The Tired Look

Introduction

Many struggle with a tired appearance that can make them look older and less vibrant—this "tired look" results from various factors affecting facial appearance over time.

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As individuals age, their faces undergo subtle but significant changes. Bone resorption leads to a sunken or hollowed look, especially in the cheeks and around the eyes. The natural loss of fat volume in these areas also contributes to a deflated, tired appearance. Muscle activity from repetitive expressions and sustained contractions can create lines and wrinkles.

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Tissue displacement, caused by the loosening of facial ligaments, causes features to descend. Additionally, a decline in skin quality, with less collagen and elastin, results in sagging and a loss of radiance, further adding to the appearance of exhaustion.

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While these changes are natural and unavoidable, modern cosmetic treatments offer promising solutions to combat the tired look and restore a more youthful, refreshed appearance. Strategic use of botulinum toxin (Botox) and dermal fillers in the upper and middle face can address many underlying factors and deliver invisible, almost instantaneous changes.

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This article explores effective treatment strategies to help achieve a revitalized and confident appearance.

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Understanding Facial Aging

Facial aging is a complex three-dimensional process involving changes to the bone, soft tissues like fat, and the skin itself.¹ These layers don't age in isolation – they are interconnected. So, when one layer ages and changes, it can trigger a cascade of effects in the other layers. This interconnectedness means facial aging is not just a single, linear process. 

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Addressing the aging co-occurring across the bone, soft tissues, and skin requires a multi-pronged approach. Understanding how these layers are interlinked and impact each other is vital to effective facial rejuvenation strategies.

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With age, the skin changes due to intrinsic (natural) aging and extrinsic (environmental) factors. Intrinsic causes lead to fine wrinkles and an even distribution of age spots over time. Extrinsic aging, caused mainly by sun exposure, pollution, and smoking, produces more pronounced coarse wrinkles, uneven age spots, roughness, dryness, and discoloration.

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The skin's resilience and youthful appearance depend heavily on the dermis layer, which contains collagen, elastin, and glycosaminoglycans. In young skin, elastic fibers allow the skin to stretch and bounce back. 

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However, these components eventually break down with age, causing the skin to thin, weaken, and dehydrate.

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Environmental aging worsens these effects by increasing collagen breakdown, disrupting collagen fibers, and causing the accumulation of abnormal elastic fibers (solar elastosis). This impairs the structural integrity of the dermis and causes skin elasticity loss, along with the formation of static wrinkles and folds.

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At a molecular level, factors like increased enzymes that degrade the dermal matrix and oxidative stress from UV radiation contribute to skin aging over time. Additionally, the reduction of certain cells and hormones involved in skin functions also plays a role in the overall aging process.

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The changes¹ usually seen in the upper and middle thirds of the face are listed below:

A better understanding of aging layer-wise is mentioned as follows:

Anatomic Considerations

Injecting neuromodulators or dermal fillers requires extreme care to avoid potential neurovascular complications. The face is densely packed with critical blood vessels and nerves essential for function and aesthetics. Accidental damage to these structures can lead to severe adverse effects.

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For example, injecting fillers into or near arteries can cause vascular occlusion, leading to ischemia and tissue necrosis. This is particularly hazardous in regions supplied by the ophthalmic artery, such as the glabella, nose, and forehead, where it can result in blindness. 

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Injecting near nerves can result in numbness, pain, or function loss in affected areas. For example, the facial nerve’s branches are critical for facial expression, and damage can lead to asymmetry and functional deficits. 

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Vascular Supply - Upper Face²

Vascular Supply - Midface

Nerve Supply - Upper Face

Nerve Supply - Midface

General Treatment Considerations for Facial Injections

To inject neuromodulators and dermal fillers, it's important to understand facial anatomy, pay close attention to gender differences,³ and prioritize patient safety. These guidelines cover general principles, preparation, treatment, and posttreatment considerations.

Differences in Genders

Common Principles for Facial Injections

Pretreatment Considerations

• Patient Selection and Counseling:some text
  • Screening: Evaluate the patient’s medical history, including medications, allergies, and previous aesthetic treatments.⁴
  • Expectations Management: Have a thorough discussion with patients about their desired outcomes and potential complications. This helps ensure they have realistic expectations.
  • Contraindications: Identifying conditions such as active infections at the injection site, hypersensitivity to injection ingredients, and certain medical conditions early on.
• Preparation:some text
  • Setup: Prepare a sterile tray with syringes, dosing, cleansing agents, and antiseptics. Secure the patient’s hair with a headband.
  • Cleansing and Antisepsis: Remove dirt and makeup with a wipe or cleanser. Apply antiseptic solutions like alcohol wipes or povidone-iodine carefully to avoid eye irritation. Use dampened, not soaked, gauze to prevent excess fluid dripping.
• Aseptic Technique:some text
  • ANTT®: The Aseptic Non-Touch Technique ensures that the sterilized area is only touched by the needle to minimize contamination risk.

We will now discuss the role of Botulinum toxin type A (BoNTA) and Hyaluronic Acid (HA) fillers in rejuvenating the upper and middle third of the face. 

Botulinum Toxin Type A (BoNTA) Treatment

Pretreatment Considerations

• Due to the lack of data on the developmental risks to a fetus and potential reproductive toxicity in animal studies, BoNTA should not be used during pregnancy and breastfeeding.
• Document medication use, allergies, and other planned procedures. Evaluate present conditions such as myasthenia gravis, hypersensitivity to BoNTA components, Lambert-Eaton syndrome, or infection at the injection site.
• Ensure patients understand the procedure, potential side effects (e.g., mild pain, tenderness), and complications (e.g., eyelid ptosis, altered smile). Provide clear instructions on what to report post-treatment.

Treatment Process

• Pain Management:

Use slow injection techniques, ice, cooling tools, or vibration anesthesia to reduce pain. Patients may find themselves relaxed with distraction methods like guided breathing or engaging in conversation.

• Antisepsis and Injection Technique:

Cleanse the skin thoroughly and mark injection sites if needed. Use sterile gauze and adhere to ANTT. Avoid interpatient transfer by using single-use vials.

Posttreatment Recommendations

• After 4 hours, patients can resume normal activities. For first-time treatments or new areas, follow-up appointments are recommended 2 weeks after treatment.
• Provide written instructions on potential complications and after-hours contact information.

Hyaluronic Acid Filler Treatments

Dermal filler injections are now a popular non-surgical option for adding volume and defining facial contours. Hyaluronic Acid (HA) fillers are popular because they are biocompatible, reversible, and can provide long-lasting results.

Not All HA Fillers Are the Same

While all HA fillers start from the same base ingredient, they can vary a lot in their properties and behavior. This is due to differences in how they are manufactured - the size of the HA molecules, how they are chemically modified, and how concentrated the final gel is. These variations allow different HA fillers to be tailored for specific treatment areas and goals.

Describing a Filler's Unique Qualities

To understand how a particular HA filler will perform, experts look at several key properties:

• Elastic modulus (G') - Measures how firm or resistant to deformation the gel is
• Viscous modulus (G'') - Indicates how thick and flows the gel is
• Cohesivity - How well the gel sticks together
• Swelling ability - How much the gel can absorb fluid and expand

Some HA fillers are monophasic (single phase), while others are biphasic (two phases). This can impact how well the filler integrates into tissue over time, though more research is still needed.

New Ways to Evaluate Fillers

Recently, some new concepts have emerged to describe an HA filler's performance better:

• Strength score - Measures the gel's overall resilience and ability to maintain its shape.
• Stretch score - Indicates how well the gel can flex and adapt to facial movement.

These scores help predict if a filler is better suited for areas needing firm structural support versus areas requiring more flexibility.

Pretreatment Considerations

• Assess for conditions that increase infection risk (e.g., poor periodontal hygiene, immunocompromised state). Stable autoimmune conditions can be evaluated case by case.
• Contraindications include pregnancy, breastfeeding, known hypersensitivity to filler components, and active inflammatory or infectious skin conditions.
• Remember to discuss potential risks and ensure patients understand the need to report uncanny symptoms such as nodules or visual disturbances immediately after treatment.

Treatment Process

• Similar to BoNTA, secure hair, cleanse the face, and mark injection sites if needed. Inject filler slowly with minimal pressure, using continuous needle movement in the same plane.
• Use sterile dressing packs and change gauze frequently. Adhere to ANTT during the procedure to prevent contamination.

Posttreatment Recommendations

• Lumps can be corrected with gentle massage. Avoid postinjection icing as it may mask signs of occlusion. Provide clear instructions on recognizing potential complications.
• Patients should return for follow-up 2 to 4 weeks posttreatment for evaluation and possible touch-ups. 

Management of Tear Trough Deformity

Tear trough deformities (TTD) pose distinct difficulties because of the anatomical and physiological features of the periorbital region. To achieve the best results and minimize risks, it is crucial to have a comprehensive grasp of the underlying structures and to assess treatment options carefully.

Understanding Tear Trough Deformity

Periorbital lipoatrophy involves the loss of supraperiosteal and subcutaneous fat. This process is noticeable due to inherited anatomical differences and aging, which contribute to the development of tear trough deformity. 

Gender differences, congenital or age-related maxillary hypoplasia, laxity of the retaining ligaments, cutaneous elastosis, structural changes in fat compartments, and genetic predisposition are among many factors that play a role in TTD.

Classification of Tear Trough Deformity

Accurate classification of TTD⁶ is essential for selecting the appropriate treatment approach. Two primary classification systems, Hirmand and Belhaouari, provide a framework for understanding the severity and unique anatomy of TTD.

Therapeutic Strategies and Myomodulation

The treatment strategy for TTD is based on the MD Codes®, developed by Mauricio de Maio. Myomodulation refers to the mechanical effect of hyaluronic acid (HA) on muscle function. 

By placing HA fillers under or above the muscle, the tensile strength and mechanical advantage can be increased, or muscle action can be restricted, respectively.

MD Codes®

Special Considerations and Safety

Injecting HA fillers requires a thorough understanding of the vascular anatomy to avoid complications. Important regions to note are:

• Awareness of the superficial frontal artery and deep temporal arteries at T1.
• Attention to the zygomaticofacial artery at Ck2.
• Caution with the infraorbital artery at Ck3 and Tt1.
• Vigilance around the angular artery and vein at Tt3.

Treatment Approach

Addressing TTD should consider structures in addition to the tear trough groove itself. A comprehensive approach that includes structural support and interventions on dynamic processes is advisable. 

Injection Techniques and Recommendations

To get the best outcomes, experts recommend several recommendations for injecting HA fillers:

• Perform injections with the patient seated for better visualization of the tear trough deformity.
• Use low-viscosity HA to minimize adverse effects.
• Avoid superficial injections to prevent the Tyndall effect.
• Massage the HA filler gently for even distribution.
• Adhere to the "less is more" principle to avoid bulges under the eye.
• Inject slowly and carefully around the infraorbital foramen to prevent injury to the neurovascular bundle.
• Consider using blunt-tipped cannulas to reduce the risk of damaging vessels and nerves.

Direct and Indirect Approaches

The management of TTD can be categorized into direct and indirect approaches based on the severity and specific anatomy:

• Direct Approach: Suitable for patients with negative snap-tests and normal or excessive suborbicularis oculi fat pad volume. It involves injecting HA fillers in the central, lateral, and medial infraorbital regions.
• Indirect Approach: Involves treating adjacent areas such as the anterior temple, zygomatic arch, zygomatic eminence, and various cheek regions to provide structural support and enhance overall facial contour.

Adverse Events and Their Management

• Early events include pain, erythema, edema, bruising, and itching.
• Delayed events can involve nodules, infections, and skin discoloration.

Using HA fillers with lidocaine, applying ice packs, and using hyaluronidase for the Tyndall effect can be effective in managing these complications.

Special Considerations

Certain MD Codes® need special attention due to their proximity to critical arteries and veins. Aspiration is recommended when performing deep injections to reduce the risk of vascular occlusion.

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Management of Forehead Lines

When it comes to smoothing forehead lines, BoNTA injections are a go-to treatment. However, before proceeding with the treatment, it's important to understand patient expectations. Do they want to eliminate every last wrinkle for a completely smooth look? Or would they prefer to maintain natural movement and expression on the forehead? Getting on the same page is essential. 

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Causes of Forehead Wrinkles 

A combination of intrinsic (genetic) and extrinsic (environmental) factors contribute to rhytid formation. UV exposure is a primary extrinsic culprit. Deep horizontal lines may stem from chronic brow elevation in older patients to counteract blepharoptosis.⁷

Relevant Anatomy

• Frontalis - This large paired muscle originates from the galea aponeurosis and inserts into the skin and orbicularis oculi at the brows. A central muscle-free zone separates the right and left frontalis bellies.
• Corrugator Supercilii - Arising from the frontal bone's nasal process, this muscle creates vertical glabellar lines by adducting the brows medially.
• Orbicularis Oculi - The superior vertical fibers insert into the medial brow and function as the depressor supercilii.

Pre-Treatment Examination:

• Assess brow position, density, and hairstyle (bangs can conceal the forehead)
• Check for blepharoptosis or dermatochalasis that could be exacerbated post-treatment
• Inspect the number of vertical lines and associated corrugator muscle hypertrophy for Glabellar rhytids.
• In the case of horizontal rhytids, evaluate the contribution of dynamic (frontalis) versus static (skin laxity) factors.

A comprehensive examination directs proper muscle targeting, dosing, and adjunctive treatments for an optimal, natural-looking result.

Procedure

• Needle Size: A 30-gauge needle is typically used for precise and minimally painful injections.
• Volume and Units per Injection Site:some text
  • Glabellar lines: Inject 2.5 to 5 units per site for a total dose of 20 to 30 units.
  • Horizontal forehead lines: Inject 2 to 4 units per site, with a total dose ranging from 10 to 30 units.
• Injection Depth: Injections should be intramuscular, just deep enough to target the muscle fibers without causing unnecessary diffusion into surrounding tissues.
• Injection Points:some text
  • Horizontal Forehead Lines: To avoid ptosis, injection points are distributed evenly across the forehead, approximately 1.5 to 2 cm apart, avoiding the central muscle-free zone.

Technique Specifics

• Angle of Injection: The needle should be inserted at a 45-degree angle to the skin to minimise bruising and ensure accurate placement within the muscle.
• Aspiration: Before injection, slight aspiration is recommended to avoid intravascular injection.
• Symmetry: Ensure symmetrical injection patterns to maintain balanced muscle relaxation and natural facial expressions.

Patient Management

• Pre-Treatment: Patients should avoid blood-thinning medications, alcohol, and supplements at least week before treatment to reduce bruising risk.
• Post-Treatment: Advise patients to remain upright for at least four hours post-injection and avoid strenuous exercise, massaging the treated areas, or lying down for the first 24 hours to avoid migration of toxins.
• Onset and Duration: It typically takes 3-5 days to see visible results, with peak effect at 2 weeks. These effects usually last 3-4 months and may require repeat treatments to maintain results.

Complications and Management

• Common Side Effects: Mild bruising, swelling, headache, and transient discomfort at the injection sites are common and generally resolve within a few days.
• Ptosis: Eyelid drooping can occur if the toxin diffuses into the levator palpebrae superioris muscle. This can be minimized by avoiding injections below the superior orbital rim and ensuring proper injection technique.
• Asymmetry: Uneven muscle relaxation may result in asymmetrical facial expressions. Touch-up injections can often correct this.
• Allergic Reactions: Though rare, hypersensitivity reactions to botulinum toxin can occur. Immediate medical attention is required if symptoms of an allergic reaction arise.

Long-Term Effects
Repeated BoNTA injections to the frontalis can lead to permanent localized muscle atrophy, providing prolonged smoothing. While glabellar muscles typically recover between treatments, they may diminish over years of BoNTA exposure. Many patients opt for annual maintenance, especially in the glabellar and lateral canthal regions.

Management of Glabellar Lines

Glabellar lines (GL), or frown lines, are vertical lines that form between the eyebrows. Initially, these lines appear during facial expressions such as frowning but can become static over time, leading to a perpetual expression of anger or concern. This persistent appearance can adversely affect social interactions and self-esteem.⁷

Glabellar lines primarily develop due to the repetitive contraction of the procerus and corrugator supercilii muscles. These muscles at the central forehead pull the eyebrows together, resulting in vertical lines that deepen with age and repetitive muscle activity.

Use of Botulinum Toxin 

Clinical studies demonstrate that botulinum toxin type A (BoNT-A) treatments significantly smooth glabellar lines. With visible improvements within a week and optimal results in 1-2 months, patients are highly satisfied with their refreshed, relaxed facial appearance.

Procedure:

• Injection Sites and Dosage: The standard treatment protocol involves five injection sites: one in the procerus muscle and two in each corrugator supercilii muscle, totalling 20 units of BoNT-A.
• 5 units are injected into the procerus muscle.
• 2.5 units are injected into the medial and mid-pupil regions of each corrugator supercilii muscle.

Common Side Effects

• Bruising, pain, and erythema at the injection site are common but usually transient.
• Eyelid Ptosis: A rare but notable complication is eyelid ptosis, which can occur if the toxin diffuses to the levator palpebrae superioris muscle. To mitigate this risk, avoid injecting near the mid-pupil line. If ptosis does occur, alpha-adrenergic eye drops (e.g., apraclonidine) can temporarily improve eyelid symmetry by causing contraction of Mueller’s muscle.

As alternatives to botulinum toxin injections, dermal fillers can help add volume and mitigate the appearance of glabellar lines. Still, they do not address the underlying muscle activity causing the wrinkles. For severe cases, surgical options such as brow lifts may be considered, although these are more invasive procedures that carry higher risks and require longer recovery times.

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Management of Crow’s feet 

Crow's feet are wrinkles that form at the outer corners of the eyes due to the contraction of the orbicularis oculi muscles. These wrinkles become more pronounced with age due to the resting tension of these muscles and cause drooping of the lateral third of the eyebrow. This, in turn, affects both the aesthetics and function of the eye area.

Anatomy and Function of the Orbicularis Oculi Muscle

The orbicularis oculi muscle has three key functions:⁷

• Closing the eye
• Tear drainage
• Allowing for expressions like smiling and squinting

Treatment with Botulinum Toxin 

Injecting botulinum toxin type A into the orbicularis oculi muscle can temporarily reduce wrinkles at the outer corners of the eyes. However, this treatment can have side effects, including loss of muscle bulk and changes in facial appearance. 

Repeated injections may cause the muscle to become flaccid and atrophic, making the eyes appear "thin" and the face look "drawn" or tired as the midface falls over the zygomatic arch. These changes are usually reversible as the orbicularis muscle rarely atrophies permanently.

Patient Examination

A thorough examination is essential before treatment:

• From the front and side: Evaluate at rest and when smiling.
• Tone and position of rhytids: Check for deep wrinkles by spreading the skin between fingers. If the wrinkles are still very noticeable, alternative treatments like laser resurfacing may be suggested. Mild wrinkles might improve permanently with good skincare.
• Simulate the paralysis effect: Press on the zygomatic arch while smiling.
• Facial skin and muscle tone: Use the zygomatic arch test by asking patients to smile while pressing lightly on the zygomatic arch.

Procedure

• Wrinkles in motion: Typically treated with 0.05 mL injections on each side.
• Wrinkles in motion with lateral brow depression: Add 0.025 mL injection lateral to the point of contraction.
• Deep wrinkles at rest extending over the zygomatic arch: Include 0.05 mL injections 1 cm inferolateral to the lateral canthus.
• High, wide cheekbones: 0.05 mL at the outer canthus and 0.05 mL below the zygomatic arch.
• Older skin: Use subcutaneous microdoses over the zygomatic arch with doses of less than 0.0125 mL.

Some Factors to Consider

• Mild wrinkles may respond well to treatment, but severe sun damage may require surgical or laser interventions.
• Note the contour of the socket, the height and width of the zygomatic arch, and the risk of lower lid sagging.
• Large eyes and high cheekbones may increase the risk of undesirable effects like sagging lower lids.
• Avoid injecting near the lower lid punctum to prevent watery eyes. The lacrimal pump's paralysis can be avoided by staying lateral to the mid-pupillary line and using low doses of high concentrations.
• Weak orbital septum or protruding fat pads: Avoid treating the skin under the eyelid in these patients.

Adverse Events

• Weakening of the pretarsal orbicularis muscle can widen the palpebral aperture, potentially worsening dry eyes.
• Lower lid bags or dermatochalasis may develop due to orbicularis muscle relaxation.
• Lower lid sagging, especially in patients with high, broad cheekbones.
• Hollowing and sagging in the midface can occur, particularly in patients with prominent cheekbones.
• The "Mickey Mouse" sign can appear when wrinkles bunch up below the zygoma.
• Persistent "hooding" wrinkles may result if brow ptosis or frontalis sagging is not addressed.
• Dry eyes may occur due to the widened palpebral aperture.
• Lacrimal pump paralysis can result from injections near the lower lid punctum and result in watery eyes.
• Watery eyes can be caused by lacrimal pump paralysis.
• Facial asymmetry.
• Repeated injections may cause the orbicularis oculi muscle to become flaccid and atrophic, leading to muscle atrophy.

While Botox can effectively address fine lines, deeper wrinkles may require a more comprehensive treatment plan. This could involve combining Botox with resurfacing procedures, fillers, or even brow repositioning for a more dramatic rejuvenation.

Precautions

• Avoid injecting medial to the mid-pupillary line to prevent lacrimal pump paralysis.
• Do not inject inferolateral to the orbital rim in patients with lower lid bags/fat protrusion.
• Counsel on potential post-treatment hollowing over high, broad cheekbones.
• In severe cases with poor skin quality, avoid using Botox

Management of Temporal Region

The temple region is one of the most anatomically complex areas of the face, with multiple layers containing blood vessels, nerves, muscles, and fat compartments. This region can be divided into five layers, with various nomenclatures used for the same structures:

• Skin
• Subcutaneous tissue (lateral temporal cheek fat)
• Superficial temporal fascia (STF)/Temporoparietal fascia
• Loose areolar tissue is subdivided into:some text
  • Upper temporal compartment (UTC)
  • Lower temporal compartment (LTC)/Parotid temporal fascia
• Deep temporal fascia (DTF)/Temporalis fascia - splits into superficial and deep layers

The superficial temporal fat pad (STFP) lies between the STF and DTF layers. Temporal hollowing can result from STFP volume loss, in addition to muscle thinning or deflation of the deep temporal fat pad (extension of the buccal fat pad) located inferiorly.

The UTC is a potential safe space as it lacks major neurovascular structures. It is bordered superiorly by the superior temporal septum (STS) and inferiorly by the inferior temporal septum (ITS), which blocks superior progression of the facial nerve temporal branch.

In contrast, the LTC contains more fat and has anterior openings (superior interval and temporal tunnel) where neurovascular structures traverse, necessitating utmost caution. The LTC also lacks a well-defined inferior border, being loosely bordered by the zygomatic ligaments.

Key Neurovascular Structures:

• Superficial temporal artery (STA): Emerges above the superior orbital rim, bifurcating into frontal (60.8° angle toward frontalis) and parietal branches. Small STA branches may be subcutaneous near the lateral canthus.
• Facial nerve temporal branch: Travels within the LTC, piercing the DTF to become more superficial 1.5-3 cm above the zygomatic arch and 0.9-1.4 cm posterior to the lateral orbital rim.
• Middle temporal vein (5 mm thick): Passes between the DTF layers, 2 cm superior to the zygomatic arch.

Potential Injection Planes:

• Subperiosteal plane below temporalis muscle: May not show changes despite large volumes.
• Between DTF layers: Risk of middle temporal vein injury.
• Within LTC: Highest risk of facial nerve/STA injury.
• Subcutaneous plane: Safe but uneven spread possible if thin.

Injection Technique:^8,9,10

• Make entry point with a 23G needle.
• Insert a 23G cannula until touching DTF.
• Inject filler between STF and DTF layers.
• At the hairline, use a 5 cm 23G cannula between STF/DTF.
• Employ bolus injection technique.
• Avoid the anterior temporal area near STA/facial nerve branches.

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Management of Midface 

Aesthetic Characteristics of the Midface

A youthful midface typically exhibits prominent malar projection, full cheeks, and a smooth convexity extending from the lower eyelid to the nasolabial fold, creating an ogee curve. Over time, aging alters the volume and shape of these features across all tissue layers. This often results in a concavity at the junction of the lower eyelid and cheek, flattening of the upper cheek, and the appearance of a prominent nasojugal groove. 

Factors such as orbital and maxillary bone resorption, fat pad atrophy or hypertrophy, and changes in muscular or ligamentous structures contribute to a sunken, aged appearance with prominent folds.

Anatomical Considerations 

Successful midface rejuvenation requires a thorough understanding of the area's anatomy, including the five-layered structure from bone to skin. This involves deep static fat compartments and superficial mobile fat pads separated by a thin muscular layer. Knowledge of neighboring vascular structures helps minimize procedural risks.

Changes in Different Layers Due to Aging

In addition to the changes discussed earlier, the midface region experiences a variety of changes in different layers.¹¹

Ideal Candidates:

• Mild to Moderate Volume Loss: Patients presenting with subtle malar hypoplasia (underdeveloped cheekbones) or submalar hollows are prime candidates for midface filler augmentation. Younger individuals with premature midfacial flatness and well-defined cheekbone structure can also benefit.
• Skin Quality: Patients with good skin elasticity and minimal elastosis (loss of elasticity) are ideal. Those with significant elastosis may require additional interventions like low-viscosity hyaluronic acid fillers, fractionated lasers, or peels before volumization. Thin skin is generally favorable, while very thin skin necessitates careful filler selection and injection technique.
• Realistic Expectations: Patients seeking natural-looking rejuvenation and understanding the limitations of fillers are ideal candidates. Midface fillers are unsuitable for correcting severe facial deformities or significant volume loss.

Considerations for Suboptimal Candidates:

• Severe Malar Deformities: Patients with significant malar hypoplasia or substantial submalar volume loss may require conventional malar implants for optimal correction.
• Extreme Midfacial Deficiency: Individuals with a narrow nose, shallow dorsum, and sunken upper lip typically require maxillary advancement surgery, with fillers complementing soft tissue augmentation post-operatively.

Treatment Planning and Injection Techniques:

• Prior to treatment, take a thorough history, document facial asymmetries and capture baseline photographs for reference.
• Tailor treatment plans to the patient's unique anatomy, considering gender-specific differences. The ideal female cheek is typically ovoid, while the ideal male cheek is more subtle and broader.
• Utilize established guidelines like Hinderer's Lines to determine ideal facial shape and malar prominence location. This helps avoid overfilling and maintain natural-looking results.
• Knowledge of facial fat compartments and their age-related changes is essential for optimal volume restoration. The Midface Volume Deficit Scale (MFVDS) can quantify concavity in specific areas, guiding filler selection and volume estimation.

HIV Lipoatrophy:

Special attention is required for patients with HIV-associated lipoatrophy, a condition leading to facial wasting. Fillers can significantly improve their quality of life and self-perception. The Carruthers Lipoatrophy Severity Scale helps assess the degree of lipoatrophy and estimate filler volume needed.

Filler Selection:

A variety of FDA-approved fillers are available, each with its unique properties and suitability for specific areas. Common options include:

• Hyaluronic Acid Fillers: Provide immediate volumization with temporary to long-lasting results depending on the formulation.
• Poly-L-Lactic Acid (Sculptra): Stimulates collagen production for gradual volumization with long-lasting effects.
• Calcium Hydroxylapatite (Radiesse): Offers immediate volumization with additional collagen stimulation for extended results.
• Highly Purified Silicone Oil: Provides substantial, long-lasting volumization, but carries a risk of late-appearing nodules in a small percentage of cases.

Injection Techniques

This section explores various injection techniques for achieving successful midface rejuvenation.

Deep Fat Layer Augmentation:

• Multiple Bolus Technique with Needle: This method targets the deep fat layer (mSOOF, lSOOF, DMCF) for foundational support. Typically, 0.2 to 0.3 mL of filler is injected per fat pad, followed by a gentle massage for even distribution.
  
  
• Multiple Bolus Technique with Cannula: A 25G cannula allows for deep bolus injections from safe entry points. The filler is deposited in targeted areas (mSOOF, lSOOF, DMCF) for optimal volume restoration.
  
  
• Fanning Technique with Cannula: This technique involves injecting small aliquots (0.1 to 0.3 mL) of filler along cannula tracks, either in a retrograde or anterograde direction. It ensures even distribution while avoiding sensitive areas medial to the mid-cheek safety line.
  
  

Superficial Fat Layer Enhancement:

• Fanning Technique: This approach is particularly beneficial for older patients. Using the same entry points as deep injections but at a shallower angle, filler is delivered to the medial and middle fat pads for a smoother, more youthful appearance.

Individualized Treatment Plans:

Each patient’s unique anatomical features, gender, and ethnicity require a customized approach. For example, high injection volumes in the lateral SOOF should be avoided in male patients to prevent feminizing the face. Ethnic considerations are important, such as avoiding exaggerated lateral projections in Asian patients.

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Conclusion

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The safety and effectiveness of injectable procedures depend heavily on following stringent safety protocols and guidelines. Ensuring that healthcare practitioners are thoroughly trained and certified in non-invasive cosmetic techniques is crucial. By proactively managing risks and potential complications, we can safeguard patient well-being and deliver exceptional treatment results.

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References:

1. Swift, A., Liew, S., Weinkle, S., Garcia, J. K., & Silberberg, M. B. (2021). The Facial Aging Process From the “Inside Out”. Aesthetic Surgery Journal, 41(10), 1107-1119. https://doi.org/10.1093/asj/sjaa339 
2. Cotofana S, Lowrey N, Frank K, Ziebart R, Guertler A, Freytag L, Helm S, Alfertshofer MG, Moellhoff N. Vascular Safe Zones for Facial Soft Tissue Filler Injections. Plast Aesthet Nurs (Phila). 2022 Oct-Dec 01;42(4):238-245. doi: 10.1097/PSN.0000000000000480. PMID: 36469395. 
3. Bannister JJ, Juszczak H, Aponte JD, Katz DC, Knott PD, Weinberg SM, Hallgrímsson B, Forkert ND, Seth R. Sex differences in adult facial three-dimensional morphology: application to gender-affirming facial surgery. Facial Plast Surg Aesthet Med. 2022;24(S2). Published online September 27, 2022. doi:10.1089/fpsam.2021.0301 
4. Goodman, G. J., Liew, S., Callan, P., & Hart, S. (2020). Facial aesthetic injections in clinical practice: Pretreatment and posttreatment consensus recommendations to minimise adverse outcomes. The Australasian Journal of Dermatology, 61(3), 217-225. https://doi.org/10.1111/ajd.13273 
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