November 17, 2022

Are you injecting cheeks? Have you considered your injection point precision with   reference to the angle of the zygoma?

In this blog Dr Tim Pearce will explain everything you need to know about injecting the zygoma or zygomatic bone, including using dermal fillers for cheek restoration and shaping, the correct injection points, arteries

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What is the angle of the zygoma or zygomatic bone?

The angle of the zygoma, or cheekbone is the defining point of the cheek – the visual reference used by our brains to determine that we are looking at a cheek. The shift in angle of the bone, from the lateral to the medial, on both males and females, is a very important point of a beautiful face, and as aesthetic clinicians, we often augment it for various reasons.

Why might you inject the angle of the cheek or zygoma?

Dr Tim answers this question by breaking it down into the reasons why we might choose to treat the zygoma.

  • Focusing
    This is the simplest, you inject the zygoma to focus in on the area. If the patient’s cheek is relatively lost in the fat and you cannot see the shape of the cheek – our brains will lack that important reference point – you lose the sense of definition to the whole face. By injecting with dermal filler, we can create the impression that there is a zygomatic bone and a sense of structure and attractiveness to the face.
  • More aggressive overall shaping
    The next reason is if you wish to widen a face. Some patients have relatively narrow cheekbones and perhaps a broader jawbone, particularly in men, but with women, this also happens as they get older because the cheek fat pads become more dominant in the lower face. Therefore, we may want to widen the mid-face and increase the feminine angle – the heart shape between cheek and jawline – specifically when looking directly at the face.
  • Increase the anterior projection
    This reason for injecting the zygoma is more apparent when you look at a face from a three-quarter or profile view, because sometimes a weaker cheek needs projecting anteriorly. Dr Tim notes that he performs this most commonly in male patients. He explains that it is a very useful injection to add to your armoury and can add important support and overall beauty from those different angles. He cautions that mirror angles often distort an injector’s perception, thus, we need to look at the patient’s head in 3D, which allows you to see that anterior projection is another reason to inject near the angle of the zygoma.
  • Restoration for the periorbital area
    Dr Tim loves good cheekbones because they create a highlight underneath the eyes that presents the eyes to the world in a more beautiful way. Often if he sees a sallow appearance, a compression, or a lack of volume underneath the eyes that creates a shadow, the anterior projection increase gives a good platform to then perform a lateral lid-cheek junction or tear trough treatment to create a lighter area underneath the eyes to make them look more beautiful.
  • Inject lateral to the zygoma
    This is somewhat controversial, points out Dr Tim, but he believes that if you inject lateral to the angle of the zygoma, it can be supportive for the face beneath. You can create a small additional lift, and it can help support the lower face in combination with other injections, particularly when you are lateral to that point, in the right patient.

Is there a right way to inject the zygoma?

injecting zygomaYou will often see the zygoma injected in different ways by the same clinician in different patients, or by different clinicians differently in the same patient. The reason comes down to the different understanding of what is going on underneath the skin.

Dr Tim has learnt over the years that the surface of the zygoma gives subtly different   results depending on where you are placing the needle. If you look very closely at the surface of a zygomatic bone, there are different planes. Thus, in his mental model of what is happening when you are injecting on the bone, it means that wherever the bone is angled towards, you will get projection in that direction, which makes intuitive sense.

If a bolus of dermal filler is placed on the bone, which is angled up slightly, it will push the skin up slightly. Whereas if you are on a different position on the same bone, it might be anterior, lateral, or even inferior (if you are in the wrong spot). He uses this knowledge and observation to create better results for his patients and is constantly thinking about the angle of the surface of the zygomatic bone where he is injecting, trying to maximise the result.

When injecting the zygoma, Dr Tim thinks of the bone as having four different projecting surfaces, thus each time you place dermal filler on the surface of the periosteum, it projects outwards at 90 degrees to the surface of that part of the bone.

You can follow more of Dr Tim’s explanation of the quadrants of the zygomatic bone as he uses his 3D model for illustration in the episode on injecting the zygoma: safety advice and injection points of the Aesthetic Mastery Show.

What are the risks of injecting on the angle of the zygoma?

Dr Tim explains that if you are precisely on the angle of the zygoma, there should be very few structures that present a risk. The transverse facial artery tends to be running inferiorly, i.e., underneath the zygoma, although it may curl up in small branches anteriorly, but your injections should not be very close to that major vessel.

Superior to the zygoma

If, however, you start to move more superiorly, then in about a third of people you can encounter the zygomatic facial artery, (this is thankfully very small, and most people do not have one). You will sometimes see this on cadavers and mentioned in some anatomy textbooks, but Dr Tim notes that you can feel it on certain faces during palpation superior to the injection point, in the lateral lid-cheek junction. You may find a small foramen that is tender if touched due to a nerve in the same spot. If this is present, it would be a potential risk for vascular occlusion, but due to the sensitivity of the area, the patient discomfort from injection would alert you before any likely damage was done.

Aesthetically speaking, if you inject too superiorly, above the cheekbone, you start to squash the appearance of the eyes, thus instead of becoming framed by the cheek, they start to become crowded by the cheek.

Inferior to the zygoma

If you move inferiorly, you start to slip off the zygoma and into the zygomaticus major insertion point. Underneath, we also have the transverse facial artery and the nerve plexus which you risk injuring. Dr Tim recalls a case of Bell’s Palsy caused by skidding off the   zygoma and traumatising the nerve in this area.

Aesthetically speaking, if you inject too inferiorly, it can result in the opposite of your goal, creating a heaviness, which can be more obvious when the lateral lid-cheek junction has not been treated. The aim is to create an apex of the cheek, which should be blended in, but if you have an emptiness by the orbit and then a fullness on the zygoma that is slightly low, the junction will look like something has fallen, creating a heaviness laterally.

Medial to the zygoma

As you move more medially, we are essentially turning the corner and crossing the face, starting to get closer to some of those other vessels, which may vary, but the facial artery could be running in this place, although not on the bone which provides some protection. If you continue in a medial direction, there is the infraorbital artery, but this is a long way from the zygoma if you are trying to inject the cheek.

Lateral to the zygoma

If you move too far laterally from the point of the angle of the zygoma, you will begin to run out of the breadth of the zygoma and it will become narrower. The danger here is that you can miss each side of the bone, hence, instead of inserting the needle and touching periosteum, you end up underneath the periosteum and then you’re in that same zone as the maxillary artery, inferiorly, with the added potential of being in the temple, superiorly, and worrying about the deep temple arteries.

Aesthetically speaking, if you inject too laterally, you start to flatten the cheekbone because the cheek is at an angle, but the addition of an overly lateral injection creates the subtle appearance of two bones, leading to one bony angle, a little dip, and another bony angle. It can also over define a cheek if you place too much product, thus, resulting in a line of filler that does not look like a natural rounded cheek.

Similarly, if you treat anteriorly and do not do anything else, thus placing too much volume   anteriorly, it can make the cheek look too full and round, which can be very ageing because there is not enough support, laterally, to make it look youthful. The cheek will slump anteriorly and medially, due to the excess volume which can happen because the product slightly spilled over, or because the needle tip was more on the anterior surface of the zygoma instead of lateral where you should be aiming for in many cases.

Catch up with the Aesthetic Mastery Show video –  injecting the zygoma: safety advice and injection points – for more detailed explanations from Dr Tim on the ideal location for injection and how to tell where you are when you are injecting.

You can find Dr Tim Pearce on Instagram if you have any further questions or comments about injecting the zygoma and cheek area with dermal fillers.

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Aesthetics Mastery Show

Vascular Occlusion & Necrosis Prevention | Dermal Filler Safety Advice for Injectors

In this episode, Dr Tim explains the issues when injecting near the zygomatic bone; including how to use dermal filler for restoration and shaping the cheek, plus the correct points you need to inject, the arteries you should avoid and top tips for creating a great aesthetic result for your patient. Watch the full Aesthetics Mastery Show here.

The video has been watched over 16,000 times and has great comments from practitioners and injectors, including:

Thanks Dr. Pearce. I would love it if you do more videos like this, focusing on one injection point. I am really thankful for your content. Greetings from Germany.

ClassyMess Channel

This was SOOOOOO helpful. As a new injector I am always looking for more information especially how to mark the face for proper placement of fillers! Thank you(:

L Cannon

This is outstanding. I love the way you look at anatomy and how it integrates with beauty and technique. I think it would be great if you took this “focused lecture” approach into other areas: temples, chin, jaw, perioral, and of course, lips….but I know the lips have become a discipline all on their own (as they should). Bravo! I especially like the part where you break the zygomatic arch into 4 quadrants and talked about what would happen if you were “off” in any direction. Probably the most potent and effective education I have had in a while. Words cannot express my gratitude. –Sundance

sunnyfairchild

There is so much value in this post!!! Thank you Dr Tim! I’ve always trusted palpation here over anything. While palpating a zygoma and the arch in a training environment I asked the model were you in an accident? And she said yes she was kicked by a horse in her cheek. Upon palpation there was a massive dip in the zygomatic arch and you could feel trauma. She’s been a model for years and no one had ever revealed that or discussed it with her… Also using the needle tip as a tool is some thing I found to be as extremely great value as my injections have gotten better. this free advice here is solid gold!

Constance Hall

Read more and join in the debate on our YouTube channel.

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Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

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