The starting point to rejuvenating a face showing signs of ageing more often than not includes treatment of both temple hollows and the lateral and medial cheek. If a global, natural improvement to appearance is to be achieved this approach prioritises addressing anatomical changes that affect the whole face.
Medical aesthetics is in it’s infancy¹ relative to other specialties and the last two decades have seen a quiet revolution in injection techniques together with a massive increase in the range of dermal filler products available. The skills of the injector and the quality of the products used are vital components in delivering the most effective injection techniques; both are imperative for successful treatment outcomes and building your reputation as a practitioner. Meeting modern treatment expectations means venturing into multiple anatomical territories, each of which carries its unique set of possibilities and risks.
The ageing process involves a combination of factors involving changes in each layer of tissue starting with skin and soft tissue. These are subtle at first but gradually bone resorption follows, resulting in displacement of fat pads aided by the effects of gravity and weakening of retaining ligaments. The most dramatic changes in soft tissue volume occur between the ages of 30 and 60 years and become increasingly apparent.
The temporal fossa is an important, frequently overlooked area for treatment. It incurs the greatest loss of fat volume in the entire face, decreasing on average 3.4mm in depth throughout adulthood.2 These changes to the temple region and the impact on the adjacent structures make them an important target of volumising treatments, particularly the upper two thirds of the temple fossa. ²
Risks and Complications
The most widely publicised and feared complication of temple fossa injection is injecting into the deep or superficial temporal artery, resulting in possible emobolisation into the ophthalmic artery.³ There is also the potential risk of intracranial penetration when performing deep temporal injection when direct pressure is exerted on the bone. The thickness of the bone is variable at the pterion⁴ and excess force or exceptionally thin bone can be contributing factors. Slight headache resolving spontaneously within 24 hours is not an uncommon side effect following treatment of this area due to pressure created by the filler within the tissues. This can be avoided or mitigated by injecting very slowly and limiting the volume placed at each treatment session to less than 0.5ml, if necessary utilising multiple treatment sessions with smaller volumes.
Over- treatment of the temporal fossa can result in tenderness, discomfort or pain on biting and chewing.3
Getting Results and Avoiding Problems
The fat compartments in the face are broadly characterised as superficial or deep relative to the SMAS. The fibromuscular layer of the SMAS integrates with the superficial temporal fascia and frontalis muscle superiorly and with the platysma muscle inferiorly.5
Volumising the temple hollow can create traction in the inferior tissues, in turn making augmentation of the cheeks more effective, improving the midface and jawline more than cheek augmentation alone. When using the needle it should always be placed at a depth where it is least likely to make contact with blood vessels. When working in the temple fossa there are two strategies likely to achieve the safest possible augmentation. The first is a deep supra-periosteal approach targeting product delivery under the temporalis muscle6 when using a needle. The point of insertion is described as approximately 1cm back from the edge of the bony orbit and 1cm down from the Sphenofrontal suture line, inserted perpendicular to the skin, aspirated with a five-second delay prior to commencing slow injection. Any resistance to injection should be monitored continuously and if undue pressure is required then immediately STOP. Withdraw the needle and observe the area for swelling, bleeding or bruising before recommencing. More superficial injection should be undertaken using a cannula.⁶ The latter technique is useful in blending irregularities transitioning between the adjacent areas.
An early component of facial ageing is the reduction of fat volume of the lateral, medial and middle cheek fat compartments7 resulting in a reduction of the Ogee curve, giving rise to a flattened cheek appearance on semi profile. This, accompanied by increasing laxity in the ligaments of the face, allows descent of the tissues resulting in bulging against fat compartments in an inferior position, e.g. the nasolabial and jowl fat pads. Historically cheek augmentation often resulted in over-injection of a single area, commonly the anterior cheek. As injection techniques have evolved this can now manifest as an overly widened bi-zygomatic dimension. The ideal is an appropriate re-volumisation of the lateral, middle and medial fat compartments with a smooth transition between each area.
Particularly important structures to consider in midface injection include the zygomaticofacial artery, situated close to the promanence of the zygomatic arch –a frequent target for augmentation; the transverse facial artery, which has been implicated in instances of blindness following filler injections7 ; the infraorbital foreamen with its associated neuro-vasculature; and laterally, the superficial temporal artery and its associated branches.
Between January 2015 and September 2018 there were 48 published cases of filler induced ophthalmic complications; the majority related to vision loss.8 The cause of this rise in visual complications is of course open to debate, but as healthcare professionals our role is to consider riskbenefit ratio of a procedure to ensure we are competent to carry it out in the safest way possible, therefore mitigating risk as far as possible.
Because of the numerous anatomical hazards associated with midface injections, needle use is safest when reserved for areas where the injector is confident of the tissue plane into which they are injecting, e.g. supraperiosteal, otherwise a cannula may be a safer option. A detailed strategy should be individual to each patient and injectors should be competent in making a visual, artistic assessment of appropriate volume, shape and proportion, identifying “hills and valleys” in order to ensure optimum results.
Over-correction will distort proportion and create obvious delineation between treated and untreated areas. A multi-level approach combining supra-periosteal placement of filler with a needle followed by threads of filler in the deep fat using a cannula provides projection, soft volume and lift.
When selecting a product it is important to consider the characteristics of the tissues in the area as well as the characteristics of the product itself. It is helpful to understand product rheology in four domains. How viscous is it? This affects how it injects and how it sits within the tissue. How elastic is it? Will it withstand compression, stretch and return to shape? What is its degree of plasticity? To what extent can it be moulded and shaped once injected? Finally, how cohesive is it? Is it able to hold together and not fragment? These properties are indicators of how the filler will behave once injected and the results over time as the product degrades. A key feature of the Belotero® range is its Cohesive Polydensified Matrix® (CPM) technology, providing good duration of effect and minimal product migration.9 BELOTERO® Volume combines 26 mg/ ML hyaluronic acid with a variable degree of cross-linking giving excellent volumising capacity, a smooth injecting experience and integrates particularly well, ensuring soft contours and a refined profile. In the period immediately post injection it is possible to shape and mould the BELOTERO® Volume to adjust or perfect contours. Choosing a product that volumise while seamlessly integrating with surrounding tissues provides a smooth, harmonious transition between treated and untreated areas, a particularly useful quality where the overlying tissue has only a thin fat compartment present such as when treating patients who are older or who have thinner skin, or anatomy where facial fat is naturally limited, e.g. those with slim faces or who exercise vigorously and have prematurely depleted facial fat volume.
1. Fitzgerald R, Carqueville J, Yang PT. 2019 An approach to structural facial rejuvenation with fillers in women. International Journal of Women’s Dermatology. Vol 5:1 p52-67.
2. Wysong A, Joseph T, Kim D, Tang JY, Gladstone HB. 2013. Quantifying soft tissue loss in facial aging: a study in women using magnetic resonance imaging. Dermatol Surg (12):1895-902.
3. Lai Wun Juász M, Marmur E S. 2015. Temporal foster defects: techniques for injecting hyaluronic acid filler and complications after hyaluronic acid filler injection. Journal of cosmetic dermatology 14 (3) 254 2259.
4. Philipp-Dormston WG, Bieler L, Hessenberger M, Schenck TL, Frank K, Fierlbeck J, et al. 2018. Intracranial Penetration During Temporal Soft Tissue Filler Injection—Is It Possible? Dermatologic Surgery;13:84–91.
5. Zackary B, Whitney MJ, Zito PM. 2020. Anatomy, Skin, Superficial Musculoaponeurotic System (SMAS) Fascia StatPearls [https://www.ncbi.nlm.nih.gov/books/NBK519014/].
6. Breithaupt AD, Jones DH, Braz A, Narins R, Weinkle S. 2015. Anatomical basis for safe and effective volumization of the temple. Dermatol Surg;41 Suppl 1:S278-83.
7. Wulc AE, Sharma P, Czyz CN. 2012. The anatomic basis of midfacial aging. In: Hartstein ME, Wulc AE, Holck DE, eds. Midfacial Rejuvenation. New York, NY: Springer New York:15-29.
8. Beleznay K, Carruthers JDA, Humphrey S, Carruthers A,Jones D. 2019. Update on Avoiding and Treating Blindness From Fillers: A Recent Review of the World Literature, Aesthetic Surgery Journal, Volume 39, Issue 6, P662–674, https://doi.org/10.1093/asj/sjz053.
9. Micheels P, Vandeputte J, Kravtsov M. 2015 Treatment of Age-related Mid–face Atrophy by Injection of Cohesive Polydensified Matrix Hyaluronic Acid Volumiser The Journal of Clinical and Aesthetic Dermatology 31: vol 8.
Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://www. hpra.ie/homepage/about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.
M-BEL-UKI-1162 Date of Preparation May 2021 This advertorial is sponsored by Merz Aesthetics UK & Ireland.
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