Rian A. Maercks, MD, PA, says that many filler injections make patients look older, not younger.

By Tonya Johnson

When plastic surgeons learn how to treat patients who have mid-face volume deficiency, surgeons are typically trained to inject the facial filler directly into the “Y-Zone” of a patient’s face; that is, the balls of the cheeks, the lips, and chin area.

But Rian A. Maercks MD, PA, founder of The Maercks Institute in Miami, Fla, says this longtime industry standard goes against achieving a balanced facial structure. “I’ve never really liked the way filler interventions have looked because they create a new kind of aesthetic that appears unnatural and different,” he says.

He goes on to explain: “When we’re in our youth, late teens, and early 20s, we have some nice padding around our cheekbones that make our faces look supported and elevated.” But over time, older adults naturally collect volume in the balls of their cheeks (Maercks calls this the “volume of age)”. So when plastic surgeons inject filler into the Y-Zone, “we’re plumping up this area where we naturally retain volume as we age. As a result, we’re getting this indeterminate aged-look where people’s faces are fuller and skin is tighter, but they look bottom heavy and strange,” he says.

Rian A. Maercks, MD, PA, produces YouTube vlogs at The Maercks Institute in Miami, Fla, to provide education about Aesthetic Facial Balancing, Cold-SubFascial Breast Augmentation, and more.

So other than for patients who have already lost a tremendous amount of weight, the balls of the cheeks, the lips, and chin area are not where he injects fillers. Indeed, Maercks says that for most patients, filler injections administered in these places actually make patients look older and can cause facial deformities.

The average patient typically only receives a 0.5 to 1 cm3 amount of filler injection into the mid-cheek area, which is usually satisfying. The real problem occurs, Maercks says, when wealthier clients (which may include celebrities and socialites) request multiple cubic centimeter doses in that area. If a surgeon acquiesces, the patient may experience “the golf ball cheeks, monkey cheeks, or lion face,” Maercks cautions. This artificial look then proliferates as fans notice the “caricature-like” faces across social media platforms and try to mimic that.

To create a younger, light-lifted, aesthetically pleasing face, Maercks developed “Aesthetic Facial Balancing.” This procedure rejuvenates the aging face by using fillers (or the body’s own fat) at volumes that are considered excessive by mainstream practitioners. Rather than target one specific area, he analyzes facial region sub-units. He says, “When someone comes into my office for a lip injection, it’s relatively rare for me to place the injection straight into the pink lips like most practitioners do. That could result with the patient possibly ending up with a ‘duck lip.’” Instead of only focusing on the lip, Maercks’s approach also spends an equal amount of time evaluating additional sub-units of the face independently—including the base of the nose, the chin, and everything in between—to make sure everything blends in harmony.

This 25-year-old woman requested a slimmer looking appearance with a more defined nose and chin. Maercks’s Aesthetic Facial Balancing gave the patient a correction from top to bottom, resulting in a natural refreshed look.

“My patients have been happy with these types of results and would be horrified to have the over-inflated, strange, projecting cheeks that most people have,” Maercks says.

Maercks is working on a manuscript to document the complete Aesthetic Facial Balancing process, as well as setting up a fellowship program to be offered at the Institute in Miami. For now, Maercks provides informational vlogs on a regular basis.  

For fellow plastic surgeons who want to revise their filler techniques, he recommends studying old faces, young faces, and the faces that have been treated with conventional filler procedures to recognize the difference. “Every human face is unique, and there are ways to highlight the unique beauty of any individual. The most important part of surgery is analysis and observation—if you can’t see, you can’t do.”

Tonya Johnson is the associate editor of Plastic Surgery Practice.