The Aging Cheek

A youthful face generally looks round and full. Aging causes sagging that suggests tiredness. These changes, which can be further compounded by the effects of gravity, occur at every layer of the facial anatomy that begins at the facial skeleton. Lipoatrophy, bone resorption, and increased laxity of the membranes contribute to the pseudo-herniation of facial fat over the zygoma and maxilla bony structures. As they migrate medially, the skin cannot be maintained in its original position. At the lower face, it leads to the formation of jowls at the mandibular border.

The current trend regarding facial rejuvenation seems to be moving away from the traditional facelift and blepharoplasty, which can incur long downtimes and can be a heavy financial burden for most patients. Soft-tissue volume augmentation procedures, such as dermal filler injections, can have a significant impact on the delay of facial aging, as they provide natural-looking, long-lasting results. It is shown that approximately 70% of women that were injected with only 1.0 cc of hyaluronic acid into both cheeks had a subjective experience of increased attractiveness.

Even in the 16th century there was a marked correlation between attractiveness and cheek fullness. Silver, gold, and leather were often used to produce artificial implants that could lift and enhance the cheeks, but many succumbed to infection and other complications. Luckily for modern society, no longer are we subject to crude experimentation that has a high likelihood of jeopardizing the lives of patients. Through many dedicated years of research and development, the safety, convenience, and effectiveness of dermal fillers seen today offer amazing results without the need for any surgical procedure.

Today, a popular dermal filler material is hyaluronic acid. It is used because it is consistent with the glycosaminoglycan compound that occurs naturally in connective, epithelial, and neural tissues, which lowers the risk of hypersensitive reactions. It is also a part of the ground substance in the reticular dermis that enables natural facial movements even after a filling procedure. However, more reports have surfaced that point toward the use of a variety of treatment modalities for the most optimal result(s). This, in turn, lends further credence to the fact that there are multiple components that affect the aging process.

Underlying causes of aging cheeks

Rorich and Pessa have concluded that the deep fat structures are packaged into separated anatomical compartments that are not affected equally by aging. The malar fat pat is found to have three sections: lateral, middle, and medial. They show significantly more amounts of atrophy with age than the superficial fat areas, such as the nasolabial and jowls. This discrepancy in atrophy causes sagging of the arcus marginalis and the orbital septum, which contributes to the bulging of the aponeurotic fat. This causes signs of aging in the cheek, including nasojugal grooves, malar bags, and tear trough deformities. Fortunately, there are minimally invasive treatment options available via dermal filler injections. For permanent, semi-permanent, or temporary dermal fillers in the infra-orbital region, these injections can be done with either needles or cannulas. Practitioners have advocated that volumizing the deep cheek compartments may have more natural results than directly targeting tear trough deformities with infraorbital injections. This method ensures that the root cause of the problem is addressed rather than its symptom. As mentioned before, this approach contributes to safer, better-looking, and longer-lasting.

Treating the cause

When patients seek aesthetic help, the cosmetic defects that they want corrected are usually clear and highly specific, e.g., tear trough deformities, jowls, and nasolabial folds. Knowing what patients want fixed will help you determine what must be done to deliver satisfactory results. To help you achieve this, aim to solve the root cause of these cosmetic problems, so that any form of correction done will last longer and have a more natural appearance. For example, injecting dermal fillers to augment the volume of the cheeks has a comparable effect to directly filling in the nasolabial folds. This was demonstrated in a 2014 randomized comparison found that low-volume deep-placement cheek injections versus mid-to-deep dermal nasolabial fold injections for the correction of nasolabial folds were similarly efficacious.

Treatment technique

There are a multitude of techniques to consider when augmenting the facial features at the midfacial region. Specific techniques were developed to tackles issues regarding the nasolabial folds, jowls, and tear trough deformity. One such technique is the deep bolus technique. Inject the filler deep into a position just above the periosteum of the zygoma, as this will cause the hyaluronic acid dermal filler material to rest below the muscle. Any dynamic movements around this area, such as smiling and laughing, will not interrupt the filler material resting underneath it. However, take note that bruising more frequently occurs using this technique and that more hyaluronic acid dermal filler may be required. An infra-orbital anesthetic block may be used prior to this injection technique to reduce patient discomfort. Keep in mind that the needle may also reach the depth of the bone, which may cause major discomfort for the patient. However, compared to more serious complications, such as vascular occlusion, these adverse effects can be considered minor. In addition, it eliminates the possibility of the Tyndall effect, where a bluish discoloration can occur on the skin if injected too superficially.

Deep Bolus Injection

The vital points to consider when augmenting the cheek via the deep bolus injection technique are as follows:

• You must counsel your patients thoroughly on the procedure and make sure you answer any questions from them. Demonstrate the post-procedure appearance by pushing their cheek pad upwards. Taper down their expectations to ensure a successful outcome.
• Both informed oral and written consent must be received prior to initiating treatment.
• A local anesthetic should be used. This can be infra-orbital blocks, an ice application, or the topical application of Emla (lidocaine and prilocaine) cream. The decision to reduce patient discomfort through one of these agents should also always be based on the preferences of the patient.
• Approximately three to six injections should be made in the cheek, but this number may vary based on the patient’s cosmetic needs.
• Demarcate a curved line 2cm below the infraorbital rim along the malar eminence and indicate three points for injection.
• The second line should be 1cm below and parallel to this line, and again, mark three similar injection points.
• Utilize a hyaluronic acid dermal filler with high viscoelasticity. Orientate 90° perpendicular to the bone, just above the periosteum. Squeeze the tissue at the area of interest before injecting.
• Make sure that you are below the muscle layer before injecting the bolus.
• Gently massage the area after injection to adjust the contours to match the surrounding skin.
• Aim to use 1ml of dermal filler material on each side of the cheek; however, this amount may depend on the cosmetic needs of the patient.
• Once injected, the filler will be distributed to the most lateral part of the malar eminence and the medial point at the nose region. With this said, use the least effective amount of filler between these two points, as it will overlap.
• Treating the male face will require different contouring than a female patient’s face. Be cautious not to feminize the male face.

Minimizing risks

Though many complications of dermal fillers are transient and minimal, there are instances where these events have caused permanent damage to the patient. Serious complications, such as permanent edema and blindness, have occurred with the use of semi-permanent fillers. Particular areas of note are the fragile vasculature that governs the eye regions, as they have a higher chance of arterial occlusion and subsequent skin necrosis. Moreover, the area behind the septum is also particularly at risk for inadvertent intravascular injections. The permanent fillers, on the other hand, have been largely discontinued due to its unreasonable risk-to-benefit ratio. Currently, the FDA only approves of polymethylmethacrylate permanent fillers that are indicated for nasolabial fold correction. As such, hyaluronic acid fillers offers the safest material to be injected due to its reversibility through the application of hyaluronidase. Though this is can be an option for some practitioners, there also exists another way to minimize the risk of vascular occlusion and infra-orbital edema: deep injections of filler in the cheek. Indeed, the periosteal layer offers better protection, as it is not as vascularized as the other layers. If performed with aspiration before the injection, the chances of arterial occlusion are very rare. Usually, a bolus of hyaluronic acid dermal filler that is injected deep into the zygoma stretches the skin below the orbital rim and tightens the tissues. The malar eminences may be targeted with lateral injections to augment the cheekbones, but the medial aspect should not be forgotten, as these can be severely affected by lipoatrophy and bone resorption. An injection of about 0.5ml of hyaluronic acid to both sides of the cheeks can improve nasolabial folds and the initial parts of tear trough deformities.

Conclusion

The desire to look and feel young is a frequent wish among many people in society. This desire has created a huge demand for aesthetic medicine. As the decades come to pass, elective nonsurgical interventions for facial rejuvenation continue to gain wider acceptance and popularity. The targeted lines and wrinkles on the face can be regarded as just a series of hills and valleys. It is then easy to comprehend that filling these valleys in the skin can minimize the wrinkles. This premise has led to the techniques described above. The deep bolus technique for tear trough deformity, nasolabial folds, and jowls is safe, effective, and easy to use. Although there has not been much evidence supporting its use in jowls, many practitioners have anecdotal reports that advocate its use in smoothening the mandibular border. Although the volume of superficial facial fat cannot be altered, you may consider augmenting the amount of volume of the deeper fat compartments in the cheeks. The development of these techniques show that the trend has been to perform medical facelifts instead of simply augmenting volume to eliminate the lines. For patients that have tight budgets, enhance the mid-facial region as best as you possibly can even with the set limitations. Usually, the contours desired can be achieved despite a significant financial burden with this deep bolus technique. Educate the patient of all aspects of treatment, so that they can appreciate the cost-effectiveness and general effectiveness of facial rejuvenation through this method.