Sagging cheeks

Cheek sagging is a component of multilayered facial aging. Changes do not occur uniformly or within a single anatomical plane. They include:

• The skin and extracellular matrix. With age, the quantity and quality of collagen decrease, elastic fibers become fragmented, glycosaminoglycan content declines, and fibroblast activity is reduced. The skin becomes thinner, less elastic, and less resistant to gravitational forces. Photoaging further exacerbates collagen degradation by matrix metalloproteinases.
• Facial fat compartments. Adipose tissue does not form a uniform layer, but is divided into superficial and deep compartments. Some of them lose volume, while others may undergo relative enlargement or displacement. Atrophy of deep fat in the midface reduces support for superficially located structures.
• Retaining ligaments and fibrous septa. They connect the skin and the SMAS to deep fasciae or the periosteum. Age-related changes in their environment and in their superficial branches can facilitate tissue displacement between points of stable attachment.
• SMAS. This is a fibromuscular layer connected to the mimetic muscles and the platysma of the neck. Changes in the tension and position of this system affect the contour of the lower face.
• The facial skeleton. Remodeling of the maxilla, mandible, and orbitozygomatic region reduces support for soft tissues. This does not merely mean general "bone loss", but regional changes in its shape, projection, and dimensions.

Sagging can be accelerated by chronic sun exposure, smoking, significant weight fluctuations, and pronounced genetically determined laxity. Rapid weight loss does not necessarily cause skin damage, but it can reveal skin excess previously masked by adipose tissue.

These terms are sometimes used interchangeably, but they are not fully identical. A sagging cheek refers to a broader problem: the loss of the correct position and shape of cheek tissues from the zygomatic region to the lower third of the face. It may include flattening of the midface, excess skin, deepening of the nasolabial fold, and sagging of tissues below the jawline.

“Jowls”, referred to in anatomy and English-language literature as jowls, are localized bulges situated primarily along the border of the mandible, usually lateral to the marionette line. They form when tissues shift downward in the area between the ligamentous structures that stabilize the lower third of the face. The visibility of a jowl is also increased by the depression in front of it, known as the prejowl sulcus.

The main differences are as follows:

A “jowl” does not always mean excess fat. An attempt to reduce it without prior diagnosis may worsen laxity or cause unnatural facial gauntness. It must also be distinguished from masseter muscle hypertrophy, the buccal fat pad (Bichat's fat pad), edema, and neck laxity.

There is no single procedure that is effective for all patients. The procedure should correspond to the layer where the main cause of the deformity is located. The offer of Ambasada Urody Clinic & SPA includes, among others, the following methods used in therapies that improve skin firmness and facial contour:

• Polylactic acid (PLLA or PDLLA) stimulates fibroblasts to produce collagen, gradually increasing skin density and rebuilding lost tissue support. It works particularly well for skin laxity combined with volume loss. At Ambasada Urody, products such as Sculptra, AesPlla, and hybrid combinations of PDLLA with hyaluronic acid, such as Lenisna, are used.
• DeAge EX 3D microneedle radiofrequency delivers RF energy at several skin levels, stimulating its spatial remodeling, thickening, and tension improvement.
• Combo Jector 2D microneedle radiofrequency combines the effects of RF with the precise delivery of active substances. It supports collagen remodeling and improves skin quality and firmness.
• Pixel RF microplasma utilizes the fractional action of microplasma and RF energy. It primarily improves skin structure, density, and tightness.
• Pellevé RF, Reaction RF, Alma Accent Prime, and Indiba use various forms of radiofrequency without microneedles. Controlled heating of tissues leads to collagen remodeling and a gradual improvement in skin tightness. Reaction RF combines bipolar radiofrequency with vacuum, while Alma Accent Prime additionally utilizes ultrasound.
• SonoQueen HIFU uses focused ultrasound, which heats deeper tissue layers in targeted points, stimulating collagen remodeling. The treatment can improve skin tension, slightly lift sagging cheeks, and define the facial oval. It works best for mild to moderate laxity, but does not replace a surgical facelift in cases of significant tissue sagging.
• Laser lifting stimulates collagen remodeling through controlled thermal action. It can improve skin surface quality and tension, but does not provide the same tissue repositioning as surgery.
• Collagen stimulators induce a gradual regenerative response and can improve tissue quality and support. Their application requires careful planning, especially in the heavy lower part of the face.
• Lifting threads, including barbed threads, are used for the mechanical suspension of tissues while adequate skin quality is preserved. Smooth threads primarily have a biostimulatory effect, and an equally pronounced lift should not be expected from them.
• Hyaluronic acid modeling can correct the loss of support in the zygomatic, temporal, chin, or pre-jowl areas. It does not consist of simply „filling the sag”, but of restoring proportions and support at carefully selected points.
• Calcium hydroxyapatite (CaHA) is a biocompatible preparation with dual action: it provides immediate tissue support and stimulates the production of collagen and elastin. When properly administered, it can improve cheek firmness, define the jawline, and reduce the visibility of „jowls”. However, it does not lift significantly sagging tissues.

In cases of significant ptosis, the effectiveness of minimally invasive procedures is limited. In such cases, a consultation with a plastic surgeon should be considered. Every procedure should be preceded by a medical history review, assessment of contraindications, and qualification performed by a properly qualified professional.