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Supplement to the March 2009 issue of
Facial Shaping:
Cheeks are the New Lips
A proceeding based on a satellite symposium during the
2008 ASCDAS 7th Annual Meeting & Exhibition
Jointly sponsored by Postgraduate Institute for
Medicine and EHC Communications, Inc.
This activity is supported by an educational
grant from Dermik Aesthetics.
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Facial Shaping: Cheeks are the New Lips
A proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
Release date: March 16, 2009
Expiration date: March 31, 2010
Estimated time to complete activity: 1.25 hours
Target Audience. This activity has been designed to meet the educational needs of cosmetic dermatologists and aesthetic surgeons
involved in the management of patients with facial aging.
Statement of Need. Today, nonsurgical techniques play a primary
role in reversing age-related changes. However, the optimal selection
of nonsurgical options and the application of injection techniques to
ensure the best results for patients are a major issue of debate. From
the perspective of plastic surgeons and cosmetic dermatologists,
should fillers or sculptors be used, is there an advantage of combining
and layering one product over another, and what is the preferred injection technique?
This symposium proceeding highlights injection techniques and recommendations for optimal use of fillers, with insights on the use of
these agents in patients of varied ethnic backgrounds.
Educational Objectives. After completing this activity, the participant should be better able to:
1. Specify nonsurgical treatment options that enhance the
mid-face and lower face in order to lift, redefine, rebalance,
and re-proportion the whole face.
2. List the indications for the use of dermal fillers for nonsurgical
treatment of facial biometric volume loss and alteration.
3. Describe proper injection techniques for facial shaping agents,
including both replacement and stimulatory fillers.
4. Explain ethnic considerations to optimize outcomes with
the use of facial shaping agents.
Accreditation Statement. This activity has been planned and
implemented in accordance with the Essential Areas and policies of
the Accreditation Council for Continuing Medical Education
(ACCME), through the joint sponsorship of Postgraduate Institute for
Medicine and EHC Communications, Inc. Postgraduate Institute for
Medicine (PIM) is accredited by the ACCME to provide continuing
medical education for physicians.
Credit Designation. Postgraduate Institute for Medicine designates
this educational activity for a maximum of 1.0 AMA PRA Category 1
Credit(s)TM. Physicians should only claim credit commensurate with
the extent of their participation in the activity.
Disclosure of Conflicts of Interest. PIM assesses conflict of interest with its instructors, planners, managers and other individuals who
are in a position to control the content of CME activities. All relevant
conflicts of interest that are identified are thoroughly vetted by PIM
for fair balance, scientific objectivity of studies utilized in this activity,
and patient care recommendations. PIM is committed to providing its
learners with high-quality CME activities and related materials that
promote improvements or quality in health care and not a specific proprietary business interest of a commercial interest.
The faculty reported the following financial relationships or relationships to products or devices that they or their spouse/life partner have with commercial interests related to the content of this
CME activity:
Pearl Grimes, MD, FAAD
Consulting Fees: Combe
Contracted Research: Allergan, Altana, Inc., Astellas (Formerly
Fujisawa), Galderma, Inamed, SkinMedica, Stiefel Laboratories,
Young Pharmaceuticals
Gary D. Monheit, MD, FAAD, FAACS
Consulting Fees: Allergan, Electro-Optical Sciences, Inc., Medicis,
Genzyme, Revance, Stiefel
Contracted Research: Allergan, Colbar, Contura, Dermik Aesthetics,
Kythera, Ipsen/Medics, Medicis
Wm. Philip Werschler, MD, FAAD, FAACS
Consulting Fees: Allergan, Bioform, Dermik, Medicis
Contracted Research: Allergan, Bioform, Dermik, Medicis
The planners and managers reported the following financial relationships or relationships to products or devices that they or their
spouse/life partner have with commercial interests related to the content of this CME activity:
The following planners and managers, Phyllis Enfanto, RN, Liza
Risoli, and John Russo Jr, PharmD, have no real or apparent conflicts of interest to report.
The following PIM clinical content reviewers, Trace Hutchison,
PharmD; Jan Hixon, RN, BSN, MA; and Linda Graham, RN, BSN,
BA have no real or apparent conflicts of interest to report.
Method of Participation. There are no fees for participating in and
receiving CME credit for this activity. During the period March 16,
2009 through March 15, 2010, participants must 1) read the learning
objectives and faculty disclosures; 2) study the educational activity; 3)
complete the posttest by recording the best answer to each question in
the answer key on the evaluation form; 4) complete the evaluation
form; and 5) mail or fax the evaluation form with answer key to PIM.
A statement of credit will be issued only upon receipt of a completed activity evaluation form and a completed posttest with a score of 70% or better.
Your statement of credit will be mailed to you within 3 weeks.
Media. Printed supplement
Disclosure of Unlabeled Use. This educational activity may contain discussion of published and/or investigational uses of agents that
are not indicated by the US Food and Drug Administration. PIM, EHC
Communications, and Dermik Aesthetics do not recommend the use of
any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of PIM, EHC
Communications, and Dermik Aesthetics. Please refer to the official
prescribing information for each product for discussion of approved
indications, contraindications, and warnings.
Disclaimer. Participants have an implied responsibility to use the
newly acquired information to enhance patient outcomes and their
own professional development. The information presented in this
activity is not meant to serve as a guideline for patient management.
Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible
contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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Facial Shaping: Cheeks are the New Lips
A proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
Faculty
Contents
Moderator
Page 4
Wm. Philip Werschler, MD,
Anatomy of the Aging Face
FAAD, FAACS
Assistant Clinical Professor
Wm. Philip Werschler, MD, FAAD, FAACS
Medicine and Dermatology
University of Washington
Seattle, Washington
Pearl Grimes, MD, FAAD
Clinical Professor of Dermatology
University of California
Los Angeles, California
Page 7
Customizing Treatment to Enhance
the Zygoma and Maxillary Regions:
Case Presentation
Wm. Philip Werschler, MD, FAAD, FAACS
Page 9
Fillers for Facial Enhancement:
Focus on the Mandible and Perioral Region
Gary D. Monheit, MD, FAAD, FAACS
Total Skin and Beauty
Dermatology Center
Associate Clinical Professor
Gary D. Monheit, MD, FAAD, FAACS
Page 12
Department of Dermatology
Ethnic Considerations in the Use of Fillers
University of Alabama at Birmingham
Pearl Grimes, MD, FAAD
Birmingham, Alabama
Dear Colleagues:
“Mirror, Mirror on the wall…” Everyone over the age of 40
facial shaping agents in the various facial treatment zones to
has looked in the mirror and noticed changes in their reflection
regionally augment and enhance the aesthetic appearance of
develop over time. Several major events such as dropping of the
the aging face. Dr. Pearl Grimes complemented these technique-
brows, deepening nasolabial folds and marionette lines, and loss
based presentations with a discussion of ethnic considerations
of youthful cheek volume occur. The definition of the mandibu-
in skin of color to optimize outcomes and minimize complica-
lar sweep, thinning of the lips, and atrophy of the entire perio-
tions with the use of facial shaping agents.
ral region combine to create an aged facial appearance. In addi-
We hope these pages provide guidance and help create a
tion, the malar fat pad begins its descent down the cheek. The
framework that you, the core specialists in dermatology and plas-
result is a drawn, tired look with a vertical lengthening of the
tic surgery, can use to achieve a greater sophistication in using
lower eyelids and a flattened midface on profile.
nonsurgical techniques to address age-related changes and the
Today, nonsurgical techniques, primarily facial shaping
concerns of your patients for mid and lower face rejuvenation.
agents, play both a primary and a complementary role in reversing, disguising, and moderating age-related changes. The opti-
Sincerely,
mal selection and application of these treatment options to
achieve the best results for our patients are major issues of
debate among leading dermatologists and plastic surgeons.
During this symposium held at the 2008 ASCDAS 7th Annual
Meeting & Exhibition in Las Vegas, Dr. Gary Monheit and I
shared our views on enhancing the midface and lower face in
Wm. Philip Werschler, MD, FAAD, FAACS
order to lift and redefine, rebalance, and reproportion the whole
Assistant Professor, Medicine and Dermatology
face. Emphasis was placed on proper product selection and
University of Washington School of Medicine
injection techniques for soft tissue augmentation, and using
Seattle, Washington
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Anatomy of the Aging Face
Wm. Philip Werschler, MD, FAAD, FAACS
Abstract
Today, nonsurgical techniques play a primary and complementary role in reversing age-related changes. However, the optimal
selection and application of these treatment options to ensure the best results for our patients are major issues of debate. Many
anatomical descriptions and ratios have been published that attempt to guide clinicians in planning cosmetic or reconstructive
surgery. In this article, the features that characterize a youthful appearance and the changes that accompany aging are discussed
from a clinical perspective. In addition, the goals and concept of nonsurgical total facial rejuvenation are introduced, as well as
its value as an educational tool to guide patients’ expectations.
Glance at someone, and in that briefest instant you are aware
of their relative age: child, youth, adult, or senior. Regardless of
gender or ethnicity, we are all capable of recognizing the youthful face, because certain characteristics are universally present
(or absent).
Many authors and researchers have published anatomical
descriptions and ratios meant to guide surgeons in planning cosmetic or reconstructive surgery. Much of this information is readily available to patients.1,2 As an alternative, Figure 1 illustrates the
characteristics of a youthful, attractive female face from a clinical
perspective. While the details vary with ethnicity, beginning with
the forehead and eyebrow, there is a pronounced elevation of the
brow above the orbital rim, especially laterally. This results in an
opening of the aperture of the globe, by supporting the upper eyelid, giving a “wide-eyed” alert appearance. The forehead overlying
the frontalis is smooth with a sharply demarcated hairline. The
Figure 1. Characteristics of a youthful face (reproduced with
glabellar complex is smooth in repose and the medial brow is sim-
permission, Irene Matiatos Russo, PhD).
ilarly supported above the bony rim.
Continuing with the nose, the bridge tends to be straight; the
zygoma, forming the structure of a youthful widened midface.
tip or lobule of the nose is heart shaped; the columella, which
The lips are full and well defined with a distinct border separat-
typically hangs inferiorly is well defined, and opens up the
ing the mucosal and keratinized components. Typically the
nasolabial angle. The nasal sidewall to the medial cheek junc-
lower lip has a more pronounced protrusion volume than the
tion — the nasofacial angle — is smooth and rounded, with a roll
upper lip. However, ethnic variability in the shape, size, and pro-
of soft tissue extending up onto the nasal sidewall. A pronounced
portion of lips may be significant.
malar fat pad provides lift and supports the upper lip, commissure, and to some extent the prejowl area. It also tends to push
The mandibular sweep is curvilinear and smooth. It extends
up the lower eyelid, and blends seamlessly laterally with the
from the chin, across the angle of the jaw and up to the ear
4
S u p p l e m e n t t o Th e Jo u r n a l o f C l i n i c a l a n d A e s t h e t i c D e r m a t o l o g y
[ M a r c h 2 0 0 9 • Vo l u m e 2 • N u m b e r 3 ]
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Facial Shaping: Cheeks are the New Lips
A proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
where the earlobes are smooth, full, and rounded with variable
attachment geometry. The zygomata (cheekbones) are well
defined and support the lateral face, providing structural definition. This is important for maintaining balance and symmetry,
especially as the boundary between the face and neck are concerned. The bony midface structure helps define the transition
from face to neck, developing the lateral jawline and medial
transition from chin to horizontal submental neck.
Facial Aging and Volume Loss
As the face ages, the characteristic taut inverted triangular
shape of youth that extends laterally from the top of the zygomata down to the muscularis mentalis point of the chin becomes
inverted. Jowls form, bones and muscles atrophy, the dermis
sags, and the face takes on an upright triangular shape. The
base is the broadened chin and prejowl area, with the sides
framed by the nasolabial folds and marionette lines, culminat-
Figure 2. As the face ages, the characteristic triangle shape (1) that
ing with the apex at the nasal radix (Figure 2).
extends across from the top of the malar zygomata and the point
extending down to the muscularis mentalis of the chin becomes
The changes that underlie these observations are more com-
inverted (5) (reproduced with permission, Irene Matiatos Russo, PhD).
plex than once thought. As the face ages, both hard (bone, cartilage) and soft (muscle, fat, dermis) tissues undergo transformation. In addition to actual volume loss (atrophy, osteopenia)
ment — attempts to aesthetically manage the changes that
there is a progressive alteration of the relative size, distribution,
transform the youthful facial architecture to the typical features
and proportion of tissue. Combined, these effects of biologic tis-
of the aging face. It combines structural and volumizing fillers
sue atrophy and remodeling may be termed “biometric volume
with toxins, lasers and light sources, peels and resurfacing, and
loss and alteration” (BVL/A). As an example of the evolving
skin care with daily sunscreen to meet each patient’s specific
nature of the understanding of BVL/A, recent dissection studies
needs (Table 1).
of facial fat have been published.
We now understand that malar fat is actually comprised of
Table 1.
three separate compartments: medial, middle, and lateral tem-
Nonsurgical Total Facial Rejuvenation (NSTFR):
poral-cheek fat, while the nasolabial fold is a discrete unit with
The five key components
distinct anatomical boundaries The forehead is similarly comprised of three anatomical units including central, middle, and
lateral temporal-cheek fat. Orbital fat is noted in three compart-
Step 1. Neuromodulation of hyperdynamic facial musculature to
reduce dynamic rhytids
ments determined by septal borders. Jowl fat is the most inferior of the subcutaneous fat compartments. Structures previously
referred to as “retaining ligaments” are actually formed by
Step 2. Volume replacement and facial shaping with stimulatory
fillers (poly-L-lactic acid, calcium hydroxylapatite)
fusion points of adjacent septae.3 Drs. Rod Rohrich and Joel
Pessa from the University of Texas Southwestern Medical
Center propose that facial aging is not a uniform and contiguous
Step 3. Focal area enhancement and correction (lips, tear troughs,
fine lines) with replacement fillers (hyaluronic acids, collagen)
process. Rather, it is a combination of volume loss and repositioning between different compartments occurring in a dynamic
process.
Step 4. Resurfacing and tightening of dermal collagen mask utilizing
lasers, light sources, radiofrequency and optical (LLRO)
devices plus chemical exfoliation
Comprehensive Facial Rejuvenation
Nonsurgical total facial rejuvenation (NSTFR)4,5 — a nonsur-
Step 5. Comprehensive skin care regimen, including daily sunscreen
gical approach to facial restoration, rejuvenation, and enhance[ M a r c h 2 0 0 9 • Vo l u m e 2 • N u m b e r 3 ]
S u p p l e m e n t t o Th e Jo u r n a l o f C l i n i c a l a n d A e s t h e t i c D e r m a t o l o g y
5
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Facial Shaping: Cheeks are the New Lips
A proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
ing from removing lines and filling wrinkles to true facial shaping as an art form.
Facial shaping agents — especially injectable fillers — make
it possible to add volume and more closely offset the muscle, fat
and dermal atrophy, and redistribution (BVL/A) that contribute
to biometric volume loss of the face. The succeeding articles in
this series focus on application of fillers to achieve NSTFR.
References
1. Anonymous. Facial Analysis and Symmetry: Section 1.
Ideal Beauty. 2006. Accessed 12/9/08. Available at URL:
http://www.yestheyrefake.net/ideal_beauty.htm
2. Stevens R, Calhoun K. Facial Analysis. Dr. Quinn’s Online
Textbook of Otolaryngology. 1007. http://www.utmb.edu/
Figure 3. Three facial treatment zones, including the upper
otoref/grnds/facial2.html. Accessed December 9, 2008.
facial treatment zone, which overlaps with the middle facial
treatment zone, and in turn overlaps with the lower facial
3. Rohrich RJ, Pessa JE. The fat compartments of the face:
treatment zone and includes the submental and anterior
anatomy and clinical implications for cosmetic surgery. Plast
cervical portions of the neck (reproduced with permission,
Reconstr Surg. 2007;119:2219–2227.
Irene Matiatos Russo, PhD).
4. Werschler WP. The aging face and nonsurgical total facial
restoration. Cosmet Dermatol. 2006;19:3.
The goal of NSTFR is to create balance and symmetry among
three facial treatment zones.5,6 These include the upper facial
5. Werschler WP. Combining advanced injection techniques:
treatment zone, which overlaps with the middle facial treatment
poly-L-lactic acid as the foundation for nonsurgical total facial
zone, which in turn overlaps with the lower facial treatment
rejuvenation and restoration. Cosmet Dermatol. 2007;20
zone and includes the submental and anterior cervical portions
(2 Suppl 1):9–13.
of the neck (Figure 3).
6. Kirn F. Fillers changing cosmetic approach. Skin and Allergy
From this perspective, patients can be taught to approach facial
rejuvenation as a series of treatments that improve each zonal
News. 2008. http://findarticles.com/p/articles/mi_hb4393/
is_/ai_n29403701. Accessed December 9, 2008.
area of the face, rather than individual lines and wrinkles. This
systematic approach offers patients the option of addressing their
7. Werschler WP, Fried R. The key to mastering cosmetic derma-
needs and desires in a prioritized fashion resulting in an overall
tology patient selection. Skin & Aging. 2006; 14(10):42–50.
more satisfying, aesthetically pleasing, naturally balanced visage.
By including the patient in the decision-making process, this
approach may lead to greater patient satisfaction as well.7
Conclusion
Today, cosmetic treatment of the aging face extends beyond
simply using fillers for lines and wrinkles. Rather, the goal is to
restore lost volume in the mid-to-lower face. Indeed, we are mov6
S u p p l e m e n t t o Th e Jo u r n a l o f C l i n i c a l a n d A e s t h e t i c D e r m a t o l o g y
[ M a r c h 2 0 0 9 • Vo l u m e 2 • N u m b e r 3 ]
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Customizing Treatment to Enhance
the Zygoma and Maxillary Regions:
Case Presentation
Wm. Philip Werschler, MD, FAAD, FAACS
Abstract
The patient is a 70-year-old woman with marked changes in the upper, middle, and lower face. The original triangular facial
shape has become trapezoidal. Her goal is to “look good for her age,” especially when compared to her peers. The objective in this
article is to illustrate the appropriate use of a structural, collagen-stimulating filler to achieve dermal structural support and
volume replacement, as the first procedure in a series of nonsurgical total facial rejuvenation treatments.
Several structural fillers are available to achieve dermal structural support and volume replacement. However, calcium hydroxylapatite (Radiesse®) and poly-L-lactic acid (Sculptra®) are most commonly used. General guidelines for the use of these products are presented in Table 1. Technique subtleties include the angle at which
the needle should penetrate the skin, the discrete depth at which the
material should be inserted, the volume deposited per needle pass,
and the technique of needle tracking (thread, fan, depot, serial punc-
Table 1.
Comparative injection technique guidelines
for two commonly used structural fillers:
calcium hydroxylapatite and poly-L-lactic acid2
Product
Technique
Calcium
hydroxylapatite
(Radiesse®)
Injected with a 27-gauge (5/8", 3/4", 1", 11/4") needle
angled at 45°, moving steadily through the
dermis to the juncture of the subcutaneous space
ture, etc.).1 For the vast majority of these devices, the actual volume
Needle angle is adjusted until parallel to the
skin surface, then advanced to the distal
portion of the target area
deposited during each injection is minimal.2
Product is implanted at a constant rate of
needle withdrawal for smooth, even delivery
Case History
This 70-year-old Caucasian woman is retired and lives an
active life in a resort community. She has marked changes in the
0.1 to 0.3mL implanted per injection
upper, middle, and lower face, characteristic of the aging
Multiple injections can be made in an area
process. The original triangular facial shape has morphed to a
Do not overcorrect or inject intradermally
trapezoidal contour. As a first step in her treatment, correction
of the descent of facial soft tissues will help return this patient
to a more aesthetically appealing, age-appropriate appearance.
Following application of a lidocaine and tetracaine topical anesthetic (Pliaglis® Cream), treatment begins by adding poly-L-lactic acid (reconstituted with 5mL sterile water for injection +
3mL 1% lidocaine with epinephrine) to create volume to the
midface over the maxilla, the nasolabial fold, the modiolus and
labial mental sulcus, and finally the lateral canthal region.
Poly-Llactic acid
(Sculptra®)
Tunneling (threading) and depot-type
injections are used. 25 gauge 5/8", 1", 11/2"
or 26 gauge by 5/8"
During tunneling, the skin is made taut
opposite to the direction of injection, and the
needle is introduced at 30° to 40° into the deep
dermal subcutaneous plane
Needle angle is lowered and then advanced
at this level
Ensure that a blood vessel has not been entered
by using a reflux maneuver before injection
Midface
The skin is pinched and the 25-gauge x 11/2-inch needle inserted through the dermis perpendicular to the skin surface (Figure 1).
The needle is then advanced horizontally (parallel to skin surface)
along the subdermal plane. As the needle is withdrawn, poly-L-lac[ M a r c h 2 0 0 9 • Vo l u m e 2 • N u m b e r 3 ]
Deposit 0.1 to 0.2mL as needle is withdrawn,
leaving a visible and palpable elevation of the skin
Avoid deposition into the superficial dermis
Massage after each injection
S u p p l e m e n t t o Th e Jo u r n a l o f C l i n i c a l a n d A e s t h e t i c D e r m a t o l o g y
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Facial Shaping: Cheeks are the New Lips
A proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
Figure 1. The photo shows linear threading
Figure 3. Injecting poly-L-lactic acid
Figure 3. Two injections of poly-L-lactic
and fanning injections in the midface
along the nasolabial fold using a fanning
acid are placed in the mid-dermis, lifting
(A, B, and C) and into the lateral canthal
technique toward the nasal columella and
the alar groove and canine fassa in order
area (D). After inserting the needle through
just superior to the vermillion space (A).
to lift and define the smooth contour of
the dermis perpendicular to the skin surface
A single injection is also made at the level
the area.
and advancing it horizontally along the
of the modiolus (B), and a fanning injection
subdermal plane, poly-L-lactic acid is
at the labial mental sulcus (C).
injected as the needle is withdrawn.
tic acid (~0.3mL per 11/2 inch needle pass) is injected using a linear
Canine Fossa and Alar (Nasofacial) Groove
threading and fanning technique. This process is repeated working
Restoring volume to the alar groove and canine fassa to com-
down the midface area and into the lateral canthal area using a
pensate for bone loss is critical in order to define the smooth con-
fanning technique.
tour of the area and help restore the supporting nature for the
upper lip (Figure 3).
Lateral Canthus and Tear Trough
After a single fanning injection along the lateral canthus, the
Conclusion
patient receives a single injection just below the area of the tear
As the resources, capabilities, and skill sets of cosmetic sur-
trough (Figure 1). The injections are placed in the subdermis, lift-
geons and aesthetic dermatologists continue to develop and
ing the cheek to eyelid junction at the level of the arcus of the skin.
improve, it is time to move on from simply correcting superficial
facial lines and wrinkles toward a more global understanding
Nasolabial Fold
and approach of the dynamics of facial aging. To this end, appli-
In preparation to inject along the nasolabial fold, the needle is
cation of a collagen stimulator structural filler to initiate the
inserted subcutaneously at the level of the modiolus and
treatment regimen provides the foundation for succeeding treat-
advanced along the nasofacial groove. Using a fanning tech-
ments with volume replacement fillers, toxins, lasers, skin care,
nique, poly-L-lactic acid is injected each time as the needle is
and other procedures.3,4
withdrawn. The needle does not exit the skin during the fanning
injection technique.
References
1. Werschler WP, Narurkar VN. Facial volume restoration: selecting
As the needle is redirected toward the nasal columella, it is
necessary to move the tip of the needle across a compound curve.
and applying appropriate treatments. Technique poster. Cosmet
Dermatol. 2006;19(Suppl 2):S1.
This involves lifting and adjusting the tip of the needle as it
advances to maintain its position in the tissue plane and avoid
placing the tip too superficial or deep. The final injection in the
2. Vleggaar D, Forte R. Cosmetic injectable devices: a review of the
injection techniques. J Drugs Dermatol. 2006;5:951–956.
sequence is placed just above the vermillion space (Figure 2).
3. Werschler WP. Combining advanced injections techniques: inteModiolus and Labial Mental Sulcus
A small amount of poly-L-lactic acid is injected at the level of
grating new therapies into clinical practice. Cosmet Dermatol.
2008;21(2):3–6.
the modiolus. This is particularly important when oral commissure correction is a treatment objective. This sequence concludes
with fanning injections at the labial mental sulcus (Figure 2).
8
4. Werschler WP, Smith SA. Mechanism of action of poly-L-lactic acid: a
stimulatory dermal filler. J Drugs Dermatol. 2007;6(1 Suppl):18-20.
S u p p l e m e n t t o Th e Jo u r n a l o f C l i n i c a l a n d A e s t h e t i c D e r m a t o l o g y
[ M a r c h 2 0 0 9 • Vo l u m e 2 • N u m b e r 3 ]
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Fillers for Facial Enhancement:
Focus on the Mandible
and Perioral Region
Gary D. Monheit, MD, FAAD, FAACS
Abstract
It was once thought that the aging process was a result primarily of gravity and sagging skin. Contrary to this commonly held
belief, it is now recognized that facial aging is a complex cumulative response to ongoing atrophy and changes in bone, muscle,
fat, and skin. Successful aesthetic outcomes require sophistication and skill in the proper selection and application of a range
of injectable devices to successfully address these changes. This article compares the commonly used fillers in aesthetic practice
today, with emphasis on selected product characteristics that may affect treatment outcomes.
Facial aging is the cumulative response to complex ongoing
the malar fat pad pushing on an atrophic perioral border. A nat-
changes in bone, muscle, fat, and skin. Accordingly, it is not sur-
ural correction of the phenomenon thus requires more than fill-
prising that familiarity with the use of only one or two fillers is
ing the wrinkle, but rather blending the units requiring volume.
unlikely to achieve optimal facial rejuvenation. To assist cosmetic surgeons and aesthetic dermatologists in becoming more
With regard to specific bony aspects of the face, researchers at
expert in the use of a range of facial fillers, this article com-
Stanford University Medical Center report that the glabellar
pares the commonly used products in aesthetic practice today,
and maxillary angle in males and females decrease with
with emphasis on important differences that affect treatment
increasing age.2 There is also a significant increase in pyriform
outcomes.
aperture area from the young to the middle aged. These findings
suggest that the appearance of the aged face is influenced by
Adipose Tissue and Skeletal Changes Over Time
Recent study results provide insight into the underlying
dramatic changes in bony elements of the midface, coupled with
soft tissue changes.
changes in fat and muscle tissue that contribute to facial aging.
It is now understood that subcutaneous facial fat is partitioned
Categorizing Facial Fillers
into multiple, independent anatomical compartments.1 For
Facial wrinkles are cumulative with aging, and successful
example, malar fat is composed of three separate compartments
treatment requires appropriate selection and application of
(ie, medial, middle, and lateral temporal cheek fat), while the
facial fillers to meet specific needs. The products listed in
nasolabial fold is a discrete unit with distinct anatomical bound-
Table 1 can be grouped into two categories. These include
aries. Orbital fat is partitioned in three compartments deter-
structural fillers, which replace the lost underlying support
mined by septal borders. Some of the structures referred to as
structures. Examples include fat, poly-L-lactic acid, and cal-
“retaining ligaments” are formed simply by fusion points of
cium hydroxylapatite. Volume fillers can be placed over
abutting septal barriers of these compartments. Researchers
structural fillers to correct lines and wrinkles locally.
concluded that facial aging is, in part, characterized by how
Examples include hyaluronic acid and collagen. Table 2 clas-
these compartments change with age. The concept of separate
sifies fillers based on the indication for use and the author’s
compartments of fat suggests that the face does not age as a con-
experience. It illustrates that many products containing
fluent or composite mass, and shearing between adjacent com-
hyaluronic acid are marketed, and although they are inject-
partments may contribute to soft-tissue malposition. For exam-
ed in a similar fashion, they are not completely interchange-
ple, the depth of the nasolabial fold is a result of the descent of
able due to differences in physical characteristics.3
[ M a r c h 2 0 0 9 • Vo l u m e 2 • N u m b e r 3 ]
S u p p l e m e n t t o Th e Jo u r n a l o f C l i n i c a l a n d A e s t h e t i c D e r m a t o l o g y
9
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Table 1.
Introduction of fillers over three decades
1972
Collagen
Zyderm®
1975
2002
2004
2006
2008
Collagen
Collagen
HA
HA
Collagen
Zyplast®
Cosmoderm®
Captique®
Juvéderm®
Evolence®
Fibrel
Cosmoplast
Calcium hydroxylapatite
PMMA
HA + lidocaine
Radiesse®
Artifill®
Prevelle®
®
®
HA
Restylane
®
Poly-L-lactic acid
Hylaform®
Elevess™
Sculptra®
HA: Hyaluronic acid; PMMA: Polymethylmethacrylate
Fat Autograft Muscle Injection
Fat augmentation has been a popular structural filler, despite
nique and massage of the treated area may reduce or eliminate
the occurrence of device-related adverse events such as subcuta-
the fact that longevity and symmetry of the procedure can be
neous papules and nodules.7 In one study where massage signif-
unpredictable. In addition, when large volumes are injected for
icantly decreased the incidence of subcutaneous papules, the
panfacial correction, prolonged edema may result for months.
treated area was massaged by the physician for five minutes following treatment and twice daily by the patient for the next
To address these deficiencies, a relatively new technique
month.8 In the author’s experience, using 10mL to reconstitute
known as fat autograft muscle injection (FAMI) for fat augmen-
the product results in a dilution that works well during injec-
tation was developed. When using FAMI, fat is harvested in an
tions and reduces the risk of developing nodules and papules.
atraumatic and sterile manner, centrifuged, and injected with
specific blunt-tipped cannulae for different muscle groups.4 In
Calcium Hydroxylapatite
one report, 100 patients were injected with volumes ranging
Compared with poly-L-lactic acid, where the response to
from 3 to 63mL of centrifuged fat in a single session. There were
treatment is delayed due to increased collagen deposition, the
no complications, and downtime was 5 to 7 days. Patient satis-
clinical response to calcium hydroxylapatite is related to injec-
faction was reportedly high during the subsequent 3 to 6
tion volume.9 In addition, the microspheres act as a “scaffold” to
months. The authors concluded that FAMI offers the potential
promote collagen in-growth.
for symmetric, long-term results.
5
Five minutes following an injection, the correction appears to
The key to long-lasting fat filling is:
expand. Massage following injection corrects inconsistencies. As
Atraumatic harvesting
treatment-related swelling can mask the degree of actual cor-
•
Microdoplet delivery
rection, additional treatment may have to be delayed until
•
Deep injection with adequate blood
swelling subsides.7 Clinical results last up to 18 months.9
•
supply to support the fat graft
Collagen and Hyaluronic Acid
Poly-L-Lactic Acid
Among the local volume fillers, many of the collagen-based
Volume restoration following injections of poly-L-lactic acid
products have flow characteristics that facilitate injection and
occurs gradually, and is incremental over the course of 3 to 6 ses-
are forgiving if mistakes are made. However, the less viscous
sions. The results last up to 2 years with repeated treatment.
products tend to be more technique sensitive. A gradual thickening of the skin does not occur following injection of collagen.7
The official product information instructs reconstituting the
lyophilized powder using 3 to 5mL of sterile water for injection.
Hyaluronic acids are similar to collagens in their longevity
The author prefers to reconstitute the product in 9mL of sterile
and injection technique. They give correction through pure vol-
water, adding an additional 1mL lidocaine prior to injection.
ume augmentation and immediate effect.
After waiting for at least two hours but up to 72 hours, the
reconstituted product is agitated prior to withdrawing the con-
Hyaluronic acid is particularly useful for patients who may
tents and repeatedly during treatment.6 Correct injection tech-
react to collagen fillers or desire immediate and predictable clin-
10
S u p p l e m e n t t o Th e Jo u r n a l o f C l i n i c a l a n d A e s t h e t i c D e r m a t o l o g y
[ M a r c h 2 0 0 9 • Vo l u m e 2 • N u m b e r 3 ]
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Facial Shaping: Cheeks are the New Lips
A proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
Table 2.
Use of fillers based on the author’s experience
Superficial fine lines
Primary Indication
Occasional
Never
Zyderm
Juvéderm Ultra
Perlane®
Captique
Radiesse®
®
®
Cosmoderm
®
Evolence Breeze®
®
Restylane®
Sculptra®
Artefill®
Medium depth grooves
Zyplast®
Cosmoplast
Juvéderm® Plus
Sculptra®
Radiesse
Silicone®
®
Juvéderm® Ultra
®
Perlane®
Artefill®
Perlane®
Restylane®
Zyderm®
Juvéderm Ultra Plus
Sculptra
Cosmoderm®
Radiesse®
Silicone®
Restylane®
Deeper folds
®
®
Artefill
®
Evolence®
ical improvement, without the need to wait several weeks for
4. Butterwick KJ. Fat autograft muscle injection (FAMI): new
the results of skin tests. A range of hyaluronic acid-containing
technique for facial volume restoration. Dermatol Surg. 2005;
products is available. Because each differs in rate of cross-link-
31:1487-1495.
10
ing, size, formation of hyaluronic strands or particles, and concentration, they should be injected into different dermal levels.
5. Butterwick KJ, Lack EA. Facial volume restoration with the
For example, Perlane should be injected deeply into the dermis.
fat autograft muscle injection technique. Dermatol Surg.
Restylane® is injected into a slightly higher dermal plane, as is
2003;29:1019-1026.
®
Juvederm®, which delivers a soft, natural result because of its
6. Sculptra
flow characteristics.
Official
Prescribing
Information.
Dermik
Laboratories. A business of sanofi-aventis U.S. LLC.
Bridgewater, NJ 08807. June 2006.
Conclusion
A variety of injectable fillers have become available over more
than three decades. These products are not identical. Each
7. Vleggaar D, Forte R. Cosmetic injectable devices: a review of
requires an appreciation of its characteristics and a skilled
the injection techniques. J Drugs Dermatol. 2006;5:951-956.
injection technique, as subtle variations directly influence the
8. Unemori P, Eden C, Conant M. Twice-daily massage can
cosmetic result.
reduce papule formation among HIV-infected patients receivReferences
ing poly-L-lactic acid injection. Interscience Conference on
1. Rohrich RJ, Pessa JE. The fat compartments of the face:
Antimicrobial Agents and Chemotherapy, 2005; Washington,
anatomy and clinical implications for cosmetic surgery. Plast
DC, USA.
Reconstr Surg. 2007;119:2219-2227.
9. Sengelmann RD. Exploring Management Options for Facial
2. Shaw RB Jr, Kahn DM. Aging of the midface bony elements:
Lipoatrophy: Focus on Semipermanent Fillers. Medscape.
a three-dimensional computed tomographic study. Plast
2006. http://www.medscape.com/viewprogram/5213. Accessed
Reconstr Surg. 2007;119:675-681.
December 11, 2008.
3. Andre P. Hyaluronic acid and its use as a “rejuvenation” agent
10. Grimes P. Aesthetics and Cosmetic Surgery for Darker Skin
in cosmetic dermatology. Semin Cutan Med Surg. 2004;
Types.
23:218-222.
2007:225.
[ M a r c h 2 0 0 9 • Vo l u m e 2 • N u m b e r 3 ]
Conshohocken, PA: Wolters
Kluwer
S u p p l e m e n t t o Th e Jo u r n a l o f C l i n i c a l a n d A e s t h e t i c D e r m a t o l o g y
Health;
11
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Ethnic Considerations
in the Use of Fillers
Pearl Grimes, MD, FAAD
Abstract
There is no question that injectable fillers are becoming substantially more popular among individuals with darker skin. In this
article, cultural considerations, injection techniques, and safety and tolerability issues during nonsurgical total facial rejuvenation of people of color are reviewed.
All racial ethnic groups have a keen interest in procedures to
Hispanics (45%). Asian Americans are most likely receiving
enhance aesthetic appeal. For many minorities, cosmetic sur-
blepharoplasty or eyelid surgery (39%), while Caucasians
gery is no longer viewed as a sign of self-hatred or a rejection of
are evenly split among rhinoplasty (27%), blepharoplasty,
racial identity. It is about enhancing natural beauty.1
(24%) and face lifts (26%).3
Cultural Considerations
Growth in Aesthetic Procedures
It is important to understand what is culturally acceptable to
The overall frequency of cosmetic procedures among
patients of color and what is desired. Individualization is key, as
patients of color has increased to about 20 percent and is
there is natural variation that can affect treatment decisions.
climbing.2 Data from the 2007 American Society for Facial
For example, patients may want to maintain the features they
Plastic and Reconstructive Surgery survey of members sup-
view as part of their ethnicity. Also, some races are more likely
port this view. Over the past eight years, the numbers of cos-
to opt for certain cosmetic procedures than others. Lip augmen-
metic surgical patients have increased among African
tation is common among Caucasians. Yet, few African American
Americans (40%), Hispanics (19%), and Caucasians (7%). Only
women request this procedure. Once these factors are consid-
among Asian Americans was there a reduction in cosmetic sur-
ered, clinicians must select the appropriate treatment(s), and
gical patients (-8%).3
adjust their application to achieve an aesthetically pleasing yet
culturally acceptable outcome.
Injectable fillers and botulinium toxin injections are among
the cosmetic procedures most commonly performed in darker
Considerations in Injection Technique
racial ethnic groups. Other procedures reflect a broad range of
It is important to optimize correction techniques. To do other-
needs and aesthetic expectations. They include chemical peels,
wise is a disservice to the patient. Techniques such as cross-
microdermabrasion, laser hair removal, liposuction, and breast
hatching and fanning are used for optimal correction of moder-
implants. Nonablative resurfacing procedures, including intense
ate-to-severe nasolabial folds. Considering the propensity for
pulsed light and radio-frequency procedures are also increasing
darker skin to develop post-inflammatory hyperpigmentation,
in popularity.
linear threading is preferred to serial puncture. However, there
1
are some areas of the face (eg, marionette lines) where serial
With respect to surgical procedures, African Americans
are most likely to undergo rhinoplasty (63%), as are
12
puncture is performed, without increasing the likelihood of causing post-inflammatory hyperpigmentation.
S u p p l e m e n t t o Th e Jo u r n a l o f C l i n i c a l a n d A e s t h e t i c D e r m a t o l o g y
[ M a r c h 2 0 0 9 • Vo l u m e 2 • N u m b e r 3 ]
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Facial Shaping: Cheeks are the New Lips
A proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
When using cross-hatching and fanning for optimal correction
3. AAFPRS. American Academy
of
Facial
Plastic
and
of moderate-to-severe nasolabial folds, it is important to opti-
Reconstructive Surgery. 2007 Statistics on Trends in Facial
mize the correction. To do otherwise is a disservice to the
Plastic Surgery. file:///%20MCR%20/EHC/EHC0805%20ASC-
patient. Prior to injecting, the patient should be advised that a
DAS%202008/AAFPRS%20survey.html. Accessed December
full correction with a little bruising is desired versus using
12, 2008.
insufficient filler to minimize bruising. Bruising can be treated
4. Grimes PE, Few JW. Injectable fillers in skin of color. In:
later, if necessary.2
Carruthers J, Carruthers A, eds. Procedures in Cosmetic
Dermatology Series: Soft Tissue Augmentation. 2nd ed.
Safety and Tolerability
Prescribing information for fillers carries a safety warning
Saunders; 2007:143-150.
regarding the susceptibility to keloid formation and hypertrophic scarring. Yet despite this statement, the safety profile
in every study has been outstanding for skin of color. Except
for a slightly higher incidence of post-inflammatory hyperpigmentation, no data suggest that patients of color are at an
increased risk of developing keloids or hypertrophic scars. In
addition, the incidence of post-inflammatory hyperpigmentation and hypopigmentation is minimal.1,4 In the author’s experience, dermal fillers tend to have increased longevity in skin
of color.2
Conclusions
The key to successful facial aesthetic procedures is the same
for all patients. It begins with knowledge of patients’ cultural
expectations as well as their treatment objectives and concerns.
The clinician must analyze each face and be skillful in the
selection and application of products that will best achieve the
desired outcome. Although more data are needed, people of
color do not appear to be at increased risk of hypersensitivity
reactions, bruising, keloids, or hypertrophic scars. As with
Caucasians, the goal of treatment in people of color is to
counter the effects of aging and achieve a natural youthful
appearance.
References
1. Grimes PE. Fillers in ethnic skin. In: Aesthetics and Cosmetic
Surgery for Darker Skin Types. Conshohocken, PA: Wolters
Kluwer Health; 2007.
2. Grimes PE, Schneider LK. Injectable fillers in skin of color: An
expert interview with Pearl E. Grimes, MD. Aesthetic Medicine
CME/CE Collection: Volume 1; 2008. http://www.medscape.com/
viewarticle/572083. Accessed December 12, 2008.
[ M a r c h 2 0 0 9 • Vo l u m e 2 • N u m b e r 3 ]
S u p p l e m e n t t o Th e Jo u r n a l o f C l i n i c a l a n d A e s t h e t i c D e r m a t o l o g y
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Facial Shaping: Cheeks are the New Lips
A proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
Evaluation Form
A proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
Project ID: 5945 ES 40
To assist us in evaluating the effectiveness of this activity and to make recommendations for future educational offerings, please
take a few minutes to complete this evaluation form. You must complete this evaluation form to receive acknowledgment
for completing this activity.
Please answer the following questions by circling the appropriate rating:
1 = Strongly Disagree
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5 = Strongly Agree
Extent to Which Program Activities Met the Identified Objectives
After completing this activity, I am now better able to:
Specify nonsurgical treatment options that enhance the mid-face and lower face in order to lift and redefine,
rebalance, and re-proportion the whole face.
12345
List the indications for the use of dermal fillers for nonsurgical treatment of facial biometric
volume loss and alteration.
12345
Describe proper injection techniques for facial shaping agents including both replacement and stimulatory fillers.
12345
Explain ethnic considerations to optimize outcomes with the use of facial shaping agents.
12345
Overall Effectiveness of the Activity
The content presented:
Was timely and will influence how I practice
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Enhanced my current knowledge base
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Name one thing you intend to change in your practice as a result of completing this activity:
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As part of our continuous quality improvement effort, we conduct postactivity follow-up surveys to assess the
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Facial Shaping: Cheeks are the New Lips
A proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
If you wish to receive acknowledgment for completing this
4. Select the false statement for injecting
activity, please complete the post test by selecting the best
calcium hydroxylapatite.
answer to each question, complete this evaluation verification of
a) 0.1 to 0.3mL implanted per injection
participation, and fax to: (303) 790-4876.
b) Multiple injections can be made in an area in
order to overcorrect
Post Test Answer Key
1
2
3
4
c) Do not inject intradermally
5
6
7
8
9
10
d) Answers a and c are incorrect
5. Select the false statement for injecting
Request for Credit
Name ___________________________________________________________________
Degree __________________________________________________________________
poly-L-lactic acid.
a) Deposit 0.1 to 0.2mL as needle is withdrawn, leaving
a visible and palpable elevation of the skin
b) Massage after each injection
Organization ___________________________________________________________
c) Aim for deposition of product into the superficial dermis
Specialty _______________________________________________________________
d) Answers a and c are incorrect
Address ________________________________________________________________
City____________________________________ State _______ ZIP _____________
6. Identify the filler that is not considered
“structural.”
Telephone ____________________________ Fax ____________________________
a) Collagen
Email ___________________________________________________________________
b) Fat
Signature ___________________________________________ Date ____________
c) Poly-L-lactic acid
d) Calcium hydroxylapatite
For Physicians Only
I certify my actual time spent to complete this
7. Hyaluronic acids are similar to collagens in
educational activity to be:
longevity, injection technique, and achieving
I participated in the entire activity and claim 1.0 credits.
correction through volume augmentation and
I participated in only part of the activity
immediate effect.
and claim ____ credits.
a) True
b) False
Quiz
1. Select the changes that are characteristic
8. Select the cosmetic procedures most commonly
of the aging face.
performed in darker racial ethnic groups.
a) Transformation of bone and cartilage
a) Chemical peels, microdermabrasion
b) Transformation of muscle, fat, and dermal tissues
b) Liposuction and breast implants
c) Volume loss (atrophy, osteopenia)
c) Injectable fillers and botulinium toxin injections
d) All of the above are correct
d) Laser hair removal
2. Select the correct statement describing nonsurgical
9. Considering the propensity for darker skin to
total facial rejuvenation (NSTFR).
develop post-inflammatory hyperpigmentation,
a) A nonsurgical approach to facial restoration,
linear threading is preferred to serial puncture.
rejuvenation, and enhancement
b) Combines fillers with toxins, lasers and light sources,
a) True
b) False
peels and resurfacing, and skin care
c) Answers a and b are correct
d) Focuses on the correct use of volumizing
(not structural) fillers
10. Select the accurate statement for using
fillers in people of color.
a) Slightly higher incidence of post-inflammatory
hyperpigmentation
3. Three facial treatment zones do not include the
submental and anterior cervical portions of the neck.
a) True
b) False
b) Increased risk for keloids or hypertrophic scars
c) Post-inflammatory hyperpigmentation and
hypopigmentation is minimal
d) Answers a and c are correct
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