Dr. Niamtu’s Weblog

….on cosmetic facial surgery

Simultaneous rejuvenation of the lower eyelids and the cheeks is a winning combination.

This image shows an actual surgery patient of Dr. Niamtu.  The aging midface (left) is rejuvenated by lower eyelid surgery and cheek implants (right).


Facial aging is an interesting multi factorial phenomenon.  Many things contribute to an aged midface including sun damage to skin, atrophic and gravitational changes to fat, muscle and bone.  Two of the biggest things that make us look old and tired occur in the lower eyelids and cheeks.

The lower eyelids can undergo aging changes as early as the third decade.  The skin becomes crinkly and sags, fat can protrude from around the eyeball and produce sausage shaped fat bags on the lower eyelids.  This protruding fat also causes a shadow from overhead light which contributes to the dreaded “dark circles” under the lower lids.  In addition, due to the aforementioned changes, the “tear trough” (technically the nasojugal groove) becomes accentuated.  This produces a deep grove under the eye from the side of the nose across the cheek.

Extremely related to midface aging is volume loss in the midface.  Young patients have full, plump and rounded cheeks.  This good fat in good places produces a smooth, continuous contour under the eyes and around the cheeks.  Gravitational and atrophic aging changes causes volume loss in the cheeks and gives us a drawn, gaunt and hollow appearance.  This is also very related to the lower eyelid aging as the lower lids are the upper cheeks.  The combination of aging produce an old and tired look and the only means to address this aging comprehensively is to address both the lower eyelids and cheeks at the same time.  I find it rare that patients with lower eyelid aging don’t need attention to the cheeks (midface).  I would say that 95% of my lower lid patients that are over 40 would benefit from simultaneous midface augmentation.  Fortunately, many of these patients understand this and combing procedures.

My approach to the healthy lower lid is pretty simple.  I remove conservative fat with a laser incision from the inside of the lid (transconjunctival blepharoplasty).  This means no external scar and no bleeding due to the laser.  No bleeding means faster surgery and recovery with less bruising and pain.  I am always very careful to only recontour the excess fat as not to produce further volume loss.  The second step of lower eyelid rejuvenation is addressing the aging skin of the lower lids.  Although some surgeons still cut off lower eyelid skin, I think that is a bad idea.  It only stretches the skin; it does nothing for rejuvenating the skin.  The skin will return to its normal wrinkling in a short time.  More of a problem is the fact removing skin from the lower eyelid can also contribute to lower eyelid malposition.  Due to the scarring that can occur inside the lower lid, the eyelid can be pulled down which looks unnatural and can cause problems.

To truly rejuvenate the lower eyelid skin, it needs to be resurfaced.  I prefer CO2 laser resurfacing or chemical peeling.  These modalities actually remove wrinkles and brown spots and makes new, younger skin. That is truly rejuvenation!

Since the aging does not stop at the lower lid, this is an excellent time to also address the midface.  The patient is already sedated and will be taking a week off of work, so why not be comprehensive with the rejuvenation?   My most common method of augmenting the aging midface is the use of silicone cheek implants. (Click here to view a video about cheek implants and facial aging)There are many reasons that I like cheek implants.  Among them is the fact that they are inserted from the inside of the mouth so there is not visible scar.  They are held to the cheekbone with a micro screw, so they are permanent, but they can be changed or removed in 30 minutes if the patient desires.  Not many things in cosmetic surgery are permanent but reversible!

By placing cheek implants, the youthful contour of the midface is reestablished and many times the tear troughs and even the nasolabial folds are also improved.  Alternatively, the cheeks and tear troughs can be volumized with injectable fillers.  This is non-surgical and is also reversible.  The downside of midface filler augmentation is that it is a temporary fix.

Simultaneous rejuvenation of the lower eyelids and the cheeks is a winning combination.  If a patient seeks lower eyelid rejuvenation and the surgeon does not discuss the midface aging, a second opinion may be in order.

To find out more about cosmetic facial surgery by Dr. Joe Niamtu, III in Richmond, Virginia visit www.lovethatface.com


Joe Niamtu, III DMD

December 6, 2011 Posted by | cheek implants, Cosmetic Eyelid Surgery, Eyelid Surgery, minimally invasive facelift | , , , , , , , | 4 Comments

Cheek Implants: small surgery, big changes


Providing patients with a natural rejuvenation requires a firm understanding by the surgeon and the patient of all the areas of the face.  Brow and forehead lift are common surgical procedures used to improve the upper face.  Facelift and liposuction are used to rejuvenate the lower face.  Botox and fillers are used to enhance both the upper and lower face.  On huge problem that exists, even with experienced surgeons, is that the midface is often overlooked when performing facial rejuvenation.  Because of this, many patients end up looking tighter but not younger. The youthful face has abundant volume (fat) and it is in the right places.  It is also oval due to having more volume in the cheeks and a tight jaw line and neck.  With aging, we lose the oval shape and when the cheeks droop, the jowls form and the tissue around the jaw and neck sag, the face takes on a square appearance.  As we age, we go through a process of deflation (like the grape to the raisin) and we lose the good fat.  The youthful cheek fat (malar fat pads) undergoes atrophy and due to multiple causes sags into the lower face and becomes the jowls.  This leaves a hollow and gaunt appearance that is a common sign of middle age.  If you are over 40 years old, the chances are that you have lost some of your youthful midface volume.  Look in a mirror and smile.  Most of us look younger when we smile because we are artificially elevating our sagging tissues.  Smiling produces facial volume.  If you smile and hold your cheeks up, then relax your smile and let go of your cheeks, you will notice that elevated cheeks sink into the jowls of the lower face when you relax your smile. The above illustration shows that in order to look younger, we need volume in the midface.  There are numerous ways to augment the midface including midface lifting procedures, injectable fillers and cheek implants.  While all of these procedures are useful, cheek implants have numerous advantages.  First of all, they are permanent.  Since they sit under the deep tissue over the bone (periosteum) there is no where for them to go and the will sit in their original position for years.  This is especially true if they are secured with a micro fixation screw.  Midface lifts will sooner or later fall and injectable fat or fillers will sooner or latter dissolve.  Cheek implants will stay where they are placed!  Another huge advantage is that they are totally reversible.  It only takes about 10 minutes per side to place cheek implants and if the patient is unhappy with them, they can be removed with local anesthesia in several minutes.  Having the ability to reverse a procedure is a very big advantage and an unusual one in cosmetic facial surgery. Contemporary cheek implants (www.implantech.com) come in a vast array of sizes and shapes to give the surgeon and the patient many options in augmentation.  In fact there are so many possible choices of implants, it can become confusing.  In my practice, I use hundreds of facial implants.  I place them as a solitary procedure in younger patients and in conjunction with facelift and other procedures on a routine basis.  In reality, probably 80% of my cosmetic surgery patients are candidates for midface implants.  Getting the patient to realize this is sometimes difficult. To simplify the choice of cheek implants, I utilize three main implants.  The submalar implant is my most common choice.  This implant is designed to fill in the hollow area in the front of the face.  The submalar area is under the eye and the cheekbone.  If you look around, most people over 40 have some deficiency in this area.  These patients usually have normal cheek bones, but the area below them is hollow.  The submalar cheek implant fills out the deflated face without adding bulk to the cheekbones. The malar shell implant looks like a small calm shell and is used to produce the high cheekbone look.  This implant is designed for patients that have adequate fill in the submalar area but require more augmentation in the cheekbones on the side of the face.  This used to be a popular choice, but the over done, too high cheekbones look is out of style.  I personally only use the malar shell implant on patients that lack adequate fill in the cheekbone areas.  These patients require augmentation on the high portion and the side of the upper face. The second most common cheek implant that I use is the combined submalar shell implant.  This implant is basically a combination of the above two implants.  It provides the lower facial fill (like the submalar implant) but also provides augmentation on the cheek bones like the malar shell.  This implant is used on patients that either have developmental (hereditary) midfacial deficiency, or on patients that, through aging, have atrophy in this region. Cheek implants are placed through a ½ inch incision, inside the mouth, just above the eye tooth.  The implants can be placed with local anesthesia or light IV sedation.  The tissues over the cheek and cheek bone are lifted and the implant is placed on the cheek bone.  The implant is sometimes held in place with a micro fixation screw or a suture.  The entire procedure takes about 10 minutes on each side.  The patient will experience swelling, mild discomfort, and possibly temporary numbness for about 4-5 days.  Most patients are back to normal in about a week. Cheek implants are a great example of minimally invasive cosmetic facial surgery and also an example of a small procedure that can make a big difference.  In younger patients, those in their late 30’s and early 40’s,placing cheek implants as a solitary procedure can provide youthful reshaping of the midface.  The beautiful thing about this is that the change is a very subtle facial lift and although the patient looks better, no on can put their finger on why.  These implants provide a very natural look. To find out more about midface augmentation and cheek implants, click on www.lovethatface.com/cosmetic_facial_surgery_richmond_va/cheek_implant..html Joseph Niamtu, III DMD, FAACSCosmetic Facial Surgery

March 10, 2008 Posted by | cheek implants | , , , | 1 Comment