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Transcript of Facial Shaping: Cheeks are the New Lips · Meeting & Exhibition in Las Vegas, Dr. Gary Monheit and...
Facial Shaping:Cheeks are the New Lips
A proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
Jointly sponsored by Postgraduate Institute forMedicine and EHC Communications, Inc.
This activity is supported by an educationalgrant from Dermik Aesthetics.
Supplement to the March 2009 issue of
FacialShaping_Rd01_02.qxd 2/11/09 4:15 PM Page 1
Release date: March 16, 2009Expiration date: March 31, 2010
Estimated time to complete activity: 1.25 hours
Target Audience. This activity has been designed to meet the edu-cational needs of cosmetic dermatologists and aesthetic surgeonsinvolved in the management of patients with facial aging.
Statement of Need. Today, nonsurgical techniques play a primaryrole in reversing age-related changes. However, the optimal selectionof nonsurgical options and the application of injection techniques toensure the best results for patients are a major issue of debate. Fromthe perspective of plastic surgeons and cosmetic dermatologists,should fillers or sculptors be used, is there an advantage of combiningand layering one product over another, and what is the preferred injec-tion technique?
This symposium proceeding highlights injection techniques and rec-ommendations for optimal use of fillers, with insights on the use ofthese agents in patients of varied ethnic backgrounds.
Educational Objectives. After completing this activity, the partici-pant should be better able to:
1. Specify nonsurgical treatment options that enhance the mid-face and lower face in order to lift, redefine, rebalance,and re-proportion the whole face.
2. List the indications for the use of dermal fillers for nonsurgicaltreatment of facial biometric volume loss and alteration.
3. Describe proper injection techniques for facial shaping agents,including both replacement and stimulatory fillers.
4. Explain ethnic considerations to optimize outcomes with the use of facial shaping agents.
Accreditation Statement. This activity has been planned andimplemented in accordance with the Essential Areas and policies ofthe Accreditation Council for Continuing Medical Education(ACCME), through the joint sponsorship of Postgraduate Institute forMedicine and EHC Communications, Inc. Postgraduate Institute forMedicine (PIM) is accredited by the ACCME to provide continuingmedical education for physicians.
Credit Designation. Postgraduate Institute for Medicine designatesthis educational activity for a maximum of 1.0 AMA PRA Category 1Credit(s)TM. Physicians should only claim credit commensurate withthe extent of their participation in the activity.
Disclosure of Conflicts of Interest. PIM assesses conflict of inter-est with its instructors, planners, managers and other individuals whoare in a position to control the content of CME activities. All relevantconflicts of interest that are identified are thoroughly vetted by PIMfor fair balance, scientific objectivity of studies utilized in this activity,and patient care recommendations. PIM is committed to providing itslearners with high-quality CME activities and related materials thatpromote improvements or quality in health care and not a specific pro-prietary business interest of a commercial interest.
The faculty reported the following financial relationships or rela-tionships to products or devices that they or their spouse/life part-ner have with commercial interests related to the content of thisCME activity:
Pearl Grimes, MD, FAADConsulting Fees: CombeContracted Research: Allergan, Altana, Inc., Astellas (FormerlyFujisawa), Galderma, Inamed, SkinMedica, Stiefel Laboratories,Young Pharmaceuticals
Gary D. Monheit, MD, FAAD, FAACSConsulting Fees: Allergan, Electro-Optical Sciences, Inc., Medicis,Genzyme, Revance, StiefelContracted Research: Allergan, Colbar, Contura, Dermik Aesthetics,Kythera, Ipsen/Medics, Medicis
Wm. Philip Werschler, MD, FAAD, FAACSConsulting Fees: Allergan, Bioform, Dermik, MedicisContracted Research: Allergan, Bioform, Dermik, Medicis
The planners and managers reported the following financial relation-ships or relationships to products or devices that they or theirspouse/life partner have with commercial interests related to the con-tent of this CME activity:
The following planners and managers, Phyllis Enfanto, RN, LizaRisoli, and John Russo Jr, PharmD, have no real or apparent con-flicts of interest to report.
The following PIM clinical content reviewers, Trace Hutchison,PharmD; Jan Hixon, RN, BSN, MA; and Linda Graham, RN, BSN,BA have no real or apparent conflicts of interest to report.
Method of Participation. There are no fees for participating in andreceiving CME credit for this activity. During the period March 16,2009 through March 15, 2010, participants must 1) read the learningobjectives and faculty disclosures; 2) study the educational activity; 3)complete the posttest by recording the best answer to each question inthe answer key on the evaluation form; 4) complete the evaluationform; and 5) mail or fax the evaluation form with answer key to PIM.
A statement of credit will be issued only upon receipt of a completed activ-ity evaluation form and a completed posttest with a score of 70% or better.Your statement of credit will be mailed to you within 3 weeks.
Media. Printed supplement
Disclosure of Unlabeled Use. This educational activity may con-tain discussion of published and/or investigational uses of agents thatare not indicated by the US Food and Drug Administration. PIM, EHCCommunications, and Dermik Aesthetics do not recommend the use ofany agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the fac-ulty and do not necessarily represent the views of PIM, EHCCommunications, and Dermik Aesthetics. Please refer to the officialprescribing information for each product for discussion of approvedindications, contraindications, and warnings.
Disclaimer. Participants have an implied responsibility to use thenewly acquired information to enhance patient outcomes and theirown professional development. The information presented in thisactivity is not meant to serve as a guideline for patient management.Any procedures, medications, or other courses of diagnosis or treat-ment discussed or suggested in this activity should not be used by cli-nicians without evaluation of their patient’s conditions and possiblecontraindications on dangers in use, review of any applicable manu-facturer’s product information, and comparison with recommenda-tions of other authorities.
Facial Shaping: Cheeks are the New LipsA proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
FacialShaping_Rd01_02.qxd 2/11/09 4:15 PM Page 2
“Mirror, Mirror on the wall…” Everyone over the age of 40
has looked in the mirror and noticed changes in their reflection
develop over time. Several major events such as dropping of the
brows, deepening nasolabial folds and marionette lines, and loss
of youthful cheek volume occur. The definition of the mandibu-
lar sweep, thinning of the lips, and atrophy of the entire perio-
ral region combine to create an aged facial appearance. In addi-
tion, the malar fat pad begins its descent down the cheek. The
result is a drawn, tired look with a vertical lengthening of the
lower eyelids and a flattened midface on profile.
Today, nonsurgical techniques, primarily facial shaping
agents, play both a primary and a complementary role in revers-
ing, disguising, and moderating age-related changes. The opti-
mal selection and application of these treatment options to
achieve the best results for our patients are major issues of
debate among leading dermatologists and plastic surgeons.
During this symposium held at the 2008 ASCDAS 7th Annual
Meeting & Exhibition in Las Vegas, Dr. Gary Monheit and I
shared our views on enhancing the midface and lower face in
order to lift and redefine, rebalance, and reproportion the whole
face. Emphasis was placed on proper product selection and
injection techniques for soft tissue augmentation, and using
facial shaping agents in the various facial treatment zones to
regionally augment and enhance the aesthetic appearance of
the aging face. Dr. Pearl Grimes complemented these technique-
based presentations with a discussion of ethnic considerations
in skin of color to optimize outcomes and minimize complica-
tions with the use of facial shaping agents.
We hope these pages provide guidance and help create a
framework that you, the core specialists in dermatology and plas-
tic surgery, can use to achieve a greater sophistication in using
nonsurgical techniques to address age-related changes and the
concerns of your patients for mid and lower face rejuvenation.
Sincerely,
Wm. Philip Werschler, MD, FAAD, FAACSAssistant Professor, Medicine and Dermatology
University of Washington School of Medicine
Seattle, Washington
Page 4
Anatomy of the Aging Face
Wm. Philip Werschler, MD, FAAD, FAACS
Page 7
Customizing Treatment to Enhance the Zygoma and Maxillary Regions:Case Presentation
Wm. Philip Werschler, MD, FAAD, FAACS
Page 9
Fillers for Facial Enhancement:Focus on the Mandible and Perioral Region
Gary D. Monheit, MD, FAAD, FAACS
Page 12
Ethnic Considerations in the Use of Fillers
Pearl Grimes, MD, FAAD
ModeratorWm. Philip Werschler, MD,FAAD, FAACSAssistant Clinical Professor
Medicine and Dermatology
University of Washington
Seattle, Washington
Pearl Grimes, MD, FAADClinical Professor of Dermatology
University of California
Los Angeles, California
Gary D. Monheit, MD, FAAD, FAACSTotal Skin and Beauty
Dermatology Center
Associate Clinical Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama
Dear Colleagues:
Faculty Contents
Facial Shaping: Cheeks are the New LipsA proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
FacialShaping_Rd01_02.qxd 2/11/09 4:15 PM Page 3
Glance at someone, and in that briefest instant you are aware
of their relative age: child, youth, adult, or senior. Regardless of
gender or ethnicity, we are all capable of recognizing the youth-
ful face, because certain characteristics are universally present
(or absent).
Many authors and researchers have published anatomical
descriptions and ratios meant to guide surgeons in planning cos-
metic or reconstructive surgery. Much of this information is readi-
ly available to patients.1,2 As an alternative, Figure 1 illustrates the
characteristics of a youthful, attractive female face from a clinical
perspective. While the details vary with ethnicity, beginning with
the forehead and eyebrow, there is a pronounced elevation of the
brow above the orbital rim, especially laterally. This results in an
opening of the aperture of the globe, by supporting the upper eye-
lid, giving a “wide-eyed” alert appearance. The forehead overlying
the frontalis is smooth with a sharply demarcated hairline. The
glabellar complex is smooth in repose and the medial brow is sim-
ilarly supported above the bony rim.
Continuing with the nose, the bridge tends to be straight; the
tip or lobule of the nose is heart shaped; the columella, which
typically hangs inferiorly is well defined, and opens up the
nasolabial angle. The nasal sidewall to the medial cheek junc-
tion — the nasofacial angle — is smooth and rounded, with a roll
of soft tissue extending up onto the nasal sidewall. A pronounced
malar fat pad provides lift and supports the upper lip, commis-
sure, and to some extent the prejowl area. It also tends to push
up the lower eyelid, and blends seamlessly laterally with the
zygoma, forming the structure of a youthful widened midface.
The lips are full and well defined with a distinct border separat-
ing the mucosal and keratinized components. Typically the
lower lip has a more pronounced protrusion volume than the
upper lip. However, ethnic variability in the shape, size, and pro-
portion of lips may be significant.
The mandibular sweep is curvilinear and smooth. It extends
from the chin, across the angle of the jaw and up to the ear
4 Supp lement t o The Journa l o f C l in i ca l and Aes the t i c Dermato l og y [March 2009 • Vo lume 2 • Number 3 ]
Anatomy of the Aging FaceWm. Philip Werschler, MD, FAAD, FAACS
AbstractToday, nonsurgical techniques play a primary and complementary role in reversing age-related changes. However, the optimal
selection and application of these treatment options to ensure the best results for our patients are major issues of debate. Many
anatomical descriptions and ratios have been published that attempt to guide clinicians in planning cosmetic or reconstructive
surgery. In this article, the features that characterize a youthful appearance and the changes that accompany aging are discussed
from a clinical perspective. In addition, the goals and concept of nonsurgical total facial rejuvenation are introduced, as well as
its value as an educational tool to guide patients’ expectations.
Figure 1. Characteristics of a youthful face (reproduced with
permission, Irene Matiatos Russo, PhD).
FacialShaping_Rd01_02.qxd 2/11/09 4:15 PM Page 4
where the earlobes are smooth, full, and rounded with variable
attachment geometry. The zygomata (cheekbones) are well
defined and support the lateral face, providing structural defini-
tion. This is important for maintaining balance and symmetry,
especially as the boundary between the face and neck are con-
cerned. The bony midface structure helps define the transition
from face to neck, developing the lateral jawline and medial
transition from chin to horizontal submental neck.
Facial Aging and Volume LossAs the face ages, the characteristic taut inverted triangular
shape of youth that extends laterally from the top of the zygo-
mata down to the muscularis mentalis point of the chin becomes
inverted. Jowls form, bones and muscles atrophy, the dermis
sags, and the face takes on an upright triangular shape. The
base is the broadened chin and prejowl area, with the sides
framed by the nasolabial folds and marionette lines, culminat-
ing with the apex at the nasal radix (Figure 2).
The changes that underlie these observations are more com-
plex than once thought. As the face ages, both hard (bone, carti-
lage) and soft (muscle, fat, dermis) tissues undergo transforma-
tion. In addition to actual volume loss (atrophy, osteopenia)
there is a progressive alteration of the relative size, distribution,
and proportion of tissue. Combined, these effects of biologic tis-
sue atrophy and remodeling may be termed “biometric volume
loss and alteration” (BVL/A). As an example of the evolving
nature of the understanding of BVL/A, recent dissection studies
of facial fat have been published.
We now understand that malar fat is actually comprised of
three separate compartments: medial, middle, and lateral tem-
poral-cheek fat, while the nasolabial fold is a discrete unit with
distinct anatomical boundaries The forehead is similarly com-
prised of three anatomical units including central, middle, and
lateral temporal-cheek fat. Orbital fat is noted in three compart-
ments determined by septal borders. Jowl fat is the most inferi-
or of the subcutaneous fat compartments. Structures previously
referred to as “retaining ligaments” are actually formed by
fusion points of adjacent septae.3 Drs. Rod Rohrich and Joel
Pessa from the University of Texas Southwestern Medical
Center propose that facial aging is not a uniform and contiguous
process. Rather, it is a combination of volume loss and reposi-
tioning between different compartments occurring in a dynamic
process.
Comprehensive Facial RejuvenationNonsurgical total facial rejuvenation (NSTFR)4,5 — a nonsur-
gical approach to facial restoration, rejuvenation, and enhance-
ment — attempts to aesthetically manage the changes that
transform the youthful facial architecture to the typical features
of the aging face. It combines structural and volumizing fillers
with toxins, lasers and light sources, peels and resurfacing, and
skin care with daily sunscreen to meet each patient’s specific
needs (Table 1).
Facial Shaping: Cheeks are the New LipsA proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
[March 2009 • Vo lume 2 • Number 3 ] Supp lement t o The Journa l o f C l in i ca l and Aes the t i c Dermato l og y 5
Figure 2. As the face ages, the characteristic triangle shape (1) that
extends across from the top of the malar zygomata and the point
extending down to the muscularis mentalis of the chin becomes
inverted (5) (reproduced with permission, Irene Matiatos Russo, PhD).
Table 1.
Nonsurgical Total Facial Rejuvenation (NSTFR):The five key components
Step 1. Neuromodulation of hyperdynamic facial musculature to
reduce dynamic rhytids
Step 2. Volume replacement and facial shaping with stimulatory
fillers (poly-L-lactic acid, calcium hydroxylapatite)
Step 3. Focal area enhancement and correction (lips, tear troughs,
fine lines) with replacement fillers (hyaluronic acids, collagen)
Step 4. Resurfacing and tightening of dermal collagen mask utilizing
lasers, light sources, radiofrequency and optical (LLRO)
devices plus chemical exfoliation
Step 5. Comprehensive skin care regimen, including daily sunscreen
FacialShaping_Rd01_02.qxd 2/11/09 4:15 PM Page 5
The goal of NSTFR is to create balance and symmetry among
three facial treatment zones.5,6 These include the upper facial
treatment zone, which overlaps with the middle facial treatment
zone, which in turn overlaps with the lower facial treatment
zone and includes the submental and anterior cervical portions
of the neck (Figure 3).
From this perspective, patients can be taught to approach facial
rejuvenation as a series of treatments that improve each zonal
area of the face, rather than individual lines and wrinkles. This
systematic approach offers patients the option of addressing their
needs and desires in a prioritized fashion resulting in an overall
more satisfying, aesthetically pleasing, naturally balanced visage.
By including the patient in the decision-making process, this
approach may lead to greater patient satisfaction as well.7
ConclusionToday, cosmetic treatment of the aging face extends beyond
simply using fillers for lines and wrinkles. Rather, the goal is to
restore lost volume in the mid-to-lower face. Indeed, we are mov-
ing from removing lines and filling wrinkles to true facial shap-
ing as an art form.
Facial shaping agents — especially injectable fillers — make
it possible to add volume and more closely offset the muscle, fat
and dermal atrophy, and redistribution (BVL/A) that contribute
to biometric volume loss of the face. The succeeding articles in
this series focus on application of fillers to achieve NSTFR.
References1. Anonymous. Facial Analysis and Symmetry: Section 1.
Ideal Beauty. 2006. Accessed 12/9/08. Available at URL:
http://www.yestheyrefake.net/ideal_beauty.htm
2. Stevens R, Calhoun K. Facial Analysis. Dr. Quinn’s Online
Textbook of Otolaryngology. 1007. http://www.utmb.edu/
otoref/grnds/facial2.html. Accessed December 9, 2008.
3. Rohrich RJ, Pessa JE. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery. Plast
Reconstr Surg. 2007;119:2219–2227.
4. Werschler WP. The aging face and nonsurgical total facial
restoration. Cosmet Dermatol. 2006;19:3.
5. Werschler WP. Combining advanced injection techniques:
poly-L-lactic acid as the foundation for nonsurgical total facial
rejuvenation and restoration. Cosmet Dermatol. 2007;20
(2 Suppl 1):9–13.
6. Kirn F. Fillers changing cosmetic approach. Skin and Allergy
News. 2008. http://findarticles.com/p/articles/mi_hb4393/
is_/ai_n29403701. Accessed December 9, 2008.
7. Werschler WP, Fried R. The key to mastering cosmetic derma-
tology patient selection. Skin & Aging. 2006; 14(10):42–50.
Facial Shaping: Cheeks are the New LipsA proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
6 Supp lement t o The Journa l o f C l in i ca l and Aes the t i c Dermato l og y [March 2009 • Vo lume 2 • Number 3 ]
Figure 3. Three facial treatment zones, including the upper
facial treatment zone, which overlaps with the middle facial
treatment zone, and in turn overlaps with the lower facial
treatment zone and includes the submental and anterior
cervical portions of the neck (reproduced with permission,
Irene Matiatos Russo, PhD).
FacialShaping_Rd01_02.qxd 2/11/09 4:15 PM Page 6
Several structural fillers are available to achieve dermal structur-
al support and volume replacement. However, calcium hydroxylap-
atite (Radiesse®) and poly-L-lactic acid (Sculptra®) are most com-
monly used. General guidelines for the use of these products are pre-
sented in Table 1. Technique subtleties include the angle at which
the needle should penetrate the skin, the discrete depth at which the
material should be inserted, the volume deposited per needle pass,
and the technique of needle tracking (thread, fan, depot, serial punc-
ture, etc.).1 For the vast majority of these devices, the actual volume
deposited during each injection is minimal.2
Case HistoryThis 70-year-old Caucasian woman is retired and lives an
active life in a resort community. She has marked changes in the
upper, middle, and lower face, characteristic of the aging
process. The original triangular facial shape has morphed to a
trapezoidal contour. As a first step in her treatment, correction
of the descent of facial soft tissues will help return this patient
to a more aesthetically appealing, age-appropriate appearance.
Following application of a lidocaine and tetracaine topical anes-
thetic (Pliaglis® Cream), treatment begins by adding poly-L-lac-
tic acid (reconstituted with 5mL sterile water for injection +
3mL 1% lidocaine with epinephrine) to create volume to the
midface over the maxilla, the nasolabial fold, the modiolus and
labial mental sulcus, and finally the lateral canthal region.
MidfaceThe skin is pinched and the 25-gauge x 11/2-inch needle insert-
ed through the dermis perpendicular to the skin surface (Figure 1).
The needle is then advanced horizontally (parallel to skin surface)
along the subdermal plane. As the needle is withdrawn, poly-L-lac-
Customizing Treatment to Enhance the Zygoma and Maxillary Regions:Case PresentationWm. Philip Werschler, MD, FAAD, FAACS
AbstractThe patient is a 70-year-old woman with marked changes in the upper, middle, and lower face. The original triangular facial
shape has become trapezoidal. Her goal is to “look good for her age,” especially when compared to her peers. The objective in this
article is to illustrate the appropriate use of a structural, collagen-stimulating filler to achieve dermal structural support and
volume replacement, as the first procedure in a series of nonsurgical total facial rejuvenation treatments.
Table 1.Comparative injection technique guidelines for two commonly used structural fillers:calcium hydroxylapatite and poly-L-lactic acid2
Product Technique
Calcium Injected with a 27-gauge (5/8", 3/4", 1", 11/4") needle hydroxylapatite angled at 45°, moving steadily through the (Radiesse®) dermis to the juncture of the subcutaneous space
Needle angle is adjusted until parallel to theskin surface, then advanced to the distalportion of the target area
Product is implanted at a constant rate ofneedle withdrawal for smooth, even delivery
0.1 to 0.3mL implanted per injection
Multiple injections can be made in an area
Do not overcorrect or inject intradermally
Poly-L- Tunneling (threading) and depot-typelactic acid injections are used. 25 gauge 5/8", 1", 11/2"(Sculptra®) or 26 gauge by 5/8"
During tunneling, the skin is made taut opposite to the direction of injection, and the needle is introduced at 30° to 40° into the deep dermal subcutaneous plane
Needle angle is lowered and then advanced at this level
Ensure that a blood vessel has not been enteredby using a reflux maneuver before injection
Deposit 0.1 to 0.2mL as needle is withdrawn,leaving a visible and palpable elevation of the skin
Avoid deposition into the superficial dermis
Massage after each injection
[March 2009 • Vo lume 2 • Number 3 ] Supp lement t o The Journa l o f C l in i ca l and Aes the t i c Dermato l og y 7
FacialShaping_Rd01_02.qxd 2/11/09 4:15 PM Page 7
tic acid (~0.3mL per 11/2 inch needle pass) is injected using a linear
threading and fanning technique. This process is repeated working
down the midface area and into the lateral canthal area using a
fanning technique.
Lateral Canthus and Tear TroughAfter a single fanning injection along the lateral canthus, the
patient receives a single injection just below the area of the tear
trough (Figure 1). The injections are placed in the subdermis, lift-
ing the cheek to eyelid junction at the level of the arcus of the skin.
Nasolabial Fold In preparation to inject along the nasolabial fold, the needle is
inserted subcutaneously at the level of the modiolus and
advanced along the nasofacial groove. Using a fanning tech-
nique, poly-L-lactic acid is injected each time as the needle is
withdrawn. The needle does not exit the skin during the fanning
injection technique.
As the needle is redirected toward the nasal columella, it is
necessary to move the tip of the needle across a compound curve.
This involves lifting and adjusting the tip of the needle as it
advances to maintain its position in the tissue plane and avoid
placing the tip too superficial or deep. The final injection in the
sequence is placed just above the vermillion space (Figure 2).
Modiolus and Labial Mental SulcusA small amount of poly-L-lactic acid is injected at the level of
the modiolus. This is particularly important when oral commis-
sure correction is a treatment objective. This sequence concludes
with fanning injections at the labial mental sulcus (Figure 2).
Canine Fossa and Alar (Nasofacial) GrooveRestoring volume to the alar groove and canine fassa to com-
pensate for bone loss is critical in order to define the smooth con-
tour of the area and help restore the supporting nature for the
upper lip (Figure 3).
ConclusionAs the resources, capabilities, and skill sets of cosmetic sur-
geons and aesthetic dermatologists continue to develop and
improve, it is time to move on from simply correcting superficial
facial lines and wrinkles toward a more global understanding
and approach of the dynamics of facial aging. To this end, appli-
cation of a collagen stimulator structural filler to initiate the
treatment regimen provides the foundation for succeeding treat-
ments with volume replacement fillers, toxins, lasers, skin care,
and other procedures.3,4
References1. Werschler WP, Narurkar VN. Facial volume restoration: selecting
and applying appropriate treatments. Technique poster. Cosmet
Dermatol. 2006;19(Suppl 2):S1.
2. Vleggaar D, Forte R. Cosmetic injectable devices: a review of the
injection techniques. J Drugs Dermatol. 2006;5:951–956.
3. Werschler WP. Combining advanced injections techniques: inte-
grating new therapies into clinical practice. Cosmet Dermatol.
2008;21(2):3–6.
4.Werschler WP, Smith SA. Mechanism of action of poly-L-lactic acid: a
stimulatory dermal filler. J Drugs Dermatol. 2007;6(1 Suppl):18-20.
Facial Shaping: Cheeks are the New LipsA proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
8 Supp lement t o The Journa l o f C l in i ca l and Aes the t i c Dermato l og y [March 2009 • Vo lume 2 • Number 3 ]
Figure 3. Two injections of poly-L-lactic
acid are placed in the mid-dermis, lifting
the alar groove and canine fassa in order
to lift and define the smooth contour of
the area.
Figure 1. The photo shows linear threading
and fanning injections in the midface
(A, B, and C) and into the lateral canthal
area (D). After inserting the needle through
the dermis perpendicular to the skin surface
and advancing it horizontally along the
subdermal plane, poly-L-lactic acid is
injected as the needle is withdrawn.
Figure 3. Injecting poly-L-lactic acid
along the nasolabial fold using a fanning
technique toward the nasal columella and
just superior to the vermillion space (A).
A single injection is also made at the level
of the modiolus (B), and a fanning injection
at the labial mental sulcus (C).
FacialShaping_Rd01_02.qxd 2/11/09 4:15 PM Page 8
Facial aging is the cumulative response to complex ongoing
changes in bone, muscle, fat, and skin. Accordingly, it is not sur-
prising that familiarity with the use of only one or two fillers is
unlikely to achieve optimal facial rejuvenation. To assist cos-
metic surgeons and aesthetic dermatologists in becoming more
expert in the use of a range of facial fillers, this article com-
pares the commonly used products in aesthetic practice today,
with emphasis on important differences that affect treatment
outcomes.
Adipose Tissue and Skeletal Changes Over TimeRecent study results provide insight into the underlying
changes in fat and muscle tissue that contribute to facial aging.
It is now understood that subcutaneous facial fat is partitioned
into multiple, independent anatomical compartments.1 For
example, malar fat is composed of three separate compartments
(ie, medial, middle, and lateral temporal cheek fat), while the
nasolabial fold is a discrete unit with distinct anatomical bound-
aries. Orbital fat is partitioned in three compartments deter-
mined by septal borders. Some of the structures referred to as
“retaining ligaments” are formed simply by fusion points of
abutting septal barriers of these compartments. Researchers
concluded that facial aging is, in part, characterized by how
these compartments change with age. The concept of separate
compartments of fat suggests that the face does not age as a con-
fluent or composite mass, and shearing between adjacent com-
partments may contribute to soft-tissue malposition. For exam-
ple, the depth of the nasolabial fold is a result of the descent of
the malar fat pad pushing on an atrophic perioral border. A nat-
ural correction of the phenomenon thus requires more than fill-
ing the wrinkle, but rather blending the units requiring volume.
With regard to specific bony aspects of the face, researchers at
Stanford University Medical Center report that the glabellar
and maxillary angle in males and females decrease with
increasing age.2 There is also a significant increase in pyriform
aperture area from the young to the middle aged. These findings
suggest that the appearance of the aged face is influenced by
dramatic changes in bony elements of the midface, coupled with
soft tissue changes.
Categorizing Facial FillersFacial wrinkles are cumulative with aging, and successful
treatment requires appropriate selection and application of
facial fillers to meet specific needs. The products listed in
Table 1 can be grouped into two categories. These include
structural fillers, which replace the lost underlying support
structures. Examples include fat, poly-L-lactic acid, and cal-
cium hydroxylapatite. Volume fillers can be placed over
structural fillers to correct lines and wrinkles locally.
Examples include hyaluronic acid and collagen. Table 2 clas-
sifies fillers based on the indication for use and the author’s
experience. It illustrates that many products containing
hyaluronic acid are marketed, and although they are inject-
ed in a similar fashion, they are not completely interchange-
able due to differences in physical characteristics.3
[March 2009 • Vo lume 2 • Number 3 ] Supp lement t o The Journa l o f C l in i ca l and Aes the t i c Dermato l og y 9
Fillers for Facial Enhancement:Focus on the Mandible and Perioral RegionGary D. Monheit, MD, FAAD, FAACS
AbstractIt was once thought that the aging process was a result primarily of gravity and sagging skin. Contrary to this commonly held
belief, it is now recognized that facial aging is a complex cumulative response to ongoing atrophy and changes in bone, muscle,
fat, and skin. Successful aesthetic outcomes require sophistication and skill in the proper selection and application of a range
of injectable devices to successfully address these changes. This article compares the commonly used fillers in aesthetic practice
today, with emphasis on selected product characteristics that may affect treatment outcomes.
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Fat Autograft Muscle Injection Fat augmentation has been a popular structural filler, despite
the fact that longevity and symmetry of the procedure can be
unpredictable. In addition, when large volumes are injected for
panfacial correction, prolonged edema may result for months.
To address these deficiencies, a relatively new technique
known as fat autograft muscle injection (FAMI) for fat augmen-
tation was developed. When using FAMI, fat is harvested in an
atraumatic and sterile manner, centrifuged, and injected with
specific blunt-tipped cannulae for different muscle groups.4 In
one report, 100 patients were injected with volumes ranging
from 3 to 63mL of centrifuged fat in a single session. There were
no complications, and downtime was 5 to 7 days. Patient satis-
faction was reportedly high during the subsequent 3 to 6
months. The authors concluded that FAMI offers the potential
for symmetric, long-term results.5
The key to long-lasting fat filling is:• Atraumatic harvesting• Microdoplet delivery• Deep injection with adequate blood
supply to support the fat graft
Poly-L-Lactic AcidVolume restoration following injections of poly-L-lactic acid
occurs gradually, and is incremental over the course of 3 to 6 ses-
sions. The results last up to 2 years with repeated treatment.
The official product information instructs reconstituting the
lyophilized powder using 3 to 5mL of sterile water for injection.
The author prefers to reconstitute the product in 9mL of sterile
water, adding an additional 1mL lidocaine prior to injection.
After waiting for at least two hours but up to 72 hours, the
reconstituted product is agitated prior to withdrawing the con-
tents and repeatedly during treatment.6 Correct injection tech-
nique and massage of the treated area may reduce or eliminate
the occurrence of device-related adverse events such as subcuta-
neous papules and nodules.7 In one study where massage signif-
icantly decreased the incidence of subcutaneous papules, the
treated area was massaged by the physician for five minutes fol-
lowing treatment and twice daily by the patient for the next
month.8 In the author’s experience, using 10mL to reconstitute
the product results in a dilution that works well during injec-
tions and reduces the risk of developing nodules and papules.
Calcium HydroxylapatiteCompared with poly-L-lactic acid, where the response to
treatment is delayed due to increased collagen deposition, the
clinical response to calcium hydroxylapatite is related to injec-
tion volume.9 In addition, the microspheres act as a “scaffold” to
promote collagen in-growth.
Five minutes following an injection, the correction appears to
expand. Massage following injection corrects inconsistencies. As
treatment-related swelling can mask the degree of actual cor-
rection, additional treatment may have to be delayed until
swelling subsides.7 Clinical results last up to 18 months.9
Collagen and Hyaluronic AcidAmong the local volume fillers, many of the collagen-based
products have flow characteristics that facilitate injection and
are forgiving if mistakes are made. However, the less viscous
products tend to be more technique sensitive. A gradual thicken-
ing of the skin does not occur following injection of collagen.7
Hyaluronic acids are similar to collagens in their longevity
and injection technique. They give correction through pure vol-
ume augmentation and immediate effect.
Hyaluronic acid is particularly useful for patients who may
react to collagen fillers or desire immediate and predictable clin-
10 Supp lement t o The Journa l o f C l in i ca l and Aes the t i c Dermato l og y [March 2009 • Vo lume 2 • Number 3 ]
Table 1.
Introduction of fillers over three decades
1972 1975 2002 2004 2006 2008
Collagen Collagen Collagen HA HA Collagen
Zyderm® Zyplast® Cosmoderm® Captique® Juvéderm® Evolence®
Fibrel® Cosmoplast® Calcium hydroxylapatite PMMA HA + lidocaine
HA Radiesse® Artifill® Prevelle®
Restylane® Poly-L-lactic acid Elevess™
Hylaform® Sculptra®
HA: Hyaluronic acid; PMMA: Polymethylmethacrylate
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ical improvement, without the need to wait several weeks for
the results of skin tests.10 A range of hyaluronic acid-containing
products is available. Because each differs in rate of cross-link-
ing, size, formation of hyaluronic strands or particles, and con-
centration, they should be injected into different dermal levels.
For example, Perlane® should be injected deeply into the dermis.
Restylane® is injected into a slightly higher dermal plane, as is
Juvederm®, which delivers a soft, natural result because of its
flow characteristics.
ConclusionA variety of injectable fillers have become available over more
than three decades. These products are not identical. Each
requires an appreciation of its characteristics and a skilled
injection technique, as subtle variations directly influence the
cosmetic result.
References1. Rohrich RJ, Pessa JE. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery. Plast
Reconstr Surg. 2007;119:2219-2227.
2. Shaw RB Jr, Kahn DM. Aging of the midface bony elements:
a three-dimensional computed tomographic study. Plast
Reconstr Surg. 2007;119:675-681.
3. Andre P. Hyaluronic acid and its use as a “rejuvenation” agent
in cosmetic dermatology. Semin Cutan Med Surg. 2004;
23:218-222.
4. Butterwick KJ. Fat autograft muscle injection (FAMI): new
technique for facial volume restoration. Dermatol Surg. 2005;
31:1487-1495.
5. Butterwick KJ, Lack EA. Facial volume restoration with the
fat autograft muscle injection technique. Dermatol Surg.
2003;29:1019-1026.
6. Sculptra Official Prescribing Information. Dermik
Laboratories. A business of sanofi-aventis U.S. LLC.
Bridgewater, NJ 08807. June 2006.
7. Vleggaar D, Forte R. Cosmetic injectable devices: a review of
the injection techniques. J Drugs Dermatol. 2006;5:951-956.
8. Unemori P, Eden C, Conant M. Twice-daily massage can
reduce papule formation among HIV-infected patients receiv-
ing poly-L-lactic acid injection. Interscience Conference on
Antimicrobial Agents and Chemotherapy, 2005; Washington,
DC, USA.
9. Sengelmann RD. Exploring Management Options for Facial
Lipoatrophy: Focus on Semipermanent Fillers. Medscape.
2006. http://www.medscape.com/viewprogram/5213. Accessed
December 11, 2008.
10. Grimes P. Aesthetics and Cosmetic Surgery for Darker Skin
Types. Conshohocken, PA: Wolters Kluwer Health;
2007:225.
Facial Shaping: Cheeks are the New LipsA proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
[March 2009 • Vo lume 2 • Number 3 ] Supp lement t o The Journa l o f C l in i ca l and Aes the t i c Dermato l og y 11
Table 2.
Use of fillers based on the author’s experience
Primary Indication Occasional Never
Superficial fine lines Zyderm® Juvéderm® Ultra Perlane®
Cosmoderm® Captique® Radiesse®
Evolence Breeze® Restylane® Sculptra®
Artefill®
Medium depth grooves Zyplast® Juvéderm® Plus Sculptra®
Cosmoplast® Radiesse® Silicone®
Juvéderm® Ultra Perlane® Artefill®
Restylane®
Deeper folds Perlane® Restylane® Zyderm®
Juvéderm® Ultra Plus Sculptra® Cosmoderm®
Radiesse® Silicone®
Artefill®
Evolence®
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All racial ethnic groups have a keen interest in procedures to
enhance aesthetic appeal. For many minorities, cosmetic sur-
gery is no longer viewed as a sign of self-hatred or a rejection of
racial identity. It is about enhancing natural beauty.1
Growth in Aesthetic ProceduresThe overall frequency of cosmetic procedures among
patients of color has increased to about 20 percent and is
climbing.2 Data from the 2007 American Society for Facial
Plastic and Reconstructive Surgery survey of members sup-
port this view. Over the past eight years, the numbers of cos-
metic surgical patients have increased among African
Americans (40%), Hispanics (19%), and Caucasians (7%). Only
among Asian Americans was there a reduction in cosmetic sur-
gical patients (-8%).3
Injectable fillers and botulinium toxin injections are among
the cosmetic procedures most commonly performed in darker
racial ethnic groups. Other procedures reflect a broad range of
needs and aesthetic expectations. They include chemical peels,
microdermabrasion, laser hair removal, liposuction, and breast
implants. Nonablative resurfacing procedures, including intense
pulsed light and radio-frequency procedures are also increasing
in popularity.1
With respect to surgical procedures, African Americans
are most likely to undergo rhinoplasty (63%), as are
Hispanics (45%). Asian Americans are most likely receiving
blepharoplasty or eyelid surgery (39%), while Caucasians
are evenly split among rhinoplasty (27%), blepharoplasty,
(24%) and face lifts (26%).3
Cultural ConsiderationsIt is important to understand what is culturally acceptable to
patients of color and what is desired. Individualization is key, as
there is natural variation that can affect treatment decisions.
For example, patients may want to maintain the features they
view as part of their ethnicity. Also, some races are more likely
to opt for certain cosmetic procedures than others. Lip augmen-
tation is common among Caucasians. Yet, few African American
women request this procedure. Once these factors are consid-
ered, clinicians must select the appropriate treatment(s), and
adjust their application to achieve an aesthetically pleasing yet
culturally acceptable outcome.
Considerations in Injection TechniqueIt is important to optimize correction techniques. To do other-
wise is a disservice to the patient. Techniques such as cross-
hatching and fanning are used for optimal correction of moder-
ate-to-severe nasolabial folds. Considering the propensity for
darker skin to develop post-inflammatory hyperpigmentation,
linear threading is preferred to serial puncture. However, there
are some areas of the face (eg, marionette lines) where serial
puncture is performed, without increasing the likelihood of caus-
ing post-inflammatory hyperpigmentation.
12 Supp lement t o The Journa l o f C l in i ca l and Aes the t i c Dermato l og y [March 2009 • Vo lume 2 • Number 3 ]
Ethnic Considerations in the Use of FillersPearl Grimes, MD, FAAD
AbstractThere is no question that injectable fillers are becoming substantially more popular among individuals with darker skin. In this
article, cultural considerations, injection techniques, and safety and tolerability issues during nonsurgical total facial rejuvena-
tion of people of color are reviewed.
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When using cross-hatching and fanning for optimal correction
of moderate-to-severe nasolabial folds, it is important to opti-
mize the correction. To do otherwise is a disservice to the
patient. Prior to injecting, the patient should be advised that a
full correction with a little bruising is desired versus using
insufficient filler to minimize bruising. Bruising can be treated
later, if necessary.2
Safety and TolerabilityPrescribing information for fillers carries a safety warning
regarding the susceptibility to keloid formation and hyper-
trophic scarring. Yet despite this statement, the safety profile
in every study has been outstanding for skin of color. Except
for a slightly higher incidence of post-inflammatory hyperpig-
mentation, no data suggest that patients of color are at an
increased risk of developing keloids or hypertrophic scars. In
addition, the incidence of post-inflammatory hyperpigmenta-
tion and hypopigmentation is minimal.1,4 In the author’s expe-
rience, dermal fillers tend to have increased longevity in skin
of color.2
ConclusionsThe key to successful facial aesthetic procedures is the same
for all patients. It begins with knowledge of patients’ cultural
expectations as well as their treatment objectives and concerns.
The clinician must analyze each face and be skillful in the
selection and application of products that will best achieve the
desired outcome. Although more data are needed, people of
color do not appear to be at increased risk of hypersensitivity
reactions, bruising, keloids, or hypertrophic scars. As with
Caucasians, the goal of treatment in people of color is to
counter the effects of aging and achieve a natural youthful
appearance.
References1. Grimes PE. Fillers in ethnic skin. In: Aesthetics and Cosmetic
Surgery for Darker Skin Types. Conshohocken, PA: Wolters
Kluwer Health; 2007.
2. Grimes PE, Schneider LK. Injectable fillers in skin of color: An
expert interview with Pearl E. Grimes, MD. Aesthetic Medicine
CME/CE Collection: Volume 1; 2008. http://www.medscape.com/
viewarticle/572083. Accessed December 12, 2008.
3. AAFPRS. American Academy of Facial Plastic and
Reconstructive Surgery. 2007 Statistics on Trends in Facial
Plastic Surgery. file:///%20MCR%20/EHC/EHC0805%20ASC-
DAS%202008/AAFPRS%20survey.html. Accessed December
12, 2008.
4. Grimes PE, Few JW. Injectable fillers in skin of color. In:
Carruthers J, Carruthers A, eds. Procedures in Cosmetic
Dermatology Series: Soft Tissue Augmentation. 2nd ed.
Saunders; 2007:143-150.
Facial Shaping: Cheeks are the New LipsA proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
[March 2009 • Vo lume 2 • Number 3 ] Supp lement t o The Journa l o f C l in i ca l and Aes the t i c Dermato l og y 13
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Evaluation FormA proceeding based on a satellite symposium during the 2008 ASCDAS 7th Annual Meeting & Exhibition
Project ID: 5945 ES 40To assist us in evaluating the effectiveness of this activity and to make recommendations for future educational offerings, please
take a few minutes to complete this evaluation form. You must complete this evaluation form to receive acknowledgmentfor completing this activity.
Please answer the following questions by circling the appropriate rating:1 = Strongly Disagree 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly Agree
Extent to Which Program Activities Met the Identified ObjectivesAfter completing this activity, I am now better able to:Specify nonsurgical treatment options that enhance the mid-face and lower face in order to lift and redefine,
rebalance, and re-proportion the whole face. 1 2 3 4 5
List the indications for the use of dermal fillers for nonsurgical treatment of facial biometric
volume loss and alteration. 1 2 3 4 5
Describe proper injection techniques for facial shaping agents including both replacement and stimulatory fillers. 1 2 3 4 5
Explain ethnic considerations to optimize outcomes with the use of facial shaping agents. 1 2 3 4 5
Overall Effectiveness of the ActivityThe content presented:
Was timely and will influence how I practice 1 2 3 4 5
Enhanced my current knowledge base 1 2 3 4 5
Addressed my most pressing questions 1 2 3 4 5
Provided new ideas or information I expect to use 1 2 3 4 5
Addressed competencies identified by my specialty 1 2 3 4 5
Avoided commercial bias or influence 1 2 3 4 5
Impact of the ActivityName one thing you intend to change in your practice as a result of completing this activity:
Please list any topics you would like to see addressed in future educational activities:
Additional comments about this activity:
Follow-upAs part of our continuous quality improvement effort, we conduct postactivity follow-up surveys to assess theimpact of our educational interventions on professional practice. Please indicate if you would be willing to participate in such a survey:�� Yes, I would be interested in participating in a follow-up survey.
�� No, I’m not interested in participating in a follow-up survey.
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If you wish to receive acknowledgment for completing this
activity, please complete the post test by selecting the best
answer to each question, complete this evaluation verification of
participation, and fax to: (303) 790-4876.
Post Test Answer Key
Request for Credit
Name ___________________________________________________________________
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City____________________________________ State _______ ZIP _____________
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For Physicians OnlyI certify my actual time spent to complete this educational activity to be:�� I participated in the entire activity and claim 1.0 credits.
�� I participated in only part of the activity
and claim ____ credits.
Quiz1. Select the changes that are characteristic
of the aging face.a) Transformation of bone and cartilage
b) Transformation of muscle, fat, and dermal tissues
c) Volume loss (atrophy, osteopenia)
d) All of the above are correct
2. Select the correct statement describing nonsurgicaltotal facial rejuvenation (NSTFR).a) A nonsurgical approach to facial restoration,
rejuvenation, and enhancement
b) Combines fillers with toxins, lasers and light sources,
peels and resurfacing, and skin care
c) Answers a and b are correct
d) Focuses on the correct use of volumizing
(not structural) fillers
3. Three facial treatment zones do not include the submental and anterior cervical portions of the neck.a) True
b) False
4. Select the false statement for injecting calcium hydroxylapatite.a) 0.1 to 0.3mL implanted per injection
b) Multiple injections can be made in an area in
order to overcorrect
c) Do not inject intradermally
d) Answers a and c are incorrect
5. Select the false statement for injecting poly-L-lactic acid.a) Deposit 0.1 to 0.2mL as needle is withdrawn, leaving
a visible and palpable elevation of the skin
b) Massage after each injection
c) Aim for deposition of product into the superficial dermis
d) Answers a and c are incorrect
6. Identify the filler that is not considered “structural.”a) Collagen
b) Fat
c) Poly-L-lactic acid
d) Calcium hydroxylapatite
7. Hyaluronic acids are similar to collagens in longevity, injection technique, and achieving correction through volume augmentation and immediate effect.a) True
b) False
8. Select the cosmetic procedures most commonly performed in darker racial ethnic groups.a) Chemical peels, microdermabrasion
b) Liposuction and breast implants
c) Injectable fillers and botulinium toxin injections
d) Laser hair removal
9. Considering the propensity for darker skin to develop post-inflammatory hyperpigmentation,linear threading is preferred to serial puncture.a) True
b) False
10. Select the accurate statement for using fillers in people of color.
a) Slightly higher incidence of post-inflammatory
hyperpigmentation
b) Increased risk for keloids or hypertrophic scars
c) Post-inflammatory hyperpigmentation and
hypopigmentation is minimal
d) Answers a and c are correct
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