The primary aging change in the cheek area consists of a combination of deflation and descent of the cheek fat pads, creating a hollowed appearance below the lower lids and deepened nasolabial folds (oblique lines which extend from each side of the nose to the area beside the corners of the mouth). Descent of the midface/cheek fat pad can also contribute to the exaggeration of marionette lines and downturning of the corner of the mouth.
This aging change is significant, but is often not fully appreciated as a feature which can age the face considerably. When I see a person who is in their sixties or older but doesn't 'look their age' (but hasn't had plastic surgery), quite often they will have cheeks which are full and prominent, a feature that the brain immediately associates with youth. Look at an infant!
Cheek area rejuvenation by mean of a mid face lift can be performed as part of a facelift procedure, but is also sometimes performed alone to specifically address deflation and descent of the cheek fat pad. The procedure is performed through two hidden incisions. One is made inside the mouth, at the apex of the space between the gums and the lower cheek. The second incision is hidden behind the hairline of the temple area. Through the intra-oral incision, the cheek fat pad is freed from the cheekbone. A suspension suture is used to grasp the cheek fat pad, and the suture is then passed below the skin to the temple-area incision. Upward traction on the suture elevates the cheek fat pad, and with it the corner of the mouth is elevated slightly. The nasolabial folds soften and in some cases can be almost completely eliminated. The suspension suture is then anchored to the deep soft tissues below the scalp, producing a permanent elevation of the midface.
A technique which does not require incisions or sutures and which I find applicable to more and more patients is structural fat grafting, which involves carefully and painstakingly grafting (by micro-injection) a patient's own fat into areas which benefit from volume restoration. This is an excellent alternative for facelift patients who have flattening of the midface without significant aging changes in the nasolabial folds or oral commissures (corners of the mouth). In selected patients, I have found this to be a powerful but less invasive means of restoring cheek volume and projection.
Structural fat grafting can also be utilized in patients undergoing a midface lift, if additional enhancement of the lateral aspect of the cheekbones is desired. The midface lift and structural fat grafting, alone or in combination, allow me to restore or create youthful cheek and lower lid contours, without the need for cheek implants. Aside from the associated risks of migration, infection, and bone resorption, I feel that cheek implants tend to produce results that are not natural-appearing, and for that reason I do not use them in any facial rejuvenation procedures.