Best Solution for Hollowness Underneath Cheek / Submalar Area - Filler, Fat Transfer?

Hi intears,Voluma was recently FDA approved in the US for Cheek augmentation. Although the main benefit of the Voluma is it's Lifting power, because it tends to stick to itself, it is particularly good for placing on top of the cheek bone similar to your malar augmentation AKA cheek implants. The submalar area is where the natural "baby fat" in our cheeks get lost as we age. The normal baby fat is called the buccal fat pad. As we age we naturally lose it. Some people who feel their cheeks are too chipmunky or too full, may request to have the buccal fat pad reduced or removed surgically. I think this can prematurely age that person, and if it is overly full, it can help keep the person looking younger appearing than their chronologic age. Since my specialty is trying to make people look younger (facial rejuvenation), I see the benefit of preserving the natural buccal fat pad, as well as augmenting the submalar area if it is deficient.Juvederm Voluma lasts longer than Juvederm and Restylane. In the FDA studies, patientd did not need touch ups until after 2 years and even then, there was still about half of the Voluma results still present after 2 years. This means the touch up injections should be less than the original amount. It is possible that you may be a hypermetabolizer.  Some patients seem to used up their filler much faster than the majority of the patients.  Common characteristics of hypermetabolizers of filler are that they exercise ... a lot and are very careful with their diet.  Some are vegetarians or on a Raw diet or some calorie restriction.  I suspect their bodies are in a constant catabolic state, which means it is constantly breaking down it's own tissue.  I don't know how that also breaks down the filler, unless the filler is still there, but the patient ends up breaking down their own tissue, so it appears the filler is also gone, too.  For these hypermetabolizers, Restylane and Juvederm only last a couple of months where other patients seem to last 6-12 months and for Radiesse 4 months sounds about right where others it is lasting 12-15 months.  Since Juvederm Voluma is new to the U.S. I'm not sure how it will react for a hypermetabolizer like yourself.  Fat grafting may not work on these patients, or it could backfire, if so much fat is added and it doesn't seem to work and more is added.  If the patient gets sick or changes their lifestyle, they may have overpopulated their cheeks with fat and all of those fat cells may start holding fat.  I think this risk may be even more dangerous, even though fat is a natural filler.  The patient must maintain their weight very strictly to prevent this from happening.  At least with fillers, it naturally dissipates with time, like an hour glass, and not dissimilar to natural aging.  Also if the patient gains weight, the filler will not grow with the patient.  Instead, the patient may opt not to do a refill or wait longer so their face does not become too full.  Sculptra is injected directly under the skin and not in the buccal fat pad area, which is much deeper. If you place your finger inside your upper lip under your cheekbone essentially the cheek between your finger and the skin is the tissues which need to be thickened. Since you have cheek implants, we should at least discuss submalar implants. These submalar implants are not implanted into the tissue between the inside of the lining of your mouth to the skin, instead it is place under the cheek bone. I have removed submalar implants which essentially were sticking into the mouth above their upper teeth line. Perhaps they moved, but I don't like to restored appearances in an non-anatomic way. The same comment goes for fat grafting which is placed in different layers under the skin, but does not actually filler the buccal fat pad space. I don't know what is done with silicone, but it is certainly off-label as a filler in general let alone large volumes such as the submalar area. The best technique for silicone is called the microdroplet technique. If multiple cc's of volume are injected, I suspect the microdroplet technique goes out the window, since there may be more filler, and less tissue to actually hold each microdroplet. I have used Juvederm Voluma to augment the submalar area. I use a microcannula from Dermasculpt. In order to restore the buccal volume anatomically, I go deep and aim for a spot under the cheek bone, where it seems to open up anatomically. The Voluma is not felt on the surface of the skin since the goal is to try to reinflate the buccal fat pad space which has deflated.I hope that makes sense.Best,Dr. YangP.S. There is a new feature on Realself, which is the "Follow" button. It is similar to the "Like" button on Facebook. If you like my response or any of the doctor responses while you research on Realself, you should "Follow" them. You will get email updates, when the doctors you follow post any new answers to questions, post new photos, or have any new reviews.

For unique cases where a variety of modalities could be used to treat the condition, I would suggest an in-person or virtual consultation to develop a custom and effective treatment plan. It is difficult to precisely define the best option without collecting the same information. I suggest reaching out to an expert for a consultation with surgical and non-surgical methods to get a comprehensive option. Best, Dr. Emer.

In my practice, hollowness in your cheeks or sub-malar area may be treated with Silikon-1000, an off-label filler, for permanent results. In general, several treatments are necessary to obtain complete correction, and you will see a gradual, permanent improvement after each treatment. Procedures are performed with topical anesthetic, and there is typically no downtime.

I hope this is helpful for you.

Regards from NJ:

In such cases my first choice is free fat transer, second is sculptra, third is other dermal fillers and fourth is a submalar implant. This is based on cost, ease of the procedure, risk of complications, reliability of the result, longevity of the procedure etc. Without photos or a face to face examination one cannot say what would be best in your situation.

In general, if the volume loss is truly submalar, submalar implants are a permanent, yet reversible option, and are my preference in patients willing to accept the cost, risk, and recovery of surgery.

In many patients, we will use filler instead, as cost, risk, and recovery are less. I generally avoid Radiesse, as 30% or so of the product is a carrier gel that is absorbed over the first few months. I find many patients feel that their immediate result "doesn't last" when that initial carrier gel resorption occurs. I much prefer Juvederm Ultra plus, as this emotional "let down" does not occur.

I generally reserve fat transfer for patients in whom I'm already doing other surgery, as it is neither as fast and recovery-free as fillers, nor as predictable and permanent as implants.

More details would be helpful but if your cheeks have sunken a non-invasive treatment is obviously fillers, but I prefer the hyaluronic acids like Perlane. If your cheeks have "dropped" you may be a better candidate for a facelift.  Like I said more details and an exam are importantt.

A malar or submalar implant, properly chosen and placed, should give results lasting a lifetime. Some surgeons have lasting tresults with fat transfer.