One of the key features of an attractive and youthful face is the cheek area. The desire for fuller cheeks, however, is driven more than just by that of model and celebrity faces. Part of the aging process is losing volume (fat) in the cheeks and temple areas, creating more hollowed or gaunt type look. For those that start out with thinner faces, this process is more accentuated even earlier in the aging process. This form of facial aging can not be treated by any form of a facelift or tissue shifting approach. It requires restoration of facial volume.

So it is no surprise that plastic surgeons over the years have used every available option in their armamentarium to reshape and lift the cheek area. While once only able to be treated by synthetic implants up to the early 1990s, injectable fillers of differing compositions for cheek enhancement became a dominant force over the past two decades as they have surged in popularity. The use of autologous fat in just a few short years has also become now a major tool for use in the cheek.

The single greatest advantage to synthetic injectable fillers for cheek enhancement is its immediate result. The hyaluronic acid-based fillers, such as Restylane or Juvederm, offer the greatest margin of safety because of their lack of inflammatory response and assured resorption profiles. Other fillers such as Radiesse and Sculptra offer longer results but a somewhat higher risk of soft tissue reactions to their particulated content. Composition aside, the biggest disadvantage to fillers is that they are temporary. (which is also their advantage) This makes them expensive to maintain over time if one likes the result. But they are actually a low cost approach to doing a trial cheek enhancement that is completely reversal. Using a microcannula delivery technique, injectable fillers can now be delivered painlessly and without bruising.

On the surface, fat carries with it many of the same features as synthetic materials because it is injected. But beyond being injectable, it is a very different filler material. Because it is harvested from each individual patient, there is no chance of any inflammatory reaction and a very low risk of infection. It’s other tremendous advantage is that there is no limit on the volume that can be injected (in the small face) and its inherent composition of stem cells has its own list of theoretical advantages. In addition, it is done for a set procedure price rather than by a cc cost for synthetic fillers. It is similarly injected by small cannulas so placement can be very exact without bruising. The best fat placement is down at the bone level and in the muscle, where survival is better. But with all these advantages comes two distinct disadvantages…it is a minor surgical procedure and there is no assurance as to how much fat will survive. For these reasons, fat grafting is often advocated when the patient is in surgery for other procedures (e.g., facelift, lkipsouction etc) or the patient has been previously qualified by having had successful cheek augmentation with synthetic fillers.

Implants offer the one permanent method of cheek enhancement. With no external scarring as a result of being placed from inside the mouth, implants are not only permanent but can provide the most dramatic of cheek augmentation effects. The most difficult aspect of using cheek implants is selecting the proper style and size. With dozens of implant options the choices can be overwhelming and there is no clear-cut quantitative way to know what effect the implant will create in any particular patient. It can also be surprising how much change can occur in the cheeks from what appears to be a relatively small implant.The cheek is a very volume-sensitive area. So it is always better to ‘undersize’ or choose a size below what you think you should use in many cases. The disadvantages to cheek implants are infection, displacement and asymmetry. Fortunately infections are very uncommon and displacement can be circumvented by securing the implant position with small self-tapping screw fixation. Avoiding asymmetry is a matter of experience and matching carefully the position of the implant in reference to various bony landmarks.

With three cheek augmentation options available, how does any patient know what is best for them? Cheek augmentation is a lot more art than it is science and appreciating the underlying bony anatomy, the overall facial shape and what look the patient is after is key. But you have to take the whole patient into analysis not just the cheeks. Thin people with low body fat may do poorly with fat grafting, the devout non-surgery patient can only have synthetic fillers, or those seeking the most efficient and long-term method may opt for implants. Good cheek results defy a cookie-cutter approach and the most natural outcomes come from knowing how to use all three…occasionally even blending two of the techniques together.

Dr. Barry Eppley

Indianapolis, Indiana

There are many reasons that patients request surgical changes to their face. With over twenty different facial regions that can be altered, there are seemingly endless options and combinations. But when you break it down, there are two main reasons for making cosmetic changes to the face. I divide these into either facial anti-aging surgery and facial structural surgery. For the most part, this is the difference between soft vs hard tissue facial surgery.

Anti-aging facial surgery includes many of the most recognizeable procedures such as a facelift, blepharoplasty (eyelid tucks) and skin resurfacing. These are done to counteract the effects caused by time, age and sun exposure. Changes are made to the soft tissues of the face, largely the outer skin layer. Facial structural surgery goes much deeper and makes changes to the bone and cartilage. The most common structural procedure historically is rhinoplasty but today includes everything from forehead augmentation and brow reduction down the face to chin and jaw angle augmentation.

Besides the tissue levels which these two types of cosmetic facial surgeries affect, there are also very significant psychological differences between them. Anti-aging facial surgery is more psychologically comfortable for patients because the goal is to take them back to once how they looked, a place in which there is familiarity. The surgery and recovery may be scary but the end result is a look that the patient can recognize and has known in the past. In contrast, structural facial surgery is very different. The end result is one that is not familiar. It is a new look, an alteration of a face that one has known their whole life.

Having done many facial structural procedures in my practice from rhinoplasty to jawline enhancement, I have made several observations about these types of plastic surgery. Some of these are not new and have been known in plastic surgery for a long time. But new technologies and biomaterials have changed what is possible today and with that comes new psychological ramifications for patients.

Changing the structure of one’s face obviously requires an understanding as to what the patient’s goals are. Patients provide that information by descriptions of their concerns and often provide visual aids such as drawings, self-photographs and photographs of other people. These are all really helpful and collectively important. But one concerning issue is the overuse of model or celebrity facial photos. Seeing too many of these or having a patient show a whole notebook of other people’s or famous face may be a sign of unrealistic expectations after surgery. While everyone willingly acknowledges that they can not look like someone else, whether they believe that or not may be another story.

To aid presurgical discussions and goals, I consider computer imaging essential to any facial structural surgery. For the psychological reasons previously mentioned, I rarely do it for anti-aging facial surgery but consider it essential for structural changes. But computer imaging can be misinterpreted and often is. It is not a guarantee of results and such imaged results may never actually be achieved. It is a communication tool about surgical goals and what a patient wants changed and the degree of those changes. It is only as good as the person doing it and is really an integration of surgical experience and how well one knows computer imaging technology. This is why a plastic surgeon should be doing the imaging, for only they know what can really be achieved by different types of facial surgery. But even in the best of hands, a patient should not assume that is exactly the way they will look after surgery. It is an estimate or prediction but human tissues induce more variables than pixels on a computer screen.

When going through structural facial surgery, the recovery is going to be longer and more psychologically difficult that most patients envision. The swelling and bruising on the face can be quite shocking and no patient is ever really prepared for it. When the dressings, splints or sutures come out days or a week later, it is not a moment of celebration or expectation. It is just the first step in the recovery process. One is not looking at the final result and, depending upon the procedure(s) being done, full recovery is not just a few weeks away.

Facial areas will be puffy, swollen and distorted and usually far more than one anticipates. It may be significant or not all that bad, but this is not the time to judge the results. More importantly, and I have seen this many times, one should not assume that the changes are too big and need an immediate revisional surgery. What appears too big at two or three weeks after surgery may be just perfect at two or three months. My minimal time for judgment of facial structural surgery results is three months and I will not consider any revision before then unless they are compelling medical reasons. (e.g., infection) One should not attempt aesthetic revision on a moving target.

When three or more structural facial procedures are done at the same time, the appearance of the face the first few weeks after surgery can be very disturbing. Patients will often feel that they have made a mistake and even wish to return to how they looked before even though they obviously did not care for that appearance. Such after surgery appearances disrupt work and social interactions but are part of the process. If one thinks they will go back to work in two or three weeks after such surgery and will look perfectly normal…this is not realistic. Plan accordingly and I mean this from a psychological perspective. Living through the process of facial swelling resolution and tissue adapation around the bone or implant shape requires tolerance, explanations and even an openness about what has been done if necessary.

One of the most important considerations about structural facial surgery is an appreciation that the risk of needing revisional surgery is significant. At the least, it is much higher than that of a facelift or eyelid surgery. On the most simplistic level, let’s compare the risk of complications/revisional surgery of eyelid surgery (1 % to 2%) vs a chin implant (5% to 7%) in my experience. Both are fairly straightforward and relatively simple procedures. But the use of an implant introduces issues of infection, malposition and size and shape issues that do not exist as much in manipulating one’s natural skin. Now multiple that times the number of facial structure procedures being done, each with their own percent of risk, and it is easy to see why the risk of revisional surgery in facial structural surgery is significant.

For example, take a patient who is having rhinoplasty (5% revision risk), a chin implant (5% revision risk) and jaw angle implants (10% revision risk) done as a single procedure. On an additive risk basis, the real risk of revisional surgery in this case is 20% or higher, If you take more extreme cases of five or more facial structural procedures being done at the same time (a not uncommon collection of procedures in my practice), the potential risk of revisional surgery could be as high as 50%. This doesn’t mean that the complications are devastating or severe but are almost always about symmetry and the size of the changes done in the various areas. It is hard aesthetically to make so many facial changes and have them all look perfect afterwards…particularly when one is not precisely sure how they will interpret the changes.

Facial structural surgery can make significant aesthetic changes to either give the face a better shape, more definition and improved balance or to improve asymmetries between the two sides. But it is harder surgery to undergo both in planning and during recovery and has a higher risk of the need for revisional surgery.

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 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

1.      What are the different types of facial implants?

All facial implants are designed to highlight or augment weak facial bone structures. Most commonly, three specific areas are most commonly done including the cheeks, chin, and jaw angles. As a result, there are numerous sizes and styles for these frequently used implants.

But there are other areas of the face for which implants also exist including the nose, paranasal, maxilla, premaxillary, orbit, forehead and temple areas. Even if specifically shaped implants are not commercially available, carving blocks of various materials are available to ‘make your own’ for any specific facial need.

2.      What are facial implants made of? Is one material better than another?

There are several synthetic materials from which most facial implants are manufactured. These include silastic (silicone), Gore-tex (polytetrafluoroethylene, and Medpor. (polyethylene) Each has some different handling properties which affects the flexibility and stiffness of the implants. While they are all chemically and structurally different, the body sees them all the same way…as a foreign material which it tolerates by surrounding it with scar tissue. (capsule)

Each plastic surgeon may have their preference but that is not based on whether it is a ‘better’ implant material. It is a function of what they are familiar with and have had good experiences. For me, I am more interested in the shape of the implant that I need to treat the patient’s problem and the ease with which it can be placed in the correct anatomic position. The actual material composition is not that the most critical factor.

3.      How are facial implants placed?

The method of introduction, or incision, is most commonly done through the mouth. Short of farway places on the skull and orbit, all facial implants locations can be reached intraorally. This approach offers numerous advantages over an external skin approach. The one exception to this is for chin implants. They usually are best inserted through a skin incision under the chin which is associated with fewer potential complications.

4.      How do you select the right size of a facial implant?

The sizing of any specific implant has a lot to do with experience and an artistic judgment. Some facial areas, like the chin, can be measured and the exact amount of augmentation needed can be precisely determined.

But most facial augmented areas are not profile structures so they lack a silhouette or outline which can be easily measured. This is why many implants have intraoperative sizers. By initially placing a temporary implant to determine what effect it creates, a final sterile implant is not opened until one is certain the effect matches what the patient wants.

5.      What can go wrong with facial implants?

Like any synthetic material placed into the body, there is the risk that it can become infected. When infection occurs around an implant, it can be difficult to eradicate with antibiotics alone. Often the implant may need to be removed. Many people mistakenly think an infection is the body rejecting the implant but that is not so.

While infection is the worst complication of a facial implant, it is fortunately very uncommon. The more common problems are aesthetic…size and position issues. Implants can be too big or not big enough, creating too strong or too weak of an effect. The implant(s) can be off center (chin) or asymmetric. (cheeks and jaw angles)They can also shift for their desired position after surgery. This is why some plastic surgeons secure them into position with a screw.

6.      Can multiple implants be used in a single facial surgery?

Yes. Implants are often part of many combined facial procedures. Most commonly, chin implants are used in rhinoplasty and facelift surgery to improve the lower facial profile. A multiple implant strategy is part of sculpting the male face and may include cheek, chin and jaw angle implants all together. Cheek and maxillary implants can bring out a flat or recessed midface.

The use of facial implants is only limited by the imagination and artistic eye of the plastic surgeon. Computer imaging can help one understand what effect one or more facial implants may cause.

7.      When should facial implants not be used?

The long-term success of facial implants is primarily determined by the amount of healthy soft tissue around them. A good barrier or buffer of soft tissue is needed between the overlying skin and the inside of the mouth.

Implants have a much higher rate of complications in facial sites that have received radiation or been scarred by prior surgery or injury. Patients that are edentulous (without teeth) are also at risk as they have less bone and overlying soft tissue onto which to place and keep an implant adequately covered.

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

Cheek augmentation is done for a variety of different aesthetic reasons. Besides the obvious need to fill out a sunken in cheek appearance and improve facial balance, they are just as commonly used for an anti-aging effect. By augmenting the soft submalar tissue to fill midfacial hollows, the lifting of this tissue provides a facial rejuvenating effect and may even soften the depth of the nasolabial fold beneath it. This tissue lifting or anti-aging effect is unique amongst facial implants.

The shape of the cheekbone and its location between the convex orbital rim and the concave maxillary wall make it the most complex facial area to augment from an aesthetic standpoint. Where along the cheekbone should the implant be positioned and what shape and size of implant should be used are what the plastic surgeon ponders. There really are no guidelines as to how to exactly to make these selections. Artistic technique is as important as any type of scientific approach. This high degree of variability lends to revision rates that are higher than any other facial implant currently used.

Cheek implant complications usually are of two types, undesired aesthetic outcome and implant shifting or migration. Unhappy outcomes come from either an implant that is too big or positioned in the wrong location. Either way, an unnatural appearance often results. Because of where cheek implants are located, they catch attention almost as much as one’s nose or eyes. Cheek implants come in a variety of sizes and shapes but can fundamentally be divided into malar and submalar implants. Malar implants being placed on top of the zygomatic bone and submalar implant highlighting the underside of the bone. (submalar hollow or buccal space) Malar implants have different extension that either go back further onto the zygomatic arch, up around the lateral orbital wall , or anteriorly along the underside of the orbital rim. Because of these variable implant shapes, it takes a good aesthetic eye and communication with a patient beforehand to get a good result.

Cheek implants are also unique because of where they are positioned on the zygomatic bone. They often are sort of hanging from the side of the cliff, which makes them prone to shifting. Shifting will usually occur in a downward direction from whence they were initially inserted, which is usually through the mouth. For this reason, it is possible for cheek implants to shift around and end up with asymmetry. This is particularly true if the implant is made from silicone which is very smooth and slippery. Other implant composition have a much greater frictional grip on the bone and will not move as easily.

One interesting silicone cheek implant design which can effectively address the shifting problem is that of the Conform midfacial implant. Its undersurface is not smooth silicone but rather a pebbly or nubbed surface. The many little ‘’fingers’ of silicone allow it to develop some degree of frictional gripping to the bone surface. Also when soft tissue grows around it, the capsule will absolutely lock it into place. This is very similar to the concept of placing a textured surface on a breast implant which was developed nearly twenty years ago. Its shape also allows it to be trimmed and used as either a malar or submalar implant. 

Dr. Barry Eppley

Indianapolis, Indiana