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What we're going to do next is injection of the malar area. The
different zones here, as we talked before, are the tear troughs. You can
see, some patients have a little shadow or a dark circle around the
eyes. It can be medially. It can be laterally or all the way across the
mid-face. You can need filling of that area, especially as patients age.
They lose volume in the mid-face, and everything kind of sags down, down
and in, creating these labial folds. So, re-volumizing with either fat
injections or fillers is the way to go. Implants are also another
option. Mid-facelift would be the surgical option.

But as you'll see in just a few seconds, injection of fillers is
beautiful, simple, very safe, very low-risk. In my opinion, it's better
than fat injection, implants, or mid-facelift. The downside of a
mid-facelift, that it takes about two months to recover from the
swelling, and the results last about five years. Implants, they can
shift. They can become infected. There can be size issues, desire for
larger or smaller sizes. Fat injection, it can take several treatments.
Most of it doesn't take. It's great for volume, but not so much for
contour, as it doesn't have the structure of fillers. That's why fillers
such as Perlane, Juvederm Ultra Plus, and Radius work so well.

In this face, what we're going to do is basically focus on this zone and
create a little bit of fullness right in this malar area. To do that,
we're going to use Perlane, which is a safe hyaluronic acid. Again, it's
a clear gel. It's roughly 1 CC. What I like to do is start by taking off
any makeup in this area. In your first few times that you do this, you
should mark the face so you know where you're going. Make sure you do it
symmetrically. After a while, you'll see that marking is something the
patients can do without. Even though the markers are erasable, it takes
several days to remove it completely. Also, you don't want to make a
huge case out of this. You don't want to spend 45 minutes doing this
injection. The longer you take, the more you inject, the more swelling
and bruising you'll have. So, you want to do this as atraumatically and
as quickly, but as meticulously and symmetrically as possible.

What I'm going to do for this part is put her head back a little bit.
So, as we talked about, there's two ways of doing this injection: under
the lips, sliding just like a dental block, filling the area. That's a
nice way of doing it, but when you need more control, penetrating from
the outside, right down to the bone, is a much more precise way of doing
this. It's really not a painful injection. Patients tolerate this very
nicely. The injection is all the way down to the bone, and you fill on
top of the bone. You don't want to inject into the skin or subcutaneous
area because you'll get lumps and bumps. So as you'll see, what I do is
I basically just enter right down through the skin, right on top of the
bone, and fill the bone. Then, I inject. Then I just go across another
centimeter, do the same thing, all the way down to the bone, fill the
area.

I do a zone, typically. I do several triangular zones. It gives me the
three-dimensional contour that I'm looking for. You can see already, the
volume that she's getting in that area. You want to be very symmetric.
What I do is I inject roughly half. I don't do the full half because I
like to be able to contour [inaudible 00:04:11]. Doing okay? After I
inject it, I just massage it again, smoothing out. I don't feel any
lumps or bumps, perfectly smooth. You can actually compare the two sides
right now. You can see the fullness. Only a little bit of pressure,
stops these tiny little vessels. So, what I do at this point is I hand
the patient a cold, moist sponge and I go on the other side. So, we're
going to do the same thing.

Again, for your first few, you definitely want to mark the patient in an
upright position, so you know exactly where you're going. So, you end up
as symmetric as possible. This is not an injection you want to do into
the skin or subcutaneous. This is right on top of the bone, just like an
implant. This is also not an injection that you're going to do in a
serial, parallel fashion. This has to be done straight down. Go
perpendicular to the skin and bone. Fill as you go. Now, you may also
note some hyperpigmentation on the face. It's from recent sun damage.
This can be treated just a few days later with IPL, which basically
erases these pigments very nicely. So now, I come on top. Hold it this
way. This is the best view to be able to tell symmetry.

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Filler Provides a Natural Midface Lift Without Surgical Intervention

A liquid midface lift, which is a non-surgical technique using fillers, is another facial softening technique used in place of a surgical lift and implants.

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