Injectable fillers has become one of the most requested minimally invasive treatment options from patients to re-volumize their aging face. However, the use of Bovine collagen was limited both by its short duration of effect and its potential for allergic reaction. With the introduction of hyaluronic acid (HA) as a facial filling agent in 2003, the world of fillers was revolutionised.
For the augmentation of the cheekbones, or lateral malar prominence, fillers may be used. (Alternatively, permanent malar implants may be inserted surgically, or fat augmentation can be performed). This week, we will cover techniques on filler injection for cheekbone augmentation, which is a procedure highly demanded in the market at the moment.
The malar bone and overlying soft tissue form the lateral malar prominence. Having high cheekbones contribute to a youthful arc seen in three-quarter view. Some patients with aging of the mid-face display a fat pad of the lateral malar prominence, referred to as the “malar mound.” This triangular prominence results from the orbital retaining and zygomaticocutaneous ligaments.
Fig. 54.1: The zygomaticomalar subdivision of the midface lies inferior to the infraorbital rim and lateral to the infraorbital nerve. The prominence of the cheekbones is improved by augmenting the zygomaticomalar region. Injection may include deep injection along the infraorbital rim and zygomatic arch as well as a more superficial injection to camouflage the malar mound.
For this procedure, topical anesthesia may be used. Fillers with lidocaine may be placed deeply at first injection to anesthetize the infraorbital nerve. The reason dental blocks are discouraged is because it may actually distort the anatomy. To volumize the lateral malar prominence, fillers may be placed through the intraoral or percutaneous route. Intraoral injection does not predispose the patient to infection. Filler can be placed deep in the subcutaneous tissue and pre-periosteal planes.
To conceal the malar mound, hyaluronic acid (HA) fillers can be used more superficially (deep dermal or subcutaneous) over the retaining ligaments. In addition, deep injection over the malar prominence will camouflage the malar mound and elevate the lateral cheek.
Please see below for the short video of the injection technique:
For this indication, HA or CaHA may be used. Although it is a safe location for injection, it is best to avoid injecting into the malar mound fat as this might increase the swelling of the fat pad.
Post-Injection Instructions and Risks
Ice may be used as needed, but patient needs to be informed to not to press on the injected site firmly or to sleep on that side for a few days. This is to minimize flattening of the product.
Bruising may occur. However, the greatest challenge with performing this procedure is ensuring symmetry.
Pearls of Injection
Lateral malar augmentation may be performed through a single-entry point on each cheek. Cannulas may be used for the deep injections.
Injections that are placed too inferior or medial, as well as over-injection of this area, can create an unnatural look in many patients.
Preexisting asymmetry is the rule in most patients, and achieving a symmetrical final outcome should be the goal.
Reference: Cosmetic Injection Techniques - Theda C. Kontis, Victor G. Lacombe
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