Stretched Pores May Not Be Due to Sebum — Anterior Cheek Sagging and Elongated Pores

Three-Line Summary

• The reasons pores look larger come down to three: excess sebum production, reduced elasticity around the pores, and increased volume of the hair follicle itself. In practice, a mix of these is the most common picture.
• If the nose is fairly clear but the anterior cheek pores alone are lengthening vertically, and they are less visible when the cheek is lifted toward the cheekbone, we first consider whether sagging is part of the picture. This is a clue that points us in a direction, though, not a validated test.
• For anterior cheek pores with sagging in the mix, one approach to consider is dividing the work within a single session between the deeper Ultherapy transducers (tips) and the 1.5 mm transducer. There is clinical data that the 1.5 mm transducer helps with pores, but no direct comparison study has been identified showing that this combination is better than the 1.5 mm transducer alone.

Three Routes to Enlarged Pores

It is hard to explain enlarged pores with a single cause. A literature review that Lee and colleagues published in Dermatologic Surgery in 2016 grouped the clinically relevant causes into three: excess sebum production, reduced elasticity around the pores, and increased volume of the hair follicle itself. In other words, there are three routes to larger pores, and each person has a mix of them.

Recurrent acne, sex hormones and skincare habits are layered on top of these, so pore shape differs even among people of the same age. The same review noted that because the causes are multiple, treatment should also differ from person to person. That is where a pore consultation starts.

What This Article Covers

We have set out how to tell the sebum pattern from the elasticity pattern in our article on treatment order. Here we take the second of the three causes, reduced elasticity, and narrow it down to one area, the anterior cheek.

A Pore Is Not a Fixed Hole

If you think of a pore as a fixed hole punched in the skin, you cannot explain why pores on the anterior cheek in particular look so elongated. A visible pore is the spot where a hair follicle and its sebaceous gland open onto the skin surface, seen as a small depression, and its shape changes with how tautly the surrounding skin holds it.

Sebum and Elasticity — Correlations in Two Directions

Kim and colleagues reported a study in Skin Research and Technology in 2013 that took instrument measurements in 60 people, 30 men and 30 women. Sebum output showed a positive correlation with pores, and the elasticity reading (R7 on the Cutometer) showed a negative correlation. That is, the lower a person's elasticity, the more pores were visible.

This was an observational study measured at a single point in time, however, so it does not prove the order of events — that elasticity fell first and pores enlarged as a result. Even so, the result shows why explaining pores by sebum alone keeps falling short.

Pores That Are Less Visible Lying Down — What Posture Tells Us

"They look fine when I check the mirror in the morning, but worse in the evening." Some patients tell us this. That impression is not just imagination.

Iida and Ono published a study in the Journal of Japanese Cosmetic Science in 2016 (volume 40, issue 1) that analyzed skin replicas taken from the central cheek of 23 Japanese participants in their 20s to 60s. When readings taken sitting and lying down were compared, pore area and depth were significantly reduced lying down, even though it was the same part of the cheek. In other words, with the pull of gravity removed, the pores looked less deep and less wide.

In the same study, skin elasticity in the middle and lower cheek fell with age while pores grew deeper, and the elongation and depth of the pores were associated with elasticity and with sagging scores.

Two Things We Check in Consultation

• A question — we ask whether your pores look different first thing in the morning and in the evening after a full day, and how they look when you are lying down.
• Lifting the cheek — we push the skin of the anterior cheek about 1 cm toward the cheekbone, that is, diagonally up and outward, and see whether the pores look less stretched.

If the pores change noticeably when the cheek is lifted, we suspect that stretching caused by sagging is part of the picture. But these two checks are clues that point us in a direction, not validated diagnostic tests.

With Age, Pores Lengthen More Than They Enlarge

Judging pore aging by size alone misses part of the picture. Lee and colleagues published a study in Skin Research and Technology in 2022 that measured the cheeks of 101 Korean women in 3D and sorted the pores into five groups.

The value expressing pore elongation was 1.78 in the group with a mean age of 10.1 years and 3.92 in the group with a mean age of 55.8 years. That means pores that had been round became more than twice as long. In the older groups, neighboring pores were also seen joining up with one another, and the authors wrote that this may be related to wrinkle formation.

On the Phrase "Comb-Pattern Pores"

When patients say "they look like comb marks" or "I can't tell whether these are fine lines or pores", this is usually what they are describing. "Comb-pattern pores", though, is not a formal diagnosis found in textbooks. It is an expression used for explanation. In the terms the research uses, it is close to pores that have lengthened and joined up with one another.

Why the Anterior Cheek — It Is Not a Problem of the Skin Layer Alone

A review by Swift and colleagues in the Aesthetic Surgery Journal in 2021 describes facial aging from the inside out. Bone remodels, deep fat shrinks, superficial fat shifts downward, muscles and ligaments change, and finally the skin thins — and these processes overlap. In other words, it is not just the skin that ages; the face sinks from underneath.

Recent data point the same way. Oya and colleagues published a study in the Journal of Cosmetic Dermatology in 2026 that analyzed 220 women aged 20–79 using ultrasound and skin measurements, and the degree of sagging was associated with dermal viscoelasticity, subcutaneous fat thickness and zygomaticus major muscle thickness together. The authors concluded that sagging cannot be explained by the aging of a single layer.

The anterior cheek is skin where pores show easily, and at the same time it is where the descent of midface tissue shows first. So a surface problem and a structural problem overlap in the same view. We cover the anatomy of anterior cheek sagging separately in our article on anterior cheek volume loss and our article on cheek hollowing.

How Far Has This Been Confirmed?

No direct trial has confirmed a causal link in which anterior cheek sagging creates new pores. What has been confirmed so far goes as far as this: elasticity and sagging are associated with pore shape, and pore area and depth change when posture changes. So we explain it at this level: "anterior cheek sagging can make pores that were already there stand out more."

Sebum or Sagging — Four Things We Look at in Clinic

• Shape — whether the pores are round, or vertically elongated with one end fading out like a teardrop
• Whether the nose is involved — whether the nose is just as affected, or the nose is fairly clear and the anterior cheek alone is affected
• What changes when the cheek is lifted — whether the pores are less visible when the anterior cheek is lifted lightly, diagonally up toward the cheekbone
• Accompanying findings — whether shine and comedones come with the pores, or fine lines and thinning skin do

The Nose Is the Quickest Dividing Line

The anterior cheek is practically the same place as the so-called butterfly zone, the inner cheek beside the nose, so the location of the pores alone does not separate the two types. Both have pores in that spot. What separates them is whether the nose is part of the picture. The nose is where sebaceous glands are densest, so when sebum is the main cause, the nose is unlikely to be spared.

So when the nose is shiny too and has round pores along with it, we think of sebum first. When the nose is fairly clear, the anterior cheek pores alone are elongating, and nasolabial folds are visible as well, we think of sagging first.

The Limits of This Distinction

This is not an official classification validated by research. It is a practical distinction we use in clinic, based on several studies of what causes enlarged pores. Having a lot of sebum does not mean there is no sagging component, and being older does not mean the sebum factor has disappeared. In practice, a mix is the most common picture.

If you have kept up exfoliation and sebum control for years and the anterior cheek pores alone keep standing out more, it may not be that your care was wrong; something different may be under way in the anterior cheek. This is the case where the pores are clean at the surface but sagging underneath is progressing, and the pores look stretched along with it.

Why We Talk About Lifting When the Concern Is Pores

Patients are often puzzled when we bring up lifting in a pore consultation. It is easier to follow if you turn the order around. If the skin around the pores is being pulled downward, a treatment that refines the surface alone is touching up the result while leaving the downward pull in place.

Two things can overlap in stretched pores on the anterior cheek. One is reduced elasticity in the dermis immediately around the pore. The other is the tissue underneath being pulled down by gravity, which makes pores that were already there look longer. Treat just the skin around the pore, and the downward pull remains. Treat just the sagging, and the slack skin around the pore remains.

Ultherapy Is a Device Used at Separate Depths

Ultherapy does not work at a single depth. Its 1.5 mm, 3.0 mm and 4.5 mm transducers (tips) each create thermal coagulation points at a different depth, so their roles can be divided within one session. We use deeper transducers such as the 3.0 mm or 4.5 mm for the tissue that has sunk, and the 1.5 mm transducer for the elasticity of the dermis around the pores. The depth of each transducer and how it works are set out in our article on how Ultherapy works.

Changes Confirmed in Tissue

An animal histology study published by Marquardt and colleagues in the Journal of Cosmetic Dermatology in 2025 confirmed that, after treatment at three depths, distinct thermal coagulation points formed at each focal depth: 1.5 mm, 3.0 mm and 4.5 mm. At day 90, HSP47-positive fibroblasts and mature collagen had increased at those sites, and newly formed elastic fibers were also significantly more abundant at day 90 than at day 14. That is, changes were observed in elastic fibers as well as in collagen.

Ultherapy 1.5 mm and Pores — How Far Does the Evidence Go?

A Randomized Split-Face Study

Lee and colleagues published a study in the Journal of Dermatological Treatment in 2015 in which 22 people with enlarged pores had one session on each side of the face: the 1.5 mm transducer on one side and the 3.0 mm transducer on the other. On blinded photographic assessment, pore improvement was reported in 86% of the 1.5 mm sides and 91% of the 3.0 mm sides. Mean improvement scores were 1.7 and 1.9 respectively, with no statistically significant difference between the two.

In the same study, skin elasticity improved significantly, and the degree of improvement in elasticity correlated positively with the pore improvement grade, whereas the reduction in sebum was not statistically significant. That is, the change in pores tracked the change in elasticity rather than a reduction in sebum. The study followed 22 people for just 6 weeks, however, and because both sides were treated, it had no untreated control area.

A Protocol Proposed by Korean Physicians

Park and colleagues published an article in Plastic and Reconstructive Surgery Global Open in 2023 that drew on experience treating about 150 people over 3.5 years and proposed the 10 MHz, 1.5 mm transducer at energy level 2 (0.18 J), with 100 lines per cheek. It advises dividing the anterior cheek into 2.5 cm × 2.5 cm zones, delivering 25 lines per zone where pores are most prominent, and treating in at least two directions or in crossing directions to reduce pain and excessive overlap.

The example in the article is a single case, a 30-year-old woman: after 3 months, the pore count on both cheeks was reported to have fallen significantly and the pore grade to have improved by two grades. This paper is not a controlled clinical trial, however. It sets out expert experience and an illustrative case, so the protocol should not be read as a universal standard.

To Sum Up

There is clinical data that the 1.5 mm transducer is worth using for the elasticity of the skin around pores. But stretched pores on the anterior cheek may not be a matter of that elasticity alone, and in someone who also has sagging, using the 1.5 mm transducer alone addresses just one side of the problem. So we address sagging with the deeper transducers and the skin around the pores with the 1.5 mm transducer, together in a single session.

It is worth noting that in the 22-person study above, pores improved to a similar degree on the 3.0 mm side as well. But that study used the two transducers separately on opposite sides of the face, so it does not show how much more changes when they are used together.

What This Approach Can and Cannot Take On

What It Can Take On

For anterior cheek pores with sagging in the mix, the main advantage is that the deeper transducers can address the sinking tissue while the 1.5 mm transducer addresses the dermis around the pores as well. There is no need to change devices or come in on separate days; we just change the transducer within the same session.

What It Cannot Take On — Four Things

• Round pores caused mainly by sebum and comedones — here, treatment aimed at sebum and keratin build-up comes first.
• Fast change — in histology, too, the increase in collagen and elastic fibers was clear at day 90, and the clinical studies assessed results over a span of months.
• Pores widened by acne scarring — this is a different area of treatment. Scars have to be assessed as scars.
• Proof that the combination is better — no direct comparison study has been identified showing that this combination, which targets sagging and pores together, is better for pores than the 1.5 mm transducer alone. Saying that dividing the depths is biologically plausible is different from saying the combination has been proven better.

On Session Numbers and How Long Results Last

You may come across claims that a single device resolves all pores, or that a set number of sessions holds for a set number of years. But follow-up in pore studies has mostly run from a few weeks to about 6 months, and evidence on long-term durability and on the right interval for repeat treatment is still limited. So we do not recommend a fixed number of sessions across the board. We decide the treatment and interval that suit your current condition together in consultation, and adjust them as we follow your progress.

When Ultherapy Alone Is Not Enough

The mixed type, with plenty of sebum and a descended anterior cheek at the same time, is in practice the most common. In that case, treating the deep layers alone leaves the round pores around the nose as they are, and treating sebum alone leaves the elongated pores on the anterior cheek as they are. So we first work out how much of each is in the mix and, where needed, schedule treatment aimed at sebum and keratin build-up and treatment aimed at the dermis at different times.

What a Study of Combination Treatment Tells Us

A randomized, single-blind, split-face study published by Vachiramon and colleagues in the Journal of Cosmetic Dermatology in 2021 compared micro-focused ultrasound with visualization (MFU-V) alone with a combination that added injection of lightly cross-linked hyaluronic acid, in 46 participants. On both sides, pore volume was significantly lower than baseline at every visit, and the lowest mean value came at 4 months. Blinded physician assessment found no significant difference between the two methods; patient satisfaction was the one measure that was higher on the combination side, at 4 months and at 6 months.

It is more accurate to read this not as showing that combination is always better, but as showing that what to add depends on the mix in each person's pores. If facial sagging is your more pressing concern, you may want to read our article on sagging self-diagnosis and treatment order first.

What You Can Check at Home

In front of a mirror, look at just two things.

• Whether the pores are less visible when you gently lift the anterior cheek diagonally up toward the cheekbone
• Whether your pores look different in the morning and in the evening

If round pores extend to the nose and there is shine, we look at sebum first. If the nose is clear but the anterior cheek pores alone are lengthening vertically and are less visible when the cheek is lifted, we look at sagging first. If both apply, the two are mixed, and this is in fact the most common case. If either applies to you, please mention it first at your consultation. It changes where we look.

What to Know Before Treatment

• Individual variation — the causes of pores and the condition of the skin differ from person to person, so results can differ even with the same treatment. This article is a general explanation and does not replace an individual diagnosis.
• Side effects and cautions — after micro-focused ultrasound treatment, temporary redness, swelling, tenderness, bruising and a tingling sensation can occur, and, rarely, nerve irritation symptoms or fat atrophy are reported. Your skin condition and any medication you are taking need to be discussed before treatment.
• Level of evidence — the sources cited in this article include observational studies with samples of 22–220 people, randomized split-face studies, a protocol based on expert experience, and an animal histology study. No causal study has been identified proving that anterior cheek sagging directly causes enlarged pores, and no direct comparison study has been identified showing that combining several depths is better for pores than a single depth.

References

1. Lee SJ, Seok J, Jeong SY, Park KY, Li K, Seo SJ. Facial Pores: Definition, Causes, and Treatment Options. Dermatol Surg. 2016;42(3):277-285.
2. Kim BY, Choi JW, Park KC, Youn SW. Sebum, acne, skin elasticity, and gender difference - which is the major influencing factor for facial pores? Skin Res Technol. 2013;19(1):e45-e53.
3. Iida T, Ono T. Morphological Changes of Facial Pores on Cheek with Sagging. Journal of Japanese Cosmetic Science. 2016;40(1):1-7.
4. Lee S, Cherel M, Gougeon S, Jeong E, Lim JM, Park SG. Identifying patterns behind the changes in skin pores using 3-dimensional measurements and K-means clustering. Skin Res Technol. 2022;28(1):3-9.
5. Swift A, Liew S, Weinkle S, Garcia JK, Silberberg MB. The Facial Aging Process From the "Inside Out". Aesthet Surg J. 2021;41(10):1107-1119.
6. Oya M, Takeuchi Y, Touma Y, Yamazaki K. Structural Characteristics of Facial Sagging: A Quantitative Analysis Linking Visual Assessment to Dermal, Fat, and Muscle Properties. J Cosmet Dermatol. 2026;25(5):e70896.
7. Marquardt K, Hartmann C, Wegener F, Park JY, Halbert D, Hsu S, Hengl T. Microfocused Ultrasound With Visualization Induces Remodeling of Collagen and Elastin Within the Skin. J Cosmet Dermatol. 2025;24(1):e16638.
8. Lee HJ, Lee KR, Park JY, Yoon MS, Lee SE. The efficacy and safety of intense focused ultrasound in the treatment of enlarged facial pores in Asian skin. J Dermatolog Treat. 2015;26(1):73-77.
9. Park JY, Youn S, Hong W, Lee KC, Kim I. Treatment Protocol on Using Microfocused Ultrasound with Visualization for Skin Quality Improvement: The Korean Experience. Plast Reconstr Surg Glob Open. 2023;11(5):e5029.
10. Vachiramon V, Namasondhi A, Anuntrangsee T, Kositkuljorn C, Jurairattanaporn N. A study of combined microfocused ultrasound and hyaluronic acid dermal filler in the treatment of enlarged facial pores in Asians. J Cosmet Dermatol. 2021;20(11):3467-3474.

From Consultation Through Treatment

A board-certified dermatologist examines you directly, identifies which layer the cause sits in, sets the device and the parameters, and then carries out the procedure as the same physician. This is not a structure in which a consultant sells the treatment.

The number of sessions, the intervals, the maintenance point and the cost are agreed together before the first session.