Filling out hollow cheeks
Difference between adolescent and adult cheeks
Adolescent cheek fullness is the “apple cheek” or “plum cheek” where the fullness is more medial and inferior as seen here.
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Adult cheek fullness is the fullness which is higher and more lateral, giving a wider midface and narrower lower face which gives us a more elegant look.
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Over time, we all lose collagen in the skin, our elastin ages and our deeper fat pads thin out. This change is visible even in our third and fourth decades. The cheeks lose some of the round contour. Those of us with low body weight may notice hollowing in their cheeks in their 40s. Some see the hollowing more in their temples or in the area right in front of their ears. In any event, if you treat hollow cheeks before they get too severe, you can help to correct the gauntness that comes with hollowing of the cheeks.
The “apple cheeks” of pre-adolescence that gives us the youthful look are different from the cheeks of maturity. The “apple cheeks” are full below the malar eminence, whilst in mature, attractive, adult faces, the fullness is higher and more laterally. This is an important anatomical and physiological difference that is usually missed by injectors who inject by the numbers. Without a proper study of anatomy and physiology, male and female differences, and changes of maturation, these subtleties are ignored, to the detriment of results. In the adult face, it is important to create a fullness over the malar eminence and zygomatic arch. In men it should be more medial an in ladies, higher and more lateral. Again, this distribution of fullness also varies according to race, age, associated facial changes, skin type and other factors.
The “apple cheeks” of pre-adolescence that gives us the youthful look are different from the cheeks of maturity. The “apple cheeks” are full below the malar eminence, whilst in mature, attractive, adult faces, the fullness is higher and more laterally. This is an important anatomical and physiological difference that is usually missed by injectors who inject by the numbers. Without a proper study of anatomy and physiology, male and female differences, and changes of maturation, these subtleties are ignored, to the detriment of results. In the adult face, it is important to create a fullness over the malar eminence and zygomatic arch. In men it should be more medial an in ladies, higher and more lateral. Again, this distribution of fullness also varies according to race, age, associated facial changes, skin type and other factors.
"Well, the last time I had a picture taken I could hardly see my eyes because of the weight of heavy eyelid. Then I paid attention to how I was actually using my eyes and I really noticed when I was looking at anything especially the computer I was straining my forehead to see better. Since I have had it done I no longer have to lift the forehead and tilt my head to see. It is amazing! I love..." D. Rock 63 Yrs Old with Fat Droopy Eyes - Salt Lake City, UT
Non-surgical options for cheeks: different types of fillers
options and indications
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Non-surgical options of giving cheeks their volume and structure back are several. An early material which has worked well is Sculptra. You may need two to four treatments approximately 4 to 8 weeks apart. They take about 4-9 months to stimulate your body’s natural collagen production to reduce some of the hollowness, but the results can be very good. Sculptra is very natural, and it can give a long-lasting correction to hollow cheeks that requires maintenance only once a year after your initial series of injections.
Juvederm Ultra Plus and Perlane, the hyaluronic fillers, are also good for filling in hollow cheeks. They will not promote the growth of significant natural collagen, unlike Sculptra, and you will need to repeat the treatments every 4 to 9 months. However, they give excellent results and are less costly than Sculptra. Radiesse is an excellent material when one wants to give volume and create a defined cheek mound and zygomatic arch eminence. It can be moulded into position and gives what I call the model’s cheek bone with a slight hollow just below the created fullness of the zygomatic arch. This also makes the lower part of the face look leaner and more attractive. When combined with treatment of the nasolabial and melolabial folds and smoothing out the jaw line, Radiesee is a powerful filler that makes the biggest difference of all the fillers we use. It can be combined with restylane for the grooves in the lower eyelids and to give lips volume. One other option for filling in hollow cheeks is fat transfer. We always perform fat transfers when carrying out surgical procedures such as facelifts, the Hammock Lift, cheek lifts, etc. Indeed, it is best to combine fat grafting with a surgical procedure as that allows us to reposition ptotic (droopy) tissues and then use the fat to give the fullness needed to give shape and definition. |
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non-surgical options for Sagging cheeks: Combination of fillers and radiofrequency
Radiofrequency treatments, when repeated, will give, over time, a nice tightening of cheek tissues
Sun damage and age tend to naturally weaken the elastic and collagen fibers under the surface of our skin. In the cheek area, this becomes noticeable as “sagging skin”.
The three non-surgical options to correct sagging cheeks are Radiofrequency treatments like Accent and Thermage, Sculptra, and the heavier-weight fillers, which are Juvéderm Ultra Plus and Perlane.
Radio-frequency skin tightening treatments are administered every few weeks over several months. The energy penetrates several millimetres belowthe skin surface, causing tightening of collagen and gives a secondary thickening of the skin. The tightening of the skin is noticeable but not dramatic. We often use this modality to maintain the result of facelifts long-term. It is ideal for maintenance of surgically firmed facial skin and deeper tissues with appropriate surgery. When radio-frequency treatments are used in isolation, it works best if the sagging in your cheeks is mild to moderate and you are under 55.
Sculptra is also a good option in that it adds volume in the upper cheek area which helps dilute the sagging. You may need two to four treatments approximately 4 to 8 weeks apart. The results are good to excellent, and, as with radio-frequency treatments, take approximately 6 months to show, primarily because the Sculptra stimulates your body’s natural collagen production.
A more short-term fix for sagging cheeks is to use the heavier molecular weight of the hyaluronic acid fillers. The trade names for these are Juvéderm Ultra Plus and Perlane. These will give immediate results but will not build collagen. They must be repeated every 4 to 9 months.
The three non-surgical options to correct sagging cheeks are Radiofrequency treatments like Accent and Thermage, Sculptra, and the heavier-weight fillers, which are Juvéderm Ultra Plus and Perlane.
Radio-frequency skin tightening treatments are administered every few weeks over several months. The energy penetrates several millimetres belowthe skin surface, causing tightening of collagen and gives a secondary thickening of the skin. The tightening of the skin is noticeable but not dramatic. We often use this modality to maintain the result of facelifts long-term. It is ideal for maintenance of surgically firmed facial skin and deeper tissues with appropriate surgery. When radio-frequency treatments are used in isolation, it works best if the sagging in your cheeks is mild to moderate and you are under 55.
Sculptra is also a good option in that it adds volume in the upper cheek area which helps dilute the sagging. You may need two to four treatments approximately 4 to 8 weeks apart. The results are good to excellent, and, as with radio-frequency treatments, take approximately 6 months to show, primarily because the Sculptra stimulates your body’s natural collagen production.
A more short-term fix for sagging cheeks is to use the heavier molecular weight of the hyaluronic acid fillers. The trade names for these are Juvéderm Ultra Plus and Perlane. These will give immediate results but will not build collagen. They must be repeated every 4 to 9 months.
"I had a excellent eye lift done by Dr. Patel. He knows what he is doing and is very pleasant. Dr.Patel was easy to get an appointment and he works with you. The office staff was very pleasant and made you feel calm." D. Gull Highly recommended for eye lift surgery - Salt Lake City, UT
Defining and restoring cheekbones
Three main reasons for redefining cheekbones include:
The nonsurgical options to define cheekbones are the hyaluronic acid fillers, Restylane and Juvéderm, or Sculptra or Radiesse. Some of my younger patients generally want to get cheekbones that have just a bit more definition. For them, I recommend Restylane/Juvéderm as the most cost-effective solution but Radiesse is also very effective. Radiesse is a filler composed of calcium, hydroxylapatite crystals, a naturally occurring substance similar to cartilage. Radiesse can result in an immediate and long-lasting correction that can last for even 12 to 15 months. With one or two syringes of one of the hyaluronic acids that will last 6 months or more, they can get a nice result. For my older patients, I use the thicker, higher molecular weight forms, called Juvéderm Ultra Plus or Perlane or Radiesse.
Sculptra is more expensive up front—the initial series of injections can run $2,000 to $6,000 for the cheekbones depending on your age and how much filling is needed—but Sculptra lasts much longer than the hyaluronic acid fillers, which means you need less maintenance treatments down the road. Sculptra also stays more even throughout the whole cheekbone area, whereas Restylane and Juvéderm gradually “deflate.”
And lastly, Sculptra improves skin texture and color through its building of natural collagen. Sculptra can be temporarily lumpy or uneven in the hands of an inexperienced injector, so find someone who knows what they are doing. Sculptra also takes about 6 months to achieve the desired result.
- . The area is flattening with age.
- . The cheekbones are becoming bony or gaunt looking.
- . The skin over the cheekbones is sagging.
The nonsurgical options to define cheekbones are the hyaluronic acid fillers, Restylane and Juvéderm, or Sculptra or Radiesse. Some of my younger patients generally want to get cheekbones that have just a bit more definition. For them, I recommend Restylane/Juvéderm as the most cost-effective solution but Radiesse is also very effective. Radiesse is a filler composed of calcium, hydroxylapatite crystals, a naturally occurring substance similar to cartilage. Radiesse can result in an immediate and long-lasting correction that can last for even 12 to 15 months. With one or two syringes of one of the hyaluronic acids that will last 6 months or more, they can get a nice result. For my older patients, I use the thicker, higher molecular weight forms, called Juvéderm Ultra Plus or Perlane or Radiesse.
Sculptra is more expensive up front—the initial series of injections can run $2,000 to $6,000 for the cheekbones depending on your age and how much filling is needed—but Sculptra lasts much longer than the hyaluronic acid fillers, which means you need less maintenance treatments down the road. Sculptra also stays more even throughout the whole cheekbone area, whereas Restylane and Juvéderm gradually “deflate.”
And lastly, Sculptra improves skin texture and color through its building of natural collagen. Sculptra can be temporarily lumpy or uneven in the hands of an inexperienced injector, so find someone who knows what they are doing. Sculptra also takes about 6 months to achieve the desired result.
Wrinkles on the cheeks: A combination of smile lines and cheek lines
TCA peels can give a nice improvement in the texture and fine lines of the face.
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There is no single, great, non-surgical option that can eliminate cheek wrinkles. Even combining different treatments that I will give you below, you can realistically expect a 40 to 80% improvement in cheek wrinkles.
The least expensive treatment option is a TCA chemical peel for wrinkles. This is a chemical peel that should be done only by a physician who knows skin physiology and anatomy and skin types. But, it can give a good result with a series of three to five peels. |
If the TCA peel does not give you the results you want, then you will need a laser treatment for your wrinkles. The most promising development here is the fractional lasers, and they have produced some good results for cheek wrinkles. You will probably need a series of three to five treatments. The treatments take place over about 6 months and require maintenance once every year or two.
Various fractional lasers are now available and give excellent results. Depending up the type of laser used (erbium, CO2, etc) and the settings, the down-time can be tailored to the needs of the patient. The most aggressive fractionated lasers like Active FX and Deep FX CO2 lasers give the best long-term results, but also have longer down time.
Radiofreqency lasers penetrate and heat collagen deep to the epidermis, resulting in improving skin thickness as well as showing improvements in the wrinkles. These lasers do not actually lift tissues, so be careful of what your aim is. These radiofrequency treatments are repeated once a months over several treatments. Over 6 months or more, you should notice a stimulation in the production of collagen which will help to reduce some of the cheek wrinkles and restore a little bit of glow to your cheeks.
Carbon dioxide resurfacing laser for wrinkles is the gold standard but carry risks of scars or pigment changes if the correct parameters are not used. Plan on 2 weeks in the house and several weekness of pink to red after that. The red can last much longer in some patients. Still, if you have a lot of wrinkles and a good laser surgeon, a very nice result can be obtained in one treatment.
Fractional lasers are attempting to provide the same result but with less downtime and in a series of three to five treatments.
Various fractional lasers are now available and give excellent results. Depending up the type of laser used (erbium, CO2, etc) and the settings, the down-time can be tailored to the needs of the patient. The most aggressive fractionated lasers like Active FX and Deep FX CO2 lasers give the best long-term results, but also have longer down time.
Radiofreqency lasers penetrate and heat collagen deep to the epidermis, resulting in improving skin thickness as well as showing improvements in the wrinkles. These lasers do not actually lift tissues, so be careful of what your aim is. These radiofrequency treatments are repeated once a months over several treatments. Over 6 months or more, you should notice a stimulation in the production of collagen which will help to reduce some of the cheek wrinkles and restore a little bit of glow to your cheeks.
Carbon dioxide resurfacing laser for wrinkles is the gold standard but carry risks of scars or pigment changes if the correct parameters are not used. Plan on 2 weeks in the house and several weekness of pink to red after that. The red can last much longer in some patients. Still, if you have a lot of wrinkles and a good laser surgeon, a very nice result can be obtained in one treatment.
Fractional lasers are attempting to provide the same result but with less downtime and in a series of three to five treatments.
Redness and dilated or broken blood vessels on cheeks and face
Having redness or broken blood vessels on your cheeks does not necessarily mean that you are an alcoholic, contrary to popular myth. Often people with Celt genes develop redness or even broken blood vessels on and around the cheeks or nose. This can be caused by rosacea, sun damage, or even some systemic diseases, like lupus. You will need a doctor to help you figure out the cause of your redness. If redness is due to rosacea, the first step is to look at lifestyle changes, like diet and exercise.
If the redness is due to sun damage, or you have rosacea that is under control, you may want to consider IPL/photorejuvenation laser treatments to reduce the redness. These treatments are administered once a month over five treatments. The results are excellent. Many patients will have their faces treated first, followed by similar treatments to the neck and chest. These treatments can also be used on hands, arms and legs. You’ll need maintenance treatments once or twice a year.
If the redness is due to sun damage, or you have rosacea that is under control, you may want to consider IPL/photorejuvenation laser treatments to reduce the redness. These treatments are administered once a month over five treatments. The results are excellent. Many patients will have their faces treated first, followed by similar treatments to the neck and chest. These treatments can also be used on hands, arms and legs. You’ll need maintenance treatments once or twice a year.
Brown spots from age and sun damage on cheeks and face
Brown spots are essentially caused by sun damage. Many of us get freckles when we are younger, but as we age they get larger and often darker. We would examine the spots carefully to ensure none of them look suspicious.
The first thing to do about brown spots and age spots is to prevent more of them by applying sunscreen daily. Make sure you use a broad spectrum sunscreen that protects you from UVA radiation by having at least 5-10% zinc or titanium or 3% mexoryl.
You can also try over-the-counter “bleaching” creams if your age spots are localized or not too bad. “Bleaching” creams do not really bleach but they do temporarily decrease the production of brown pigment in your skin. Drugstore bleaching creams contain 2% hydroquinone and are not very effective. They generally cost under $50.
Keep in mind that continued sun exposure will stimulate the growth of brown spots, so bleaching creams will not protect you against the regrowth of brown spots or the development of new spots on your cheeks and face. Only sunscreen can do that.
Prescription bleaching creams all contain 4% hydroquinone plus or minus other ingredients like hydroxy acids, sunscreens, or tretinoin. These prescription strength creams are more effective but still temporary. For some patients who are allergic or don’t want to use hydroquinones, I have also used plant-based bleaching creams. These ingredients are ones like arbutin, thymol, and kojic acid. They seem to be less effective than the prescription creams.
Microdermabrasion and light peels are also options for mild to moderate brown spots. A good aesthetician can perform microdermabrasion or a low-strength peel, and these can often give good results, but need to be done in a series, usually to 3-6, to be effective.
A medium peel, like a TCA peel, can also give good to excellent results but should be done by an experienced surgeon. The most effective treatment option for brown spots is a series of laser treatment. This is also, unfortunately, the most expensive.
The first thing to do about brown spots and age spots is to prevent more of them by applying sunscreen daily. Make sure you use a broad spectrum sunscreen that protects you from UVA radiation by having at least 5-10% zinc or titanium or 3% mexoryl.
You can also try over-the-counter “bleaching” creams if your age spots are localized or not too bad. “Bleaching” creams do not really bleach but they do temporarily decrease the production of brown pigment in your skin. Drugstore bleaching creams contain 2% hydroquinone and are not very effective. They generally cost under $50.
Keep in mind that continued sun exposure will stimulate the growth of brown spots, so bleaching creams will not protect you against the regrowth of brown spots or the development of new spots on your cheeks and face. Only sunscreen can do that.
Prescription bleaching creams all contain 4% hydroquinone plus or minus other ingredients like hydroxy acids, sunscreens, or tretinoin. These prescription strength creams are more effective but still temporary. For some patients who are allergic or don’t want to use hydroquinones, I have also used plant-based bleaching creams. These ingredients are ones like arbutin, thymol, and kojic acid. They seem to be less effective than the prescription creams.
Microdermabrasion and light peels are also options for mild to moderate brown spots. A good aesthetician can perform microdermabrasion or a low-strength peel, and these can often give good results, but need to be done in a series, usually to 3-6, to be effective.
A medium peel, like a TCA peel, can also give good to excellent results but should be done by an experienced surgeon. The most effective treatment option for brown spots is a series of laser treatment. This is also, unfortunately, the most expensive.
Advanced Photofacial treatments, where we use a number of different wavelengths to treat the brown spots (and vessels and red spots) will usually give excellent results. A series of five treatments performed once a month are necessary. Most patients will look for an improvement not only in the brown spots, but also with broken vessels, red cheeks and telangiectasias. These treatments, when administered using different wavelengths, will stimulate some mild collagen growth, and add to your skin’s glow. You will need maintenance treatments when brown spots reappear, usually once or twice a year.
The fractional lasers are newer and are one of the best options if you also have wrinkles or acne scarring. Many clinics, including ours, are reporting excellent results. These fractional lasers vary from those that have minimal down time of about two days (erbium and Fraxel lasers fall into this category), to more aggressive fractional lasers like Active FX and Deep FX which have a 4 – 8 day downtime. The results develop over a few months as the collagen builds up.
Brown spots or splotches due to melasma on cheeks and face
If you have larger splotches of brown spots that appear on the cheeks, jaw line, upper lip, or forehead they may be due to melasma from pregnancy, oral contraceptives or other hormones. If you think you might have melasma, you should be examined before you start any over-the-counter treatments as many treatments can make melisma worse. Melasma is a difficult condition to treat effectively. Aggressive treatments like lasers will invariably make melisma worse. A combination of superficial gentle peels, hydroquinone cream treatment and fractional lasers can help improve, if not cure this annoying condition.
Lumps, bumps, and moles on cheeks and face
Lumps and bumps can be removed with lasers and with surgical resection and repair. As plastic surgeons, we design the removal to give you the least amount of scarring. If any of the lesions look suspicious, we always submit them for histopathological assessment.
Frequently Asked Questions
Where will my procedure be performed and what kind of anesthesia will be used?
Even full face resurfacing can be performed in our surgical suite without general or sedation anesthesia. We prescribe the appropriate medication to be taken about an hour before your procedure. With more localized areas, topical anesthesia and local injection blocks work very well. For example, when treating the “lip lines” and the mouth area, a dental block is administered. Similar local anesthetic injections can be administered for lower eyelids, forehead, etc.
Some patients prefer to undergo sedation when having a full-face resurfacing or laser to the neck and chest areas.
Some patients prefer to undergo sedation when having a full-face resurfacing or laser to the neck and chest areas.
What other procedures are usually done or requested with skin resurfacing?
Lasers and fillers work beautifully together, giving an improvement in lines and deeper grooves. Lip fillers give shape to the lips and fillers to the nasolabial and melolabial folds give less sharper edges to these natural grooves, giving us a more relaxed and less aged appearance.
Skin resurfacing is also done at the same time as surgical procedures like brow lifts, upper and lower blepharoplasty, face and neck lifts, fat grafts, liposuction, etc.
Skin resurfacing is also done at the same time as surgical procedures like brow lifts, upper and lower blepharoplasty, face and neck lifts, fat grafts, liposuction, etc.
How long does resurfacing the full face take?
Preparation, applying anesthesia, cleansing, sterilizing, lasering and applying the appropriate lotions on the face take 30 to 40 minutes.
How much bruising and swelling will I have?
Besides redness (which has been addressed above), the lasered areas always swell as this is a controlled injury to the skin. Ice will help reduce the swelling. Bruising is less of an issue than the redness and pinkness related to the type of laser used.
How painful is the face after skin resurfacing?
You will need to use prescription pain medication for about one to two days after the more aggressive types of fractionated skin resurfacing. Thereafter, the skin is sensitive but you will not need strong pain medication. When erbium or more gentle fractionated laser treatments are administered, there will be less need for oral pain medication. The healing is quicker, but the results are also more moderate.
How much bruising and swelling will I have?How do I look after my skin before and after Laser Skin Resurfacing?
- Depending upon your skin type and what the aims are, we may prescribe two facial creams for you to use for four to six weeks prior to your laser resurfacing.
- You will be prescribed an anti-viral agent, an antibiotic and a pain medication prior to your procedure. Please get these before your date of the procedure. Commence the antibiotic medication and the anti-viral medication on the morning of your procedure. The directions of use will be on the prescription bottle.
- Please remove all makeup prior to coming for your procedure. Do not wear false eyelashes, eye liner, foundation or blush: nothing!
- After your laser, we will apply a moisturizer to your skin. It is important for you to use a moisturizer (or Vaseline) four to five times a day to the lasered skin for the first week and then about two to three times a day. Any moisturizer will do: Eucern, Lubriderm and Aquaphor are examples of common moisturizers.
- Mix one teaspoon of kitchen vinegar in a glass of water and apply this mixture to the whole lasered area with a clean face cloth, four to five times a day: this helps to remove the exfoliating skin. After you have done this soak, apply the moisturizer.
- You can shower and get the face wet the morning after your laser. Many patients find that showering more than once a day and allowing warm (or cold!) water to run down the face helps with the exfoliation.
- As the skin heals, it may develop some scabbing and oozing: this is normal.
- The skin becomes itchy as it heals: the moisturizer helps as does over-the-counter Benadryl.
- After two weeks, you may apply Hydrocortisone 0.05% or 0.1% cream on the face once a day: this will help settle the pinkness down a little quicker.
- We encourage our patients to take a photograph and share it with us via e-mail if they are concerned about the healing. If necessary, we can always physically see and examine you but sending a photograph can save you a lot of time as in most instances, what the patient is experiencing is normal.
What are the most common risks of Laser Skin Resurfacing?
Persistent pinkness for a number of weeks: this is normal but can persist longer in some patients.
Viral or bacterial infection.
Delayed healing.
Results not what you expected: this is where a careful assessment and choosing of the depth of treatment is important. In some instances, repeating the laser helps improve the results.
Loss of pigment: this was more common when CO2 lasers were applied with multiple passes and at full strength. We now use more nuanced treatment levels, giving us nice results without noticeable loss of pigment.
Viral or bacterial infection.
Delayed healing.
Results not what you expected: this is where a careful assessment and choosing of the depth of treatment is important. In some instances, repeating the laser helps improve the results.
Loss of pigment: this was more common when CO2 lasers were applied with multiple passes and at full strength. We now use more nuanced treatment levels, giving us nice results without noticeable loss of pigment.
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