Unit 2: Cheek Volumisation and Contouring

Functional MRI studies have demonstrated an association of high cheekbones with trustworthiness and approachability.

The cheekbone region consists of both the zygomatic (malar) bone and the zygomatic arch. The zygomatic bone is adjoined, via four processes, to the maxilla, temporal, sphenoid and frontal bones, and is responsible for creating the cheek prominence. The zygomatic arch is formed by the zygomatic process of the temporal bone and the temporal process of the zygomatic bone. Nerves and vessels arising from this area include:5

  • The zygomatic nerve, a branch of the trigeminal maxillary nerve that emerges from the zygomaticofacial foramen
  • The zygomatic artery, which emerges alongside the zygomatic nerve
  • The zygomatic branches of the facial nerve, which travels along the zygomatic bone to the lateral margin of the orbit

It is the zygomatic arches that are predominantly responsible for the ‘high cheekbone’ look. One study using computed tomography (CT) indicated that as we age, posterior retrusion of the bony maxilla leads to a flattened mid-face and loss of support for the surrounding soft tissues. Facial fat loss is also contributory to the remodelling of ageing.

It is important to note that in females, the malar prominence is 1.5 times thicker than the lateral cheek (zygoma), whereas in men, the soft tissue is evenly distributed.

Injection Technique:

Malar Prominence

The most commonly utilised way of identifying the malar prominence is Hinderer’s lines, which involves overlaying two intersecting lines from the lateral canthus to the oral commissure and the tragus to the ala wing. The area immediately superolateral to this intersection is the most prominent point that should be augmented for projections.

At this point, insert a 22G cannula into the supraperiosteal layer and inject the medial cheek in a fan-shaped retrograde manner (or bolus, depending on volume loss) until sufficient revolumisation is achieved.

Filling of the cheek also provides structural support to the tear trough and palpebral malar groove.

Zygomatic Arch

Draw a triangle connecting the lateral canthus, ipsilateral oral commisure and ipsilateral tragus.

Within the triangle, draw an oval with three points contacting the lines of the triangle tangentially.

Divide the oval into lateral, middle and medial thirds.Identify and draw the lower border of the zygomatic arch.

In the lateral third of the oval, pull the lateral cheek taut along the zygoma – and while maintaining the tissue in taut position, inject a single depot of 0.2ml supraperiosteally using a needle (perpendicular approach).

Apply pressure on the depot post-injection to distribute it evenly.

Further injections should be repeated in the middle and medial third of the oval until sufficient revolumisation in the lateral cheek is achieved. Augmenting the middle third and posterior third of the zygomatic arch will broaden the bi-zygomatic width, so caution should be exercised here to not distort facial proportions.