Injection Guidelines for Treating Midface Volume Deficiency With Hyaluronic Acid Fillers: The ATP Approach (Anatomy, Techniques, Products)

Abstract

Midface rejuvenation is among the most valuable indications of hyaluronic acid dermal fillers, because malar projection and full upper cheeks significantly contribute to a youthful appearance. Hyaluronic acid fillers have evolved over the past 2 decades to meet specific clinical needs such as strong projection capacity and adaptability to facial dynamism. As a result, they now represent the treatment of choice for midface rejuvenation throughout age ranges by offering the potential for noninvasive treatment, immediate results, and minimal downtime. Because the 5-layered structure of the midface plays a central role in the human face, injecting the midface area may also indirectly improve other aesthetic concerns such as infraorbital hollowing and nasolabial folds. Nonetheless, midface rejuvenation requires a tailored treatment approach and a thorough knowledge of anatomy to minimize procedural risks and achieve natural-looking results. This article provides an extensive anatomical description of the midface and of the usual course and depth of vascular structures circulating nearby to delineate a treatment area and minimize procedural risks. Furthermore, considering the differential mobility and mechanical constraints of each layer of the midface, a multilayer treatment algorithm is proposed for adapting the treatment strategy to patient specificities (including age, gender, skin type, and morphology). Emphasis is also placed on desirable filler properties to create deep structural support on the one hand and accompany facial movement on the other hand.

Figure 1.

(A) The multilayer anatomy of the cheek spanning from bone to skin. (B) The mobile superficial fat compartments: 1, infraorbital fat compartment; 2, medial cheek fat compartment; 3, middle cheek fat compartment; 4, nasolabial fat compartment. (C) The static deep fat compartments: 1, medial sub-orbicularis oculi fat; 2, lateral sub-orbicularis oculi fat; 3, deep medial cheek fat (medial and lateral deep medial cheek fat).

Figure 2.

Vascular dangers of the midface and proposed safety lines delineating a relatively avascular area. 1, facial artery; 2, infra orbital foramen; 3, superficial temporal artery; 4, transverse facial artery; 5 facial vein 6, mid cheek safety line; 7, lateral safety line.

Figure 3.

Deep fat injection technique: bolus. The medial sub-orbicularis oculi fat (1), lateral sub-orbicularis oculi fat (2), and deep medial cheek fat (3) can be located employing the following anatomical landmarks: (4) vertical facial line, (5) mid-cheek line, (6) zygomatic line. Blue dots can be employed as needle entrance points. The red circle shows the lateral entry point that may be utilized to perform the bolus technique with a cannula.

Figure 4.

Deep fat injection technique: fanning. Blue arrows represent cannula tracks from a lateral entry point (light blue) or a medial entry point (dark blue).

Figure 5.

Superficial fat injection technique: fanning. Blue arrows represent the fanning technique employing a needle or cannula from a lateral entry point (light blue) or a medial entry point (dark blue).

Figure 6.

Multilayer treatment algorithm for filling deep (1) and superficial (2) fat layers of the mid-cheek (A) with hyaluronic acid fillers adapted to specific patient needs depending on age, gender, and skin type (B).

Figure 7.

Before and after photographs of this 45-year-old male patient are shown from (A, B) a three-quarter view and from a frontal view, (C, D) in a neutral expression, and (E, F) during smiling. He received 1.2 mL of TEOSYAL Ultra Deep in the deep fat and 2.4 mL of RHA 4 (both Teoxane, Geneva, Switzerland) in the superficial fat of the midface (total volumes for both sides). A 25G, 38-mm cannula was utilized to perform both deep and superficial injections.

Figure 8.

Before and after photographs of this 40-year-old female patient are shown from a frontal view in a (A, B) neutral expression and from a (C, D) three-quarter view during smiling. She received 0.7 mL of TEOSYAL Ultra Deep in the deep fat and 3 mL of RHA 4 (both Teoxane, Geneva, Switzerland) in the superficial fat of the midface (total volumes for both sides). A 27G, 13-mm needle and a 25G, 50-mm cannula were utilized to perform deep and superficial injections, respectively.

Figure 9.

Before and after photographs of this 50-year-old female patient are shown from a (A, B) frontal view and from a 3-quarter view in a (C, D) neutral expression and (E, F) during smiling. She received 1.2 mL of TEOSYAL Ultra Deep in the deep fat and 1.2 mL of RHA 4 (both Teoxane, Geneva, Switzerland) in the superficial fat of the midface (total volumes for both sides). A 25G, 38-mm cannula was utilized to perform both deep and superficial injections.