In the past, cosmetic surgeons concentrated on making patients look tighter, not necessarily younger. Contemporary cosmetic surgeons appreciate the importance of volume in facial aging and rejuvenation. Today’s surgeons utilize many options including injectable fillers, fat transfer, lifting procedures and midface (cheek) implants to restore volume.
Cheek implants have numerous advantages over other methods of restoring midface volume. Fillers and fat will dissolve over time. Fat and permanent fillers will droop over time, worsening the problem and cheek or midface lifting procedures will sag over time. Cheek implants are fixed to the cheek bones with tiny micro screws, so they will always remain in place and not droop. This makes them the only three dimensional method of cheek rejuvenation that is permanent and won’t move. Perhaps the biggest advantage is that if the patient does not like them, they can be removed in 5 minutes! If the patient desires smaller or larger implants, they can be changed. There are not many options that are both permanent and reversible. When considering the available options for midface rejuvenation (fillers, fat, lifting procedures and implants) nothing rivals the versatility of silicone cheek implants. One thing that has never ceased to amaze me is how many surgeons will perform cosmetic facial rejuvenation on the upper face and lower face and completely ignore the midface. A volumized midface is the hallmark of youthfulness and contemporary cosmetic facial surgeons realize this fact and address this important area.
Don’t consider cheek implants without watching this video!
View a comprehensive video of Dr. Niamtu explaining midface rejuvenation options and cheek implants
Types of Facial Implants
The most common facial implants are used for chin and cheekbone enhancement. These implants are available in various materials but the vast majority of successful and FDA approved implants are made of surgical silicone. They feel natural and the infection or rejection rate is extremely low and silicone surgical implant material has been used for many surgical applications for decades. Many types of facial implants exist for correction of cosmetic or reconstructive problems. These implants are anatomical which means that they are specifically designed to augment specific areas. Some implants augment the actual cheekbone area while others augment the area of the cheek under the eye. Many styles of cheek implants are available but the most common used are the following. The submalar implant is designed to provide maximal augmentation on the sunken part of the cheek under the eye and to the side of the nose. This implant does little for cheek bone augmentation. The malar shell (malar means cheek) implant is designed to augment the actual cheekbone area for patients that desire more fullness in this area. The combined submalar implant augments the entire midface and is a combination of the submalar implant and the malar shell implant.
Submalar Implant, Malar Shell Implant and Combined Submalar Implant
(See the video at the bottom of this page discussing implant size and selection)
One of the simplest procedures for rejuvenating the midface is submalar implants. The submalar region is the area that is just below the lower rim of the eye and the cheek as shown in the following picture. The fat in this area begins to descend in the fourth decade and gives the face a drawn and hollow appearance. Although many patients think that “cheek bone implants” are what they need, this could actually make the situation worse. What is important is to fill up the void in the midface and not necessarily on the cheeks. This is the ideal indication for submalar implants. The implants are placed through tiny incisions inside the mouth just above the gum.
The patient to the left is an absolute example of the purpose of cheek implants. This female patient underwent minifacelift, upper eyelid surgery and submalar implants. Although there is improvement from all procedures, it is the cheek implants that truly make her look younger.
Click to enlarge
Facial proportion is one of the key components of beauty. Look at the picture below. This was from a study done in Germany. A picture of a female was altered 25% in terms of proportions in each box. That means that the size, shape and spacing of the features changed. The images were then shown to 1,000 college students and they were asked to pick the most attractive picture. 100% of the people chose number 5 or 6. This shows the power of proper proportion to the overall perception of beauty.
We are not symmetric creatures!
One of the things that many patients do not realize is that almost every person has one side of the face that is smaller or larger than the other. This is the rule rather than the exception in nature. Most people have subtle asymmetries that are not readily noticeable but others have significant differences from one side to the other. In the picture below, Dr. Niamtu is shown in a normal photo (B). A mirror image of both right halves of his face (A) and both left halves (C) is shown. Dr. Niamtu is left hand dominant and the mirror image of both left halves of the face make him look like an NFL linebacker while superimposing both right sides of the face in a mirror image makes him look more like an alien!
click to enlarge
This same photo-manipulation can be performed on any person with similar results and it is important for patients to recognize this fact. If a patient has a slight asymmetry before surgery, they are likely to have a similar one after surgery. In some patients steps are taken to improve the disparity between sides. In patients with more noticeable asymmetries, Dr. Niamtu may elect to place a medium cheek implant on one side and a smaller on the other side or vice versa.
The patient below underwent cheek and chin implant surgery by Dr. Niamtu and no other treatment. This case is an excellent example of how small changes in facial proportion can make big differences in overall beauty.
Cheek Implant Surgical Procedure
Cheek implants are a relatively simple procedure that takes about 15 minutes per side and can be performed under local anesthesia or IV sedation. The surgery causes moderate swelling and the recovery is usually about a week. They are placed through a very small incision above the gums.
The picture above shows an actual submalar implant placed over the area that will be augmented. The implant is placed through the mouth.
Cheek and midface implants are placed through a small incision just above the gums.
This patient is shown 1 week after cheek implants, eyelid tuck and chemical face peel. The average patient can return to work or play in about a week after cheek implants.
One of the biggest advantages of cheek implants is their longevity as they can literally last a lifetime. Since they are secured to the cheek bones with microscrews they cannot move. Unsecured implants can migrate but secured implants will stay in place. Similarly, placing fat or other fillers in the cheeks is not stable as anything placed in the soft tissues of the cheeks can descend or droop with continued aging. The patient below shows the longevity of cheek implants.
Custom Facial Implants
Custom facial implants are also available to fill in facial defects caused by disease, trauma or developmental problems. These implants are made with computer techniques and Dr. Niamtu was one of the first surgeons in the state to use this technology over 15 years ago.
Simultaneous rejuvenation of the lower eyelids and the cheeks is a winning combination.
More information about Cheek Implant Surgery from Dr. Niamtu's library of articles
Cheek implants are a 40 minute procedure that is one of the most powerful rejuvenation techniques in cosmetic facial surgery. Dr. Niamtu discusses cheek implants, interviews a post op patient and shows before and after pictures cheek implant cases.
Dr. Joe Niamtu, III cosmetic facial surgeon in Richmond, Virginia is internationally recognized for facial implants. In this video he discusses choosing the right size, shape and position for silicone cheek implants. Choosing the right surgeon and right implant placed in right place equals success.
For more information on cheek implants or cosmetic facial surgery visit www.lovethatface.com
From time to time I hear patients say that their surgeon told them that cheek implants are not a good option because “they don’t work” or they “dissolve bone” or they have “taken out more than they have put in”.
Having placed hundreds and hundreds of implants and having cheek implants in my own face, I whole heartedly disagree and feel that there are common problems with the technique of some surgeons that leads to implant failure. Let’s examine some.
- Improper Diagnosis- to have a successful implant result, the surgeon must make the correct diagnosis and utilize the correct configuration of implant. Placing a submalar implant in a patient with later malar deficiency may not look normal and placing a combined submalar shell in a patient with only submalar deficiency may look worse. It is key for the surgeon to understand the various midface deficiency patterns and understand the proper style and size of the correct implant. Good oral hygiene without dental or periodontal disease is also important. Although implants can be placed in smokers, they may have a higher rate of complications.
Diagnosis of the patients condition and proper implant choice are paramount for a great result.
- Unrealistic Patient Expectations- all cheek implants can make a great impact on facial rejuvenation, they are not a panacea for all patients. Some patients present with full faces thinking implants will give them a chiseled look. This will not happen. In other situations, a patient can present with severe facial wasting and think implants will fill out the entire face. Finally, some patients think that a cheek implant will lift the jowls and lower face. This won’t happen. It is important to have patients with realistic expectations.
- Incorrect Implant Material– cheek implants come in numerous materials and nothing has more advantages than silicone. It is very biocompatible, very easy to bend to the contours of the facial bones, very easy to penetrate with fixation screws and very easy to trim. Perhaps the most important quality is that they are easy to remove. We rarely need to remove cheek implants, but if desired or necessitated, silicone implants come out in seconds. Some materials such as plastic or polyethylene are not as forgiving. They do not bend to the underlying contours, they can fragment when drilling or trimming and they can be difficult if not impossible to remove. These implants become ingrown to the tissues and when removed usually fragment into many pieces. In addition, they can be very damaging to surrounding tissues which can tear or come out do to being ingrown to the implant.
- “Floating Implants”- for decades I have advocated securing all implants to the underlying bone with micro fixation screws. Yes, it is possible to have successful implants that are not screwed in, but I can testify that I have treated many failed implants placed by other surgeons that migrated due to lack of fixation. Cheek implants are subject to movement by the powerful facial muscles and it is not uncommon for them to migrate, especially in the early post-operative period. If an implant is fixated with micro screws, it won’t migrate; it can’t. Also, I feel that there is definitely increased bone resorption with non-fixated implants. Moving the face day in and day out can produce micro movements to non-fixated implants which can dissolve underlying bone. Finally, if a non-fixated implant becomes infected, it has to be removed. Implants that are screw fixated can frequently be salvaged with antibiotics and open antibiotic irrigation. I have done this numerous times.The image above shows an implant placed by another surgeon that was not screw fixated and has eroded through the tissues into the mouth. I have never seen this happen with an implant secured with a screw.
- Improper Placement- Successful cheek implants require a surgeon who truly understands midfacial anatomy, biomaterials and possess good surgical skills. Generally, the more implants a surgeon has placed the better his or her experience. Proper placement requires close observation to natural landmarks such as the infraorbital foramen, pyriform aperature, orbital rim and teeth. The implant must be placed so it follows the natural contours of the face and lie symmetric on both sides in the three dimensions. Failure to understand this can produce unbalanced and unnatural results.
Close attention must be paid to the placement and alignment to ensure a symmetric result. Experienced surgeons such Dr. Niamtu appreciate this concept. The lower sided picture shows how an implant can “roll under” if close attention is not paid to proper placement.
- Numbness and Facial Pain- I hear patients say that their surgeon told them that there is a high incidence of numbness and facial pain from cheek implants. Most patients will have minor post-operative pain and numbness for the first week or so, but it is EXTREMELY RARE to have permanent nerve problems. Experienced surgeons know where the nerves lie and also can relieve the implant to prevent it from rubbing on the nerve.
The above image shows an implant placed by Dr. Niamtu. Notice how the implant is retained by a micro screw and notched to prevent impingement on the supraorbital nerve.
The following cases show successful cheek implant cases by Dr. Joe Niamtu, III. Some of these patients also had other simultaneous cosmetic facial surgery procedures. Study their midface and you will appreciate how the cheek implants enhanced the rejuvenation.
Like everything else in life, knowledge and experience usually produce great things and this is true with implants. When the above five parameters are understood and followed, facial implants are an easy, effective, permanent and reversible means of producing a youthful midface. Experienced surgeons with realistic patients and great surgical technique rarely have implant failures.
A screw fixated implant can last a lifetime, but be removed in 10 minutes or changed in size in about 25 minutes, making silicone facial implants a mainstay of cosmetic facial surgery. Cheek implants are a simple, effective, customizable, permanent and reversible procedure.
Some doctors say “cheek implants don’t work”. I have successfully treated hundreds of patients over the last 20 years with cheek implants and have them in my own face. I say “cheek implants work great in experienced hands”.
For more information about facial implants by Dr. Joe Niamtu, III visit www.lovethatface.com
Joe Niamtu, III DMD
Cosmetic Facial Surgery
Paper or Plastic?
I frequently get asked what material is the best for facial implants and my answer is usually silicone. Silicone rubber has been used in the body for decades and is in many medical and surgical devices. When silicone is placed over bone, it feels like bone. A big advantage is that since it is soft, it will conform to the underlying anatomy and never feel like a sharp edge. Perhaps the biggest advantage is that if a silicone implant needs removal or replacement, they are very serviceable. Some implants are made from porous polyethylene and there are potentially significant problems with these implants if they need to be removed or replaced. Believe me when I say this because I have taken them out from patients from all over the world that were placed by other surgeons. These implants enable soft tissue growth and when removed can cause tissue loss and soft tissue defects. It is not uncommon to have connective tissue and muscle attached when removing them and some surgeons refuse to remove them because the risk of tissue and nerve damage. Another problem with the rigid implants is that they do not conform to the underlying tissue and it is not uncommon to feel a ledge or ridge. Having said this, these implants are OK if they integrate and don’t need removal. In actuality, there are many materials that are suitable for implantation. It is not my place to condemn any implant, I can only relate my personal experiences and those of respected colleagues. I have successfully used silicone for over 25 years and when fixating the implants with a microscrew, have had very little problems.
How Long Will My Implants Last?
This is a frequently asked question. The answer is decades, maybe forever. Since the implant is placed on the bone deep beneath the skin and usually secured with a single micro screw, it can’t move anywhere. Unlike injectables, fat and lifting procedures, the cheek implants become a permanent part of your facial bones. Remember, although the result is extremely long lasting, the implants may be easily removed with local anesthesia at any time.
How Do I Know What Size to Use?
This is the art of facial implants and largely depends on the physicians experience. Dr. Niamtu spends significant time with facial implant patients assisting them in the selection of the proper implant. Besides listening to what the patient wants and accessing what the patient needs, there are also implant “try ins” that allow Dr. Niamtu to select the best fitting and shaped implant for each patient.
How Long does the Cheek Implant Procedure Take?
Cheek implants can be placed with local anesthesia alone or with IV sedation. The procedure takes about 15 minutes per side.
How Long is the Recovery?
The recovery for cheek implants varies but generally after several days most patients can return to light activity. Some patients will also return to work after 3-4 days. Recovery depends upon the amount of swelling that occurs with individual patients as some people swell more than others. In addition, the ability to smile and pucker will be slightly different for the first week to ten days. The average patient misses one week from work.
Can the Implants Move Around?
Dr. Niamtu secures the cheek implants with a tiny micro screw (no, it won’t set off the metal detector at the airport!) to keep them in place. Failure to do this can lead to problems with result, infection and bone loss under the implant. By securing the implant these mobility related problems are eliminated.
The image on the right shows the microscrew used to secure cheek implants.
Young people have positive fat distribution in the face that contributes to a “young” look. As we age, this fat atrophies and sags and produces a hollow and aged appearance.
Aging is a process of deflation and as the youthful midface fat changes position, we look drawn and aged. Young people have plentiful midface volume which decreases with age.
The above image shows three generations of the same family. The 5 year old has maximum facial volume, the 54 year old has moderate loss of midface volume and the 80 year old has extreme midface volume loss.
Midface implants can reverse these changes. Cheek implants are a small procedure that can deliver big improvements. They are frequently used with other rejuvenation procedures such as facelift, eyelid and brow surgery, laser resurfacing, etc.When used with other procedures, the main procedures are the “cake” and the cheek implants are the “icing”. Cheek implants can also be used as a solitary procedure as they add youthful volume to the face. To illustrate the importance of cheek implants, look in the mirror and smile. Most of us look better and younger when we smile because we are elevating the sagging tissues to where they were in youth. While smiling, hold your cheeks up with your fingers and relax the smile. When you let go of the cheeks, they will droop to the jowl area. Restoring the midface volume makes us look younger for several reasons. First of all, young people have volume in their cheeks; secondly the aging midface droops and makes the younger oval face appear square as we age. By replacing the volume in the midface, the face takes on a youthful oval shape.
An additional means of seeing what you may look like with midfacial augmentation is to lie back and lift your chin while looking in mirror. The gravitational change allows the sagging cheek tissue to return to its normal position. Lying back and tilting the chin forward can simulate midface augmentation and is a means of “previewing” what cheek implants may enhance ones appearance.
Part 1 discusses midfacial and teartrough aging
Part 2 shows actual midface and teartrough injection (shows actual injection which may be offensive to some viewers)
The video below shows Dr. Niamtu injecting a patient with facial defects, cheek volume loss, tear trough deformity and nasal hump.
Dr. Niamtu has published a 1,000 page comprehensive textbook on cosmetic facial surgery which includes a large chapter on his cheek, chin and facial implant techniques. Few surgeons receive the honor to publish such a text with a major medical publisher like Elsevier.
Dr. Niamtu is very involved with the use of facial implants and teaches other surgeons these techniques on an international basis. He has lectured to all cosmetic specialties including plastic surgeons, oculoplastic surgeons, dermatologists, facial plastic, ENT, oral and maxillofacial, here and abroad. Some of the multiple specialty lectures given by Dr. Niamtu are shown in the course brochures below. Click on any images below to enlarge.
Dr. Niamtu among distinguished faculty at St. Louis Facial Plastic Surgery Facelift Course Nov. 2010
Dr. Niamtu speaks in Vegas with other recognized facial implant experts
Dr. Niamtu speaks in Vegas with other recognized facial implant experts
Dr. Niamtu addresses osteopathic physicians on facial implants and facelift techniques
Drs. Niamtu, Terino and Binder shown at the cadaver instructional lab of Touro University in Las Vegas.
The brochure to the right is from a maxillofacial surgery cosmetic surgery course at Louisiana State University in New Orleans where Dr. Niamtu lectured on facial implants. Click on the image to enlarge.
Dr. Niamtu teaches four courses in Richmond, Virginia that are attended by cosmetic surgeons from plastics, facial plastics, Dermatology, ophthalmology, and maxillofacial surgery. Click on the image to enlarge.