Cheek volumisation and augmentation is when a temporary hyaluronic acid filler is injected into the layers of the cheek area and mid-face, often along the zygomatic bone. This can also be performed with stimulatory semi-permanent fillers that contain calcium hydroxylapatite, polycaprolactone or poly-L-lactic acid, but the most commonly used filler type is hyaluronic acid. This is due to the reduced risk of permanent vascular occlusion and the ability to use hyaluronidase (Hyalase) to dissolve this, should there be an undesired complication (King et al, 2018).
Hyaluronidase is a prescription-only medicine (POM) and, within aesthetic medicine and practice, it is used off-license to reverse the effects of vascular occlusion or elective correction. Nurse prescribers must always ensure that they are insured appropriately for the prescribing and use of hyaluronidase within their aesthetic practice.
Treatment of the cheeks with filler can be identified in up to three categories: restoration, rejuvenation and/or beautification. Differentiating what type of treatment the cheek filler is for your patient is essential in achieving a natural and desired outcome. Establish whether it is a beautification, restoration or rejuvenation treatment, or if the desired outcome is achieving more than one of these results.
Volumisation of the cheek and mid-face area is predominantly performed by supraperiosteal injections into layer five in the first instance. This is to provide restoration to the ageing face and the reintroduce shape, structure and support that decreases with natural ageing.
Additionally, fillers can be placed into layer four (in addition to layer five or alone) to help with rejuvenation where the bony structure is not as reduced but fat pad atrophy is evident, with volume loss and redistribution.
Lastly, fillers can be used to beautify a younger face (or older, once restoration and structure have been restored). In these cases, the filler can be injected in the more superficial layers, as the younger face has the shape and structure present, and the aim of the treatment is enhancement.
Cheek augmentation can be carried out with a needle, cannula or both, depending on individual cases regarding patient assessment, training, competence and confidence. Often, cheek augmentation should be combined with other areas of filler augmentation, such as the temples, orbital area and preauricular area, to provide a holistic approach and balance the face. Knowing when additional treatments to cheek augmentation with filler are required comes not only from education but from experience and knowledge of the ageing process. Training, mentoring and supervision from more experienced medical injectors will assist with this, as well as attending conferences and observing world-renowned injectors. The Comma Community app is also a great resource for videos.
Recommending cheek augmentation
Cheek augmentation is recommended when there is evidence of bony resorption and/or fat pat atrophy that results in skin laxity and/or evidence of general ageing. All of this can be assessed medically and physically during the face-to-face consultation and assessment.
Often, patients will attend a clinic and state that they feel very aged, their face is sagging and they look tired, and they will point to the mid- and lower face. Their mid-face and cheek area will appear flat or concave and almost sunken, as gravity, the ageing processes and possible medical conditions have affected facial ageing. Additionally, other intrinsic and extrinsic factors, such as sun damage, cause skin damage and laxity. When a high level of experience has been gained and the ageing processes have been studied in detail, clinicians will be able to identify volume loss and redistribution. They can then explain what treatments will benefit the patient and why this is happening.
» When assessing the patient's face, make sure to assess them not only at rest, but also dynamically; ask them to smile and relax. If they have a very full cheek apex, clinicians should aim to inject more laterally to avoid overtreating this area «
Achieving a natural cheek and mid-face result
During consultations, it is paramount that the cheek volumisation process is explained in detail to the patient. It often requires clinicians to take photos from all profile angles to show patients the convexities of the face and how it will be restored. Treating the mid-face helps patients to feel more youthful, fresh and rejuvenated. Although the more cohesive filler with a higher hyaluronic acid content is more expensive to treat the cheeks and mid-face, clinicians need to inform patients that this is because it has greater longevity and is more cost-effective in the future, which means fewer treatments and clinic visits. This, in turn, reduces the risks of complications, infections and other undesired results. The filler must be very cohesive with a high G prime and hyaluronic acid content to enable an effective lasting result, as the filler is placed deep supraperiosteally under the muscle. Knowing which filler types sit best in with layers of the face is imperative (Gold, 2007).
Assessing the patient holistically for suitability and from the whole face perspective (from top to bottom) is paramount in achieving a natural, balanced and proportionate result. When treating the mid-face and cheeks, clinicians must ensure they do not overtreat and exacerbate other ageing areas. Examples of this can be exacerbating or creating an appearance of hollow temples and/or preauricular area, which can make patients appear older and does not enable a rejuvenated and less aged appearance. Treating the mid-face also indirectly treats other areas of the face. It helps to support the orbital and tear trough area and should always be considered if the patient has a tear trough concern. This enables the convexities of the face to be restored and light to fall differently, which reduces shadows and folds (Porcheron et al, 2013; Harrar et al, 2018).
No area treated with filler is safe; however, treating the mid-face laterally and the ageing process deeply can carry a lower risk anatomically, as there are fewer major facial arteries and vessels to occlude. Yet, it is always possible, and the risk is never eliminated, no matter if you aspirate or use a cannula. There is only ever a lower risk. Therefore, it is a lower risk area to treat compared to more medial and superficial areas such as the nasolabial folds and marionette lines. When assessing risk for fillers you must consider the correct product, correct technique, ideal tool, correct depth, correct layer and correct patient selection.
Ensuring these factors will reduce the risks and risk of undesired complications and side effects (Rohrich et al, 2019; Goodman et al, 2022).
Treating the temples will benefit mid-face treatments (if clinically indicated), and treating the piriform fossa to lift the head of the nasolabial fold. However, the author would always treat the temples and mid-face prior to the tear troughs or the lower face, again, if clinically indicated and bony resorption and fat pat atrophy are evident.
Avoiding overfilling the patient's cheeks and mid-face
To avoid overfilling, use small needle boluses and/or retrograde linear threads with a cannula. This will not only provide a natural result, but product can also be added at the review rather than dissolving. This will also reduce the risk of complications and undesirable results. Observing the tissue when injecting for projection is difficult, especially for new injectors who are trying to watch the amount they are injecting and the placement, while also keeping a steady hand. Confidence in carrying out this procedure will come with practice. The moment that projection is seen, stop injecting and aim to use no more than 0.3 ml per bolus or 0.2 ml per retrograde linear thread. Again, this can depend on the cannula size. Evidentially, there is more current research and support for a 25 g 38/50 mm cannula (van Loghem et al, 2017).
When assessing the patient's face, make sure to assess them not only at rest, but also dynamically; ask them to smile and relax. If they have a very full cheek apex, clinicians should aim to inject more laterally to avoid overtreating this area and leaving patients feeling like they ‘look like a hamster’ or have the ‘pillow face’ effect. However, if the patient's temples and/or preauricular area are hollow, do not inject laterally, as this could cause the effect of more hollowing and an aged appearance. Remember: patients want to look themselves but younger and/or rejuvenated, not different or unbalanced.
Ensure you understand the profile and proportions of the face, especially for patients from different ethnic backgrounds. No two faces are the same and should not be treated as such.
The ideal face shape is said to be heart-shaped, as it ensures minimal evidence of hallowing and there is a bizygomatic distance slightly larger than the bigonial distance. Where this is not achieved, we have a more aged, square appearance (Richmond et al, 2018).
Common mistakes that injectors make
When treating the mid-face, the most common concern that injectors have is knowing how much filler to inject. For new or less experienced injectors, the author recommends starting with a minimum of 2ml if the treatment is for restoration and rejuvenation. Try to underpromise and overdeliver. Injectors should also advise that this may not be enough but, after 4 weeks and once the filler has settled, it can be reviewed and, if required, more filler can be added. It is very difficult to evidence this opinion, as everyone you treat is so individual. All the layers of their face will be different, and so, affect each mid-face filler treatment. This is an opinion comment based on the author’s personal experiences and advice from other more established injectors over the past 5 years. When the author first began injecting the mid-face, this lesson was learned very quickly, as they were undertreating and the author was not achieving their desired outcomes. Hopefully, this advice will help other nurse injectors moving forward.
Most undesirable results come from underinjecting/treating and injecting in the wrong place/plane for the intended treatment, which comes from lack of experience or poor assessment.
The author recommends:
- Assessing physically from the top of the face to the bottom and treat in that systematic process
- Choosing a highly crosslinked filler that has a high G prime, high hyaluronic acid content and good longevity, as it will be placed deep supraperiosteally
- Ensuring that you make the patient aware of the benefits of treating the way detailed above: there is reduced risk, increased desirable outcome of a balanced and natural result. While there is a higher financial outlay initially, the treatment lasts longer, meaning less treatments and less clinic visits.