Correcting the Mid-Cheek Groove

On today's episode of AP Class, we're reviewing an anatomy-based injectable technique for correcting the midcheek groove with hyaluronic acid filler. This study emphasizes structural understanding in anatomical precision. We'll explore how technique, depth, and product placement grounded in anatomy can enhance outcomes and why that foundation matters for both safety and results.

Episode participants:
Radiance Wellness | @radiance.well
Megan Ucich | @the.skin.practitioner
Aayesha Patel | @aaestheticsbyaayesha
Sarah Pertschuk | @beautyinjectorsarah

Episode show notes / blog: Link

Disclaimers & disclosures: Link

Transcript

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In practice, I'm constantly telling my patients that these are all symptoms and you know, we're not going to chase those lines. We're not going to go after your nasal labial folds or your midcheek groove just because that's that symptom we see. We have to fix the problem. Um, it's a lot of trust from our patients to follow us down that path because they see one thing and they think, "Oh, this is the anecdote." And then we have to explain to them that hey, it's something that you can't see that we know about and creating that trust and having your patients trust you to get a great outcome with something that they don't know is even there. Yeah. And the only way they can trust us is if we can educate them. And we can only do that if we do the research to learn. Exactly. Which is why we're here. Welcome to AP Class, your virtual journal club for all things aesthetic medicine. Created by injectors for injectors. This is where we take a clear evidence first look at the research shaping modern aesthetics. Each episode we'll unpack a study. What's solid? What's questionable? And how the evidence informs natural refined results in real practice. Class is now in session. On today's episode of AP Class, we're reviewing an anatomy-based injectable technique for correcting the midcheek groove with hyaluronic acid filler. This study emphasizes structural understanding in anatomical precision. We'll explore how technique, depth, and product placement grounded in anatomy can enhance outcomes and why that foundation matters for both safety and results. Welcome back to AP class. I'm Megan Ucich, nurse practitioner. I'm Aayesha Patel, physician associate. And I am Sarah Pertschuk, physician associate. We are the providers at Radiance Wellness. So, we are coming to you with our fourth episode. Number one, we broke down how to read a research study. Number two, we talked about BBL and its changes in molecular structure of the skin. Number three, we went over micro needling with PRP for acne scars. And number four, we are going to talk about techniques using filler. So in particular, this title is a new approach in the correction of the midcheek groove, the liquid malar lift technique. I've seen this study buzzing around Instagram a little bit. I've been seeing people posting about it, talking about it. So figured it would be interesting. I feel like as providers, we're always looking for new techniques to improve. So hopefully this will help some people if they've been wanting to learn a new technique, especially in the midface area. We'll uncover it a little bit and then talk about how it applies to practice. Yeah. So, the nice thing about this paper is that although it's not maybe reproducible, so we can't, you know, go to practice tomorrow and say for sure that we're going to get the same outcome, it at least gives us some objective data about what we're doing because subjectively when we treat someone's midface, we can see a visual improvement, but it's nice to reinforce that with with some objective data. And so this study did that with an MRI. It used some photos. It goes over the technique. So I really liked this paper, too, because it uncovers the anatomy beneath something that we all see in practice every day, which is the midcheek groove. And it's something that more and more patients are coming to us with because it gives you that kind of tired look. And people are wanting treatment for that. And it's our job to guide them to the appropriate place to put that filler and not treat the face inappropriately in that regard. So the midcheek groove is something every injector sees and it's one of the most commonly misunderstood problems in the midface. um you know so historically a lot of treatments have trended towards filling the groove itself superficially and that just leads to anterior heaviness and distortion and short-lived results. So what this paper does really well is it reframes the concept of the midcheek groove as more of like a structural and compartment-based issue, not a superficial defect. Yeah. It's a symptom of something happening deeper under the surface of the skin. Yeah. And I think this paper is so clinically relevant because it kind of forces us to zoom out and ask ourselves, are we filling in the line or are we restoring support? And we see this in practice all the time where patients come in and they're pointing to that mid cheek groove and they just are like, "My under eyes are making me look so tired." But realistically, it's not the under eyes. And anatomically, it's because of that lack of support. The study really reinforces a metaphor that I use with my own patients. I'm sure you guys have heard of it. Is that look at the face like the framework of a house. So if your foundation, which is your deep fat compartments, um your bones, if that's sinking or shrinking down, you don't fix the problem by, you know, repainting the drywall. And in our world, that's our skin and our superficial tissue. We have to go back in and fix that foundation. And that foundation is going to be our deep fat compartments and our bony structure that helps support our tissue. And that's that lack of support that's causing that groove. Yeah. Yeah. We definitely don't want any sinking and shrinking. That doesn't sound good. I don't want a foundation. No. Not sound good at all. But it's so true. And I think even, you know, a few years ago, a few years ago, 10, 20 years ago, before we were really like delving into the physiological signs of aging in the face, we were allowing patients to kind of dictate our treatments because we didn't really know better either. So, they would come in and complain of their under eyes and we'd be like, "Okay, well, let's treat your under eyes." And then it didn't look good. It didn't fix the problem because that was a symptom. The source of the problem was something very different. And I think modern aesthetics really pushes that that like we're not just trying to put a band-aid on a symptom. We're getting to the source of the problem when we're treating that first. That's how filler is supposed to be used. I feel like it gets this bad rep. And that's just when it's used inappropriately, right? Like when a provider doesn't know what they're doing, when they don't understand anatomy, when they don't understand the physiology of aging and they're not prescribing it appropriately to the patient. So I love that. Like you said, Sarah, this study is going back to what is happening to the face, why is it happening, and then let's treat appropriately. Yeah. I think in practice, I'm constantly telling my patients that these are all symptoms, and you know, we're not going to chase those lines. We're not going to go after your nasal labial folds or your midcheek groove just because that's that symptom we see. We have to fix the problem. Um it's a lot of trust from our patients to follow us down that path because they see one thing and they think, "Oh, this is the anecdote." And then we have to explain to them that, hey, it's something that you can't see that we know about and creating that trust and having your patients trust you to get a great outcome with something that they don't know is even there. Yeah. And the only way they can trust us is if we can educate them. And we can only do that if we do the research to learn. Exactly. Which is why we're here. AP class full circle. Um, okay. So, let's just break down again hierarchy of evidence here. This is low, but it's low for a reason. Like we talked about, this is a technique driven by anatomy paper. So, kind of a case report going over some patients that a physician has seen on his own and then uses an MRI to kind of review it. But, so we're low on the hierarchy of evidence. We already know that it's probably not going to be completely reproducible. We'll need to do some randomized control trials, compare it to other techniques using filler in the same area before we can use this and say, "Hey, this can be applied to a general population." Yeah. And so that's important to say that out loud because this paper isn't really a superiority of this type of technique. It's not saying, "Oh, this is better." It's not saying, "Oh, needle is better than canula or this type of filler is better than that type of filler." It's really demonstrating an anatomically driven approach with radiologic evidence, which isn't that common in the aesthetic world. No. Yeah. So, in the hierarchy of evidence, this is kind of like a level four. Um, couple episodes we talked about a proof of concept study, and that was kind of in the middle. In comparison, this study has no control group. So, it's not necessarily saying that this technique is superior than others. Um, it also has no p value. Um, it has no comparative arms and it has no statistical significance. Has no arms. That's not good. We need arms. Two legs. No arms here. It's hard to do things without your arms. Yeah. Um but instead in this study the strength is from that anatomical reasoning, the consistency in the results and that radiological support. So no statistical power here but still good evidence. Yeah. So diving into PICO population. So we had 64 patients ages 25 to 60, both a mix of men and women. Um I think more women than men um with visible midcheek grooves and it's important to note that the midcheek grooves were only age volume related. So it is possible to have midcheek grooves as a child. Um you do have some patients that will come in and say I've had this my whole life. So that's different. It will worsen over time just like it will for these patients too. Then an age volume related midcheek groove and so that's something that they kind of call out as well a little bit. Okay. So then getting into the intervention and what was actually done for these patients to fix the midcheek groove is called the liquid malar lift technique. And I'm so excited to read a paper about this because this is something that I'm really trying to harness in my practice and to be able to have really great outcomes for my patients because I think it does change and improve the face so much with such minimal filler that patients are just it's such a high reward technique. It is. You guys did mine? Yeah, we did. I did. Do you use the liquid malar lift technique? We kind of did. We kind of did. This paper uses a canula. True. And they make it very clear in the beginning that the canula point where they start the injection is 2 cm lateral to kind of the regular lines that we'll use to bisect a face. And so it's from the lateral rim, the lateral orbital rim down vertically. And then from the subnasal horizontally. And so where those intersect, it's about 2 cm lateral to that. That was to avoid the facial vein. Yeah. Yeah. Yeah. So that's was kind of an important point for where they in inserted the canula at first. And then basically what this technique does is it focuses on the deep fat compartments prior to the superficial fat compartments. So there's the deep medial cheek fat compartment, the deep lateral cheek fat compartment, and then the superficial fat compartments. And the way that they started with this technique was they used the canula to inject anywhere from 0.2 to 0.4 milliliters of hyaluronic acid filler onto the periosteum using a bolus in the deep medial cheek fat. Then the canula is redirected to the lateral deep cheek fat and it is placed again on the periosteum in small adjacent boluses. And this is to really help recreate lateral support and smooth the transition from anterior to lateral cheek without overbuilding the apex. So you're not just focusing everything right here where the groove is or deep to the groove. You want it to kind of have more surface area so that it doesn't sit too anteriorly and because you're replacing two anatomical landmarks, right? Talking about anatomy and there's two deep cheek fat compartment. So this is more about projection and support. Yeah. and support and in turn that will help with the surface smoothing. Yeah. And so once the deep structures are supported then the technique moves to the superficial fat compartments and specifically the superficial medial and middle cheek and that's where they place the filler directly below the malar groove and in a retrograde linear. Yeah. technique. Yep. Yeah. And also that mar groove also is known as the ZCL, the zygomatic cutaneous ligament. It attaches to the skin and that's why it becomes so prominent too because as those fat pads atrophy and age, it's still adhered to the skin. You're still you're seeing that more as well. What do we call it? The bra strap of the face. I call it the bra. I always say to my patients, the deep medial cheek is like the bra holding it up. And so as it falls Yeah. They get they're like, "Oh, yeah." And as we age, we just don't wear bras anymore. Yeah. Oh, I am whipping that bra when I get home. We need one. Yeah. So, as we kind of work through that PICO framework, we're now at comparison. So, there is no formal comparison in this study. Instead, the comparison comes from that pre and post treatment clinical photography. And then we have that one patient who had an MRI. Yep. And that showed um that demonstrated objective changes after the filler was placed. Yeah. So the imaging piece was subtle. Um they only did it on one patient. Um but it did show that it did replace or restore that intended deep fat compartment um with no evidence of inferior migration, which I think is good to know. Um especially because migration is such a big scare for our patients. Hot topic. Yeah. So that was nice to see that they it was there and it intended to do what it was supposed to do from a technique standpoint. It kind of supports that deep compartment placement that provides that structural stability. Yeah. So without a comparison arm, we can't necessarily say that this technique is superior than others. But we can take that mechanistic insight and kind of prove that yes, the deep fat compartment restoration does restore that midcheek groove. Yeah, for sure. Yeah. And clinically patients showed a visible improvement. So, and that was done with the before and after photos, and they show it in the study, too. You can see it, and it does look really good. Um, he the author describes a prominent improvement, but he doesn't list any specific validated tools that he uses to define that. So, again, we don't have any tools that are validated to say for sure. This is just his subjective measure to say like, oh, yes, it did make a difference um in the midface contour and in that groove. radiologically. Um so they they did that MRI looked at fat saturated coronal and axial MRI. Um and they basically he measured so he looked at the distance from the anterior wall of the maxillary sinus to the skin surface. So that's how they were measuring that change the projection. Exactly. Um and so he states that the deepest part of the midcheek groove is kind of at that spot that maxillary sinus area. Um, and that's how he used the MRI to then show the after and the changes in the numbers of how much projection there was after treating the area. Nice. Um, like you said, the the MRI was great because it showed that it didn't migrate, that it stayed in the area that it was intended to be in, that he treated the area appropriately as well. Um, but again, the outcomes are reported descriptively. So without confidence intervals, without p values, the right side showed a 43% increase in volume. The left side showed a 10% increase, which I thought was really interesting. That's significantly less. But he mentions that the left side didn't have the same deficit that the right side did. So, but it's interesting cuz if the left side didn't have the same deficit than the right side did and they added more filler to the right, but wouldn't they look equal on MRI after that? Yeah. Like, wouldn't the space be like the same? I don't know. That was interesting to me. Yeah. Yeah. I think the volume was the same, but it was the percentage of increase. Oh, I see. Got it. So there was a more percent increase on the left side. So this study is also great because it supports Rohrich and Cotofana's work and we all love love Cotofana. You sure do. You don't know me yet, but maybe you will someday. Not to be creepy. Um but we it basically says that the deep fat acts as the structural pillar and when you replace the support of those structural pillars it repositions the superficial tissue and it causes it to look more natural. And that's really a big shift from treating this this malar groove like we would treat like a nasal labial fold. Mhm. Cuz we were treating them the same. Yeah. For a minute. Yeah. And now even with nasal labial folds, I find myself going in and treating the pyriform aperture space before I go and I mean we've largely moved away from treating nasal labial folds in general. It's interesting because as injectors we think that this is common sense, but our patients still come in saying, "Can you fill my nasal labial folds?" And don't get me wrong, there's still a time and a place for it. We did mine not too long ago, but but that's not the first place to go where before it was like just treat the nasal labial fold over and over and over and over again. Um, and now that's shifted a little bit. And so this paper really shows that if we do understand the deeper anatomy of the face, we can create these beautiful natural looking results and that's that just excites me so much. Yeah, it's amazing. So, some limitations with this study is that they did only do MRI on that one patient. Um, there were no scales to kind of prove the outcomes that they saw and follow-up wasn't as extensive as we would hope for it to be. It was only one week and I think that creates that bias where one week after injection, we do see some swelling. So that improvement can be due to some residual swelling that we see. Yeah. Um they also didn't mention any inclusion or exclusion criteria for the patients that they selected. Um so we don't know why they selected the patients that they did. With all this considered, this case report should shouldn't necessarily guide your clinical practice. I mean, we've all seen those other like cadaver courses and imaging studies that they do prove that multi-layer injection. This is to just say that this technique isn't superior to others. But I think the takeaway from this is that we when treating the mid cheek, it's not about it's anatomy first, not the line first. Right. Yeah. And I think that's a big takeaway. Yeah. We always go directly to the line and now we know we've got to treat underneath. Yeah. Yeah, absolutely. One thing that he calls out too, the older face required a little bit more product in the deep cheek fat compartments whereas the younger patients required a little bit more in the superficial fat compartments which makes sense which yeah that tracks for sure but I will call out and there is a paper from Cotofana that talks about the platysmal bands and its pull on the superficial fat pads in the midface and the descent of those and so that's just important to keep in mind too that like don't go run to all of your young patients and throw a ton of filler in their superficial midcheek fat because we want to know long term in 20 years how does that look too in 10 years how does it look so also just Botox platysmal bands just keep them quiet a naughty muscle but tell them to chill just chill out I think it was cra I thought it was crazy that the platismal band really it just reaches so much further than we thought I mean it really affects everything on the on the face cuz it's just a sheet. Where are you going here? Everything. It's all connected. It is all connected. Like every muscle, fat compartment, bone, it all works together. Yeah. And we're really trying to work from the bottom up. Yeah. Yeah. I think the other key to this technique is that it starts with placement on the bone, which we know is not going to migrate as much because there's not a lot of moving structures around it. So, I liked that it didn't show a lot of migration. Granted, they only followed up one week later and there's not a lot of time for migration, but we know that with the technique there was no migration with the actual injection and which we have found in other types of techniques. So, um I did like that it starts on the bone and that is going to be a low migration area because there's not a lot of muscle movement around it. Mhm. When you guys are cheating treating cheating treating the midcheek um are you canula or are you needle? I'm a little bit of both. It depends on how close to the infraorbital foramen I'm getting which I think is why he's using canula as well. But curious to hear your thoughts. You know, personally, I love the projection I get from a needle. Um, but I agree, I'm a little bit more weary as closer I get to the medial side. Um, so I feel like I'd like to incorporate more canula. Um, but I'm just trying to learn that mastering that technique and getting the same results with canula is something I'm still working on. Mhm. I'm a little bit of both, too. I like that initial point to be with the needle to create that support and that projection and then fanning around with the canula to smooth everything and have it look really natural. Yeah. Mhm. Um also I don't use a 22 gauge 2 in. I'm generally a 25 gauge one and a half inch. Yeah. But curious to maybe play around with that to see if it's a little bit different. I'm wondering if you can get a better bolus. Oh, that makes sense with a 22. Um, just food for thought. Yeah, I haven't done a lot of boluses with a canula. Yeah, I I usually do my boluses with a needle. So, that is an interesting thought because maybe you do get a better bolus with a 22. Mhm. So, yeah. Well, that's interesting. I'd like to see it like on paper and maybe we could try that out because when I think of in my head when I'm thinking of boluses with a needle I'm thinking of that like kiss the chocolate kisses to give that projection versus when that canula is just laying parallel. Right. It's kind of in my head it's creating like a deflated ball. Yeah. Right. You can bololis with a canula if you pull the canula up perpendicular to the skin. right and leolas. But it it feels different at that point. I would rather just go in with a needle on periosteum. It does feel tight and it feels like you're kind of stuck within layers of the skin. Yeah. Um but it's cool to see that there wasn't a lot of migration with that. For sure. Yeah. Exactly. It was where where he intended for it to be. Yeah. Yeah. So maybe that's finesse. So I guess we're gonna have to practice our finesse. Our canula finesse. Yeah. So for real world adoption as clinicians we need more evidence right we need some randomized control trials comparing this technique to maybe established approaches uh validated measures etc but again not the point of the study I think it I think it's definitely valuable information I think it helps to reinforce our own knowing of like yes we're treating people appropriately treat the source of the problem don't treat the symptom um I think it's really clinically based like this is for the injectors. Like we love this because not only does it review a technique that we're all using regularly, it tells us that hey, you are probably doing it right. So I like that. Love that for us. All right. So at the end of the day, this paper doesn't necessarily give us a gold standard protocol, but it gives us strong anatomical argument for treating the cause instead of the consequence. And we know that's where good aesthetic medicine lives. So, thank you guys again for joining us. Episode four of AP class. Woohoo. We're doing it. Thought four episodes deep. I know. Wow. If you guys have any research you want us to take a look at, please let us know. We're happy to. And we'll see you next time. You've been listening to AP Class, your virtual journal club for all things aesthetic medicine. If you found today's episode helpful, like and subscribe, share it with a colleague, and join us next time as we break down more evidence that helps elevate your practice.