facial shaping: cheeks are the new lips

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

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


“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



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).


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).


[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


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.



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).


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



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.



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).


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


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.


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-


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


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.



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®


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.


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.


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.




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.



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

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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.

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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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