• Basic administration
• Painless
• Outpatient (minimal recuperation)
• User-friendly
• Large amount available
• Easy storage

Material

• Non-allergenic (decreased risk of hypersensitivity)
• FDA approved
• Non-carcinogenic/non-teratogenic
• No migration
• Minimal inflammation
• No overt cutaneous change (undetectable)
• Reproducible
• Durable
• Minimal adverse sequelae
• Stable (inert)
• Affordable

Filler Material

There is an ever-expanding menu of materials and devices for soft tissue augmentation and they can be classified, based on either derivation or site of cutaneous placement. Autologous materials (adipose, collagen) are harvested from the same patient and hence have no risk of immunologic reaction. However they require an initial harvesting procedure and are limited by a potentially limited donor reservoir. Xenografts are semi-synthetic formulations harvested from a different species (bovine and porcine collagen, avain hyaluronic acid derivatives). These are readily available and carry a low risk of infection and rejection. Allograft materials are harvested from human cadaveric tissue, have a minimal risk of hypersensitivity reaction but pose a theoretical risk of infection from the donor tissue. While synthetic substances (expanded polytetrafluoroethylene) may provide longer lasting results and have an unlimited supply, they frequently require surgical insertion, as opposed to injection, and they may cause site-specific mechanical difficulties. The injectable collagen products meet many of the criteria of the ideal product for soft tissue augmentation as they are ambulatory, reproducible, predictable in their effect and FDA-approved, and they have an extensive safety profile.

Lexor, in 1910, used large-block grafts to treat malar depressions associated with chin recession. This was followed by Brunings, who in 1911 first described using the syringe technique to transfer free fat. In 1950, Peer reported 50% survival of transplanted fat using syringe aspiration. Baronders published a review of permanent soft tissue augmentation with liquid silicone in 1953. Although useful when injected by an experienced physician, this product has had a tumultuous history and continues to be controversial. Silicone’s sole approval is for retinal tamponade in patients with retinal detachments. Fortunately, there is an ongoing multi-center study exploring the benefits of injectable microdroplet silicone for patients suffering from facial lipoatrophy due to infection with the human immunodeficiency virus (HIV). Due to the FDA Modernization Act, which allows the use of medical devices off-label, silicone (Silikon 1000, Alcon Inc., Fort Worth, Texas) has been used for off-label indications with increasing frequency for permanent soft tissue augmentation. In fact, when used appropriately by experienced physicians with the microdroplet technique, medical grade silicone has provided good results. However, when administering this product physicians must discuss its use with their medical malpractice carriers because the administration of silicone may not be covered in the event of legal action.

One of the most significant advances in soft tissue augmentation was the introduction of bovine collagen. Initial investigations began in earnest in 1958 and continued through the next 2 decades. In 1981 Zyderm I (McGhan Medical, Santa Barbara, CA) became the first FDA-approved xenogenic agent for soft tissue augmentation. Following this the two additional formulations of bovine collagen, Zyderm II and Zyplast, were granted FDA approval. Until 2003, when the injectable hyaluronic acids became available, bovine collagen remained the most commonly used dermal filler. It is perhaps the success and availability of these products that ushered in a renewed quest for the ideal formulation for soft tissue augmentation. In 2006, following the acquisition of Inamed Corporation (Santa Barbara, CA), all of the commercially available collagen products became available from the sole distributor, Allergan (Irvine, CA).

No two wrinkles are created equal as each has a different derivation, and they vary in shape and size. As such there is no one filler agent that is suitable for all defects.

Therefore treatment should be predicated based on the defect and individualized to each patient’s needs. The selection of the appropriate implant; whether dermal or subcutaneous, temporary or permanent; liquid or solid, requires knowledge of all of the available materials as well as their characteristics. Furthermore filler substances may be used as monotherapy or combined with other dermal implants or other procedures such as resurfacing, botulinum toxin, or surgery.

All other uses, although legal are considered off-label. The primary utility for collagen is augmentation of the central and lower third of the face; the NLF, the peri-oral area: the lips and bolstering the adjacent lateral oral commissures. Other areas that are amenable to soft tissue augmentation with collagen include the marionette lines, soft atrophic scars, and combination therapy: static rhytids that are unresponsive to chemode-nervation with botulinum toxin preparations above the zygomatic arch (the forehead, glabella, peri-ocular regions), and peri-oral area (vertical lipstick lines’, mentalis crease, and the oral commissures).

Fueled by the overwhelming success of botulinum toxin chemodenervation for dynamic rhytides, combined with patients’ demand for ambulatory procedures with little time needed for recuperation, the field of soft tissue augmentation has gained significant momentum and popularity. This has been well chronicled by recent surveys by both the American Society of Dermatologic Surgery, which reported all 2% increase in the use of dermal fillers from 2001-2005, and a second poll by the American Society of Aesthetic Plastic Surgery mirrored this growth and yielded comparable statistics. Despite the development of many newer fillers, in particular the hyaluronans, injectable collagen remains an optimal minimally invasive modality. Their unparalleled historical safety profile, the admixture of anesthesia with diminished injection discomfort, and relatively reduced edema and bruising make them a treatment of choice and the cornerstone treatments for many facial ‘imperfections’.

The authors recommend that facial esthetics be approached from an anatomic standpoint: the determination of what is wrong must precede how it should be corrected. An anatomic approach to the aging face will allow the physician to select the optimal therapeutic tool from a wide variety of therapeutic options. Often physicians develop a preference for one or several techniques, and then apply them to all situations. Using a therapeutic technique that does not address the underlying anatomic basis for a cosmetic problem is inappropriate, and leads to mediocre results at best and disasters at worst.

During the preoperative consultation, the patient will usually indicate an area of their face that they wish to have improved. A thorough assessment of the patient’s current facial structure and position of the anatomic sub-units should be made. Often patients may not be aware of subtle facial asymmetries, and using a mirror to demonstrate these may be useful in ensuring that the patient understands their own baseline condition. Underlying bony and cartilaginous causes resulting in altered facial esthetics and symmetry may not be adequately addressed with filler substances, and this should be made clear during the initial consultation. Rhytides primarily resulting from underlying facial muscle movement may be addressed with filler substances in concert with other approaches. For example, patients with deep glabellar furrows treated with filler substances may experience transient improvement; however, unless the underlying muscles causing these hyperdynamic lines are paralyzed with botulinum toxin, the wrinkles will rapidly recur.

As filler substances are applicable to restoring focal losses of subcutaneous tissue, the physician must be able to assess the quality and position of these tissues. Are the lips thin? Have they lost their shape? Are the cheekbones flattened? Is there wasting in the temporal fossae, above the eyebrows, or in the buccal fat pads? The patient’s desired goals and the realistically achievable results should then be agreed upon prior to beginning treatment. With an appreciation of facial esthetics and a working knowledge of the capabilities and limitations of each filler substance, the physician will be able to use the most appropriate filler substance to achieve maximal cosmetic improvement.

Changes in dentition and absorption of maxillary and mandibular bone may result in an overall loss of height and volume. The chin rotates forward and is seen to sharpen and protrude. These changes may result in the lower third of the face appearing smaller relative to the upper and middle thirds, straying from the ideal, approximately equal proportions. Aging changes from the middle third of the face may contribute to this appearance, as nasal tip ptosis may create the appearance of a shortened upper lip. The constant effects of gravity combined with loss of elasticity in the tissue may allow for excess skin to droop off the mandible, manifesting as ‘jowls’ along the mandibular rim and ‘wattles’ in the anterior neck.

The origin of the melolabial fold is unclear. Some authors feel that it is derived from insertions of lip elevator muscles into the skin, whereas others hypothesize that it results from differences in the subcutaneous structure in the cheek and oral areas. In any case, the prominence of this fold varies with age. In childhood, the lips and cheeks contain more abundant subcutaneous tissue, such that this fold is inapparent; however, age-related loss of subcutaneous fat, combined with the loss of elasticity of the skin, results in the draping of redundant tissue over the muscular insertion point into the groove. Clinically, this results in an apparent deepening of the melolabial fold.

Wrinkles form around the lips as a result of the constant pulling of the orbicularis oris muscle on progressively more inelastic upper- and lower-lip skin, creating angular, radial, and vertical wrinkles. Marionette lines may form as vertical wrinkles extending downwards from the oral commissures. The effects of gravity result in drooping of the oral commissures laterally and downward, which may lead to a tired and sad appearance. Loss of elasticity may lead to lip skin redundancy, enhancing the drooping and vertical elongation. Fullness of the lips and a strong definition of the philtrum are seen in youth; however with advancing age there is atrophy of the orbicularis oris muscle and loss of subcutaneous tissue, leading to an overall flattening and loss of fullness in the lips, with less of the vermillion showing. ‘Cupid’s bow’, the central arch of the upper lip, may flatten. In severe cases, there may be disruption of normal lip position. Loss of subcutaneous tissue and hypotonic lip musculature may allow the lips to invert, creating a ’sucked-in’ appearance; however the occasional patient may develop a lip ectropion due to excess tissue and hypotonic lip musculature.

Upper third of the aging face

Changes in the upper third of the face are primarily related to chronic ultraviolet light damage, to the intrinsic muscles of facial expression and their influence on the skin, and to gravitational changes from loss of elasticity of the tissue. Occasionally filler substances may be used in conjunction with botulinum toxin to soften hyperdynamic wrinkles after the underlying causative muscles have been paralyzed.

Middle third of the aging face

Aging of the middle third of the face affects the eyelids and periorbital regions, the cheeks, and the nose. These changes primarily result from a combination of photo-aging, loss of subcutaneous tissue, loss of cutaneous elasticity, and remodeling of underlying cartilaginous and bony structures.

Aging of the periorbital tissues results in both cosmetic and functional impairments. Dermatochalasis results from the combination of progressive cutaneous inelasticity of the eyelids and the effects of gravity. In severe cases, the upper eyelid skin may become so redundant that the visual fields are impaired. The canthal tendons and the tarsal plates provide the support structure of the eyelids, and loss of elasticity of these structures results in decreased lid tone and ability to ’snap back’ after stretching of the eyelids. In severe cases, stability of eyelid position may be affected, resulting in either ectropion or entropion. The orbital septum may weaken over time, allowing for protrusions of the upper and lower lid fat compartments; however, some people may experience a loss of periorbital subcutaneous tissue, resulting in a ’sunken-in’ skeletonized appearance to the orbits.

The cheeks may be affected by volume loss of the buccal fat pad, which is positioned between the masseter muscle anteriorly and the buccinator muscle posteriorly. In childhood, an ample buccal fat pad contributes to the fullness of the cheeks; however, with age this fat pad atrophies. A buccal depression may develop, leading to the appearance of prominent malar eminences.

Aging of the nose results in both structural and surface changes. The support mechanisms of the nasal tip may become inelastic and stretch with age, resulting in nasal tip ptosis and an apparent elongation of the middle third of the face. The fibrous attachments between the inferior margin of the upper lateral nasal cartilage and the superior margins of the lateral crura of the alar cartilages elongate from a combination of gravity and remodeling of the underlying bony and cartilaginous tissues. Additionally, the sling supporting the dome area weakens and there is loss of subcutaneous tissue, resulting in nasal ptosis, a downward and posterior rotation of the nasal lobule, retraction of the columella, and prominence of the nasal hump and cartilages. On the surface, enlargement of sebaceous glands may alter the skin texture, resulting in a rhinophymatous appearance.

Glogau type I patients have early photoaging changes, and are usually in their 20s or 30s. These patients generally have no rhytides at all, even when the face is animated during speaking or expression. Early photoaging, if present, may include mild pigmentary changes causing a disruption in the homogeneity of skin color. These patients generally wear no make-up foundation at all, as they do not require it for either rhytides or pigmentary alterations.

Glogau type II patients are usually in their late 30s or 40s. These patients have early to moderate photoaging changes, and chronic ultraviolet damage to the elastic fibers impairs the inherent ’snap back’ quality of the skin. These patients are without wrinkles while the face is at rest, but wrinkles begin to appear as expression lines when the face is in motion, appearing parallel to the melolabial fold, corners of the mouth, lateral canthal areas, and over the zygomatic arch and malar eminences. Early solar lentigines begin to appear and patients frequently utilize make-up foundation to conceal the pigmentary irregularities. As these patients only have wrinkles while the face is in motion, they most aptly demonstrate the effects of the underlying musculature on the skin, a critical consideration when contemplating the use of botulinum toxin.

Patients classified as Glogau type III have advance photoaging changes, and are typically in their 50s or olde Damage to the cutaneous elastic fibers becomes moi severe, and the wrinkles produced by facial movement eventually persist even at rest. These may present as wrinkles radiating outwards from the lateral canthi, inferiorly from the lower eyelids onto the malar cheeks, parallel to the oral commissures, and outward from the upper and lower lips. Advanced photoaging results in obvious pigmentary dyschromias, telangiectasias, and visible keratoses. Patients commonly wear heavy make-up foundation to conceal these changes.

Glogau type IV patients have severe photoaging changes and are usually in their 60s or 70s, but may be younger in the most severe cases. Wrinkles gradually spread to cover the majority of facial skin, and these patients may not have any unlined skin remaining on their faces. The dermis becomes engorged with thick debris, rendering a thickened, coarse quality to the skin. Pigmentary dyschromias are present as a yellow-gray sallow color of the skin, and patients have often had prior cutaneous malignancies. Glogau type IV patients are not able to wear makeup, as the uneven facial surface often causes the make-up to have the texture of ‘cracked mud.’

1. Chronic ultraviolet light damage to the skin: Photoaging adds to the inevitable changes seen with intrinsic chronologic aging; indeed, cumulative sun exposure is the single largest factor involved in our clinical perception of aging skin, and it is responsible for a large portion of unwanted esthetic effects.
2. Loss of subcutaneous fat: In general, with age there is a loss of the fullness and roundness of the facial contours of youth, resulting in a flattened or sunken appearance to facial structures.
3. Changes in the intrinsic muscles of facial expression and their influence on the skin: The muscles of facial expression are unique in that they insert directly into the skin. Years of facial expressions constantly folding the skin result in the progressive development of hyperdynamic wrinkles, which initially appear only with facial movement, but may ultimately remain as wrinkles at rest. Hyperdynamic wrinkles are more prominent in areas where the underlying muscles and fascia have more direct attachments to the skin, such as in the frontal, glabellar, nasolabial, perioral, and periocular areas.
4. Gravitational changes from loss of elasticity of the tissue: With aging, the facial soft tissues lose their inherent resiliency and ability to resist stretching; inevitably, they begin to sag under the effects of gravity.
5. Remodeling of the underlying bony and cartilaginous structures: Over time, bony resorption may result in a decrease in apparent facial volume, and gravitational stretch of cartilaginous structures may result in the drooping of structures such as the nasal tip. Facial asymmetry due to underlying bony or cartilaginous structural changes is difficult to correct, and pointing out these differences at the initial consultation is important in setting realistic patient expectations.

• 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.