Cheek filler: supporting the midface without overfilling

Why the midface changes with age

The midface, from the lower eyelid to the corner of the lips, includes the cheekbone, the cheek and the upper part of the nasolabial fold, the crease between the nose and the mouth. With age, three structures change there:

• Bone. The maxilla, which carries the cheek and the side of the nose, resorbs and loses its forward projection. The rim of the eye socket also recedes, especially at the bottom and on the outer side.
• Fat. It is divided into separate compartments, which sag with age; volume is less well distributed.
• Ligaments. These fibrous attachments, which connect the tissues to the bone, lose strength. Where they hold the skin back, a hollow appears; next to them, the tissues descend.

What this means for under-eye hollows and folds

Under the eye, the junction between eyelid and cheek lengthens and deepens: this is one component of the hollow dark circle, or tear trough. Lower down, the descending cheek and the receding bone beside the nose deepen the nasolabial fold. The cause therefore often lies higher up: I look at the face as a whole before treating a fold.

Measuring before correcting

Before any injection, I analyse your face by computer, on standardised photographs: proportions, symmetry, areas that have lost support. This does not replace the examination: I also observe your face while you talk and smile, and I feel the tissues. The photographs serve as a comparison at the check-up, around day 15.

What hyaluronic acid can do

Injected deep, hyaluronic acid can restore support to the cheekbone and a little forward projection. In the main trial, funded by the manufacturer of the gel tested, 282 people were randomised: at six months, 85.6% of those treated had improved, according to blinded evaluators. A review of 18 studies reports high satisfaction for up to two years.

On under-eye hollows and folds, the effect remains indirect and variable: it can soften their shadow, without erasing a deep fold.

What it cannot do

Hyaluronic acid adds volume; it does not tighten the skin. It does not correct excess skin, marked jowls or significant sagging; adding more to "lift" the face makes it heavier. Other approaches exist, including surgery, which I do not perform: we can talk it through together.

Firmer gels for support areas

Gels do not all have the same firmness. It is expressed in particular by G' ("G prime"): the gel's ability to resist when pressed, then return to its shape, like a spring. A high G' means a firmer gel, which gives more support; a low G', a softer gel, suited to thin, mobile areas.

For the cheekbone, a firm gel is generally chosen and placed deep, where it can be neither felt nor seen. G' does not explain everything: I tell you at the consultation which gel I use, and why.

How I work

On the upper cheekbone, the gel is most often placed deep, beneath the muscle, in contact with the bone; lower on the cheek, a plane just under the skin is sometimes better. I use a fine needle or a cannula, a thin blunt-tipped tube, depending on the area and your anatomy: both are valid when used properly. I inject slowly, a little at a time, and in stages: it is better to add a little at the check-up than to put in too much at once.

The risks

• Bruising (haematoma), swelling (oedema) and tenderness: common, usually mild, they resolve within two weeks.
• Asymmetry or a small irregularity: I reassess it at the check-up; a small top-up or hyaluronidase can correct it.
• Nodule, a small lump under the skin: most often early, linked to the gel deposit; more rarely late and inflammatory. Treatments exist.
• Tyndall effect, a bluish reflection: it occurs mainly when gel is too superficial under thin skin, as under the eye; deep on the cheekbone, it is rarely a concern.

The most serious complication is rare: accidental injection into an artery, which can block the circulation. The skin can suffer, up to necrosis; exceptionally, vision can be affected, because the arteries of the face connect with those of the eye. Neither the cannula nor aspirating before injecting removes this risk completely.

That is why hyaluronidase is always available at the practice. This enzyme dissolves hyaluronic acid. Injected without delay and in sufficient quantity, it is the mainstay of treatment when the skin's circulation is threatened; for vision, treatment results are limited and every minute counts. After the session, if pain increases or the skin turns pale or mottled, call the practice without waiting. Any visual disturbance means calling 112.

How long does the effect last?

It depends on the gel, the amount, the area and each person. For the cheekbone, studies report an effect that can last one to two years: in the trial mentioned, nearly half of the people still had their correction at two years.

A natural result: small amounts

Too much product, or product in the wrong place, can give a "puffy" face, with heavy cheekbones and a less natural smile: this is facial overfilled syndrome. It often results from repeated injections, because the gel can persist longer than the visible effect, sometimes for more than two years on MRI. So I prefer small amounts and I wait for the check-up before any top-up; sometimes I advise adding nothing.

When I do not offer an injection

• A skin infection or a cold sore in the area (we wait until it has healed), or an ongoing infection elsewhere, for example in a tooth.
• An active autoimmune disease, a known allergy to a component of the gel, or multiple severe allergies.
• A permanent product already injected in the area.
• Pregnancy and breastfeeding, as a precaution.
• Unrealistic expectations or excessive concern about one's appearance: we then talk it through together.

Anticoagulant treatment does not necessarily rule out an injection, but increases the risk of bruising: never stop it without the advice of the doctor who prescribes it.