Facial hollowing

Our face is part of our identity and bears the marks of our life history. The midface is the most visible determinant of an individual’s perceived age. A youthful midface is characterized by smooth midfacial skin without wrinkles or pigmentary changes, well-volumized cheeks whose point of maximum projection lies high on the cheek bones, an absence of irregular grooves and bulges, and transits smoothly and imperceptibly from the lower eyelid into the lower face. When viewed from the side, the midface should form a gentle convexity. 

Successful midfacial rejuvenation significantly reduces one’s perceived age, and imparts the image of someone who is confident and in good health.

How Does It Manifest?

Facial hollowing may occur in different parts of the midface. The distribution and severity of fat loss may differ between individuals and within the same individual as well. These changes start to manifest in the third decade of life. In Orientals, it is common to have hollowing in the central under-eye area, and in Caucasians, the lateral (outer) midface lying just in front of the ear.

Age-related facial fat loss leads to deflation, descent and loss of the cheek prominence, and formation of the tear trough deformity, mid-cheek groove, nasolabial folds (laugh lines) and marionette lines. The lower eyelid, cheek and lower face appear to be one single unit in youth. 

With advancing age, the lower eyelid, cheek and lower face gradually become distinct and separate parts of the face delineated by bulges and grooves. These changes may appear as sad, angry or tired-looking to others. The constellation of changes to the midface brings about the most significant difference to an individual’s perceived age.

How does it arise?

Midfacial aging is a complex multi-factorial process including skin laxity, loss of facial fat, loosening and lengthening of the muscles, and overall loss of the facial bone skeleton. There are several well-defined superficial and deep fat compartments of the face, divided by the muscle (SMAS) layer. The distribution and severity of fat loss may differ from between individuals and within the same individual as well.

The reduction in soft tissue volume of the face results in relative skin excess and drooping of the facial skin that is not supported by ligaments. This skin drooping causes formation of visible bulges. Skin that is well-supported by facial ligaments do not droop with age and instead form grooves, such as the midcheek groove, nasolabial folds and the marionette lines.




Attaining beautiful and bespoke results that retain an individual’s expressivity is frequently possible and requires a combination of accurate assessment, precise technical execution and an experienced practitioner. Because the distribution and severity of fat loss may vary greatly between individuals and even within the same individual, individualized treatment targeting the affected fat compartments produces the optimal results. The treatment options available are filler injection and structural fat grafting. Successful outcomes help to restore self-confidence and improve social functioning.

Filler injection

Facial hollowing is reliably treated with filler injection and attains a high degree of satisfaction in most cases. Filler injection is a popular ambulatory procedure and is often used for restoring soft tissue volume in areas where age-related fat loss has occurred. There is a wide range of fillers with various different characteristics to suit each individual’s unique anatomy and help them meet their aesthetic goals. 

Individuals with mild-to-moderate cheek deflation and minimal skin laxity are good candidates for filler injection. Filler injection does not reverse drooping caused by skin and muscle laxity. Individuals with other accompanying signs of facial aging such as face or neck skin and muscle laxity, double chin deformity etc. may wish to consider face lift surgery for harmonious and comprehensive correction of these deformities.

When administered appropriately, filler injection smoothens out the facial grooves and lifts the soft tissue. There is improvement to the tear troughs, midcheek grooves, nasolabial folds (laugh line) and marionette lines. It elevates and increases the cheek projection, simulating that of a younger individual. Filler injection restores the natural convexity of the cheek when viewed from the side, which begins at the lower eyelid and ends at the corners of the mouth. The fine wrinkles visible on the skin are effaced and there is gentle elevation of the corners of the mouth. These improvements often restore self-confidence and often have positive effects on their professional and social relationships.

We frequently see or hear of people who look unnatural following aesthetic treatments. This is often due to practitioners who attempt to reverse all the signs of aging by using revolumization techniques alone, resulting in an overfilled “pillow face”. Filler injection does not reverse skin and muscle laxity or ligament lengthening. Choice of the incorrect filler type will also result in irregularities that become more prominent when an individual animates the face.

Attaining bespoke and natural-looking results that retain an individual’s expressivity is frequently possible and requires accurate assessment, appropriate product choice, precise administration by an experienced practitioner.

The anatomy of the midface is complex and contains important nerves and blood vessels that should be avoided when delivering filler injection. Injection for facial hollowing is a fine art and strikes a balance between delivering the sufficient filler at the appropriate locations for optimal results whilst avoiding creation of an over-filled and unnatural looking face. Injection site pain is significantly reduced with the use of a pain distraction device at Picasso Plastic Surgery.

The effects of filler injection may be observed almost immediately following the procedure. Most of the filler will be resorbed in 6 to 9 months and repeat treatment is required to maintain the result. their usual activities immediately following the procedure.

Individuals are advised to avoid vigorous massage or rubbing of the treatment area for 2 hours following filler injection to minimize the potential for bruising. Individuals may resume their usual activities immediately following the procedure.

Dr Yeo is an experienced plastic surgeon in Singapore. He is a known filler injector and is a trainer for several filler product lines. He frequently delivers lectures and conducts workshops on effective and safe filler administration in the Asia Pacific region. Injection site pain is significantly reduced with the use of a pain distraction device at Picasso Plastic Surgery.


Structural Fat Grafting

Structural fat grafting involves harvesting fat from areas of excess, purifying it, then grafting it in volume-deficient areas. A high proportional survival of fat cells may be attained with the use of specialized fat grafting cannulas available at Picasso Plastic Surgery. Structural fat grafting delivers elegant and long-lasting results. Structural fat grafting is a minimally-invasive ambulatory surgical procedure performed under local anesthesia, with optional intravenous sedation if requested.

Individuals with any degree of facial hollowing and seeking long-term improvement are good candidates. Structural fat grafting may be simultaneously performed in other areas of hollowing and volume loss such as the face, neck and hands, and deliver benefit in multiple sites in one single procedure. Those with severe hollowing will benefit from significant cost saving in the long term as compared with recurrent treatment using large volume filler injection. Individuals with other accompanying signs of facial aging such as face or neck skin and muscle laxity, double chin deformity etc. may wish to consider face lift surgery for comprehensive correction of these deformities.

Common sites for fat harvest include the inner thighs, hips, flanks and lower abdomen. Small incisions are made near the areas of intended liposuction, and local anesthetic is infused for optimal intra- and post- operative pain relief. The fat is broken up and aspirated under negative pressure. It is purified before being grafted into the specific facial fat compartments using purpose-made fat grafting cannulas for optimal survival. The fat is deposited in small parcels for optimal survival. Grafting is performed through 1-mm incisions that are well-concealed.

Many individuals are able to return to work on the day after the surgery. Depending on the extent of fat harvesting performed, most of the swelling and bruising will resolve by the 7th postoperative day. Stitch removal is usually performed on the 5th postoperative day.

Individuals are advised to avoid pressure on the grafted areas to optimize graft survival. Face washing is possible on the 2nd postoperative day. Postoperative swelling is reduced by remaining upright during the daytime and by elevating the head of the bed with extra pillows when asleep at night. Bruising may be minimized by avoidance of strenuous activity for the first 2 weeks. Individuals may return to their original exercise and gym routines after 2 weeks.

After structural fat grafting is performed, blood vessels grow into the fat grafted area (neovascularization). The degree of neovascularization determines the proportion of fat graft survival. In general, 60 to 80% of the grafted fat will survive and the appearance at 2 months postoperatively is normally representative of the long-term result. The body absorbs the non-surviving fat during the first two months. The fat grafts that survive persist for many years.

Dr Yeo is passionate about facial rejuvenation with non-surgical and surgical methods, and he delivers lectures in the Asia Pacific region on this topic. He is experienced in facial fat grafting and applies special technique to deliver enhanced results while keeping postoperative recovery time to a short duration. Picasso Plastic Surgery has an en suite operating facility that assures you maximal privacy and convenience, and keeps facility and equipment costs contained.