Cheek augmentation with dermal fillers: considerations for optimal results

Skin quality and condition

Once the practitioner and patient have agreed that cheek augmentation is a suitable treatment, it is important that the patient fully understands the realistic outcomes of treatment. Knowledge of anatomy and the ageing process and facial and skin assessment skills are vital in order to predict how the skin will respond to the treatment and therefore give the patient realistic expectations of the treatment.

The quality of the skin is of maximum importance when considering dermal fillers, as treatments carried out on poor-quality skin (for example, skin that is dehydrated or sun damaged) will give suboptimal results (Kilgariff, 2017). It is therefore important to optimise skin quality before treatment in order to obtain the best outcomes possible. One possible way this could be achieved is by putting the patient on a good at-home skincare regimen prior to treatment. Following assessment of suitability for treatment, strategies such as the use of Retinol, peels or hydrating agents such as Profhilo or Volite can be used to optimise the skin condition prior to a filler procedure being undertaken.

It could be argued that, if every patient walking through the door was in their 20s or 30s, the job of the aesthetic practitioner would be easier. Generally speaking, this age group has youthful skin and denser underlying structures (Farage et al, 2013) and, in the author's opinion, usually responds well to treatment with dermal fillers. More mature skin requires greater consideration, but it can still benefit greatly from volumisation with dermal fillers.

Determining product volume requirements

Assessment of the skin and observation of facial atrophy are essential in order to predict outcomes and manage patient expectations, but, even then, it is possible to underestimate how much filler is required for a satisfactory result. Underestimating the volume of filler needed is a difficult lesson to learn, as it will generally result in a patient being disappointed with their clinical outcome.

The ageing process results in changes to the skin and structures of the mid-face that must be considered when planning any treatment in this area. Fat deposition in this area begins to reduce as the patient ages; the associated ligaments holding the malar fat pad in place weaken, and a nasolabial fold develops along with the malar fat pad shift (Kaur et al, 2015). This shifting of the malar fat pad and reduction of fat makes the cheeks appear hollow or flat (Meneghini and Biondi, 2012; Kaur et al, 2015).

Ageing also affects the skin, with a process of atrophy being responsible for volume reduction in the face (Meneghini and Biondi, 2012). Furthermore, the epidermis thins and turnover rate slows dramatically throughout the ageing process (Farage et al, 2013).

In older patients, it is likely that greater volumes of filler will be needed to create the desired effects due to the sagging, soft tissues of the ageing face. Often, this is because the skin is much less dense than it appears, and it therefore soaks up the filler like a sponge, with minimal visual changes apparent. Underestimating the effects of atrophy when treating this part of the face can result in dissatisfaction among patients, and the aesthetic practitioner may end up retreating the patient at their own expense. Effectively managing expectations, establishing a full treatment plan and providing an accurate depiction of the results are therefore all crucial parts of the consultation, as is being clear that one treatment may not be sufficient to achieve the patient's visual goals.

There have been a number of attempts to help practitioners determine the volume of filler required per treatment. Niforos et al (2017) developed a photonumeric scale to facilitate this assessment, and within the distinction programme of the Mauricio De Maio training from Allergan, formulas are also discussed to address volume calculation. A basic rule of thumb is that younger patients will require a lower volume of filler product than older ones. Always set conservatively realistic expectations among patients, especially if there is clear atrophy of the soft tissues.

Establishing firm treatment aims

Determining what makes a face attractive is difficult. In some cases, attractiveness can be associated with similar facial features between partners, or even being attracted to features similar to those of our parents (Perrett et al, 2002). Other studies have shown that facial symmetry is thought to be attractive, as it is thought to demonstrate good health and good genes (Jones et al, 2001). However, exact facial symmetry can look odd. In an article by Berry (2014), fashion photographer Alex John Beck spoke about how, although facial symmetry may be desirable in the beauty world, it can sometimes give the impression of a lack of character, and argued that asymmetry can equate to complexity and is therefore compelling. It is therefore important that treatment aims and expected outcomes are discussed in full with the patient before treatment commences. This will help to ensure that the patient is satisfied with the outcomes of the treatment, while also managing their expectations.

Taking before and after photographs can assist the practitioner in providing an accurate and objective view of the results of treatment, and it can be especially helpful in cases where the patient displays asymmetry prior to treatment.

Female contouring

Male and female faces differ in shape, and so it is important that this is considered when determining the best course of treatment and technique. Mature features in adult human faces reflect the masculinisation or feminisation of secondary sexual characteristics that occurs during puberty, partly due to hormones such as testosterone (Little et al, 2011).

There is considerable evidence that feminine female faces are considered attractive (Perrett et al, 1998; Little et al, 2011), and it is widely accepted that soft, flowing curves are characteristic of the feminine face. While there is a current trend for jawline defining in women, it is the author's opinion that sharp angles can be harsh, masculine and ageing. High, defined cheekbones lift, enhance and soften the angular face, helping to create a heart shape to the face. The heart shape has long been considered the epitome of female beauty and allows the facial features soft, delicate definition, which creates a beautiful flow to the female face.

However, as discussed earlier, there is more to consider than the issue of cheek definition alone. When enhancing any area of the face, a holistic outlook is required. Meneghini and Biondi (2012) discussed the notion of facial points of interest as an assessment tool; other practitioners use the rule of thirds for a visual assessment (Zhang et al, 2018). These approaches consider the whole of the face in relation to proportion and features.

An early study by Cunningham (1986) looked at the foundations of female facial attractiveness. The study is now very dated, only used a small sample group of 50 participants, and attractiveness was rated by 75 men, so the results cannot be relied upon too heavily. However, the study concluded that specific facial physical attributes of female attractiveness include large eyes, small nose, small chin, prominent cheekbones, narrow cheeks, high eyebrows, large pupils and a large smile. Certainly today's aesthetic trends appear to demonstrate these findings to be still relevant; many of the ‘beautifying’ filters on popular photography apps, such as Snapchat and Instagram, enhance these specific features. While the patient will often focus on their specific areas of concern, it is the medical aesthetic professional's duty to consider the face in relation to how each feature sits with the next and the overall ‘look’ we are trying to achieve, rather than dealing with single features alone.

Male contouring

Larger jawbones, more prominent cheekbones and thinner cheeks are all features of male faces that differentiate them from the female face (Little et al, 2011). We need look no further for evidence of the difference in beauty ideals between women and men than popular culture—specifically, animated films such as those by Disney and Marvel. As beautiful flowing and feminine as the lines of the female characters are, their male counterparts are renowned for their chiselled lines and angular cheeks and jawlines. While this may seem like a frivolous comparison, animators draw on real-life beauty ideals and exaggerate them.

Human preferences and choices are always far more complex than a study can determine, but a number of studies have been undertaken to analyse male facial attractiveness. Burriss et al (2014) found that women expressed a preference for, gazed longer at and fixated more frequently on feminised male faces. Holzleitner and Perrett (2017) recruited over 500 women to participate in a study exploring male facial attractiveness. Participants were asked to rate the attractiveness of a set of male faces that had been manipulated in order to appear more feminine or more masculine. The more masculine faces were those that had a more robust jaw, narrower eyes and lips and a wider nose. The results showed that, generally, women preferred male faces that were moderately masculine. The respondents determined that very masculine or feminine faces were less appealing to them. However, the results also suggested that the degree of masculinity a woman preferred in a man's face depended somewhat on her own characteristics and personal desires. The results of this study show that male facial attractiveness is by no means a straightforward, one-size-fits-all issue.

When enhancing the male face to define the masculine features, a different approach to filler placement is required. This includes creating a strong cheek and jawline, which run almost parallell to one another and which provide the basis of a masculine face—the wider jaw is a strong defining feature, balanced by cheeks running a near-to 90o angle along the face. Although an overly harsh or gaunt appearance is to be avoided, harsher lines are generally thought to be more acceptable when looking to masculinise a face than when seeking to feminise it. Techniques for achieving this contouring echo those for feminising the face; however, placement is the critical point. Where the feminine face has high, angulated cheekbones, the masculine face has defined cheekbones running at a much lower angle, often near-parallel to the jawline if the natural facial structure will allow this. Generally speaking, this means that placement of filler is lower, more aligned with the base of the tragus (rather than the top of the tragus for a feminine look) flowing across at a 90o angle. Facial hair can be used to further sculpt the masculine face.

Avoiding complications

A case report by Al-Mukhtar (2016) concluded that ‘Whilst we cannot guarantee to our patients that a complication may not occur, we can guarantee that we will do our utmost to manage a complication if it does occur’ (Al-Mukhtar, 2016:38). This should always be upheld, and it is therefore a good idea for solo practitioners to establish themselves as part of a network of practitioners who can offer support, advice, second opinions and cross-cover if necessary; being a newly qualified solo practitioner working in an isolated environment with no back-up can be daunting.

Realistic expectations must be set and, importantly, accepted by the patient way before any injecting takes place. Zamani (2015) stated:

A number of techniques can be employed to avoid complications when injecting patients with dermal fillers: habitually aspirating, compressing major vessels near to the injection point while injecting and using a cannula for intradermal injections are just a few (Vedamurthy, 2o18). However, the most important is that the practitioner has an extensive understanding of the anatomy of the face, which is vital in order to ensure safe injecting.

Complications that may arise

Zamani (2015) stated that, even in the most experienced of hands, complications can arise and they can range from pain, swelling and bruising to vascular occlusion. As with all treatments involving dermal filler injections, the most serious complications of vascular occlusion and blindness need to be considered and discussed with the patient as part of the consent process, and the practitioner needs to be equipped, prepared and qualified to manage them should the need arise.

Fortunately, most complications associated with dermal filler injections are mild. Nevertheless, all patients should be prepared to experience pain, bruising and swelling, and they should be fully versed in post-treatment care to manage these side effects. The discussion of side effects and complications must be absolutely explicit and should take place during the pre-treatment consultation. This gives the patient sufficient time to consider the risks and decide whether they still wish to undergo treatment.

Treacy (2015) discussed how most adverse reactions are mild and transient and that adverse events can be grouped into expected procedure-related events (bruising, erythema, tenderness), events potentially related to improper techniques (nodule formation) and reactions to the product (granuloma formation) (Treacy, 2015). However, it is important not to neglect or underestimate the impact of milder complications. Even bruising and swelling can have a significant impact on a patient's wellbeing and experience of treatment, and therefore they should be managed carefully and competently. Patients who do not respond well to side effects or symptoms such as these require considerable time and effort to manage well.

Asymmetry

Asymmetry after treatment can be very distressing for a patient, even if their face was asymmetrical before. Trying to even up asymmetrical cheekbones can be challenging, often requiring the contouring of a cannula and lifting via bolus injections directly onto the periosteum with greater volumes of filler on one side than the other. A useful approach is to start on the side that will require the most volume and aim to restore some initial asymmetry before proceeding with the enhancement as a whole. Educating patients to be mindful of which side they sleep on and guidance about how to maintain their treatment for the longest time (good hydration, good skin care) are all helpful tools in setting and managing patient expectations.

As with all aesthetic interventions, pre- and post-procedure photographs are essential; some results can be subtle and good images help the patient to understand what enhancements have been achieved.