Avoiding Malar Edema During Midface/Cheek Augmentation with Dermal Fillers（1）
David K. Funt, MD
J Clin Aesthet Dermatol. 2011 December; 4(12): 32–36.
PMCID: PMC3244361
（http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3244361/）
Abstract
As dermal fillers have evolved, Volume restoration and Contour enhancement have become the objective of advanced injectors. The value of injections of dermal fillers into the midface is well documented in the literature. However, the Midface, particularly the Infraorbital hollow, is the facial area most prone to adverse events from filler treatment. Malar edema is a particularly significant and long-lasting untoward event that is frequently reported. This article reviews the anatomic basis for malar edema, relates it to filler injection technique, and presents the author's preferred method of injection to help ensure avoidance of this adverse event.
The introduction of more durable and robust dermal filler materials has expanded the indications for dermal fillers, especially for the face. There probably is no area of the face that has not been treated with injectable fillers. Clinicians are now approaching facial aesthetic improvement and rejuvenation in a more global fashion, rather than focusing exclusively on the correction of wrinkles and folds. In contrast to amelioration of isolated wrinkles and folds, volume restoration and contour enhancement have become the objectives of advanced injectors. The value of midfacial volume restoration and enhancement has been well documented in the literature.1–5 However, when treating this area, the injector can experience adverse events, including the significant and long-lasting complication of malar edema. This article presents the anatomic basis of malar edema and the author's preferred injection technique to prevent this untoward event.
Midfacial Volume Restoration
The malar fat pad is a discrete, Triangular shaped area of thickened Subcutaneous fat, Based at the Nasolabial fold with its Apex at the Malar eminence in the youthful face. It is attached to the overlying skin and is supported by Multiple fibrous septae that extend from the superficial musculoaponeurotic system (SMAS) and into the Dermis. Loss of skin elasticity and Weakening of these septae, as well as Volume loss within the Deep medial cheek fat,6 lead to a Downward and forward descent of the Skin and Malar fat pad until it bulges against the fixed nasolabial fold.
These sequelae of aging result in Deepening of the nasolabial folds, progressive Hollowing of the cheeks, and Loss of prominence of the malar eminences. The Lower eyelid lengthens, increasing visibility of the Orbicularis oculi muscle, coupled with the formation of Tear trough and a Crescent or “V”-shaped deformity along the maxilla and zygoma. There is Recession of the nasal alar cheek junction. Individual fat pockets become discernable as separate entities rather than the smooth transitions from convexities to concavities seen in youth (Figure 1). It is the author's view that no other facial injection site provides greater rejuvenation than the midface.
Figure 1
Volume loss in the aging face
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