Anatomy

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Complete Reflection

 

Mid face anatomy

 

The mid face is one of the most common sites for injection, and it is important to understand the importance of depth and safety. In the upper cheek, we have the support from the zygomatic bone, and therefore when we inject in this region we inject deep onto the periosteum of the zygomatic bone. However, below this area, we have a number of important structures and therefore we would need to be more superficial. We have the transverse facial artery and transverse facial vein, and running along these two important structures, we will often find the parotid duct and the buccal branch of the facial nerve. We also have the parotid gland and the masseter muscle in this region. Accordingly, if we treat the subzygomatic region it is vital to be superficial and use a soft tissue cannula. When we treat higher up, we can use a needle to get precision, however there are a number of blood vessels, and in this specimen we can see the zygomaticofacial artery. Therefore, even though we use a needle, it is important to aspirate to avoid inadvertent injection into a blood vessel.

 

Mid face injection

 

In this video, we want to examine deep injection of the mid face. After reflecting back the orbicularis oculi muscle, we can see the SOOF, or the suborbicularis oculi fat. Medially, we can see one of the lip elevators, the levator labii superioris alaeque nasi muscle. Just underneath this muscle, we are also aware of a deep fat compartment, the deep medial cheek fat, and this particular structure is an excellent target for mid face rejuvenation. If we take our filler and inject deep into this region, we can get excellent anterior projection of the mid face and help efface a nasolabial fold. You will notice that the filler can also fill a space below this fat, called the deep pyriform space, or Ristow space, and we can actually see the product sitting just under the deep medial cheek fat.

 

Cheek injection

 

In this video, we want to explore the injection depth when treating the cheek region. What I will do is demonstrate by treating both the correct depth, which is deep, and also a superficial depth to see where the product will lie. We begin on the zygomatic arch, and my first injection is deep. My target tissue here will be the SOOF, or the suborbicularis oculi fat. Just for comparison, I will so another injection slightly more anterior in the superficial fat. Finally, I will inject one more injection medially into the deep medial cheek fat. Following these injections, let’s have a look to see where the filler is actually located. As we retract the skin back, we can immediately see that there is some visible filler just on the subcutaneous fat. Remember, this is a mobile area, so any product injected here will move on animation such as smiling, and we can see a small amount of product just under the skin on the subcutaneous fat. If we peel this layer back, we will see more of the filler lying just below the subcutaneous fat, and this is why it is so important not to inject this region as it leads to an unpleasant appearance, especially on animation.

 

Now let’s look to see where the deep injection has been deposited. This structure here is the SOOF. If we take a scalpel and cut into the SOOF, we will start to see that our product is becoming visible as we get deeper. The advantage of injecting into this location is that the product is well compartmentalised and won’t move, but it will still give us the projection and augmentation that we are trying to achieve. Finally, let’s look to see where the product that we injected most medially is. Again, we need to dissect down through the muscle layers, and in this case it is the levator labii superioris alaeque nasi. As we dissect further down and get into the deep fat, or the deep medial cheek fat, we start to see the filler is visible. For demonstration purposes, we did this with a needle, but because there are so many blood vessels in this region, it would be prudent to inject this area with a cannula when injecting a patient.

 

Preauricular injection

 

In this video, I want to explore the treatment of the preauricular or subzygomatic region. This is an area that we would commonly inject to get a lift of the lower face or also if there was excessive hollowing which was leading to an emaciated appearance. Remember, in this region there is no deep support so the injection needs to be superficial and performed with a cannula. The most important thing to bear in mind is the depth, which will be in the subcutaneous fat. There is often resistance here from the retaining ligaments, primarily the masseteric retaining ligaments, which are false cutaneous ligaments from the masseteric fascia to the skin. You will notice that the cannula is used to inject the product in a fan-like distribution throughout the region. Following injection, let’s have a look at the location of the injected filler. On reflecting the skin, we can see the subdermal region and the subcutaneous fat. If we then retract the fat, we will notice that the product is actually sitting within the subcutaneous fat itself and has just expanded this region. We don’t see any product underneath this layer, which is the premasseteric fascia. It is important to see that when we pull this fat back, there is a very tight retaining ligament, and this is the zygomatic cutaneous ligament. A second ligament below is the masseteric cutaneous ligament, and this is a false ligament, therefore not as firm as the zygomatic ligament above.