Lower blepharoplasty plus cheek lift or fat graft? (Photos)

Question

I've always had a relatifly flat face with lips ponting downards (flat cheekbones, tight palate), I mean not a v-shaped face with strong bone structue. These last twenty yers, I've been having a series of non surgical procedures tha have for some done nothing and for some have caused permanent damage. The very first injenctions in the tear troughs led to some malar bags that, twenty years later and despit some tardive hyaluronidase injenctions, are still there. Hyaluronidosa only made my under eyes more hollow and wrinkly but the malar bags stayed! Two bad results! Years after year I've been suggested to fill the part under the malar bags with different HA fillers but none stayed more than two months then supposedly migrated "south", making my face saggier, heavier, my lips pointing more and more downard, exactly the opposite of what I needed. The last procedure I had was radiofrequence plus micronnedlign: a disaster! It made my mid face fat melt, acctuatin my malar bags. I look olde and gaunt. Now I'm suggested to have a low blepharo to tigthen the skin an muscle in order to mae the malar bag less ovious and my eyes fresier and to have a fat graft or a cheek lift to make the malar bags less noticeable too. I

Carl Truesdale, MD · Answer

The combination of flat cheekbones and a downward-tilted, hollow lower lid-cheek junction is one of the most common reasons a lower blepharoplasty alone disappoints. Adding either a cheek lift or fat grafting addresses what the bleph can't, and the right add-on depends on your specific anatomy.
First, the core issue with your description:
Flat cheekbones with a downward tilt (often called a negative vector &mdash; the cheek sits behind the front of the eye rather than supporting it) means a lower blepharoplasty alone carries a higher risk of pulling the lid down (retraction, scleral show). The lid needs underlying support, and a flat midface doesn't provide it. So adding cheek support isn't optional in your case &mdash; it's protective.
Cheek lift (midface lift):Repositions your own descended cheek tissue upward and provides structural support to the lower lid. Best when there's genuine descent &mdash; the cheek pad has dropped and lifting it back restores both the cheek and the lid-cheek junction. Downside: more involved procedure, longer recovery, and if your cheekbones are flat by bone structure rather than descent, a lift repositions soft tissue but doesn't add the projection a flat bony cheek lacks.
Fat grafting:Adds volume to the flat cheekbone area and the lid-cheek junction. Best when the issue is volume deficiency or flat structure rather than descent. For genuinely flat cheekbones, fat grafting addresses the actual deficit &mdash; it builds projection where there isn't any. Downside: 50 to 70 percent long-term retention, so slight overcorrection is planned, and the result takes 3 to 6 months to settle.
For your specific situation (flat cheekbones, downward tilt):
Flat cheekbones is a volume and projection problem more than a descent problem. That generally points toward lower blepharoplasty with fat grafting (or fat repositioning from the lid itself) rather than a pure cheek lift. The fat adds the projection your bone structure lacks and supports the lid.
That said, if there's also descent (some patients have both flat bone AND dropped tissue), a combined cheek lift plus fat grafting gives the most complete result.
A third option worth knowing: cheek implants. For truly flat cheekbones, a cheek implant permanently adds the bony projection. Some surgeons combine a conservative lower bleph with cheek implants rather than fat &mdash; more permanent, but a bigger commitment.
What to do: see a surgeon who does all of these &mdash; lower bleph, midface lift, fat grafting, and implants. The key exam findings are whether your cheek is flat from bone or from descent, and what your vector is. Ask them to show you the difference on your own photos. A surgeon who only offers one of these procedures will recommend that one regardless of fit &mdash; get evaluated by someone with the full toolkit.
Whatever you choose, the important takeaway: with flat cheekbones and a negative vector, lower blepharoplasty alone is risky. The cheek support component isn't an upgrade &mdash; it's necessary to protect your lid position.

Lower blepharoplasty plus cheek lift or fat graft? (Photos)

Answers (1)

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