FILLING OUT HOLLOW CHEEKS
DIFFERENCE BETWEEN ADOLESCENT AND ADULT 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.
NON-SURGICAL OPTIONS FOR CHEEKS: DIFFERENT TYPES OF FILLERS OPTIONS AND INDICATIONS
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.
NON-SURGICAL OPTIONS FOR SAGGING CHEEKS: COMBINATION OF FILLERS AND RADIOFREQUENCY
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.
DEFINING AND RESTORING CHEEKBONES
Three main reasons for redefining cheekbones include:
- . 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
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.
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.
BROWN SPOTS FROM AGE AND SUN DAMAGE ON CHEEKS AND FACE
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.
REDNESS AND DILATED OR BROKEN BLOOD VESSELS ON CHEEKS AND FACE
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.
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.
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With a 3-D procedure, there are several layer of sutures, accurately placed to give the lifting, tightening and filling, without leaving any tell-tale pull-lines. Some are slow dissolving sutures, others are more permanent. The skin sutures are generally removed between 7 and 14 days.
Bleeding is not common as we pay close attention to proper hemostasis. On rare occasions, a small hematoma may collect.
Everyone will experience some numbness in the face: this resolves over weeks to months. This occurs because of the dissection of the face. This is not a complication.
Because of the dissection and repositioning of the tissues, it is common for there to be small differences in the smile between the right and left sides: this is usually only noticeable to the patient and to Dr. Patel! It recovers over a few weeks.
All faces have asymmetry and there will be some degree of asymmetry. This is to be expected.
Permanent weakness of nerves and muscles is rare.
The scars are usually very well hidden. However, some patients may have a tendency to cause hypertrophic scarring: in such cases, certain lasers and treatments will help. By-and-large, scars are rarely a problem. With Caucasian skin, pinkness of scars is to be expected for several weeks. With darker skin, some hyperpigmentation may occur.
In the first few days, everyone will experience some degree of dryness and blurry vision. You will also feel that your lids look a little tight on the outer corner where you will also feel some of the deeper sutures if you put your finger there: this is of no concern. The tightness and the bumps under the skin settle over a few weeks.
More serious complications which are very rare include excessive bleeding, hemorrhage and loss of vision.
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CONTACT DR. PATEL
Do you have questions or need more answers?
Dr. BCK Patel MD, FRCS
Salt Lake City, Utah 84106, USA
(801) 413-3599 (phone/text)
Dr. BCK Patel MD, FRCS
617 E Riverside Dr Suite 101
Saint George, UT 84790, USA