PEER-REVIEW | FACIAL AESTHETICS | Figure 4 Botulinum toxin
injection points for orbicularis oculi muscle
massaging to blend the filler into the tissue. This technique will not only remove lateral smile wrinkles, but also enhance the facial contour to allow the light to fall on the lateral cheek area. This gives a very attractive appearance, especially in female patients. The tear trough area can be quite challenging to treat.
It is important
to evaluate each patient
individually to
assess where the greatest
enhancement is needed. Some patients require
more volume over the medial cheek, and others over
the lateral cheek area.
dangerous intravascular placement. This area can be
enhanced with hyaluronic acid fillers to reduce upper eyelid hollowness and enhance brow lifting. Figure 5 illustrates the recommended lines of injection with a cannula to enhance the supraorbital and brow areas.
Infraorbital dermal filler injections The infraorbital region can be enhanced at a few different points, including the tear trough, lateral cheek and especially by lifting the mid-face that significantly enhances the infraorbital area. The upper lateral cheek area can appear aged and
unattractive owing to the loss of zygomatic projection and wrinkles as a result of hyperactivity of the orbicularis oculi contracting underneath and progressively thinning the skin. The lateral eye wrinkles soften quite easily with botulinum toxin injections over the lateral aspect of the orbicularis oculi muscle; however, some wrinkles often remain over the zygomatic arch as a result of the contraction of the zygomaticus major and minor muscles, which cannot be treated using botulinum toxin. This area can be successfully enhanced with a two-layer approach, by placing a low viscosity hyaluronic acid filler as micro-droplets into the superficial wrinkles, and a high viscosity hyaluronic acid filler over the lateral cheek area. These techniques are illustrated in Figure 6, with the blue circles showing the micro-droplets of the low viscosity hyaluronic acid filler that is injected with a multi-puncture technique into the deep dermis. The white circular line shows the area in which the high viscosity dermal filler is placed in the subcutaneous tissue. This can be performed using either a needle or a cannula, followed by liberal
Figure 5 Supraorbital dermal filler injection with a cannula, to enhance hollowness and the brow
Few patients need only tear trough filling exclusively, while the majority will need enhancement of the malar fat pad area. As discussed, the descent and decline of the malar fat pad betrays the tear trough area. Therefore, if the patient does not have sufficient volume over the medial malar area, then exclusive tear trough treatment will result in increased heaviness and worsened shadows under the eyes. In younger patients, exclusive tear trough treatment with
a medium reticulated hyaluronic acid filler can be injected using either a needle or cannula. Placing the filler with a cannula will reduce the risk of bruising, but will not eliminate this risk. An article by the Carruthers’ recommends the preferred needle technique to be injecting the filler at the base of the tear trough and then manually pushing the filler with a finger into the tear trough area. The older patient will often require malar enhancement
to lift the tear trough by replacing the lost volume. This treatment is performed using either the cannula or needle technique, with a high viscosity filler to replace a rather large volume loss. There are a number of approaches to enhance the malar and cheek areas, which may include placing the filler with three bolus injections in a line 1–2 cm below the inferior orbital rim, or by performing a fanning technique with either a needle or cannula injection. It is important to evaluate each patient individually to
assess where the greatest enhancement is needed. Some patients require more volume over the medial cheek, and others over the lateral cheek area. This evaluation for treatment must be performed by assessing the patient from anterior, lateral, and three quarter views. The anterior view is ideal to evaluate where light and shadows fall on the face, whereas the lateral and three quarter aspects are ideal to evaluate malar projection and the ogee curve. Only then, with all aspects in mind as discussed, can one formulate a treatment plan and areas for injection. Malar enhancement lifts the tear trough in the majority
of cases, and further improves overall facial proportions, including infraorbital shadows. Treatment of the mid-face should not be seen as only
improving facial profile and enhancing cheek projection, but should be strongly considered for enhancing the
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Figure 6 Lateral cheek enhancement of wrinkles
March 2013 |
prime-journal.com
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