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HOLLOW CHEEKS THE COMPLETE GUIDE
anatomy | why you do or do not have them | every method ranked
bones | fat pads | muscles | body fat | surgery | non-surgical
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all anatomical claims from StatPearls, NCBI, and peer-reviewed plastic surgery literature.
[1] StatPearls NBK551530. Anatomy Head and Neck Face. Cheek anatomy, fat pads, muscles, bones.
[2] StatPearls NBK546659. Anatomy Head and Neck Cheeks. Bony structures, muscles, fat compartments.
[3] IMAIOS e-Anatomy. Buccal fat pad: location, lobes, extensions, clinical significance.
[4] PMC11505344. The Buccal Fat Pad: Unique Human Anatomical Structure. Frontiers Bioengineering.
[5] OA Text. Anatomy and aging of cheek fat compartments. Fat pad deflation and hollowing mechanism.
[6] Cleveland Clinic. Buccal Fat Removal: overview, procedure, recovery.
[7] Plast Reconstr Surg Global Open (2023). Success rate of buccal fat pad removal study n=200.
[8] ASPS 2022 Statistics. Buccal fat removal first tracked in procedural statistics.
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CONTENTS
01 what hollow cheeks actually are
02 the responsible bones
03 the fat pads
04 the muscles
05 why you do not have hollow cheeks the four causes
06 body fat percentage and the threshold
07 method 1 body fat reduction
08 method 2 buccal fat removal surgery
09 method 3 facial liposuction
10 method 4 injection lipolysis
11 method 5 masseter botulinum toxin
12 method 6 zygomatic filler
13 method 7 mewing and tongue posture
14 how to diagnose your specific cause
15 the full stacked protocol by goal
16 verdict
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01 WHAT HOLLOW CHEEKS ACTUALLY ARE
Hollow cheeks are the visible concavity in the lateral midface,
specifically the shadow that appears in the submalar region:
the area beneath the zygomatic arch and above the jawline.
This shadow is created by a specific geometry:
the zygomatic arch projecting outward at the top
reduced volume in the mid-cheek region below it
the masseter and jawline creating the lower boundary
the highlight-shadow contrast reads as facial definition
THREE COMPONENTS REQUIRED ALL THREE MUST BE PRESENT
1. PROJECTION ABOVE the zygomatic arch must project laterally and anteriorly
a flat cheekbone creates no high point to cast a shadow below it
2. CONCAVITY BELOW reduced volume in the submalar region
buccal fat pad size, overall facial fat, and muscle volume all determine this
3. LOWER FRAME defined jawline to close the composition at the bottom
a defined jaw makes the hollow readable as a complete structure
You can have prominent cheekbones but no hollow if submalar fat is full.
You can be very lean but have no hollow if zygomatic projection is minimal.
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02 THE RESPONSIBLE BONES
StatPearls NBK546659: the three bony structures forming the cheek are
the zygomatic bone, the maxilla, and the mandible.
THE ZYGOMATIC BONE (the cheekbone) most important
Forms the lateral orbital rim and the cheek prominence.
The zygomatic arch extends posteriorly to the temporal bone,
creating the lateral projection that defines the high point above the hollow.
High lateral and anterior zygomatic projection:
creates a strong shadow below. hollow reads clearly.
Flat or minimally projecting zygoma:
no shadow. no hollow regardless of body fat or buccal fat size.
Zygomatic projection is determined entirely by genetics.
No non-surgical intervention changes the bone itself.
Surgical options: zygomatic implants or osteotomy.
Non-surgical: zygomatic filler to simulate projection.
THE MAXILLA
Forms the upper and medial cheek region and the anterior midface.
Maxillary projection affects overall midface depth.
Also determines the infraorbital region appearance.
THE MANDIBLE
Forms the lower lateral cheek region and the jawline.
The ramus is the attachment point for the masseter muscle.
A defined mandibular angle creates the lower frame of the hollow.
Masseter hypertrophy over the ramus widens the lower face.
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03 THE FAT PADS
The cheek contains multiple fat compartments. They behave differently.
BUCCAL FAT PAD primary driver of cheek fullness
Location: between the buccinator muscle (medially) and the masseter
and zygomatic muscles (laterally). Sits directly in the submalar region.
Structure: three lobes (anterior, intermediate, posterior) and four extensions
(sublevator, melolabial, buccal, pterygoid).
IMAIOS anatomy: the buccal fat pad contributes to fullness of the cheek
and is directly implicated in hollow cheeks when atrophic or absent.
PMC11505344: the buccal fat pad is a unique encapsulated anatomical structure.
It is NOT subcutaneous fat. Diet and exercise do not meaningfully reduce it.
Its size is determined primarily by genetics.
It remains relatively constant regardless of total body fat percentage.
SUPERFICIAL FAT COMPARTMENTS (respond to body fat)
nasolabial fat pad medial cheek. contributes to nasolabial fold.
medial cheek fat below the infraorbital fat pad.
middle cheek fat lateral to medial cheek. anterior to masseter.
lateral temporal-cheek fat above the middle cheek fat.
malar fat pad (SOOF) over the zygomatic arch. descends with age.
OA Text aging review: deflation of the medial SOOF produces the infraorbital hollow.
These compartments DO respond to body fat reduction, unlike the buccal fat pad.
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04 THE MUSCLES
MASSETER the largest and most relevant for cheek shape
Origin: zygomatic arch and maxillary process of the zygomatic bone.
Insertion: ramus and angle of the mandible.
Function: elevates and protrudes the mandible during chewing.
The only cheek-region muscle involved in mastication (StatPearls NBK546659).
WHY IT MATTERS FOR HOLLOW CHEEKS:
masseter hypertrophy from bruxism or heavy chewing widens the lower face
a wide lower face competes visually with the submalar hollow
makes the face appear rounder and reduces the hollow appearance
reducing masseter with botulinum toxin narrows the lower face
allowing the hollow to read more clearly against a narrower jaw
BUCCINATOR
Muscle closest to the oral cavity. Compresses cheeks against teeth.
Forms the medial boundary of the buccal space.
The buccal fat pad sits directly lateral to it.
ZYGOMATICUS MAJOR AND MINOR
Run from the zygomatic bone to the corner of the mouth.
Middle cheek region. Primary role in facial expression.
Not a direct driver of cheek hollowing.
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05 WHY YOU DO NOT HAVE HOLLOW CHEEKS THE FOUR CAUSES
CAUSE 1 LARGE BUCCAL FAT PAD (genetics)
The most common cause of persistent fullness at low body weight.
Buccal fat pad size is genetically determined. Not diet-responsive.
Cleveland Clinic: patients seek buccal fat reduction because cheeks remain
disproportionately full despite stable body weight.
Can remain large even at 8-10% body fat in males.
This is the surgical indication for buccal lipectomy.
CAUSE 2 HIGH BODY FAT IN SUPERFICIAL COMPARTMENTS
The superficial compartments DO respond to body fat percentage.
At higher body fat these compartments fill and mask underlying structure.
Reducing total body fat reduces these first.
Must be addressed before evaluating whether buccal fat is the issue.
CAUSE 3 FLAT ZYGOMATIC PROJECTION
Minimal zygomatic bone projection means no high point to cast a shadow.
Even with low body fat and small buccal fat, no hollow appears.
Structural bone limitation. Cannot be changed non-surgically.
Solution: zygomatic filler to simulate projection non-surgically.
CAUSE 4 MASSETER HYPERTROPHY
Enlarged masseter from bruxism, heavy chewing, or genetics.
Widens the lower face below the potential hollow zone.
Face appears rectangular or trapezoidal.
Reduces apparent hollow by widening the surrounding frame.
Solution: botulinum toxin to masseter.
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06 BODY FAT PERCENTAGE AND THE THRESHOLD
The superficial facial fat compartments respond to total body fat reduction.
No spot reduction of facial fat is possible.
Approximate thresholds where facial hollowing becomes visible:
males below ~10-14% body fat: cheekbone definition begins
below ~8-12%: significant submalar hollowing visible
females below ~18-22% body fat: cheekbone definition begins
below ~16-20%: visible submalar hollowing
These are population averages. Genetic fat distribution causes large variation.
The face loses fat at different rates for different individuals.
KEY: if cheeks remain full at 10% body fat (male) or 18% (female),
buccal fat pad size is likely the primary remaining cause.
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07 METHOD 1 BODY FAT REDUCTION
The foundational intervention. Cannot be skipped.
All other interventions are secondary to this.
APPROACH
caloric deficit 300-500 kcal below TDEE
high protein diet: 1.6-2.2g/kg bodyweight to preserve muscle
resistance training: maintains lean mass and metabolic rate during deficit
TIMELINE
visible facial changes begin within 4-8 weeks of sustained deficit
full facial hollowing (where genetics allow) at target body fat
WHAT IT CANNOT DO
does not reduce buccal fat pad
cannot change bone projection
cannot reduce masseter hypertrophy
verdict: S-TIER. foundational. do this first before evaluating everything else.
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08 METHOD 2 BUCCAL FAT REMOVAL SURGERY
The only intervention that directly removes the buccal fat pad.
Also called buccal lipectomy or cheek reduction surgery.
THE PROCEDURE
small incision inside the mouth on both sides (no external scarring)
surgeon applies external pressure to expose the fat pad through the incision
fat pad is excised partially or fully depending on desired result
dissolvable sutures close the incisions
duration: 30-60 minutes. local anaesthesia or light sedation.
recovery: 1-2 weeks swelling. final result visible at approximately 3 months.
WHAT IT DOES
creates hollowing in the submalar region directly
enhances cheekbone definition by removing volume below the zygoma
permanent: buccal fat pads do not grow back
does NOT enlarge cheekbones, does NOT affect superficial fat, does NOT affect masseter
EVIDENCE
PRS Global Open 2023 (n=200 cheeks): high success rate.
complications: 0% in standard group. 6.6% in those with prior injection lipolysis.
ASPS began tracking buccal fat removal as a distinct procedure from 2022.
IDEAL CANDIDATE
full lower cheeks that persist at stable or low body weight
disproportionate cheek fullness relative to the rest of the body
adequate zygomatic projection to make the resulting hollow meaningful
RISKS
permanent: excess removal causes gaunt look at 40-50 as remaining fat thins with age
aging: natural facial fat atrophies over time. buccal removal accelerates this.
asymmetry: unequal fat removal between sides
damage to parotid duct or facial nerve: rare but serious
cost: approximately $2,000-$5,000 USD.
verdict: A-TIER for genetically large buccal fat. most targeted permanent solution.
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09 METHOD 3 FACIAL LIPOSUCTION
Targets the superficial cheek fat compartments, NOT the buccal fat pad.
Different procedure. Different fat. Different result.
HOW IT DIFFERS FROM BUCCAL FAT REMOVAL
buccal fat removal: intraoral. removes deep encapsulated buccal fat pad.
facial liposuction: small external incision. cannula suction of subcutaneous fat.
targets lower face and jowl region, not the submalar hollow specifically.
BEST CANDIDATE
generalised lower face heaviness or excess jowl fat
NOT for isolated buccal fat prominence (wrong compartment)
verdict: B-TIER for hollow cheeks. better for lower face contouring than submalar hollow.
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10 METHOD 4 INJECTION LIPOLYSIS DEOXYCHOLIC ACID
Kybella (deoxycholic acid) is FDA-approved for submental fat.
Used off-label in cheeks.
MECHANISM
deoxycholic acid disrupts fat cell membrane integrity causing localised fat destruction
followed by macrophage clearance and fibrosis
THE PROBLEM
PRS Global Open 2023: prior injection lipolysis in cheeks significantly complicates
subsequent buccal fat removal: 6.6% complication rate vs 0% in clean group.
fibrosis from injection lipolysis makes surgical buccal fat removal harder.
risk of permanent skin irregularity.
verdict: C-TIER. if surgical removal is a future option, avoid injection lipolysis first.
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11 METHOD 5 MASSETER BOTULINUM TOXIN
Botulinum toxin injected into the masseter causes muscle atrophy.
The lower face narrows over 4-8 weeks.
HOW IT CREATES THE APPARENT HOLLOW
narrowing the lower face reduces the lower frame width
the mid-cheek region appears more recessed by comparison
enhances the contrast between cheekbone and lower face
does not reduce submalar fat. creates the optical effect through frame narrowing.
EVIDENCE
multiple RCTs confirm masseter volume reduction with botulinum toxin
typical thickness reduction: 20-30% at 4 months
duration: 4-6 months. maintenance injections required.
IDEAL FOR
masseter hypertrophy from bruxism or heavy chewing
wide lower face disproportionate to upper face width
hollow visible in upper face but obscured by wide jaw below
verdict: A-TIER for masseter hypertrophy. B-TIER if masseter is normal size.
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12 METHOD 6 ZYGOMATIC FILLER
Instead of reducing volume below, this adds projection above.
Hyaluronic acid or CaHA placed over the zygomatic arch.
HOW IT CREATES THE HOLLOW
enhanced zygomatic projection creates a stronger highlight above the hollow zone
the contrast between the projected cheekbone and the mid-cheek
creates the appearance of a hollow even without changing the volume below
this is the upper frame approach vs the buccal fat lower volume approach
PRODUCTS
hyaluronic acid (Juvederm Voluma, Restylane Lyft): reversible with hyaluronidase
calcium hydroxylapatite (Radiesse): semi-permanent 12-18 months
poly-L-lactic acid (Sculptra): stimulates collagen. gradual. 2 year duration.
IDEAL FOR
flat or minimally projecting zygomatic bones
already lean face where projection is the missing element
those who want to preview the result before surgical options
verdict: A-TIER for flat cheekbones. immediate. reversible. no downtime.
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13 METHOD 7 MEWING AND TONGUE POSTURE
IN ADULTS (fused skeletal sutures)
bone geometry cannot be meaningfully changed by tongue posture post-fusion
no peer-reviewed study has measured submalar hollowing as an outcome of mewing
indirect benefits: improved nasal breathing, potential neck-jaw definition
IN ADOLESCENTS (still growing)
some orthodontic evidence supports tongue posture effects on palatal width
maxillary development may be modestly influenced during active growth phase
verdict: C-TIER for hollow cheeks in adults. B-TIER for adolescents in growth phase.
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14 HOW TO DIAGNOSE YOUR SPECIFIC CAUSE
STEP 1 ARE YOU AT TARGET BODY FAT?
males below ~12%? females below ~20%?
NO: body fat reduction is the intervention. everything else is premature.
YES and cheeks still full: continue to step 2.
STEP 2 WHERE IS THE FULLNESS?
pinch the cheek at the submalar region.
significant pinchable subcutaneous fat: superficial compartments still present.
firm tissue that does not pinch easily: buccal fat pad is likely the driver.
STEP 3 DO YOUR CHEEKBONES PROJECT?
feel the zygomatic arch. look at your face from 45 degrees in a photo.
YES: bone projection adequate. fat reduction or buccal removal will create hollow.
NO: zygomatic filler needed alongside any volume reduction.
STEP 4 IS YOUR LOWER FACE WIDE?
clench jaw. do the muscles at the jaw angle visibly bulge?
YES: masseter hypertrophy present. botox to masseter indicated.
NO: lower face width is structural (bone).
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15 FULL STACKED PROTOCOL BY GOAL
STACK A FAT IS THE MAIN ISSUE
01 caloric deficit targeting body fat reduction
02 high protein diet (1.6-2.2g/kg) to preserve muscle
03 resistance training
04 reassess at target body fat before adding anything else
STACK B LEAN BUT BUCCAL FAT IS THE DRIVER
01 confirm at target body fat
02 consult board-certified plastic surgeon for buccal lipectomy
03 assess whether masseter botox would complement the result
04 if cheekbones are flat: add zygomatic filler simultaneously
STACK C FLAT CHEEKBONES ARE THE MAIN ISSUE
01 complete body fat reduction first
02 zygomatic filler to create projection above the hollow
03 if buccal fat also prominent: buccal fat removal consultation
04 masseter botox if lower face is wide
STACK D WIDE LOWER FACE MASSETER IS THE DRIVER
01 complete body fat reduction first
02 masseter botulinum toxin both sides
03 reassess hollow visibility at 3 months post-treatment
04 add buccal removal or zygoma filler as needed
STACK E MAXIMUM APPROACH
01 target body fat (always first)
02 buccal fat removal (if buccal fat prominent at lean body fat)
03 masseter botox (if masseter hypertrophy present)
04 zygomatic filler (if cheekbone projection is insufficient)
in this order. fat reduction first. surgical. then injectables.
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16 VERDICT TIER RANKINGS
S-TIER foundational cannot skip
body fat reduction reveals all structure. prerequisite for everything else.
A-TIER high evidence significant direct impact
buccal fat removal only way to reduce buccal fat. permanent. precise.
masseter botox A-TIER for hypertrophy. narrows lower face frame.
zygomatic filler A-TIER for flat cheekbones. immediate. reversible.
B-TIER good supporting evidence indirect or limited application
facial liposuction better for lower face and jowls than submalar hollow.
mewing (adolescents) potential maxillary development benefit in growth phase.
C-TIER weak evidence or significant risk vs alternatives
injection lipolysis fibrosis risk. complicates buccal removal later.
mewing (adults) bone cannot change post-fusion.
THE HONEST HIERARCHY
1. get lean first. everything else is irrelevant until you know what is genetic.
2. buccal fat still prominent at lean: surgical removal is most targeted.
3. bones are flat: filler gives the projection that makes a hollow possible.
4. lower face is wide: masseter botox lets the hollow read.
5. these stack. full approach does all four in order.
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@Nothing.special @#sensitiveyoungwoman
@TxT this is for you lil r****d. "how to activate hollow cheeks"HOLLOW CHEEKS THE COMPLETE GUIDE
anatomy | why you do or do not have them | every method ranked
bones | fat pads | muscles | body fat | surgery | non-surgical
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
all anatomical claims from StatPearls, NCBI, and peer-reviewed plastic surgery literature.
[1] StatPearls NBK551530. Anatomy Head and Neck Face. Cheek anatomy, fat pads, muscles, bones.
[2] StatPearls NBK546659. Anatomy Head and Neck Cheeks. Bony structures, muscles, fat compartments.
[3] IMAIOS e-Anatomy. Buccal fat pad: location, lobes, extensions, clinical significance.
[4] PMC11505344. The Buccal Fat Pad: Unique Human Anatomical Structure. Frontiers Bioengineering.
[5] OA Text. Anatomy and aging of cheek fat compartments. Fat pad deflation and hollowing mechanism.
[6] Cleveland Clinic. Buccal Fat Removal: overview, procedure, recovery.
[7] Plast Reconstr Surg Global Open (2023). Success rate of buccal fat pad removal study n=200.
[8] ASPS 2022 Statistics. Buccal fat removal first tracked in procedural statistics.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
CONTENTS
01 what hollow cheeks actually are
02 the responsible bones
03 the fat pads
04 the muscles
05 why you do not have hollow cheeks the four causes
06 body fat percentage and the threshold
07 method 1 body fat reduction
08 method 2 buccal fat removal surgery
09 method 3 facial liposuction
10 method 4 injection lipolysis
11 method 5 masseter botulinum toxin
12 method 6 zygomatic filler
13 method 7 mewing and tongue posture
14 how to diagnose your specific cause
15 the full stacked protocol by goal
16 verdict
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
01 WHAT HOLLOW CHEEKS ACTUALLY ARE
Hollow cheeks are the visible concavity in the lateral midface,
specifically the shadow that appears in the submalar region:
the area beneath the zygomatic arch and above the jawline.
This shadow is created by a specific geometry:
the zygomatic arch projecting outward at the top
reduced volume in the mid-cheek region below it
the masseter and jawline creating the lower boundary
the highlight-shadow contrast reads as facial definition
THREE COMPONENTS REQUIRED ALL THREE MUST BE PRESENT
1. PROJECTION ABOVE the zygomatic arch must project laterally and anteriorly
a flat cheekbone creates no high point to cast a shadow below it
2. CONCAVITY BELOW reduced volume in the submalar region
buccal fat pad size, overall facial fat, and muscle volume all determine this
3. LOWER FRAME defined jawline to close the composition at the bottom
a defined jaw makes the hollow readable as a complete structure
You can have prominent cheekbones but no hollow if submalar fat is full.
You can be very lean but have no hollow if zygomatic projection is minimal.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
02 THE RESPONSIBLE BONES
StatPearls NBK546659: the three bony structures forming the cheek are
the zygomatic bone, the maxilla, and the mandible.
THE ZYGOMATIC BONE (the cheekbone) most important
Forms the lateral orbital rim and the cheek prominence.
The zygomatic arch extends posteriorly to the temporal bone,
creating the lateral projection that defines the high point above the hollow.
High lateral and anterior zygomatic projection:
creates a strong shadow below. hollow reads clearly.
Flat or minimally projecting zygoma:
no shadow. no hollow regardless of body fat or buccal fat size.
Zygomatic projection is determined entirely by genetics.
No non-surgical intervention changes the bone itself.
Surgical options: zygomatic implants or osteotomy.
Non-surgical: zygomatic filler to simulate projection.
THE MAXILLA
Forms the upper and medial cheek region and the anterior midface.
Maxillary projection affects overall midface depth.
Also determines the infraorbital region appearance.
THE MANDIBLE
Forms the lower lateral cheek region and the jawline.
The ramus is the attachment point for the masseter muscle.
A defined mandibular angle creates the lower frame of the hollow.
Masseter hypertrophy over the ramus widens the lower face.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
03 THE FAT PADS
The cheek contains multiple fat compartments. They behave differently.
BUCCAL FAT PAD primary driver of cheek fullness
Location: between the buccinator muscle (medially) and the masseter
and zygomatic muscles (laterally). Sits directly in the submalar region.
Structure: three lobes (anterior, intermediate, posterior) and four extensions
(sublevator, melolabial, buccal, pterygoid).
IMAIOS anatomy: the buccal fat pad contributes to fullness of the cheek
and is directly implicated in hollow cheeks when atrophic or absent.
PMC11505344: the buccal fat pad is a unique encapsulated anatomical structure.
It is NOT subcutaneous fat. Diet and exercise do not meaningfully reduce it.
Its size is determined primarily by genetics.
It remains relatively constant regardless of total body fat percentage.
SUPERFICIAL FAT COMPARTMENTS (respond to body fat)
nasolabial fat pad medial cheek. contributes to nasolabial fold.
medial cheek fat below the infraorbital fat pad.
middle cheek fat lateral to medial cheek. anterior to masseter.
lateral temporal-cheek fat above the middle cheek fat.
malar fat pad (SOOF) over the zygomatic arch. descends with age.
OA Text aging review: deflation of the medial SOOF produces the infraorbital hollow.
These compartments DO respond to body fat reduction, unlike the buccal fat pad.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
04 THE MUSCLES
MASSETER the largest and most relevant for cheek shape
Origin: zygomatic arch and maxillary process of the zygomatic bone.
Insertion: ramus and angle of the mandible.
Function: elevates and protrudes the mandible during chewing.
The only cheek-region muscle involved in mastication (StatPearls NBK546659).
WHY IT MATTERS FOR HOLLOW CHEEKS:
masseter hypertrophy from bruxism or heavy chewing widens the lower face
a wide lower face competes visually with the submalar hollow
makes the face appear rounder and reduces the hollow appearance
reducing masseter with botulinum toxin narrows the lower face
allowing the hollow to read more clearly against a narrower jaw
BUCCINATOR
Muscle closest to the oral cavity. Compresses cheeks against teeth.
Forms the medial boundary of the buccal space.
The buccal fat pad sits directly lateral to it.
ZYGOMATICUS MAJOR AND MINOR
Run from the zygomatic bone to the corner of the mouth.
Middle cheek region. Primary role in facial expression.
Not a direct driver of cheek hollowing.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
05 WHY YOU DO NOT HAVE HOLLOW CHEEKS THE FOUR CAUSES
CAUSE 1 LARGE BUCCAL FAT PAD (genetics)
The most common cause of persistent fullness at low body weight.
Buccal fat pad size is genetically determined. Not diet-responsive.
Cleveland Clinic: patients seek buccal fat reduction because cheeks remain
disproportionately full despite stable body weight.
Can remain large even at 8-10% body fat in males.
This is the surgical indication for buccal lipectomy.
CAUSE 2 HIGH BODY FAT IN SUPERFICIAL COMPARTMENTS
The superficial compartments DO respond to body fat percentage.
At higher body fat these compartments fill and mask underlying structure.
Reducing total body fat reduces these first.
Must be addressed before evaluating whether buccal fat is the issue.
CAUSE 3 FLAT ZYGOMATIC PROJECTION
Minimal zygomatic bone projection means no high point to cast a shadow.
Even with low body fat and small buccal fat, no hollow appears.
Structural bone limitation. Cannot be changed non-surgically.
Solution: zygomatic filler to simulate projection non-surgically.
CAUSE 4 MASSETER HYPERTROPHY
Enlarged masseter from bruxism, heavy chewing, or genetics.
Widens the lower face below the potential hollow zone.
Face appears rectangular or trapezoidal.
Reduces apparent hollow by widening the surrounding frame.
Solution: botulinum toxin to masseter.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
06 BODY FAT PERCENTAGE AND THE THRESHOLD
The superficial facial fat compartments respond to total body fat reduction.
No spot reduction of facial fat is possible.
Approximate thresholds where facial hollowing becomes visible:
males below ~10-14% body fat: cheekbone definition begins
below ~8-12%: significant submalar hollowing visible
females below ~18-22% body fat: cheekbone definition begins
below ~16-20%: visible submalar hollowing
These are population averages. Genetic fat distribution causes large variation.
The face loses fat at different rates for different individuals.
KEY: if cheeks remain full at 10% body fat (male) or 18% (female),
buccal fat pad size is likely the primary remaining cause.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
07 METHOD 1 BODY FAT REDUCTION
The foundational intervention. Cannot be skipped.
All other interventions are secondary to this.
APPROACH
caloric deficit 300-500 kcal below TDEE
high protein diet: 1.6-2.2g/kg bodyweight to preserve muscle
resistance training: maintains lean mass and metabolic rate during deficit
TIMELINE
visible facial changes begin within 4-8 weeks of sustained deficit
full facial hollowing (where genetics allow) at target body fat
WHAT IT CANNOT DO
does not reduce buccal fat pad
cannot change bone projection
cannot reduce masseter hypertrophy
verdict: S-TIER. foundational. do this first before evaluating everything else.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
08 METHOD 2 BUCCAL FAT REMOVAL SURGERY
The only intervention that directly removes the buccal fat pad.
Also called buccal lipectomy or cheek reduction surgery.
THE PROCEDURE
small incision inside the mouth on both sides (no external scarring)
surgeon applies external pressure to expose the fat pad through the incision
fat pad is excised partially or fully depending on desired result
dissolvable sutures close the incisions
duration: 30-60 minutes. local anaesthesia or light sedation.
recovery: 1-2 weeks swelling. final result visible at approximately 3 months.
WHAT IT DOES
creates hollowing in the submalar region directly
enhances cheekbone definition by removing volume below the zygoma
permanent: buccal fat pads do not grow back
does NOT enlarge cheekbones, does NOT affect superficial fat, does NOT affect masseter
EVIDENCE
PRS Global Open 2023 (n=200 cheeks): high success rate.
complications: 0% in standard group. 6.6% in those with prior injection lipolysis.
ASPS began tracking buccal fat removal as a distinct procedure from 2022.
IDEAL CANDIDATE
full lower cheeks that persist at stable or low body weight
disproportionate cheek fullness relative to the rest of the body
adequate zygomatic projection to make the resulting hollow meaningful
RISKS
permanent: excess removal causes gaunt look at 40-50 as remaining fat thins with age
aging: natural facial fat atrophies over time. buccal removal accelerates this.
asymmetry: unequal fat removal between sides
damage to parotid duct or facial nerve: rare but serious
cost: approximately $2,000-$5,000 USD.
verdict: A-TIER for genetically large buccal fat. most targeted permanent solution.
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09 METHOD 3 FACIAL LIPOSUCTION
Targets the superficial cheek fat compartments, NOT the buccal fat pad.
Different procedure. Different fat. Different result.
HOW IT DIFFERS FROM BUCCAL FAT REMOVAL
buccal fat removal: intraoral. removes deep encapsulated buccal fat pad.
facial liposuction: small external incision. cannula suction of subcutaneous fat.
targets lower face and jowl region, not the submalar hollow specifically.
BEST CANDIDATE
generalised lower face heaviness or excess jowl fat
NOT for isolated buccal fat prominence (wrong compartment)
verdict: B-TIER for hollow cheeks. better for lower face contouring than submalar hollow.
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10 METHOD 4 INJECTION LIPOLYSIS DEOXYCHOLIC ACID
Kybella (deoxycholic acid) is FDA-approved for submental fat.
Used off-label in cheeks.
MECHANISM
deoxycholic acid disrupts fat cell membrane integrity causing localised fat destruction
followed by macrophage clearance and fibrosis
THE PROBLEM
PRS Global Open 2023: prior injection lipolysis in cheeks significantly complicates
subsequent buccal fat removal: 6.6% complication rate vs 0% in clean group.
fibrosis from injection lipolysis makes surgical buccal fat removal harder.
risk of permanent skin irregularity.
verdict: C-TIER. if surgical removal is a future option, avoid injection lipolysis first.
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11 METHOD 5 MASSETER BOTULINUM TOXIN
Botulinum toxin injected into the masseter causes muscle atrophy.
The lower face narrows over 4-8 weeks.
HOW IT CREATES THE APPARENT HOLLOW
narrowing the lower face reduces the lower frame width
the mid-cheek region appears more recessed by comparison
enhances the contrast between cheekbone and lower face
does not reduce submalar fat. creates the optical effect through frame narrowing.
EVIDENCE
multiple RCTs confirm masseter volume reduction with botulinum toxin
typical thickness reduction: 20-30% at 4 months
duration: 4-6 months. maintenance injections required.
IDEAL FOR
masseter hypertrophy from bruxism or heavy chewing
wide lower face disproportionate to upper face width
hollow visible in upper face but obscured by wide jaw below
verdict: A-TIER for masseter hypertrophy. B-TIER if masseter is normal size.
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12 METHOD 6 ZYGOMATIC FILLER
Instead of reducing volume below, this adds projection above.
Hyaluronic acid or CaHA placed over the zygomatic arch.
HOW IT CREATES THE HOLLOW
enhanced zygomatic projection creates a stronger highlight above the hollow zone
the contrast between the projected cheekbone and the mid-cheek
creates the appearance of a hollow even without changing the volume below
this is the upper frame approach vs the buccal fat lower volume approach
PRODUCTS
hyaluronic acid (Juvederm Voluma, Restylane Lyft): reversible with hyaluronidase
calcium hydroxylapatite (Radiesse): semi-permanent 12-18 months
poly-L-lactic acid (Sculptra): stimulates collagen. gradual. 2 year duration.
IDEAL FOR
flat or minimally projecting zygomatic bones
already lean face where projection is the missing element
those who want to preview the result before surgical options
verdict: A-TIER for flat cheekbones. immediate. reversible. no downtime.
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13 METHOD 7 MEWING AND TONGUE POSTURE
IN ADULTS (fused skeletal sutures)
bone geometry cannot be meaningfully changed by tongue posture post-fusion
no peer-reviewed study has measured submalar hollowing as an outcome of mewing
indirect benefits: improved nasal breathing, potential neck-jaw definition
IN ADOLESCENTS (still growing)
some orthodontic evidence supports tongue posture effects on palatal width
maxillary development may be modestly influenced during active growth phase
verdict: C-TIER for hollow cheeks in adults. B-TIER for adolescents in growth phase.
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14 HOW TO DIAGNOSE YOUR SPECIFIC CAUSE
STEP 1 ARE YOU AT TARGET BODY FAT?
males below ~12%? females below ~20%?
NO: body fat reduction is the intervention. everything else is premature.
YES and cheeks still full: continue to step 2.
STEP 2 WHERE IS THE FULLNESS?
pinch the cheek at the submalar region.
significant pinchable subcutaneous fat: superficial compartments still present.
firm tissue that does not pinch easily: buccal fat pad is likely the driver.
STEP 3 DO YOUR CHEEKBONES PROJECT?
feel the zygomatic arch. look at your face from 45 degrees in a photo.
YES: bone projection adequate. fat reduction or buccal removal will create hollow.
NO: zygomatic filler needed alongside any volume reduction.
STEP 4 IS YOUR LOWER FACE WIDE?
clench jaw. do the muscles at the jaw angle visibly bulge?
YES: masseter hypertrophy present. botox to masseter indicated.
NO: lower face width is structural (bone).
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15 FULL STACKED PROTOCOL BY GOAL
STACK A FAT IS THE MAIN ISSUE
01 caloric deficit targeting body fat reduction
02 high protein diet (1.6-2.2g/kg) to preserve muscle
03 resistance training
04 reassess at target body fat before adding anything else
STACK B LEAN BUT BUCCAL FAT IS THE DRIVER
01 confirm at target body fat
02 consult board-certified plastic surgeon for buccal lipectomy
03 assess whether masseter botox would complement the result
04 if cheekbones are flat: add zygomatic filler simultaneously
STACK C FLAT CHEEKBONES ARE THE MAIN ISSUE
01 complete body fat reduction first
02 zygomatic filler to create projection above the hollow
03 if buccal fat also prominent: buccal fat removal consultation
04 masseter botox if lower face is wide
STACK D WIDE LOWER FACE MASSETER IS THE DRIVER
01 complete body fat reduction first
02 masseter botulinum toxin both sides
03 reassess hollow visibility at 3 months post-treatment
04 add buccal removal or zygoma filler as needed
STACK E MAXIMUM APPROACH
01 target body fat (always first)
02 buccal fat removal (if buccal fat prominent at lean body fat)
03 masseter botox (if masseter hypertrophy present)
04 zygomatic filler (if cheekbone projection is insufficient)
in this order. fat reduction first. surgical. then injectables.
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16 VERDICT TIER RANKINGS
S-TIER foundational cannot skip
body fat reduction reveals all structure. prerequisite for everything else.
A-TIER high evidence significant direct impact
buccal fat removal only way to reduce buccal fat. permanent. precise.
masseter botox A-TIER for hypertrophy. narrows lower face frame.
zygomatic filler A-TIER for flat cheekbones. immediate. reversible.
B-TIER good supporting evidence indirect or limited application
facial liposuction better for lower face and jowls than submalar hollow.
mewing (adolescents) potential maxillary development benefit in growth phase.
C-TIER weak evidence or significant risk vs alternatives
injection lipolysis fibrosis risk. complicates buccal removal later.
mewing (adults) bone cannot change post-fusion.
THE HONEST HIERARCHY
1. get lean first. everything else is irrelevant until you know what is genetic.
2. buccal fat still prominent at lean: surgical removal is most targeted.
3. bones are flat: filler gives the projection that makes a hollow possible.
4. lower face is wide: masseter botox lets the hollow read.
5. these stack. full approach does all four in order.
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@Nothing.special @#sensitiveyoungwoman
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