Introduction

The cheeks are facial cosmetic units that easily reveal one’s age, owing to their progressive volumetric reduction after the third decade of life. They play a fundamental role in facial expression, transmitting happiness through smiles and laughs.

Each cheek is composed by the soft tissues covering the paramedian central facial skeleton (Table 18.1). The upper third of the cheek can be further divided into zygomatic and infraorbital subunits. The zygomatic subunit (cheekbone) represents the area of maximal projection of the cheek, called the malar eminence (Fig. 18.1A). The ideal malar eminence diffusely reflects light regardless of the angle one looks at the face. The cheeks work as a frame for adjacent cosmetic units such as the lips, eyes, and ears, allowing the observer to instinctively calculate cosmetic ratios related to those structures.

Table 18.1 Borders of the cheek

Figure 18.1 Important cosmetic features of the cheek: (A) anatomical limits and subunits (IO = infraorbital, Z = zygomatic, SMT = submalar triangle, TT = tear trough, PSP = parasagittal profile contour); (B) location of the malar eminence by the Hinderer method.

Modified from Naini FB 2011.

Although prominent cheekbones are usually associated with beautiful individuals, it is their relationship with the other facial structures that defines attractiveness. Several techniques are available to identify the optimal location of the malar eminence. Hinderer’s method is easy to obtain, helping to optimize filler placement when augmenting the cheeks. The ideal reflection of light should be kept in the upper outer quadrant formed by the intersection of two virtual lines: the first one runs from the lateral canthus of the eye to the angle of the mouth; the second one goes from the nasal crease to the tragus. Other aesthetic features of the cheeks are superficial textural homogeneity, lack of shadows, and smooth transition towards adjacent cosmetic units. Accordingly, the ideal parasagittal profile contour should have a smooth curvilinear shape from the eyelids to the cervical jaw angle (Fig. 18.1B).

Aging of the mid-face is essentially caused by atrophy of the cheek bones and fat pads. In two areas these changes are striking: (1) within the submalar triangle (an inverted triangle defined medially by the nasolabial fold, superiorly by the malar eminence, and laterally by the anterior border of the masseter muscle) and (2) along the tear trough and eyelid / cheek junction. These changes lead to a deflated balloon pattern – folding the overlying skin. In addition, mid-face atrophy loosens the tissue surrounding the angle of the mouth, leading to a sad appearance (Fig. 18.2A). Filling the cheeks helps in restoring a gracious oral commissure (Fig. 18.2B).

Figure 18.2 Artistic illustration of oral commissure groove improvement by mobilizing tissue around the angle of the mouth when performing augmentation of deep planes in the upper cheek: (A) before, and (B) after filler placement.

The young face can be depicted as a descending triangle with the lower vertex on the chin and the lateral ones on the malar eminence. Mid-facial atrophy accentuates the jowls, inverting that triangle by placing its vertex on the glabella. A traditional surgical lift can partially reverse those changes; however, it may not provide a youthful look since it does not adequately reconstitute volumetric loss. Solid implants successfully augment the cheek bones, but are not suited to reconstitute volume in the submalar units. Filling the cheeks can be combined with lifting techniques to produce more natural results. Augmentation per se provides significant rejuvenation for many patients. The added volume effaces undesirable shadows, restores luminosity to the malar eminence, improves marionette folds, and reduces jowls.

Autologous fat transfer offers excellent overall cheek augmentation (Fig. 18.3). However, it requires harvesting of tissue, which may be difficult to obtain in the presence of generalized fat loss, as seen in some patients with drug-related HIV lipoatrophy. The duration of fat grafts is variable according to the technique used and recipient area (the cheeks usually have good retention rates); it also varies among individuals. Coleman reported that injecting small droplets of donor tissue, so that the whole graft receives enough nutrients, improves graft survival. Sterodimas et al found that adipose-derived stem cell-enriched lipografts may also prolong results. Despite those advances, liposculpture may not be attractive to individuals looking for office-based procedures.

Figure 18.3 Fat-transfer augmentation of the mid-face anterior temples (total bilateral volume = 25 mL) associated with submandibular liposuction: (A) before, and (B) after 8 months.

Fat augmentation techniques have been adapted for exogenous materials. Non-resorbable fillers may offer excellent long-term results but also impose permanent risks of foreign-body reactions and migration. Silicone, polymethylmethacrylate suspensions, and polyacrylamide gel are permanent fillers approved in many countries. Over the past decade, poly-l-lactic acid (PLLA) and hydroxylapatite became popular and transformed cheek augmentation in a low-risk office-based procedure, as reported in the studies by Burgess and by Tzikas respectively. Recent improvement in the cost-effectiveness of high-density monophasic and large-particle biphasic hyaluronic acids (HAs) continues to revolutionize the field (see Carruthers et al and Grover).

This chapter and attached video focus on using HA for mid-face augmentation. PLLA and hydroxylapatite are briefly discussed.