Dr Tino Solomon explores the attractiveness of cheeks and shares advice for augmentation
Objective standards of beauty are observed across many cultures. Be it plump lips to certain ratios, symmetrical faces or a particular face shape. It has never been fully understood why some of these features are ‘standard attractive’, despite various hypotheses proposing evolutionary advantages and involving facial metrics, which attempt to explain this.1,2,3 High cheekbones are a facial trait that is universally valued in terms of attractiveness. When our subconscious is assessing one’s character, higher cheekbones have been shown to be considered more trustworthy than individuals with shallower cheekbones.1
In the field of aesthetics, as practitioners, we facilitate augmentation of the cheekbones. Various non-surgical techniques are available and utilised to achieve this aesthetic ideal. This article will explore what it is about the mid-face that people find facially attractive, anatomical considerations, and what modalities we have available to augment and achieve the desired aesthetic outcome.
The beauty of cheeks
Recent evidence suggests we naturally judge faces in a fraction of second.2 A functional MRI study has demonstrated an association of high cheekbones with trustworthiness and approachability, together with large eyes and a broad smile, which also indicate attractiveness. Conversely, lower inner eyebrows and shallow cheekbones were seen as untrustworthy.2
Facial metrics, often cited as the mathematical explanation for attractiveness, are particularly relevant here, with cheekbones playing a significant part in shaping and volumising the mid-face longitudinally and laterally.3 A neurophysiological study utilising functional MRI on subjects viewing a multitude of faces of varying proportions showed the attraction response to different facial ratios, noting the importance of facial width to length with evidence for the hypothesis that human faces with variable proportions have differential attractiveness.3
A more detailed mathematical approach was taken in a study of facial metrics, which was assessed on a scale of beauty and attractiveness. Whole face length and width measurements, symmetrical division of the face into vertical thirds and horizontal fifths were also measured and rated (Figure 1). The importance of the cheekbone, with its contribution to width in all these measurements was determinant in facial ratio calculations.2
Figure 1: Depiction of facial fifths and ‘ideal’ vertical to horizontal ratios.
Prominent cheekbones are a marker of sexual maturity. The rounded child face elongates as puberty sets in and the development of the zygomatic bone correlates with maturation into adults. Men’s cheekbone growth is directly linked to the testosterone surge in puberty. A theory put forward by evolutionary biologists suggests that selection of sexual partners historically preferred strong features, such as prominent cheekbones. Evolution of our bony structure may also have positively selected the appropriate bone structure to compete for female partners, food and other resources, acting as a protective buttress from physical blows.4
When considering the anatomy of the cheeks, the adjacent areas must also be taken into account to ensure proportional facial metrics and maintain beauty standards
Mid-face anatomy
Understanding the anatomy of the mid-face and the changes that occur is crucial when augmenting the cheek and cheekbone area. When considering the anatomy of the cheeks, the adjacent areas must also be taken into account to ensure proportional facial metrics and maintaining beauty standards. Beauty and restoration of the structure of youth are the concepts here.
The cheekbone region consists of both the zygomatic (malar) bone and the zygomatic arch. The zygomatic bone is adjoined, via four processes, to the maxilla, temporal, sphenoid and frontal bones, and is responsible for creating the cheek prominence. The zygomatic arch is formed by the zygomatic process of the temporal bone and the temporal process of the zygomatic bone. Nerves and vessels arising from this area include:5
The zygomatic nerve, a branch of the trigeminal maxillary nerve that emerges from the zygomaticofacial foramen
The zygomatic artery, which emerges alongside the zygomatic nerve
The zygomatic branches of the facial nerve, which travels along the zygomatic bone to the lateral margin of the orbit
It is the zygomatic arches that are predominantly responsible for the ‘high cheekbone’ look. One study using computed tomography (CT) indicated that as we age, posterior retrusion of the bony maxilla leads to a flattened mid-face and loss of support for the surrounding soft tissues.6 Facial fat loss is also contributory to the remodelling of ageing.6
The mid-face extending to the zygomatic (malar) facial area can be dissected into six main layers: skin, subcutaneous fat tissue, superficial musculoaponeurotic system (SMAS), deep fat tissue, deep fascia and bone.6 As well as bony resorption, deep fat compartments undergo hypotrophic changes, causing a flattening and downward shift in the prominence of the mid-face.6
Figure 2: The zygomatic (malar) bone, zygomatic arch and relevant foramen.5
Danger zones to be aware of in the mid-face area include the angular artery (a terminating branch of the facial artery) with awareness of its variations, the transverse facial artery that runs across the submalar region, and the infraorbital foramen, through which the infraorbital neurovascular bundle emerges. The zygomaticofacial foramen (Figure 2), through which a neurovascular bundle perforates, is located laterally on the zygomatic arch and is often not considered when injecting the area, despite it being a terminal branch of the ophthalmic artery, with the risk of retrograde flow of filler and obstruction.5
An imaging study accurately determined that the average distance from the intra-orbital foramen (IOF) to the infraorbital margin is 8.61mm, and 17.43mm to the piriform. Therefore, this allows for safe injection in the region.7 When augmenting the cheekbone region, the mid-face must be considered for augmentation to balance the volume of soft tissue and contours of the entire malar area, while maintaining alignment with the rest of the face.
Contouring the mid-face
Makeup artists apply the concept of working with shadow and light when contouring the face. Working to individualised face shape, including oval, square, round, heart-shaped and long, highlights are selectively applied to the central more prominent parts, with shadows outlining the edged. Photographers, myself included, similarly apply this concept to complement an individual’s shape or elongate/shorten faces and ratios. The aesthetic treatment approach should similarly respect the balance between shadow and light on the face for contouring.8
When treating the cheekbone area, a layered approach should be considered, from supraperiosteal deep augmentation to superficial beautification of the skin. A number of treatment options are available to the practitioner to facilitate this process, including dermal filler, fat grafting, energy-based devices, threads, neuromuscular toxin, skin peels, among others.
For cheek augmentation using dermal fillers, it’s well known that a filler with lifting capacity should be selected. Cheek augmentation is not exclusively about volumisation, but also reshaping.
Augmentation of the cheeks can aid in lifting the lower third of the face by supporting the more superficial soft tissue layers from anchor points in the deeper tissue. I find that this approach creates structure in the zygomatic bone area and replaces volume loss in the malar region by filling the deep medial cheek fat (DMCF) and the suborbicularis oculi fat compartments (SOOF).
Anecdotal reports suggest it is common practice to aspirate before supraperiosteal injections to minimise intra-arterial injection, although this is unreliable and varies based on syringe, needle and tissue depth.9 In my experience, when injecting more superficially in the sub dermis, if deemed necessary to improve skin texture, the injection of filler should remain in the same depth plane for uniformity. Concurrent treatment of the temples and lateral part of the face (parotid region) may be added for creating the mid-face contours and convexity desired.
Injection of filler in the mid-face can be performed using a needle or cannula; one cadaver study indicated that the use of a cannula was more precise in placement of product.10 The sharp needle technique also showed a higher complication risk with intra-arterial injection occurring, however personal preference and experience dictates here.10
As alluded, facial shadows are as important as the light on the face when shape is considered. Contouring the cheekbone area should respect the balance between shadow and light on the face. Facial highlights can be enhanced by lighting the areas that have lost volume and deflated. Areas of shadow that complement the facial contours are best left untreated to maintain the ‘trough’. I find that adding volume more towards the forward facing part of the face, supraperiosteally, does not widen the face but allows light to fall on the prominence. If volume is added more laterally on the zygomatic bone and superficially, the face will widen, either bringing the ratio of length to width closer towards the aesthetic ideal or shortening the face.
Figure 3: Hinderer’s (A), Wilkinson’s (B) and Powell’s (C) techniques for locating the malar eminence11
The area of maximal malar prominence can be identified using four reliable and reproducible methods.11 The clinically relevant ones are Hinderer’s, Wilkinson’s and Powell’s methods (Figure 3).11 Others require specialist devices to measure.
The most commonly utilised is Hinderer’s lines, which involves overlaying two intersecting lines from the lateral canthus to the oral commissure and the tragus to the ala wing (Figure 4). The area immediately superolateral to this intersection is the most prominent point that should be augmented for projections.11
Figure 4: Patient before and after filler augmentation of cheekbone alone. Hinderer’s lines were used as a guide and 0.5ml filler was injected on each side supraperiosteally at two points in the superolateral quadrant. Treatment performed at DrMedispa.
Wilkinson’s line involves dropping a vertical line from the lateral canthus to the mandibular edge with the malar prominence located at one third the distance. Powell’s method, a more complicated and less applicable clinically, involves drawing two parallel lines, one from the ala to lateral canthus and one from the oral commissure in parallel; a third line bisecting the nasion to nasal tip, drawn horizontally across both parallel lines, forms an intersection with the second parallel line where the malar eminence is likely located.11 These lines are all there to triangulate the malar eminence, so where these meet is where the best point to inject is for the ideal projection.11
These ‘triangulation’ methods have been shown to be consistent in locating symmetrical points due to the use of superficial landmarks when compared to the ‘direct palpation’ method.11 This is another cruder method where the soft and bony contours of the malar eminence are palpated, but where a high percentage of facial asymmetry was noted.11 Augmenting the middle third and posterior third of the zygomatic arch will broaden the bi-zygomatic width, so caution should be exercised here to not distort facial proportions.
Aesthetic ideals, individual preferences, ethnic variation and cultural trends should also be respected; one template does not fit all.11
Figure 5: Example of cheek contouring treatment. After photos of a patient who has had dermal fillers and a beautification treatment performed using skin peels and finished with makeup contouring to highlight the cheekbones. Treatment performed at DrMedispa.
Addressing skin on the mid-face
Skin overlying the cheekbones must also be considered and addressed to optimise results with injectable treatments. Laxity here can result in the appearance of a flatter malar bone due to a poor light reflex and irregular tenting of the skin over the underlying periosteum.12 To address this, tightening the skin can be performed using threads to lift the skin at the dermal layer or radiofrequency energy delivered through microneedles. The main physiological effect of radiofrequency treatment is to stimulate collagen formation, tightening the skin and aiding in lifting – this has been shown to be effective in a review of numerous studies.12 Fat contraction when the energy is delivered at a deeper level can aid in shaping the lower third of the face to contour and shape to the desired aesthetics. Noninvasive means include the use of skin peels and pharmaceutical grade skincare to stimulate collagen formation and to hydrate the dermal/epidermal layers.
Summary
Strong and contoured cheekbones are a proven attractive feature based on their perceived representation of physical capabilities and personality. As aesthetic practitioners, we have a toolbox of modalities we can utilise to augment the cheekbones and create the aesthetic or personalised ideal. Understanding that these ideals and perceived beauty is a marriage of art and science, but also beauty, is very individual. It is important to note that quantifying the proportions that result in most people perceiving a face as beautiful takes nothing away from its uniqueness.
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