Figure 1
In the previous blog we discussed the crucial things to consider before proceeding with the middle third augmentation, and the importance of mark-up before the treatment.
In this blog, I want to emphasise the multi-layered (taking into account all 5 layers of the structures of the middle third of the face) augmentation tactics, which also indirectly improve the condition and tightening of neighboring problem areas. For example, infraorbital depression and deep nasolabial folds.
There are essentially 4 superficial fat pads that contribute to midface aging through changes in volume distribution: the infraorbital fat compartment (IOF), the medial cheek fat compartment (MCF), the middle cheek fat compartment (MiCF), and the nasolabial fat compartment (NLF).
Deep Fat Injection Techniques
Figure 2
Multiple bolus technique (with a needle or cannula)
The original tri-site bolus technique was adapted to create deep pillars supporting the superficial mid-cheek structures. This technique involved the injection of 3 boluses targeting the suborbicularis oculi fat, ISOOF and deep medial cheek fat. The injection has to be performed slowly, at low pressure and inserting the needle bevel down at 90 degrees.
The first step of a midface rejuvenation treatment is to provide structural support through injection into the deep fat layer, targeting the mSOOF (Medial Suborbicularis Oculi Fat), the lSOOF (Lateral Suborbicularis Oculi Fat), and the DMCF (Deep Medial Cheek Fat), which can be mapped by tracing 3 lines on the patient’s face: the vertical facial line descending vertically from the lateral canthus, the mid-cheek line coinciding with aforementioned safety line, and the zygomatic line (following the path of the zygomatic major muscle) spanning from the oral commissure to the lowest peak of the cheekbone
Figure 3
Fanning technique (with a cannula)
The last option for injecting the deep fat layer of the midface is to perform a horizontal fanning technique with a cannula, accessing the area from similar entry points as for the deep bolus technique (Figure 3). Following cannula insertion, gentle retrograde or anterograde injection of the filler is performed employing a low pressure, with constant motion, evenly delivering 0.1 to 0.3 mL along each cannula track. The cannula is retracted and readvanced in several directions targeting the different fat compartments without completely withdrawing it from the skin.
Superficial fat injection technique (with a needle or cannula)
In older patients, injecting into the mobile fat pads aims to create a roof above the structural support provided by deep injections. Fanning is the gold standard technique and may be performed with either a needle or a cannula.
Entry point(s) are the same as previously described for deep cannula injections (Figure 4), but needle or cannula insertion is performed at a more acute angle (30°), stretching the skin with the fingers of the non-dominant hand to ensure the needle or cannula slides within the superficial fatty layer. The filler is delivered through several gentle retrograde or anterograde injections, redirecting the needle or cannula several times without completely withdrawing it and placing 0.1 to 0.3 mL along each track. The medial and middle-fat pads are the main targeted compartments and can be accessed from both entry points. Of note, employing a lateral entry provides access to the lateral infraorbital fat in case it needs to be filled.
Figure 4
My favourite products for mid-cheeks
*Based on instructions for utilization in force in Europe at the date of article writing. ** Strength and stretch scores were obtained according to mechanical and rheological testing protocols previously described by Faivre et al.
With the right technique and products you can achieve incredible results that will leave your patients satisfied and make them come back to you. On the image below you can see one of my latest works using the full face technique. If you want to learn more about it and participate in a workshop with me, please get in touch with Top Dermal team.
There are many other fillers as well which are perfect to use for the cheeks/middle face augmentation, for example:
- Neauvia intense Flux with highest concentration of hyaluronic acid 26 mg/ml cross linked with PEG
- Neauvia Stimulate is perfect bio stimulator and with 26mg/ml HA, cross linked with PEG + 1% calcium hydroxyapatite
- Fillmed Art Filler Volume, Revolax Sub-Q , e.p.t.q S500 and so on.
All these products you can find at Top Dermal online shop.
