Injections over the malar bone are prone to cause severe reaction, leaving a puffed appearance just below the eyelids. This may be more or less permanent and is very undesirable. It should be avoided by injecting very small quantities at that site. It is always safer to add a little subsequently.
The reaction, generally, is not severe, and is readily controlled by cold applications, yet the author has experienced considerable swelling and tenderness in two cases of total cheek deficiency corrections which lasted for several weeks after the operation, giving excellent result eventually, however. Such symptoms are dependent upon circulatory interference, but resolution should take place without untoward results with judicious treatment, unless the operator has been negligent by injecting one or more blood vessels, in which case the resultant thrombosis may cause breaking down of the subcutaneous tissue, abscess, evacuation of the mass, and possibly death in part of the integument. The precautions referred to in avoiding any such possibility have been fully given heretofore.
Never should the operator hyperinject the cheeks, even if the patient insists upon looking like a puffed ball. He should be satisfied with a normal contour, and truthfully assure the patient such hyperinjected contour could not be retained owing to the weight and dropping down of the mass before nature could properly replace it by organized tissue.
Subsequent injections may be made about three weeks after the first sitting.
With nervous and hypercritical patients the surgeon may elect to give the patient a number of sittings, injecting only small quantities at two or three places each time. This in the majority of cases will give better results than when an entire cheek is injected, for the reason that the larger mass is likely to be displaced by the unconscious act of the patient in sleeping on one or both of the rebuilt cheeks or the willful massage to improve the handiwork of the surgeon in their own belief.
Massage of the cheeks after the replacement period is not to be tolerated. It tends to create hyperplasia by circulatory stimulation.
It is not unusual to have the patient tell you that for weeks after the replacement period the cheeks are swollen considerably in the morning upon arising, going down gradually during the day.
This is due to the spongy or loose character of the new tissue caused to be formed by the foreign mass, which gradually takes on a harder and more compact form.
The post-operative dressing will be either adhesive isinglass plaster or collodion. With the former, moist applications during the stage of reaction are not permissible.