Radiesse® and Sculptra® (Galderma Inc., Lausanne, Switzerland) can also be used.39 Radiesse® is a biostimulatory filler made of CaHa micropsheres suspended in an aqueous gel of sodium carboxymethylcellulose and water. The microspheres stimulate new vessel and collagen production. The filler lasts for 1-2 years depending on the location in which it is used (lasting less time in locations with active muscle movement).1
Cheeks
The male cheek tends to be less prominent and flatter than the female cheek.9 The ratio of the medial to lateral cheek of 1.1:1 points to a more even distribution of volume, while in women the medial cheek is fuller.9 The apex of the male cheek is more medial, wider, and more subtle. Another distinction between the male and female cheek is the shape of the ogee curve, an S-shaped curve from the cheekbone to the mid-cheek hollow. The male ogee curve should be flatter in its lower S curve (concave portion).
Keeping such differences in mind, the physician should assess where the volume loss has occurred by examining the patient from the front, from the profile, and from below. Locating the malar eminence is also helpful. Two techniques can be used. In Hinderer’s method, two lines are drawn (Figure 4). The first line is drawn from the lateral oral commissure toward the ipsilateral lateral iris, stopping at the infraorbital rim. The second line is drawn from the nasal ala to the ipsilateral infratragal notch. Where the two lines intersect denotes the point of maximal convexity and light reflection.40
In Wilkinson’s method, a vertical line is drawn from the exocanthion to the edge of the mandible. The malar eminence is located about one-third the distance from the exocanthion to the mandible.41
Unlike the glabella and infraorbital hollow, more dense and large particle fillers can be used in the cheek. These include Juvéderm® Ultra Plus and Voluma, and Perlane®.9 Product should be injected in a retrograde threading technique as well as laying down a foundation with initial depots onto the periosteum (where applicable). In the medial cheek, a subcutaneous plane is desired, whereas in the lateral cheek, a supraperiosteal plane will give more foundation. In the submalar cheek, since there is no bony support, a cross hatching technique, in the dermal and subdermal plane, can provide the needed structural support. Cross hatching combines multiple injections of linear threading that crisscross at right angles to provide volume in a square shape. A cannula can achieve similar results with decreased risk of puncturing the angular artery. Having the patient animate after injection will help identify any bulges or bumpy product contour. Gentle initial molding of the product right after injecting can ameliorate unevenness.
Nasolabial fold
Changes to the nasolabial folds manifests in different ways, including superficial lines, deep rhytids, or grooving due to ptosis of the cheek. If grooving is due to the descent of the malar fat pad, it may be helpful to start with volume correction of the zygoma prior to approaching the nasolabial fold.
Superficial lines are best filled with Restylane® or Juvéderm® Ultra or Ultra XC using a linear threading or serial puncture technique. Deeper grooves may be augmented by Perlane® or Juvéderm® Ultra Plus, Ultra Plus XC, or Voluma.
Smith et al. suggests that Artefill® (Suneva Medical Inc., San Diego, CA), a PMMA filler, may be useful in men who have difficulty maintaining appointments and may benefit from a long lasting product.42 Artefill® is made of 30-50 micron spheres of PMMA suspended in non-crosslinked bovine collagen. After 3-4 months, the body produces new connective tissue in response to the PMMA. The author recommends using Artefill® incrementally 3 to 4 months apart until the desired level of correction is achieved. The filler should be injected in the deep dermis due to the risk of superficial papules. Thereafter, touch ups may not be needed for 5 years. The author notes many men prefer this treatment as results are gradual and less noticed by their coworkers.
