According to statistics from the American Academy of Facial Plastic and Reconstructive Surgery, the demand for nonsurgical facial-rejuvenation treatments continues to skyrocket.1 The availability of new injectable facial fillers continues to fuel this trend. There has been a dramatic rise in the number of patients undergoing filler treatments using hyaluronic acid, poly(l-lactic acid) (PLLA), and calcium hydroxyapatite (CaHA).
Since the advent of collagen injections, filler treatments have been associated with filling in rhytides and folds throughout the aging face. Today, their utility has been expanded to produce additional rejuvenation and to deliver a lifted appearance that approaches the results of endoscopic brow lifts, midface lifts, traditional rhytidectomy, and blepharoplasty. Although these treatments lack the longevity of the surgical approach, their wash-and-wear nature and minimal (or no) downtime have made them mainstays of today’s aesthetic facial surgery practice.
Anatomy of Facial Aging
Facial aging reflects the dynamic, cumulative effect of time on the skin, soft tissues, and deep structural components of the face. The aging of the human face has two main components. The first is facial ptosis resulting from the combined effects of gravity and decreases in tissue elasticity. The second is facial deflation with the loss of soft-tissue bulk, fat redistribution, and craniofacial skeletal resorption.
The youthful face is characterized by a diffuse, balanced distribution of superficial and deep facial fat. The aging face is characterized by fat redistribution and skeletal remodeling.
In the upper third of the face, there is a loss of soft-tissue fullness in the infrabrow region, accompanied by temporal atrophy. In the middle third, there is fat loss in the infraorbital and malar regions, along with maxillary resorption accentuated by hypertrophy of fat in the lateral nasolabial fold. In the lower third of the face, mandibular and mental atrophy are accentuated by redistribution of fat to the lateral labiomental crease and jowl.2
Most conventional facelift procedures incorporate lifting and tightening techniques to defy the facial soft-tissue descent that results from atrophy and loss of skin elasticity, but these procedures fail to address soft-tissue atrophy. Restoring the balanced distribution of facial fullness that exemplifies the youthful face is the goal of wrinkle correction using fillers.3 This can be achieved by using autologous fat transfer, but also—and less invasively—by using injectable, semipermanent, bioabsorbable fillers.
Two readily available nonanimal stabilized hyaluronic acid (NASHA) fillers have been approved by the FDA. The first is formulated at a concentration of 20 mg/mL, with 80% of the product cross-linked and 3% to 5% cross-linking between polymers. The second product has a concentration of 24 mg/mL, with 90% of the product cross-linked and 6% to 8% cross-linking between polymers.
The 90% cross-linked version has a hardness of 200 Pa, versus 400 Pa for the 80% cross-linked form; this allows smoother injection. Both NASHA fillers are injected through 30-gauge needles into the mid-to-deep dermis, and have been shown to be superior to collagen They last for approximately 6 months.
The manufacturer of the 90% cross-linked NASHA filler claims that the product has superior longevity and smoother injecting and molding characteristics. Although no prospective randomized trials are available to date, I have noticed greater patient satisfaction, longevity of results, smoothness, and malleability for this product.
A third filler is composed of a suspension of 30% CaHA microspheres in a gel. CaHA filler is now approved by the FDA for the correction of moderate-to-severe facial folds and wrinkles around the nose and mouth, including nasolabial folds.
|Figure 1. Areas most commonly treated in filler wrinkle corrections.|
Treatments are administered through a 27-gauge needle, and the material is delivered into the mid-to-deep dermal plane as well as the subcutaneous plane. More superficial injection is associated with nodularity and white discoloration of the skin (due to the white color of the hydroxyapatite cement). In studies,4 approximately 50% of the correction persisted 12 months after treatment.
A fourth filler is made from PLLA and is widely used, off label, in facial contouring; it has gained FDA approval only for the treatment of HIV-associated facial wasting. PLLA creates volume augmentation associated with a foreign-body reaction. It degrades and is replaced by collagen.
One vial of PLLA is reconstituted with 4 mL of sterile water and 1 mL of 1% lidocaine diluent, and can be used for full facial treatments. The mixture needs to set for 24 hours prior to use. Injections, immediately subdermal for the majority of locations, are performed using a 25-gauge needle.
Three to five monthly treatments are required. The number of treatments needed depends on the degree of soft-tissue loss, and corrections lasting for 1.5 to 2 years are expected after a full series of treatments.5
Injection Location and Technique
Regardless of the choice of filler, a similar injection technique is used. Before treatment, patients are counseled to stop taking aspirin, other nonsteroidal anti-inflammatory drugs, vitamin E, ginkgo biloba, and nutritional supplements other than a multivitamin. Those who bruise easily take three arnica montana 30x sublingual pellets three times daily beginning 24 hours—preferably, 72 hours—prior to treatment.
Patients are anesthetized using a combination of topical anesthetic and nerve blocks. All locations for injection are treated topically with 4% lidocaine cream, applied for a minimum of 10 minutes. Infraorbital and mental nerve blocks using 1% lidocaine (without epinephrine, to avoid tachycardia) are administered by palpating the foramen and injecting 0.5 mL; this amount is used to avoid volume distortion, which would affect the location of filler placement.
|Before & After|
|Figure 2. This 48-year-old female underwent a filler wrinkle correction and received three 0.8-mL vials of 90% cross-linked nonanimal stabilized hyaluronic acid filler. Areas treated included the lateral infrabrow, infraorbital and nasojugal depressions, upper and lateral malar prominences, nasolabial folds, and prejowl sulcus. A brow lift using botulinum toxin Type A was also performed, blocking the brow-depressor muscles. She is shown before and 1 week after treatment.|
Serial parallel passes with a linear retrograde technique constitute the most controlled injection pattern, preventing nodularity and uneven injections with all materials. Reinjecting at an angle of 90° to the initial injection (perpendicular cross-hatching) results in a more even distribution of filler than injecting in one direction only would produce. Serial-point injecting is also used to supplement irregularities left behind after linear threading.
Injection is usually done into the mid-to-deep dermis, with subcutaneous injections and submuscular or supraperiosteal injections used in specific regions. Between injection passes, the material is massaged and smoothed to prevent uneven contouring. In the middle and lower third of the face, bimanual manipulation using one finger intraorally and one on the skin surface allows better sculpting.
One-to-one replacement is practiced, and overcorrection is avoided with these fillers; unlike collagen injections, these fillers are not subject to large volume losses within a week of treatment. Ice is used throughout treatment and for 1 hour after treatment to minimize swelling and potential downtime.
Injectable fillers replace volume in areas of facial soft-tissue loss, as well as support ptotic regions (Figure 1). The results are similar to those of rhytidectomy in many patients, and are most impressive in patients with mild-to-moderate facial aging, who are usually 35 to 55 years old (Figures 2 this page, and Figure 3, page 36).
With greater degrees of ptosis and facial deflation, these techniques, although helpful, do not deliver as satisfactory a result. Often, a combination of different fillers will be used in different regions, depending on the correction longevity requested by the patient, the degree of bulk and consistency required to treat the patient’s deficit, and the skin type and thickness of the area treated.
In the upper third of the face, facial deflation results in drooping of the brow with flattening and thinning of the infrabrow skin, which leads to upper-eyelid hooding. The glabellar region contracts, leading to vertical rhytides. Placing injections in the subdermal plane in the lateral two thirds of the infrabrow region supports the brow, creates a lifted appearance, fills lateral eyelid hooding, and creates a rounded, youthful contour.
Due to the thinness of the skin in this area, filler irregularities are more visible. NASHA fillers result in fewer irregularities than the others because of their softness and malleability. I believe that 90% cross-linked NASHA filler is easier to manipulate; this is corroborated by its reduced hardness compared with the other NASHA gel.
|Before & After|
|Figure 3. This 52-year-old female underwent a filler wrinkle correction and received 2.6 mL of calcium hydroxyapatite filler in the upper and lateral malar prominences, nasolabial folds, and prejowl sulcus, as well as along the mandibular body. She also had 2 mL of 80% cross-linked nonanimal stabilized hyaluronic acid filler injected into the more superficial aspect of her nasolabial folds, infraorbital hollows, lips, and perioral rhytides. A brow lift using botulinum toxin Type A (BTTA) was performed, blocking the brow-depressor muscles, and the oral commissures were turned up by blocking the depressor anguli oris muscles with BTTA. She is shown before and 1 week after the treatments.|
About 0.2 mL is used in this region. The vertical glabellar rhytides in the mid-dermis are filled with NASHA gels so that the central and lateral brow is rejuvenated. A combination of serial-point injections and linear threading is used in the glabella.
In the middle third of the face, multiple depths of injection are required to restore youthful contours. For the nasojugal fold and infraorbital hollows, fillers are placed deeper than the orbicularis oculi muscle in the supraperiosteal plane, using a serial-point injection technique and smoothing massage.6 This creates a flat eyelid shelf, with a smooth transition between the lower-eyelid bag and cheek—a “nonsurgical eye lift.”
Nodularity is a common complication when injections to this plane are more shallow. CaHA, NASHA gels, and PLLA can all be injected in this region. Malar deflation is usually present in these patients, and augmentation over the upper malar eminence, fanning out toward the zygomatic arch, supports the midface and re-creates facial height that has been lost.
Injections are usually in the deep dermis–subdermal plane, and larger volumes are needed because of the larger surface area covered. Often, using 0.5 to 1 mL per side is necessary, depending on the degree of ptosis and volume loss.
Filling of nasolabial folds in the mid-dermis and deep dermis balances the lower midface with the upper midface. NASHA gels can be injected more superficially in the dermis and are a better choice for superficial rhytides on the surface of nasolabial folds. NASHA gels combined with CaHA filler have been shown in prospective studies7 to give greater overall improvement in the nasolabial folds than CaHA filler alone due to the inability to inject CaHA filler more superficially.
In the lower third of the face, skeletal volume loss and facial atrophy create a prejowl sulcus, chin-pad ptosis, and downturning of the corner of the mouth. The prejowl sulcus is filled in the deep dermis and subdermal plane using the crosshatching technique.
Proper injection placement also supports the lateral lip commissures by continuing the injections medially along the inferior aspect of the lower lip. Subdermal injections along the mandibular body and mentum help lend support to the skin and limit the appearance of jowling. All fillers noted above can be used, and because of the surface area treated, 0.5 to 1 mL is often used on each side.
Synergy with Dynamic Suspension
It is now well accepted that using botulinum toxin Type A (BTTA) to manipulate the balance between muscular elevators and depressors can elevate portions of the face. Combining BTTA with the lifting fillers has a greater-than-additive effect and maximizes the wrinkle correction. All uses of BTTA other than treatment of vertical glabellar rhytides are off-label uses.
In the upper third of the face, the corrugator supercilli, orbicularis oculi, and procerus muscles are the major brow depressors, and the frontalis is the major brow elevator. The glabellar complex is blocked with 25 to 40 units of BTTA injected in three to five sites between the medial aspects of the brow and over the radix. Each lateral orbicularis complex is injected with five to 10 units of BTTA in the infralateral brow, starting just lateral to the inner aspect of the lateral orbital rim.
This allows for unopposed frontalis tone and brow elevation medially and laterally. Combining this with NASHA-gel injections can create brow elevations of 3 to 4 mm.8
In the lower third of the face, selectively blocking the depressor anguli oris helps support a downturned lateral oral commissure. Injections are generally directed 1 cm inferior and lateral to the oral commissure, and five units are usually placed per side.
Having the patient grimace and flex the corner of the mouth downward helps guide placement of this injection by identifying the bulk of the muscle. This is the major commissural depressor; once blocked, it allows the oral commissure elevators to act unopposed and can help minimize the prejowl sulcus.
Filler wrinkle correction provides a minimally invasive treatment, with little to no downtime, for facial aging, including facial ptosis and deflation. In the proper candidate, the results can approach those of more invasive surgical lifting procedures.
Major drawbacks include the need for repeat treatment and the high cost of large volumes of soft-tissue fillers and BTTA. Some patients with more advanced facial aging can spend $3,000 to $4,000 per visit and $6,000 to $8,000 per year, which can exceed the cost of some surgical procedures.
This approach should be within the armamentarium of all aesthetic surgeons, and can help patients improve their appearance until they are ready for their eyelid lift, brow lift, or facelift.
|See also “New Life for Lips” by Robert Trow, MS, in the January 2007 issue of PSP.|
Andrew A. Jacono, MD, FACS, a dual board-certified facial plastic surgeon and head and neck surgeon, is the director of the New York Center for Facial Plastic and Laser Surgery, Great Neck, and assistant clinical professor, Division of Facial Plastic and Reconstructive Surgery, New York Eye and Ear Infirmary, New York City. He can be reached at or via his Web site, www.newyorkfacialplasticsurgery.com.
- American Academy of Facial Plastic and Reconstructive Surgery: Trends in Facial Plastic Surgery. February 2007. Available at: [removed]http://www.aafprs.org/media/statspolls/m_stats.html[/removed]. Accessed March 12, 2007.
- Coleman SR, Grover R. The anatomy of the aging face: Volume loss and changes in 3-dimensional topography. Aesthetic Surgery Journal. 2006;26: S4-S9.
- Donofrio LM. Fat distribution: A morphologic study of the aging face. Dermatol Surg. 2000;26:1107-1112.
- Jansen DA, Graivier MH. Evaluation of a calcium hydroxylapatite-based implant (Radiesse) for facial soft tissue augmentation. Plast Reconstr Surg. 2006;118:22S-30S.
- Jones DH, Vleggaar D. Technique for injecting poly-l-lactic acid. J Drugs Dermatol. 2007;6:S13-S17.
- Goldberg RA, Fiaschetti D. Filing the periorbital hollow with hyaluronic acid gel: Initial experience with 244 injections. Opthal Plast Recontr Surg. 2006;22:335-341.
- Godin MS, Majmundar MV, Chrzanowski DS, et al. Use of Radiesse in combination with Restylane for facial augmentation. Arch Facial Plast Surg. 2006;8:92-97.
- Maas CS, Kim EJ. Temporal browlift using botulinum toxin A: An update. Plast Reconstr Surg. 2003;112:109S-112S.