Best Procedure for Gaunt Cheeks?

Question

I am 55, and have always been on the tall, thin side. I am healthy and into sports.  My issue is that I have high cheekbones but the middle of my face all the way down to my chin is deflated (think Abe Lincoln!)  I would love to get some fullness back.

Daniel Reichner, MD, FACS · Answer

There are several options for augmenting your cheeks:

Micro-Fat grafting - Long lasting, more expensive*

Mid-Face Lift - Long lasting, more expensive

Cheek Implants - Long lasting, more expensive

Restylane, Juvederm or Perlane - Lasts about 12 months, less expensive, better for augmentation of the cheek, tear trough and peri-orbital tissues*

Radiesse - Lasts about 24 months, less expensive, firmer than hyaluronic acid fillers, not ideal in the soft tissues around the eye

Sculptra - Lasts about 36 months, less expensive, can cause "sculptomas" not ideal in the soft tissues around the eye

*I prefer micro-fat grafting for a long-lasting cheek augmentation and hyaluronic acid fillers for augmentations lasting 1 to 2 years.  You should discuss the advantages, disadvantages, risks and benefits of these with your plastic surgeon.
I also recommend that your seek consultation with a Board Certified Plastic Surgeon for this type of mid-face augmentation.  They understand all the options available to you and the surgical anatomy of this area.

Jason Emer, MD · Answer

Thank you for your question. Volume and contouring of the cheeks can be created with well-placed fillers (Voluma, Radiesse, Bellafill) and Sculptra. Implants or fat are alternatives. Botox and radiofrequency can help slim and contour the jawline. Liposuction can help slim the face. Ultherapy, J Plasma and rf treatments can provide skin tightening and lift. I recommend getting a formal evaluation with a facial sculpting expert. Best, Dr. Emer

Anil R. Shah, MD · Answer

Typically gaunt cheeks will improve with the use of facial filler. Gaunt cheeks usually implies a slim person seeking improved shape to the face. Placement of facial fillers is key here, choosing the appropriate filler and artistic placement in the face.

Nelson Lee Novick, MD · Answer

Gaunt cheeks are a real problem for many women with long, thin faces. Until the advent of volumizing agents in the last few years, little could be done. Surgery was limited at best in dealing with this condition. In addition to being an aggressive, invasive surgical procedure, a facelift had the potential for making things worse by giving rise to a cadaverous or skeleton-like look when skin got stretched over underlying bone. 

	Replacing volume, or actually providing volume where nature never did, is the best approach to contouring gaunt cheeks. Fat injections were useful for dealing with the problem, but this required a two-step process of sucking fat from the hips, abdomen or buttocks, then processing it, and finally reinjecting it. This multi-step process was relatively expensive and involved making wounds on the body in addition to those at the actual treatment site. Duration of results was also variable and seldom permanent as had been hoped.

	The introduction of volumizing materials, i.e. injectable products with sufficient viscosity to lift, contour and replace lost or absent volume, changed the nonsurgical esthetic landscape. Hyaluronic acid volumizers, such as Juvederm Ultra Plus and Perlane (and a whole variety of others available in Europe and Israel) and Radiesse, a calcium-based agent, can be used to reshape and recontour the face in a matter of minutes. Results may last between 8-16 months for the hyaluronic acids and between 12-18+ months for Radiesse.

Brent Moelleken, MD · Answer

There are many ways to augment cheek volume (and reduce hollowness).
On a temporary basis, hyaluronic acid fillers such as Juvederm or Restylane or similar products work well.  At deep levels in the face, Sculptra also works well, although we don't use Sculptra in our practice because of lumpiness concerns.
Cheeklifts help the area below the eye and can adjust up cheek center mass.  Cheekl implants, when cleverly placed, can also achieve very nice results in the malar and submalar regions.
In a patient with existing hollowness, if a facelift is performed, it is vital not to remove any volume from the face, as occurs with SMAS operations or deep plane operations. Rather, the deep tissues can be restructured, retaining and redistributing all the volume.
If you are interested in your very best result, for most patients at 55 this will come from a volume adjusting facelift plus material added to your cheeks. For this we prefer LiveFill, nontraumatized tissue from the patient's own tissues.

Robert W. Kessler, MD, FACS · Answer

There are many great options for adding volume to the cheeks today. You have mentioned fat grafting which is an excellent option but does require a surgical procedure. This requires liposuction from the abdomen, flanks or legs. The fat cells are then processed and transplanted into the cheek. You can not use smart lipo to harvest the fat because the light energy destroys the fat cells you want to transplant.  Besides recent review by our society demonstrates smart lipo is no more effective than current techniques.
As some of the fat dies on transfer the possibility of requiring further surgery always exists. Fillers are a simple office based procedure to give excellent immediate results. The options are Sculptra, Perlane, Juvederm, Evolence and Radiesse to mention the dominant fillers on the market. All are temporary with varying lenght of duration. This is in fact a positive attribute as the face changes with age and permanent fillers can create contour irregularities over time.
Sculptra is an excellent filler which is FDA approved for HIV positive facial wasting. Once a product is approved by the FDA and deemed safe it can be used for like indications but is considered off label use. Many of the applications of botox are actually off label. Scultpra will require a few treatments over time but the product will last 18 months. I am very pleased with the results I get with Sculptra, and so are my patients.
Perlane and juvederm are hyaluronic acids which is a natural component of human skin and they will last 6-8 months. If you don't like them they can be dissolved with a simple injection of an enzyme.
Evolence is a relatively new filler introduced about 4 months ago. it is a collagen product which is expected to last about a year. Radiesse is a mineral based filler in a gel carrier which works nicely in th cheek but also lasts about a year. Ask your surgeon to review the options. With an experienced surgeon you will be amazed at the improvements which can be made in your face.

David Shafer, MD, FACS · Answer

Shellseeker25,
Fat grafting will make a nice change. The fat can be harvested from your belly or thigh, processed and then injected into your face. Since it sounds like you need a lot of grafting, then this may also be the most economic way to go as well. To fill the same volume with off-the-shelf fillers could get expensive if you need more than just a few syringes.
As for the question of Smartlipo, I think you are mixing up issues.  Fat aspirated after Smartlipo cannot be used for grafting.
Good luck.

David C. Mabrie, MD · Answer

Dermafillers like Radiesse, Restylane, Perlane, and Juvederm are excellent for adding fullnes back to the cheeks and midface. They typically last 6-12 months and each time you have it done there is some build up of your own collagen.

Chris Thiagarajah, MD · Answer

I think sculptra works quite well for cheek hollowness. A cheek implant or midface lift can help also. Alternatively filler material can work as well.

William Portuese, MD · Answer

Gaunt cheeks are usually caused by genetics and very thin people where buccal fat pad atrophy has occurred. Depending upon the exact location of the buccal fat atrophy, one can consider Silastic cheek implants. Other injectables can also be performed in the area, as well as fat injections into the deep buccal fat pad space.

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