Novel Injection Technique for Malar Cheek Volume Restoration
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Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
The authors present a very concise overview of malar anatomy and the history of our current techniques of filler injections. It is an interesting and timely subject as few of the readers will have learned injection techniques during training, and most of us have just picked up these techniques over time by trial and error. As the authors state the evolution of fillers has been from line filling in the lower face to upper face placement to correct volume loss from aging and to “lift” the lower face. Many of us who perform facial fat grafting as well as fillers utilize similar techniques in the operating room often with rhytidectomy to provide a more natural, less pulled result.
The authors made some very valid points: firstly, choice of appropriate filler for malar rejuvenation. Their recommendation, and one in which I agree, is the use of a high G prime filler as softer, lower G prime fillers will fail to provide adequate lift. The authors recommend hyaluronic acid, and there are several FDA approved hyaluronic acid products that fit in the category. Calcium hydroxyapatite is another alternative filler that would work well.
Secondly are markings for injection. They recommend filler placed laterally to medially in an area defined by two supero-lateral lines as described in the article. Their markings and technique are simple and reproducible and one which I intend to incorporate in my technique.
Thirdly is injection technique of small aliquots of filler placed superficial to the malar periosteum. This is a technique many of us use and taught and popularized by Arthur Swift. It provides significant tissue lift and is easy to perform.
The only other point not mentioned by the authors is patient positioning. I often will lay the patient down and perform 3-D imaging to assess asymmetries. The more malar and cheek injections I perform, the better I get at finding asymmetries and using filler placed asymmetrically to correct these asymmetries.
In summary, this is a very easy to read article that provides a simple road map for malar augmentation for beginners and more advanced injectors.
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Conflict of interest
The author declares that he has no conflicts of interest to disclose.