Introduction

A young and attractive face is characterized by a well-contoured and convex malar region. This area of the face is best visualized at a 75° angle and has been used since ancient times by artists to emphasize facial beauty and, more recently, by photographers and in the preparation of 3D digital models. At this angle, the facial contour presents the shape of the Greek letter ζ (sigma), also called the “cyma line.”

Nonetheless, bone remodeling caused by the aging process associated with atrophy and a downward shift of the local fat pads result in volume loss in this area, which gradually flattens and, in extreme cases, becomes concave. Weight loss and congenital predisposition can also cause this loss of volume. ¹⁴

Volumization of the malar region requires the injector to have an in-depth knowledge of anatomy, a keen sense of esthetics, and technical skill (Fig. 10.7 and10.27). Overcorrection of the zygomatic region can broaden the horizontal diameter of the face, conferring a more masculine look to women. When treating the infraorbital region, it is essential to choose the correct application plane, as a very deep injection may not give the desired result, while a very superficial one, or an injection into the nasojugal groove, could cause persistent edema or visibility of the product.

Anatomy

Vascularization

The superficial medial cheek fat pad and the medial SOOF are supplied by branches of the facial ^a and infraorbital arteries.

The facial vein crosses the middle third of the face more laterally than the artery, and after crossing below the zygomatic major muscle, it becomes more superficial bordering the SOOF medially. In its superior portion, it is located deep to the superficial medial cheek fat pad and superficially to the SOOF, then below the OM.

More laterally, the middle cheek fat pad and the lateral SOOF are supplied by the perforating branches of the transverse facial artery ^b and the zygomatico-orbital artery. In this region, the perforating arteries are sparse and large, contrary to what occurs in the medial region, where they are thin and numerous (Fig. 10.3–10.6). ⁷ – ⁹

Innervation

Malar Fold

The malar fold translates clinically as an extension of the nasojugal groove in the malar region. According to Furnas, ¹⁰ it is an imaginary oblique line that extends from the zygomatic ligament ^c to the medial commissure of the eye. Its origin is still somewhat unclear, but it is thought to contribute to the formation of the malar fold.

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  Skin ligaments: Fibrous strand that covers the medial bundle of the OM whose fibers insert into the skin.

  
  
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  Malar septum: The malar septum seems to be primarily a structure of the OM. It originates in the periosteum of the inferior orbital rim (marginal arch) and takes a caudal direction, going around the medial portion of the OM, to then fuse with the fibrous septum of the superficial fat pad (SFP), inserting into the skin 2.5 to 3 cm from the lateral commissure. The malar fold divides the malar region into two: The external part, over the cheekbone and SOOF, and the internal and inferior part, which rests over the region of the levator muscle of the upper lip. ^{11 15}

Technique

The objective is to restore the volume lost during the aging process or during weight loss, providing the patient with infraorbital projection and, if necessary, projection of the cheekbone area. Augmentation of the latter is necessary in specific cases where the additional volume does not confer a masculine look when the diameter of the face is increased. For a natural and balanced effect, it is necessary to concentrate on the area of volume loss, without changing the form of the patient’s face.

A filler injection using a cannula is preferable, due to the lower risk of intravascular injection and formation of hematomas. When treating the deeper planes, such as the medial SOOF, it is important to remember that the facial vein flows above the SOOF and below the orbital part of the orbicular muscle. There are fewer incidences of edema, and greater patient comfort is achieved, when using a cannula because it makes it possible to fill the entire infraorbital and zygomatic area using only one entry point.

While using a needle for the filler injection, avoid the infraorbital foramen. Aspire and inject slowly.

Some practitioners suggest filling the medial cheek fat pad below the SMAS, which requires larger volumes of hyaluronic acid (HA). We do not use this approach not only because of the abovementioned reasons, but also because it is riskier given the presence of the vessels and nerves in the SMAS. ⁶

The techniques used are described below:

Complications

Mild to moderate edema may occur immediately after the procedure that is associated with the volume injected, the patient’s individual susceptibility, the injection planes, and the type of product. Pain or discomfort at the site of injection are common and resolve spontaneously within 2 to 3 days. Hematomas can be minimized by using a cannula, but they can still occur at the entry point of the cannula, albeit to a lesser extent.

A rare complication is the occurrence of delayed-onset edema, months after the procedure.

Conclusion

Familiarity with the fat pads of the middle third of the face, as well as with the local musculature, vascularization, and innervation is fundamental for achieving adequate and safe volumization of the malar and zygomatic regions. An injection into the correct fat pad and plane yields excellent results, leading to both patient and physician satisfaction (Fig. 10.35–10.37).

References

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