@eppleyplasticsurgery.com.