Which procedure is suggested to lift sagging cheeks, under eye bags and nasolabial folds? (Photo)

Thank you for your question. You submitted a photo with your eyes blocked out, describing a situation where you’ve had sagging cheeks for your entire life, and your nasolabial folds are worsening as you get older, even if you are still young at 28-years-old. You also state you have under eye bags, which we can’t see in your blocked out image. You ask if there is some way to lift the area of the cheeks to improve the overall appearance. You also mention some acne scarring.

I can certainly help you understand what is probably contributing to this perception. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I’ve been in practice in Manhattan and Long Island for over 20 years, and I perform a full range of procedures including minimally invasive, to advanced surgical procedures, so I can give you an understanding of how I would interpret what you describe.

At 28, you are still very young, so what you have dealt with throughout your life is more about anatomy and not about age-related changes. You can have the perception your cheeks are sagging, but I believe what is equally relevant and probably more appropriate for you is your cheek is not well-defined. There is a difference how we treat people with facial aging, which is about restoring volume loss and sagging. With younger people, it is more about subtle but natural-looking enhancement to beautify and create balance. I would suggest for someone like yourself to do the least amount possible to try to get the best outcome.

For the cheek and nasolabial folds aspects, it is worth considering a procedure we call structural volumizing. Structural volumizing is the application of traditional fillers such as Juvederm Ultra Plus and Juvederm Voluma, but in placement different than traditional filler application. Traditional fillers are typically placed in the cheeks, and right under the skin whether it is in the nasolabial folds or the cheeks. In structural volumizing, we are placing it between the bone and muscle. We do this keeping the Golden Ratio of facial harmony facial balance in mind, which is a width of 1.6 to 1, so the upper part of the face is slightly wider than the lower part. Interestingly, it can make a person look thinner. The Golden Ratio is a concept that has been around since ancient times. With structural volumizing in the cheekbone area, accentuating the cheekbones can actually really enhance the overall appearance of the face. What I like about considering a hyaluronic acid filler like those I mentioned is in a worst case scenario, you can dissolve these fillers and start from scratch. The reversibility of this approach makes it very appealing.

If you have had under eye bags for most of your life, then there is a very good chance you are dealing with lower eyelid fat prolapse, which means that the fat pockets normally around the eyes pushed forward and created a bulge. I’m not getting ahead of ourselves and saying you are a good candidate for one procedure or another, but the options for under eye bags in my practice are based on the relative prominence of the under eye bags. If they are subtle, they can be blended with an injectable filler like Restylane to fill the area of the tear trough to create a better transition between the under eye bags and the adjacent area. We also use platelet-rich plasma (PRP) derived from your own blood, but that is a different story if you don’t have much wrinkling or discoloration under the eyes. If the under eye bag is more prominent, it is not amenable or appropriate to treat this area with fillers because you might create too much volume. In such cases the option is a procedure called lower eyelid blepharoplasty, specifically a transconjunctival blepharoplasty.

I recommend you take little steps. You are still very young, so my personal style is to tend to be very conservative. I always tell younger people that once you get into your 40s and over, there will be plenty of opportunities to do things because facial aging changes will manifest more significantly. Prior to that, little things can go a long way, whether it is cheek augmentation or lip augmentation. Little things can make a nice difference for people who genetically do not have volume on those areas they desire to address.

Learn about these options, and find a doctor you are comfortable with. You really need to feel comfortable with the doctor’s style, their aesthetic, learn about what you like, and what you want to try. Very often, when we discuss these issues with patients, we come up with a priority list, figure out what’s the highest priority, and go with what has the most significant impact, cost the least, and will likely be satisfactory. You may need to visit a few different doctors to find what you are comfortable with, then move forward to take your first step.I hope that was helpful, I wish you the best of luck, and thank you for your question.

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The malar area is the most projecting part of the midface skeleton. It is what we consider the "cheekbone." Prominent malar bones are considered attractive. Hence, the malar area is frequently augmented with implants. Oftentimes, a deficiency in cheek prominence is part of a more generalized deficiency in the midface skeleton. For that reason, malar (cheek) implants are often used in combination with other implants - most frequently, with infraorbital rim implants, which build up the area directly beneath the eye.

You raise a host of very interesting questions.  Because you blacked out your eyes it is difficult to tell what is going on there  However from your photos it does appear that you have some under eye bags.  In general with younger people it is usually best to start out with less invasive options. You might be a good candidate for filler into the nasolabial fold's and at the infra orbital rim . You might be a candidate for a cheek lift with lower blepharoplasty and  fat grafting to the nasolabial fold But cheek lift alone will not affect the appearance of lower eyelid bags.  The only way to really tell which option would be best for you is to see a board-certified plastic surgeon who is experienced with facial plastic surgery including fillers and fat grafting 

There are a number of methods to get the result that you have indicated you wish to achieve; obviously we have both non-surgical and surgical routes; it depends on the level of improvement you wish to gain and of course what you may be prepared to go through to get there. Non-surgical options are relatively straightforward with less down time but would need to be repeated however with the range of products an experienced practitioner may be able to achieve really excellent results for you.

Surgically speaking the combination of your concerns in relation to cheeks lower eyelid bags and nasolabial folds represent an opportunity to use the latest blepharoplasty techniques to both soften the lower eyelid bags by redraping them to fill out the tear troughs whilst also lifting the cheeks by suturing the cheek fat higher up to the bone at the sides of the eyes thereby also improving the nasolabial folds; a SOOF lift. Hitching to something immovable like the lining of the bone means that the results should be long lasting yet, in experienced hands, also very natural. 

best wishes

Hi, I have performed many facial shaping procedures using dermal fillers, facial implants (cheek, chin), liposuction and/or facelifts for over 30 years. From the photo, your cheeks are flat anteriorly (in the front) which allows the tissues to fall and sag towards the mouth.  There appear to be "jowls" as well as lower eyelid fat pads, although a full photo of the eyes would confirm this and I suspect that the chin is weak (can be confirmed with a non smiling side photo of your face).  These combine to create an elongated, oval shaping faced.  Following the beauty principles outlined in my book on face and body beauty, women look the most feminine, youthful and attractive with heart shaped faces.  Heart shaped faces have cheeks that are full and round in the front. Cheek augmentation with a dermal filler or using cheek implants (for a permanent enhancement) will create full, round cheeks that will feminize the entire face. If the chin is weak, this creates an imbalance making the nose appear larger, the mid face top heavy and the lower face look short that de-emphasizes the lips and allows early formation of a double chin.  Chin augmentation using a chin implant will add projection to the chin creating harmony and balance to the lower face.  I have found that placement of a silastic chin implant, through a small curved incision under the chin (also allows excess skin removal) to be very safe, quick, highly effective and far less invasive than a sliding genioplasty.  I perform chin implant surgery in 30 minutes or less, often using a local anesthetic alone.    Think of facial beauty as something that "must" address all layers of the face including the skeletal structure of the cheeks and chin, the overlying SMAS muscle, amount and position of subcutaneous fat and finally the degree of skin laxity. It's an "urban myth" that pulling tissues over flat cheeks and a weak chin can create a beautiful or handsome face. Similarly, dermal fillers or facial implants alone can't lift and remove excess skin from the face and neck. Natural looking beauty is created by the aesthetic vision of what tissue layers need to be adjusted by what technique and amount. I have performed facelifts for over 30 years and have performed many minimally, invasive type facelifts.
"Jowls” are sagging facial tissues and an indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed. My most popular facelift is the minimally invasive, short incision facelift that has all the benefits of more invasive facelifts (traditional, mid-face, deep plane, cheek lift and subperiosteal facelifts) but with these added benefits:

• very small incisions
• minimal tissue dissection = less bruising and swelling = rapid recovery ( several days instead of weeks or months with the more invasive type facelifts mentioned)
• can be performed in 90 minutes or less, with or without general anesthesia
• no incisions within the hair = no hair loss
• excess fat can be removed
• excess skin removed
• cheeks, chin and jaw line can be augmented with dermal fillers (I prefer Restylane Lyft) or facial implants
• most patients fly back home to parts all over the world in as little as 3 days post-op

I combine facial shaping with every facelift procedure.  When jowls are present, these should be done in concert and not alone or separately in order to create a naturally, more attractive face.

Hope this helps.

There are good surgical and nonsurgical options.  Nonsurgical options involve the use of fillers to fill in the upper cheek area.  A little bit goes a long way.  Lifting the central upper cheek area softens the nasolabial fold. It is best to develop a relationship with a qualified injector to work up to the best look for you.  In other words start off with a little bit and let it settle then return for more,... if necessary.  Gradually work towards the best look for you.  Surgically, the mid face cheek lift is ideal for your facial characteristics.  The results are very natural with no visible scarring.   I think the above two options work well.

Dear Caligirly88, An in office examination would be advised to determine the best course of action for a patient your age. Most likely I would suggest buccal fat pad extraction to reduce the fullness in the lower third of the face providing better balance to your overall facial aesthetics. I am not a big fan of fillers in the lower eyelids however some fillers to augment the cheek area as well as the buccal fat pad removal may be a nice combination to provide a more youthful and feminine appearance. An example of buccal fat pad removal in the video above and link below. Best regards, Michael V. Elam, M.D.

Not sure if you need any lifting as it is more invasive and possibly giving surgical look at this young age. You can achieve natural results by doing some filler injection in hollow under eye area and possibly removing some buccal fat from lower cheek area. 

When patients have a flat maxilla and a flat cheek profile, cheek implants offer permanent augmentation for volume restoration in that area.  Fillers can also be used for that purpose, but are only temporary.  Fillers work very well to improve the nasal labial fullness.  The primary  goal of lower eyelid surgery is to remove fatty deposits creating the eye bags in the lower lids.  A transconjunctival approach accomplishes removal of the fatty deposits to improve the puffiness look.  Both procedures can be performed together when necessary.  A full set of facial photographs are required to make a determination about what may be needed in addition to in-person examination. For more information and many examples of both procedures, please see the video and the link below

in short, the best choices are either using fillers, tightening device like the profound or an extended deep plane cheek lift like the auralyft. I would absolutely stay away from fat grafting and implants in your face