Volume loss is a well recognized aspect of facial aging. This has led to a now popular and widespread use of facial volume augmentation techniques. Synthetic injectable fillers and fat are most commonly used since most of volume loss occurs in soft tissue compartments and these materials are easily placed by injection. The re-establishment of volume loss in the cheeks is often done as part of a facelift, for example, for an improved rejuvenative effect.
While injected fat or fillers can virtually be placed anywhere in the face, it is not always appreciated as to what the external effect may be. Since the face has well known soft tissue compartments, located in the deeper layers, it will have surface topographic effects based on the anatomic compartment boundaries.
In the May 2016 issue of Plastic and Reconstructive Surgery, an article was published entitled ‘Three-Dimensional Topographic Surface Changes in Response to Compartmental Voluminization of the Medial Cheek: Defining a Malar Augmentation Zone’. In this cadaveric study the authors injected a fat analogue into the deep medial cheek compartment. 3D analysis was done to assess the external volume changes on the face. They found that voluminization of this medial cheek region had distinct boundaries with the superior edge at the level of the arcus marginalis of the inferior orbital rim. When the arcus marginalis was released the upper edge of the augmentation zone was no longer restricted.
In this paper the authors have identified a very specific medial cheek zone that is often overlooked in facial volume augmentation. Its location is often part of a large area of volume loss that involves the tear trough region as well. Given its location over the medial orbital region and nasomaxillary skeleton, it is also an area that can be treated by facial implants as well. This requires a special type of facial implant design that I refer to as the extended tear trough implant.
The extended tear trough implant has one of its effects along the medial orbital rim for the classic tear troughs that many people develop or even have congenitally. But because the implant is designed to be placed intraorally, it has an inferior extension down over the medial maxillary wall. This puts it right under the medial cheek zone as described in this paper. Since an arcus marginalis release is needed to place the implant, its augmentation effect can cover two facial augmentation zones.
Dr. Barry Eppley
Indianapolis, Indiana