Does a cheek implant push the muscles and fat pads upward so that these structures now "sit on top of" the new implant?

Question

I have a flat midface. I was told to go for Voluma but I just don't think one or two syringes of "gel" will give me new cheekbones. In the mirror, when I push my cheeks up, I am happy with the look I am getting. I had a buccal lipectomy over a year ago and when I push my cheeks up, you can clearly see the nice hollowing from that procedure. My face is flatter than the average person and I was hoping a cheek implant would be the right solution to get cheeks. Feedback is appreciated. Thanks

Gregory S. Keller, MD, FACS · Answer

The cheek implant is useful for people with a congenitally narrow on non-projecting face with eyelids that hang over the cheek (negative vector).  They are placed along the bone and under the lining of the bone, pushing the bone upward and outward, depending on the type of implant used.

Richard W. Westreich, MD · Answer

When a cheek implant is placed, it is on the bone and is placed after a pocket is created, which separates the muscles and fat pads from the underlying facial skeleton. The implant goes below them and physically repositions these structures in doing so. When filler is injected, it is often placed below the muscles and fat, also lifting them. However, it is a limited lift, given that the structures are still connected to the facial skeleton.

Burke Robinson, MD, FACS · Answer

Thank you for your question.  Your initial question is true in that the implant is placed directly on bone, and thus will project the full thickness of your cheek soft tisse (fat, muscle, skin) out, not up.  It appears from the limited one photo that you have a "negative vector" of the midface, as well as hypoplastic (under-developed) cheek bones known as the malar eminence.  A proper placed cheek implant will definitely help the cheek projection, but he midface (area below your eye in the mid-pupillary line) may still require filler to complete your appearance.  For this I would recommend Restylane Lyft instead of Voluma, as it is the most stiff product (has the highest g prime, a measurement of stiffness) on the market, which you will need as it also will be projecting out the full thickness of the mid-face soft tissues.  I hope this helps!

Jeffrey H. Spiegel, MD · Answer

Good question.  First of all, yes, a cheek implant, if done correctly, will go directly on the bone so all structures above get lifted.  This somewhat "recreates" the structure of your face so that everything sits where it belongs.Secondly, the buccal fat pad removal was probably a good choice for you.  However, if it is inadequate we should see why.  Perhaps more remains. Perhaps a cheek implant is the right answer.  Or, it may be something that only a small "lift" will do. An in person visit or video consultation is the best way to go.

Barry L. Eppley, MD, DMD · Answer

Cheek implants create their effect by release of the osteocutanous ligaments and the Introduction of a spacer (implant) which pushes up and out the overlying tissues...as you have correctly surmised. This is not an effect that injectable fillers can provide and they do not release the tissues at the subperiosteal level., they merely push out the skin and add volume but not a true lifting effect. How the midfacal tissues are lifted depends on implant shape, location and volume.

Francis R. Palmer, III, MD (retired) · Answer

Hi, I have performed many facial shaping procedures using dermal fillers, silastic facial implants (cheek implants, chin implants and lip implants), liposuction and/or facelifts for over 30 years.  Following my beauty principles, men look chiseled and handsome with angularity in the cheeks, chin and mandibular angles.  From the photos, your cheeks are flat in the front (red arrow in the photo), the chin is weak as are the mandibular angles and there appears to be some excess facial fat in the lower face (yellow arrow in the photo).  The following procedures would create a more ruggedly handsome face.
Cheek augmentation with silastic cheek implants to add angularity to the cheeks and mid face.  Liposuction can be combined to reduce any excess fat to further shape the cheeks and face.  The red arrow is over the cheeks and this tissue is the only part that will be affected.  The yellow area is in the lower face, in an area where "jowls" form.  This is well below the cheek bone and will not be affected by cheek implants.
Chin augmentation, using a chin implant, to add projection to the chin creating harmony and balance to the lower face.  I have performed many facial shaping procedures, including Chin Augmentation with dermal fillers or silastic chin implants, for over 30 years.  When the chin is weak, this creates an imbalance making the nose appear larger, the mid face top heavy, the lower face looks short, de-emphasizes the lips and allows early formation of a "double chin".  Proper placement of a silastic chin implant adds forward projection to the chin thereby creating harmony and balance to the lower face.  Using the same incision, liposuction can be performed to reduce the fat and further shape the neck.  Excess skin, from below the chin, can also be removed through the same incision.  I have found that placement of a silastic chin implant, through a small curved incision under the chin (also allows excess skin removal) to be very safe, quick, highly effective and far less invasive than a sliding genioplasty (requires extensive tissue dissection, bone cuts and placement of metal screws and plates to secure the cut bone segments).  I perform chin implant surgery in 30 minutes or less, often using a local anesthetic alone.  In my opinion, you are a good candidate for chin implant surgery.  
Augmentation of the mandibular angles using a dermal filler (jaw implants have too many unwanted side effects IMHO) to add volume, angularity and flare to the jaw line. Cheek implants can be placed using several different approaches but using a small incision on the inside of the mouth remains the "gold standard" and most accepted manner of placement.  This technique places the silastic "cheek implant" on the cheek bone itself below the tissue covering of the bone in what is called an "implant pocket or space".  The tissues are closed in layers from the inside outward and a double water tight closure is done along the incision line. 
 I have placed silastic cheek implants for 30 years in military, SWAT, LE, professional fighters, as well as actors and many regular people who are active.  When placed below the covering of the bone and when the layers of the cheek are closed from the inside out, there is no need for fixation screws or sutures in my humble opinion.  I do ask that all my cheek implant and chin implant patients sleep on a U-shaped pillow for 1 month following the surgery.  In addition, I have had the opportunity on numerous occasions to replace silastic cheek implants (placed by others) that had been screwed into the cheek bone.  During the replacement it was evident that the metal screws pushed right through the soft implant as it was tightened down on the hard cheek bone.  Which makes perfect sense.  So in the long run, these fixation methods alone are no guarantee that the implant won't move.  Proper placement, proper implant pocket creation and meticulous closure of all the tissues layers is what is required in my humble opinion.  the cheek implant sits beneath the periosteum covering of the bone with all of the facial tissues above.
 In contrast, a sub-malar cheek implant is as the name applies placed below the cheek bone thereby being incapable of actually changing the shape of the cheek bone itself and since the implant isn't placed below the periosteum, the implant must be sutured to the tissues themselves which is why I do not use or recommend sub-malar cheek implants.  
 Hope this helps.

Paul J. LoVerme, MD, FACS (retired) · Answer

Danny 
You have a pretty good understanding of the effects of fillers vs implants. While both of these options will improve your problem to some extent, neither one will really lift the area by the yellow arrow.  If you like the way it looks when you push up your cheek, why not do just that? A mid facelift with an Endocrine will release the attachments to the bone and allow the soft tissues to “slide” up over the malar (cheek) bone. It is held in place by the Endotine. The device absorbs over a 6 month period at which point the soft tissues have healed in their new position. This avoids an implant and uses your own tissue to accomplish your goal.

Oleh Slupchynskyj, MD, FACS (retired) · Answer

Hi,Cheek implants will push out the red arrow and will enhance upper cheek. This should make the yellow arrow less prominent but it will not push up yellow arrow.Best,Dr.S.

Does a cheek implant push the muscles and fat pads upward so that these structures now "sit on top of" the new implant?

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