There are various processes that cause the unkind effects of aging on our facial skin. Among the most conspicuous of these aging processes is known as facial lipoatrophy. This is where the fat below the skin wastes away, reducing the volume of the cheeks and flattening the contours of the face. Eventually this may even lead to a sunken appearance in the mid-face. It’s a normal but particularly unforgiving part of aging. As the cheeks lose their supporting fat tissue, the skin sags and becomes dry, wrinkled, and lined. Facial lipoatrophy is why facelift surgery (removing excess skin) often produces unsatisfactory results; it doesn’t correct the volume loss in the cheeks. Even without experiencing face lipoatrophy, some people are just not satisfied with the shape and contours of their cheeks. The ampleness of mid-facial volume is one of the main factors that makes people look young, so many individuals wish they had fuller, more defined cheeks to compliment their face. Cheek augmentation – also known as malar augmentation – is an option for people who wish to improve the contours and fullness of the cheeks. There are several cheek augmentation options available:
- Injectable fillers
- Synthetic implants
- Natural tissue grafts
Are you a good candidate?
Very few people are excluded from getting filler injections. However, there are a few contraindications to the procedure: (1)
- Allergy or sensitivity to the filler or local anesthetic
- Active infection
- Previous serious adverse reaction to filler injection (such as glabellar necrosis)
- Being pregnant or nursing
- Having a bleeding disorder or taking medications that cause bleeding
In general, for surgical cheek augmentation, patients must be in good overall health and at a stable weight in order to be considered. If there are pre-existing dental or sinus issues, they may need to be treated before surgery is possible. Good surgical candidates have realistic expectations (best discussed with the surgeon), deficient cheekbones with “weak” cheek structure, a narrow/flat face, or have lost cheek contour or volume due to ageing or disease.
Cheek augmentation options
Options for cheek augmentation include both surgical and non-surgical techniques. Surgical techniques involve placing implants in the cheeks that provide volume and support. The implants may be either fat taken from your own body (“autologous fat transfer”) or synthetic (“alloplastic”). Cheek augmentation surgery procedures usually take 30 minutes to 2 hours to complete. Most surgeons use a local anesthetic, but some prefer a general anesthetic. (2, 3) Non-surgical cheek augmentation involves injecting some kind of synthetic “filler” agent into the cheek, below the skin. Filler injections are much less invasive and cheaper than implants, and they often take less than an hour, involving minimal downtime. However, their main disadvantage is that their effects are temporary. (1) Often a combination approach is chosen; for example, many surgeons will advise injectable fillers in addition to surgery. Let’s now take a closer look at the three options: Autologous fat transfer: in this augmentation technique, fat is “harvested” from the patient’s own body, most commonly the abdomen, but sometimes from the thigh or flank. (2) The harvested fat is then treated to prepare it for implantation into the cheek, and then it is injected through a tiny hole (usually 1-3 mm) using a tube (a cannula). The main drawbacks of the fat transfer option are: (3)
- The donor site requires care and healing.
- In some people there may be limited fat available to harvest.
- The surgeon cannot mold the fat very much.
- The body will reabsorb some of the transplanted fat, and it is difficult to predict how much will disappear.
- More than one fat transfer is sometimes required.
Synthetic (alloplastic) implants: synthetic implants are made from a wide variety of materials. (3) Among the most commonly used are Gore-Tex and Softfoam, but they are also made from silicone, metals (such as titanium), and a variety of polymers. The surgeon makes incisions usually located either in the lower eyelid or inside the mouth to avoid any exterior scars. Injectable fillers: this non-surgical approach to cheek augmentation involves placing volume-enhancing gels under the skin to provide volume and contour to the cheeks. The fillers work in several ways:
- The gel itself provides volume.
- The fillers induce the body to produce its own volume replacement by stimulating collagen production and drawing in water.
- They improve skin elasticity and appearance by providing lasting hydration.
There are several types of injectable fillers in use:
- Hyaluronic acid (HA) – this is a synthetic version of a natural compound found throughout the body. Although HA fillers are usually used to treat facial lines and wrinkles, they are also used off-label (without FDA approval) for restoring volume to the cheeks. However, cheek augmentation requires quite a bit more product, making the procedure more costly. Their effect usually lasts 6-12 months depending on the product. Brand names include Juvederm, Restylane and Belotero.
- Calcium hydroxyapatite (CaHA) – this is a synthetic form of a compound found naturally in our bones and teeth. The only available CaHA filler is marketed under the brand name Radiesse. The volumizing effect is immediate, and lasts up to 18 months due to stimulation of continued collagen production
- Poly-L-lactic acid (PLLA) – this filler is marketed under the brand name Sculptra, and is FDA-approved to treat facial lipoatrophy. Rather than push up the skin with its own volume, it stimulates natural collagen production to fill in the space under the skin. This takes time, so it may take a few months to see the full effect. Up to three treatments a month apart may be required to get the desired effect. Its main advantage is that the effect lasts up to two years, much longer than other fillers.
Risks and complications
Of the three options, filler injections are the safest and easiest; however, there are potential complications involved. The side effect rate is largely determined by the skill and experience of the injector. The potential adverse effects of filler injections include: (1)
- The Tyndall effect – this is where the skin takes on a bluish hue following improper HA injection.
- Short-term injection site reaction – may include redness, swelling, bruising, pain, itchiness, and infection.
- Long-term injection site reaction – nodules form under the skin, sometimes accompanied by redness.
- Migration of the filler to adjacent areas – may create asymmetry and an odd appearance.
- Allergic reaction to the filler
- Embolism (entry of the filler into the bloodstream)
- Tissue necrosis (local tissue dies)
Cheek augmentation surgery – as with any surgical procedure – has potential risks involved. Your surgeon will review the risks with you thoroughly to make sure that you are fully aware of the risks involved. As with any surgery, post-operative pain, swelling, bruising, and bleeding can be expected. The other main risks involved include: (3)
- Unsatisfactory implant selection and/or placement
- Altered lip function affecting the smile
- Migration of the implants
- Injury to a facial nerve
- Fluid collection under the skin (seroma)
- Protrusion of the implant from its pocket, causing it to be visible and/or palpable
- Bone erosion (this rarely occurs with the implants currently in use)
- Anesthetic risks
- Possibility of revision surgery
Following cheek augmentation surgery, you can expect your smile and speech to be abnormal for 1-2 weeks. (3) Significant swelling should be expected, and ice packs and steroid medications are routinely used to address this. Sometimes internal bleeding can occur, in which case it must be drained by the surgeon. Minor bleeding or bruising will heal on its own. No dressings are usually used, and your surgeon may give you a prescription for painkillers, antibiotics, and steroids. You will likely be asked to avoid talking or moving your mouth too much, and follow a liquid diet for the first 48 hours. After surgery, most patients take about a week away from work and other obligations to recover. You may find it uncomfortable to chew, smile, or yawn until your cheeks have healed. It is important to keep your head and neck elevated at all times for the first few days to keep the implant from shifting out of place and to reduce swelling. Recovery from filler injections is usually much easier than surgery. For many people, filler injections are a lunchtime procedure, and they return to work immediately afterwards. However, cheek injections are more involved than other filler injection procedures, so it may be best to plan to rest at least one day after receiving injections.
Cost of cheek augmentation
Implants: According to the American Society of Plastic Surgeons (ASPS), the average surgeon’s fee for cheek implants in 2019 was $2,986. (4) However, in addition to the surgeon’s fee, you will have to cover the operating room costs, the anesthesia fee (if something other than a local anesthetic is used), the cost of the implant, and the cost of medications. As well, many surgeons recommend using filler injections in addition to the surgical implant, which can further drive up the cost. Fillers: According to the ASPS, the average surgeon’s fee for filler injections in 2019 ranged from $343 to $2,169. (4) The cost depends on the specific product chosen and the amount of product that is used. Another factor that can affect the cost is that more than one filler injection is often required (for example, Sculptra is often given as a set of three injections, one month apart), and the injections will have to be repeated when the original injection wears off if you wish to maintain your look. With such a degree of cost disparity, the only way to get an accurate measure of how much a cheek augmentation is going to cost you is to speak with a qualified practitioner about a specific procedure.