Avoiding Malar Edema During Midface/Cheek Augmentation with Dermal Fillers（3）
The final injection (not shown) is at the medial portion of the zygomatic arch. At each site, the needle is walked along the periosteum, depositing small amounts of filler without withdrawing the needle to limit the number of puncture sites and their resultant ecchymosis and edema. HA-JU is injected with a 30-gauge, ½-inch needle. CaHA is injected with a 28-gauge, ¾-inch needle.
The material is molded to smoothness gently so as not to predispose the patient to ecchymoses. The purpose of Molding is to smooth and manipulate the filler into the area of volume deficiency. Attention is directed when molding not to overly flatten or disperse the filler, necessitating higher volume of filler as a result of loss of correction. Overzealous massage can result in filler moving more superficially through needle tracts, thus increasing the propensity for visible material and malar edema. The ultimate objective is a Smooth blending between the lower eyelid, nasolabial fold, and the cheek. All bleeding points are treated with immediate and sustained direct pressure. Postinjection ice packs and Head elevation are employed.
Midfacial volume restoration using fillers is performed Medially to Laterally, since Volumes should be most Limited Medially beneath the malar septum. Volumes need only be restricted by aesthetic goals when treating the malar eminence, lateral orbital rim, zygomatic arch, and submalar hollow. Facial volume restoration is performed correcting the Midface prior to the Lower face. Expansion of the midfacial soft tissue envelope will result in an Effacement of the nasolabial folds and a reduction of the filler volume required for their correction.
Figures 5 and and66 show three patients with malar edema who had been treated for volume enhancement using HA or CaHA, both injected through a transcutaneous approach using Fanning and Threading technique in the Suborbicularis plane. In Figure 5, a 39-year-old female received HA into her tear troughs and infraorbital rims. She was treated with 20 units of Vitrase (ISTA Pharmaceuticals, Inc.) to ameliorate her malar edema. In Figure 6, a 44-year-old woman received a total of 1.3mL of CaHA in her midface (0.65mL per side), with malar edema evident five weeks post-treatment (A), and a 40-year-old woman received a total of 2.6mL of CaHA (1.3mL per side), with malar edema evident at three weeks post-treatment (B).
Figure 5A and 5B
A 39-year-old woman received hydroxylapatite in her tear trough and infraorbital rim. Malar edema could be observed three weeks post injection (A). The patient was treated with 20 units of Vitrase, which led to resolution (B).
Figure 6A and 6B
A 44-year-old woman received a total of 1.3mL of calcium hydroxylapatite in her midface (0.65mL per side), with malar edema evident five weeks post-treatment (A). A 40-year-old woman received a total of 2.6 mL of calcium hydroxylapatite (1.3mL per side), ...
The author has performed more than 350 midfacial augmentations using this technique without any occurrence of malar edema or other significant adverse events, such as severe bruising, contour irregularities, visible material, or infraorbital nerve injury. The majority of patients were treated with a combination of CaHA and HA-JU. Average volume was one Half a syringe of each material Per side, i.e., 0.65mL of CaHA per side (in 1.3mL syringe) and 0.4mL of HA-JU per side. The HA-JU was injected in the area Beneath the Malar septum and the CaHA for Enhancement of the Malar eminence Lateral to the Lateral canthus. This approach was selected because of the ability to dissolve hyaluronic acid using hyaluronidase, if malar edema or other adverse event should occur. In addition, HA-JU has a significantly lower G' than CaHA, making it less likely to compress the lymphatics of the area bounded by the malar septum. The higher G', or Lifting force exerted by CaHA, the more successfully elevated the thicker cheek tissues of the Malar eminence, Lateral orbital rim, and Zygoma. Figure 7 is representative of
the results obtained in the use of HA in the treatment of tear trough and infraorbital hollow.
Figure 7
Correction of tear trough and infraorbital hollow using calcium hydroxylapatite.
Recently, the author has employed the HA Belotero Basic (Merz), approved in Europe and recently approved in the United States, placed subcutaneously, for correction of tear troughs and infraorbital hollows, without adverse events. No Tyndall effect or visible material was observed. This HA was again combined with CaHA treatment of the malar eminence and inframalar hollow as aesthetically necessary.
Conclusion
Facial volume restoration and contour enhancement using dermal fillers have become a valuable addition to the aesthetic surgeon's armamentarium. These techniques are relatively quick to perform, have little down time, and result in a high rate of patient satisfaction. Adverse events have been reported however, particularly when the area of the lower eyelid are injected. Although malar edema is a severe adverse event, its incidence can be reduced by proper patient selection, proper filler selection, limiting filler volume, and by placing filler material deep into the Malar septum at the immediate Preperiosteal level.
Acknowledgment
The author appreciates the editorial assistance of David J. Howell, PhD, RRT (San Francisco, California) in the development of this manuscript.
Footnotes
DISCLOSURE :
Dr. Funt has received consulting fees for his work with Merz Aesthetics and serves as one of the company's medical advisors. He is also part of the national speakers bureau of Allergan Corporation and receives honoraria for educational activities. Financial support for preparation of this manuscript was provided in part by Merz Aesthetics (San Mateo, California).
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