Concerns / Mid Face / Cheek Volume
Cheek volume loss:
why cheeks flatten
A cheek that looks flatter in the mirror is usually showing a change in structure rather than a change in skin quality.
The midface relies on three things: bone for shape, retaining ligaments for position, and fat compartments for projection over the cheekbone. When one of those layers weakens, the upper cheek starts to read as emptier even when the skin still feels reasonably smooth.
Dr Ibrahim Hawli
MBBS · Registered Medical Practitioner
Ahpra registration MED0002627622
Ahpra registration MED0002627622
In short
Cheek flattening has two separate causes that look similar in the mirror. Volume can deplete, or tissue can descend. The midface contains distinct deep and superficial fat compartments that behave differently as they age, and the ligaments holding them explain why the upper cheek can stay full while the lower cheek sags. Which of these is happening in your face determines what is appropriate, and it can only be established by examination.
01 / The Key Question
Depletion or descent?
Two patients can describe the identical concern and have entirely different underlying changes.
Depletion
Volume has reduced
The compartments that project the cheek forward over the bone have lost bulk, so the face reads as flatter and less supported.
Descent
Volume has moved
The volume is still present but sits lower. The upper cheek looks empty while the lower cheek looks heavier.
Facial ageing research describes both occurring together: deflation of the deep medial cheek and buccal fat, followed by an inferior shift of the superficial medial cheek fat, with weakening of the retaining ligaments contributing to visible concavity and a flatter midface.
The reason this matters is practical. If the change is descent and it is assessed as depletion, the response addresses the wrong problem. Establishing the balance between the two is the first job of an examination, and it is done by palpation and by comparing your face at rest with your face when lying back, not from a photograph.
02 / Anatomy
What the cheek
is actually made of
The compartments are not one blended mass. The deep compartments include the medial and lateral sub-orbicularis oculi fat and the deep medial cheek fat. The superficial compartments include infraorbital, medial cheek, middle cheek and nasolabial fat.
Worth noting: the commonly used term “malar fat” is described in the literature as probably a misnomer, because the region contains both distinct superficial and deep compartments rather than a single pad.
01
Skin
Dermis, thinning with age as collagen and elastin reduce.
02
Superficial malar fat pad
The layer most people mean when they say cheek fat.
03
Orbicularis oculi
The ring shaped muscle around the eye, extending down into this region.
04
SOOF, within the deep malar fat
Sub-orbicularis oculi fat, supporting the lower eyelid area.
05
Facial expression muscles
Zygomaticus muscles and levator labii superioris.
06
Preperiosteal fat
A thin layer directly over the bone covering.
07
Periosteum and bone
The foundation.
03 / The Pattern
Why the upper cheek can stay full
while the lower cheek sags
This is the pattern patients describe most often, and there is a clear anatomical reason for it.
The zygomatico-cutaneous ligaments run diagonally from the deep periosteal layers up to the skin, travelling from the upper inner part of the cheek to the lower outer part. They anchor tissue in place.
Above the ligament
Fat including the SOOF and malar fat is stabilised by the tear trough ligament and the orbicularis retaining ligament, and does not sag significantly.
Below the ligament
Fat including the nasolabial and medial cheek compartments loses both volume and support, so it descends.
Your face is not ageing unevenly by accident. It is ageing according to where the ligaments are.
04 / Connected Areas
Why cheek change affects
the lines beside your nose
Many patients arrive concerned about the folds running from the nose to the corners of the mouth, and are surprised when the cheek comes up.
A cadaver study using fourteen hemifacial dissections established that reduced volume in the deep medial cheek fat compartment creates an excess skin envelope and the illusion of a more prominent fold beside the nose. The study named this pseudoptosis, meaning a false appearance of drooping.
In plain terms: the fold looks deeper not because the fold has changed, but because the support behind and above it has reduced.
This is why the cheek and the nasolabial region are assessed together rather than as separate items, and why addressing the fold in isolation can produce a result that does not look like what the patient hoped for.
05 / The Evidence
What the research shows,
including where it disagrees
The imaging research on midface ageing does not all point in the same direction, and being straight about that is more useful than a confident claim.
Longitudinal imaging
Shows measurable loss in the midface over time.
Superficial fat study
Found superficial cheek fat remained stable as subjects aged from roughly fifty to sixty, with no significant change in total volume or redistribution.
Both can be true, because the cheek is layered. One compartment can hold its fullness while another empties. That is precisely why the region has to be read as separate layers rather than as one mass, and why a general statement such as “your cheeks have lost volume” is not an assessment.
Individual results vary. Not all people are suitable candidates.
06 / Causes
What causes cheek
volume change
These changes often begin in the twenties but become more noticeable in the forties and fifties, and in women particularly around and after menopause due to hormonal change.
01
Deep compartment reduction
The compartments providing forward projection lose bulk. The most common single contributor.
02
Ligament weakening
As the retaining ligaments attenuate, tissue that was held high begins to sit lower.
03
Bone change
The maxilla and surrounding bone remodel gradually across decades, reducing the foundation beneath the soft tissue.
04
Skin changes
Loss of collagen and elastin means the contour shows through, and the skin envelope no longer fits the reduced volume beneath it.
Weight loss
Produces the same appearance at any age. Facial fat reduces along with body fat, and the midface shows it early. If your cheek flattening followed significant weight loss, that is likely the primary driver rather than ageing.
Sustained very low body fat
As maintained by endurance athletes, this has the same effect for the same reason. It is not the training itself but the maintained low body fat.
07 / Assessment
How cheek volume
is assessed
Grading scales exist for midface volume change, describing the progression from mild flattening, through hollowing below the cheekbone prominence, to substantial indentation. These are useful for recording a baseline and reviewing change over time rather than for deciding anything on their own.
- Whether the change is primarily depletion, descent, or a combination, established by palpation
- Position of the cheek fullness relative to the cheekbone and the orbital rim
- The contrast between upper and lower cheek, which indicates ligament behaviour
- Depth of the folds beside the nose, and whether they change when the cheek is supported manually
- Skin quality, thickness and elasticity, since the envelope matters as much as the volume
- Asymmetry between sides, which is very common and often unnoticed by the patient
- Whether recent weight change, hormonal change or medical history explains the pattern
- Whether anything is clinically appropriate, including the option of nothing
08 / Before You Decide
What to know before
your consultation
Every option carries potential risks as well as potential benefits, and no cosmetic medical procedure is risk free. The midface contains vascular structures and numerous perforating vessels, particularly around the ligamentous zones, which is why anatomical knowledge and in person examination matter here.
Bring a list of your current medications, and a photograph from several years ago if you have one. For this region in particular an older photograph is genuinely useful, because it shows where your fullness used to sit.
Assessed at consultation
Factors that may make an approach inadvisable
- Pregnancy or breastfeeding
- Active infection or inflammation in the area
- Certain autoimmune or connective tissue conditions
- Certain medications, including blood thinning medication
- Unexplained rapid facial fat loss, which should be investigated medically first
- Previous facial surgery or trauma affecting the midface
- Unrealistic expectations about achievable change
In some cases the appropriate recommendation is that nothing be undertaken.
09 / What Happens
What happens at your consultation in Glenroy
Appointments run 30 to 45 minutes. A consultation fee applies and is confirmed when you book. No referral is required.
01
Discussion
What you have noticed, when it changed, any recent weight or hormonal change, medical history, current medications and previous cosmetic work.
02
Assessment
The midface is examined seated and reclined, with palpation to distinguish depletion from descent. Cheekbone position, ligament behaviour, fold depth, skin quality and asymmetry are assessed.
03
Information
What is clinically appropriate, what it involves, expected timeline, risks, alternatives and the option of proceeding with nothing.
04
Decision
You are not asked to decide on the day. Time to consider information is part of informed consent.
10 / Service Area
Assessment for patients across Melbourne's northern suburbs
Tajmeel Cliniq is on Glenroy Road, close to Glenroy Station and the Pascoe Vale Road corridor. Patients attend from Glenroy, Oak Park, Pascoe Vale, Hadfield, Gowanbrae, Fawkner, Broadmeadows, Moonee Ponds, Campbellfield, Craigieburn and Roxburgh Park.
The clinic is on Level 1. Street parking is available on Glenroy Road and adjacent side streets.
Opening hours
- Sunday10am to 5pm
- Monday10am to 5pm
- TuesdayClosed
- Wednesday10am to 5pm
- Thursday10am to 5pm
- FridayClosed
- SaturdayClosed
Tajmeel Cliniq
Level 1, 10 Glenroy Road, Glenroy VIC 3046
0404 342 222
info@tajmeelcliniq.com.au
Level 1, 10 Glenroy Road, Glenroy VIC 3046
0404 342 222
info@tajmeelcliniq.com.au
11 / Common Questions
Questions patients ask
about flat cheeks
If your question is not answered here, ask it at your consultation. There is time set aside for exactly that.
Usually a change in structure rather than skin. The compartments that project the cheek forward over the bone lose bulk, the ligaments holding tissue in place weaken, and the bone beneath remodels. All three reduce support, so the cheek reads as flatter.
Both are possible and they look similar in the mirror. Volume can deplete, or tissue can descend while the volume remains. The distinction is established by palpation and by comparing your face seated with your face reclined. It changes what is appropriate.
Yes. Research using cadaver dissections established that reduced volume in the deep cheek compartment creates an excess skin envelope and the illusion of a deeper fold beside the nose. The fold may not have changed. The support above it has.
Because of where the ligaments sit. Fat above the retaining ligaments is anchored and does not sag significantly. Fat below and outside that anchoring loses both volume and support, so it descends. The contrast you are seeing follows the ligament pattern.
Yes, and at any age. Facial fat reduces along with body fat and the midface shows it early. Sustained very low body fat has the same effect. If your change followed significant weight loss, that is likely the main driver.
Midface changes often become more noticeable in the forties and fifties, and in women particularly around and after menopause, which is attributed to hormonal change.
Because the cheek is layered, and one compartment can hold its fullness while another empties. Distinguishing depletion from descent requires palpation and examination in more than one position. It cannot be done from a photograph.
A consultation fee applies and is confirmed when you book. Call 0404 342 222.
Related concerns
The midface is assessed as a whole
Written and medically reviewed by
Dr Ibrahim Hawli
MBBS. Level 1 Certification, American Academy of Aesthetic Medicine. Advanced training in non surgical rhinoplasty with Aesthetic Intelligence.
Ahpra registration MED0002627622. Dr Hawli practises cosmetic medicine at Tajmeel Cliniq in Glenroy, Melbourne, and conducts every consultation in person.
Last reviewed: [insert month year] · Next review due: [insert month year]
Your first step is
an assessment.
0404 342 222 · Level 1, 10 Glenroy Road, Glenroy
This page provides general information about cosmetic medical consultations and does not constitute medical advice. Any cosmetic medical procedure carries risks. Individual outcomes vary and not all people are suitable candidates. Any decision follows an individual consultation and assessment with a registered medical practitioner. Dr Ibrahim Hawli, Ahpra registration MED0002627622.