The desire to restore the focal loss of facial volume that occurs with age has driven the development of numerous filler substances. Before embarking on a treatment plan with a patient seeking cosmetic improvement of the signs of aging, the physician must have a thorough understanding of the realistic capabilities of the available filler substances and a systematic approach to assessing facial esthetics.
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.