Q: Dr. Eppley, I had both buccal fat pad removal (10+ years ago) and cheek implants (6 mos ago).  I'm now considering fat transfer to go over my cheek implants since that didn't seem to add enough volume. I was also considering perioral mound lipo, but I have a concern that I hope you can advise me on.  Ever since my buccal fat pad removal (10+ years ago) I've felt a constant throbbing in my cheeks, the Dr. that did my cheek implants said it was likely due to nerve damage.  Do I face a higher risk (than the typical person) of further nerve damage because of this?  If further nerve damage did occur, what would be the extent of it? i.e., do I run the risk of paralyzing all the nerves in my face, or having thick scar tissue, or…??  Also, do you think with the fat transfer that I could look like I did before?  My goal is to not only look like before, but also go back into modeling and acting. I very much like your website and it seems you have a lot of experience.

A: Knowing your prior facial surgery history explains your younger appearance with the indentation in the submalar/buccal fat pad space from an earlier picture. Since you had cheek implants just six months ago, that explains several current findings. First, the throbbing that you feel in your face is not likely nerve damage. The nerve that runs around the  buccal fat pad is a branch of the facial nerve which is partially responsible for upper lip and nostril movement. If that nerve was damaged you would have some observable facial weakness not a throbbing sensation. The most likely reason you feel a throbbing sensation is the loss of the buccal fat pad which helps buffer the pulsations from a large branch of the facial artery that crosses around it. You always have to remember that the buccal fat pad was there serving some purpose. Thus your face is not at any higher risk of further nerve damage no matter what additional procedures that you may undergo. Second, if the cheek implants didn't give enough volumetric addition that would indicate that the style or size of your current cheek implants is inadequate. When considering additional cheek augmentation, your options would be an exchange to cheek implants that have more projection (much easier the second time around because of the existing pockets) or fat injections. Each of these has their own advantages and disadvantages. While you can certainly put fat injections above cheek implants (not actually on the implants) there is always the unpredictability of how much fat will survive. But certainly fat injections are easier with next to no recovery other than the temporary acceptance that they will be a little too big, compensating for some injected fat absorption in the first 6 weeks after the procedure. That combined with perioral mound liposuction creates a complementary cheek effect.

In terms of can you get back to exactly to how you were when you were younger, I would say no not exactly. At best I would anticipate you would get closer but never exactly that exact look again as you are now older.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implants in 1991…through the years they have shifted upward….more on the right, the right also is sore when applied pressure on it. I’m interested in having a revision.

A: All facial implants when placed ultimately form a layer of scar around them known as a capsule. This capsule not only envelopes the implant to separate it from the rest of the body but also serves to anchor or maintain the implant in its location. It is interesting as to why, years later, that the capsule somehow changes and allows the implant to change location even if it is only slightly. This is not unique to facial implants as it is seen in some breast implants as well as they bottom out or move too far to the side over time in some patients. What this indicates is that the interaction between implants and the body’s tissues is not just a static one. This is why I feel it is important to screw all facial implants into place when possible so implant micromotion and sliding around is not possible.

The question with your current indwelling cheek implants is whether they should be merely repositioned and secured with screws or replaced with new ones. That would depend on how you feel they look now and whether you have had any significant facial tissue sagging over them over their twenty years of implantation. Seeing some pictures of your face would be very helpful.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m currently 30 years old and after a long career of modeling I see that I’m not longer as popular as when I was younger. Since I have seen good plastic surgery turn people 5 to 10 years younger, I was wondering if the same thing could be done for me. Could implants help me to retrieve a more youthful look. I’m not expecting to look any younger then 25, I am realistic about the possibilities. What would you suggest? What would help me the most to fight the “aging”. Even though I’m still young, it is important to me to know what my options are. From what I have understood. Elasticity of the skin declines and the cheeks start to sag, so will an implant help with that? I also have a bit hollowness under my eyes. What could be done against that? People have advised me to get some kind of fillers, or fat transfer to create that younger look again. But what is your opinion? Is it surgically possible to make even a fairly young person look younger? Thanks.

A: Most likely at your age the initial changes that you see are best treated by some skin rejuvenation techniques and fat injections. The quality of your skin can be improved, at any age, by such techniques as light fractional laser resurfacing. Loss of some facial volume, particularly over the cheeks, is very amenable to improvement by fat injections as is the infraorbital hollowing. Depending upon your natural skeletal anatomy of the infraorbital-malar area, the concept of cheek implants is also an option. But I would have to see pictures of your face for further assessment as to the benefits of fat injections vs cheek implants.

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 had two cheek implant surgeries. Initially I had 4mm malar shell implants which were barely noticeable. Then I switched to 6mms implants which are now too big. I have a question regarding projection size.  I’ve attached two photos showing my face with Conform Terino Malar Shell medium implants with 4mm projection.  As you can see, I didn’t feel that these 4mm implants gave me enough definition in my cheekbones or enough outward projection. Therefore, I just had these implants exchanged with Terino Malar Shell 6 mm, but I now feel that the 6mm projection sticks out way too much.  I’ve heard that a 1 mm difference in implant thickness (projection) is equivalent to about 1/2 inch difference in actual cheek shape.  So, looking at the attached photos (and now that I know through trial and error that 6 mm projection is too large), do you think the same implant with a 5mm projection would still look too large, so I should go with a 4.5mm implant when I exchange the implants next month?

A: It is not true that 1mm of cheek augmentation equals a half inch difference in how the cheek looks. What I can tell you is that it can be striking how a few millimeters in the cheek area can make a big difference. So I think the statement that a little augmentation goes a long way in the cheek area. You case illustrates that in particular. If 4mms is too small and 6mms is too big, one would logically assume that 5mms would be the right size for you. Be aware, however, that in any cheek implant style and size that not just the thickness changes but overall size of the implant (height and width) as well. It is unfortunate that you will have had to go through three surgeries to finally get the right size implant. But there remains no quantitative way before surgery to determine how any amount of cheek implant augmentation will look

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a couple of questions and I have

included a photo of me now (right side) and when I was younger (left side). I’m currently overweight and intend to lose that weight but what interests me the most is if it is possible to look like my younger and fresher self again, like the left side of the picture. I have seen surgery that make people look at least 5 years younger. Is it realistically possible to make me look like that younger me again? And if so, what are my options? What procedure would suit me best? I would say that my cheekbones, used to be wider, the cheek pads were higher, there is a lot of sagging in my cheeks. Also the area around my eyes has become hollow. The bone is more visible and my eyes look deeper placed. If I would be my own surgeon I would probably suggest to lose that weight. And maybe then turn to possible cheek implants and fillers to reduce the hollow look. I’m not sure because I’m no expert. I could be totally wrong?

A: The first question you have to asked yourself is what has changed that makes you look older. By identifying the changes then you can see what may be able to be done. Thus I would first ask you what you see. I have my thoughts but what do you identify that you see has changed? What changes do you think would make you look more refreshed? You have done that and I feel that you are totally right. That is exactly what I would recommend and what I see as beneficial…small cheek implants and fat injections to the lower eyelid hollows.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley,  it’s been exactly 2 months since my cheek implants were inserted and I cannot move my upper right lip & have numbness in the lower cheek area. My upper lip movement has SLIGHTLY increased since the surgery but I’m very concerned that I have permanent nerve damage or lip upper paralysis. In your experience, have you seen any cases where patients get permanent lip/facial paralysis as a result of cheek implant surgery?

A: The intraoral

insertion of cheek implants is a subperiosteal pathway to the zygomatic body that lies way below where the buccal branches of the facial nerve lie in the more superficial overlying muscles. The dissection does expose the large  infraorbital nerve (2^nd division of the trigeminal nerve) which is a sensory nerve that exits the bone below the infraorbital rim and usually transects the small zygomatico-orbital nerve branch (sensory nerve branch) as the dissection crosses the zygomatic body.  Thus it is very common to have some temporary numbness to the cheek area and even the upper lip which can take several months to resolve. It is very difficult to get motor weakness/paralysis of the buccal facial nerve branches which supply movement to the upper lip given where the nerve lies and where the deeper dissection is done. If weakness is present, it is likely due to a traction injury rather than nerve branch transection. In addition, there are numerous branches of the buccal nerve which have some cross-innervation. This means that eventual return of full lip function is assured. The return of nerve function may be slow and the fact that you are seeing some upper lip movement indicates that the recovery process is ongoing. It may take up to six months or more for complete function to return.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 25 year old male and I am interested in facial cosmetic surgery. My previous history of cosmetic surgery is otoplasty, rhinoplasty and a chin implant. I would like a more balanced face and more of an oval/square shape. 

Frontal/anterior view:

-Is it possible to augment more on the weaker side (jaw and cheeks) to balance asymmetry?

-On the cheekbone I would like to augment both the temporal process and the zygomatic bone, augmenting both the sides and front of the cheek bone (particular more augmentation on the right side to balance the weakness)

-On the mandible, i would like the Ramus more laterally augmented (a more square jaw) (also particularly more augmentation to balance the weakness on the right side)

-On the nose, a narrower and more defined tip

Left and right profile views:

-augmentation of the cheekbone (both the temporal process and the zygomatic bone)

-more square mandible angle

-slight de-projection of the nasal tip, lower and upper cartilage*

*Tip projection is more pronounced in the photos of the oblique smiling views. 

I am sending pictures of anterior view and right oblique smiling view. If you could please send me altered photos with your expected results explaining the procedures you have added and why you feel so.

Thank you for your time and consideration

A: Thank you for your inquiry. Unfortunately the images you have sent me are inadequate for imaging. Only the front view is useful. A NON-SMILING oblique and side views are needed to get a more complete analysis.

Other issues:

1) It is not clear if the images are flipped or not. As I see them, the left side of your face is the smaller or weaker side.

2) The concept of oval and a square face are contradictory. As a male I will assume you mean more of a square facial shape is what you desire.

3) While the temporal hollows can be augmented, the bony zygomatic arch and its temporal process  which lies below it can not.

4) Correction of facial asymmetries is difficult even using differently sized implants for each side. Improvement may be obtained but do not expect perfect symmetry as that will not happen.

5) Since you have already have a rhinoplasty, what was done to the tip of the nose initially? What tip changes ere already done and didn’t achieve your goals? It is now a scarred tip and a review of the previous operative note would be helpful to know what now lies underneath and whether cartilage grafts were harvested from your septum. You also have a right middle vault collapse, a step-off at the osteocartilaginous junction, significant nasal deviation and nostril retraction/asymmetry. These and the desire for tip de-projection are going to require cartilage grafts.

All this being said, I have done some imaging based on the one useful frontal view that you have provided with jaw angle, cheek and temporal implants as well as

revisional rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in silicone malar cheek implants and wanted a dramatic look to change the shape of my flat face. I for sure want to get a medium size implant and was wondering if a 3mm falls in that category or if a 4mm is considered a medium? Thank you.

A: The determination of size is but one consideration in the selection of a cheek implant. It would be equally important to select the style or shape of cheek implant that works best for your face and could create the look you are after. But back to size, a cheek implant’s size has numerous dimensions of which thickness is but just one of them. Generally as the thickness of the implant increases so does the height and width of it as well. (total surface area that it covers) Whether a 3mm thick cheek implant would be considered a ‘medium’ would depend on what cheek implant style you are talking about. For some

silicone cheek implants such as the malar shell, 3mms in thickness would be considered an intermediate sized implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m now thinking I want to move forward with doing cheek implants and picked out the style of implant I want but need to know it the implant is falls into the category of small, medium or large. It’s by spectrum design and is called( malar profile ) the nominal dimensions are 5.4×3.2×0.5. But it doesn’t say if its a

medium implant or large and this is something that is important for me to know. Pls help. Thank You. 

A: To help answer your question, here is the schematic on that particular cheek implant style.

Profile Malar Implants
	Catalog Number	NOMINAL DIMENSIONS
		A	B	C
	S140-414S	4.6 cm	2.3 cm	0.4 cm
	S140-424S	5.1 cm	2.7 cm	0.5 cm
	S140-434S	5.4 cm	3.2 cm	0.5 cm
	S140-444S	5.7 cm	3.5 cm	0.5 cm
	Sizer set 900-014		Designed to enhance the entire malar region, this implant features thin tapered edges and provides a smooth transition to the malar prominence.

You can think of the four options as Small, Medium, Large, and Extra Large.  Therefore what you inquiring about is S140-434S which would be considered a large implant. As you can see by this dimensional chart on cheek implants is that the thicknesses don’t differ that much but the surface area that they cover do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had Medpor midface rim implants placed a year ago and have had no issues so far. However, I have been considering getting a malar shell or combination submalar implant to add more contour and definition to my cheeks and midface. My only concern is that having the medpor implant would preclude this procedure. Would the cheek implants overlap the existing Medpor implant and can they be secured and screwed in over the Medpor implant? Also, would the surgery be much more difficult as I hear that Medpor implants are hard to remove, and I assume that this difficulty in removal might make it harder to create a pocket. Thank you for taking the time to read this!

A:  The simple answer to your question is that is no problem on any of those issues. The silicone malar implants can be viagra online canadian pharmacy placed and overlap the Medpor material and then secured by screw fixation into place. The pocket dissection over the top of the Medpor implants is minimally more difficult and that also is not a concern.

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, I am interested in having the following procedures done:

* Ear surgery – ear pinning + fix right ear that sits lower than left ear or fix left ear that sits higher than right ear + improve general appearance of ear cartilage
* Blepharoplasty – lower eyelid of my left eye (when I smile, it creates a prominent bag under the eye – not the case with my right eye though)
* Septoplasty – nose veers a little bit to right (possibly due to deviated septum)
* Rhinoplasty – remove slight bump & also looking to have a thinner nose
* Lip augmentation – improve general appearance
* Liposuction under chin – just to get rid of dreaded dubble chin
* Other possible procedures (if doctor recommend them): cheek implants, jaw implants and chin implant – I would like to have more masculine facial structure
Other possible procedures, if you offer them: tear trough implants, cheek lift
PICTURES:
First pic: how I actually look
Second pic: alterations I made to my face on your website (not perfect, just played around).

A: In answer to the facial procedures:

1)      It is possible to raise an ear .5 to .75 cms but it is not possible to lower an ear. Ear pinning or antihelical fold setback can effectively reshape the outer ear cartilage.

2)      The ‘bag’ of the left lower eyelid is hard to appreciate in your non-smiling views so I am not sure if it is a skin issue or a fat issue.

3 and 4) A septorhinoplasty is needed to straighten the nose, reduce the bump and have a thinner tip.

5) To make that amount of lip augmentation change, you would have to think about fat injections even though their survival in the lips is anything but assured.

6) Submental liposuction can be done but, more importantly, significant chin augmentation will eliminate

that concern on its own. Cheek and jaw angle implants would be complementary to the chin and, in your thin face, would make it very sculpted and angular.

7) Cheek implants will obviate the need for a cheek lift. Tear trough implants can be done to fill out the under eye hollows.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am interested in cheek augmentation and an African-American rhinoplasty. I have fat cheeks and I want them smaller. I also want a more refined and less fat nose. I have attached a picture of me so you can see what needs to be done.

A: Thank you for sending your picture. This one view is not the best picture to judge the result but it is helpful. I believe you are looking for a buccal lipectomy to reduce buy cialis online without a prescription the fullness under your relatively flat cheek bones. Or you could leave the buccal fat alone and augment the cheekbones which I think is a better alternative. (maybe just a little buccal fat removal. Your nose shows many of the typical ethnic features and that could be improved by an open rhinoplasty in which the nasal bridge is built up with an implant, the tip lengthened and narrowed and the nostril flaring/width reduced. I have just imaged the buccal lipectomy and the rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m considering cheek implants to address the following problem. I have a wide round face with a flat midface and I want to avoid implants that make my face look wider or rounder. Should I go for malars without edges (so ones that only address the cheekbone) what part of the cheek contributes the most at creating forward projection? My main goal is to achieve a less wide face with more projection. Thank you so much!

A: When it comes to increasing midface projection without making the face wider, all implants have to remain inside of a vertical line drawn down from outside of the lateral orbital rim. This means the options of using orbital rim implants with small malar extensions relegated to the anterior cheekbone surface, paranasal, and premaxillary implants. These are the implants that can increase midfacial projection without creating width.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, my husband had maxillofacial surgery for an under bite and put cheek implants in to balance his facial features about five years ago. He has had problems with the left cheek implant moving slightly and when he … Continue reading →

The post What Is Making My Cheek Implant Move When I Blow My Nose? appeared first on Eppley Plastic Surgery.

Q: Dr. Eppley, I had cheekbone reduction using the L method. Now cheeks are really low. I want to ask can you put an implant on top of the cheekbones which have been cut and screwed in a lower position? … Continue reading →

The post Can I Get Cheek Implants After Having A Cheek Reduction? appeared first on Eppley Plastic Surgery.

Q: Dr. Eppley, I had all my stiches break open (only left side) 1 week after my cheek implant surgery so my left cheek got infected. I was in pain with swelling. The Dr .chose to do revisional surgery in … Continue reading →

The post Why Do My Cheek Implants Not Look Symmetrical After A Healed Infection? appeared first on Eppley Plastic Surgery.

Q: Dr. Eppley, I am very sorry to disturb you, I live in a remote area of Russia, and my grandson was born with craniofacial distortions of his  face and skull. My friend found your contact details in the Internet. … Continue reading →

The post What Craniofacial Surgery Procedures Does My Grandson Need? appeared first on Eppley Plastic Surgery.

Q: Dr. Eppley, Can I benefit from cheek implants? I have a long thin face that has always bothered me. I don’t know what if anything can be done to add fullness or reduce length? I always look like I … Continue reading →

The post Can Cheek Implants Help Widen A Long Thin Face? appeared first on Eppley Plastic Surgery.