“I had facial liposuction and now my cheeks look hollow and older” — this is one of the risks that patients considering facial liposuction fear most. Hollow cheeks are not simply the result of removing too much fat. In many cases, the underlying problem is that subcutaneous fat and the buccal fat pad were treated as if they were the same tissue, so deep fat that should have been preserved was damaged. In this column, Dr. Moriwaki of the Japan Society of Aesthetic Surgery explains the anatomy of facial fat and the design principles required to avoid hollow cheeks after facial liposuction.

Key Points of This Article

・Hollow cheeks are not simply the result of “taking too much” — they arise from confusing subcutaneous fat with the buccal fat pad, combined with age-related atrophy of the fat compartments.

・The buccal fat pad is an independent fat body deep to the facial muscles, in a plane not normally reachable by a subcutaneous liposuction cannula.

・The key to avoiding hollow cheeks is clearly separating the “safe-to-remove zones” (submalar, along the jawline, submentum) from the “preserve zones” (mid-cheek, under-eye, temple).

・Removal of the buccal fat pad is irreversible; cases have been reported worldwide of patients treated in their 20s who developed severe hollowing in their 40s–50s.

The Real Reason “Hollow Cheeks” Occur After Facial Liposuction

Facial fat is not a single sheet but a three-dimensional structure of stacked fat compartments. From superficial to deep, there are four layers: (1) subcutaneous fat, (2) SMAS (superficial musculoaponeurotic system), (3) deep fat, and (4) the independent buccal fat pad. Each layer plays a distinct role in cheek fullness, how light falls on the face, and how the face hollows with age.

When we say “hollow cheeks,” the cause is not necessarily the volume of fat removed. In patients in their 20s and 30s, hollowing is usually due to one of three things: (1) excessive suction of subcutaneous fat in a plane that was too superficial, (2) inadvertent damage to deep fat or the buccal region that should not have been touched, or (3) inadequate anticipation of age-related atrophy of fat compartments. More often than a simple “took too much,” the fundamental cause is misjudgment of the anatomical plane.

Anatomical Difference Between the Buccal Fat Pad and Subcutaneous Fat

The Buccal Fat Pad Is an “Independent Fat Body”

The buccal fat pad (corpus adiposum buccae) sits beneath the zygomatic arch and medial to the masseter muscle, in a position accessible from the buccal mucosa side. Unlike subcutaneous fat, it cannot be reached by a cannula from the skin surface — its removal requires an intraoral incision. In other words, standard facial liposuction (subcutaneous approach) does not manipulate the buccal fat pad itself.

However, if strong retraction or inappropriate cannula direction is used, damage can occasionally extend to the deep fat of the cheek. This risk is higher in thin patients or those with delicate facial bone structure, because the boundary between the subcutaneous and deep planes is thin and effects can propagate deeper than intended.

Location of Subcutaneous Fat and the “Safe-to-Remove Range”

Facial subcutaneous fat lies from just beneath the skin down to the SMAS, and contributes to jawline heaviness, double chin, and lower-cheek sagging. Facial liposuction essentially treats this subcutaneous layer, designed with line awareness around the sub-jawline, along the mandibular angle, and the inferior border of the zygoma. Deep fat is preserved as a “protected layer” as a rule.

Design to Avoid the Risk of Hollow Cheeks

“Safe-to-Remove Zones” and “Preserve Zones”

To minimize the risk of hollow cheeks in facial liposuction, we must clearly distinguish where suction is acceptable and where it is not. Safe-to-remove zones are three areas: the submalar triangle, the mandibular angle to jawline, and the submentum. Preserve zones are the mid-cheek (malar fat), under-eye, temple, and the buccal line lateral to the mouth corner. Because these preserve zones naturally atrophy with age, removing them in your 20s or 30s makes cheek hollowing conspicuous later.

Age-Based Indication

Early 20s: even with sufficient subcutaneous fat thickness, restraint is safer to allow for future atrophy. Late 30s and beyond: because atrophy of mid-cheek fat may already have begun, the “remaining deep fat” should be evaluated by palpation and ultrasound separately from the subcutaneous volume. 40s and beyond: often, lifting of ptotic tissue (surgical or thread) yields better results than liposuction alone. Comprehensive assessment of age, bone structure, and skin thickness is essential.

Why Buccal Fat Removal Is Not a “Casual Procedure”

On social media, there is a trend of equating “small face” with buccal fat pad removal — but this is an irreversible procedure. Once removed, the buccal fat pad does not regenerate. Cases have been reported worldwide of patients treated in their 20s who, when they reached their 40s and 50s, developed exaggerated hollowing and an aged appearance as age-related mid-face volume loss combined with the earlier removal. Even if the buccal fat pad looks “excess” in youth, it later serves as “the foundation supporting facial three-dimensionality.” For safety standards and indication criteria in cosmetic surgery, please also refer to information from the Japan Society of Aesthetic Surgery.

AVAN TOKYO’s Design Philosophy for Facial Liposuction

At our clinic, we view facial liposuction not as “a subtraction procedure only,” but as “three-dimensional design of the facial line.” Our handling of the buccal fat pad is also kept to the minimum necessary after comprehensively evaluating the patient’s age, bone structure, skin thickness, and projected future atrophy. Rather than simply removing volume, we prioritize a design aimed at “a face that will not look aged even 10 or 20 years from now.” For other facial cases and related topics, please also see our liposuction column archive.

Frequently Asked Questions

Q. Is the buccal fat pad accidentally suctioned during subcutaneous liposuction?

In standard facial liposuction (subcutaneous approach), the buccal fat pad lies outside the plane reachable by the cannula, so it is not directly suctioned. However, strong deep retraction or inappropriate cannula manipulation may damage surrounding tissue, so the operator’s anatomical understanding and experience have a major impact on the outcome.

Q. If hollowing occurs, can it be reversed with fat grafting?

Superficial (subcutaneous) depressions can often be improved to some extent with fat grafting. However, loss of the buccal fat pad itself cannot be completely reproduced with injected fat. Stable engraftment in the deep space is technically difficult, and improvement is often only partial.

Q. Is it too early to have facial liposuction in your 20s?

It depends on your bone structure and subcutaneous fat volume. Patients with clearly excess subcutaneous fat and jawline heaviness may be candidates in their 20s. However, designing conservatively in anticipation of future atrophy is essential to avoid the risk of hollow cheeks. In particular, buccal fat pad removal is not recommended in the 20s.

Q. Is a submalar depression the same as hollow cheeks?

They are different. A moderate depression in the submalar triangle is called the “Ogee line” and is actually a three-dimensional contour that is aesthetically favored. On the other hand, depression extending into the mid-cheek (malar region) — “hollow cheeks” — gives an aged impression. Distinguishing between the two preoperatively is at the very heart of facial liposuction design.

Medical Supervision: Shin Moriwaki, M.D. (Supervising Physician)

Member, Japan Society of Aesthetic Surgery (JSAS) / Member, American Academy of Aesthetic Medicine

ECFMG Certificate (U.S. Medical Licensing Qualification)

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