The midface has traditionally been overlooked in cosmetic surgery, However, cheek augmentation has been gaining popularity as one of the most effective anti-aging procedures available, restoring youthful fullness and appeal to the face.
Updated, September 2017
What Is Cheek Augmentation?
High cheekbones and full cheeks are universally celebrated as markers of beauty. However, the cheeks also serve a functional purpose: they provide scaffolding to structure and support the facial landscape.
Unfortunately, as we age, volume loss in the cheeks causes the skin and muscle to slide downwards, resulting in jowls and facial folds. Elevated and voluminous cheeks are synonymous with youthfulness, while sunken and hollow cheeks are generally associated with aging. For some individuals, weak or undefined cheeks are caused by genetics, making them appear older than they really are.
Cheek augmentation has recently been seized upon as one of the most effective anti-aging procedures, restoring youthful fullness and appeal to the face. The midface has traditionally been overlooked in cosmetic surgery, with previous trends seeing surgeons making the patient’s face look tauter but not necessarily younger.
Heightened awareness of the importance of replacing lost volume in the midface has been one of the primary advances in cosmetic facial surgery in recent years.
“When you fill in the cheeks, everything is pulled up,” confirms New York based dermatologist Dr. Patricia Wexler. “You diminish the nasolabial folds, decrease the downturn of the mouth, and reduce the hollow of the eye, all without touching any of those areas.”
The cheeks can be enhanced and plumped through several surgical and non-surgical methods: dermal fillers such as Restylane offer a less invasive technique of acquiring fuller cheeks, while fat transfers and cheek (malar) implants present a more enduring solution for cheeks that lack volume.
For many individuals, injectable fillers represent an appealing entry point to cheek augmentation: patients often use fillers for several years before deciding that they are ready to commit to implants, the permanent surgical alternative.
Individuals who benefit most from cheek augmentation procedures generally share some or all of the following characteristics:
- Sunken hollows beneath the eyes
- Deep nasolabial folds
- A downturned mouth
- Prominent jowls or facial folds
- A lack of definition or contour in the cheek area
- Sagging facial skin
If you identify with any of the above issues and have realistic expectations about what surgery can achieve, then you are most likely a good candidate for cheek augmentation.
Dermal fillers offer an excellent option for those seeking non-surgical cheek augmentation. There are a range of FDA approved injectable fillers available that can be used to enhance cheek volume safely. As anesthetic is not required for the procedure, patients also have the added ability of providing feedback to the surgeon as he or she injects the filler to achieve their desired result.
Fillers can be subdivided into three main categories:
- Hyaluronic acid fillers (Juvederm, Voluma, Restylane)
- Calcium hydroxyapatite fillers (Radiesse)
- Poly L-lactic acid fillers (Sculptra)
There are also subcategories based on concentration and whether anesthetic (Lidocaine) is included in the compound. Surgeons have their own preferences regarding fillers, based on their experience and familiarity with different products. Each category of filler boasts different properties and is suited to different anatomical aspects of the face.
Hyaluronic fillers are composed of a molecule which occurs naturally in the skin, meaning a diminished likelihood of an allergic reaction. Surgeons often use hyaluronic fillers for first time patients to add volume and shape to their cheeks. Interestingly, hyaluronic acid can be reversed by the enzyme hyaluronidase, so that patients who experience filler mishaps or don’t like their results can melt away the effects almost instantly.
Calcium hydroxyapatite fillers, such as Radiesse, provide immediate lift and volume as the the compound is injected into the deepest tissue of the cheeks. They also boast long term benefits as they stimulate collagen production in the skin, supporting results for up to a year. Over time, the gel is absorbed into the skin and metabolized by the body completely. It contains Lidocaine, an anesthetic, to render the injection less painful.
Poly L-lactic acid fillers offer more subtle results over time. These fillers stimulate collagen production and work to repair the underlying skin structure over a series of treatments, allowing for a more natural look and gradual cheek augmentation. When treatment has been completed, results last for up to two years, with maintenance treatments required once per year. These fillers are also metabolized by the body over time.
For the patient interested in experimenting with cheek augmentation, dermal fillers represent an ideal way to ‘try out’ fuller cheeks. Fillers offer the following advantages:
- The effect of hyaluronic acid based fillers can be reversed if necessary
- Some fillers promote collagen production in your own skin, enhancing the results and offering longevity
- Instant volume and lift of the cheeks
- Filling and softening of nasolabial folds and under eye area
- No downtime, except some minor swelling
- Less costly than implants
- Results are long-lasting but not permanent
Awareness of some of the limitations of dermal fillers can help inform your decision about which cheek augmentation procedure is right for you.
- Fillers can cause nearby facial regions to become stiff or difficult to move.
- Dermal fillers offer a short-term solution, with results lasting up to a year. Regular injections can become costly.
- Fillers can leave your skin looking red and irritated post-treatment. It is vital to find an experienced cosmetic professional to carry out the procedure.
Risks and Potential Complications
Not every filler is right for every type of wrinkle. Risks and complications can be reduced if you engage the services of a board-certified dermatologist or plastic surgeon to administer your filler. Your surgeon will be able to explain any possible side effects or risks linked to the particular filler he or she uses.
Some of the main complications linked to dermal fillers include:
- Redness and swelling
- Allergic reactions
- Nodules or bumps forming under the skin
- Breakouts similar to acne
- Facial asymmetry
- Palpability of the filler beneath the skin’s surface
Based on 2016 statistics, the American Society of Plastic Surgeons offers the following price estimates for dermal fillers:
- Calcium hydroxyapatite (e.g. Radiesse): $687
- Hyaluronic acid (e.g. Juvederm Ultra, Juvederm Ultra Plus, Perlane, Restylane): $644
- Poly-L lactic acid (e.g. Sculptra): $773
Cost can also be influenced by other aspects such as the surgeon’s experience or reputation in administering the filler, the brand and quantity of filler used, and the geographical location of the surgeon.
Fat Grafting — Autologous Fat Transfer
Fat grafting represents an evolving technique in plastic surgery. By harvesting fat from the abdomen or thighs through liposuction, a natural filler material from the body’s own tissue can be sourced to restore volume to the cheeks.
Fat is taken from the abdomen or thighs through liposuction, cleaned and processed, and injected into the treatment site. The procedure is performed in an office under local anesthetic. As fat can be sourced freely from the body, it is plentiful and can provide a significant source of volume for severely sunken cheeks. Many patients undergo a series of fat transfer treatments over several months for the best results.
When comparing the efficacy of fat transfer with dermal fillers, many surgeons confirm that considering patients on a case-by-case basis is essential.
Dr. Jay Lucas, a Knoxville-based plastic surgeon, emphasizes that fat offers multiple benefits as a filler. “The advantage of fat is that it is cheaper to obtain than manufactured materials. In most cases, there is a relatively unlimited supply. Furthermore, peripheral stem cells may direct cellular differentiation leading to improved tissue quality.”
There are also other advantages to using fat as a volumizer for the cheeks:
- Fat transfer offers excellent results for extensive volume loss
- Fat is naturally harvested from the body so there is no danger of an allergic reaction or rejection
- The procedure has high safety records
- Fat transfer offers long-lasting results
Fat is, however, characterized by some weaknesses as a dermal filler. Because it is entirely natural, there is the possibility that fat may be completely reabsorbed by the body. In addition:
- Fat is more technically demanding to inject than fillers
- A distorted or swollen look may result if the fat transfer is overdone
- Fat is a softer material than synthetic dermal fillers
- Fat does not exert the same force on the skin as fillers
- There will be a gradual loss of volume in the cheeks over time: 65% of the fat injected will be reabsorbed by the body. However, the remaining 35% will last for years.
Risks and Potential Complications
Fortunately, risks linked to fat transfer are rare. However, some of the complications that may occur include:
- Allergic reaction to the local anesthetic
- Permanent discoloration caused by a ruptured blood vessel at the injection site
- Calcification (hardening of soft tissue at the treatment site)
- Blood clotting at the donor site
- Formation of scar tissue
- Fat embolism (caused by fat inadvertently injected into a blood vessel)
Autologous fat transfer can cost anywhere from $350-$5,000. The cost of fat transfer to the cheeks varies widely because it is determined by the unique needs and preferences of the patient.
The most effective and accurate way to gain an idea of how much you can expect to spend is to book an appointment with a board-certified plastic surgeon whom you trust. However, expect some of the following factors to figure in what you will ultimately pay:
- The extent of cheek augmentation to be performed and number of injections necessary
- The quantity of fat to be harvested
- The type of anesthesia used
- The experience and skill level of the surgeon
- The geographic area in which your surgeon is located
- How successfully your skin retains the fat
Cheek Implant Surgery
Cheek implants, also known as malar implants, offer a permanent way to increase the projection of the cheekbones and add volume to cheeks that are recessed or lack contour. Implants come in a range of sizes, shapes and materials (solid and semi-solid) to suit diverse facial structures.
The surgery is straightforward with a proven safety record, and does not require a lengthy postoperative recovery period.
For individuals looking for a long-term solution to undefined or hollow cheeks, the greatest appeal of cheek implant surgery is that augmentation is permanent.
However, cheek implants carry a range of other benefits:
- Customized cheek implants offer balance and proportion to the face
- The materials used for implants (silicone, hydroxyapatite) are safe and biocompatible
- Hydroxyapatite implants eventually integrate with the underlying bone to become part of the facial structure
- It is a comparatively cheap surgical procedure which can dramatically improve the aesthetics of the face
- Cheek implant surgery can be carried out in conjunction with other plastic surgical procedures such as a face lift or brow lift
- The results are controllable and can range from a slight augmentation to a more marked enhancement
- Very low postoperative risks
- Implants can be used to correct facial asymmetries or congenital defects
Similar to dermal fillers and fat transfer, cheek implant surgery also has some disadvantages which must be weighed up:
- Cheek implants require surgery and anesthesia
- Contour abnormalities may develop if the implants are not correctly positioned
- Implants may shift during the healing period
- If you are unhappy with the results, revision or corrective surgery may be required
Am I a Candidate for Cheek Implant Surgery?
If you have already experimented with dermal fillers, enjoyed the results and are looking for a more enduring method of augmenting your cheeks, cheek implants may be an option worth considering.
Individuals who benefit most from cheek implants include those with:
- A weak cheek structure
- A narrow or flat face lacking contour
- Lost cheek contour due to the effects of ageing
Cheek implant surgery costs $3,500 on average. However, your surgeon can provide a more accurate estimate of how much you can expect to pay. Factors that may influence the total cost of surgery include:
- The type of facility (ambulatory, office-based, hospital) where your surgery is performed
- The expertise and reputation of your surgeon
- The geographic location of your surgeon
- Preoperative medical tests/checks
If cheek implant surgery is performed in conjunction with other facial surgical procedures, the cost can be significantly reduced.
Preparing for Surgery
Being well-prepared for surgery means a greater likelihood of achieving the results you desire, and a swifter recovery period. Follow any preoperative instructions provided by your surgeon.
The following guidelines are usually given:
- Undergo any required lab testing or medical evaluations prior to surgery.
- Provide a detailed medical history.
- Stop smoking at least 6 weeks before surgery.
- Advise your surgeon of any medication you are taking. She or he may recommend adjusting your dosage or substituting a different medication.
- Avoid taking aspirin, anti-inflammatory drugs or herbal supplements as they may increase bleeding.
- Cheek implants are generally performed on an outpatient basis in a hospital, ambulatory facility (day clinic) or office-based surgery. Ask a friend or loved one to drive you to and from surgery, and make sure you have someone to stay with you for the first night after surgery.
The Surgical Procedure: Step-by-Step
Cheek implant surgery may be performed under a local anesthetic with IV or oral sedation, or general anesthesia. Your surgeon will discuss the most suitable option with you prior to surgery. She or he will also explain your options regarding surgical techniques.
The implants can be inserted through the mouth or underneath the lower eyelids. However, it is more common to insert implants through the mouth. If the incision is made through the lower eyelids, it will be made just beneath the eyelid so it can be easily concealed by the eyelashes.
Cheek implants come in a range of materials, however, solid silicone implants are the most popular. Gore-Tex, made from expanded polytetrafluoroethylene, represents another common option. Medpor implants, made from porous polyethylene, represent a unique implant type: Medpor integrates with the facial tissue to fuse the implant with the bone over time. However, this means if removal is desired at a later date, it can be difficult.
Your preferences regarding implant technique and material type will be taken into account during your initial consultation with your surgeon. Cheek implant surgery generally takes 30-45 minutes unless it is part of more extensive facial surgery.
Surgery is characterized by the following key steps:
- Surgical markings are made on the face to guide the surgeon regarding the placement of the implants, and to draw attention to underlying structures that must be avoided.
- Anesthesia is administered. Monitors will keep track of your heart, blood pressure, pulse and oxygen saturation once you are under anesthetic.
- A small incision will be made either beneath the eyelid, or in the mouth, depending on the technique that was agreed prior to surgery.
- A pocket is made in the facial tissue to hold the implant.
- The implant is carefully inserted into the pocket using a sterilized clamp. Malar implants are inserted into the outer upper cheek to add volume and contour to the cheekbone. Submalar implants are inserted in the lower or mid-cheek region to provide fullness to a sunken face.
- The implant is positioned and secured in place.
- The incision is closed with sutures. It may also be taped with a compression or support bandage to reduce swelling.
Following the procedure, you will be taken into a recovery area where you will be closely monitored until you wake up. In most cases, patients are permitted to go home after a brief observation period.
The recovery process for cheek implants can be brief and straightforward, provided you follow your surgeon’s post-operative guidance and take good care of yourself.
It is normal to experience some bruising and swelling after surgery. Both symptoms should subside within two weeks, though swelling can sometimes linger a little longer. Cold compresses applied to the operative site may help to alleviate the discomfort.
To expedite the healing process, do the following:
- Rinse with mouthwash to diminish the probability of infection developing at the incision site (if incisions were made in your mouth).
- Avoid strenuous exercise and contact sports for six weeks after surgery or until your surgeon advises otherwise.
- Keep the head elevated for a few days after surgery to prevent fluid accumulating around the implants. You will also need to find a comfortable elevated sleeping position. The American Society for Aesthetic Plastic Surgery recommends reclining at a 45 degree angle.
- Keep the eyes lubricated with drops if incisions were made beneath the eyes.
- Eat soft nourishing foods for up to ten days after surgery as chewing may cause discomfort and disturb oral sutures; soups, mashed vegetables, hummus and yogurt are wholesome options.
- Wear the bandage provided by your surgeon for a week or more following surgery; it ensures that any swelling is minimized and the implants stay in place.
- Return to work and everyday activities based on the advice of your surgeon; for most patients, this is a week after surgery. Vigorous activity should be avoided for four to six weeks.
- Keep all follow-up appointments with your surgeon. These allow him or her to check up on your progress. Under eye stitches will be removed after five to ten days in the office, while oral stitches simply dissolve within the same time frame.
If you experience any symptoms such as bleeding that will not cease, prolonged pain or discomfort, or have any concerns about your sutures or implants, do not hesitate to seek advice from your surgeon or a physician as soon as possible.
Risks and Potential Complications
Awareness of the risks and complications linked to cheek implant surgery is vital to ensuring that you make an informed decision. However, choosing a board-certified facial plastic surgeon with experience in performing cheek implants will minimize any chance of complications.
Some complications that can arise as a result of cheek implant surgery include:
- Retraction of the eyelids, causing dryness and irritation
- Change or loss of sensation in the cheeks either temporarily or permanently
- Infection at the incision site necessitating the removal of the implants
- Adverse reaction to anesthesia
- Poor healing at the incision site
- Damage to deeper facial structures such as the nerves, blood vessels or muscles
- The need for revision or corrective surgery if you are dissatisfied with the results
Ultimately, cheek implant surgery is a quick and straightforward procedure that offers multiple benefits, a short recovery time and enduring results. After 3-6 months, you can expect to be fully healed with your final results visible. Results are permanent, and can be maintained by staying in contact with your surgeon and advising them if you notice any changes.
A survey on facial implants (both chin and cheeks) conducted by the American Society for Aesthetic Plastic Surgery reported a 96% patient satisfaction rate. Patients enjoy an improved, more balanced aesthetic appearance and boosted self-confidence as a result of surgery.
Cheek Enhancement Procedures in 2017: Latest Advancements
Exciting new advances in cheek augmentation are developing all the time as surgeons recognize the importance of midface rejuvenation. In late 2016, the Plastic and Reconstructive Surgery journal published a study on a cutting-edge new technique: a comprehensive three-step approach to autologous fat grafting cheek augmentation coined the “Boomerang Effect”.
The technique uses 3D surface imaging to ensure proper distribution of fat at three key sites of the cheek, resulting in boomerang-shaped cheek augmentation. As fat grafting cheek augmentation surgery can be technically demanding and difficult, this procedure offers a novel way to ensure well-proportioned but voluminous contours.
Another recent development has seen innovations in cheek implant material. The journal of Facial Plastic Surgery published a study in early 2017 that reported on trials using implants made of silicone covered in expanded polytetrafluoroethylene. These hybrid implants are made of a textured surface that simultaneously encourages integration and ingrowth into the surrounding cheek tissue.
Frequently Asked Questions
Can you feel cheek implants?
Some patients can feel their implants at first, however, the sensation of the implants quickly becomes normal and difficult to notice after several months. The degree to which you can “feel” the implants will also depend on whether you have silicone implants placed into a pocket in your facial tissue, or implants secured to the cheek bone.
How do I know which cheek augmentation procedure is right for me?
The best way to gain an idea of which augmentation procedure is most appropriate for you is to book a consultation with a board-certified facial plastic surgeon or dermatologist. She or he will be able to consider your facial anatomy, budget, goals and preferences, and will suggest an option or range of options that are suitable.
Is there a chance of facial scarring if I undergo cheek implant surgery?
Surgery is invasive so there is always a chance of scarring when incisions are made. However, in the case of cheek implant surgery, most procedures are performed through the mouth so any scar will be completely concealed. For surgeries carried out under the eyes, there may be a small chance of scarring but it will be concealed by the lower eyelashes.
Can cheek implant surgery be carried out in conjunction with other facial surgeries?
Yes. It is common to undergo cheek implant surgery at the same time as eyelid surgery, rhinoplasty, chin implant surgery or a facelift for more extensive facial rejuvenation.
Which dermal filler will provide me with the best results for my cheek augmentation?
Your plastic surgeon will advise you on the most suitable dermal filler for you based on your needs, preferences and goals. Generally, hyaluronic fillers such as Juvederm offer a safe, initial option for first-time patients, calcium hydroxyapatite fillers (eg. Radiesse) offer instant volume, and poly L-lactic acid fillers such as Sculptra offer more gradual results over a series of treatments.