Getting cheeky: Midface area is key to overall patient satisfaction

August 1, 2008

In rejuvenating the midface, it's important to remember the impact that addressing lost cheek volume has both in this area and on the lower face, a Canadian expert says.

Key Points

Colorado Springs, Colo. - Although many aesthetic physicians overlook the cheek area, strategically addressing volume changes here can help rejuvenate the appearance of the entire face, an expert says.

In facial rejuvenation, "One of the key areas that's often missed - and that people are often afraid of - is injecting the cheek or the midface," says Nowell Solish, M.D., F.R.C.P., director of dermatologic surgery and assistant professor of dermatology, University of Toronto.

However, he says, "Facial aging involves not only skin. It's not just a fold, a line or individual feature a physician can circle with a pen."

"If you can get to that next step," he says, "you will have the expertise to give your patients a better overall experience."

To that end, he advises physicians to consider problems such as muscle and bone atrophy. For example, he says the malar fat pad includes three separate fat components, "and the fat atrophies at different rates within each compartment."

Consequences of this atrophy include descent of the cheek and a degree of medial rotation of the fat pads, Dr. Solish says.

"But what's key is that the anterior cheek, or the superior part, is supported by the orbitomalar septum."

As a result, he says, "The top of the cheek tends to stay in place, and the cheek fat pad falls, creating a trough and what is commonly referred to as a 'malar crease.'"

When the malar fat pad falls, he says, it can create hollowness above it or superior-laterally.

Additional consequences include deepening of nasolabial folds (NLF) and an appearance of tiredness, he says.

Lower-face manifestations of aging include ptosis of the oral commissure, thinning of the lips, flattening and lengthening of the upper lip, atrophy of the Cupid's bow and depression of the pre-jowl region, Dr. Solish says. It's important to address all these features, he says.

"Don't just put a syringe per side in the NLF. That NLF will look better, but globally you won't be doing the patient much of a service," Dr. Solish tells Dermatology Times.

Formulate a strategy

Formulating a comprehensive strategy begins with evaluating the malar crease, Dr. Solish says.

In this regard, he says, "In grade 1, there's hardly any visible crease. In grade 2, the crease is starting to form - I believe it's a continuation of the tear trough - and the NLF starts to deepen."

The malar crease gets deeper, wider and longer through grades 3, 4 and 5, to the point where it can be nearly uncorrectable.

In treating malar creases, Dr. Solish says, "Don't just inject a line. Inject whole zones and areas in order to lift the area," keeping in mind the complex relationship of the malar crease to underlying tissue, muscles and gravity.

In a typical patient with a malar fat pad that's descending and rotating medially, he says, "When the fat pads sits a little higher, it gives a more youthful, rounded appearance to the cheek rather than a concave appearance."

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