Inceratonal journal of Women's Dermatology 5 (2018) 52-67 Contents ists avaiable at ScienceDirect International Journal of Women's Dermatology ELSEVIER An approach to structural facial rejuvenation with fillers in women R. Fitzgerald, MD **, J. Carqueville, MD "*, P.T. Yang, MD, FRCSC “ * te pati, ot Agee Caos * Pie praca ins « Depron of Bematlo Sager Has f Cok Coun Chic, iis * Deparment of Opts, Universo Cara San Diego, San Diego, Caf £ e ARTICLE INFO ABSTRACT ‘tice tory Received 29 July 2018 Reclved in eis frm 2 August 2018 Accepted 24 August 2018 [Newer understanding of volume los sa critical component of facial aging andthe integration of volume replacement into the surgical and nonsurgical therapeuticalgorithm is arguably the most significant recent {development in the field of facial rejuvenation, Asal structural issues ply aroein the aging face, restoring {youthful characteristics (or establishing them where they ae congenitally absent) starts rom the skeletal Frameworkand builds progressively tthe canvas othe face Te purpose ofthisaticle isto prewide an in- Pe ‘toduction and bref summary of some ofthe current concepts concerning fail anatomy andthe anatomy eyo lag offal aging, which serve athe bass for predictable ae reproducible resus withthe ue of injectable ‘aca vemuatn fillers This article doesnot incl the various types of ils o techniques of ile injection, ut overs faa hw to decide where ous the ile and why. in ferent faces, a5. res of the recogition aa targeted (ail ft compartments correction of curently recognized specific anatomic deficiencies. (© 2018 Published by Elsevier Inc. on behalf of Women's Dermatologic Society. Thisis an open access article under the CC BY-NC-ND license (hp: /ceativecommonsorilicenses/by-ne-nd/40) Introduction ‘As noted by Pessa, “there are many arbitrary definitions of what constitutes a youthful face but the appearance of youth is not arbi- wary; itis simply difficult to define” (Pessa etal, 2008). Facial mor- phology from infancy to old age is a complex, three-dimensional (3D) interplay of multiple structural tissue layers, and our under- standing ofthis process isin a constant state of evolution and refine- ‘ment. Current understanding of the facial aging process has historically been largely empirical, given that it has traditionally been based on the effectiveness of various treatments, both surgical and nonsurgical, aimed at rejuvenation but sometimes result in an ‘did or “done” appearance. Although most of us would agree that this field is stil in its in- fancy. growing understanding of this complex process has informed and driven the change from an empiric approach to an anatomic one, in hopes of enabling improved and more natural-appearing results Figure 1 was adapted from an article on facial aging by Cotofana et al (2016) and provides an impressive illustration of how innovation and advances in technology, which have given us newer and faster © Covesponny Auth. mal adress Ftnl@artlik ot (R Feral) ops: dota 10.1016)jwe.2018.08.011 ‘ways Co both gather and share information, are accelerating our un- derstanding of facial anatomy (with more advances in the last few decades than in the last couple of centuries). This has led to a para~ ddigm shift in the way we perceive and approach the changes that are observed in the aging fae. At this time, facial aging research is defining the basic changes that occur in specific tissues, but it is how these changes affect what is observed in the aging face that remains to be defined (Robrich and Pessa, 2012b). The answer to the question of whether we sink ‘or we sag has become a yes to both, Newer understanding of volume loss asa critical component of facial aging and the integration of vol- lume replacement into the surgical and nonsurgical therapeutic algo rithms arguably the most significant recent development in the field ‘of facial rejuvenation. As all structural tissues play a role in the aging ‘ace, restoring youthful characteristics (or establishing them where they are congenitally absent) starts from the skeletal framework and builds progressively to the canvas of the face. Even with the aforementioned limitations in mind, with careful evaluation, some ‘age-related changes or congenital deficiencies can naw be addressed ina site-specific manner to achieve natural-looking results. The purpose of this article is to provide an introduction and brief summary of some current concepts concerning facial anatomy and the anatomy of facial aging, which serve as the basis for predictable and reproducible results with the use of injectable filler. This 2352-64750 2018 Published by Eker Inco behalf Women's Dermatokg Sct This an open aces arte unde the CCBY-NCND eens (htpretvecomons taylensesy-ncad/A0,‘Fea eb ternational journal of Womens Dematloy 5 (2019) 52-67 2 summary of current concepts is presented along with clinical exam- ples of congenital absence or aging changes in each tissue layer to better illustrate the discussion, Ths article does not include various types of filles or techniques of file injection, but covers how to de- cide where to use the filler and why, in different faces, as a result of the recognition and targeted correction of currently recognized spe- ciffe anatomic deficiencies. The practical use of these concepts sllutrated using a number of 50 years). he authors emphasized the importance ‘of a better understanding of the contribution of craniofacial support in achieving natural appearing results ‘Stuzin (2007) noted that a youthful face seems to represent a point in time when a particular set of skeletal proportions are ideal for ther soft-tissue envelope. Enlargement of the pyriform aperture and orbital aperture may effectively decrease the bony surface area available to support the overlying soft-tissue envelope, leading to Some of the observed soft-tissue changes noted with age. These Fe 24. In this schematic arowsndicate the areasafthe caniofcil skleton hat are sssceple wo resorption wit ping The size ofthe aru colts wit he aun of resorption. Reproduced wh persion fom Mendelson and Wong (2012) changes share some similarity with the soft-tissue draping seen in an infant face (Pessa et a, 1998). ‘The schematic in Figure 25 illustrates the impact of adequate pyt- iform support on the convexity ofthe midface and is best seen ina profile view. The frst figure shows the lack of pyriform and anterior ‘maxillary support resulting in midface concavity and an acute nasolabial angle. Note how this lack of support causes the philtrum to fall further back and gives the impression of an overly prominent upper lip. This problem can be worsened with the addition of filler into the body and vermillion border ofthe upper lip (Fig. 18). The sec ‘ond picture in tis schematic illustrates how pyriform augmentation Fig 28 Deep prio spaces re medal byte pyritorm aperture and depressor sept nas. he angular ary cares between the space an deep mad cheek a com patent Note thatthe ster st dietly on the peristeu,but athe supefial and aeral witha the roo of he pace: entire green Reprod ‘with permission fram Sure tl (2015).oe A Pageraet termatonalJoural of Waren’ Dermat 5 (2019) 52-67, Fg 25 Relationship o the ip nd ose afletoveral fail balance. This schematic depts the poston the ip elton wo the amount of prior support. Reprod with permission rom Yaremcik 2007 creates a convex profile and opens the nasolabial angle, resultingin a rnormal-appearing upper lip. clinical example with no prior treat- ‘ment i shown in Figure 26. Recall that the aforementioned longitudinal study on cranio- facial aging discussed above showed that 100% of the patients studied (albeit a small sample size) showed bony remodeling in this area over a 10-year period. Also recall that the authors of the study delineating the pyriform space noted that bony reces- sion of the maxilla with age predisposes this space for use as a potential area of deep volumization to support the overlying cheek fat and draping lip elevators and may prove to be a vital target area for restructuring the aging anterior midface. The presence and maintenance of bone volume and contour are nec- essary to provide and preserve ideal soft-tissue relationships. The result of addressing this one structural tissue is seen in young patients with congenital skeletal hypoplasia (Fis. 27). ‘This was the biggest deficit in this patient, and addressing that one tissue issue served to bring this face closer to its ideal shape and proportions. Clinical examples ‘The practical use of these concepts in injectable treatment of the face is illustrated in a number of patients of different ages, ny Fig 25. Cla coneain ofpcement of prac (here wing pol Hhetic ac 2es- Sion) inthe preperiostal perm space which pshesthe ase ofthe nose antsy fd serves vert the upoe lip and inrease the prominence fhe cups bow and phkal clans without direct augmentation othe ip Prod! was abe ped the {hinintearea of abiomansbar ft and deep sabres fat, which serves weve thelower ip.ttent uncommon a se the wath thei boren sight with hese injections No product was use in thelpsPhaxographs courtesy o Rebecca gerald ethnic backgrounds, and with different issues (Fig. 28). To con- sider a number of examples, and to more easily compare and con- trast different faces, these cases are presented in a “composite” format. This smaller format also facilitates the recognition of facial shapes and proportions, the harmony or disharmony of the three thirds of the face, and determination of what is present or missing that may be moving the face away from ideal shapes and propor- tions (Fig. 3). The patient photographs are lined up vertically for easy comparison of the morphology of these faces, both before and after treatment. The faces were analyzed by looking at the tis- sue structures independently (one tissue issue vs. multiple tissue issues), facial shape and proportions (oval face, phi ratio in lower third of face), harmony of the three thirds ofthe face, and topogra~ Phy (concavity vs. convexity). Patient A (age in the early 50s) had previously been treated in the tear troughs. The undereye filler is too high, too superficial, and excessive. [n addition tothe Tyndall effec, the irregular topogra~ Phy created by this placement gives the face an odd look. This is probably the most common novice placement error. The volume Toss in the temples is skeletonizing and affects the facial frame. In ‘the lower face, there isa U-shaped hollow around the chin. The HA in the tear trough was dissolved, and the patient was initially treated inthe superficial temporolateral cheek compartments and the super- ficial medial and middle fat pads with PLLA. The patient was also tweated in the four deep fat pads of the midface with HA improvement. ‘Months later, the treating physician (RL.) eventually recog- nized that the flattening of the anterior convexity ofthe face was consistent with bony remodeling, and she was treated along the inferior lateral orbital rim, the supraperiosteal midface (pyriform, anterior maxilla, zygoma), and lower face (anterior mandible) (using PLLA), which restored some convexity to her midface and Improved her outcome. A small amount of filler was also placed inher oral commissures. Patient B (age in the mid 40s) had some regional disparity with ‘the upper third of her face, which was abit smaller than the lower ‘two thirds. There is also mild flattening of the mid face. The patient ‘was treated with HA in her temples, middle forehead fat compart- ments, and PZS. HA was also used around the pyriform fossa. Note the improvement in the shape, topography, and regional harmony of her face.Fg tb Iteration url of Women’ Derma 5 (2019) 52-67 6 Fig 22. (A) Patents shown befor and (8) immediatly ater the fist eatment and (C again 6 yeas ater. maintain with annual treatment. Calum hydrops admin- ‘ted wth 25 gange canada war edn the mice and sles alin the chin Al treatnente were dane wth 425 guge cancul Aen chin plane ws placed by surgeon after heir tretmen but dda ge the vlume te palent desired Since hat time, yak acd va sed afer stele sou using cae vod contact with he Patient C (age in the mid 50s) had one main tissue issue that, needed craniofacial augmentation, The biggest issue was the fatness of her midface, followed by the hollowing in her temples and a U- shaped hollow in her chin, Her midface was addressed with fil (PLLA) over the entire zygoma, anterior maxilla, and pyriform aperarure bilaterally. Note how these miface ares and convexities, improve the shadow patterns and seem to make her face look smaller (ie ess wide), Patient D (age in the mid 30s) primarily had a one tissue issue in the bone. However, it was only in the bone of the lateral mid- third and lower third of her face, which gave her face an odd- looking regional disparity. The congenital ack of craniofacial sup- port in the lateral zygoma, the mandible, and chin in this patient made her forehead look too large for her face, an illusion that dis- appears with correction of the aforementioned areas (here done with HA). In addition it gives the impression of early jowling, often seen in young patients with a suboptimal chin, This i, of course, normal jow! fat with inadequate bony support, but it can also exacerbate what is seen in older patients as they lose bone inthis area Patient E (age in the late 20s) had a facial shape that was ad- dressed with treatment of both the upper and lower thirds of her face. Neuromodulator in the hypertrophic masseters served to ovalize and feminize her lower face. Filler in the temples brought the face closer to the ideal 5-eyes across (Fig. 3). Temple filler also served to harmonize the upper thitd with the lower two thirds of her face. A small amount of filler inthe chin was added to harmonize this area with her large cheekbones. Patient F (age in the mid 40s) has good skin and minimal fat loss, but poor craniofacial support. This is initially obscured by hher masseteric hypertrophy. However, on closer observation, the soft tissue of her temples has more lateral projection than her cheekbones (opposite of patient E), and her brow and midface are flattened. Neuromodulater was used in the masseters and gla- bella, and HA was used in the lateral brows and over the lateral in- feriot orbital rim, PLLA was used over the anterior and lateral ‘maxilla and zygomatic arch and in the pyriform aperature. This combination served to ovalize her facial frame and her anterior face. Patient G (age in the early 40s) had enough fat loss to make her zygoma quite visible. She was treated with HA in the temple and two sessions of PLLA inthe superficial lateral and middle cheek com. partments. The patient did not want to remave any fille inher lips or ‘around her eyes (performed elsewhere prior to first visit); therefore, PLLA (two sessions) was also used in the pyriform fossa to minimize the upper lip projection, and HA was used in the deep fat pads ofthe lower Ii lip with the chin, Upon further review in the preparation of this manuscript, the patient may have benefited from a small mount of HA filler in her medial SOOF. Patient H (age in the early 40s) is an endurance exercise pa- tient with both superficial and deep-fat compartment volume loss and suboptimal anterior maxillary craniofacial support. The global oval facial frame was addressed with treatment in the su perficial temporal lateral fat compartments (one session of PLLA). The suboptimal bony support in the midface left the patient with a negative vector (i.e, shallow orbits and rettusive orbital rim where the cornea has more projection than the orbital rim, ‘much like the patient in Fig, 22), and a deep tear trough and nasojugal fold with visible infraorbital fat. Direct treatment of this area requires alot of product and often results ina Tyndall effect such asin Patient A. Therefore, she was first treated with three sessions of PLLA over the anterior maxilla and in the pyriform space, as well as in the DMCF and DLCF. to ‘minimize the amount of HA filler needed under her eyes. The pa- tient was also treated with HA in the PZS prior to treatment of the tear through with HA. The patient had much improvement, but still has a slight Tyndall effect from the amount of HA needed to treat her tear trough, Conclusions Systematic assessment and site-specific nonsurgical rejuvenation ofthe face with fillers may lea to increased safety, accuracy, and tech nique reproducibility in this commonly performed procedure, Al- though out of the scope ofthis article, several publications referenced herein offer excellent detailed descriptions of techniques (often ac- companied by anatomical dissections) used to access some of these areas safely, effectively, and reproducibly (Fitzgerald and Vieggaar, 2011; Pessa and Rohrich, 2012: Lamb and Surek, 2018: Scheuer I et al, 2017; Sieber et al, 2016; Surek et al, 2015b; Wang etal, 2017). Conflicts of interest None, Funding. None.Fg 28 Practical uso theseconceptsin injectable teste of thefacecan berate sing amber of patients ferent ages nd ehnicackgruns. To examina numb ofc. a wel ast compare an contra iflerent faces thes cas ae pesete ina “composite fmt This sale format aes easier to recoil shape so orton nd harmony ordharmony ofthe thre this ofthe a. wel aso determine whats preset or missing that maybe moving the face ay rm the eal bape and operons lasted in gure 3. The phsographsate ined up vertical tenable areas) camparsn ofthe morphaogy of these faces oth before and afer eatmene Inala the acl shapes more ovale and convex the ater pcre Photographs courtesy o Rebecca Fgeald MD. Study Approval References ‘velar Li, Caza CE. Ave MN Shitra DI Dynamic changes offal supporting cor ‘nerstones (plas: Considerations in aesthetic approach. J Droge Dermatol Appendix A. Supplementary data 2018;17(4):466-70. 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