Cheekbone (festoons, malar bags) area Restylane was done 18 days ago. How long will it stay puffy and what can I do? (photo)

Thank you for your question. You submitted several photos, and state you are 18 days out after getting Restylane in the cheekbone area. You are concerned there is still swelling and asymmetry. You state there was initially significant swelling and bruising, but that has gotten better, and when you did research, you found most of this should have resolved at 2 weeks. You are concerned, and state your doctor advised you to wait 4 weeks.
I can understand your cause for concern reviewing your photos. I can suggest to you a strategy that might be relevant, and should be discussed with your doctor. 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 use of injectable fillers is a very significant part of my practice. Helping people get nice looking cheekbones has been an evolution in my own practice. I’ll certainly share with you my philosophy that guides how I avoid situations like what you are in currently.
Understand first of all your doctor’s intention of adding volume to compensate for volume loss. The general philosophy of fillers is to place them within the skin which is intradermal, or under the skin, just below the layers of the skin which is the fatty cell layer.
The way I look at facial aging is what guides my approach. I look particularly in the cheekbone area as a function of bone loss.  As a function of bone loss, the placement of filler more superficially can commonly result in something like what you are experiencing now. When I look at your photos, I see a very distinct outline of the filler particularly in the right cheek area. And it is often perceived as looking okay, but if it looks obvious, then it’s not so great. What is often a criticism is the filler is placed superficially.
These layers of tissue are very thin. Understanding that this filler was probably placed in a way to mimic the appearance of the cheekbone is something commonly practiced, and we have seen patients with this situation. What I’ve done is dissolved the filler and started from the beginning.
When I say the beginning, what I do is a technique called Structural Volumizing that addresses the volume deficit at the level of the bone. That means through specific techniques, I place filler between the muscle and the bone using blunt cannulas. I also use a different type of filler. in the thicker category such as Juvederm Ultra Plus and Juvederm Voluma.
When placed at the bone level in a specific way, we’ve been able to achieve very nice cheekbone definition with no evidence of irregularities, avoid swelling and bruising, and ultimately getting very nice balance and symmetry. Our patients very often can see the results immediately with a mirror we give them . It’s been a significant paradigm shift in my approach to helping people with the same issues you are dealing with right now.
The solution is defined by the problem, and the problem is bone loss. However, the majority of colleagues place fillers more superficially with the idea of trying to mold and shape. When it’s under the skin, it’s less easy to create that shape, and it’s a challenge to get it to behave in a consistent and predictable.
I think this discussion should be brought to your doctor. At this point in time, this degree of asymmetry and the appearance of swelling is not optimal. Therefore, it is up to you and your doctor to decide what to do. It may mean some dissolving, or changing the strategy overall.
I think this frustration you’re experiencing is very common, and we see patients with this challenge very frequently Often, people see others who had fillers placed in their cheeks and they don't like the result because they look too rounded or pillowy. With Structural Volumizing, the layers of tissue over it prevents this very obvious outline appearance that is more characteristic of the material and the layer in which it’s placed.
I don't think you need to abandon your doctor. If this is the first time you’re doing this, it’s important you and your doctor figure out what’s best for you. I think it’s fairly straightforward that your anatomy is reflective of many of your contemporaries where soft tissue loss, bone loss, and thinner skin are kind of a set-up for a limited volume correction unless the material is placed deeper. That’s basically the strategy I would employ for a person like yourself in my practice. I hope that was helpful, I wish you the best of luck, and thank you for your question.This personalized video answer to your question is posted on RealSelf and on YouTube. To provide you with a personal and expert response, we use the image(s) you submitted on RealSelf in the video, but with respect to your privacy, we only show the body feature in question so you are not personally identifiable. If you prefer not to have your video question visible on YouTube, please contact us.

It is possible that the Restylane was injected too superficially.  You may need to have it dissolved with injections of hyaluronidase.  Make sure that you are seeing an expert injector.Regards,Dr. Ort