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Cheeks: Sculpting and volumising with Restylane® SubQ In this
article Dr Bob Khanna describes his novel sculpting approach in
this second article of the masterclass series
IntroductionThe cheek is one of the most influential fea-tures
of the ageing face. Rohrich and Pessa (2008) studied the
chronological changes in subcutaneous fat distribution and observed
the existence of separate anatomical com-partments which appear to
lose volume in a specific order (see Figure 1). Volume deple-tion
and re-positioning of the malar fat pad occur early in the ageing
process (Rohrich and Pessa 2008, Coleman and Grover 2006). They
create a gradual flattening of the malar emi-nence, both frontally
and laterally, and lead to a hollowing out of the mid-facial region
and emphasis of the nasolabial furrow (see Figures 5-7). The
downturn of the oral commissure is also exacerbated and, in some
cases, tissue decent extends as far as the pre-jowl sulcus,
accentuating the S-shaped curve of the lower mandibular border.
Cheek augmentation re-stores youthful convexity and helps support
the lower facial tissues, giving rise to a mid-
face elevation. Although it is indicated in both males and
females, re-creating high cheek-bones enhances the tapered, or
heart-shaped, feminine facial features and consistently gener-ates
high patient satisfaction (Khanna 2007).
Non-surgical volumising of the cheekThe continual evolution of
injection tech-niques and products tailored to specific areas of
the face has increased the treatment options for patients seeking
aesthetic correction or en-hancement. The introduction of
Restylane® SubQ (Q-Med, Uppsala, Sweden) means that patient choice
is no longer limited to surgi-
cal lifting or insertion of alloplastic implants. Restylane®
SubQ has a larger particle size (1000 per mL) and greater thickness
and vis-cosity than other products in the Restylane® range. It has
been developed specifically for use as a subdermal, submuscular and
supra-periostal filler in areas where greater volume augmentation
is required. As a product of NASHA™ technology, Restylane® SubQ is
supported by extensive safety and efficacy data (Friedman et al
2002, Verpaele and Strand 2006) and published clinical experience
of its use in the chin and cheek area shows it to be associated
with long-lasting efficacy, typically between 9-12 months
(Belmontesi et al 2006,
Dr Bob Khanna is a cosmetic and reconstructive dental sur-geon.
He runs clinics in Ascot, Reading, Harley Street and Manchester,
and carries out a full spectrum of treatments
from aesthetic dentistry, surgical implan-tology and bone
regeneration procedures to full-mouth rehabilitation. He is
inter-nationally renowned as a leading lecturer, trainer and expert
in aesthetic medicine and has trained over 6500 doctors, dentists
and plastic surgeons in non-surgical facial rejuvenation procedures
and has pioneered many of the techniques. Dr Khanna is also the
president of the International Academy for Advanced Facial
Aesthetics (IAAFA) and Clinical Lecturer in facial aesthetics at
the Royal College of Surgeons (London). For more information on
facial aesthetics courses at the Dr Bob Khanna Training Institute
contact [email protected] or call 07956 378526. For other
clini-cal enquiries contact the clinic manager, [email protected]
or call 01189 606930.
Figure 1: Chronological depletion of subcutaneous fat
compartments in the face. Adapted from Rohrich and Pessa (2008)
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Facial aesthetics
Lowe and Grover 2006, DeLorenzi et al 2009). The cheek is a
relatively safe area into which to inject Restylane® SubQ but
nevertheless important anatomical features to consider include
branches of the facial nerve, in par-ticular the zygomatic and
buccal branches, the infraorbital nerve and vessels and the parotid
duct. The position of the associated muscu-lar tissue, i.e. the
zygomaticus major and mi-nor and orbital aspect of the obicularis
oculi should also be noted alongside the superficial
musculo-aponeurotic system (SMAS).
In my practice, the cheek is divided into upper, middle and
lower areas as this helps me to adopt a staged approach to
treatment (see Figure 3). In younger patients, it is rarely
necessary to treat beyond the upper cheek (stage one); however, in
older patients, we of-ten need to consider stage two or stage three
treatment following malar fat atrophy.
Cheek sculpting and augmentation with Restylane® SubQ – a
step-by-step guide
(1) Patient counsellingManaging patient expectations with regard
to what they can expect both during and after treatment is a key to
achieving success in facial aesthetics. An accurate and
comprehensive as-sessment of the face is essential before
discuss-ing all aspects of the procedure. Good clinical
pre-operative photographs are then taken of the facial,
three-quarter and full profile views (see Figure 2). This provides
an invaluable medico-legal record and diagnostic tool.
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September 2009 Volume 3 Number 5
(2) Marking of the skin (see Figure 3)After cleansing the cheek
area with topical an-tiseptic to avoid the risk of subsequent
infec-tion, the area is marked for augmentation (see Figure 3).
This is usually done prior to numbing as anaesthesia distorts
the facial tissue. For aug-mentation of the upper cheek, the
orbital rim is marked as the outer limit - I inject no closer than
1.5cm from the orbital margin. Then, starting anteriorly, a line is
drawn vertically down the face from the mid-pupillary line. This
defines the anterior extent of the augmen-tation. Continue back
posteriorly by approxi-mately 6cm and the superior–inferior extent
is between 2 and 3cm. These dimensions are of course only
approximate and vary from indi-vidual to individual. The mid-cheek
area is a continuation of the upper cheek extending a further 2 to
3cm inferiorly. The lower cheek compartment can extend inferiorly
up to a fur-
ther 4cm, as far as the level of the oral com-misure and
therefore be commensurate with the buccal fat.
Figure 2: (Top and middle rows) Pre-operative clinical
photographs: full facial, three-quarter profile and full profile
views
Figure 3: Marking up the patient for upper-cheek (stage one),
mid-cheek (stage two) and lower-cheek (stage three) augmentation.
The tear trough area for augmentation is also marked. The needle
entry points are depicted as a single black dot●
Stage one
Stage two
Stage three
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(3) AnaesthesiaAugmentation of the upper cheek alone can be
carried out using topical anaesthesia. However, if the patient
prefers a totally pain-free procedure or is particularly anxious,
the area can be infiltrated with local anaesthetic. The anaesthetic
is usually injected (usually no more than 0.5ml of lignocaine plus
adrenalin) about 1cm posterior to the entry point extra-orally.
Anaesthesia of the mid- to lower-cheek region requires intra-oral
administration of local anaesthesia to block the infraorbital
nerve.
(4) Injecting Restylane® SubQAlthough a cannula can be used to
place Restylane® SubQ in this area (Lowe and Grover 2006) to
minimise neurovascular trau-ma and damage, in my experience the
rigidity of the needle provides tactile feedback, help-ing to
achieve greater control and precision during placement. A needle
between 18 and 21G is tended to be used, of at least 1.5 to 2
inches in length, to ensure access to the entire area requiring
augmentation.
In the upper cheek, it is desirable to place the Restylane® SubQ
just supraperiostally or in the subobicularis oculi fat (SOOF)
follow-ing the contour of the bone and accentuating the natural
contour of the zygomatic arch and malar prominence. Placing the
product more superficially, for example above the obicularis oculi,
can lead to an impairment of muscular function and early migration
of the product. The needle is inserted posterior to the
an-ticipated area for augmentation at the point marked on Figure 3.
Generally speaking, the aim of treatment for the upper cheek region
is to improve both frontal and lateral projection. Between 0.5 and
3.0ml of Restylane® SubQ is used depending on the amount of
augmenta-tion required or indicated for a given case.
It is rare for a younger patient (i.e. below 35 years of age) to
require anything other than stage one upper cheek augmentation (see
Figure 4). However, in the older patient, there can be some benefit
from also inject-ing Restylane® SubQ in the mid- and lower-cheek
area, i.e. carrying out stage two or stage three augmentation (see
Figures 5 and 6). Tear trough or nasojugal augmentation may also be
indicated in older patients. This can be achieved by continuing a
stage one augmenta-tion anteriorly and superiorly (see Figure 7).
Thinner overall tissue cover in this area means that a less viscous
product, such as Restylane® or Perlane™, is usually required.
When augmenting the mid-cheek, Restylane® SubQ is injected
subdermally in
the mid to deep subcutaneous fat and gener-ally above the SMAS,
as injecting too superfi-cially in this area can lead to a lumpy
appear-ance, especially if there is extensive loss of tissue cover
and skin thinning. It is important to note that both the
supraperiostal injection for the upper cheek and the subdermal
injec-tion of the mid-cheek can be achieved from the same entry
point as shown in Figure 3. The same size needle is used (between
18 and 21G) in this area but inject slightly smaller volumes of
Restylane® SubQ, usually between 0.5 and 2.0ml.
Injecting into the lower cheek area requires careful attention
to the parotid duct. The entry point for augmentation of this
region is much lower, approximately 3cm below the ala-tragal line
(the imaginary line joining the tragus of the ear to the alar of
the nose). When injecting into the mid- or lower-cheek areas,
whilst it is important to make sure that the needle is placed
subdermally care must be taken not to place the product too deep
through the SMAS and underlying muscular tissue thereby
poten-tially penetrating the oral mucosa. Inserting a gloved finger
into the mouth when injecting minimises the risk and allows you to
palpate the Restylane® SubQ from inside the mouth. I normally
inject 0.5 to 1.5ml in this region.
I would usually only inject in all three zones in the older
patient (see Figure 6). One of the problems, however, is that the
skin can be quite thin; therefore, the Restylane® SubQ is carefully
manipulate under the skin to help
Figure 4: Mild upper-cheek augmentation only i.e. stage one
augmentation - typically for patients below 35 years old –
pre-treatment (a) and post-treatment with 1.5ml of SubQ™ injected
each side (b)
Figure 5: Mild upper- and mid-cheek augmentation i.e. stage one
and two augmentation – pre-treatment (a) and post-treatment with
2.0ml of SubQ™ injected each side (b)
confine it to the desired area and then overlay it with
Restylane® or Perlane™ to smooth out step deformities and create a
smooth contour.
(5) Post-treatment recommendationsMy recommendations to patients
following cheek augmentation are identical to those fol-lowing any
facial aesthetic procedure involving Restylane®. The patient is
instructed to avoid manipulation of the area, which includes
ad-vising them to go to sleep lying flat on their back and not on
their side. In addition, the patients are warned that they may
experience a little post-procedural discomfort and recom-mend the
use of standard NSAIDs for a couple of days following treatment if
required.
(6) Patient reviewPatients are usually reviewed three weeks
af-ter treatment for a `fine-tuning’ appointment. At this point,
they are assessed for any asym-metry and checked if they are
satisfied with the result. If necessary they are re-injected, using
small volumes of Restylane® SubQ as described above or Perlane™, to
address any small inaccuracies. Post-operative photo-graphs are
usually taken at this appointment.
ConclusionAs treatment techniques for facial aesthetic
enhancement continue to evolve at a phe-nomenal rate, it is our
responsibility as ethi-cal professionals to discuss both surgical
and non-surgical options with our patients.
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A
implant for malar and mental enhancement. Dermatol Surg 2006;
32:881–885.Rohrich RJ, Pessa JE. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery. Plast
Reconstr Surg 2008;
Restylane® SubQ is a safe and effective, non-invasive option for
cheek augmentation which can be tailored specifically to address
age-relat-ed changes in a structured and staged way. It is
extremely easy to use and creates a big impact in patients of all
ages.
AcknowledgementsI would like to sincerely thank all my patients
for their kind permission to use their clinical photographs in this
article. In Figures 4, 5 and 6, full facial shot is not shown to
respect pa-tient’s wishes.
ReferencesBelmontesi M, Grover R, Verpaele A. Transdermal
injection of Restylane SubQ for aesthetic contouring of the cheeks,
chin, and mandible. Aesthetic Surg J 2006; 26(suppl):S28-S34.
Coleman SR, Grover R. The anatomy of the aging face: volume loss
and changes in 3-di-mensional topography. Aesthetic Surg J 2006;
26(1S):S4-9.DeLorenzi C, Weiberg M, Solish N, Swift A. The
long-term efficacy and safety of a sub-cutaneously injected
large-particle stabilized hyaluronic acid-based gel of nonanimal
origin in esthetic facial contouring. Dermatol Surg
2009;35(Suppl1):313-321Friedman PM, Mafong EA, Kauvar ANB,
Geronemus RG. Safety data of injectable non-animal stabilized
hyaluronic acid gel for soft tissue augmentation. Dermatol Surg
2002; 28:491-494.Khanna B. Total Facial Sculpting. Aesthetic
Medicine 2007; 28-30.Lowe NJ, Grover R. Injectable hyaluronic
acid
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119(7):2219-27.Verpaele A, Strand A. Restylane SubQ, a
non-animal stabilized hyaluronic acid gel for soft tissue
augmentation of the mid- and lower face. Aesthetic Surg J 2006;
26(suppl):
Figure 7: Extensive treatment using a total of 3 mL SubQ™ in the
upper-, mid- and lower-cheek areas plus 0.5 mL Perlane™ injected
into the tear-troughs
Figure 6: Moderate mid- and lower-cheek augmentation i.e. stage
two and stage three augmentation – pre-treatment (a) and
post-treatment with 3.0ml of SubQ™ injected each side plus 0.5ml
Perlane™ placed intradermally (b)
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