Dr. Beer shares some methods — his own and those of two innovative colleagues — for using volumizers and fillers.

Advances in filler technology have enabled us to greatly change the way we treat patients. Volumizers such as Sculptra allow us to replace lipoatrophy. Perlane, Voluma and Radiesse have the bulk to move facial structures such as cheeks and jaws. Juvederm and Restylane can augment the areas of the tissue troughs and lips, while Evolence can be used to fill areas that have lost volume.

Recently, at The Cosmetic Bootcamp University Program, I had the opportunity to learn more about such advances from from Drs. Doris Day and Patricia Wexler. As always, I learn best from being on the faculty and watching my colleagues in action.

Nasolabial Crease Formation

Doris, Pat and others point out that the nasolabial crease forms not from the lack of soft tissue in this area — except in rare instances — but rather from mid facial descent, that slow march south of the mid face that begins in one’s 20s when bone resorption and ptosis of the fat pads combine with skin laxity to allow the face to drift downwards. The result of this is a line that deepens into the nasolabial crease.

Correcting the Crease using Volume and Structure

While some filling of the crease will help ameliorate this — and in the case of superficial, etched-in lines may in fact be the best treatment — much of the nasolabial crease can be corrected by injecting the zygomatic arch in a supero-lateral direction.

Structural fillers work best here and I like to use Radiesse, Evolence or Perlane for this indication. By adding volume with Sculptra, one can obtain a similar effect, and by combining volume with structure, a true “face lift” can be attained. Products used in Europe and Canada are directly indicated for this purpose and among the ones that are most popular is Voluma, which is related to Juvederm but with shorter chains.

Injections to lift the face are among the best uses of fillers that we can offer our patients, and for those of you who are still trapped in the line filling paradigm, I recommend that you consider changing the way you inject.

Dr. Day’s Approach

Doris likes to inject the preauricular sulcus to add lateral dimension to the mid face. This is not an area that I frequently inject, but her demonstration of small additions of volume added in this location were impressive. Juvderm, Restylane, Perlane and Evolence are great for this indication. One of the cardinal signs of facial aging is the dent that appears in this location, and few injectors address this appropriately. Volumes ranging from 0.25 mL to 1.0 mL are appropriate starting points for this area.

Dr. Wexler’s Approach

Pat Wexler demonstrated a technique that I like and am looking forward to incorporating it into my repertoire. She injects Sculptra above the eyebrows to stimulate collagen production and lift the brow. Combining this with botulinum toxins — and perhaps fractional CO2 laser treatment — will produce a better lift than most surgical procedures. The dilution of product for this area should be at least 9 mL, and more volume is probably better. Injections into this area obviously need to avoid the vasculature and placement into the plane just above the periosteum help to avoid papule formation.

Other Areas

Injections into some other areas also help to reverse the signs of aging, and some require small amounts of product for high yields.

Ear Lobes

For instance, injections into the ear lobes can be accomplished with any filler and as little as 0.25 mL will make a difference that patients will appreciate. Many women who undergo cosmetic procedures are unhappy with the creases that form in the ear lobe and the sagging that occurs. This is easily reversed, and the replaced volume frequently provides dramatic results.

Nose

The dorsum and tip of the nose are areas that droop with aging. Both can be restored with small injections of hyaluronic acid, calcium hydroxyapatite or collagen. Caution should be exercised when injecting areas that have had previous surgery as the vasculature may not have the same collateral supply as untouched skin. The actual number of cases of nasal tip necrosis following injections of fillers is quite small but it is an area of potential risk that needs to be respected.

Dorsal Hands

Additional areas that are frequently undertreated are the dorsal hands. These should be addressed with either dilute PLLA (11 mL dilution), calcium hydroxylapatite, collagen or hyaluronic acids. In addition to volume correction, it is important to correct damage to the surface of the skin, and this can be accomplished with salicylic acid peels, fractional laser, and tretinoin. This procedure should address each of the existing needs to optimize the outcome.

Moving Beyond Spackling

The advanced techniques described offer specialists the opportunity to distinguish themselves and make their patients happy. As new techniques and products are introduced, opportunities for novel indications will continue to appear. Those that benefit our patients most will surely elevate the art of using fillers beyond what some may regard as mere “spackling.”

However, it is essential that we use caution when adopting these new techniques and embrace only those that are reasonable and advocated by respected colleagues. We are fortunate to have peers who enjoy teaching and sharing so that we can constantly evolve.

Dr. Beer is in private practice in West Palm Beach, FL. He’s also a Volunteer Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University, and Director of The Cosmetic Boot Camp meeting.

Disclosures: Dr. Beer is an owner of Theraplex LLC, and consults, speaks or performs clinical trials for 3M, Bioform Medical, Lumenis, Medicis, Sanofi Aventis, Solta Lasers and Stiefel.