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Indications
Indications
The cheeks are bounded by the zygomatic arch and inferior orbital rim superiorly, the nose and nasolabial fold medially, the preauricular sulcus and the anterior border of the masseter muscle posteriorly, and the jawline inferiorly. Each cheek can be further subdivided into the upper medial cheek, upper lateral cheek (with the zygoma and malar prominence), and submalar cheek.
Aging leads to gradual maxillary bone resorption, anchoring ligament laxity, and adipose tissue atrophy, all of which lead to the development of concavities and tissue redundancy accentuated by gravitational effects. This in turn contributes to downturning of the angle of the mouth and accentuated jowls. Fillers are helpful in restoring volume loss and lifting the face. It is generally accepted that facial rejuvenation is best started in the midface, especially when the patientโs budget is limited, as it has beneficial effects extending to untreated neighboring aesthetic units.75 A tent-like effect from filler
placement under the superficial musculoaponeurotic system (SMAS) on the zygoma yields lifting forces on the oral commissure, jowls, and nasolabial folds. Filling the upper medial cheek and infraorbital area elevates the upper lip elevators leading to indirect enhancement of nasolabial folds and marionette lines.
Cheek augmentation has been found to improve facial wrinkles and enhance the perception of attractiveness.76
HA products with volumizing and lift capacity such as Juvederm Voluma, Juvederm Ultra Plus, Restylane Volyme, Belotero Volume, and Restylane Lyft are examples of suitable products. Calcium hydroxylapatite and PLLA have been also used. A singleblind controlled trial of 235 subjects demonstrated Juvederm Voluma as an effective filler for restoring midface volume with an acceptable safety profile and high patient satisfaction even with repeat treatments.78 Juvederm Voluma was FDA-approved in 2013 as the first filler for age-related midface volume loss. PLLA was FDA-approved in 2009 as diluted suspension. Injection of PLLA is either by fanning through cannulas or longer needles with a series of approximately three treatments repeated every 6 weeks to achieve long-lasting volumizing effects.79 CaHA was FDA-approved as a softtissue filler in 2006 with perceived longevity of results.80โ83