• A larger, smooth forehead with a smaller nose
• Eyebrows that have an arch or gull-wing shape
• Eyes that are set wider apart, creating a bigger look
• Prominent cheekbones
• A heart-shaped taper to the lower face, with a smaller lower-to-upper face ratio
• Full, vermillion lips

The attractive masculine face tends to have:

• An overhanging, horizontal brow with minimal arch
• Deeper set eyes that appear closer together
• A somewhat larger nose
• A wider mouth
• A squared lower face with a more equal ratio of lower-to-upper face proportions
• A beard or coarser texture to the lower facial skin

Aesthetics is a scientific attempt to explain a subjective concept by assigning proportions to various components of the face. Although these proportions may be used to define the ‘ideal,’ ‘attractive,’ or ‘perfect’ face, the real value in studying these principles lies in clarifying the range of normal relationships that exist between facial units. Harmony and balance of the face exists through a wide range of sizes, shapes, and configurations of the individual parts. The cosmetic surgeon must appreciate this in order to understand the changes that the face endures over time.

It has been shown for instance that the combination of hyaluronans such as Restylane and Botox will provide a superior result than either alone for the upper face. Studies have also demonstrated that it is safe and effective to combine previously injected fillers with radiofrequency skin-tightening procedures. Reports have demonstrated that Botox combined with light procedures such as intense pulsed light and laser resurfacing tend to increase the rejuvenation effect. Many practitioners have added facial fillers to this comprehensive rejuvenation philosophy, particularly when using non-ablative light therapy.

Similarly the combination of a rhytidectomy and fat transfer to the cheeks, or filler injection to the perioral region, will not only provide smoother lower facial contours, but will replace the volume that a face lift alone cannot achieve. This is particularly crucial in an individual with a thin, elongated face. A face lift may also reduce the amount of filler needed in the NLFs and marionette lines.

The major limitation of today’s fillers, and a concern of patients, is that they are very temporary in the hands of most practitioners. While this is true, permanency can present unforeseen problems when an individual’s face ages, when there is deepening and subtle repositioning of lines. Perhaps in the future there will be a filler that is easy to inject, inexpensive and remains effective for 2-3 years. Until that time, appropriate education of the patient and combination therapies will result in the highest patient satisfaction.

In contrast to current collagen, Evolence is reported to last up to 12 months in less mobile facial regions such as NLFs. It has a visco-consistency similar to that of hyaluronic acid and can be injected with a 30 gauge needle. Its adverse effect profile is similar to that of commercially available collagen in the United States. Currently, it is not FDA-approved.

Polyacrylamide hydrogel is a nonabsorbable long-term filler. The gel consists of 2.5% cross-linked polyacrylamide covalently bound to 97.5% sterile water. In one animal study, it was highly bioactive inducing a tissue reaction. Yet, it has been used in Europe and Asia for the past decade with excellent results and a minimal complication rate. In a prospective study enrolling 251 patients who were injected primarily in their NLFs, lips and glabellar folds, the effect remained for up to 2 years - though only 101 patients were evaluated at 24 months. Because of its consistency and semi-permanency, hydrogel may be better for NLFs and for panfacial augmentation. Polyacrylamide hydrogel is not FDA approved, but is currently undergoing clinical safety and efficacy trials.

Dressings are generally not needed for injectables, though the donor site for fat transfer will need to be bandaged. Though the patient may not be compliant, it is worth reminding them to try to reduce facial expressions for the first 48 hours. For some fillers such as calcium hydroxylapatite, having the patient gently pat the area injected - without a shearing motion - may help set the material. Pre- and postprocedure photographs are a necessity.

Complications

In addition to allergic reactions, infection and hematomas, which are rare, other adverse events may include asymmetry, granulomas, migration and extrusion. More common than the last three complications is lumpiness and dimpling, which is usually the result of placing the material in too superficial a plane. This ‘bumpiness’ will usually resolve over 1 or 2 weeks without therapy. Massage may expedite resolution of this problem. True granulomas are rare and can be treated initially with a low-dose steroid injection. Larger or persistent granulomas may need to be excised if treatment with intralesional steroid, topical tacrolimus or oral allopurinol is not successful.

Direct injection of lidocaine with epinephrine, particularly in NLFs and marionette lines, will not only make this a much more pleasant procedure, but will reduce bleeding. Generally, waiting 15 minutes will not only allow the anesthesia to take effect, but will reduce any distortion of the target site.  Massaging the  site will provide a more uniform distribution of lidocaine with potentially fewer needle sticks as well as reducing transient swelling.

In terms of injecting fillers such as collagen or hyaluronic acid, there are two techniques, both of which have advantages and disadvantages. For these two substances a 30 gauge needle will suffice. For thicker substances such as Artecoll or calcium hydroxylapatite, a 27 gauge needle is necessary. RJ Maxflo needles, which are also 30 gauge on the outside but 27 gauge on the inside, but permit a higher flow rate, may also be appropriate as they retain their sharpness. Fat injection requires larger gauge needles or specialized Coleman injection cannulae. Many practitioners prefer the threading technique, which injects the filler along either most or the entire length of the defect. These ‘threads’ are injected in toto so that they lie on top of each other. The advantage of this technique is that there are fewer needle punctures, and potentially a smoother result is obtained since it is easier to produce contiguous layering. In contrast, the multiple puncture technique requires several needle sticks. Beads of filler are injected. The advantage of this technique is more control and precise placement. With both methods, the filler is injected as the needle is retracted, thus reducing the risk of vascular injection.

The depth of injection depends on the type of filler. For Zyderm or Cosmoderm, the superficial dermis is appropriate. For Zyplast or Cosmoplast, or hyaluronic acid, the deep dermis (maintaining the needle at a 45-degree angle) provides the best results . Often, using Cosmoplast or hyaluronic acid in the deep dermis and then Cosmoderm more superficially will achieve very satisfying results. The dermal-subcutaneous border or subdermal plane is appropriate for both Artecoll and calcium hydroxylapatite. Fat is layered into the subcutaneous space. For these fillers, it is important not to inject too superficially as this will result in lumpiness and possibly in an increased incidence of granulomas. Of course, too deep an injection technique will result in a less than desirable augmentation. Injecting into the lips requires a great degree of finesse and judgment. While there are a number of different techniques, it is important to inject smoothly along the vermilion border and within the vermilion lip in order to avoid lumpiness.

Traditional fillers have been biodegradable, i.e. absorbed and ultimately excreted. Though these substances can result in hypersensitivity reactions, they have a proven safety record. The disadvantage to these fillers has been their relatively short duration, in some cases necessitating injections every 3 months. Over the past decade semipermanent fillers have been used in Europe, South America and Asia. Several of these fillers are in the final stages of FDA approval. While they do have a longer effect, they may have an increased incidence of granulomas; in many cases the granulomas are of late onset (longer than 1 year after treatment). These fillers tend to have microspheres which are nonbiodegradable. Finally, there are the truly nonbiodegradable, permanent fillers. These substances may play a substantial role in patients with HIV lipoatrophy or stable morphea. Traditionally, they have resulted in a high incidence of granulomas and extrusion, but new formulations may decrease granulomas from these fillers. Ultimately, patient safety is the paramount consideration.

While autologous fat is historically the oldest available filler, bovine collagen in the form of Zyderm I, Zyderm II and Zyplast have been the most frequently used substances until 2003. They can provide excellent results for depressed acne scars, NLFs and lips. The well-known disadvantage of these fillers is the potential for allergic reaction, which necessitates two separate skin tests. Depending on the site, it is rare for collagen to have a significant effect after 6 months. In areas with increased mobility such as the lips, it is unlikely that collagen will remain for more than 3 months. Recently, human collagen has been introduced. It has the advantage of not requiring skin testing, but its duration is similar to its bovine predecessor. There have been other types of collagen derived from cadavers or from the patient. While they also don’t require skin testing, their efficacy is similar to that of human  collagen. Though, as mentioned earlier, these to use in the lips, though in the hands of an experienced practitioner, it can provide outstanding results. The disadvantages of using fat are that the patient must have areas of fat deposits, and fat graft augmentation requires extraction and injection.

The hyaluronic acid group of fillers represents a recent breakthrough for augmentation technology (Fig. 1.4). Because this substance is completely homologous in structure between species it can be generated by both bacteria fermentation and from chicken combs so there is no need for allergy testing. It is a very versatile filler and appears to have a longer effect than earlier collagens. Initially, in Europe, there were reports that at 8 months 80% of the filler remained. However, in a multi-center double-blind, randomized study comparing hyaluronic acid to collagen in the NLFs, its effect appeared to begin to diminish at 6 months. Approved by the FDA in late 2003, it is too early to judge the exact duration of this filler. While hyaluronic acid does not quite have the ease of use of injectable collagen, it still provides excellent long lasting results for the lips, NLFs, marionette lines and acne scars. Compared to collagen, it appears that not as much hyaluronic acid is required to fill a specific defect. Longer lasting hyaluronic acid gels which have larger particles and are cross-linked are now FDA approved and tend to have a longer lasting effect than some of the previous hyaluronic acid products. Two recent trials comparing Perlane, a hyaluronic acid gel (20 mg/mL), to Zyplast and to Hylaform for augmentation of the NLFs, demonstrated superior efficacy and less material needed.
Another recent addition to fillers has been polymethylmethacrylate microspheres. This substance has the advantage of not only remaining in the skin for an extended period of time, but also causing fibrosis around the beads leading to a longer lasting effect. It has been used successfully for the deeper lines such as NLFs and marionette lines. Because of its consistency, it can lead to lumpiness and unevenness in the lips. While it can potentially last for several years, each injection sequence is not as full as one of the biodegradable fillers. Significant granulomas have been reported with Artecoll as with other permanent fillers. However ArteFill, which has succeeded Artecoll and is now FDA approved, has been shown to have a low complication rate over a 5-year period. In the FDA-associated trials, there was a 2.2% rate of adverse effects. Less than 1% was rated as severe. Long-term efficacy at 4-5 years was also significant. In a recent retrospective series of approximately 500 patients, Carruthers and Car-ruthers reported only four patients who had late granulomas. These were treated successfully with triamcinolone injections. Because this filler can be less forgiving than others, the authors emphasized that thorough training and technique are required to produce consistently excellent results and minimal complications.

Calcium hydroxylapatitc (Radiesse™), another semipermanent substance which has been used as a radiologic marker and for vocal cord stabilization, has been used off-label for filling facial lines (it received FDA approval for cosmetic uses in late 2006) (Fig. 1.5). Based on its longevity in these other areas, it was felt that as a facial filler, it may last up to several years. That has not been the case. According to one study, it retains significant effects in NLFs for 6-9 months. In clinical experience it tends to last 10-12 months in less mobile areas of the face. Much less of this substance is needed to fill a particular defect compared to collagen. It is not difficult to inject but it should be injected in the subdermal plane. It is particularly efficacious for NLFs and marionette lines. Because of its viscosity, it is also reasonable to use for hollowing of the cheeks or substantial acne scars. In experienced hands, calcium hydroxylapatite can be very versatile. The prejowl sulcus can be augmented, which provides a smoother jawline, and there have been a number of reports of a ‘nonsurgical rhinoplasty’ using calcium hydroxylapatite. FDA has approved use in HIV patients for lipoatro-phy as well as possible chin augmentation. Similar to Artecoll, calcium hydroxylapatite can lead to lumpiness when used in the lips and this site is not currently recommended for the current formulation of Radiesse.

Poly-1-lactic acid received FDA approval in 2004 for the treatment of HIV-related facial lipoatrophy. It is injected into the subcutis and stimulates fibroplasia. Multiple injections are necessary, but the results for cheek/ malar atrophy have been impressive. In the European trials, the effect remained for 18-24 months. Cosmetic use of this product is considered off-label, but has been used for pan facial augmentation. It is very important to inject this substance in the correct plane. Injection into the dermis will heighten the risk of granulomas.

Silicone has historically been used as a facial filler. There have been reports of granulomas, foreign-body reactions and extrusion. These adverse reactions may have been secondary to impurities. Recently, the microdroplet technique has been advocated with excellent results in selected patients using Silicone 1000. This filler is permanent, and with repeated injections can augment large defects or augment significant areas. It is currently undergoing FDA testing for cheek augmentation in subjects suffering HIV facial lipoatrophy. According to reports, it is easy to use and has had excellent cosmetic results with a minimal side-effect profile as long as the microdroplet technique is used.

Subjects may be helped by prioritizing their concerns and their interest in the various treatments to optimize their appearance. During this discussion, subjects can understand the components of facial aging including lines of dynamic expression, static wrinkles and folds caused by photodamage and elastosis of the skin, and loss of posterior tissue support from bone remodeling and fat atrophy. Treatments appropriate for each component should be explained and outlined. This discussion is particularly important because subjects are more accepting of treatments that they understand and have chosen themselves. Many individuals are well informed because of the Media and the Internet. Some patients may be focused on wanting only one treatment even though it may not be appropriate for their concerns. When it is determined that fillers are the appropriate therapy, several alternatives should be discussed and a choice made as to the most appropriate choice. Outlining normal postoperative sequelae such as bruising, lumpiness and swelling is important as well as the pretreatment discussion of possible adverse events. If the filler is being used in an off-label manner, then this fact should also be discussed with the patient.

A complete medical history including medications and allergies should be taken. As with any other elective surgical procedure, the patient should not take aspirin for at least 8 days, or vitamin E, or nonsteroid anti-inflammatory drugs (NSAIDs) for at least 5 days prior to treatment. If the patient is on Coumadin, the prothrombin time (PT) should be checked. Generally if the PT is under 2.0, then the risk of hematoma or excessive bruising from injection is low. It should also be ascertained whether the patient takes herbal medication such as Gingko Biloba since these can cause bleeding. Some homeopathic medications such as Arnica Montana taken preoperatively are believed to reduce bruising, but this has not been demonstrated in clinical studies.

There are very few absolute contraindications to fillers. A patient with a known allergy to a specific filler would obviously not be a candidate for the procedure. Finally, preoperative photos from the frontal, oblique and profile angles are not only important from a medico-legal standpoint, but are also an extremely important part of subsequent patient satisfaction follow up.

Aesthetic physicians should be aware that glabellar augmentation with deep dermal hyaluronans such as Restylane appear to be safe, unlike injections of autologous fat and bovine collagen, which have caused cases of iatrogenic blindness. In the periorbital region, low viscosity fillers may be used for ‘etched-in’ crow’s feet, particularly those that extend inferior to the inferior orbital margin, past the origin of zygomaticus major on the zygoma.

Some practitioners advocate using filler in the upper eyelid as a substitute for blepharoplasty. In the lower eyelid, restoring this subunit’s volume and contour rather than ritually removing fat has become a guiding principle in restoration of the upper third of the face. The appropriate use of a filler can remove the ‘double bubble’ between the lower eyelid and the upper cheek as well as filling the lateral and inferior nasojugal groove as it extends into the orbitomalar groove bisecting the malar fat pad. Fillers create a more uniform smoothness in the transition between the upper and midface by effacing the tear trough deformity; the subject promptly loses the tired appearance caused by the dark circles and is provided with a more rested, energized appearance.

In the midface, fillers can be used to fill scars from pre-existing asymmetry, and scars resulting from trauma or acne. Two common features of the aging midface are the sinking and effacing of the malar eminence and hollowing, and descent of the cheeks. Fillers can be used to augment this area. The malar region can be directly built up, often by merely adding volume to the cheeks; this will increase the malar prominence and enhance the youthful convex appearance. Similarly, cheek hollowing is often seen in subjects suffering HIV-related facial lipoatrophy. While the thinness of nasal skin may lead to a higher rate of complications or unsatisfactory results, with experience, scars, particularly on the dorsum, can be effectively filled. Occasionally, subscision of the nasal tip to relax skin adhesion to the underlying cartilage is necessary before tip contour can be improved with injected filler.

The most popular anatomic area, and the one with the most prolonged results, is the nasolabial folds (NLFs) also known as ’smile’ lines. The NLFs cross the transition zone between the midface and lower face. Though initially these lines don’t truly reflect the aging process, their deep-ening over time creates an abnormal demarcation between these two major facial regions (Fig. 1.2). The desire of even young patients to fill these lines, which initially are only a function of expression rather than senescence, reflects the aesthetic aspiration for a smooth facial contour and the softening of the vertical depth of these lines, which cause a severe and angry facial expression. A variety of fillers can be used to effectively blunt these lines. A secondary effect of filling these lines will be to increase the profile of the medial cheeks, which is also aesthetically desirable.

The lower face is dominated by the vermilion lips, both in contour and profile. As time passes, the vertical dimension of the vermilion lip may decrease as the vermilion display turns inside the oral cavity. Fine rhytides in the upper lip allow lipstick to ‘bleed’ up into the cutaneous lip, thus giving an obvious and ’smudged’ appearance to the lip borders. Many types of fillers can be used in the lips to enhance and achieve a natural fullness.

Marionette or ‘drool’ lines are a combination of expression, aging, gravity and genetics. In many individuals, these can be not only quite pronounced, but there may be multiple perioral curvilinear depressions lateral and inferior to the oral commissures. Biomechanically, marionette lines are caused by a loss of volume and support combined with a loss of dermal elasticity. While a variety of fillers can be used to reduce them, in older individuals or those with advanced actinic damage and sagging, filling them may create ripples lateral to the injection area. The concurrent use of neurotoxin relaxation (Botox) of the depressor anguli oris, the mentalis and the orbicularis oris will not only improve the aesthetic result but also prolong the longevity of the filler in the highly mobile perioral region.

A sign of aging in the lower face is unevenness of the jawline. This is not only caused by loss of skin elasticity and gravity causing enhancement of the jowl contour, but also because of resorption of the bony mandible and subcutaneous fat. Selective injection of the appropriate filler, particularly in combination with the injection of a supporting strut of filler in the melomental fold and pre-joint sulcus, can create a smooth and robust mandibular line. Though permanent implants are the surgical procedure of choice for increasing chin projection, using injectable filler can create a more prominent chin albeit a temporary one. It may also be useful in allowing the patient to determine if he/she desires a permanent implant.

Aesthetically pleasing features include symmetry, smooth convex contours, and even, homogeneous skin tone and texture. These features may become disrupted by natural disease such as acne or by environmental agents such as sun exposure or trauma, or merely by the inevitable and natural process of aging. Scars caused by acne or trauma leave depressions of varying depth. Depressions of an entire cosmetic unit may be caused by morphea or that of lipodystrophy secondary to infection with the human immunodeficiency virus (HIV] (Fig. l.l). Fine rhytides, particularly in the perioral region can be caused by excessive actinic damage. Loss of maxillary and mandibular bone, subcutaneous fat and dermal collagen result in wider lower facial depressions and perioral grooves such as the melolabial and melomental folds. Any line of facial expression becomes accentuated with age, muscular hyperactivity and volume loss. The previous generations of aesthetic physicians have depended on the algorithm of surgical skin redraping and tightening. In the modern aesthetic world, restoration of facial volume and contour has become the first line of treatment before surgical correction is entertained.

Restoration of facial symmetry and volume, as well as a smooth contour and homogeneous skin tone are the newer goals of the cosmetic surgeon. Leonardo da Vinci divided the face into thirds from the hairline to the chin. Horizontally, the face is approximately the width of five eyes. All of these aesthetic divisions must be taken into consideration in making an aesthetic treatment plan.

The upper, mid and lower face must be in harmony. This is particularly true of the transitions between the different facial zones. In order to achieve these objectives, a comprehensive approach must be taken, and multiple modalities utilized. Fillers play a major role in this process. The appropriate filler can restore symmetry, volume and recreate a smooth skin surface. In combination with other treatments such as chemodenervation with Botox, they may lead to more enhanced aesthetic and longer lasting results.

With the slowly increasing demand for cosmetic procedures beginning in the 1970s, research into collagen production produced a bovine formulation that could be placed in a syringe and injected. Dermatologists and plastic surgeons helped develop this product, though perhaps because of its more minimally invasive nature, dermatologists such as Sam Stegman and Arnold Klein took the lead in its clinical use.

The temporary nature of bovine collagen and the requirement for double skin testing led to the development and testing of other fillers in Europe and Asia in the 1990s. Public demand was fueled by aging baby boomers demanding procedures with no down-time; media hype surrounding lunchtime’ cosmetic procedures placed fillers on center stage along with botulinum toxin (Botox). Fillers could be used as sculpting agents to dramatically change a person’s appearance in a mere 15 minutes. Today, there are a number of fillers to choose from, each with its own strengths, drawbacks and indications. The development of these substances continues, often at a dizzying pace, so it is important for the aesthetic specialist physician to understand the indications and uses of these fillers so that he or she can best serve the patient’s needs.