Cheek Filler

What is cheek filler?

Cheek filler is the injection of hyaluronic acid gel into the cheekbone and cheek area of the mid-face. The mid-face is considered one of the main areas where hyaluronic acid fillers are used. Forward projection of the cheekbones and fullness in the upper cheek are thought to contribute noticeably to a youthful-looking face.

Hyaluronic acid is widely used in this area mainly because it is compatible with the body’s tissues and can be reversed. Studies of mid-face treatments have reported high satisfaction among female and male patients of different age groups. However, technique, practitioner experience and measurement methods vary from study to study, so no single standard technique has been established. This is why the plan needs to be tailored to the individual.

Because the mid-face has a layered structure, treatment in this area can also indirectly affect how neighbouring areas look, such as under-eye hollows and nasolabial folds. This calls for a plan tailored to the individual and detailed knowledge of anatomy.

When the clinic assesses a product, approval by the US Food and Drug Administration (FDA) is not the only criterion. The assessment is based on the product’s CE marking, its registration and conformity status in Türkiye, and the manufacturer’s intended purpose. Before treatment, you can ask which class of substance the product used on you belongs to and what its registration covers.

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Where does the name come from?

In Turkish, this treatment is widely known by the everyday name ‘elmacık kemiği dolgusu’ (literally ‘cheekbone filler’), but the filler is not injected into the bone. The substance is placed in the soft-tissue layers covering the cheekbone and supports the volume and contour of the tissue over the bone, not the bone itself. The names ‘cheek filler’ and ‘mid-face filler’ also usually refer to the same treatment.

Which layer the filler goes into depends on the sub-area. Studies of mid-face treatments show that upper-cheek injections near the cheekbone are placed beneath the muscle, while lower-cheek injections are placed in the tissue just under the skin. An anatomical study on cadavers also confirmed that the mid-face has two fat layers, separated by the muscle around the eye and by partitions of connective tissue.

In other words, the name describes an area, not a single procedure. Under the same name, quite different goals may be discussed, such as the prominence over the cheekbone, the inner front of the cheek or the hollow below the cheekbone. What the consultation really establishes is which sub-area and which layer the deficit is in.

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Why does the cheek lose volume?

Volume loss in the cheek is not limited to one layer. Facial fat is made up of compartments with clear boundaries, and these compartments change in different ways with age. The shift from a view that explains facial ageing by gravity alone to one that also takes volume change into account began when these compartments were described.

The superficial and deep fat compartments are separated by partitions of connective tissue and lose volume to different degrees with age. The compartments mainly affected by volume loss include the deep inner (medial) cheek compartment, the nose-to-mouth (nasolabial) compartment and the superficial middle and outer cheek compartments. It has been suggested that volume loss in the deep inner cheek fat creates a relative excess of overlying skin and contributes to the nasolabial fold looking more pronounced. This appearance is called false sagging (pseudoptosis).

In a study comparing magnetic resonance imaging (MRI) scans of the same people taken years apart, the volume and thickness of the superficial cheek fat compartments in the mid-face decreased significantly in both women and men. The upper and middle compartments shrank while the lower compartment expanded; the researchers interpreted this as a downward shift of volume within the fat tissue. In other words, loss and displacement can occur together in the same area.

An anatomical study in which a smile was simulated on cadavers showed that the mid-face consists of deep fat compartments that do not move and a superficial fat layer that moves with facial expressions. This matters for planning: the two layers may need products with different properties and different approaches. How to tell volume loss apart from sagging is explained in the guide article Volume loss or sagging?.

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Mid-face first: the under-eye area and nasolabial folds

Under-eye hollows and nasolabial folds are often considered together with loss of support in the mid-face. A review of under-eye hollows also stresses that restoring mid-face volume is important both for the result under the eyes and for the overall appearance of the face.

An anatomy-based guideline for mid-face filler points the same way: because the mid-face has a five-layer structure, injections in this area can indirectly improve under-eye hollows and nasolabial folds. In an anatomical study based on cadaver dissections, the researchers suggested that supporting the deep inner cheek fat would increase the forward projection of the cheek and soften the nasolabial fold.

In practice, this means that a shadow under the eye or a nasolabial fold may begin not where it shows, but with a loss of support in a neighbouring area. In such cases, focusing only on the line or the hollow can miss the source of the problem.

However, this is not a rule. Under-eye conditions that can overlap, such as malar mounds (swelling over the cheekbone), festoons or dark circles, are separate issues, and surgical options have also been described for some under-eye conditions. Mid-face support does not have the same effect on all of these conditions. Which factor is most important is identified at the consultation.

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Over the cheekbone, the inner front of the cheek and hollow cheeks

The cheek is not a single target. Mid-face treatments are studied by dividing the area into sub-areas such as the zygomaticomalar area (over the cheekbone), the inner front of the cheek and the area below the cheekbone. Hollows in the inner front, buccal (beside the mouth) and side parts of the cheek are also considered separately. According to an anatomy-based assessment, these hollows mostly result from age-related volume loss and structural changes.

The suggested approach is to assess separately, in each sub-area, the layered structure of skin, fat compartments, muscles, blood vessels and nerves, and to choose the right tissue layer. Anatomical differences and aesthetic expectations between Western and Asian populations are also said to change the technique and the plan. These recommendations are at the lowest level of evidence; they rely largely on anatomical knowledge and expert experience.

Differences between sub-areas can also be reflected in the results. In a controlled study using a single volumising product, the responder rate at six months and the duration of the effect differed by sub-area, and the responder rate rose as the amount injected into each sub-area increased. This study’s findings on duration are covered separately in the section How long does it last, and can it be reversed?.

A recent proposed approach draws attention to the different roles of the deep and superficial fat layers in the mid-face: the deep layer is more static, while the superficial layer moves with facial expressions. On this basis, rather than putting all the volume into one layer, it recommends treating each layer in a balanced way with a product suited to its properties. This is a suggested approach based on anatomical knowledge, not a standard tested in comparative studies.

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What does the evidence say?

For mid-face filler, the highest level of evidence comes from randomised controlled trials, in which participants are randomly assigned to groups, and these trials report significant improvement with hyaluronic acid. In a meta-analysis (an analysis that combines data from several studies) pooling five randomised trials and 748 participants, the aesthetic improvement response was significantly higher in the hyaluronic acid group than in the control group, and there was no significant increase in moderate or severe adverse effects. However, no clear difference was shown in aesthetic improvement scores at weeks 4, 8 and 24.

The researchers are also open about the limits of the evidence: hyaluronic acid fillers may not offer a clear subjective (based on personal perception) aesthetic advantage over other fillers; the current evidence is limited, and future studies need to include objective volume measurements and longer follow-up. Another analysis combining six randomised trials also found no significant difference in aesthetic improvement scores between different hyaluronic acid products.

Individual studies paint a similar picture. In a study in China with an untreated control group, in which the person assessing the results did not know which group had been treated, the responder rate at six months was 76% in the treatment group and 8% in the control group; the effect was still present in 51% of participants 12 months after the last treatment. In a randomised trial that followed 235 patients for two years, the proportion of patients who rated their cheek volume as improved was 92.8% at six months and 79% at two years; the proportion who reported reaching their treatment goal fell to 49% at two years.

These figures need to be read carefully. Most studies look at a single product, in a particular population and with a particular rating scale. These results are not a promise of how long the effect will last or of a particular result, and they are not data from this clinic. In a 52-week randomised trial comparing two products in the inner front of the cheek, scale scores were reported to partly return towards baseline after week 26, while about 70% of participants were still satisfied with the result at week 52.

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How long does it last, and can it be reversed?

Hyaluronic acid cheek filler is not permanent; how long the effect lasts depends on the product, the sub-area and the person. In a controlled study using a single volumising product, with similar median amounts injected, the effect was reported to last 24 months in the inner front of the cheek, 19 months in the zygomaticomalar area and 15 months below the cheekbone. It should also be noted that in this study a top-up treatment could be given 30 days after the first treatment. The results cannot be generalised to other products or to any one individual.

Reversibility is what sets hyaluronic acid apart from other classes of filler. The enzyme hyaluronidase breaks down the hyaluronic acid molecule and is considered the preferred way to manage complications related to hyaluronic acid fillers. However, this use of hyaluronidase is off-label in many countries (outside the uses covered by the product’s licence or approval), and doses and protocols have not yet been standardised.

According to a review of filler complications that resulted in permanent damage, hyaluronic acid fillers continue to be preferred because they are reversible, while permanent fillers increase the risk of long-term complications. Hyaluronidase is kept at the clinic.

If you have had filler in your cheeks elsewhere before, the first question is not a new treatment but what the existing filler is. In this case, you will first be asked about the type of filler, when it was injected and where. Filler of unknown type, or filler that cannot be confirmed to be hyaluronic acid, is not dissolved straight away. If you have any record of the previous treatment, it will be useful at the consultation.

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How it differs from a liquid facelift with collagen stimulators

Cheek filler and a liquid facelift with collagen stimulators can be used in the same area; the difference between them lies not in the area but in the class of substance used. Cheek filler uses hyaluronic acid. A liquid facelift with collagen stimulators treats the same area with substances that stimulate the body’s collagen production, such as calcium hydroxylapatite (CaHA) or poly-L-lactic acid (PLLA).

Studies of fillers other than hyaluronic acid in the mid-face found that the volumising effect of PLLA and CaHA appeared gradually and that patient satisfaction therefore increased over time; nodules (small, firm lumps that can be felt under the skin) were also reported in studies of these two substances. It is recommended that patients are told about this delayed effect in advance. According to a guideline for mid-face filler, however, hyaluronic acid fillers stand out in this area because the result is visible straight away and recovery time is short.

The second difference is reversibility. The enzyme hyaluronidase breaks down the hyaluronic acid molecule; how things stand with collagen stimulators is explained on the Liquid Facelift with Collagen Stimulators page. Which option makes sense for you is discussed at the consultation, based on the nature of the mid-face deficit and your priorities; in some cases, neither treatment may be suitable.

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Limits of this treatment

Cheek filler provides support for volume and contour; it does not reposition sagging tissue and is not a substitute for a surgical facelift. According to a review of the facial fat compartments, once volume loss has been corrected, laxity in the overlying connective-tissue layer and in the skin can be addressed separately. In a suitable patient, facial filler can be done on its own; however, it is often seen as a procedure that complements a surgical facelift.

The lifting effect of filler has also not been measured as clearly as is often assumed. According to a review that looks critically at filler studies, the terms ‘tightening’ and ‘lifting’, widely used in this field, have no agreed definition, no measurement standard and no threshold for what counts as clinically meaningful; all published numerical measurements reflect changes at the skin surface. The researchers stress that this does not show that fillers have no lifting effect; it shows that this effect has not yet been defined with the precision the claims require.

The second limit concerns the amount. The condition known as ‘facial overfilled syndrome’ shows itself through distorted facial features at rest and unnatural facial expressions. According to a review on the subject, the cause is not only excess volume but also anatomical mismatch, disrupted tissue mechanics and the build-up of repeated treatments. An international consensus statement also considers naturalness not only in terms of appearance but also of touch, feel and expression, and sums up the principle as ‘treat the patient, not the photograph’.

If marked skin laxity (loose skin) and downward movement of the tissue are the main issues, surgery or methods aimed at repositioning tissue, such as a thread lift, are discussed as separate options; these also have their own limits. Filler, another method or nothing at all: which option makes sense is decided by the assessment at your consultation and by your own decision.

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Blood vessels and nerves in this area

Among the areas treated with filler, the mid-face is one with a dense concentration of blood vessels and nerves. For this reason, it is recommended that the treatment area be limited according to the usual course and depth of the blood vessels in this region, and that risk be reduced through detailed knowledge of anatomy.

Below the lower rim of the eye socket, the infraorbital nerve emerges through an opening in the upper jawbone (the infraorbital foramen). This nerve carries sensation from the mid-face, the side wall of the nose, the upper lip and the lower eyelid. A CT (computed tomography) study of surgical cheek implants stated that injury to this nerve can cause loss of sensation in these areas, and found that the opening is usually in the same vertical line as the second premolar tooth. This study concerns surgery; it gives no information on how often such nerve injury occurs with filler injections.

In a study of 18 cadavers, the infraorbital artery, the artery of the same area, was found in commonly used injection sites and was shown to connect with the supratrochlear artery, the dorsal nasal artery (the artery along the bridge of the nose) and the angular artery. The study identified two danger zones: injections placed too superficially in the mid-cheek, and injections at the level of the periosteum (the membrane covering the bone) in the under-eye hollow. The researchers state that this artery may play a role in the process that leads to vascular occlusion (a blocked blood vessel), blindness and stroke.

A separate finding concerning the side of the face has also been reported. In a cadaver study of 35 cheek specimens, the facial artery was undeveloped in some individuals, and the transverse facial artery took its place, continuing as the angular artery and joining the dorsal nasal artery. The researchers suggested that blindness after injections into the side of the face could be explained by this anatomical variation.

This information is given not to put you off, but to explain why this area needs care. The doctor chooses a needle or a cannula (a thin tube with a blunt tip) individually, according to the treatment area and the person’s anatomy.

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Known risks

The most common side effects of cheek filler are bruising, swelling and tenderness; these are usually temporary. Studies of mid-face treatments have reported that these effects generally last no longer than two weeks.

A meta-analysis combining randomised trials of hyaluronic acid fillers in the face compared the mid-face, lips and area around the lips, as one group, with the nasolabial folds. There were significant differences between the areas in the rates of swelling, and of lumps and firmness you can feel; there was no significant difference in pain, redness, bruising, tenderness, itching or discolouration.

Delayed-onset inflammatory reactions are rare, but they can appear months or even years later. In an analysis combining studies of facial treatments, the frequency of these reactions was calculated as about one event for every 2,000 patients followed for one year. The time until symptoms began was a median of 3 months (shortest two weeks, longest 12 years). Commonly seen forms are nodules, redness, swelling and hardening.

A rare finding specific to the mid-face has also been reported. In a case series, three-dimensional CT scans after hyaluronic acid treatment showed bone loss (bone resorption) in the under-eye area and beside the nose. The researchers note that this finding had previously been reported only in the chin area. They add that the subject needs further research because the bones of the mid-face are thin and close to the sinuses and nerves.

The most serious risk is filler entering an artery; reported consequences include tissue loss, vision loss and even stroke. A recent review of cases of filler-related blindness reported the nose, the forehead and the area between the eyebrows as the highest-risk areas; this does not mean that the cheek is risk-free. In most of these cases where the visual outcome was reported, vision did not return. According to an analysis of vascular occlusions, early recognition and treatment are associated with recovery; for occlusions related to hyaluronic acid, the first-line treatment is hyaluronidase.

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