Cheek Enhancement

As the name suggests cheek enhancement or augmentation is to add volume or lift the cheeks by surgical (using fat graft, cheek implants) or non-surgical (using injectable fillers) means.

Techniques of cheek enhancement:
1. Injectable Dermal and Soft Tissue Fillers:
These nonsurgical cosmetic treatments are more popular than surgical intervention. The technique is based on the surgical concepts and for maintenance and longevity of the results the strategy of injection, minimal downtime, and combination with other nonsurgical techniques is required.

The commercially available dermal fillers include:

• Collagen-based fillers

• Volume replacement fillers such as hyaluronic acid

• Biostimulatory fillers such as calcium hydroxyapatite and poly-L-lactic acid.

1.1 Hyaluronic acid–based fillers
For the temporary effect, the hyaluronic acid-based fillers are used. Their temporary effect is due to the higher rate of degradation, which is inversely proportional to the amount of crosslinking in the filler and amount of hyaluronidase formation in case of adverse events.

Indications for hyaluronic acid-based fillers include the zygomaticomalar area, anteromedial cheek, and both subcutaneous and supraperiosteal injection sites areas, the nasolabial fold and tear trough.

1.2 Coralline calcium hydroxyapatite
It is indicated in the augmentation of the facial skeleton over the anterior maxilla, zygoma, and mandibular body.

1.3 Poly-L-lactic acid
It is traditionally used in the treatment of human immunodeficiency virus (HIV)-mediated lipodystrophy, however, it has got traction in the cosmetic medicines. It is injected subcutaneously to augment skin creases like the nasolabial fold by stimulating fibroblasts to produce collagen.

1.4 Autologous fat
For soft tissue filling autologous fats procured from the thighs or the anterior abdominal wall are used. It is used in the voluminization or contour problems in the nasolabial, nasojugal, malar, or submalar areas. It is injected either subcutaneously or preperiostealy. It also gives a temporary effect as 50% of the initial volume gets resorbed.

Complications of fillers:

• Hyaluronic acid in high concentration given superficially leaves a bluish tint to the skin, the “Tyndall effect”.
• If injected intravascularly can produces soft tissue necrosis, blindness, and stroke.
• Other common complications include overfilling or underfilling, inappropriate tissue depth or location or filler, and infectious or allergic complications.

Complications created after use of hyaluronic acid–based filler can be resolved partly with hyaluronidase.

2. Implants
The most common types of implants are:

• Silicone
• Porous polyethylene

The procedure is performed under either local anesthesia, intravenous sedation or general anesthesia. The choice mainly depends upon the surgeon’s preference. Based on the type of material different sizes of incisions are required. Commonly, the incision of few millimeters in length is required. The site of incision is also a surgeon’s choice. Some prefer cheek implant through incision inside mouth while others prefer through incision under eyelids. The solid cheek implants gives permanent effect.

2.1 Silicone implants
These are more advantageous than others. The advantages include customizability due to simple cutting procedure with a scissor or a blade, easy removal, and higher flexibility that allows placement through a smaller incision.

2.2 Porous polyethylene implants
The advantages of porous polyethylene implants include permanent effect due to soft tissue integration, customizability.

Complications of implants:

• Infection and/or extrusion of the implant

• Hematoma and/or persistent swelling

• Deformation of the overlying soft tissues due to encapsulation of the implants

• Malpositioning despite of screw fixation

For resolving most of the complications the implant is required to be removed.

Other techniques of cheek enhancement:

• Rhytidectomy: Used as an adjunct with other techniques to treat skin excess

• Osteotomy