Lipoatrophy and facial volume loss: why hollows appear and how they are corrected
Hollow cheeks and temples are not always ageing. Some causes are medical and treatable, and identifying the cause changes the correct treatment.
Lipoatrophy means loss of subcutaneous fat, and on the face it produces hollow temples, flat cheeks, prominent bony rims and a tired appearance that no amount of skincare will change. Before treating the shadow it is important to know why the fat disappeared, because some causes are ongoing and will undo the correction if they are not addressed [1].
Key points
- Facial fat sits in discrete compartments that deflate at different rates
- Localised lipoatrophy can follow steroid injection, trauma, panniculitis or autoimmune disease
- Generalised loss can be medication related, notably with older antiretroviral drugs
- Correction options are hyaluronic acid filler, collagen stimulators and autologous fat
- Treating the cause comes before treating the contour
Why the face loses fat
With age, deep and superficial fat compartments shrink and descend at different rates, so the midface flattens while the lower face becomes heavier. Bone resorption around the eye socket and jaw magnifies the effect. This pattern is predictable and is the usual reason for cosmetic volume treatment.
Localised lipoatrophy is different. It follows an insult to a specific area: an intramuscular or intralesional corticosteroid injection, blunt trauma, inflammation of the fat layer known as panniculitis, or an autoimmune process such as lupus panniculitis or morphea [1]. Rapid weight loss and some genetic lipodystrophy syndromes cause generalised loss.
Medication and disease related lipoatrophy
Older antiretroviral medicines, particularly thymidine analogue drugs, were a well documented cause of facial lipoatrophy, and the appearance itself became a source of stigma and reduced treatment adherence [2]. Modern regimens have largely removed this problem, but patients treated years ago may still carry the contour changes.
Insulin injection sites, repeated corticosteroid injections for keloids or joint disease, and localised scleroderma all produce well demarcated depressions that respond to volume restoration once the underlying disease is quiet.
How correction is planned
The first step is deciding whether the process is active. Injecting into an inflamed autoimmune lesion produces an unstable result. Once quiet for at least six to twelve months, correction is safe.
For small, well defined depressions, hyaluronic acid filler placed deeply gives immediate and reversible correction. For diffuse loss over larger areas, collagen stimulating products such as poly L lactic acid build volume gradually over several sessions with a natural, non lumpy result. For severe loss, autologous fat transfer supplies the largest volume and adds a regenerative effect on the overlying skin.
- Small localised depression: hyaluronic acid filler, deep placement
- Diffuse cheek and temple loss: collagen stimulator over three sessions
- Severe or long standing loss: autologous fat grafting
- Active inflammation: treat the disease first
What to expect from treatment
Filler results are immediate and last twelve to eighteen months in deep planes. Collagen stimulators show little at first and build over two to three months after each session, which requires patience and clear explanation at the outset. Fat grafting settles at three months.
Correction rarely needs to be complete to make a large difference. Restoring around seventy percent of the lost contour usually reads as normal, while chasing full correction risks an overfilled appearance.
Frequently asked questions
Will a steroid injection dent come back on its own?
Many steroid induced dents improve over six to twelve months as the fat partially regenerates, so early observation is reasonable. If it persists beyond a year, filler or fat correction is appropriate.
Can I prevent further loss?
Sun protection, not smoking, stable weight and treating any active inflammatory disease all slow the process. Nothing stops age related bone and fat change entirely.
Is this covered as a medical rather than cosmetic issue?
Disease and medication related lipoatrophy is a medical problem and is documented as such, which matters when reports or letters are needed.
References
- [1] Wollina U, Wetzker R, Abdel-Naser MB, et al. Adipose tissue and facial ageing and lipoatrophy: clinical review. Clinical Interventions in Aging. Source
- [2] Carr A, Cooper DA. Adverse effects of antiretroviral therapy including lipodystrophy. The Lancet. Source
This content is general medical education and does not replace a personal consultation. Any prescription must be coordinated with your local doctor.
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