The apple-like cheek muscle, also called the smiling cheek muscle, which is located underneath the eye socket, is the flattest spot on the zygomatic bone. When we are young, this area is full of tissue and fat, so the cheek muscles look plump and red apple-like when we smile or express emotion. That is where the expression “apple-like cheeks” comes from.

What we call the apple-like cheek muscle does not refer to the actual face muscle, but instead to the fat and hypodermis that are attached to the cheek bone. When this area is full, the face is warm and friendly, with vivid curves, and a young and energetic appearance. Without this fullness, a face tends to look serious and two-dimensional. As we age, our cheeks start to sag as fat and collagen diminish—the so-called apple-like cheek muscle gradually disappears. As a result, tear troughs and cheek creases deepen and the face looks less youthful.

In addition to the loss of fat and collagen on the cheek muscle due to aging, the other main factor that can diminish apple-like cheeks is a lack of support by the congenital bone structure, such as a sunken zygomatic bone. We refer to this as an underdeveloped mid-face. This type of underdeveloped mid-face is often seen in Taiwan, and has the characteristics of a wide and flat zygomatic bone, protruding maxilla, and noticeable tear troughs, cheek creases and nasolabial folds. It can cause an aged appearance, even at a young age. This type of problem often occurs due to hereditary or postnatal bone structure, or overbite problems. In order to properly correct those problems, a surgical treatment is required, rather than a non-surgical hyaluronic acid injection procedure.

Currently, there are several methods for improving a lacking or diminished apple-like cheek muscle.

1. Macromolecules Hyaluronic Acid (Sub-Q) Injection
For minor aging, Sub-Q injection can temporally improve the fullness of the apple-like cheek muscle. The advantages are instantaneous, the procedure is simple, and the results are very natural. Therefore, before having surgical treatment, some people choose Sub-Q injection to simulate the results of surgical treatment. The drawbacks to Sub-Q injection are the short duration of the effect (about 1-2 years), the need for repeat injections, and the increasing cost due to the increasing dosage that is injected.

2. Endoscopic Mid-Face Lift Surgery
This surgical operation for aging and sagging apple-like cheek muscle is tremendous for facial rejuvenation. Incisions are made on the scalp and inside the mouth with a bio-absorbable device that incorporates five tiny tines. The recovery time is 3-5 days, so it is an ideal solution for working women, or elderly women who do not want traditional face lift surgery. The advantage of this surgery is its remarkable and wide-ranged results. It provides many benefits with one procedure, not only improving sagging cheeks, but also lifting apple-like cheek muscle to help reduce partial nasolabial folds. The drawbacks are that patients experience a temporary stiff feeling in the cheeks after surgery, it is not applicable to patients with over-thin skin and surgery costs are higher than some other procedures.

3. Zygomatic Implant Surgery
This new surgery is suitable for younger patients who have congenital dented or flat zygomatic bone problems. Either a silicone gel cartilage or Medpor is inserted on top of the cheekbone to create a fuller result. The incision is inside the mouth, so it is not visible on face. The advantages are effective correction, long-lasting results, no modification between the cheek muscle and tissue, and no interference with the facial expression. In addition, a patient can decide the size and style of their apple-like cheeks. The primary drawback is that, because it is a more sophisticated operation, the surgeon’s aesthetic sensibility can determine how effective and satisfactory the results are. Moreover, there is some risk of infection and dislocation.

Hopefully, the author’s explanation has given the reader a better understanding of this complicated surgery for mid-face rejuvenation. In order to tailor the most suitable apple-like cheek muscle to each individual, the treatment has to take into consideration that person’s unique facial characteristics and the relationship between bone structure, muscle, fat and skin condition. Which surgical treatment is right for you? Let’s pass this tough question on to a professional plastic surgeon!