Deeper malar lines after cheek filler dissolved. Residual filler or my actual anatomy/true baseline? (Photos)

Question

37, F. I have had malar lines my entire life, since I was a child. I had cheek filler to add volume for years and it looked ok, but the lines were still always there. I recently had it dissolved, and now it looks like this (images). The dissolving was about 2 weeks ago. There is less puffiness in general, but the malar lines are much deeper and noticeable than before. Does it look like there might still be filler causing this? Or is this likely to just be the reality of the situation underneath the filler, which the filler was previously hiding? What are my options?

Anna Chacon, MD, FAAD · Answer

What you're noticing two weeks after dissolving your cheek filler is very understandable, especially since you've had these malar lines naturally since childhood. Based on your history alone, I would not assume that the deeper lines mean there is still filler present. It is quite possible that the filler had been providing volume that softened or camouflaged your natural anatomy, and you're now seeing that anatomy more clearly.

There is also an important timing issue. Two weeks is still relatively early after hyaluronidase. The tissues can continue to settle, and residual swelling or changes in the soft-tissue fluid balance can temporarily alter the contours of the cheek. Malar/periorbital edema is a recognized issue with HA filler in this region and can sometimes persist even after the filler itself has been substantially dissolved.

At the same time, residual HA filler is possible, particularly if you've had multiple treatments over the years. Different HA fillers have different resistance to hyaluronidase, and some products—including certain firmer cheek fillers—can be more resistant to dissolution.

If there is uncertainty about whether filler remains, high-frequency ultrasound can be very useful. It can help distinguish residual filler from edema, fibrosis, or your underlying soft-tissue anatomy rather than relying solely on how the area looks.

The fact that you've had malar lines since childhood is particularly relevant. That makes it very plausible that the lines are part of your natural facial anatomy rather than something caused by filler. The previous cheek filler may simply have provided enough volume to make the transition less obvious.

I would therefore resist the temptation to immediately dissolve more filler or add new filler. First let the area settle and establish whether there is actually residual product. If HA is still present and contributing to an unwanted contour, a carefully targeted additional hyaluronidase treatment can be considered. However, if the filler has already been adequately removed, further dissolving won't improve a naturally occurring malar line.

Once everything has settled, your options depend on what is actually creating the contour:

If there is residual HA, selective hyaluronidase may help.
If the issue is primarily loss of cheek volume, carefully placed midface filler could restore some of the previous camouflage.
If the line is related to your natural anatomy or a structural transition between the cheek and lower eyelid, simply adding more filler directly into the line may not be the best solution.
If there is significant skin laxity or true malar fat-pad descent, a surgical approach may eventually be more appropriate than repeatedly adding filler.

And I would not interpret the deeper appearance at two weeks as necessarily your final result. Give the tissues some time to settle before making another major change. Your long-standing history of malar lines actually makes me think the goal should be improving and balancing your natural anatomy rather than trying to completely erase a feature that has always been part of your face.

Julian De Silva, MD · Answer

Hi mossice, thank you for laying this out so clearly, and the fact that you have had these lines since childhood is actually the most important detail in your question. Malar lines that predate any filler are anatomical: they follow a natural attachment zone where the cheek tissue is tethered, and filler tends to soften their appearance by inflating the tissue either side rather than treating the line itself.

At two weeks after dissolving, you are also not yet looking at your true baseline. Hyaluronidase changes the water content of the tissue as well as removing filler, and in my experience the area can continue to settle and rehydrate for four to six weeks. I would not judge the final picture, or make any treatment decision, before then.

Once things have settled, an in-person examination is the right next step, ideally with someone experienced in the lid-cheek junction and midface, because the options for genuine malar lines are quite different from simple volume replacement and depend on what is happening in the deeper layers. From photographs alone it is not possible to say reliably whether residual filler is contributing, so please have that assessed in person rather than guessing.

Camille Cash, MD · Answer

It's hard to say if filler is still present from photos alone.  Sometimes, depending on the amount of filler present, it can take multiple attempts to completely dissolve it.  I encourage you to return to your injector for an evaluation to determine if more hyaluronidase is needed or if this is your final result.

Michael Davitt, MD · Answer

Thank you for your question. You have what is commonly referred to as a tear trough deformity. Filler placed in the cheeks can make these appear more severe. However, filler can be placed more along the bony lower orbit to help camouflage these lines. Filler injection to this area can require more finesse than other types of injections and can come with risks of persistent bruising, swelling/edema, and, in rare instances, injury to nearby nerves and blood vessels. Alternatives to filler in this area can include lower blepharoplasty with or without additional adjunct techniques performed through the same incision. I recommend an in-person discussion with a plastic surgeon to determine what options would best suit your situation.

Deeper malar lines after cheek filler dissolved. Residual filler or my actual anatomy/true baseline? (Photos)

Answers (4)

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