Aesthetic Surgery of the Periocular Region and Face

Overview of the Layers of the Face: Descent and Deflation

Let’s look at the facial anatomy from a very simple layered point of view. Sometimes you hear the explanation that the face, like an onion, has many layers. I apologize for the simple-mindedness of this, but sometimes simple is good. From deep to superficial think of the face as layers:

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  Bony skeleton

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  Deep fat pads

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  Superficial musculoaponeurotic system (SMAS)

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  Superficial fat pads

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  Skin

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  Retaining ligaments

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    Extending through many layers

A big part of the shape of your face is related to the underlying bony skeleton . This is fairly obvious, but keep this in mind, because the majority of procedures discussed have to do with the soft tissue only. Changing the fabric on the sofa does not change the shape of the couch.

There is a layer of deep fat that cushions and allows the overlying muscle layer to move easily. This fat layer also provides some fullness to the facial features. The ROOF and SOOF (retroorbicularis and suborbicularis oculi fat) are examples of this deeper fat tissue. Named and unnamed fat pads and layers exist all across the face, so that the muscle is not densely attached to the periosteum.

You are well aware of the SMAS , the fibromuscular layer composed of the mimetic muscles and the fibrous tissue that coordinates the movements of facial expression. The SMAS essentially covers the entire head.

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  SMAS: across the face

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  Temporal parietal fascia (TPF): across the temple

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  Frontalis muscle and galea aponeurotica: across the calvarium

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  Platysma muscle: extending into the neck

A superficial layer of fat exists between the skin and the SMAS. The organization of these fat pads is described. This fat provides many of the smooth contours of the facial surface. For the most part, these fat pads are firmly attached to the deep layers of the skin.

The skin is made up of the subcutaneous fat, dermis, and epidermis. The skin contains the adnexae, hair follicles, and sweat and oil glands. Loss of collagen, elastin, and the ground substance contribute to the thinning, stretching, and surface changes in color and texture.

You can compare the layers of an onion to the layers of the face. In some areas, the layers are quite adherent (near the stalk and root). In other areas, the layers are more loosely attached. The same is true of the face. The areas of adherence are known as the retaining ligaments . Some of these attachments extend from the bone to the skin; they are the osseocutaneous ligaments , sometimes called the true retaining ligaments. Other attachments occur between the muscle fascia layers and the skin, called the false retaining ligaments. These “ligaments” anchor the skin to the deeper layers in more or less the same arrangement in all faces. The next paragraph should put these anatomic concepts into the context of aging changes.

You can expect aging changes to occur in all these layers. As we have discussed several times, it is easiest to think of aging as a loss of fullness (atrophy or deflation) and a stretching of tissues (descent). The face gets thinner as we age, that is, it loses its baby fat. The tissues sag to some degree. Faces become heavier, fuller at the jaw, squarer, and less heart shaped with aging. Recall that the attachments of the soft tissues to the bone and underlying muscles are defined by the retaining ligaments; therefore, some parts of the face tend to sag more than others. A great example is the formation of jowling along the mandible. The mandibular osseocutaneous ligament attaches the skin to the underlying bone, so there is little drooping of the skin at that point. The lax and deflated tissues superior and lateral to this point hang over the ligament, creating the jowling that we see as our patients age. The position and strength of the retaining ligaments throughout the face determines, to a large degree, how the soft tissues drape, forming the hills and valleys of aging. It is rather like your grandfather’s favorite armchair, with button tufting making indents in the leather at certain points. Over time the leather stretches out and the padding thins but the buttons stay in place ( Figure 7.2 ). This is somewhat of an oversimplification, but it is helpful for me when evaluating the aging changes in my patients. The next step is to translate these anatomic changes to procedural steps that can rejuvenate the face. Is the underlying bone structure a problem? Can we improve the situation with more fullness? How much tightening is necessary? The retaining ligaments are reviewed in more detail later in this section.

Next, we review the anatomy in a bit more detail. There is some necessary redundancy to our discussion, so I apologize for that. As with most of the topics we are discussing, it helps to get the big picture first and then move on to the details. Once you understand the anatomic concepts, you find that the procedures about which you want to learn make more sense and are easier to do, and you understand how to tailor a procedure to your patient’s particular anatomy and goals.

The Skin

In Chapter 2 we discussed the facial anatomy in some detail. Here, we review features that you can easily apply to the sags, bags, and wrinkles approach to the evaluation and treatment of your patients. We start at the surface and work our way inward.

The skin has two layers, the epidermis and the dermis. The epidermis rapidly turns over, with young cells originating at the deep basal layer and maturing as they migrate toward the surface. As the cells move upward, they lose their nuclei, flatten, and eventually become keratinized. Pigment cells are scattered in the deep layers of the epidermis. With aging, the epidermis thins. A generalized loss of pigment occurs, but at the same time, focal areas of pigmentation, dyschromias , occur. Premalignant and malignant changes include actinic keratosis, basal cell carcinoma, and squamous cell carcinoma. Laser resurfacing (the ablative type) and chemical peeling remove the epidermis, which therefore removes abnormal surface cells and improves color changes. The real improvement that results from these procedures comes in improvements in the underlying dermis, however.

The dermis is a connective tissue layer made of collagen and elastin fibers surrounded by a watery mixture known as the ground substance . The dermis also contains fibrous cells and the skin adnexae , that is, the hair follicles and oil and sweat glands . We discuss a variety of lesions related to the adnexae in Chapter 11 . Blood vessels, lymphatics, and nerves also travel within the dermis.

There are two layers of the dermis: the more superficial papillary dermis and the deeper reticular dermis . Aging changes damage the collagen and elastin fibers of the dermis. The ground substance of the skin, hyaluronic acid, reduces. These changes result in a loss of dermal thickness and elasticity. Loss of the dermal thickness allows normal and telangiectatic vessels to become apparent.

The loss of skin elasticity and fullness causes wrinkles , or rhytids , to form. Wrinkles that form while the underlying muscle contracts are called dynamic wrinkles . Over time, the repeated folding of the skin creates lines that remain without any underlying muscle contraction, known as adynamic wrinkles . Resurfacing and peeling procedures remove the epidermis and cause thermal damage to the dermis. Repair of the damage results in thickening of the dermis and the return of some elastin and collagen fibers, resulting in a thicker, more elastic skin—and fewer wrinkles. A new layer of epidermis grows back from regenerative cells derived from the underlying adnexae. The new epidermis is lighter in color, with fewer patchy dyschromias and premalignant changes. Botulinum injections relax the underlying muscles, resulting in an improvement of dynamic wrinkling. When adynamic wrinkles remain, injectable filler agents plump up the dermis and fill in the creases.

A part of facial deflation is a loss of subcutaneous fat in aging. The cherubic look of the youthful face is lost, especially in patients who are of normal weight or tend to be slim (see Figure 7.2 ). In heavier patients, some of the typical deflation features may not be obvious and the patient may have a more youthful facial appearance. Injection of filler materials or autologous harvested fat can mask the loss of facial fat, giving a more rounded, youthful look.

Superficial Facial Fat Pads

In Chapter 2 we discussed the fat pads of the face. You are familiar with the SOOF (suborbicularis fat) and the ROOF (retroorbicularis oculi fat) that contribute to the graceful transition from the eyelids to the cheek and brow. Certainly, these are affected by the aging process. In the last chapter, you saw how a simple functional browplasty improves the transition from the upper eyelid to the forehead. In this chapter, we see how lower eyelid blepharoplasty and midface lifts do the same for the lower eyelid–cheek junction. First, let me remind you about the fat pads of the face and the osseocutaneous ligaments that form lines and patches of support for the fat and other soft tissues.

The fat pads of the face are shown in Figure 7.3 . The boundaries of the fat pads are closely related to the underlying retaining ligaments of the face. These ligaments extend from the bone through the soft tissue layers of the face to attach in the facial skin. Similar fibrous bands extend from the underlying muscles to the skin. As I explained above, that means that some parts of the facial soft tissues are more tightly adherent to the facial skeleton than others. This allows some parts of the face to sag more than others with age. The loss of fullness of the facial fat and this differential sagging accounts for a big part of the aging facial contours.

SMAS and Related Deep Fat Pads

We have devoted a lot of attention to the concept of the SMAS and the related structures of the galea, temporal parietal fascia, and platysma muscle. Now we go into a bit more detail about the SMAS itself. Remember that the SMAS is a fibromuscular layer that invests the muscles of facial expression. It is a true anatomic structure but not as distinct as other planes with which you may be more familiar. In some patients, it is more distinct than others. The thickness of the SMAS also varies with regard to the location in the face. The SMAS is well formed over the parotid gland and fuses with the parotid fascia. As you move toward the melolabial fold, *

* The melolabial fold is also known as the nasolabial fold. Many facial anatomists prefer the term melolabial fold because the term more accurately describes involutional facial anatomy ( melo = cheek, labial = lip). The fold forms as lax, redundant cheek tissue falls over the more rigidly fixed lip tissue. Consequently, we use the term melolabial fold throughout the text.

the SMAS becomes thinner. In the perioral area, the SMAS is very thin. The melolabial fold forms where condensations of the fascia overlying the masseter muscle extend through the SMAS, attaching to the skin. Inferiorly, the SMAS is continuous with the platysma muscle as it crosses the mandible.

Pads of fat exist anterior and posterior to the SMAS overlying the zygoma. The malar fat pad is a collection of fat on and within the anterior surface of the SMAS over the malar eminence (part of the facial fat pad system discussed above). A full, normally positioned malar fat pad contributes to the high full cheek in children and young adults.

A deeper plane of fat exists behind the orbicularis muscle overlying the inferior rim (suborbicularis oculi fat pad [SOOF]) and extending superiorly over the lateral rim to overlie the superior orbital rim (retroorbicularis fat pad [ROOF]) ( Figure 7.4 ). The fullness of the lateral portion of the superior orbital rim seen in youth is due to a robust ROOF.

The malar fat pad, ROOF, and SOOF allow the SMAS to move freely while maintaining an attachment with the underlying bone. For this reason, I consider them to be a part of the SMAS. Lifting of the forehead by tightening the galea repositions the ROOF. Lifting the midface (cheek) by tightening the SMAS has a similar action, elevating the SOOF and malar fat pads. Both procedures are part of rejuvenation surgery. There are many other deep fat pads that are not covered here.

The deep and superficial fat pads of the face become important as you learn how to restore facial fullness or volume in rejuvenating procedures. Rohrich and Pessa showed that the superficial fat of the face is partitioned as distinct anatomic compartments (it is worth reading this paper) (see Figure 7.3 ). For example, the nasolabial fold is a distinct anatomic compartment. The malar fat pad is composed of three separate compartments: medial, middle, and lateral temporal cheek compartments. Similarly, the forehead is composed of three compartments.

As you get familiar with this anatomy you notice that some of the retaining ligaments are formed by fusion points of adjacent boundaries of the fat compartments extending the bone through the soft tissues of the face. As you understand the relationship between the fat compartments and how these ligaments support or hold the fat into position against the bone, you can appreciate how the sags and bags of the face start to form with aging. If you combine this concept with aging changes such as the loss of facial bone, loss of facial fat, and thinning of the deep skin layers and the textural and color changes of the skin surface, you can begin to understand the process of facial aging. These aging changes are influenced by genetics and external factors (think sunshine and smoking). This understanding is important because it provides the framework for your work in facial rejuvenation!

Time, genetics, and environment cause our known aging changes:

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  Time

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    Loss of facial bone

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    Loss of connective tissue support and facial fat

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    Descent

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    Deflation

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    Loss of deep skin elasticity and thickness

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    Changes in the texture and color of superficial skin

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  Genetics

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    “I am starting to look like my father”

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  Environment

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    Sun

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    Smoking

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    Alcohol use

Let’s discuss the retaining ligaments of the face in a bit more detail. If your interests lie mainly in periocular procedures, you may want to skip this next section. If you have already had enough detail, skip this section.

The Retaining Ligaments

There are areas where the SMAS is particularly well attached to the underlying and overlying tissues. The lateral portion of the face is fairly immobile. The medial portion of the face, surrounding the oral, orbital, and nasal cavities, is fairly mobile. In general, broad attachments of the deep tissues to the skin form tight adhesions laterally, for example, over the parotid. More or less, along a vertical line, separating the medial from the lateral face is a series of anchors that support those mobile structures ( Figure 7.5 ).

Similarly, there are strong areas of attachment of the soft tissues along the borders of the facial cavities (think arcus marginalis along the orbital rim [a part of the orbital retaining ligament]). These supporting elements exist with varying degrees of density, area, and shape. They have been called ligaments, septa, and adhesions, depending on the robustness of the attachment. Importantly, rather than thinking of these structures as discrete individual anatomic structures, think of them as variable amounts of tethering or anchoring of the facial tissues to the underlying structures and bone. As you become experienced with facial dissections, you notice that some layers of tissue are more densely attached to the underlying structures than others. These attachments are formed by the retaining ligaments; they are like the upholstery tufting of the face that forms the familiar hills and valleys of the aging face. To make matters confusing, different authors use different names for the same structures. It is enough to realize that there is a consistent pattern of anchors supporting the soft tissues of the face.

For now, the concept of some parts of the soft tissue being more attached to the underlying structures is probably enough, but if you are keen to learn more, it is worth identifying the most important of these. True retaining ligaments extend from the periosteum through the SMAS to the dermis (osseocutaneous ligaments). False retaining ligaments are broader, less well defined areas of thickened fibrous tissue that connect the deep fascial layers to the more superficial fascial layers within the skin. These anchor points tend to stay fixed with aging. The ligaments are identified as:

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  Midface

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    Orbital osseocutaneous ligaments are near the frontozygomatic suture; they attach the eyebrow to the dermis, a function also called lateral orbital thickening.

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    Zygomatic osseocutaneous ligaments (McGregor’s patch) are at the periosteum at the inferior border of the zygoma, just posterior to the origin of the zygomaticus minor muscle to the dermis.

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    Septum or ligaments along the orbital rim; the inferior ligament is the orbitomalar ligament or orbital retaining ligament, which attaches to the dermis.

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  Lower face

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    Mandibular osseocutaneous ligament extends from the periosteum anterior to the depressor anguli oris origin to the dermis, forming the anterior border of the jowl.

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    Masseteric cutaneous ligaments are false retaining ligaments that arise from the anterior border of the masseter muscle and insert into the SMAS and overlying dermis of the cheek.

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  Lateral face

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    Platysma-auricular ligament is fibrous tissue in the region where the lateral temporal cheek fat compartment meets the posterior auricular fat compartment.

Over time, neighboring less well anchored tissues tend to sag over these fixed points, creating the characteristic facial folds of aging. In the midface, the SMAS is tightly attached to the parotid gland, along the inferior and lateral orbital rim and near the frontozygomatic suture. Note that there is little sagging of the lateral portion of the face. The regions of attachment are referred to as retaining ligaments, which is something of a misnomer because they do not connect bone to bone. Rather, osseocutaneous ligaments attach the SMAS and skin to underlying bone. At the melolabial fold, false retaining ligaments extend from the fascia overlying the masseter muscle to the skin.

In the forehead, galea laxity allows the ROOF and the eyebrow to droop over the superior orbital rim, creating the typical temporal brow droop. In the lateral midface, the malar and suborbicularis fat pads descend in a characteristic manner, creating the malar triangle laterally ( Figure 7.6 ). Medially, the masseteric ligaments attenuate and the cheek drops, creating the melolabial fold. As the cheek falls, the soft tissues anchored along the inferior rim (orbitomalar ligament or orbicular retaining ligament) on the inferior orbital rim lose their padding, and the characteristic deepening of the nasojugal fold occurs (so-called tear trough deformity). As the orbital septum thins, fat prolapses forward. With this characteristic midfacial aging, the youthful cherubic single soft curve of the cheek falls and forms the double convexity ( Figure 7.7 ) of the eyelid–cheek profile.

In the lower face, the descending cheek hangs over the mandibular retaining ligament along the mandible. The fat pads of the mandible (superior and inferior jowl fat compartments) drape over the ligament inferiorly, forming the jowl. More specifically, the mandibular retaining ligament arises just anterior to the origin of the depressor anguli oris muscle. The superior and inferior fat compartments overlying the mandible drape over the ligament anchored just anterior to the depressor anguli oris, which is the most medial extent of the jowl. The labiomental fold continues from the corner of the mouth inferiorly, with the most medial extension of the jowl hanging over the ligamentous attachments, producing the marionette lines.

As you study the contours of the aging face, you understand the relationship of the retaining ligaments and fat pad to the characteristic aged contours of the face (think of the upholstery tufting example, above). As discussed in the section above, we can use this information to our advantage. In cases where we want to improve a prominent nasolabial fold, we can fill or volumize the medial fat pad above the fold to lift the tissues superiorly. In the past, the typical treatment was injecting into the crease, which did not improve the cheek contour and only added weight to an already descending face. We want to keep the volume full superiorly to frame the eyes. Botulinum injection into the depressor anguli oris muscle reduces the downward slant of the corner of the mouth, producing a better resting and active smile. You know that the mandibular ligament arises just anterior to the depressor anguli oris. Because the labiomental line is formed from the ligament, you can easily find the depressor muscle, just posterior to the labiomental line, at the most medial extension of the jowl. During an operation, there may be times when we may want to sever a ligament to allow the soft tissue to move. For example, cutting the orbital retaining ligaments allows a large cheek flap to rotate into position to repair a lower eyelid defect (more in Chapter 12 ). You should know that the idea of cutting or preserving the facial retaining ligaments during facelift surgery has proponents in both camps.

Superficial Musculoaponeurotic System (SMAS)

In Chapter 2 and in preceding paragraphs we spent a great deal of energy talking about the muscles of facial expression and the investing fibrous layer known as the SMAS (superficial musculoaponeurotic system). Let’s look at them in a bit more detail. The SMAS layer coordinates facial movements by physically linking the mimetic muscles together. Strong fibers attach the SMAS to the underlying bone and in turn attach to the skin itself (osseocutaneous retaining ligaments) ( Table 7.1 ). These ligaments are strongest along the inferior and lateral orbital rim extending onto the zygoma, as well as along the mandible. Lax tissues hang over the sturdy attachment points. Combined with the loss of associated fatty tissues, this process is responsible for the characteristic sags and bags of the face, that is, the deepening of the melolabial fold, jowling, and marionette lines . The anatomic extensions of the SMAS (i.e., the temporoparietal fascia, galea, and platysma muscle) develop laxity, as well. Temporal brow drooping and platysmal banding are the manifestations of this process.

Tightening of the SMAS layer and its counterparts is the basis of modern face, neck, brow, and temple lifting procedures ( Figure 7.8 ). Consider the SMAS and its equivalents when you are doing the procedures that we discuss throughout this book. It is a useful concept and you will come to appreciate its significance.

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  Upper blepharoplasty: orbicularis muscle

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  Lower blepharoplasty: orbicularis muscle and SMAS

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  Browplasty: frontalis muscle

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  Forehead lift: frontalis, procerus, and corrugator muscles and temporoparietal fascia

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  Midface lift: orbicularis muscle and SMAS

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  Facelift: SMAS and platysma muscle

As the SMAS relaxes, its associated fat pads fall, contributing to the sags and bags we have just discussed. A deep plane of fat (SOOF) exists behind the orbicularis muscle overlying the inferior rim and extends superiorly over the lateral rim to overlie the superior orbital rim (ROOF). The fullness of the lateral portion of the eyebrow and the tissues over the superior orbital rim seen in youth are due to a full and well-supported ROOF. Drooping of the ROOF is a cause of temporal eyebrow ptosis and is corrected with the browplasty or forehead lift operation. The malar fat pad is a collection of fat on and within the anterior surface of the SMAS over the malar eminence (see Figure 7.5 ) . A full, normally positioned malar fat pad contributes to the high full cheek in children and young adults. You can appreciate that as we lift the SMAS and its equivalents, the adjacent fat pads and other soft tissues become elevated with the SMAS.

The following discussion shows that the descent of the SOOF and the malar fat pad is a characteristic feature of facial aging, the formation of the so-called double convexity deformity. These soft tissue changes are accompanied by slow atrophy of the midface and mandible.

In the child, the facial profile from the lower eyelid to the jawline extends inferiorly in a smooth convexity. Over time, this single curve changes into a series of curves. Here is what happens. Let’s look at the development of the cheek convexity first. As the SMAS stretches in the lateral midface, the malar and suborbicularis fat pads fall (descend) in a characteristic manner, creating the malar mound laterally. Medially, the cheek descent causes the inferior orbital rim to lose its soft tissue padding (part of the deflation look). This used to be referred to as a long lower eyelid. Now the term skeletonization of the lower orbital rim is in vogue, emphasizing the loss of tissue over the inferior orbital rim. The feature most commonly emphasized is deepening of the nasojugal fold (tear trough deformity). As the cheek tissues descend inferiorly and medially, the melolabial fold deepens. The eyelid double convexity develops as the orbital septum thins and fat prolapses forward. The aging adult develops a bulge of fat prolapse in the lower eyelid, a hollow at the rim, and a bulge of drooping cheek, the double convexity (refer back to Figure 7.7 ).

Facial Bone Remodeling

In this chapter, we discuss primarily the soft tissue changes that occur in the face. You should know that there are accompanying aging changes of the facial skeleton. You are unconsciously aware of this. Compare the next few of your senior and junior patients. Most of the changes occur in the maxilla and mandible, with a general increase in the width and depth of the face. The orbits increase in size. The maxilla decreases in size, which accentuates the development of the melolabial fold and double eyelid convexity. Posterior shrinkage of the maxilla leads to loss of support of the lip and periorbital wrinkling. This is accompanied by a drooping of the nasal tip. Similar resorption of the mandible results in shrinkage of the alveolar ridge and loss of chin projection ( Figure 7.9 ). These changes start to appear in the sixth decade; they gradually become more pronounced in women than in men. There is little absorption in the forehead. You might notice that elderly patients tend to have fuller foreheads.

In a general sense, the midface collapses, moving posteriorly. This creates a larger orbital aperture. The inferior rim moves posteriorly and inferiorly, especially inferomedially. The central parts of the superior and inferior rims tend not to change over time. With the accompanying soft tissue changes around the eyes, these changes are seen:

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  An accentuated lower eyelid fat prolapse

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  A deepening of the tear trough

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  A loss of malar projection

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  A contribution to lower eyelid retraction

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  A more pronounced negative vector eyelid

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  An added enophthalmos of aging

The maxillary bone retrudes and loses vertical height. The pyriform aperture, especially inferiorly, widens and retrudes. These changes contribute to:

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  A loss of nasal support, resulting in a nasal droop (ptosis); the nose lengthens and appears larger

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  A fullness of the melolabial fold

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  A loss of lip projection and fullness

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  A lengthening of the distance between the nose and lip

Mandibular bone volume and dental loss contribute to:

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  A loss of lip fullness

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  Chin retrusion and ptosis (witch’s chin)

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  A decrease in the size of the lower face, although at the same time the forehead appears larger

Of course, soft tissue changes in the skin, fat, muscles, and ligaments are occurring simultaneously. Just be aware that not all aging changes can be corrected by improving the soft tissue descent and deflation. Keep in mind that periorbital rejuvenation alone may create some facial disharmony, for example, young eyes in an old face. As your surgical expertise extends away from the eyes, you may want to consider implants in the cheek and chin to improve the appearance of the entire face. These implants are especially important when a particular bony deficit was present in the youthful face that is becoming aged.

What can be done to bring about improvements or rejuvenate the midface? There are some options for restoring the smooth single curve of youth. Lifting the cheek (midface lift) improves the melolabial fold and lifts some tissue over the rim. Trimming some fat from the lower eyelid with a blepharoplasty reduces the lower eyelid convexity. Repositioning the eyelid fat over the inferior rim at the time of a lower blepharoplasty (flipping the fat) may help to fill in the hollow at the rim. A less invasive way to camouflage the double convexity is to fill in the tear trough with an injectable filler or autogenous fat transfer. If a negative vector eyelid is present, a cheek implant may be the right procedure for improving the patient’s appearance and a solution for an anatomic issue that has been present for the patient’s entire life. You can see that there are several options to consider. All of these options are based on anatomy.

My hope is that by now you are starting to understand the normal anatomy and what happens to that anatomy with aging. The options for rejuvenation are numerous and complex. So how do you decide what can or should be done? Let’s look at the options from simplest to more complicated. As you might imagine, this algorithm follows a chronologic progression of patient age ( Table 7.2 ).

Look this over a few times . It is important because it summarizes the facial aging scheme and gives you some direction as to what procedures you might consider offering your patient interested in facial rejuvenation.

The Menu

There are many reasons for the increasing interest in cosmetic surgery. Youth remains a priority in our society. We are all hard wired to be attracted to youthful features. Patients are living longer. The baby boomer population is aging and remaining active. Most patients who look younger feel younger. The introduction of less invasive procedures, especially neuroparalytic injections such as botulinum toxin, has made the opportunities for rejuvenation more available to patients, often serving as an introduction to other aesthetic procedures. Society is accepting these procedures more readily. More men are having procedures done. No doubt a constant barrage of marketing makes the option of rejuvenation procedures appear attractive to the general public.

In the next sections, we deal with the “menu” of aesthetic procedures available from which your patients might choose. Your job is to offer them procedures that suit their needs and are safe. I like the scheme of evaluating your patient in terms of:

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  Wrinkles

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  Sags and bags

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  Contributing factors

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    Intrinsic: age, genetics, skin type, diabetes, cardiovascular condition

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    Extrinsic: sun exposure, smoking

This system lends itself well to selecting the right menu choices, depending on your patient’s desire for a “snack” or a full “seven-course meal.”

All patients over 40 years have some degree of all these aging changes. So how do you and your patient make a decision about which of many choices for rejuvenation is appropriate? It all comes down to the perceived cost – benefit ratio . You are going to offer only procedures within your skill set that you think address the patient concern and offer a benefit to the patient with a minimal risk. As we said, your job is to educate the patient with regard to the benefit and risk of a particular procedure. Because cosmetic procedures are completely elective, the decision to proceed really comes down to the patient’s perception of the cost–benefit ratio. If the patient perceives no benefit, even “no risk” does not make the patient want to have the procedure (mindset 1). If the patient perceives a benefit and the risks appear minimal, he or she often elects to proceed with surgery.

The medical risks of all these procedures are very low, but you must factor in the cost and downtime (swelling, bruising, pain, and time out of the public eye) on the risk side of the ratio. Patients prefer low-cost procedures with little downtime. Many patients are interested in trying that “appetizer” from the long menu of rejuvenation options. This is where botulinum toxin and fillers have received widespread acceptance. Later, the patient may come back for a second or third course. A few patients are “hungry” and will order a “full meal” on the first visit. You might want to remind your patients that more involved treatments with a longer recovery almost always have more effect and longevity than procedures with less downtime. Ultimately, it is the patient’s choice, which is assisted with your wise counsel.

Most of the procedures done in my practice are functional operations. Most of the cosmetic operations that I do are added-on aesthetic procedures to these functional operations. Let’s look at a hypothetical ptosis patient. This patient has likely been referred to me by his or her physician. Based on that referral, before even meeting me, the patient has the expectation that I can “fix” the droopy upper lid. I am happy to do so. Now remember that I am of mindset 2. I also have never been comfortable with any sales approach to my patients for any reason. But if I see that the patient has prolapsing lower eyelid fat, I ask that patient if the puffiness in the lower eyelids is of any concern. If the answer is yes, we discuss it. If the answer is no, we do the ptosis operation, and everyone is happy. Often, I have patients that ask me about the puffy lower eyelids if I don’t ask. That being said, your patients may not appreciate you pointing out negative facial features. They are likely to be offended by any heavy “up-selling.” Be very mindful and considerate of your patients in these regards. Your goal is to have a happy patient.

Where do you start?

With regard to your level of expertise, botulinum and filler injection skills are acquired easily with some practice, so that is a good place to start. You may already know how to do a functional upper blepharoplasty and direct browplasty. An aesthetic blepharoplasty in a younger patient is not any more difficult. In some ways, it is easier because there is usually much less redundant tissue. It goes without saying that your technique must be meticulous and your bedside manner very accommodating. Next, you might want to offer laser resurfacing or chemical peels. Work toward getting perfect upper functional blepharoplasty and browplasty results, and then offer cosmetic upper blepharoplasty. Next think about lower blepharoplasty, but keep in mind that lower blepharoplasty is more difficult and risky than upper blepharoplasty. As your skills increase, you can learn pretrichial or coronal forehead lifting. With the brow and temple anatomy well understood and perhaps your familiarity with the endoscope for retrieving stents and doing endoscopic dacryocystorhinostomy, you might want to do endoscopic forehead lifting with your upper blepharoplasty (the technique that I have outlined below; doing the forehead release through the upper eyelid incision is not a big jump). Taking courses, viewing DVDs, mentoring with an experienced colleague, and making trips to the anatomy laboratory help you tremendously.

At this point, you are well on your way to a full aesthetic menu for your patients. Each of us has different interests and practice situations. Few surgeons do only cosmetic surgery. The market is very competitive for these higher-reimbursement cases. You can choose to limit your expertise to periocular procedures, or move further into midface, face, and neck lifting.

In the next sections, we consider the first of these procedures in some detail. I would like you to have an understanding of midface, lower face, and neck lifting procedures, but can’t give you all the details in this short chapter. There are many other procedures that you should at least be aware of, such as cheek and chin implants, rhinoplasty, and hair replacement, which are not covered in this text. There are many texts available that you can use when you want more specifics. Some of these are listed in the Suggested Reading section. Before we head toward the procedures, we should talk about the prevention of facial aging , an important topic for all our patients for both functional and aesthetic reasons ( Box 7.4 ).

Principles

All your patients know about botulinum toxin as a wrinkle remover. I would like you to think about the neuromodulators as a way to influence facial expression more than as purely a wrinkle remover. Let’s talk about the wrinkle remover effect first.

Botulinum toxin was introduced to the medical community in the late 1970s by Alan Scott as an investigative treatment for strabismus. The pharmaceutical industry picked up the product Botox as an “orphan drug” for the treatment of facial dystonias, primarily essential blepharospasm, in the mid-1980s. Since that time, the indications for this powerful neurotoxin have exploded. The Food and Drug Administration approval for Botox as a treatment for glabellar wrinkling was granted in 2002. The muscle-weakening effect of Botox is due to inhibition of the release of acetylcholine from the presynaptic neuron at the neuromuscular junction, causing a chemical denervation lasting 3 to 4 months.

Wrinkles in the skin are caused by contraction of the underlying muscles. As we have shown earlier, the wrinkling is directed 90 degrees from the pull of the underlying muscles. Think of the horizontal forehead rhytids resulting from the contraction of the underlying, vertically oriented frontalis muscle or the radially oriented crow’s feet at the lateral canthus resulting from circular orientation of the underlying orbicularis muscle. In Chapter 2 , we talked about the glabellar wrinkling causing contraction of the underlying procerus and corrugator muscles ( Figure 7.10 ). In youth, the plump skin barely shows a wrinkle with facial movement. As the skin thins, facial movements are accompanied by dynamic wrinkles. With further aging and loss of the elastic nature of the skin, wrinkles without muscle contraction develop, known as adynamic wrinkles. Because Botox blocks the underlying muscle contraction, it is most useful for the treatment of dynamic wrinkles. The primary regions where Botox is used are in the forehead, glabella, and crow’s feet.

Technique

Botox is available in a powder form with 100 units of botulinum toxin in each bottle. The powder is typically dissolved with 2 mL of sterile saline (resulting in a dilution of 5 units/0.1 mL of fluid). You should avoid vigorous shaking of the bottle because the Botox is easily degraded. Typically, 2.5 to 5 units are injected in each site (0.05 to 0.10 mL of solution). Some surgeons change the concentration depending on the site. Typical injection sites and dosages are shown in Figure 7.11 . You might want to review the sites for Botox injection in cases of essential blepharospasm and hemifacial spasm shown in Chapter 9 (see Figure 9.7, Figure 9.8, Figure 9.9 ).

Although we think about Botox for removing wrinkles, a better way to think about the treatment is how to shape the patient’s features and improve the “mood” of the face. Aside from improving wrinkles, consider Botox injections for the:

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  Lateral orbit : weakens the orbital orbicularis muscle

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    Raises the brow

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      Improves the contour; gives a temporal arch

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    Lifts the ROOF to show the temporal superior rim

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      High arched brows are a sign of youth

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    Reduces the upper eyelid skin fold

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    Reduces crow’s feet

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    Can improve the asymmetry of the brows

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    Makes a happy face

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  Glabellar region : weakens the corrugator and procerus muscles

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    Reduces “11” lines

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      Improves an angry look or scowl

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    Increases the interbrow distance slightly

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    Can raise the medial brow if placed low

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  Forehead : weakens the frontalis muscle

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    Smooths the forehead

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    Can shape the brows by avoiding the lateral third of forehead

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    Be conservative with the dosage, staying high in the brow

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  Chin : used primarily to weaken the depressor anguli oris muscle

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    Improves the resting smile

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    Can inject into the mentalis muscle to decrease an “orange peel” appearance

The glabella is a good place to begin treatment with Botox. Use lower doses and fewer sites until you have experience. The injection technique is straightforward. Use a short 30- or 32-gauge needle and inject under the skin. You should not be in the intradermal layer. Injection into the muscle can cause bruising. Around the eyes, stay peripheral to the orbital rim to avoid an upper eyelid ptosis. It is a good idea to always point the needle away from the eye. Try the recommended doses in Figure 7.11 . As you get experience you can customize your injections to the patient’s needs. Ask your patient to squeeze the brows together. You can see the influence of the corrugator and procerus muscles. You may want to tailor your injection dosage and position a bit depending on the strength of each muscle. If the corrugator action is strong, you can place injections slightly more temporally. If the procerus action is strong, you can add injections more superiorly. In some cases, you may want to move down on the nose to eliminate the “bunny lines” caused by the contraction of the nasalis muscle. Again, use conservative dosages. Unlike some of your surgery patients, these patients are likely to visit you many times over the years. Cautious injections and free touch-ups inspire confidence in your expertise and judgment. You want to have a steady repeat clientele receiving these injections. Once you have determined the satisfactory dosages and locations, subsequent injections are repeatable and quick. Given the cost of the product and the value of your time, I suggest that you avoid the bargain Botox shoppers, always looking for the next provider to give a discount service. Appropriate glabellar injections eliminate the facial scowl associated with the bunched-up tissues in the glabella. A happy and happy-looking Botox patient is likely to refer many other patients, some of whom become surgical patients.

The next most common injection site that I use is along the lateral canthus. This is ideal for the younger patient that wants a bit more elevation to the temporal brow. Usually, 2.5 units in three spots over the lateral orbital rim raise the lateral brow nicely. Using asymmetric dosages, you can raise one brow more than the other. Patients appreciate your awareness of these subtle differences and the fact that you care enough to customize their injections. Older patients benefit as well, but the lift may be not enough. In those cases, browplasty, makes sense.

The combination of glabellar and lateral canthal injections is very useful. One note of warning: Overaggressive glabellar treatments with a lateral brow lift can create an unpleasant Mr. Spock look. The loss of medial movement coupled with a high temporal arch can create an evil or angry look. Again, conservative treatment and touch-ups are always best. Temporal injections sometimes create a more obvious frontalis wrinkle over the lateral brow. It is wise to explain this to your patients ahead of time.

Some patients ask for brow wrinkle reduction. Keep in mind that the frontalis action that is producing the wrinkles is the same force that is keeping the brows in a good position. In younger patients with well-supported brows, these furrows can be reduced. I use 2 to 2.5 units in five spots across the top quarter of the forehead. Usually, I don’t inject any botulinum lateral to the peak of the eyebrow to keep the temporal brow up. This is where your experience and the patient’s goals come into play. In older patients, eliminating the forehead furrows exacerbates a brow ptosis, so I discourage forehead injections in older patients.

A good rule of thumb is Botox is best for the upper face. Fillers are best for the midface (and can be conservatively used in the upper and lower face).

As you get more experience, you can break this rule. When you are happy with the standard periorbital injections, try depressor anguli oris (DAO) injections (2.5 units). Remember that the mandibular osseocutaneous ligament is just anterior to the DAO. You may be able to identify the position of the DAO by asking your patient to pull the corners of the mouth inferiorly. Place 2.5 units at, or just posterior to, the marionette line for a good effect. Be attentive to placing equal amounts in symmetric positions; this is a sensitive location for injection. The improvement in the smile is pleasing to patients. The effect is subtle but noticeable and uses very little product.

You can correct minor preexisting lower eyelid position asymmetries with very small doses of 1 to 2 units just below the eyelid margin. On the upper lip, you can improve the vertical “smoker’s lines,” but be conservative. Only half-unit injections judiciously placed in two to four spots are needed to do the job. Warn your patient that the lip may feel a bit funny for a while. In patients with a “gummy smile” you can place similar injections just inferior to the nose to prevent the upper teeth from showing too much with a smile. Lip injections with filler go well with these small Botox injections. Botox injection in the neck can be used to improve platysmal banding in the neck. Injection of 5 units per site in several sites along the bands can give improvement. For patients with a square face due to masseter fullness (common in the Asian face), Botox injections into the muscle can reduce the lateral boxiness.

Undertreatment is more desirable than the total paralysis of overtreatment. Even worse is the occasional upper eyelid ptosis that may persist for several weeks once it occurs. Apraclonidine 0.5% eye drops have been recommended to treat Botox-induced ptosis. This alpha-adrenergic agonist causes Müller’s muscle to contract, elevating the upper eyelid 1 to 3 mm. I have no experience with using this drug, however. Few patients experience dry eye symptoms after treatment, but a lubrication regimen of artificial tears three or four times a day is reasonable. You should avoid treatment of the lower face, at least until you get experience. Unsightly abnormalities in movements of the mouth are telltale signs of overtreatment with Botox.

With some experience, you can use Botox in conjunction with fillers. Botox eliminates the tissue elevation (smooths the hills) caused by the underlying muscle contraction. Fillers eliminate any remaining depression (fill the valleys). Botox has been advocated prior to a surgical forehead lift in the hope of facilitating the release and maintaining the forehead elevation while postoperative adhesions form.

A few other tips can make the injection process more pleasant. If your patient would like less pain, offer to apply a numbing cream to the injection sites. The cream needs to remain in place for at least 10 minutes prior to the injection to be effective (BLT cream– [benzocaine, tetracaine, and lidocaine 12%, 8%, 7%], 60 g, SBH Medical, Worthington, OH, sbhmedical.com , or obtained from your local compounding pharmacy).

Icing prior to injection can help. Freezing aerosol sprays are available, also (they are especially helpful for lip filler injections). Small needles (30- or 32-gauge) hurt less than larger needles. Tuberculin syringes, with the needle permanently attached, waste less product than other syringes. Filling the syringe from the toxin bottle tends to dull these small needles. Some injectors draw up the toxin with a separate needle and fill the injection syringe with the plunger removed. Personally, I don’t do this, but I limit the number of injections with a single needle to four sites. You can pull or jerk the tissues just prior to introducing the needle, which minimizes the pain. Applying a vibrating device can do the same thing. I give patients a small ice bag to apply immediately after the injection and at home, hoping to minimize any bruising, which is rare. The ice bags have our logo on them. Patients seem to appreciate these packs. I ask patients not to exercise for the remainder of the day, although I am not sure that is necessary. I don’t ask patients to stop aspirin products prior to Botox injections. I don’t recommend arnica or other supplements to limit bruising, but some patients like to use them.

Throughout this text, I have used Botox as a generic name for all neuromodulators. Although there are subtle differences in each neuromodulator, I consider the effect to be essentially the same. I use them interchangeably. You may hear “injector experts” stating how much difference there is, but at this stage, treat them as the same. In my mind, the choice becomes a practical one. Choose the company that offers the best pricing and service. For simplicity, the dosages given in this book are in Botox units. That being said, you may have a difficult time persuading one of your Dysport patients to switch to Botox, or vice versa. See Video 7.1 .

A good way to practice is on your functional patients with facial dystonias or facial nerve synkinesis. It is also a wise practice to offer Botox and filler injections to your staff at a reduced or no charge. The staff endorsement and enthusiasm may spread to your patients.

Remember, the best aesthetic result occurs when a new refreshed look is not attributed to any treatment at all.

You want your aesthetic outcomes to look natural. Consider the example of hairpieces: Have you ever seen a good toupee? No, you only see the bad ones. Yes, you probably have seen a good toupee but did not realize it was not natural! Similarly, it does not matter whether you are doing Botox injections or a facelift; your patient should not have an unnatural operated-on look.

Principles

Fillers are used as volumizing agents to replace facial deflation ( Video 7.2 ). You can restore the round curves of the youthful face with the injection of filler products into the less full areas of the face. Think of a filler as improving the contour of the face in one of two ways:

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  Support for the sagging tissues: providing lift

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  Filling in the low spots: decreasing the valleys of the face

Both techniques are important.

Recall that the valleys of the face are largely formed by the anchors of the soft tissue to the underlying tissue or bone (retaining ligaments) we just discussed. Adynamic wrinkles can be considered as small valleys and can be filled to improve texture. Remember that the valleys or facial contours are seen best with directed light that highlights the shadows. The most natural view of the face is with light coming from above, similar to what we see outdoors in sunlight. As you can see from Figure 7.12 , a direct frontal flash photo shows little of the contour changes of the face. Of course, most of the lighting we see in real life is directional and casts shadows across the facial contours.

There are several methods for improving the facial contours:

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  Injectable fillers

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    Hyaluronic acid fillers

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    Radiesse fillers

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    Sculptra filler

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    Other semipermanent fillers

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  Autologous fat injections

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  Alloplastic implants

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  Facial and mandibular bone advancement

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  Providing support to the cheek: thickest filler

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  Filling a valley (prejowl sulcus): thick or thickest filler

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  Improving a surface wrinkle (crow’s feet, vertical lip lines): thin filler

When recontouring your patient’s face, start with adding support, move on to filling any remaining valleys, and then consider any surface wrinkles that remain that have not been improved by Botox. I think this way when evaluating any potential filler patient. That being said, you have to listen to your patient’s concerns. A little education goes a long way when discussing the theory of fillers with your patients, but ultimately, you want to improve what your patient sees as a problem.

The thickest materials are used for providing volume and placed deep, usually anterior to the periosteum in the superficial facial fat pads. The most common area for using the thickest products is in the midface, to fill the cheeks. These injections provide fullness of the cheek and lift the tissues so that the melolabial fold is reduced. If some hollowing still exists, you can add a conservative amount of a thick filler into the dermis of the crease. In the prejowl sulcus, you can use a thick or the thickest filler to smooth out the contour.

Botox works well for dynamic wrinkles but does not eliminate adynamic wrinkles. Thin fillers can improve these wrinkles. These wrinkles at rest can be improved with a thin filler. Adynamic wrinkles, such as a depressed scar, are most visible with a light directed from the side casting a shadow over the valley, making the depression visible. When you eliminate or “fill” the depression with injection of a filler product, the shadowing is gone. Typically, this is most useful in the area of the adynamic wrinkles at the lateral canthus, on the sides of the mouth (vertical jowl lines and marionette lines), at the margins of the lips, and in the glabella (with caution because necrosis has been seen). Thin hyaluronic acid (HA) materials are also used to provide volume in areas where the skin is thin (tear trough and lips).

The common HA fillers in the United States are Juvéderm and Restylane. Just a few years ago, there was only one Juvéderm and one Restylane product. Now each company markets several products of varying character. HA is a naturally occurring substance in our tissues. It has a huge capacity to bind water (1000 times its weight), a significant factor in giving skin its character. The half-life of HA in the skin is very short. Chemically binding the HA molecules together, or cross-linking, increases the lifetime of HA, making it a viable product for injection. The HA fillers differ in the concentration of HA in the gel and the way in which the HA is packaged in particles by the cross-linking technique (proprietary to each specific HA product). A higher degree of cross-linking equates to higher longevity. The term G prime, or the elastic modulus, describes how the filler feels or the elasticity of the gel. The G prime is the ability to withstand deformation when pressure is applied to the gel. Think of it as pushing your finger down on a bead of water compared with pudding compared with Jell-O. You can see how the higher G prime Jell-O would give more lift if injected into tissue. You can also guess that the higher G prime products would look lumpy if injected close to the surface or under thin skin. This is an oversimplification, however. There are many other physical factors involved, such as viscosity and tissue cohesiveness, which complicate the issue, but for practical purposes, it is enough to know that some fillers cause less deformation, lift better, and last longer. It is not exactly correct to use the terms thin , thick , and thickest to describe the G prime character, but it works for me, as I think it will for you and your patients. Keep in mind that only a few years ago there was only one HA product per company. As technology and the market have gained ground, each company has produced several products with varying characteristics. These newer products may be more specific to the patient’s needs but complicate your decisions because your patient can likely afford only so many syringes of filler. The specific HA product lines continue to evolve rapidly, but the theory of how to use the products stays pretty much the same.

The websites for these products ( juvederm.com , restylaneusa.com ) are worth looking at for two reasons. First, there are good diagrams and tips. Second, your patients are looking at them, too. It is always a good idea to know what your patients know, and hopefully more.

Please keep in mind that many of the uses for Botox and fillers outlined here are “off label.” These techniques are used widely in standard practice throughout the United States and Europe, however.

Juvéderm currently markets two lines of HA fillers. They vary in the type of cross-linking used and the concentration of the products. The current products listed, from thinnest to thickest, follow.

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  Juvéderm Products

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    Ultra: thin, for surface wrinkles and lips

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    Ultra Plus: thicker, for deeper valleys and filling the cheeks

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    Ultra XC: same as above but contains local anesthesia

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    Ultra Plus XC: same as above but contains local anesthesia

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    Juvéderm Vobella XC: thin gel, for lip contouring and perioral wrinkles

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    Juvéderm XC: thick gel, for moderate to severe wrinkles and folds

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    Juvéderm Voluma XC: thickest gel, for placing volume into cheeks

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  Restylane Products

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    Restylane: thick gel, for wrinkles and folds

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    Restylane L: thick gel, for wrinkles and folds and contains lidocaine

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    Restylane Silk: thin gel, for defining the lip contour and fullness

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    Restylane Lyft: thickest gel, for lift and support of cheeks

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    Restylane Refyne: for smoothing facial lines and folds

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    Restylane Defyne: for nasolabial folds and marionette lines

Restylane is the original product, an all-around gel. It was used for all areas, sometimes in diluted formulations for lips or tear troughs. Lyft and Silk came out as thin and thick gels, specifically for cheek volumizing and lip contouring, respectively. Recently, Refyne and Defyne have been introduced with new cross-linking technology, promoted as gels with more mobility and natural expression, especially good for areas with movement, such as areas around the mouth and crow’s feet. Defyne is thicker than Refyne. The newer gel products contain lidocaine. For Juvéderm products, XC means local anesthetic is added. For Restylane products, L means local anesthetic is added. The nomenclature is likely to change over time. There are other brands of HA fillers that you may want to try.

A good rule of thumb is:

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  Shorter-lasting HA products

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    Thinner HA

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    More superficial injection

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    Areas of more movement

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  Longer-lasting HA products

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    Thicker HA products

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    Deeper injection

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    Areas of less movement

Allergan markets Juvéderm, Botox Cosmetic, Kybella, Latisse, Natrelle (breast implants), and SkinMedica (skin care products). Galaderma markets Dysport, Restylane, and a large variety of prescription skin care products.

The most common injection sites are:

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  For lift and support

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    Malar region: SOOF

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    Temporal superior orbital rim: ROOF

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    Lateral oral commissure

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  For filling in the valleys

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    Tear trough

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    Prejowl sulcus

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  Wrinkles

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    Vertical lip lines: smokers’ lines

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    Perioral laugh lines

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  Lips

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    Emphasize lip vermilion border: “pout”

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    Accentuate arch: Cupid’s bow

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    Add fullness to lip body

A very helpful principle to remember that we have discussed before is the change in the facial shape with aging. Recall that the face of youth tends to be heart shaped with full cheekbones and a narrow chin ( Figure 7.13 ). As your patient’s face tends to descend and deflate, the face of aging becomes more square. The jowls fill and the cheek falls. Most of your filling should be aimed at adding volume in the mid and upper face, especially around the eyes. My primary goal is to add volume to create a nice framework around the eyes, primarily in the cheek and tear trough, and then add to the brow, as necessary. On occasion, I fill the temple. After that is achieved, my secondary goal is to fill the valleys of the lower face, placing conservative amounts of filler in the prejowl sulcus and occasionally into the melolabial fold itself. I am always keeping in mind that I want to re-create the heart-shaped face by placing most of the volume high in the face. Filling the fat pads around the eye accomplishes this. Filler injection into the prejowl sulcus can be done to smooth out the jaw line, but consider the effect of added weight to the lower face. As a last step you can treat surface wrinkles.

Filling the face does a tremendous job of rejuvenating the face. You have to learn to use the filler products wisely. They are expensive and not without risk. In most cases, more than one syringe is needed to produce a significant improvement. I suggest that you warn the patient that using only one syringe when more is necessary is a mistake. Your patient may spend several hundred dollars and may not see much improvement. This is especially true when filling deflated cheeks or when trying to fill more than one area of the face. A single syringe is enough for the tear troughs or the lips.

Before we discuss the injection procedure, a word of warning. Swelling and bruising are not uncommon after filler injection. It is safest not to do filler injections less than 1 to 2 weeks before a big social event. Both Restylane and Juvéderm products contain non–cross-linked HA, which absorbs water, so it is best not to overcorrect the lips and tear troughs too much, because the result will be fuller a few days after injection. Juvéderm absorbs more water than Restylane. If Juvéderm is injected too superficially in the tear trough, a bluish hue may be seen. It is probably worth stopping nonsteroidal antiinflammatory drugs, aminosalicylic acid, fish oil, flaxseed oil, and vitamin E for a week or so before injection if bruises are a worry. Some injectors recommend arnica before and after the injections. Ice before injection and local anesthesia with epinephrine decrease the bruising. With the exception of the 2-week social event rule, I do not require any of this, unless the patient is really concerned about bruising.

The easiest injection area is to support the cheeks. You want to provide volume, that is, support and lift. To do this use one of the thickest fillers with local anesthesia in it. You may want to apply a numbing cream for 10 to 20 minutes before the injection. Evaluate for any asymmetry that you may want to correct. To mark the injection site, draw a line from the lateral ala to the tragus. Drop a line down from the lateral canthus. The intersection is the first point of injection. I am always surprised that the most projection is more inferior than I think it would be. Place the injection deep, just anterior to the periosteum, with a couple of serial punctures (0.05 to 0.10 mL each) to build the anterior projection. Then add linear, radially oriented injections to shape the cheek. A good guide is to fill the oval area defined by lines from the corner of the mouth to the tragus and the corner of the mouth to the lateral canthus ( Figure 7.14 ). Inject a bit on both sides, and move back and forth to maintain symmetry. If you want to widen the face somewhat, direct some injections toward the arch. When you first start doing filler injections, you may want to look at the syringe to gauge the amount of injection. As you get more experience, you can inject by feel. You usually need one syringe per side. If you feel you do not need the amount in both syringes, you can add a bit elsewhere, such as the prejowl sulcus or the ROOF. As we discussed earlier, you might be able to use only one syringe, but warn the patient that more may be necessary. You can always add more product in a week or more, especially if you have discussed this possibility with the patient ahead of time. For the first injection series in a new patient, I like to have the patient return in 2 weeks to evaluate the result and make sure that the patient is satisfied. After the first injection visit, your subsequent visits go faster. Remember that you are building a long-term relationship with your patient. The patient is likely to return for other procedures.

Once you get experience with cheek injections, there are a few other regions to which you can add support and fill with the thickest of the fillers ( Figure 7.15 ). The ROOF is a good place to fill and shape. Inject deep into the upper half of the brow and just superior to it. Inject along the lateral one half to one third to fill the ROOF and shape the brow. The combination of Botox injections at the lateral canthus and the filler in the ROOF works well. You can add the same filler to the prejowl sulcus and to any general hollowing of the temporalis fossa ( Figure 7.16 ). In men, you can square the jaw a bit by injecting at the angle of the mandible. For sunken temples, deep filler injections just posterior to the conjoined tendon work well. For a more upright smile, you can place filler inferior to the lip at the lateral commissure of the mouth (often in combination with DAO Botox injections).

Once you have filled the cheek, reevaluate the support of the melolabial fold. If there is still a bit too much of a valley, you can inject a small amount of the thick (not thickest) filler into the crease. You have two goals here, to lessen the depression (inject into the deep dermis) and to iron out any crease in the surface skin (inject into the superficial dermis). If Botox injections have not helped any crow’s feet wrinkles, a medium-thick or thin filler can be injected into the dermis. Remaining glabellar wrinkles can be improved in a similar fashion, but be cautious because tissue necrosis is more common at this location.

For the tear trough, the thin HA gel fillers are best. Here you inject along the orbital rim at the level of the orbicularis muscle (ideally, posterior to the muscle). You can layer additional filler somewhat more superficially here, if necessary, as long as the eyelid skin is not extra thin. Only small amounts are needed, usually less than one syringe for both eyes. Because of the vascularity of the orbicularis muscle, bruising is not uncommon. You can apply ice before and inject a small amount of local anesthetic with epinephrine 10 minutes ahead of time if you are finding too much bruising on your patients. This is an area where a blunt 25- or 27-gauge 1-inch microcannula can be helpful (DermaSculpt blunt-tipped microcannula, CosmoFrance, Miami, FL, cosmofrance.net). You need to use a 25-gauge needle to puncture the skin laterally and place the cannula through the opening because the tip is dull. The injection is performed in a manner similar to that for using a needle. Because the tip of the cannula is dull, fewer blood vessels should be cut. Some injectors use a cannula for all injections. I used cannulas for a while with good results but seem to get the same results with needle injections. You might try both and find which you prefer. Two-inch 22-gauge microcannulas are preferred by some injectors for use in all areas of the face. These cannulas may be too flexible to push easily through the tissues.

Lip injections take some practice but are worth learning to do. Injections in other areas of the face make your patient look more rested, happier, and healthier. Lip injections make your patient look more attractive and more seductive. Obviously, this is only an opinion here, but for what it is worth, a well-done, not overdone, lip injection can add a certain je ne sais quoi to your patients. I do not inject for the drama of large lips. They look unnatural, and my patients appreciate the sensitivity to this. Aim for a full symmetric shape with cautious delineation of the lip margin, and your patient will love you.

Some prep work is important. Make a plan based on your evaluation of the lip anatomy and aging changes. Some patients are born with smaller lips, but everyone loses volume with age. Look at the general size and fullness of the lips. Is there a full Cupid’s bow, the prominent paramedian elevations of the upper lip, shaped like an archer’s bow? Do the philtral columns need more definition to accentuate the bow? Is lip asymmetry present? Are the proportions of the upper to lower lip fine? The lower lip should be 40% to 50% larger than the upper lip. Is the vermilion border, the junction between the red lip and the skin, defined? Is the “white roll,” that lighter line of skin between the pink lip and the flesh tone, present? Does the vermilion border need fullness, especially at the mounds of the bow? As you fill the upper lip, consider the proportions of the lower and upper lips ( Box 7.6 ). How about your patient’s smile? Should you raise the down-turned lateral commissure with a thicker filler or do Botox injections to weaken the DAO muscle? Does the upper gingiva show too much with a big smile? A total of 2 to 5 units of Botox spread into the orbicularis oris placed high reduces a gummy smile. Is there a deep mentolabial fold to fill? Is there a peau d’orange or stippling of the chin due to mentalis contractions? This is a lot to think about, but after looking at lots of lips you will be ready to give it a go.

Your patients appreciate some anesthesia. Numbing cream is helpful. A local injection of 2% lidocaine, with or without epinephrine, should be given as an infraorbital nerve block for the upper lip and a mental block for the lower lip. I usually use the epinephrine, thinking it may decrease bruising, but some patients do not like the small systemic effect of the epinephrine. Ideally, these regional blocks do not distort the shape of the lips, but to be safe, I mark any vertical lip lines before injection, in case the normal lip puckering is affected by the local injection. I also use a cold numbing spray directly before injection. I use fillers with local anesthesia in the product so that after the initial injections are made the subsequent injections in the same area do not hurt. Remember, most patients do not return if the procedure is too painful.

The most common area of injection is along the vermilion border of the upper lip. Your goal is to emphasize the white roll, or area of lighter skin between the pink lip and the normal skin, without making the white roll too thick. In younger patients, this may be all that they need. Be careful though, because too much filler here is a giveaway for a less-than-perfect injection technique.

The vermilion border injection improves the vertical lip lines, as well. If the lines are prominent, you can inject a tiny amount of filler into the lines as superficially as possible.

Next, see if you need generalized fullness of the upper lip. Inject directly into the muscle, adding a bit more fullness at the bow. Keep the sides of the lips symmetric. You may decide to add some filler to the vermilion border or the vermilion border of the lower lip to establish a good ratio of upper and lower lip size. A second giveaway of lip injections is an upper lip that is the same size as the lower lip.

Finally, work on the smile. So far, you have been using the thinnest HA gel filler product. If you have a thick or thickest filler left over from another area, use that to prop up the lateral commissures with injections to push up the lateral lip. Add any extra filler to the prejowl sulcus or mentolabial sulcus. After you have finished with the filler, consider some Botox to the DAO (you only need 2.5 units per side). Take care of any gummy smile or decrease in the vertical lip lines with 2 to 5 units of Botox high across the upper lip. Treat any unpleasant stippling ( peau d’orange ) of the chin with a similar dosage of Botox. As you get more experience, try to re-create the true three-dimensional shape of the lips, as shown in Figure 7.17 .

After your injections, have the patient ice the lips for 10 minutes before leaving. Advise against vigorous exercise for 24 hours. A phone call a day or two later from you to check on your patient goes a long way in relationship building.

Fillers are a great tool, but keep in mind that there are associated risks. As always, listening to your patient’s desires and concerns, a bit of education, and creating reasonable expectations are key. All fillers hurt to some degree, so use anesthetic and be supportive of your patient during the injection process. A staff member holding your patient’s hand can be a great comfort to your patient. Bruising and swelling are not uncommon. Postinjection viral outbreaks can occur but are rare (I do not generally use antiviral prophylaxis). The risk of bacterial infection is quite low but not zero, so prep the skin with alcohol and use a sterile or semisterile technique. Late inflammatory reactions and granulomas can occur but are rare. Issues related to inflammation can occur years after the initial injection. Should your patient dislike the filler effect or have inflammatory problems, hyaluronidase injections dissolve any remaining filler. You may be surprised to find that several hyaluronidase injections can be needed. In your own practice, you should rarely, if ever, need to use hyaluronidase to reverse your treatments. Choose appropriate patients. Educate them regarding appropriate expectations. Use a conservative appropriate technique and you will be successful with fillers.

All that being said, there is a serious complication that is reported with filler injection, vascular occlusion. Vascular occlusion can lead to tissue necrosis or blindness. The risk is low, but you should inform your patient and have a consent signed before each injection session. Be aware of the location of large vessels in the region that you are injecting. The risk of intravascular injection is highest in the central face, where the facial vessels are the largest. Most commonly, areas of necrosis occur in the glabella, nasolabial fold, and nose. Always inject slowly. Inject as you withdraw the needle. Cannula injection may be safer than sharp needle injection. Should you see blanching of the skin followed by a dusky discoloration of the skin, stop injecting immediately. Inject hyaluronidase *

* Hyaluronidase , 10 to 30 units of hyaluronidase diluted 1:1 with saline per 2 × 2-cm area (Vitrase, ISTA Pharmaceuticals, Irvine, CA).

and apply a half inch of nitropaste ^†

† Nitropaste 2% - apply ½ inch (Nitro-BID; E. Fougera & Co., Melville, NY).

to the area of concern. Massage into the skin. If you are doing filler injections, you must have hyaluronidase and nitropaste available in your office. Give 325 mg of aminosalicylic acid per day. Consider daily injections of hyaluronidase and applications of nitropaste if the capillary filling is slow. Hyperbaric oxygen and topical oxygen cosmeceuticals have also been suggested. If an area of skin necrosis occurs, apply topical antibiotics and consider oral treatment, as well. Fortunately, the majority of embolic events do relatively well with appropriate treatment.

Blindness can occur owing to retrograde embolization into the retinal circulation. Retrobulbar injection of hyaluronidase has been recommended in animal models, but no human reports have been published.

These can be devastating complications. However, in many cases, skin necrosis can be minimal. This is a frightening situation for both the injector and the patient. Make sure that the patient knows that you are doing everything you can. Consultation with an experienced injector colleague can be reassuring for both you and the patient. In any case, continue to offer your full treatment and support of the patient.

In practice, it is easiest to stock and use one brand of thin, thick, and thickest type of HA filler that works in all regions of the face for most patients. I would suggest that you use only HA products until both you and your patients get experience with the effect of the filler. Some patients want more volume than others (related to personal preference or expense), so do not overtreat initially. You can add more filler later if needed.

Thin HA products are injected in the mid to superficial dermis. The thicker fillers are injected a bit deeper, and the thickest fillers are injected preperiosteally. Your careful injection technique and massage give a uniform distribution of the material. The result is immediate. Swelling and bruising are minimized by ice application after injection. Areas with significant movement where you use thin fillers have a shorter effect. The effect lasts from 4 to 6 months for thin fillers and 18 to 24 months for the thickest HA filler. If any filler material is left over after the initial injection locations, you should add it where you think it may help. Most injectors do not keep partial syringes on hand. Again, as I mentioned, see or call your new filler patients a week after injection. If touch-ups are necessary, perhaps offer a reduced price. If an area is too full, encourage massage. Rarely, if ever, the injection can be reversed by the injection of hyaluronidase (Wydase or Vitrase).

Injection into the cheek does the most good for your patients. This frames the eyes and reduces the melolabial fold. If some hollowness remains in the melolabial folds, you can add a bit of the thick or thickest filler, but be conservative. When you get more experience, you can inject the nasojugal fold and the lips with the thin fillers. Small depressed scars can be improved somewhat. If adynamic wrinkles remain after Botox injection into the forehead, they may be improved with filler but may require needle undermining (subcision). Do not promise much, but sometimes you can make a really nice improvement. In the glabella you can add a small amount of filler (especially in men with deep wrinkles), but remember that this is a relatively risky zone. Check out the tips for injection of HA fillers in Box 7.7 .

I recommend that in your early experience you use HA gel fillers for most of your patients. The techniques using these fillers work very well for most people ( Box 7.8 ). The main issue is expense and the relatively short duration of effect. With repeated injections, your patients may develop “filler fatigue” and want longer-lasting fillers. HA fillers are considered temporary fillers. As you get more experience, you can consider semipermanent and permanent fillers.

Again, keep in mind that many of the injection techniques discussed are off label. I have, on occasion, used HA fillers to change the nasal profile and fill scar-related depressions. Subcision, using a needle to break up the deep scar attachments can be helpful in this regard. Other uses of filler are to add fullness to the earlobes for a more youthful look and to support earrings, fill in the nasal bridge or subtle tip and alar depressions or irregularities, increase nipple projection, provide volume on the dorsal hand, and even add filler to the finger pulp distal to the patient’s ring to prevent the ring from falling off. I don’t have any significant experience with most of these techniques, so I can’t account for their effectiveness or safety.

Semipermanent Fillers

For a longer-lasting filler effect, there are many options, but consider these:

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  Semipermanent fillers

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    Radiesse: calcium hydroxyapatite

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    Sculptra: poly-l-lactic acid (PLLA)

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  Permanent fillers

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    Autologous fat injection

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  Implants and bone advancement

Two types of patients benefit from longer-acting filler products.

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  Your patients who have very thin faces

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  Your patients who have filler fatigue

Thin faces require large amounts of expensive temporary HA filler. The result is immediate but not long lasting. The upfront expense and healing time are offset by a longer, better result. Some “perfect” temporary filler patients get discouraged by repeated injections. These patients can benefit from longer-lasting filler injections.

Semipermanent fillers stimulate new collagen in the skin. Radiesse and Sculptra work over a period of days and weeks. The HA gel products add volume that is most apparent within a few days after injection but do not alter the collagen.

Radiesse is an opaque gel with calcium hydroxyapatite (CAHA) spheres (25 to 45 microns) contained within in it. The initial injection provides volume and lift. Over time the gel is absorbed and the microspheres are metabolized, leaving new collagen in their place. The CAHA spheres are clearly visible on x-ray and CT images early on. The primary use is to provide volume to the cheek and nasolabial folds. Because the white calcium particles are visible through thin skin, Radiesse should not be used in the lips. Radiesse is also approved for injection into the dorsum of the hands to rejuvenate the hands. One telltale sign of aging is the patient’s hands. Fillers are most commonly used to rejuvenate the face, but the aged hands are often not treated, another giveaway to the patient’s age.

Radiesse was introduced more than 10 years ago. Its main advantage over HA products was that it lasted about 1 year. With the newer HA products, that advantage is not so significant. The same precautions and risks of all filler injections apply to Radiesse. I have had good results with Radiesse over the years.

Sculptra is another semipermanent filler that stimulates collagen production. It is a suspension of poly-l-lactic acid (PLLA). The product comes in a powder form that you mix with sterile water. Before 2010, the product was used to treat the HIV-related lipoatrophy with good results and entered the market for cosmetic use.

The biodegradable PLLA stimulates collagen production over time. Unlike with HA gel fillers, there is little initial volume improvement. The changes occur over 6 to 8 weeks. Depending on the amount of volume loss, three or more injection series are usually necessary 4 to 6 weeks apart.

The primary use of Sculptra is for the face that is thin all over. In particular, slim patients benefit. A typical patient might be the athletic younger woman with very little body fat and a thin, aged-looking face. The injections are given subdermally throughout the face. In the temple, the injections are given deep against the periosteum. For the patient that wants an immediate result, Sculptra is not the best choice. Injections with HA gel followed by Sculptra may be a good choice for such patients.

The same filler risks and adverse events apply to Sculptra. When it was initially introduced, Sculptra was injected at low dilutions and granulomas were sometimes seen. This problem is all but gone with higher dilutions. A good dilution is 7 mL of sterile water with 2 mL of lidocaine per bottle of Sculptra. When injecting, make sure the needle is secure on the syringe. Your needle can be obstructed by the Sculptra powder, so you may need to change the needle more frequently than with other fillers.

The typical duration of effect can last up to 2 years. The approach to selecting a patient for Sculptra is a bit different than with HA gels. It is best to select a thinner patient who is willing to wait for results. The upfront cost is more but over time can save money. HA is a better choice for one region that needs fullness. For the thin patient who wants both an immediate result and long-term overall facial fullness, the combination of HA gel and Sculptra can be used.

Autologous Fat Injections

A final option for reinflating the deflated face is using autologous fat injections . Using a small fat-harvesting cannula, you can harvest fat from the periumbilical area or other region. Prior to injection, the fat cells are separated out via centrifugation or another technique. Any amount of fat, in some cases, large amounts, can be injected into the face to reestablish the smooth contours of youth. The results and longevity are variable, but in some cases, the improvement is spectacular ( Figure 7.18 ). I suggest that you learn the practice of volumizing with fillers before moving to fat injections. You can learn to do fat injections on functional patients that have a hollow anophthalmic socket or who have sunken facial areas after trauma. In a thinner younger patient, fat injections can be a substitute for a facelift. To correct the deflation aspect of aging, fat injections are often part of current facelift procedures where tightening the SMAS corrects the descent portion but does not contribute to a more youthful full face.

Keep in mind that each patient has a variable amount of reabsorption of fat, so overcorrection to some degree is necessary. Repeated treatments can be performed. The results are more technique dependent than other fillers, so experience is required to get consistent results. There is a small outlay of money for the equipment, but it is not prohibitive. You do need to have the patient population to justify your training time and expense to proceed with autologous fat injections.

Fat injections are not a part of my practice, but if you are interested, your practice model is suited for it, and you have a patient population that is willing to have these procedures, you should pursue learning more. In my mainly functional practice, I have a few patients that would benefit from fat injections. The techniques and equipment are improving each year. Learning more about fat injections is on my to-do list!

Bone Advancement and Onlay Grafts

Lastly, don’t forget to evaluate your patient in profile. Maxillary hypoplasia, a weak chin, or a nasal hump cannot be addressed to any significant degree with a filler. Bone advancement, alloplastic onlays, or bone reduction may be a better foundational change than any improvement you can offer with a filler. Your patient is better served by referral if this is out of your area of expertise. The results of these procedures can be quite gratifying.

My goal in this section is to have you remember the principles of Botox and injectable filler use. Botox and fillers are a good place to start your aesthetic practice. Patients with less aged skin may have only dynamic wrinkles and respond well to Botox alone. Patients with more aged skin have both dynamic and adynamic wrinkles. If Botox alone does not do enough, you can add an HA-based filler.

This part of your practice is unlike the episodic care that we often offer our patients with a surgically correctable problem. You need a somewhat different mindset to establish this ongoing part of your practice. You don’t want a string of one-timers coming in looking for the best deal in town. Spend some upfront time on education. I can’t stress enough that you need to establish a trusting relationship with these patients. Proceed slowly. See your patient a week or two after the first few injections. Do touch-ups at no charge or for a reduced fee. Once you have a good relationship, repeat visits go smoothly with little time. Your happy patients send other patients to you. Many have cosmetic surgical procedures in time. Make sure that your office staff understands that this is not the same part of your practice as a functional patient. The staff support from the moment the patient enters your office can make or break the experience.

A few of the currently available products are listed in Box 7.8 . Start with one or two HA products and get confident using them. As you get more experience, you might want to learn to use longer-lasting fillers. Keep in mind that this field is changing rapidly, so check the literature and talk with your colleagues to find out the latest information on the effectiveness, duration, and safety of new products as they become available ( juvedermusa.com , restylaneusa.com ).

Keep in mind that our eyes (actually, our brainstem) are connected closely to any discordance in the facial features and eve to the body as a whole. A healthy, youthful-looking face and body suggests that one has been given good genes. Overtreatment creates a discordance to which observers (maybe not the patient) may be instinctively sensitive. Extremely full, rounded cheekbones, high arched brows, and voluptuously full lips in a 60-year-old woman (or the equivalent in a man) are not normal. In fact, they are abnormal. Decide how you want your patients to look. Remember that the best aesthetic results are unrecognizable as treatments.

Lastly, please don’t forget that these treatments are solutions to first-world problems. Looking better makes us all feel good and there is no harm there. But if your patient truly has a self-image problem, a gentle push toward counseling is of real value. I have two young adult daughters, and they started Botox in their 20s, but I really don’t want them thinking that the most important things in life are Botox and fillers. Despite the nice enhancements these treatments give the appearance, we are physicians first, taking care of the patient, not just eyebrows and cheeks.

Fitzpatrick Classification System of Skin Type

The Fitzpatrick classification ( Table 7.3 ) is useful for selecting which of your patients are good candidates for treatment. This classification is based on a patient’s tendency to tan rather than burn when exposed to sunlight. Your patients with lighter skin color respond best to resurfacing and peeling procedures with less risk of posttreatment hyperpigmentation, the most common side effect. When you are learning these treatments, pick patients with mild to moderate aging changes with skin types I to III. The effect is reasonable, and unwelcome posttreatment pigmentary changes are avoided.

Treatment Principles

Mastering the art of laser resurfacing and chemical peeling is to understand and then match the severity of the sun damage (depth of damage) with the penetration of the laser or peeling agent (depth of the treatment). The treatment and healing process leaves a healthier skin.

We talked in some detail about the intrinsic and extrinsic causes of skin damage. Because you need to match the degree of damage with the extent of treatment, let’s look at how to recognize the amount of damage present. Mild sun damage is seen as abnormalities in the skin texture and pigmentation . The damage is seen mostly within the epidermis. As wrinkling develops, the damage is first within the superficial part of the dermis, the papillary dermis. These patients have surface and pigmentary changes, as well as dynamic and early adynamic wrinkles. As the sun damage progresses, the deeper reticular dermis is affected. Vessels appear. These patients have many wrinkles at rest . The skin starts to appear leathery and can take on a yellow discoloration.

Keep in mind that lasers and chemical agents are tools. There are many variations of laser and chemical peel treatments available. As with your surgical instruments, the effect depends on which tool you use and how you use it. Weaker treatments (e.g., lunch-time chemical peels) have little downtime but provide only minimal improvement. Stronger treatments (e.g., deep CO ₂ laser treatments) have a longer recovery time but provide a longer-lasting, more profound effect. The principles apply to all treatments. You have to decide which treatment and strength are best suited for your patient’s skin problem and weigh that choice against the risks and recovery time.

Before you embark on these treatments, you should prepare the skin medically. After treatment, you should recommend a long-term skin maintenance plan. For some of your patients, retreatment as the years go by is necessary to maintain the optimal skin condition.

Pretreatment Care

You should start pretreatment care at least 8 weeks prior to resurfacing or peeling. Tretinoin (Retin-A 0.025% to 0.1%) should be applied every night at bedtime or twice a day. For patients with moderate amounts of pigmentary changes, a bleaching agent such as topical hydroquinone 4% should be applied twice a day a few weeks prior to treatment. This evens out the dyschromias and minimizes the possibility of posttreatment hyperpigmentation. It is a good idea to avoid treating patients with olive or darker skin (types IV to VI) until you have considerable experience with patients with a lighter skin color. Sun blocks containing zinc oxide or titanium oxide, rather than chemical sunscreens, are best and should be applied each morning and throughout the day. Valacyclovir 500 mg orally twice a day and cephalexin 500 mg qi should be started the day before treatment and continued until the skin is reepithelialized (usually in 7 days, depending on the treatment).

In the next two sections, we discuss the principles of laser resurfacing and chemical peeling techniques with the idea of matching the depth of treatment to the depth of the damage. As you already know, the deeper the damage, the greater the effect. However, with deeper treatments, healing is prolonged and the risk of complications, including infection, scarring, and hyperpigmentation, is increased. With moderate treatment, you get an improvement with a low risk of complications.