Objectives: Proposal of clinical guidelines for deep injection in the part of the anterolateral midface with bony support. Illustration of distortion of animation by superficial injection. Illustration of correctly deposited filler in a cadaver dissection.
Introduction: Treatment of the midface is considered pivotal in facial reshaping and for support of the lower eyelid. Superficial, subdermal injection may interfere with lower periorbital animation and malar mound oedema. It does not provide support to the lower lid. While appropriate more inferiorly in the tissues overlying the oral cavity, deep injection on bone provides stable reshaping respecting facial expression.
Materials / method: A case of unnatural animation after subcutaneous injection and successful treatment by dissolving the filler is presented. Film fragments and representative before and after clinical photography illustrate deep injection of the midface from one access point, along two axes. Coloured agarose was injected in a cadaver head to study filler depth and spread with a dissection.
Results: The midline of the malar eminence and the continuation of the tear trough are traced on the face for guidance. Injections, all from the intersection, allow real-time observation of light reflection changes in the malar area during the treatment. Anteriorly, a 30 G needle deposits filler close to bone. Medially and laterally, a 22 G cannula minimises trauma and ensures the filler stays deep enough. Cadaver dissections confirm deep filler placement, without subdermal spread.
Conclusion: Anterolateral midface volume deficits can be treated adequately by deep injection of diverse fillers along two easily traceable axes, with the least possible distortion of facial animation.
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