Dr Jenna Burton discusses the use of hyaluronic acid malar enhancement in substituting direct correction of deepened nasolabial folds, evening out of jowl formation and lifting of the infra orbital tear trough deformity through adoption of the deep ‘bolus technique’.
As a child our cheeks were high and full of life, spawning “chubby cheek” taunts, references to ‘puppy fat’ and squeezes from aunts. Gravity however is unselective. The inverted, bright ‘triangle of youth’ becomes the weary, tired ‘triangle of old age.’ Increasing age brings about lipoatrophy, bone reabsorption and laxity of ageing membranes. This, in turn, leads to a pseudo herniation of facial fat over the zygoma and maxilla. As the fat pad migrates downwards and more medially, skin loses its full supporting framework. It sags and collects, without structure, around the eyes, cheeks, and mouth. It also gathers bilaterally in a mass along the mandibular border in the form of jowls.
The tone, elasticity and hydration of the skin obviously plays a large part in how dramatic the downward migration of facial fat is realised for each particular individual. Despite this, there is little doubt as to its significant contribution to facial ageing and attractiveness. 70% of women injected with 1.0cc of hyaluronic acid into each cheek felt more attractive post-procedure than pre-procedure.1
Aesthetic practitioners appreciated this link between cheek fullness and perceived attractiveness back in the 16th and 17th century. Artificial cheek implants were adopted to lift and enhance a woman’s ogee curve in profile. Silver, gold, bone and leather were trialled to produce crude implants, leading to much complication and infection. Following many years of research, practitioners these days no longer need to encourage patients to undergo surgery to create the same enhanced look in their cheeks.2
Hyaluronic acid is now widely used in place of more artificial substances. This glycosaminoglycan is distributed widely throughout connective, epithelial and neural tissue within our anatomy. As a major component of the ground substance within the reticular dermis, it adds like-for-like and allows for natural movement of the face, post injection.
However in my experience, few practitioners presently choose to inject cheek fillers into their patients as a first line treatment. If the loss of voluminous cheeks over the zygomatic arch plays such a significant role in facial ageing, and injections of hyaluronic acid are easy, safe and effective substitutes, this should certainly be an area addressed more readily during consultations.
Patients often present complaining of specific aesthetic concerns. They complain of their tear trough deformities, their jowls, lines running along the side of their cheeks and, most frequently, of their nasolabial folds.
In order to please the patient, we reach for what they are expecting. If they hate their nasolabial folds, we want to ensure they are filled before they leave. If not, we will have dissatisfied customers. We have stopped thinking about why they have nasolabial folds and what more we can do for the patient other than just fill in the area they do not like.
Filling in the cheeks is an alternative solution to filling in the nasolabial folds. Tackling the cause of the problem itself should ensure longer lasting and more natural results, and lifting of the overall face. A randomised comparison of the efficacy of low volume deep placement cheek injection versus mid to deep dermal nasolabial fold injection technique for the correction of nasolabial folds was carried out and published in June 2014.3 The study, published in Cosmetic Dermatology, concluded that neither patients nor physicians involved noted a difference in improvement between correction of nasolabial folds with either method. Sadly, the study does not mention whether there were any further benefits gained from having cheek injections versus direct injection of the nasolabial folds themselves.
Subcutaneous fat compartments have been studied by Rorich and Pessa.4 They confirmed that deep fat is compartmentalised into discrete anatomical compartments which are not equally affected by ageing. The malar fat pad is split into three compartments; medial, middle and lateral. These deep fat compartments show greater atrophy with age than superficial fat, such as the nasolabial and jowl fat compartments, which can actually increase in volume as we get older.
Sagging of the arcus marginalis and the orbital septum allows the aponeurotic fat to bulge. The malar bag, nasojugal groove and tear trough deformity that results is not considered aesthetically pleasing and is associated with an ageing face. Previous treatments have included cannula or needle injections of permanent and semi-permanent fillers in the infra-orbital region. Dr Riekie Smit, president of the Aesthetic and Anti-Ageing Congress of South Africa, has commented that filling of the deep cheek compartments is not only more natural than direct correction of tear trough deformities via infraorbital injections, but can also be much safer.
Tackling the cause of the problem itself should ensure longer lasting and more natural results, and lifting of the overall face.
Although there have been many instances of success, complications for the semi-permanent filler range include risk of permanent oedema and loss of sight5. Use of permanent fillers to this area has been largely discontinued, and the FDA now only approves permanent fillers made of polymethylmethacrylate beads, limited to correction of the nasolabial fold5.
Intricate vasculature surrounding the eye increases the chance of arterial occlusion and ECM (‘Embolia Cutis Medicamentosa’ or full thickness necrosis).6 Further complications can be caused by inadvertent injection of, even a tiny amount, of filler behind the septum, according to Dr DeLorenzi, who has a private practice in Kitchener-Waterloo, Ontario. She says, “this can cause persistent oedema in the lower lids.” Although potentially corrected with hyaluronase, it raises questions as to whether the same effect can be had without such risks of vascular occlusion and infra-orbital oedema. Again, the answer could lie within deep dermal cheek fillers. I believe that the periosteal layer is a much safer region in which to inject as it contains fewer arteries and veins, and when combined with aspiration prior to injection, it reduces risk of arterial occlusion. Injecting a bolus of hyaluronic acid deep to the zygoma stretches the skin from below the orbital rim and pulls the tissues tight. Whilst previous fillers over the malar eminence have concentrated on lateral injections to highlight the cheekbones, practitioners may forget about injecting the medial aspect of the cheek. This becomes more important in later years, secondary to lipoatrophy and bone reabsorption of the mid-face. Therefore, we should aim to fill the entire cheek. Doing so should pull the excess skin from around the eyes outwards to look much tighter and reduce sagging.
To achieve mid face enhancement for improvement of nasolabial folds, jowls and tear trough deformity, along with improving the overall general appearance of the face, there are many techniques that can be adopted. Professor Alessio Redaelli, cosmetic medical author7 and faculty member of the American Academy of Aesthetic Medicine recommends the ‘deep bolus technique’.
His approach adopts the theory that your own tissue moves more naturally than anything that is injected. He recommends injecting deep, just above the periosteum of the zygoma. This will allow the hyaluronic acid to sit below the muscle and hence the patient’s own tissues. Smiling and laughing will recruit movement of their own muscle and dermal layers without interruption from foreign products. However, bruising can be common with this technique and it will often require more hyaluronic acid to achieve noticeable results. If the needle is inserted right to the depth of the bone, although not painful, the sensation is not always well tolerated by patients. An infra-orbital block may be used prior to injection for pain relief, but it will have little to no effect on this needle to bone sensation. Many practitioners still believe this is a minor trade off for a safer procedure, as injections are below major vasculature which avoids risk of the tyndall effect and gives a much more natural appearance.
Important points to note when carrying out a deep bolus injection for cheek enhancement:
Use of the deep bolus technique for lifting of nasolabial folds, tear trough deformity and overall improved, youthful appearance is safe, effective and simple to perform.
Little research has been published regarding how jowls can be affected by this mid-face enhancement. However, many aesthetic practitioners are already marketing its use to help even out the mandibular border, suggesting their success with such a technique. Whilst there is little we can do about the increasing volume of superficial facial fat as patients age, such as for nasolabial folds and jowls without the use of cosmetic surgery, we can consider how we can affect these areas by correcting the loss of deeper, superior fat compartments In the cheeks. As hyaluronic acid injections of the mid face are also associated with an increased feeling of attractiveness1, patients should not only look younger, but also experience an increase in self-esteem. Overall it appears that the approach to dermal fillers may slowly be changing. Practitioners are attempting medical facelifts rather than simply filling in lines. Yet it is important to remember that patients do have budgets, and enhancing the mid-face contours successfully will usually be a heavier financial burden compared to simply filling in the infraorbital rim/nasolabial fold or premature jowls. Patient education is needed to appreciate the cost-effectiveness of enhancing the face in this way, and to communicate its virtues as a safe and efficacious treatment.