Introduction
Medical technology is developing a growing number of injectable implants that can fill in the grooves, folds, and hollow areas of the aging face. First there was fat. It was cut out from one area and implanted under the skin of another area. Later collagen was developed which could be injected through a needle into desired areas but it required skin testing to screen for allergies before use. Both products do not last that long. Recently new lines of products have become available that need no skin tests and last longer.
Beauty and youth are associated with symmetry, roundness, and fullness of facial structures as well as good skin tone and texture. Age and disease can dampen this image. Acne can leave scars and pits in the face. Wrinkles form in aging skin. As the skin loses its resiliency, it can sag, deepening lines and folds in the face. Gradual loss of underlying tissue causes hollowed areas and thinning lips. Fillers can be used to treat all these defects. They can fill in acne scars, and hollowed cheeks. The most common use is smoothing over the nasolabial fold (the groove extending from just outside the nostril and running to the corner of the mouth). Drool lines are grooves that run from the corner of the mouth down towards the chin. Fillers can smooth these over as well. Injections can be made into the lips to add definition to the lip border and restoring fullness to the thinning lip body. The wrinkles fanning out from the lips (lipstick lines) can be filled in as well.
Preprocedure Planning
Patients undergoing filler injections should have a medical, social, and physical examination. The patient s concerns and treatment options must be discussed as well as the risks and benefits including possible bruising, lumps, nodules, and swelling. The patient should avoid blood thinners for a week including aspirin, nonsteroidal antiinflammatories, vitamin E, or Ginko. If the patient is on Coumadin, the INR must be below 2.0. Patients allergic to any part of the filler cannot get it. Before and after photographs should be done from the front, side, and angled views.
Choosing the right filler
There are several different types of fillers available. They have been shown to be safe. Many last short periods of time and must be reinjected every 3 months. Newer fillers last much longer but have a higher incidence of nodular scar formation. And if the patient is not happy with the result, the effect is more permanent.
Bovine (cow) collagen was most popular until 2003, as Zyderm I, Zyderm II, and Zyplast. They were used for depressed acne scars, nasolabial folds and the lips. Because of possible allergic reactions, 2 negative skin tests are required before use. The improvement rarely lasts longer than 6 months. Human collagen does not need skin testing but lasts no longer. Fat is cheaper and larger amounts can be used but duration of effect is still short.
The hyaluronic acid fillers are now the most popular fillers. No allergy tests are needed. They last longer than collagen with 80% of the filler still there at 8 months. Another filler is the polymethylmethacrylate microspheres which cause scarring around the beads and are more permanent. Nodular scars have formed with Artecoll, but Artefill has replaced it. It is FDA approved and has a low complication rate, and continued improvement at 4-5 years.
Calcium hydroxylapatite (Radiesse) is a semipermanent filler that can keep its effect in nasolabial folds for 6-9 months and 10-12 months in less mobile areas. It can be used in hollowed out cheeks, bigger acne scars, and for smoothing out the jawline. It is not recommended for lips because of lumpiness.
Poly-l-lactic acid is FDA approved for filling sunken areas in HIV patients. It stimulates scar tissue build up for a more permanent result. A new silicone preparation is being used as a permanent implant. It seems to lack the impurities that were thought to cause nodular scars, inflammation and outward migration of the older formulation.
General Technique
The patient should be sitting up. Anesthesia can be a cream applied 30 minutes prior to injection or as an injectable nerve block. Injections of collagen or hyaluronic acid are delivered with a very small needle. Thicker fillers like Artecoll or Radiesse require a little larger needle and fat needs a larger cannula or tube. Multiple injections are required to place enough filler to cover the defect. Care must be given to injecting filler at the right depth. Too superficial and the implant will be lumpy. Too deep and the effect may not be seen. Post procedure ice is used to reduce swelling and soreness. Post procedure photographs should be done and patients should try not to move the face much for 48 hours.
Injection technique
Complications include allergic reactions, infection, bruising, blood collections under the skin, asymmetrical results, nodular scars, filler movement and the implant pushing out of the skin. Lumpiness may resolve over 1-2 weeks by itself, maybe faster with massage. Nodular scars can be treated with steroid injections.
Combination therapy can maximize improvement. Fillers can be combined with Botox, laser resurfacing, and surgical face lifts.
Filler aesthetics
The term esthetics comes from the Greek term aesthesis meaning a love of what is beautiful. The perfect female face is thought to have a larger smooth forehead and smaller nose, arched eyebrows, eyes set wider apart, prominent cheekbones, full lips, and a smaller lower face. The males have lower horizontal eyebrows, deeper closer set eyes, a larger nose, wider mouth, squared jaw, and rougher lower facial skin.
The aging face
A number of things cause the face to age more. Sun damage is the biggest factor. The rounded face in the young becomes flat or sunken in places because of the deterioration of underlying fat. The facial muscles are always folding the skin. When the folds remain at rest they appear as wrinkles and larger grooves in the face. With age the skin loses elasticity and begins to sag. The cartilage and bone of the face may deteriorate. Because of this, features like the nose may droop. These changes are more difficult to correct. Patients need to understand this and be realistic about what can be changed.
Advanced photoaging
Photoaging
There is a Glogau scale documenting the changes of the aging face. Glogau I patients are in their 20-30’s. They have no wrinkles. Glogau II patients are in their late 30-40’s. Wrinkles appear with facial movements but are not visible at rest. Glogau III patients are in their 50’s and older. Wrinkles occur with movement and remain at rest. They appear from the eyes and around the lips and mouth. Glogau IV patients are in their 60-70’s. Wrinkles cover the entire face.
When discussing cosmetic procedures, the face is divided into thirds. The upper third goes from the top of the forehead to the eyebrows. The middle third goes from the brow to just under the nose. The lower third goes from the nose to the chin.
The upper third
Changes here are from sun damaged skin that wrinkle from underlying muscle activity, leading to forehead lines. The tissue has lost elasticity and the brow begins to sag.
The middle third
Aging effects the areas around the eyes, cheeks and nose. As tissues lose resiliency, the eyelids can droop. Loss of fatty tissue around the eye leads to a sunken appearance leaving patients looking like a skeleton. The cheeks may lose fatty tissue as well and appear flat or sunken. The nose tip may droop as underlying support structures deteriorate.
The lower third
Aging has effects on the lips, chin, lower cheeks, and neck. The loss of skin elasticity allows it to droop off the side of the jaw to form jowls and wattles from the neck. Tissue sagging from the cheeks and around the mouth contribute to the nasolabial fold (groove running from the nostril to the corner of the mouth) and Marionette lines (wrinkles running down from the mouth corners to the side of the chin). Vertical lines form around the lips (lipstick lines) from underlying muscle activity around the mouth. With age the lip margins blur and the lip itself looses fullness. Cupid’s bow, the arch in the center of the upper lip may flatten. Of all other defects on the face, fillers primarily address deep folds, depressed scars, hollowed areas where tissue loss has occurred, and the need for lip augmentation. It should be clearly explained to the patient that it will not remedy defects in bone structure.
Combination therapy can maximize improvement. Fillers can be combined with Botox, laser resurfacing, and surgical face lifts.
Filler aesthetics
The term esthetics comes from the Greek term aesthesis meaning a love of what is beautiful. The perfect female face is thought to have a larger smooth forehead and smaller nose, arched eyebrows, eyes set wider apart, prominent cheekbones, full lips, and a smaller lower face. The males have lower horizontal eyebrows, deeper closer set eyes, a larger nose, wider mouth, squared jaw, and rougher lower facial skin.
The aging face
A number of things cause the face to age more. Sun damage is the biggest factor. The rounded face in the young becomes flat or sunken in places because of the deterioration of underlying fat. The facial muscles are always folding the skin. When the folds remain at rest they appear as wrinkles and larger grooves in the face. With age the skin loses elasticity and begins to sag. The cartilage and bone of the face may deteriorate. Because of this, features like the nose may droop. These changes are more difficult to correct. Patients need to understand this and be realistic about what can be changed.
Advanced photoaging
Photoaging
There is a Glogau scale documenting the changes of the aging face. Glogau I patients are in their 20-30’s. They have no wrinkles. Glogau II patients are in their late 30-40’s. Wrinkles appear with facial movements but are not visible at rest. Glogau III patients are in their 50’s and older. Wrinkles occur with movement and remain at rest. They appear from the eyes and around the lips and mouth. Glogau IV patients are in their 60-70’s. Wrinkles cover the entire face.
When discussing cosmetic procedures, the face is divided into thirds. The upper third goes from the top of the forehead to the eyebrows. The middle third goes from the brow to just under the nose. The lower third goes from the nose to the chin.
The upper third
Changes here are from sun damaged skin that wrinkle from underlying muscle activity, leading to forehead lines. The tissue has lost elasticity and the brow begins to sag.
The middle third
Aging effects the areas around the eyes, cheeks and nose. As tissues lose resiliency, the eyelids can droop. Loss of fatty tissue around the eye leads to a sunken appearance leaving patients looking like a skeleton. The cheeks may lose fatty tissue as well and appear flat or sunken. The nose tip may droop as underlying support structures deteriorate.
The lower third
Aging has effects on the lips, chin, lower cheeks, and neck. The loss of skin elasticity allows it to droop off the side of the jaw to form jowls and wattles from the neck. Tissue sagging from the cheeks and around the mouth contribute to the nasolabial fold (groove running from the nostril to the corner of the mouth) and Marionette lines (wrinkles running down from the mouth corners to the side of the chin). Vertical lines form around the lips (lipstick lines) from underlying muscle activity around the mouth. With age the lip margins blur and the lip itself looses fullness. Cupid’s bow, the arch in the center of the upper lip may flatten. Of all other defects on the face, fillers primarily address deep folds, depressed scars, hollowed areas where tissue loss has occurred, and the need for lip augmentation. It should be clearly explained to the patient that it will not remedy defects in bone structure.
1 comment:
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