Cheeks: Sculpting and volumising with Restylane® SubQ

Facial aesthetics
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
Introduction
Facial aesthetics
The cheek is one of the most influential features of the ageing face. Rohrich and Pessa
(2008) studied the chronological changes in
subcutaneous fat distribution and observed
the existence of separate anatomical compartments which appear to lose volume in a
specific order (see Figure 1). Volume depletion 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 eminence, 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 restores youthful convexity and helps support
the lower facial tissues, giving rise to a mid-
Dr Bob Khanna is a cosmetic
and reconstructive dental surgeon. He runs clinics in Ascot,
Reading, Harley Street and
Manchester, and carries out
a full spectrum of treatments
from aesthetic dentistry, surgical implantology and bone regeneration procedures
to full-mouth rehabilitation. He is internationally 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 sonia@drbobkhanna.
com or call 07956 378526. For other clinical enquiries contact the clinic manager,
claire@drbk.co.uk or call 01189 606930.
xx Aesthetic dentistry today Figure 1: Chronological depletion of subcutaneous fat compartments in the face. Adapted from Rohrich and Pessa
(2008)
face elevation. Although it is indicated in both
males and females, re-creating high cheekbones enhances the tapered, or heart-shaped,
feminine facial features and consistently generates high patient satisfaction (Khanna 2007).
Non-surgical volumising of the
cheek
The continual evolution of injection techniques and products tailored to specific areas
of the face has increased the treatment options
for patients seeking aesthetic correction or enhancement. 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 viscosity than other products in the Restylane®
range. It has been developed specifically for
use as a subdermal, submuscular and supraperiostal 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,
September 2009 Volume 3 Number 5
Facial aesthetics
Figure 2: (Top and middle rows) Pre-operative clinical
photographs: full facial, three-quarter profile and full
profile views
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 particular the zygomatic and buccal branches, the
infraorbital nerve and vessels and the parotid
duct. The position of the associated muscular tissue, i.e. the zygomaticus major and minor 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 often need to consider stage two or stage three
treatment following malar fat atrophy.
Cheek sculpting and augmentation
with Restylane® SubQ – a step-bystep guide
(1) Patient counselling
September 2009 Volume 3 Number 5 After cleansing the cheek area with topical antiseptic to avoid the risk of subsequent infection, the area is marked for augmentation (see
Figure 3).
This is usually done prior to numbing as
anaesthesia distorts the facial tissue. For augmentation 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 augmentation. Continue back posteriorly by approximately 6cm and the superior–inferior extent is
between 2 and 3cm. These dimensions are of
course only approximate and vary from individual 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-
Stage one
Stage two
Stage three
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●
ther 4cm, as far as the level of the oral commisure and therefore be commensurate with
the buccal fat.
Aesthetic dentistry today xx
Facial aesthetics
Managing 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 assessment of the face is essential before discussing 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.
(2) Marking of the skin (see Figure 3)
Facial aesthetics
(3) Anaesthesia
Augmentation of the upper cheek alone can
be carried out using topical anaesthesia.
However, if the patient prefers a totally painfree 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 extraorally. Anaesthesia of the mid- to lower-cheek
region requires intra-oral administration of
local anaesthesia to block the infraorbital
nerve.
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)
Facial aesthetics
(4) Injecting Restylane® SubQ
Although a cannula can be used to place
Restylane® SubQ in this area (Lowe and
Grover 2006) to minimise neurovascular trauma and damage, in my experience the rigidity
of the needle provides tactile feedback, helping 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) following 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 anticipated 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 augmentation 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 injecting Restylane® SubQ in the mid- and lowercheek 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 augmentation 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
xx Aesthetic dentistry today 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)
the mid to deep subcutaneous fat and generally above the SMAS, as injecting too superficially in this area can lead to a lumpy appearance, 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 injection 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 potentially 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
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 recommendations
My recommendations to patients following
cheek augmentation are identical to those following any facial aesthetic procedure involving
Restylane®. The patient is instructed to avoid
manipulation of the area, which includes advising 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 recommend the use of standard NSAIDs for a couple
of days following treatment if required.
(6) Patient review
Patients are usually reviewed three weeks after treatment for a `fine-tuning’ appointment.
At this point, they are assessed for any asymmetry 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 photographs are usually taken at this appointment.
Conclusion
As treatment techniques for facial aesthetic
enhancement continue to evolve at a phenomenal rate, it is our responsibility as ethical professionals to discuss both surgical
and non-surgical options with our patients.
September 2009 Volume 3 Number 5
Facial aesthetics
Restylane® SubQ is a safe and effective, noninvasive option for cheek augmentation which
can be tailored specifically to address age-related changes in a structured and staged way. It is
extremely easy to use and creates a big impact
in patients of all ages.
Acknowledgements
I 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 patient’s wishes.
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)
References
Belmontesi M, Grover R, Verpaele A.
Transdermal injection of Restylane SubQ for
aesthetic contouring of the cheeks, chin, and
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S28-S34.
Coleman SR, Grover R. The anatomy of the
aging face: volume loss and changes in 3-dimensional 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 subcutaneously injected large-particle stabilized
hyaluronic acid-based gel of nonanimal origin
in esthetic facial contouring. Dermatol Surg
2009;35(Suppl1):313-321
Friedman PM, Mafong EA, Kauvar ANB,
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Khanna B. Total Facial Sculpting. Aesthetic
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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
implant for malar and mental enhancement.
Dermatol Surg 2006; 32:881–885.
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Facial aesthetics
September 2009 Volume 3 Number 5 Aesthetic dentistry today xx