Treatment of Malar Mounds With Hyaluronic Acid Fillers - An Anatomical Approach

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Treatment of Malar Mounds With Hyaluronic Acid Fillers: An Anatomical Approach
Multiple factors are responsible for age-related
changes of the prezygomatic area. Periorbital fat
atrophy and malar bone resorption contribute to the
loss of structural support.1 Tissue laxity andweakened
attachments of the orbicularis retaining ligament
(ORL) and inferior rigid zygomaticocutaneous liga-
ment (ZCL) can cause a downward sliding of tissue
leading to the formation of a bulging area over the
prezygomatic region.2 These bulges over the malar
eminence, known as malar mounds, are notoriously
difficult to treat.1 We demonstrate how to assess such
patients and describe an innovative technique to
reposition malar tissue through volume restoration
with hyaluronic acid filler (Figure 1).
Technique
The optimal location for volume restoration is
identified by marking 2 imaginary lines on the face:
one linking the lateral canthus to the oral com-
missure and the other linking the midtragus to the
superior nasal ala. The intersection of these 2 lines
establishes a point we term “AB” (Figure 2A). From
this point, we trace a concave line medially after the
inferior limit of the tear trough (superior black
line). A second concave line is traced from point AB
downward along the posteroinferior border of the
malar bone (lateral green line). A convex line
linking the 2 concave lines (lower brown line)
marks the anterior limit of volume loss. The area
bound by the black, green, and brown lines corre-
sponds to the malar fat pad region, superficially,
and medial suborbicularis oculi fat (SOOF), more
deeply located. The area between the upper and
lower edges of the zygomatic arch should be out-
lined (red lines) with the lateral limit of this region
being an imaginary line starting from the tail of the
eyebrow (dotted yellow line).
We recommend restoring volume in the deep com-
partments first. A cannula entry site reaching the
subcutaneous tissue (Point C) is created with a 21-
gauge needle in the midcheek, 1.5 inches below the
orbital rim. Hyaluronic acid filler is then injected in
the deep fat compartment plane through a 25-gauge,
1.5-inch cannula. The injector should aim toward the
medial SOOF, so that the injected volume produces
tissue expansion (Figure 3). The injection technique
generally consists of 4 boluses. First, we inject 2
boluses within the medial SOOF (Figure 2A, with
blue circles indicating the area of volume deposition).
Using the same entry site, the cannula is partially
Figure 1. Malar mounds treated with hyaluronic acid filler (frontal view).
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Figure 2. Superficial anatomy corresponding to the optimal placement of filler for volume restoration first with (A) deep
bolus injections (blue circles) into the medial SOOF followed by bolus injections (purple circles) into the lateral SOOF. (B)
Next, superficial injections are performed targeting the medial (green circles) and middle (yellow circles) malar fat pads. An
additional optional injection can be performed adjacent to the ZCL (red circle). SOOF, suborbicularis oculi fat; ZCL, zygo-
maticocutaneous ligament.
Figure 3. Cadaver dissection of filler in SOOF (blue) and in superficial infraorbital fat pad (green). SOOF, suborbicularis oculi fat.
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withdrawn and repositioned into the lateral SOOF,
which is filled with 2 more boluses (purple circles)
using the same technique (Figure 2A). In this step, the
injector may find some resistance secondary to fibers
of the ZCL. Alternatively, these areas can be treated
using 27-gauge needles in the supraperiosteal area. In
this case, the injector should avoid the infraorbital
foramen.
Tissue expansion from all SOOF compartments
produces the optimal lifting effect. However, even
after restoration of the volume of the SOOF, a dis-
cretemalar groovemay persist. To correct this defect,
the cannula is again repositioned toward themidface,
and a more superficial approach will aim at medial
(green circles) and middle malar (yellow circles) fat
pad restoration (Figure 2B). In addition, hyaluronic
acid may also be injected in the area adjacent to the
ZCL (red circles). We commonly use multiple retro-
grade injections, in a fanning pattern in this area. All
treated areas should subsequently be gentlymassaged
and sculpted. In our practice, this technique has
consistently provided correction of malar mounds
(Figure 4). The positioning of the cannula based on
the approach mentioned here is demonstrated in
Figure 5.
Figure 4. Malar mounds treated with hyaluronic acid filler (lateral view).
Figure 5. Diagram demonstrating the staged positioning of the cannula to achieve treatment of malar mounds with hya-
luronic acid filler.
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Discussion
Malar mounds result from anatomical changes within
the prezygomatic area.1,2 In this area, the fat under-
neath the orbicularis oculi is arranged in 2 distinct
bands, the SOOF, and the preperiosteal fat.1 These
bands are separated by a natural cleavage plane called
the prezygomatic space (PZS).1 This allows for
mobility of the orbicularis oculi, where it overlies the
zygoma and origins of the lip elevator muscles.1 The
roof of the PZS is formed by skin, subcutaneous fat,
the orbital fibers of the orbicularis oculi, and the
SOOF.1 The floor of the PZS is composed of a thin
membrane called the malar septum that adheres
tightly to the preperiosteal fat.1 The PZS is bordered
superiorly by the ORL and inferiorly by the ZCL1
(Figure 3).
Orbicularis retaining ligament weakening causes the
lid/cheek junction to descend alongwith the roof of the
PZS.1 Movement is resisted below by the stronger
ZCL, resulting in mound formation.1 We believe that
medial and lateral SOOF reabsorption leads to laxity
of the roof of the PZS and is also a key factor in malar
mound pathogenesis.
Impressive results in facial rejuvenation can be ach-
ieved through volume restoration of the malar fat pad
and medial SOOF with hyaluronic acid fillers.3,4
Despite excellent outcomes, anatomical harmony is
not always achieved due to persistence of malar
mounds. With the technique presented here, we pro-
pose malar mound correction through restoration of
the central and lateral SOOF. Introduction of fillers in
these fat compartments leads to local volume expan-
sion helping to restore tissue tone of the PZS roof and
possibly partially repositioning the ORL. Conse-
quently, the lid/cheek junction is set back into its
original location, and the prezygomatic area loses the
saggy appearance and becomes convex again. Atten-
tion must be paid to preserve facial contour and avoid
overcorrection, especially when treating the lateral
SOOF. Some patients with narrow faces may benefit
from volume expansion of this compartment. It is
important to differentiate malar mounds from fes-
toons, which are folds that hang between the medial
and lateral canthi composed purely of lax skin and
orbicularis oculi muscle.1 Festoons can occur either
alone or in associationwithmalarmounds.2Moderate
to severe cases of malar mounds and festoons are
probably best treated with surgery.2
Of note, lower lid bags secondary to herniation of
eyelid fat pads are commonly seen in association with
malar mounds and may also play a role in their path-
ogenesis.2Toaccommodate the herniated fat, theORL
is distended.1 As previously discussed, downward
expansion of the ORL will lead to descendingmove-
ment of the roof of the PZS.2 In such cases, after vol-
ume restoration of the SOOF, a hyaluronic acid filler
may be used in the palpebromalar groove to soften the
lines of the facial contour. The injector must be cau-
tious in this step because excessive volume in this area
could cause further distension of the ORL, worsening
the problem and leading to an unnatural appearance.
To date, the proposed methods for malar mound cor-
rection remain surgical.5 Volumizing of themidfacewith
hyaluronic acid has been shown to be a safe and effective
treatment for midface volume deficit.3,4 Patients with a
midface volume deficit frequently seek treatment for
malarmounds and often prefer nonsurgical options.We
present a novel and minimally invasive technique that
provides malar tissue repositioning through volume
restoration with hyaluronic acid filler. Furthermore, we
emphasize the need to evaluate volume changes in each
midface fat compartment as well as the interaction
between them to determine individualized treatments
plans and achieve optimal results.
Acknowledgments Patients provided written consent
for the use of their images.
References
1. Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek:
facial layers, spaces, and the midcheek segments. Clin Plast Surg
2008;35:395–404.
2. Furnas DW. Festoons, mounds, and bags of the eyelids and cheek. Clin
Plast Surg 1993;20:367–85.
3. Jones D, Murphy D. Volumizing hyaluronic acid filler for midface
volume deficit: 2-year results from a pivotal single-blind randomized
control study. Dermatol Surg 2013;39:1602–12.
4. Braz AV, Sakuma TH. Midface rejuvenation: an innovative technique to
restore cheek volume. Dermatol Surg 2011;38:118–20.
5. Kpodzo DS, Nahai F, McCord CD. Malar mounds and festoons: review
of current management. Aesthet Surg J 2014;34:235–48.
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André Vieira Braz, MD
Dermatology Division
Policlinica Geral do Rio de Janeiro (PGRJ)
Rio de Janiero, Brazil
Jeanette M. Black, MD
Skin Care and Laser Physicians of Beverly Hills
Los Angeles, California
Rodrigo Pirmez, MD
Dermatology Department, Instituto de
Dermatologia Professor Rubem David Azulay
Santa Casa de Misericordia do Rio de Janeiro
Rio de Janeiro, Brazil
Ardalan Minokadeh, MD, PhD
Derek H. Jones, MD
Skin Care and Laser Physicians of Beverly Hills
Los Angeles, California
A.V. Braz is a consultant and speaker for Allergan,
Galderma, Merz, and Palomar. J.M. Black is an
investigator and consultant for Allergan, Galderma
Aesthetics, Merz North America, Inc., and Revance
Therapeutics. A. Minokadeh is an investigator for
Allergan and Revance Therapeutics. D.H. Jones is an
investigator, consultant, and speaker for Allergan,
Galderma Aesthetics, Merz North America, Inc., and
Revance Therapeutics. The remaining author has
indicated no significant interest with commercial
supporters.
Long-Term Correction of Iatrogenic Lipoatrophy With Volumizing Hyaluronic Acid Filler
Iatrogenic lipoatrophy of the face or body can occur
after the administration of many different medi-
cations, particularly antiretroviral therapy (ART)
prescribed in human immunodeficiency virus (HIV)
and intramuscular corticosteroids inadvertently
injected into the subcutaneous fat. Both can lead to
permanent disfigurement and achieving a durable
correction can be challenging. To date, only a few
observational studies have documented the efficacy of
hyaluronic acid (HA) fillers in the correction of HIV-
and/or corticosteroid-related lipoatrophy for up to 12
months after treatment. This report is the first to
describe long-term improvement using volumizing, 20
mg/mL HA filler (Juvéderm Voluma [HA-V];
Allergan, Inc., Irvine, CA) lasting for at least 3 years.
A 61-year-old man presented in December 2013 for
treatment of HIV-associated facial lipoatrophy. He
had been on multiple antiretroviral medications since
his diagnosis in 1997, including proteases inhibitors
and nucleoside reverse transcriptase inhibitors
(NRTIs) such as zidovudine. At the time of consulta-
tion, the patient was taking a combination of efavir-
enz, emtricitabine, and tenofovir disoproxil (Atripla)
with undetectable viral load for nearly a decade. He
had never sought treatment for his atrophic changes,
and after thorough discussion of the therapeutic
options, including augmentation with poly-L-lactic
acid (PLLA), calcium hydroxylapatite (CaHA),
medical-grade liquid injectable silicone (LIS), poly-
methylmethacrylate (PMMA), and HA-V, he decided
to proceed with the latter.
Ten milliliters of HA-V, each admixed with an addi-
tional 0.1 mL of 2% lidocaine with epinephrine
1:100,000, were injected as periosteal depots in the
temples and by linear threading into the deep sub-
cutaneous plane at the midface. Two weeks later, the
patient returned for follow-up and received another 5
mL of HA-V to the midface, temple, and submalar
regions. Optimal correction was noted during evalu-
ation at 2 weeks, 6 months, 1, 2, and 3 years without
touch-up (Figure 1).
Similarly, a 48-year-old healthy woman complained
of a depression at the right superior buttock devel-
oping shortly after an intramuscular corticosteroid
injection of unknown brand and quantity performed
5 months before by a primary care physician for an
upper respiratory infection. After 1 year of obser-
vation, the deficit remained unchanged. Eight
milliliters of HA-V admixed with 0.1 mL of 2%
lidocaine with epinephrine 1:100,000 were injected
to achieve more than 50% improvement. The
patient received another 8 mL of HA-V subdermally
through the tower technique and linear retrograde
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