Filler Cheeks: A Bright Idea? The “Eyes” Have It

Richard G. Fried, MD, PhD

Dr. Fried is in private practice, Yardley Dermatology Associates, Yardley, Pennsylvania. Disclosure: Dr. Fried is a consultant or speaker for Allergan and Bioform Medical.

The evolving field of facial volume restoration is changing our concept of facial rejuvenation. The older concept that “tighter is better” has been largely supplanted by a philosophy recognizing the importance of volume distribution as a defining characteristic of a more youthful face. It is well recognized that restoration of volume in the upper face can lessen or reverse the bottom-heavy, deflated appearance of the aging face. Perhaps of equal or greater importance is the change in light-reflectance patterns that illuminate the upper cheeks and the eyes. The resultant brighter and “perkier” cheeks can change the objective appearance and the patient’s self perception of youthfulness. In this commentary, the author describes techniques to enhance outcomes and patient satisfaction and presents the results of a patient self-report pilot study assessing patient post-injection mood state and functioning.

The evolving field of facial volume restoration is changing our concept of facial rejuvenation. The surgical interventions of past decades implemented with the “tighter is better” philosophy often resulted in a tight but unnatural, even cadaverous, appearance that did not bespeak youth.

The availability of collagen and hyaluronic acid fillers paved the way for correction of specific and localized manifestations of volume loss, such as the nasolabial folds, tear troughs, glabellar creases, and perioral and periorbital rhytides. Clinical outcomes were often very satisfying for patients and clinicians. Stigmata of volume loss and aging were often ameliorated by removing or reducing visual cues observed by patients themselves and others.

A shortcoming of these more localized interventions and viscosity of hyaluronic acid fillers is that they often do not change the overall volume distribution of the face unless very large volumes are utilized. As has been noted by Werschler and other authors,[1,2,3] the youthful face has a fullness and elevation in the upper quadrants with a narrowing or tapering toward the perioral region and chin. It might be said that the older face becomes deflated and somewhat “bottom heavy.” The colloquial expression “why the long face?” illustrates our tacit understanding that deflation and elongation of the face is associated with an older and sad state. The availability of more viscous and durable fillers, such as calcium hydroxylapatite and poly-L-lactic acid, have allowed for volume restoration procedures that more effectively return facial proportions to those of a more youthful age.[4–5]

Illuminating Perspective
In general, it can be argued that the responsibility of the cosmetic surgeon is to offer and perform those procedures that produce a natural appearance with objective clinical benefit. Specifically, I refer to those procedures that can restore features reminiscent of the patient’s own more youthful appearance. Well-chosen procedures can make the patient look more relaxed, better rested, more youthful, less stressed, less angry, happier, more receptive to others, and healthier. Attractiveness is often enhanced and restored by injector attention to symmetry, lip volume, oral comissures, volume redistribution, and dynamic wrinkling.

I believe that skin reflectance, brightness, and adequate fullness are key features of a youthful, healthy, and rested appearance. Supporting this contention is the fact that many of our colloquial references to youthfulness allude to reflectance, illumination, and volume. Youthful, happy, vibrant, intelligent, and enthusiastic people are described as “beaming with enthusiasm,” possessing a “bright idea,” having a “radiant glow,” delivering a “shining or polished performance,” and having a “sparkle” or “glimmer” in their eyes. We also say people are “full of life,” “filled to the brim,” and “overflowing with enthusiasm.”

In contrast, colloquial expressions describing the older, tired, aged individual include washed out, drained, dull, droopy, deflated, sunken, and spent.

Death Valley
The tear trough region is the concavity spanning from the infraorbital crease to the elevated portion of the medial and lateral cheek unit. It forms and enlarges with aging as a result of numerous factors including volume loss, bony loss, and skin laxity. The volume loss and laxity in this region often results in a tired, washed out, sunken, and wasted appearance. Extensive interviews with patients have revealed an amazingly consistent propensity for the human eye to be drawn to these concavities. Perhaps it is the subconscious recognition and recollection that gravely ill people often develop a wasted or emaciated appearance in this facial region. To further accentuate this area and “add insult to injury,” the convergence of ambient light in the concavity often results in the appearance of significant darkening. This darkened appearance may be partially caused or accentuated by the Tyndall effect. To reiterate, our own gaze and the gaze of others is often drawn to this sunken and seemingly darkened area. The underlying cheek unit in aging patients is often deflated or droopy, further accentuating the dull, volume-depleted status. In fact, to demonstrate the light-refraction contribution, gently retracting the cheek unit downward often reveals much less actual darkening with distention and elevation of the involved skin. The cosmetic changes resulting from this constellation of volume loss and light refraction can change the focal point upon which the observer’s gaze is directed. Rather than being attracted to “bright eyes” with pupil to pupil contact, attention is drawn inferiorly away from the eyes and deep into this sunken area. Interestingly, the brightness and vibrancy of the eyes themselves do not diminish with age, even more reason for patients to use the tools we have to “raise the gaze.”

Restoring Youthful Reflectance: Raising the Gaze
Use of fillers to restore the more youthful reflectance pattern from the cheeks and eyes is youth restoring.[6–7] This is a powerful rejuvenation technique that is often performed intuitively by clinicians. Using fillers to elevate the medial cheeks and efface the concavity below the infraorbital rim enhances the reflectance patterns creating a brighter appearance. These changes allow for a more vibrant appearance and an elevation of the gaze to meet the eyes, moving the gaze upward from the previously depressed cheeks and an infraorbital concavity. This approach is in contrast to the common practice of filling only the infraorbital sulcus with a hyaluronic filler, sacrificing sufficient attention to the cheek unit. Specifically, simply filling the infraorbital hollow may not be sufficient to effectively change light reflection, lift the gaze, and brighten the eyes. Filling the upper cheeks with calcium hydroxylapatite or poly-L-lactic acid approaching the inferior orbital rim provides a fuller, more natural volumization and brightness that can be immediately appreciated by both the injector and the patient. Depot, linear threading, and cross-hatching injection techniques into deep dermis have all been described. I encourage reasonably firm massage to assure even layering and to minimize the likelihood of nodule formation. Injecting into the infraorbital sulcus or too superficially substantially may increase the incidence of nodule formation. Combination treatment with injection of 1.5 to 3.0cc of calcium hydroxylapatite or 2 to 3mL of appropriately diluted poly-L-lactic acid into the cheeks and 0.5 to 1.0mL of a hyaluronic filler placed into the infraorbital sulcus can further enhance cosmetic outcomes. Hyaluronic acid fillers can be safely used in the cheeks; however, due to their less viscous nature, more product is needed to achieve cheek contouring and elevation, and product degradation is usually more rapid. Avoid overfilling of the cheeks. A natural nonaugmented appearance is always the goal. More product can always be added on a follow-up visit if needed or desired.

Helping patients see the lackluster appearance of their cheeks and appreciate the negative and distracting effect of their infraorbital concavity is an important preoperative strategy. This usually paves the path to the “wow” of happiness that is spontaneously uttered when they see the immediate post-injection brightening of their cheeks and eyes. A simple preoperative maneuver can emphasize the existing volume and architectural deficiencies while providing a bit of “cosmetic foreshadowing.” While the patient holds the mirror, place three or four fingers on the inferior mid cheek and gently elevate the cheek unit. Observe together with the patient the enhanced reflectance and glow that emanates from the new convexity of the elevated and inflated cheek. I must stress that often only a modest amount of filler (0.5–2.0cc) is required to achieve this goal. Seconds after injection, patients can see themselves as brighter, more rested, perkier, and more youthful in appearance. The light reflectance brightens their eyes and gives them a “sparkle.” Often, there is a return of the “pupillary locking” of youth, pupil to pupil rather than pupil to hollow of infraorbital volume loss. For many, there is a sudden and joyful rediscovery of a youthful reflectance and animation of the eyes.

The Evidence
A recent study utilizing a 32-question, quality-of-life, happiness, and activity level self-report questionnaire was carried out in a suburban dermatology practice in the Philadelphia area. The questionnaire was given to patients on their first follow-up visit following treatment with 1.5 to 3.0cc of calcium hydroxylapatite. Treatment was performed in the manner described earlier in this article with emphasis on cheek augmentation and restoration of a more youthful infraorbital reflectance. Product placement remained inferior to the infraorbital sulcus in order to minimize the likelihood of nodule formation. A similar questionnaire was recently utilized to assess the emotional and functional effects of onabotulinum A treatment.[8] The self-report results are presented in Table 1.

It appears that calcium hydroxylapatite injected in the upper cheeks can enhance patient satisfaction regarding appearance. Patients reported feeling more attractive and happier, more confident, more optimistic, more likely to go out, more sexually confident, more comfortable with others, more social, more amorous, less irritable, and more in control. They also reported more energy, better eating habits, less anxiety, and more productivity. A significant limitation of this study is the small group size, reliance on self-report data, and failure to correlate self-report data with objective clinical improvement. Larger studies with a more objective measure of functional status are warranted. In the interim, I suggest that “filler cheeks” for our patients may be a bright idea that can restore feelings of a brighter and more youthful time in their lives—why not reflect upon it?[9]

1.    Werschler WP. Treating the aging face: a multidisciplinary approach with calcium hydroxylapatite and other fillers, part 1. Cosmet Dermatol. 2007;20(11):739–742.
2.    Werschler WP, Smith S. Mechanism of action of poly-L-lactic acid: a stimulatory dermal filler. J Drugs Dermatol. 2007;6(1 Suppl):18–20.
3.    Beer K. Popular treatments for 2010. Skin and Aging. 2011;19(3):23–24.
4.    Sapijaszko MJA. Dermal fillers: ever-expanding options for esthetic use. Skin Therapy Lett. 2007;12(8):4–7.
5.    LaTrenta GS. The aging face. In: Atlas of Aesthetic Face and Neck Surgery. Philadelphia, Pa: Saunders; 2004:46–66.
6.    Alam M, Yoo SS. Technique for calcium hydroxylapatite injection for correction of nasolabial fold depressions. J Am Acad Dermatol. 2007;56:285–289.
7.    Fitzgerald R, Graivier MH, Kane M, et al. Update on facial aging. Aesthetic Surgery. 2010;30:11S–24S.
8.    Fried RG, Werschler WP. The botulinum toxin experience: results of a patient self-report questionnaire. J Clin Aesthet Dermatol. 2009;2(11):37–40.
9.    Fried RG. Remember me? Helping patients come face to face with aging. Skin and Aging. 2009;17(10):42–44.