Chapter 10 Filler Injection of the Malar and Zygomatic Regions
Chapter 10 Filler Injection of the Malar and Zygomatic Regions
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.
The adipose tissue in the middle third of the face consists of a superficial portion and a deep one. The superficial portion comprises the nasolabial, medial cheek, middle cheek, and temporolateral fat pads. The deep portion comprises the medial and lateral portions of the suborbicularis oculi fat (SOOF), also called prezygomatic fat, and the deep medial and deep lateral cheek fat pads.5,.6
When the superficial and deep portions are separated, it is possible to see the orbital portion of the orbicularis oculi muscle (OM) and the superficial muscular aponeurotic system (SMAS) encompassing levator muscle of the upper lip and the ala of the nose, the levator muscle of the upper lip, the zygomatic major and minor muscles, and the vessels and nerves.
The superficial nasolabial and medial malar fat pads cover the orbital portion of the OM, which originates below the palpebral portion, 0.5 to 1 cm below the inferior orbital rim. The SOOF is below the orbital portion of the OM, resting over the maxilla and the zygomatic bone.
The superficial medial cheek fat pad, superficial middle cheek fat pad, and SOOF are relevant for augmenting the malar region (Fig. 10.1,10.2,10.5, and10.8–10.15).
The superficial medial cheek fat pad and the medial SOOF are supplied by branches of the facialaand 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 arteryband 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
Sensory innervation is supplied by the maxillary branch of the trigeminal nerve.
Motor innervation is supplied by the temporal and zygomatic branches of the facial nerve (Fig. 10.4–10.6).
The malar fold translates clinically as an extension of the nasojugal groove in the malar region. According to Furnas,10it is an imaginary oblique line that extends from the zygomatic ligamentcto 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.
Skin ligaments: Fibrous strand that covers the medial bundle of the OM whose fibers insert into the skin.
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.1115
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:
Superficial Cannula Technique for the Malar Region
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.
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).
1 Braz AV, Sakuma TH. Midface rejuvenation: an innovative technique to restore cheek volume. Dermatol Surg 2012;38(1):118–1202 Raspaldo H. Volumizing effect of a new hyaluronic acid subdermal facial filler: a retrospective analysis based on 102 cases. J Cosmet Laser Ther 2008;10(3):134–1423 Carruthers JD, Carruthers A. Facial sculpting and tissue augmentation. Dermatol Surg 2005;31(11 Pt 2):1604–16124 Hoff mann K; Juvéderm Voluma Study Investigators Group. Volumizing effects of a smooth, highly cohesive, viscous 20-mg/mL hyaluronic acid volumizing filler: prospective European study. BMC Dermatol 2009;9:95 Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007;119(7):2219–2227, discussion 2228– 22316 Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg 2008;121(6):2107–21127 Whetzel TP, Mathes SJ. Arterial anatomy of the face: an analysis of vascular territories and perforating cutaneous vessels. Plast Reconstr Surg 1992;89(4):591–603, discussion 604–6058 Schaverien MV, Pessa JE, Rohrich RJ. Vascularized membranes determine the anatomical boundaries of the subcutaneous fat compartments. Plast Reconstr Surg 2009;123(2):695–7009 Furukawa M, Mathes DW, Anzai Y. Evaluation of the facial artery on computed tomographic angiography using 64-slice multidetector computed tomography: implications for facial reconstruction in plastic surgery. Plast Reconstr Surg 2013; 131(3):526–53510 Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 1989;83(1):11–1611 Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg 2008;121(5):1804–180912 Pilsl U, Anderhuber F, Rzany B. Anatomy of the cheek: implications for soft tissue augmentation. Dermatol Surg 2012;38(7 Pt 2):1254–126213 Ghassemi A, Prescher A, Riediger D, Axer H. Anatomy of the SMAS revisited. Aesthetic Plast Surg 2003;27(4):258–26414 Pessa JE, Garza JR. The malar septum: the anatomic basis of malar mounds and malar edema. Aesthet Surg J 1997;17(1): 11–1715 Andre P, Azib N, Berros P, et al. Anatomy and volumizing injections. Paris: E2e Medical Publishing; 2012
a The facial artery originates at the external carotid, crosses the inferior border of the mandible, anteriorly to the masseter muscle; it then divides into the inferior and superior labial branches and continues ascending over the levator muscle of the upper lip and the ala of the nose. It anastomoses with the infraorbital artery, and ends in the medial commissure as the angular artery.b At the level of the parotid gland, the superficial temporal artery divides into two branches that supply the malar region: the transverse facial artery and the zygomatic-orbital artery. The transverse facial artery divides into two branches: the superior branch flows 5 to 26 mm (mean 14 mm) below the zygomatic arch, branching into the superior masseter muscle, zygomatic major muscle, and malar region.c The zygomatic ligament comprises robust fibers measuring 6 to 8 mm, which originate at the inferior edge of the anterior portion of the zygomatic arch below the origin of the zygomatic minor muscle, and insert directly into the skin as a point of anchor. It is important from surgical point of view, when the skin needs to be pushed forward, but can be absent in up to 10% of patients