What's the Best Way to Plump Hollow Spots on my Face?

Doctor Answers 26

Facial Rejuvenation - Fat grafting can we wonderful, but don't overdo it!

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Structural fat grafting is a powerful tool for correcting one of the primary processes of facial aging: the gradual loss of facial soft tissue volume, which primarily represents the atrophy of facial fatty tissue. The importance of restoring facial fullness cannot be emphasized enough, for without it, very few facial cosmetic surgical procedures are truly rejuvenating. As we age the skeletal features of the face become more obvious, and create subtle visual clues that tell the observer 'this is an older person'. Fat atrophy is often very obvious when it appears as hollowness in the temple area and as flattening of formerly full cheeks, but can also exist as more subtle changes that still convey an appearance of advancing age, such as the development of a hollow in the space between the upper lid and eyebrow, or as indentations in a formerly smooth and gently curving jawline.
To perform fat grafting successfully and reproducibly a surgeon must employ careful preoperative planning, appropriate instrumentation and meticulous surgical technique.  It is not something you can 'rush through' or spend just a few minutes on during a larger surgical procedure.  The unfortunate reality is that not everyone who performs fat grafting is willing to put in the level of education, training, investment in instrumentation and operative effort required to produce aesthetically ideal results.
One must also have an aesthetic vision for ideal and youthful-appearing facial fullness.   Just like traditional facelift surgery can be overdone or performed incorrectly to produce an unnaturally tight, pulled, 'windswept' look, fat grafting can be overdone to produce an excessively full and even bizarre postoperative appearance.  Too much fat grafted into any area (or any fat placed where it doesn't belong) looks unnatural.  It's analogous to breast augmentation results: if the surgeons selects an appropriate implant volume and positions the implants correctly, the patient gets a beautiful, natural-appearing breast enhancement.  If the surgeons stuffs a pair of 500cc implants behind the breasts of an average-sized patient, then that patient ends up with a cartoonish 'boob job'.  I think many of the unfavorable results in fat grafting are from the overzealous placement of excessive amounts of fat, which may have been the inevitable response to the recent paradigm shift in aesthetic facial surgery: away from the 'wind tunnel look', and towards the restoration of soft tissue volume.
Here is one patient’s experience with fat grafting posted to RealSelf:
Fat is great when used JUDICIOUSLY and CONSERVATIVELY, but too much of a good thing becomes a nightmare and deeply regrettable. Make sure your surgeon listens, draws up precise operative plans beforehand and makes plenty of time for you and your concerns. Do NOT take it lightly.
I couldn’t agree more with this patient’s response to her experience with fat grafting.  Just like breast implants, or liposuction, or browlifts, too much of a good thing is not at all a good thing.  And cosmetic surgery (and this includes the preparation for surgery) of any kind without attention to detail and a focus on natural-appearing results will leave patients feeling disappointed at best and feeling disfigured at worst.  Now regarding whether or not fat grafting is a surgically sound concept…
For transferred fat to truly qualify as a 'graft' the following must happen: living tissue must be transferred to a new location, and that tissue must gain a blood supply at the new location which provides oxygen and nutrients which allow it to persist indefinitely as living tissue.  We know that with appropriate instrumentation and technique this is achievable, so one of the opinions expressed in this thread that "most of the cells from fat injection are dead " is simply untrue (and structural fat grafting, to be clear, does not involve 'injection' of fat).  MRI studies have shown that with appropriate technique grafted fat persists long-term as living, vascularized tissue in the recipient site.
It is also well-established that adult human fatty tissue contains stem cells that have the capacity to repair damaged or injured tissues, and stem cells can be concentrated during the fat harvesting process.  This effect has applications in both cosmetic and reconstructive surgery.  Fat grafting is now being used, for example, as a means to stimulate the repair of chronic, non-healing wounds.  Several centers have reported on fat grafting immediately below non-healing chronic wounds resulting from radiation therapy for cancer, with rapid improvement and eventual healing of wounds for which no other wound treatment was successful.  The development of stem cell therapies involving the harvesting and processing of viable human fatty tissue is one of the hottest topics in both clinical and experimental medicine today.
When performed correctly fat grafting actually has the capacity to heal, revitalize and rejuvenate the local tissues at the recipient site.  I have treated a number of patients with facial fat atrophy following overly aggressive 'non-invasive' rejuvenation treatments including Thermage, Fraxel and IPL.  Most of these patients report not only an aesthetically  pleasing and permanent improvement in facial soft tissue volume, but also an improvement in the quality and vitality of their facial skin.
I perform extensive facial fat grafting during most of my facial rejuvenation procedures, and it is the very first thing I do - before making any incisions to lift the brows, eyelids, face or neck.  Fat grafting allows me to obtain results that are simply not possible with conventional, subtractive surgical techniques alone.  Patients frequently return for grafting of additional areas after their initial experience with strucutral fat grafting.  To characterize it as the pointless and potentially harmful placement of non-viable tissue is an opinion only, and it is an opinion with which quite a number of plastic surgeons who successfully rejuvenate faces (and breasts and bodies) with fat grafting would vehemently disagree, myself included.
Solid fat/fascia and fat dermis grafts are another means by which facial soft tissue volume may be significantly and permanently enhanced.  As with fat grafting, survival of the grafted tissue is variable and some of the graft material is reabsorbed.  As with fat grafting, potential complications such as infection and cyst formation are possible.  And as with fat grafting, appropriate preoperative planning and surgical technique are required in order to obtain ideal and lasting results.  In my opinion structural fat grafting is more versatile, as fat can be easily and rapidly added to any tissue plane (level); and it has the added benefit of the ‘stem cell effect’ which is difficult to quantify but unquestionably present in many cases.
Both structural fat grafting and fascia-fat (or dermis-fat) grafting can be competently performed (or not) by Board-certified plastic surgeons.  Neither should be trademarked or considered proprietary.
As with any surgical procedure take time researching your plastic surgeon. Schedule several consultation, view many photos from many patients, each from multiple perspectives (start by looking at photos on this website) and speak to former patients of any plastic surgeon you are considering.

Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Hollow spots on the face can be due to two different...

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Hollow spots on the face can be due to two different components of aging - loss of facial fat or simply descent of facial tissues.

There are several options to correct the hollow spots but there isn't one 'best way' since all have their advantages and disadvantages.

  • Facial fat augmentation - By taking fat from the abdomen or thighs and reinjecting it into the face, the effects of aging can be reversed. This solution is permanent, though it may take 1-3 injections to get the desired results. There is an anesthesia component involved and some amount of down time.
  • Temporary fillers - Temporary fillers are another good option. There are several different kinds of fillers which can be used for facial hollows. Included are the hyaluronic acid fillers (such as Restylane, Perlane, Juvederm to name a few), Radiesse, and Sculptra. Each has a different mechanism of action and can be expected to last anywhere from several months to several years. Unfortunately all of them fade over time. The amount of down time though is very minimal and most procedures are performed in the physician's office.
  • Midface lift - If your problem is hollowing of the cheeks because of descent of the cheeks with age, a midface lift may be the best answer. The downside is that it is a surgical procedure with associated anesthesia and down time. The results though are permanent.

D.J. Verret, MD
Dallas Facial Plastic Surgeon

The upper part of the youthful face is full; the...

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The upper part of the youthful face is full; the beautiful face is shaped like a heart. As we age, the upper face empties and you can see the bones under the skin. This hollowing is just as important a sign of aging as sagging and wrinkling.

Therefore, fat injections have a huge role in creating a youthful shape in the face by adding volume around the eyelids and cheek bones. I particularly like fat injections for the hollows under the eyes. With good technique, the results of fat injections can be permanent.

But fat injections are a surgical procedure with anesthesia and a recovery period that can last a couple of weeks.

So, fillers are much more practical to correct folds and lines around the mouth, folds in front of the jowl area, etc. Fillers have no down time (a little bruising can be covered with makeup), and with nerve blocks (like you get at the dentist) fillers are completely painless.

The fillers I most commonly use are Restylane, Perlane, Radiesse, and Cosmoplast. Each one has different indications and different durations. Fillers last anywhere from 4 hours to one year.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

Plumping hollow cheeks

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The procedures fall in three categories.  First, fillers such as Juvederm, Restylane and Radiesse can be used to add volume.  The results are immediate, cost is lowest, but results will last only up to a year.  Fat transfers allow for more material to be placed and will last a few years.  Sculptra works a little differently by stimulating your own collagen to grow and results can last 2-5 years.  Implants can fill the areas out and are permanent.  This can sometimes be a problem since ones face changes shape with time.  Finally, lifting techniques, in particular, mid-face lift can help volumize this area with fairly good longevity (10+ years) and can be performed via hidden incisions in the scalp and under the lip.

Pradeep K. Sinha, MD
Atlanta Facial Plastic Surgeon
4.2 out of 5 stars 10 reviews

Fat and fillers to restore the volume of youth

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Fat transfer and Fillers are both excellent options for restoring the volume loss which occurs in the face. Unfortunately, while we add fat to unwanted areas over time, we lose it in the face. Therefore the strategy for facial rejuvenation should not be exclusively  "reductive". If we add volume in a safe and customized fashion, a youthful appearance can be restored.
The choice between fat and filler depends on the individual tolerance for downtime after the procedure. Filler can often be done in a brief office visit, without significant restrictions. Fat transfer however is a more lengthy procedure, with a greater potential for post-procedural swelling and bruising.

Stephen P. Smith, Jr., MD
Columbus Facial Plastic Surgeon

Healthy Cheeks

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Healthy cheeks are very youthful.

If you are thin, especially as we age, it is very difficult to keep your cheeks from being to thin. I use fat grafting as well as Radiesse. Fat grafting is my choice if I am doing liposuction or another procedure.

If someone wants to restore a very youthful look quickly, with no downtime, and they are a good candidate, I use Radiesse. It works very well, very quickly & is fun to do because it is a very noticeable change.


Melanie L. Petro, MD
Birmingham Facial Plastic Surgeon
4.7 out of 5 stars 31 reviews

Fillers and Fat injections can fill in the hollows

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Fillers and Fat injections can fill in the hollows. Fillers like restylane, radiesse, perlane, Juvederm, can fill in small hollows that are smaller than 1cm squared or a square area about a 1/3 of an inch. Fat injections are another more longer term possibility. Sculptra is a filler made up of suture material that when digested by the body forms collagen for a more longer term solution as well. The YoungVolumizer is my method of volumizing the face and hollows. I have a great technique that leads to better fat survival and more long term results.

Philip Young, MD
Bellevue Facial Plastic Surgeon

What's the Best Way to Plump Hollow Spots on my Face?

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Most hollow areas are going to require a filler of some type. Fat is one of the most economical and long lasting fillers available. It does require more recovery time though. Other fillers require less down time and are easier to perform but in general are temporary and will require repeat injections.

Volumizing Fillers Work Well For Plumping Hollows, Flattened Areas, and Depressions On The Face

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Hollowed areas of the face typically result from the loss and and displacement of volume in the skin and underlying structures and constitutes a significant component of facial aging. Much of these changes can be attributed to loss of fat, but natural remodeling alterations over time in bone, cartilage, and muscle may also contribute to the problem. Happily, nowadays, we have available a variety of off-the-shelf, natural products that can replenish volume where needed, thereby restoring a more youthful, rested look.

The actual choice of volumizing agent (or combination of agents) depends upon the specific depth and location being treated and the expertise and experience of the physician injector. For example, in my experience, sunken temples respond well to the use of Radiesse, a calcium-based product that provides the appropriate bulk and lift needed for this area. Under the eyes, where dark circles and tear troughs are prominent, combining a tiny amount of Radiesse (whose white color can be taken advantage of to lighten darker areas) with Juvederm UltraXC, a smooth flowing hyaluronic acid based filler, yields very gratifying improvement in both color and texture. In cases where there is flattening of the upper inner check (near the bridge of the nose), Perlane, another hyaluronic acid product known for its lift capacity works well.

In my second practice outside of the U.S.many more approved products are available each with its own unique properties. It is anticipated that many of these will ultimately achieve FDA approval and with this ever-growing number of volumizing fillers entering the market, our ability to tailor  treatments for individual needs will continue to expand.  

Nelson Lee Novick, MD
New York Dermatologic Surgeon
4.9 out of 5 stars 33 reviews

Injectable fillers for facial hollows

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Injectable Sculptra or Perlane are my current preferred choices for deep facial filling.  Sculptra requires 3 or more monthly injections and another 3-6 months for optimum improvement due to collagen stimulation.                Results last 1-4 years or more.  Perlane or other hyaluronic-acid based fillers demonstrate immediate improvement and may last 1-2 years or less.  

I am not a fan of injected fat - it requires another procedure (liposuction), longevity of improvement is unpredictable and can be very short-lived.  Multiple treatments at different treatment sessions may be needed.  Because of the additional fate removal procedure, the cost of lipotransfer tends to be significantly more expensive than manufactured fillers.  

Robert Strimling, MD
Las Vegas Dermatologist
4.3 out of 5 stars 9 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.