Advertorial: Med-fx - Treating the Cheeks

By Dr Harry Singh / 05 Apr 2018

Dr Harry Singh discusses the use of Restylane fillers for facial aesthetics, available from Med-fx.

I started in facial aesthetics back in 2002, and when we saw a line/fold, we filled it – we were the original ‘line chasers’. As our understanding of the ageing process, anatomy and techniques have advanced, we now look at addressing the ‘cause’ of ageing and not the ‘consequence’ of ageing.

Anatomy

The upper lateral cheek projects anteriorly over the zygomatic arch. Anteriorly the convexity of the cheek and lid-cheek junction are due to the deep cheek fat pads below the eyes and deep-to-the-cheek muscles. Laterally, the buccal fat pad gives the cheek its roundness.1 It tapers into the nasolabial fold and this convexity followed by a slight concavity is known as the ‘Ogee curve’.2

We now know that the ageing process is a multifactorial event that involves changes to; skin, collagen/elastin, fat compartments, muscle, retaining ligaments and bone. In summary, the deep and superficial fat pads deflate and descend, the periorbital and zygoma bones resorb and the retaining ligaments become laxer.3

In reference to the mid-facial fat pads and the cheeks, we are concerned with the deep and superficial fat pads, such as the medial cheek, nasolabial, middle cheek, lateral cheek; deep fat pads – medial and lateral sub-orbicularis oculi, deep medial cheek, buccal. We will pay close attention to the retaining ligaments in this region that become laxer as we age and therefore effect the quality of the skin. The retaining ligaments we are concerned with are; orbital/malar ligaments, zygomatic ligaments and masseter-cutaneous ligaments.

Treatment options

When assessing any patient for dermal filler treatment in this region, I will categorise them into three outcomes:

Do they need volume replacement?

Do they need lifting?

Do they need contouring?

Obviously, some patients will need a combination of all three. As always, the management of patient expectations is critical to any success in the outcome.

Where to inject

Where we inject will depend on what outcome we want to achieve (as per the classification above).

I will first outline the infra-orbital rim (each side may differ) and the infra-orbital foramen (which is normally 3-5mm below the infraorbital rim and in line with the medial limbus).4 I will also use a cotton-tipped applicator to slightly depress this region and ask the patient when they feel a sensation.

Next, I will draw a line that extends to the tear trough. This is quite important as we don’t want to inject medially to this (a no-go area) as you will encounter the angular artery and leave an unnatural appearance if you deposit filler here.

Then, I will complete this triangle. The upper part is the infraorbital rim, the medial part being the extended tear trough, and the lateral part being a perpendicular line joining the lateral infraorbital rim and the extended tear trough.

I will use this area as a reference to where I need to add volume to the cheeks. I will place a finger block at the infraorbital rim to prevent any product migrating pass this structure. However, volume replacement is specific to each patient, and you may need to deviate slightly from the area marked. For lifting purposes in female patients, I will want to have a maximum projection at the intersection of the alar-tragal line and the lateral canthus of the eye. As we go laterally, the bolus amounts will decrease incrementally, and I will mark out the upper and lower borders of the zygomatic arch, making sure the bolus is between these two markings.

Needle vs. Cannula

For volume replacement, I prefer to use a cannula. Due to the larger area we need to cover, I want to reduce the number of insertion points and passes I need to make. I normally use the TSK Cannulas STERiGLIDE™ 25G x 50mm with 23G x13mm needle to make the entry point. When I require lifting, I prefer needles and will inject perpendicularly to the skin and hit bone,5 placing my deposits at the dots marked in the figure. 

Products to use

I favour hyaluronic acid fillers due to the non-permanent nature and the opportunity to remove any product by using hyaluronidase.

I prefer the Galderma range of products, which are available from Med-fx, as their range allows me to perform a tailored approach to each patient depending on the desired result and the skin quality. For example, the use of softer, less viscous products with a low G prime for a more superficial approach and those patients with poor skin quality. Then, products with more viscous and higher G prime for a deeper approach and lifting for those patients with good skin quality. For volume replacement, I will normally use Restylane Volyme™. This is injected by a cannula in the subcutaneous plane and using a fanning technique.6 You may need anything between 1-4ml dependent on the amount of volume loss. But as always, place a little, sit the patient up, reassess and then decide if you need more.

For lifting, I will use Restylane Lyft™ or Restylane Defyne™. The choice of product will depend on the patient’s skin quality. The better the skin quality, the more it can take in lifting, hence the use of the NASHA™ (Non-Animal Stabilised Hyaluronic Acid) range such as Restylane Lyft™, which has a high degree of cross-linking. For those patients with poor skin quality or thin skin, then I prefer a softer product and would look at Restylane’s OBT™ (Optimal Balance Technology) range such as Restylane Defyne™.

I would normally use a total of 1ml on both sides for the lifting result. The maximum projection may require 0.5ml and then less as we advance laterally. A word of warning, however, these are only generalisations and amounts will vary for each patient.

Risk factors

This can be divided into assessment and technique. The incorrect assessment of what the patient needs will result in an unnatural result. A common mistake I see is adding volume where there has been minimal volume loss. This results in a puffy look.

Every procedure we carry out will have some risks associated with it.7 Our role as clinicians is to predict and then minimise these risks. When injecting bolus deposits, you want to aspirate to make sure you are not directly injecting into a vessel. You should inject very slowly and while injecting, observe the skin. In addition, I recommend making sure you stay on bone, as this is a relatively safe area. At the end of the procedure, I will gently mould and massage the product to reinforce the desired outcome. 

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