What can be done with saggy cheeks and jowls in late 20s? (photos)

Thank you for your question. You’re 29-years-old, asking if a facelift is a solution for you because of resultant jowling that occurred after having a permanent filler called Aquamid placed in your cheeks, which appeared to have descended. You also state you have some marks where the Aquamid was injected.

I can give you my perspectives on this type of issue with permanent fillers, and how to handle a situation like yours. 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. The challenges of so-called permanent fillers are something I have dealt with some degree, with significant amount of experience at different levels, depending on the severity of the symptoms of a person who had this type of problem.

Aquamid is described as a polyacrylamide hydrogel, which is a soft tissue filler that appears to have some advantages compared to other so-called permanent. I feel that soft tissue permanent fillers don’t have a role in what we do because the face and soft tissue change over time. I had situations where a person who got this done like yourself at a relatively young age, had exactly the same type of problem  you did. For example a man in his late 20s who got a silicone type of injection done in another country, and ended up going down to his jawline migrating, and eventually descending - I think the physical weight was the problem. I had to open up a flap of skin like a facelift to remove this material. This material became very rubbery and hard, and it’s almost impossible to take out everything. So it’s one thing to consider, maybe not now, but maybe in the future is excision of this material. As you get a little older, the facial volume will change, so you may want to observe how things change with time.

If it doesn’t appear you had any inflammatory reaction or infection, then you can consider a different option. I would discourage you from a facelift because lifting the skin at 29 or even in your early 30s is still a little premature, and you may not have enough skin to work with, or get enough impact from the lifting. Your situation is more about volume distribution than sagging and soft tissue stretching.

One way to consider in camouflaging your situation is a procedure like structural volumizing, which we do in our practice.What we’re doing is placing volume of a filler that can be reversed, such as in the hyaluronic acid family like Juvederm Ultra Plus or Juvederm Voluma.I would consider placing it along the cheekbones to create a natural-looking golden ratio balance of your face, so you actually look better than if the face is more squared off, which looks like more of a jowl. It is of course camouflaging, but it might be a good patch for the time being as you determine what to do as time goes on. If this material continues to descend causing other issues, then maybe a surgical procedure is worth considering. If you had this material in your skin for longer than a year, then the options ultimately end up becoming surgical. From my experience, which I’ve done for patients who come here from around the world who actually had material the body formed a reaction to (not Aquamid), it created these large nodules. Trying to remove this material placed all over the face required multiple surgeries to get that material out in the maximum way, to give this person a more natural appearance. It’s very difficult technically, and also difficult for the patient to go through. I would discourage you from using more permanent fillers in the future.

In our practice for the benefit of filling we use something that’s reversible. The hyaluronic acid family whether it’s in the Restylane family or Juvederm family, has a wide variety of different levels of thickness of fillers, so you can solve a lot of issues without having to resort to something permanent. People always want something permanent naturally, but in reality our bodies are not permanent - our faces change and things continue to evolve and shift.

I suggest considering a hyaluronic acid filler at the cheekbone level to give yourself a little balance. I would discourage you from any other procedures, whether it’s a laser or energy based devices as I’m not sure they’ll make much of an impact for you. The goal is to try to give you some balance, and minimize the amount of trouble you can get further into.

Find a doctor who you’ll be comfortable doing this type of technique. Again, structural volumizing is placing the material at the bone level, because the bone actually has additional volume which doesn’t sag the way this material did. Most of the time, fillers are placed at the soft tissue compartment right under the skin. Beyond a certain level, they tend to flatten or round out, and end up looking soft and pillowy, which is something a lot of people are familiar with. With structural volumizing, by placing it at the bone level, we actually create structure and a nice, natural angularity. I think that’s a technique relevant and potentially worth pursuing. The nice thing is, if you don’t like it, it goes away by itself - it breaks down n usually about a year. If you don’t like it and really want to get rid of it, we can use an enzyme like hyaluronidase to dissolve it. I hope that was helpful, I wish you the best of luck, and thank you for your question.

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Thank you for your question and pictures.  Although I can't visualize your entire face, I believe a deep injection of filler such as Voluma or Radiesse would fill your upper cheek and provide more definition to your cheek bones while simultaneously providing a lifting effect for your nasolabial folds and jowls.  These injections would be done deep under the skin to prevent visibility and palpability.  An alternative would be non-surgical skin tightening (e.g. ThermiTight, Ulthera), but would not provide the benefit of added volume that I think would be aesthetic.  Have a blessed day!