Should I get malar, submalar or combined cheek implants? (Photos)

Thank you for your question. You submitted several photos, asking if you should get a malar, submalar, or combined implant. You state you want something permanent, and don't want fillers. You describe your face has been aging, and your nose is looking more prominent. Your goal is to have a more youthful, rounder look, not chiseled, but it has to look natural with your thin face.
I can share with you some basic concepts of how a surgeon determines what kind of implant is appropriate for a patient, as well as what I think is important that maybe has not been fully discussed with you yet. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. Helping patients like yourself with facial aging changes through different surgical and non-surgical approaches have been the core of my career for the past 20 years. I can share with you a bit of the evolution of my thinking, and an approach I think will be relevant to your situation.
Part of the challenge is that you are dealing with results of facial aging which are progressive, yet you want something permanent. Understand that facial aging from a global perspective, what you’re mostly experiencing at this point, is partly relative diminishing of bone volume, so it stands to reason that placement of an implant will make sense.
To distinguish the difference between a malar, submalar, and a combined implant: the malar implant is aiming towards increasing the projection of the cheekbone prominence, or area called the malar eminence; the submalar implant fills that area below the cheek called the submalar area; and when you combine the two, you get an implant that does both.
The challenge in your situation is how can an implant be placed that will not look so chiseled, and look rounded and harmonious with your face. From a surgeon’s perspective, there is a leaning to be more conservative because for a thin face, you’re going to avoid that disproportionality which can appear chiseled. The surgeon will lean towards placing a smaller sized implant regardless of whether it’s a submalar or combined implant. If you were to do only a malar implant, the resulting chiseled look would be accentuating the thinness of your face.
Dealing with this type of challenge has become different in my practice based in the introduction of several things. One is the use of long lasting fillers such as Juvederm Ultra Plus and Juvederm Voluma, which are used in a technique called Structural Volumizing. Structural Volumizing allows me with my surgical background and surgical knowledge to make corrections of these areas of deficit in a person’s face, not only in the cheek area, but in other areas such as the chin and the jaw angle. If you want a more softer look overall, then I recognize the resistance of wanting to do fillers with some regularity. Patients frequently ask about doing something permanent, but recognizing that aging changes are not only bone loss, but muscle, fat, soft tissue, and that the skin gets thinner with time, then there’s a challenge with putting an implant when the soft tissue overlying that implant is going to continue to thin. This is an issue that is discussed before doing an implant placement.
With Structural Volumizing, I’ve been able to place these long lasting fillers in a way where I can control and can compensate for asymmetries, and place volume in multiple areas. Often when I show a patient a before and after of a Structural Volumizing patient, I further explain to get a similar result with implants, I would have to place a cheek implant, a chin implant, and a jaw angle implant, which is considerably a lot more surgery. Further, because I can control the amount and volume of placement, it really makes this an ideal approach. More people are comfortable with the placement of long lasting fillers than doing a surgery, and taking the risk they’ll still need filler afterwards. This is an important point because when you have a facial implant, it only addresses a limited area, though it is an important area. An implant will help you look better, but when you look at your face, you want to look at the balance and harmony that are very important to look youthful, and there are many elements to that.
It is important as you do your consultations to get a realistic understanding of what the outcome will be. The last thing you want is to go into the surgery with this expectation that this will be the definitive procedure that will bring harmony to your face, and then still do fillers afterwards, so it’s important, which is what I tell my facelift patients. When patients come and say, “I want to get a facelift so I can look young for a long time,” I say that a facelift will help you restore the position of the cheek, improve the jawline, and the neck, but it doesn’t displace the need for fillers. Understand that facial aging is volume loss and descent, so you want to address all those elements to get balance and harmony.
It has become my practice, even though I am a surgeon and love doing surgery, to guide my patients based on the tools and the outcomes I feel are exceptional using Structural Volumizing. In the course of no more than 30 mins, this procedure can replace what I used to do with surgery. It’s not the case for every patient, but there are a lot of people in our practice who choose that option. The fact these fillers can last for 2 years makes it fairly easy to do.
Often people need fillers in other areas. Facial aging is not limited to the area that bothers you. People want volume in their lips, in the more superficial lines, and other areas. We have a wide range of fillers and different techniques to deliver those fillers to get a look that is customizable in real-time, which is important to consider as you’re making your decision, and strategizing in dealing with your facial aging changes. I hope that was helpful, I wish you the best of luck and thank you for your question.

I would recommend just a malar implant for you.  Your submalar area appears fairly full to me as it is.  The best advice could be given after examining you in person though.  

Hello and thank you for your question. Based on your
photograph, you are a great candidate for malar enhancement.  This can be
done in one of two ways.  Voluma is an injectable filler which can be
injected into the malar region as a temporary filler.  Malar implants can
be placed as a permanent way to gain volume in the cheek.  I always use
medpor implants with screw fixation.  Silicone malar implants tend to
have a high rate of malrotation over time.  The most important
aspect is to find a surgeon you are comfortable with. I recommend that you seek
consultation with a qualified board-certified plastic surgeon who can evaluate
you in person.
Best wishes and good luck.
Richard G. Reish, M.D.  FACS
Harvard-trained plastic surgeon