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 and weakened attachments of the orbicularis retaining ligament (ORL) and inferior rigid zygomaticocutaneous ligament (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).
The optimal location for volume restoration is identified by marking 2 imaginary lines on the face: one linking the lateral canthus to the oral commissure 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 corresponds 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 outlined (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 compartments 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 Using the same entry site, the cannula is partially withdrawn and repositioned into the lateral SOOF, which is filled with 2 more boluses (purple circles) using the same technique (Figure 2A).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 discrete malar groove may persist. To correct this defect, the cannula is again repositioned toward the midface, 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 retrograde injections, in a fanning pattern in this area. All treated areas should subsequently be gently massaged 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.
Malar mounds result from anatomical changes within the prezygomatic area.1,2 In this area, the fat underneath 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 along with 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 achieved 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 propose malar mound correction through restoration of the central and lateral SOOF. Introduction of fillers in these fat compartments leads to local volume expansion helping to restore tissue tone of the PZS roof and possibly partially repositioning the ORL. Consequently, the lid/cheek junction is set back into its original location, and the prezygomatic area loses the saggy appearance and becomes convex again. Attention 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 festoons, 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 association with malar mounds.2 Moderate 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 pathogenesis.2 To accommodate the herniated fat, the ORL is distended.1 As previously discussed, downward expansion of the ORL will lead to descending movement of the roof of the PZS.2 In such cases, after volume 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 cautious 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 correction remain surgical.5 Volumizing of the midface with 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 malar mounds 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.
Patients provided written consent for the use of their images.
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