Face Q&A: For Sunken Hollow Cheeks, Fillers, Fat Injections or Facelift?

Question – Below my cheekbone a hollow channel is inching towards the center of my face. I had a facelift two years ago and cannot figure out what is causing this. What can be done to correct this?

The facelift was two years ago. On one cheek, just below my cheekbone and along the path of the lift, a hollow channel has been inching toward the center of my face. The doctor has assured me that this was not a thread lift. The hollow is about 1.25″ in width. The skin above it is taut and looks lifeless. The hollow keeps lengthening and it looks awful. What could be happening? And can anything be done to stop it and/or correct it? – via RealSelf

Answer – Given that your facelift was two years ago, there are a couple possible reasons for why your cheeks now appear hollow/sunken based on the details you provided in your question: One possibility is that your surgeon did more ‘pulling’ & ‘tightening’ of your skin and not enough/any fat or tissue reposition. Another possibility is that you’ve experienced some fat re-absorption within the cheek area in the 2 years since your facelift as a result of weight loss, changes in diet, and/or BMI. The good new is that there are a few ways to replace the volume you’ve lost, which I’ll detail below.

How an overly tight facelift can cause hollow cheeks

Without before and after photos, it’s difficult/impossible for me to diagnosis what’s causing your cheeks to appear hollow after facelift surgery. That said, hollowing of the cheeks is most likely a result of how the skin was repositioned/draped during your previous facelift surgery. Not only does overly tightened/pulled skin create the ‘joker’ look so many over-done facelift patients have, but also, excessive hollowness in the mid-face region just below the cheek bone.

Facial wrinkles

Diagram of facial skin

Natural causes of sunken/hollow cheeks

Of course, more often than not, hollow cheeks develop naturally rather than as a result of a facelift or facial surgery.

As we age several things happen to cause the ‘sunken cheek’ look. First, gravity moves the soft tissues, skin, fat etc. down toward the jaw line. This is why we get jowling. The soft tissue of the cheeks is actually located on the lower side of the cheek bone and as it falls, the cheek bone becomes accentuated while the skin below sinks inward. Second, is the loss of good fatty tissue in the face.

How weight loss, thin skin and/or exercise causes sunken, hollow cheeks

Individuals with thin, low-fat faces can still end up with an excellent looking facelift, as long as care is taken to make the most out of the fatty tissue that’s available and if need be, restore volume to hollowed out areas *before* tightening and re-draping the skin. Here is an example of one such case, where the patient has a thin face, but not hollowing:

Before & After SMAS Facelift - note how the saggy tissue has been moved from the jowls to the upper and mid face.

Before & After SMAS Facelift – note how the saggy tissue has been moved from the jowls to the upper and mid face.

If your face is not thin and the bottom is plump, then you still have fat on your face. People who are underweight or have very low body fat often have hollowing of the cheeks because the more exposed the cheekbones are, the more shadowing there will be beneath them. And it’s the shadowing that creates and/or exaggerates the sunken or hollowed out cheek This causes exposure of the actual cheekbones and results in a shadowing below the bone line. No matter how a facelift may tighten up any excess skin, the contour of the face will still look the same, because there was no fat that could be lifted upwards to re-contour the face.

Before & after facelift on face with sunken cheeks and jowls

Patients with plenty of subdermal fat in the jowls and lower face often end up looking several years younger after facelift than equally aged patients with thinner skin because all of that fat can be moved back to where it was 10+ years ago, within the mid and upper face.

In other words, patients who exercise a lot, have very little body fat and good bone structure often need more than a facelift to obtain the full, youthful look a well performed facelift creates. Why? Because a true facelift is more about lifting and repositioning fat that has drifted down, over time, from the upper cheek to the lower cheek and from the mid cheek to the jowls than it is about pulling and removing loose/excess skin.

One thing I learned during my surgery fellowship at MEETH in NYC was that patients who were in their late 40’s to early 50’s that prior to surgery presented with some areas of facial hollowing – particular below the cheekbones – in the early post-operative period they looked altogether great. But long-term, it became clear that the initial result benefited from post-operative swelling. However, once the swelling subsided, their faces did not look quite as refreshed or youthful as the faces of patients with more subdermal fat. The reason for this was because the thinner facelift patients have far less saggy fat in the face to reposition into the areas of the upper and mid face that need it to create a fuller, more youthful looking appearance.

Before & after facelift on face with sunken cheeks and jowls

This 60 year old woman underwent a 4 lid blepharoplasty (eyelid lift) and standard facelift where the deeper fascia were placated and liposuction of the neck was performed. Instead of an over operated (or ‘pulled too tight’) appearance, she looks natural, radiant, and refreshed just like she did 10 or so years ago – this is the sign of a facelift done right. Click here to view all angles.

So I learned, very early on, how best to handle facelift cases in which the patient presented with thin skin and an angular bone structure.

The Good News Is: Hollow cheeks = a ‘correctable’ condition

A lot has happened since the 80s and 90s … we now have several ways to restore volume to areas of the face that have lost it (as a result of aging, weight loss, genetics, or even a overly tight facelift).

One option to consider for facial hollowing before considering fat grafting, fillers or Sculptra would be to gain some weight. It doesn’t cost any additional surgical fee, and there is no surgical risks, and it is completely reversible.

Another option is to reduce the overall shadowing of the face by filling in the hollow area under the cheek bone with either fat or dermal fillers.

Options for correcting sunken/hollow cheeks

#1 – Facial Fillers (e.g. Juvederm, Sculptra and Radiesse)

In post-facelift patients, either Juvederm or Sculptra will fill out your mid-face nicely. The former is one of the most popular ‘hyaluronic acid fillers’ while the later is a longer-lasting, next-generation dermal filler option that effectively smooths the creases, wrinkles, and folds that appear because of lost volume. Like natural collagen, Sculptra keeps skin hydrated and elastic. For the best results, you may have to invest in several treatments before you reach the optimal level of volume replacement. I often recommend this injectable gel to my patients because of its longer-lasting results – up to two years or more according to their clinical studies.

Before & after dermal filler for sunken hollow cheeks

This patient’s hollow cheeks, while not the result of a bad facelift, provide an excellent example of the effectiveness of fillers (in this case, 2 treatments/syringes of Sculptra) for restoring volume to the mid-face (malar & submalar) area. Note the difference in submalar ‘fullness’ between the photo taken before the 1st Sculptra treatment and photo taken 6 months after the 2nd treatment.

In most cases however, I tend to prefer Juvederm and/or Restylane, because they’re inherently safer and show results almost immediately. Downside is that Juvederm & Restylane dissolves more quickly than Sculptra (re: 9-12 months vs 2+ years).

While more and more plastic surgeons seem to be promoting fat transfer as the single best option for filling out all areas of the face, I don’t believe it’s the best option for correcting sunken hollow cheeks. The reason for this is that fat does not survive particularly well in the hollow area under the cheek bones and should only be injected at or above the cheekbone but not below it. Fat also tends to look puffy/lumpy when injected below the cheek. Fat can be injected along the jawline and it will not look puffy or lumpy, however fat injected into both the cheeks and jawline will actually accentuate the hollow under cheek area and give you a “butternut squash look” for a while. So my advice would be to steer clear of fat for sunken hollow cheeks!

This leaves us with the dermal fillers like Sculptra, Radiesse and Juvederm/Restylane. When injected properly by a surgeon with experience using the product, Sculptra can do an excellent job filling out a hollow area below the cheek bones. It will not look puffy, as the example case above does a great job demonstrating. However, Sculptra takes time to build up, is more expensive than other fillers like Juvederm and Restylane, and ultimately will need to be repeated every 1-2 years, although at a lesser amount than the initial treatment. Radiesse can give a more immediate improvement without as much down time as Fat transfer, but it can’t be used very close to the eye in the tear trough area. So I still use Restylane around the eyes.

I think that there are not perfect fillers, but you have to know the Pro’s and Con’s of each before deciding that you prefer one over another.

#2 – Fat Injections

Another option to replace lost volume in your cheeks after a facelift is autologous fat grafting. While Sculptra and Juvederm are laboratory-made gel fillers that mimic naturally occurring collagen, fat can be harvested from your own body and used as a “dermal filler”. If you choose this option though, the cost could be significantly higher since it will require some minimally invasive liposuction to harvest the fat. Injections are very small and several treatments would be necessary. Your surgeon can/will store your harvested fat for future treatments.

#3 – Weight Gain

As discussed above, gaining a little weight often will help fill out hollow areas below the eyes, above the cheek and below the cheekbone. Conversely, loosing weight and/or lowering your BMI (body mass index) will hollow out these areas. Case in point, Matthew McConaughey:


Excessive weight loss has aged and hollowed out Matthew McConaughey’s face.

#4 – Facelift Revision

Another option for correcting your hollow cheeks is facelift revision surgery. Without seeing the patient in person, it is hard to assess their need for a facelift revision. This option would be determined on a case by case basis. If the hollow cheeks could be corrected with one of the three options above, I would not suggest a facelift revision. The need for a facelift revision will depend on the severity of the hollow cheeks as well as the patients wants and needs. During a consultation, I will talk to my patients to fully assess their situation and determine if a facelift revision is necessary.

Last but not least…

While mini and micro surgical face lift alternatives are available, I would advise you to consider minimally invasive dermal fillers to treat hollowing of the cheeks. The ultimate goal of a facial cosmetic surgery is to restore the youthfulness to the face. All of these procedures, from facelift to Juvederm injections, require the steady hand and artist’s eye of a skilled and experienced plastic surgeon. More often than not, complications occur when an inexperienced surgeon tries to do too much with what the patient’s skin and tissue gives them (e.g. overzealous repositioning and/or tightening of the skin, over-use of fillers, over-focus on a single area of the face, etc.).

So please make sure to do your homework before selecting a plastic surgeon to perform your facelift or any other facial procedure such as blepharoplasty.

Look at before and after photos, read reviews and ask about pricing/financing information. Most of this information is readily available to you, and I recommend taking the extra time to ensure you have a clear understanding of what is and isn’t possible, and what you and your surgeon’s expected results are.