Sunken cheeks, often described as facial hollowing, refer to the loss of volume and contour in the mid-face region. This change occurs beneath the cheekbone, between the bony arch of the cheek and the lower jawline. Sunken cheeks are a visible sign that underlying facial structures are losing mass or support. While often associated with natural aging, this change can also signal significant, sometimes rapid, changes related to lifestyle habits or a developing medical condition. Understanding the mechanisms behind this volume loss helps differentiate between an expected cosmetic change and a potential sign of a deeper health issue.
The Anatomy Behind Facial Volume Loss
The appearance of a sunken cheek is fundamentally a structural issue resulting from changes in fat, bone, and soft tissue layers. The face is supported by distinct compartments of fat that provide volume and contour. Over time, these fat pads, particularly the deep compartments in the mid-face, undergo atrophy, meaning they naturally decrease in size and descend due to gravity.
The buccal fat pad, a deep structure that facilitates muscle movement, also changes with age, contributing to a flatter, more hollow appearance in the lower cheek. Unlike subcutaneous fat, the volume of the buccal fat pad is not correlated with overall body weight. This internal fat loss removes the natural scaffolding that keeps the skin taut and lifted.
Structural support also diminishes due to changes in the craniofacial skeleton, a process known as bone resorption. The maxilla (upper jaw) and the zygomatic arch (cheekbone) lose density and recede with age. This recession reduces the bony projection of the mid-face, causing the overlying soft tissues to lose their firm foundation and appear deflated.
The outermost layer of the skin, the dermis, also plays a role through the degradation of its structural proteins. Collagen and elastin are responsible for the skin’s firmness and elasticity. A natural decline in the production of these proteins leads to overall skin laxity and descent, further accentuating the hollow look created by the loss of underlying fat and bone support. The combination of deep fat atrophy, skeletal resorption, and skin laxity results in the characteristic appearance of sunken cheeks.
Lifestyle Factors and Rapid Weight Change
External factors and personal habits are often the primary drivers behind changes in facial volume, particularly when the change is noticeable over a shorter period. The most common cause of sudden or pronounced hollowing is significant or rapid overall body weight loss. When the body burns fat for energy, it draws from fat stores across the body. Since the face has relatively small fat compartments, it is often one of the first places where fat depletion becomes visible.
The loss of subcutaneous fat in the cheeks and temples removes the cushioning layer, causing the skin to appear loose and the underlying bone structure to become more sharply defined. This rapid reduction in facial volume can make an individual look older or more gaunt in a short amount of time. A gradual and steady weight loss approach is recommended to allow the skin more time to adapt to the change in volume.
Acute dehydration, even temporary, can cause the face to lose its natural plumpness, leading to a transiently hollow appearance. The skin’s ability to retain water is directly linked to its volume. When the body is significantly fluid-depleted, this effect is often visible in the thin tissues of the face. Addressing fluid intake can quickly reverse this specific cause of sunken cheeks.
Long-term personal habits also accelerate the degradation of facial support tissues. Smoking restricts blood flow and accelerates the breakdown of collagen and elastin fibers, leading to premature aging and skin laxity. Excessive sun exposure has a similar effect, damaging the skin’s structure and its ability to maintain volume. Furthermore, a diet lacking in necessary macro and micronutrients can compromise the health of the skin and supportive tissues. Deficiencies in essential fatty acids, protein, and vitamins hinder the body’s ability to maintain skin integrity and healthy fat stores.
Sunken Cheeks as a Sign of Underlying Health Issues
While many causes of sunken cheeks are benign, the symptom can sometimes be a physical manifestation of a more serious, chronic medical condition. When hollowing is sudden, severe, or accompanied by other systemic symptoms, it may point to an underlying health crisis. A prominent concern is cachexia, a complex metabolic wasting syndrome characterized by the involuntary loss of both skeletal muscle mass and adipose tissue.
Cachexia is frequently observed in patients with advanced chronic illnesses, including certain types of cancer, severe heart failure, and chronic obstructive pulmonary disease (COPD). The metabolic changes involve systemic inflammation and a catabolic state, where the body breaks down tissue faster than it can rebuild it. This systemic wasting causes the temples and cheeks to visibly hollow, often leaving the cheekbones noticeably protruding.
Specific chronic infections and immune conditions can also lead to facial fat loss. Lipoatrophy, the localized loss of fat tissue, was historically a known side effect of certain older antiretroviral medications used to treat HIV. Chronic infections, such as advanced tuberculosis, are also associated with significant weight loss and subsequent facial hollowing.
Issues related to the body’s ability to absorb nutrients can also result in volume loss. Malnutrition, whether due to insufficient food intake (such as in eating disorders) or malabsorption issues (like untreated celiac disease or inflammatory bowel disease), depletes the body’s fat and muscle stores. Since the facial fat compartment is small, its loss becomes quickly apparent, signaling a long-term nutritional deficit.
Medication side effects, beyond those causing rapid weight loss, can sometimes be a factor. Certain seizure medications have been associated with facial volume changes over long-term use. Additionally, structural changes in the mouth, such as significant tooth loss or severe gum atrophy, can alter the underlying jawbone structure. This indirectly reduces support for the lower cheek and changes facial contours. A medical consultation is warranted if facial hollowing appears rapidly, is asymmetrical, or is accompanied by unexplained weight loss, fever, or persistent fatigue.
Management and Treatment Options
Addressing sunken cheeks effectively requires identifying and managing the underlying cause, whether it is a lifestyle factor or a medical condition. For cases related to personal habits, simple lifestyle adjustments can help restore volume and prevent further degradation of facial tissues. Maintaining a stable, healthy weight is important, as repeated cycles of rapid weight loss followed by regain can stress the skin’s elasticity.
Consistent and adequate hydration supports skin plumpness and overall tissue health, countering the temporary hollowing caused by fluid depletion. Ensuring a balanced diet rich in protein, healthy fats, and antioxidants provides the necessary building blocks for collagen production and skin repair. Protecting the skin from environmental damage by using broad-spectrum sun protection minimizes the acceleration of collagen breakdown.
When volume loss is related to chronological aging or is a persistent cosmetic concern, several medical and aesthetic options are available to restore contour. Non-surgical treatments are the most common approach for volume restoration in the mid-face.
Injectable Treatments
Dermal fillers, typically composed of hyaluronic acid, are injected beneath the skin to immediately replenish lost volume in the cheek area. Some injectable treatments, known as biostimulators, work by encouraging the body to produce its own collagen over time, providing a more gradual and natural-looking volume increase.
Fat Grafting
For a longer-lasting solution, fat grafting is a procedure that involves harvesting a patient’s own fat from an area like the abdomen or thigh and transferring it to the cheeks. This technique restores volume with natural tissue and can offer results that last for years.
In instances where sunken cheeks are a symptom of a chronic disease, the primary focus must remain on treating the underlying medical condition, as aesthetic treatments only address the symptom. Only once the systemic cause, such as cachexia or malnutrition, is stabilized can cosmetic interventions be considered to address the residual changes in facial appearance.