Cheek implants

The cheekbone is the high point of the midface. When it is under-projected, the face can look tired or narrow even when the skin is good and the weight is stable. People often describe this as flat cheeks, a face that disappears in photographs from three-quarter view, or a midface that does not hold its own against the nose and the chin.

It helps to separate three different things that all get called “cheeks”:

• The bony prominence of the zygoma and malar eminence — the structure an implant is designed to change.

• The soft volume of the midface over and below that bone — fillers and fat transfer work here.

• The deeper fullness of the central cheek — buccal fat — which is a reduction problem when it is excessive, not an implant problem.

Mixing those up is how faces end up overfilled or still flat. An implant does not slim a heavy central cheek. Filler stacked on a deficient skeleton can look round rather than structured. Buccal fat reduction on a face that already lacks malar projection can make the midface look more hollow, not more defined.

Facial asymmetry is part of normal anatomy. The two cheekbones are never identical in height or projection. A degree of improvement is usually possible as part of cheek enhancement. Complete symmetry is not.

In our practice the consultation includes 3D capture and simulation. That lets us measure the target projection, compare implant sizes and positions, and look at the face from the front, the profile and the obliques — the views in which cheekbones either work or fail.

The same images show how much of an existing asymmetry is worth correcting. Trying to erase every millimetre of difference usually produces a result that looks less like the person, not more balanced. We agree the direction and the amount of change; we do not treat the render as a guarantee.

The simulation also helps decide whether an implant is the right tool at all. If the skeleton is already adequate and the complaint is soft-tissue descent or central fullness, the conversation moves to a facelift, fat transfer or buccal fat reduction rather than adding a block of projection the face does not need.

Volume augmentation with injectable fillers is a good option when the change wanted is modest, when someone wants to test a shape before committing to an implant, or when the deficit is more soft tissue than bone. Fillers do not give the same firm support under the skin that a well-placed implant does. They also need repeating.

Fat transfer can build midface volume and soften transitions. It is a different operation from an implant: it changes the soft envelope, not the skeletal platform. It is often the better choice when the bone is already reasonable and the face has lost fullness with age. It is sometimes used together with an implant, or later if a large implant is ever removed and the soft tissues have changed.

For a more significant and lasting change in cheekbone projection, implants remain the more direct method. They sit on the bone and give the soft tissues something stable to drape over. That is why the result can look more natural than a large volume of filler trying to do a skeletal job.

Silicone and Medpor (porous polyethylene) are both usable for this operation. In our practice I have a personal preference for Medpor. That is a preference, not an argument that one material is required and the other is not.

Whatever the material, the implant still has to be contoured to match the individual characteristics of the cheekbone — the height of the eminence, the width across the face, and the difference already present between the two sides. A stock shape that is not adjusted is how cheeks look implanted rather than like the person.

Taking out a very large implant, or one that has been present for a long time while the face has also aged, can leave a deflated midface. If removal is ever being considered, it is often better planned with fat transfer or a lift than as an isolated extraction.

The surgery is carried out through the inside of the mouth, so there is no skin scar on the cheek. A pocket is developed over the cheekbone. The implant is contoured to the plan and seated in that pocket.

I do not usually fix cheek implants with titanium screws. Medpor does not have a tendency to glide against the soft tissues, so once it is seated it self-stabilises. The work that matters is the contouring and the position, not a screw holding it there.

It is done under general anaesthetic or sedation, most commonly general anaesthetic in our practice. On its own the operation takes approximately one hour and is typically a day-case procedure.

The first week afterwards is organised around protecting those intra-oral incisions: a soft diet, mouthwash, and no chewing that pulls on the suture line. That is not an optional extra. Wound breakdown inside the mouth is how an implant becomes exposed.

Cheekbones are read against the eyes, the nose, the chin and the jawline. Lower eyelid surgery is planned in relation to the shape of the cheek and cheekbones, not in isolation. A chin that sits back, or a nose that is already strong, changes how much malar projection looks balanced rather than theatrical.

Combinations that come up often:

• Chin enhancement — when the lower third is also under-projected, so the profile is built at both ends rather than overworking one.

• Rhinoplasty — possible in the same sitting; midface swelling can last longer when the two are combined.

• Buccal fat reduction — when the central cheek is heavy and the bone is flat; they treat different layers and should not be used as substitutes for each other.

• Fat transfer — for the soft envelope around a skeletal change, or as the primary volume method when an implant is not the right tool.

• Facelift or short-scar facelift — when the midface has descended as well as lacking projection. An implant does not lift descended soft tissue.

Significant reduction of an over-projected or very wide cheekbone is a different operation. Small contour smoothing can be discussed here. Formal zygomatic reduction belongs with a maxillofacial or craniofacial colleague.

Expect swelling and bruising in the midface. Sleeping propped up on two or three pillows for the first week helps. The visible bruising usually settles over seven to ten days. A return to desk work in that same window is typical; it is not a promise that the face will look unoperated at day seven.

A soft diet for one week protects the incisions inside the mouth — soups, yoghurt, mashed food, anything that does not need real chewing. Dissolvable stitches are used in the mouth. Mouthwash several times a day keeps the suture line clear. If the upper lip or the side of the nose is numb, hot drinks are a bad idea until that feeling returns.

Strenuous exercise and anything that drives the blood pressure up should wait for three weeks. The face can feel tight, and smiling or opening the mouth widely can be uncomfortable early on. Most of the swelling has gone by six weeks; finer settling continues after that.

Numbness in the front of the cheek, the side of the nose or the upper lip is possible. More often it is limited to the first two to three weeks. Lasting change in sensation is uncommon and is part of the consent discussion.

The consultation has to cover medical history and the medicines actually taken. Blood thinners raise the bleeding risk and need specific management around facial implant surgery. Raised blood pressure does the same. Both have to be known and planned for.

The risks that belong on this page rather than in a generic list are infection (uncommon, but an implant is a foreign body next to an intra-oral wound), wound breakdown if the soft diet is ignored, implant malposition, asymmetry that cannot be fully corrected, and temporary numbness in the infraorbital territory. Pain after this operation is usually modest.

Contact sport is not an automatic reason to refuse an implant, but it is a reason to be clear about the shape first — and often to try a temporary filler change before a permanent one, particularly in a younger face that is still settling.

Fees follow the plan: implant only, or implant with chin work, rhinoplasty, buccal fat reduction or a lift in the same sitting. A figure offered before that plan exists is rarely a useful one. Costs for combined procedures are typically lower than the same operations done separately, because the anaesthetic and facility time are shared.