55 Part A: Filler Finesse: Cheeks

Rod J. Rohrich, Ira L. Savetsky, and Paul D. Durand

Abstract

The aging midface can be enhanced through volume augmentation. Injections of the arch, malar eminence, and deep medial compartments may result in adjacent hollowing or a noticeable depression in the mature female patient. Our technique addresses these secondary valleys. Focus on these areas may improve aesthetic results of malar augmentation.

Malar eminence – fat compartment – malar augmentation – cheek filler – peaks – secondary valleys

55 Part A: Filler Finesse: Cheeks

Key Points

A comprehensive and systematic facial analysis is critical in establishing goals and formulating a precise plan for malar augmentation.
A stepwise approach to malar augmentation which addresses secondary valleys restores youthful anatomical landmarks and improves facial aesthetics.

55A.1 Facial Aging

Facial aging is characterized by collagen loss and thinning of the skin, bone resorption, and lack of soft tissue support and volume.
The subcutaneous fat of the face is compartmentalized into superficial and deep compartments.
The malar fat is further divided into medial, middle, and lateral temporal-cheek compartments separated by fascial septae (Fig. 55A.1).
Loss of fat volume results in atrophy and hollowing of the midface.
Augmentation of these compartments can be performed to improve facial aesthetics.
The facial tissues, underlying structures, and fat compartments are independent and must be addressed in an individualized fashion.
Injection of the deep medial fat compartment increases midface projection.
Injections of the primary peaks (Fig. 55A.2) in female patients along the zygomatic arch, malar eminence, and deep medial compartments will enhance cheek prominence, resulting in an often aesthetically desirable “high cheek bone” appearance.
When the arch, malar eminence, and deep medial compartment are injected in mature female patients, a deepened secondary valley remains (Fig. 55A.2).
This region of hollowing lies inferior and parallel to the peaks. This area should be filled with volume to improve contour.

**Fig. 55A.2** Malar landmarks in female patient. **Peaks:** Deep malar compartment (A), malar eminence (B), and zygomatic arch (C). **Secondary Valleys:** A’, B’, and C’.

55A.2 Planning

The initial consult begins with a thorough facial analysis including facial proportions, identification of areas with volume deflations, rhytides, and tissue laxity.
Preparation, dilution, and injection of substances in facial tissues should be performed under sterile technique.
Properties of fillers including viscosity, stiffness (G´), affinity for water, degree of cross-linking, and concentration of hyaluronic acid (HA) should be considered.
Generally, it can be advantageous to choose a filler with a higher G´ value and viscosity to provide a lifting effect in midface volumization.
A 30-gauge needle is used for injections.
Topical anesthesia is applied and skin cleaned with chlorhexidine.
Ice rollers and gentle pressure can be used for distraction.
Lights are utilized for optimal visualization during the procedure.