CLINICAL ▼
Assessment and management of the
mature female face with dermal fillers
Abstract
The assessment and management of the mature female face can often pose
a challenge with regard to treatment planning, with so many procedures
now available to aesthetic practitioners and patients. This article discusses
considerations that should be taken into account when treating this patient
group with dermal fillers and attempts to give clarity and guidance on the
vast array of available treatments. Techniques such as needle vs cannula are
discussed and both techniques have their unique benefits; however, cannulas
are widely recommended for the more mature face, to provide natural results.
Product choice is also discussed; the author shares her experience with a range
of hyaluronic acid fillers, broadly discussing rheological differences between
products and outlining the reasons for choice of filler for one particular
mature female patient. The author provides an outline of the anatomy of the
ageing face and how these changes can help practitioners decide on practical
applications of dermal fillers. It is hoped that this article will give a helpful
overview of the treatment of the mature female, which is very relevant to most
practitioners, given that a large proportion of patients fit into this category.
Key words
► Dermal fillers ► Female ► Needles ► Cannula ► Ageing
T
he popularity of dermal fillers has grown rapidly
in recent years because they offer the rejuvenative
and enhancing aesthetic improvements
previously only achievable with surgery, but
at a lower cost and with little to no recovery time
(Funt and Pavicic, 2013). In the US, in 2015, 2.4 million
soft tissue dermal filler treatments were carried out,
up 6% from 2014 and 274% since 2000 (American Society
of Plastic Surgeons, 2016).
The term ‘dermal fillers’ was originally used at the time
that these products were first used and it was common
to fill the dermis to lift lines and wrinkles. Collagen
fillers were the first injectables used for this purpose
from the 1950s; however, the way aesthetic practitioners
now assess and treat facial ageing has significantly
changed. There has been a shift in movement toward
EMMA RAHE
Clinical Nurse Manager, The Laser Lounge, Sydney, Australia.
e: emma.rahe@hotmail.com
406
volume replacement in multiple areas, known as global
fillers or the liquid facelift (Taub et al, 2010), as opposed
to injecting intradermally into the papillary dermis
of the nasolabial folds (Klein, 1989). The vast array of
injectables now available include hyaluronic acid (HA)
fillers, stimulatory fillers and permanent fillers.
Types of facial fillers
Hyaluronic acid
HA dermal fillers are the most commonly used
fillers worldwide. Not only do they have an excellent
safety record, but also they are reversible and readily
available (Taub et al, 2010). Reversibility is particularly
important in the event of a vascular occlusion or even an
unsatisfactory result.
HA is a naturally occurring linear polysaccharide that
is a component of all connective tissues, such as in the
skin, bones, joints and eyes (Raspaldo, 2008). HA fillers
vary in their softness, lifting capacity and resistance
to deformation, and there is a huge variety available
for aesthetic practitioners to choose from. There are
many rheological terms that are used to describe these
qualities, which include G prime (G’), G’’ and G*. While
G’ describes the elasticity of a product, G’’ relates to its
viscosity and G* is the combination of G’ and G’’.
During the last decade, temporary dermal fillers based
on cross-linked HA have become the mainstay of non-
invasive facial rejuvenation due to their biocompatibility,
biodegradability, relatively low immunogenicity and
good safety profile, compared with permanent fillers
(Farhi et al, 2013).
Stimulatory fillers
Stimulatory fillers include poly-L-lactic acid (PLLA)
(Sculptra, Sinclair) and calcium hydroxyapatite (CaHA)
(Radiesse, Merz Aesthetics).
PLLA is considered a deep tissue regenerator, providing
soft tissue augmentation through stimulation of collagen
synthesis (Alessio et al, 2014). Most of the early problems
encountered with PLLA resulted from suboptimal
© 2017 MA Healthcare Ltd
methodology, including inadequate reconstitution
volumes, short hydration times, placement of large
volumes of highly concentrated product with short
intervals between treatments, and injection into the
dermis and in locations that were not optimally chosen
for this product (Vleggaar et al, 2014). The consensus
Journal of AESTHETIC NURSING ► October 2017 ► Volume 6 Issue 8
Downloaded from magonlinelibrary.com by 194.066.072.104 on June 5, 2018.
 CLINICAL ▼
Peter Lamb
Figure 1. Areas of the facial skeleton susceptible to resorption with ageing
paper by Vleggaar et al (2014) recommended that the
final reconstitution volume of PLLA is 9 ml for facial
injections, contrary to the Sculptra product information,
which suggested 5 ml. The reason for this, as Vleggaar et
al (2014) explained, is to ensure even PLLA distribution
and easier injection, with reduced risk of needle blockage,
and to decrease the incidence of papules and nodules.
Figure 2. Facial fat compartments (Rohrich and Pessa, 2017)
Peter Lamb
408
CaHA is an injectable dermal filler that contains
uniform CaHA microspheres suspended in an aqueous
carboxymethylcellulose gel carrier. It is considered a
long-lasting, but non-permanent, filler and is highly
biocompatible with human tissue (Pavicic 2013). Pavicic
(2013) stated that the injection of CaHA into the oral
mucosa and lips is ‘an unapproved indication’ and ‘may
result in nodule formation’. Nodule formation is observed
soon after injection and occurs due to accumulated
particles, rather than a granulomatous reaction.
Permanent
Non-biodegradable fillers, including polyacrylamide
hydrogel (Aquamid, Contura UK), are not as commonly
used as HA fillers. These fillers are not characterised by
a higher rate of foreign body granulomas per se than
temporary fillers, but their clinical appearance is more
pronounced and their persistence is longer, if not treated
appropriately (Funt and Pavicic, 2013).
Unlike HA fillers, permanent fillers cannot be
dissolved and may require treatment with steroids until
the filler resorbs or, as a last resort, excision. Because the
face continues to age following procedures, temporary
or semipermanent effects may be preferred, so the face
can be periodically augmented to accommodate ongoing
morphological changes (Burgess, 2006).
Effects of ageing
Facial ageing results from a combination of soft tissue
and skeletal changes, with bone loss in specific areas
of the facial skeleton contributing significantly to the
ageing process (Mendelson and Wong, 2012). In general,
older patients are likely to require soft tissue fillers that
primarily produce volume and correct the result of fat
atrophy by recreating the foundation and underlying
structures of the face (Burgess, 2006).
Skeletal changes
Mendelson and Wong (2012) explained that the skeletal
areas with a strong predisposition to resorption include
the mid-face, particularly the maxilla, including the
pyriform region of the nose, the superomedial and
inferolateral aspects of the orbital rim, and the pre-jowl
area of the mandible. These areas resorb in a specific and
predictable manner with ageing.
The arrows in Figure 1 indicate the areas of the
facial skeleton susceptible to resorption with ageing
(Mendelson and Jacobson, 2008). The size of each arrow
correlates with the amount of resorption. Having this
knowledge can help injectors to plan treatments in
© 2017 MA Healthcare Ltd
terms of filler selection and depth of injection if bone
resorption is evident.
Fat pad changes
Rohrich and Pessa’s (2007) cadaver study confirmed that
facial fat pads sit in separate compartments (Figure 2).
Journal of AESTHETIC NURSING ► October 2017 ► Volume 6 Issue 8
Downloaded from magonlinelibrary.com by 194.066.072.104 on June 5, 2018.
 CLINICAL ▼
This can help practitioners in further understanding
how to address fat pads when considering treatment.
The study explained that the malar fat pad is divided
into three compartments: medial, middle and lateral
temporal. Medial cheek fat is lateral to the nasolabial
fold. This compartment is bordered superiorly by
the orbicularis-retaining ligament and the lateral
orbital compartment. Jowl fat lies inferior to this
fat compartment.
Middle cheek fat lies superficial in its mid-portion. This
fat compartment is found anterior and superficial to the
parotid gland. At its superior portion, the zygomaticus
major muscle is adherent. A confluence of septa occurs at
this location where three compartments meet, and forms
a dense adherent zone where the zygomatic ligament
has been described. The fusion of septal boundaries is
an anatomical principle and can be simply illustrated by
cross-sectional anatomy. Middle cheek fat abuts medial
cheek fat, and their septal boundaries fuse into a dense
fascial network. Again, this relates to what has been
described as the zygomatic ligament. The zone where
the medial fat abuts the middle cheek fat corresponds to
the location of the parotidomasseteric ligaments.
The lateral temporal-cheek compartment is the most
lateral region of cheek fat. It lies immediately superficial
to the parotid gland and connects the temporal fat to the
cervical subcutaneous fat.
Mendelson and Jacobson (2008) described the mid-
cheek as three unique components: lid–cheek, malar and
nasolabial. When these segments appear with ageing,
they are separated by the three cutaneous grooves on the
mid-cheek: the palpebromalar groove supereolaterally,
the nasojugal groove medially, and the mid-cheek furrow
or groove inferolaterally.
Skin changes
Thornton (2013) explained that oestrogen deficiency as a
result of menopause results in atrophic skin changes and
accelerated ageing. Oestrogen insufficiency decreases
the defence against oxidative stress and the skin becomes
thinner, with less collagen, decreased elasticity, more
wrinkling, increased dryness and reduced vascularity. Its
protective function becomes compromised, and ageing
is associated with impaired wound healing, hair loss,
pigmentary changes and skin cancer.
With ageing, the supple skin of youth becomes thinned
and flattened, with loss of elasticity and architectural
regularity. Atrophy of the extracellular matrix is reflected
by the decreased number of fibroblasts and reduced
levels of collagen (especially types I and III) and elastin in
the dermis (Mendelson and Wong, 2013).
Patient assessment
Using a methodical approach to patient assessment not
only helps to ensure consistency for each patient, but
also standardises the treatment journey each time a
410
patient attends and the practitioner and patient revisit
the facial assessment. One such approach was presented
by Jain et al (2017), who discussed the Global Ranking
Scale (GRS) (Figure 3). This is a useful tool to enable
an effective consultation due to the way it includes
the patient in the process and allows a comprehensive
treatment plan to be made, which extends beyond
facial fillers and encompasses skin treatments, skincare
and enhancement of beauty. The objectives of the GRS
include implementing a patient-centred assessment
tool designed to set higher standards for consultations
and treatment experiences, ensuring a comprehensive
consultation process and increasing patient satisfaction
with facial rejuvenation treatment (Jain et al, 2017).
The GRS assesses the patient’s skin (loss of elasticity,
surface roughness, dehydration), wrinkles (dynamic
and static), facial volume (sagging and volume loss)
and morphology (symmetry and imbalance). It allows
practitioners to make a subjective assessment and grade
each of these categories from 0 (none) to 3 (severe).
Following a thorough consultation process allows
for a comprehensive treatment plan to be made.
Consent forms should always be completed and patient
photographs taken before any treatment takes place.
Treatments and techniques
Volume contouring of the face in areas such as the
periorbital region, mid-cheek and lower face, in
addition to layering techniques, have evolved to make
the face appear more natural (Arsiwala, 2015). This was
the treatment goal for a mature female patient who
presented to the author’s clinic for treatment.
This 46-year-old female (Figure 4) had global facial
volume loss and was seeking treatment to look more
youthful. Often in this more mature age group, patients
are seeking a natural result and therefore request
treatments that ‘refresh’ the face and ‘soften’ lines.
A cannula was used to administer dermal fillers in the
majority of facial areas for numerous reasons. Plastic,
reconstructive and cosmetic surgeon Patrick Trevidic
explained that it is now common to use cannulas for
virtually all injection areas because their use results in
less pain and bruising, and fewer haematomas (Jesitus,
2013). In addition, as the cannula has a blunt tip, patients
experience fewer adverse events (e.g. embolisms).
Trevidic said (Jesitus, 2013): ‘Cannulas are a little more
expensive, but they are a step forward for our patients.’
An added benefit of using a microcannula is the ease
of which blanketing of the filler can be achieved by
remaining at the same depth in the tissue and being able
© 2017 MA Healthcare Ltd
to reach a wider area with only one insertion point.
Lower face
A 25 gauge 40 mm cannula was used to treat the patient’s
pre-jowl sulcus, marionette lines and nasolabial folds,
the results of which can be seen in Figure 5.
Journal of AESTHETIC NURSING ► October 2017 ► Volume 6 Issue 8
Downloaded from magonlinelibrary.com by 194.066.072.104 on June 5, 2018.
 ▼ CLINICAL

Peter Lamb
Severity Evaluation Scale

Dehydration
in ess 0 1 2 3
Sk roughn Sta
tic
none mild moderate severe

ce

Wr
rfa
Su

ink
les
icity

Dynami
Loss of elast

c
lo s s
Imb

me
ala

lu
nc

Vo
e
Mo

ph
m
e

olo
r

Asy
in g lu
gy mm
etr y S a gg Vo

Figure 3. Global Ranking Scale (Jain et al, 2017)

As previously mentioned, often females who are With regard to the perioral area, this patient’s main
postmenopausal have lower levels of oestrogen, concerns were loss of lip volume and lipstick ‘bleeding’.
the hormone which makes the skin softer. This is
an important factor to consider when selecting an Figure 4. A 46-year-old female with global volume loss was
appropriate filler for the specific area. An HA filler treated with hyaluronic acid dermal fillers using a cannula
(Emervel Volume, Galderma UK) was chosen for its
large gel calibration and moderate firm texture. The gel
firmness allows this filler to resist deformation, resulting
in long-lasting enhancement (Segura et al, 2012).
Lips are part of the aesthetic unit that involves
the mouth and perioral tissue. Ageing of this area is
characterised by perioral fine lines, marionette lines and
flattening of the cupid’s bow. The philtrum becomes
longer and ill-defined, indirectly contributing to a
thinner upper lip (Lévêque and Goubanova, 2004).
In younger patients, the typical goal of lip
augmentation is to make the lips appear bigger and
fuller, whereas in older patients, the goal is to restore
volume to lips that has been lost through fat atrophy
(Burgess, 2006). The surroundings of the lips must
be considered, particularly the nasolabial folds and
the labiomental folds (marionette lines) (Cartier et al,
2012), as well as the various depressor muscles around
© 2017 MA Healthcare Ltd

the mouth. The depressor anguli oris and the platysma

muscle can contribute to the pulling down of the corners
Supplied by author

of the mouth, resulting in a sad appearance, and could be

addressed with botulinum toxin injections in addition to
adding a filler to revolumise and support the corners of
the mouth.

Volume 6 Issue 8 ► October 2017 ► Journal of AESTHETIC NURSING 411

Downloaded from magonlinelibrary.com by 194.066.072.104 on June 5, 2018.

 CLINICAL ▼
Supplied by author
Figure 5. A 25 gauge 40 mm cannula was used to treat the pre-jowl sulcus,
marionette lines and nasolabial folds
The vermilion border was filled using a sharp needle,
as opposed to a cannula, to create more structure, and
this helped to soften the surrounding perioral lines. The
body of the lip was also filled slightly using an HA filler
(Emervel Classic, Galderma UK) to improve hydration
and subtly restore some volume loss. Small volumes
of another HA filler (Emervel Touch, Galderma UK)
were injected into the superior perioral region using a
cannula, with the same two entry points, to revolumise
the superficial fat compartments, thus softening the fine
perioral rhytides.
Mid-face
This particular patient had retained adequate volume
through most of the mid-face; however, on an oblique
view, it was evident that there was some volume deficit.
This was restored with an HA filler (Restylane Perlane,
Galderma UK) using a bolus technique into the malar fat
pads. Injecting in this way, vertical pillars were created over
the bone in order to support and lift the malar area (Salti
and Rauso, 2015). This filler was chosen due to its high
G’ and as Sundaram (2011) explained, it might typically be
used for zones such as the mid-face, where lifting is the
objective and filler palpability is not problematic; whereas
products with a lower G’ might be preferred for areas such
as the lips, where palpability after implantation is less
desirable and some degree of filler spread into the tissue
might be considered aesthetically appealing.
412
Periorbital
The development of dark circles under the eyes is one of
the early signs of periorbital ageing, lending a fatigued and
aged appearance to the face (Hirmand, 2012). Restylane
Perlane was also used to treat the periorbital area in the
medial tear trough using a cannula. The entry point for
the microcannula was located inferiorly to the zygomatic
ligament and the cannula directed superomedially to
target the medial tear trough. Hirmand (2012) explained
that the blunt needle (cannula) glides easily through
the tissue once past the orbicularis oculi with minimal
pressure. Medially, it is easy to feel for the periosteum
with the tip of the cannula and to direct it superior to
the periosteum. Thus, the most medial part of the tear
trough is accessible safely and precisely.
Conclusion
HA dermal fillers are a safe and effective method of
restoring volume to the mature female face and softening
the appearance of rhytides, creating a more youthful
appearance. Product choice and injection technique
are important considerations, and it is vital to have a
good understanding of product characteristics and the
benefits of using different approaches with techniques.
Dermal fillers are just one modality practitioners
should consider when addressing an ageing face
to achieve optimal results and carry out a fully
comprehensive assessment. Treatment considerations
should also include varying modalities of skin
rejuvenation, including skin-tightening devices, lasers
and muscle relaxants for dynamic lines.
References
Alessio R, Rzany B, Eve L et al. European expert recommendations
on the use of injectable poly-L-lactic acid for facial rejuvenation.
J Drugs Dermatol. 2014;13(9):1057–1066
American Society of Plastic Surgeons. New statistics reflect the
changing face of plastic surgery. 2016. http://tinyurl.com/
hzq795l (accessed 14 September 2017).
Arsiwala SZ. Current trends in facial rejuvenation with
fillers. J Cutan Aesthet Surg. 2015;8(3):125–126. https://doi.
org/10.4103%2F0974-2077.167261
Burgess CM. Principles of soft tissue augmentation for the aging
face. Clin Interv Aging. 2006;1(4):349–355
Cartier H, Trevidic P, Rzany B et al. Perioral pejuvenation with
a range of customised hyaluronic acid fillers: efficacy and
safety over six months with a specific focus on the lips. J Drugs
Dermatol. 2012;11(Suppl 1):S17–S26
Farhi D, Trevidic P, Kestemont P et al. The Emervel French survey:
a prospective real-practice descriptive study of 1822 patients
treated for facial rejuvenation with a new hyaluronic acid filler. J
Drugs Dermatol. 2013;12(5):e88–93
Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of
adverse events and treatment approaches. Clin Cosmet Investig
Dermatol. 2013;6:295–316. https://doi.org/10.2147/CCID.S50546
Hirmand H. Anatomy and nonsurgical correction of the tear
trough deformity. Plast Reconstr Surg. 2012;125(2):699–708.
© 2017 MA Healthcare Ltd
https://doi.org/10.1097/PRS.0b013e3181c82f90
Jain R, Huang P, Ferraz RM. A new tool to improve delivery of
patient-engaged care and satisfaction in facial treatments:
the Aesthetic Global Ranking Scale. J Cosmet Dermatol.
2017;16(1):132–143. https://doi.org/10.1111/jocd.12297
Jesitus J. Hyaluronic acid products dominate filler market in
Europe. 2013. http://tinyurl.com/y8lkggux (accessed 22
Journal of AESTHETIC NURSING ► October 2017 ► Volume 6 Issue 8
Downloaded from magonlinelibrary.com by 194.066.072.104 on June 5, 2018.
 ▼ CLINICAL

September 2017)
Klein AW. In favor of double testing. J Dermatol Surg Oncol.
1989;15(3):263 CPD reflective questions
Lévêque JL, Goubanova E. Influence of age on the lips and ►► What role does oestrogen play in the ageing process?
perioral skin. Dermatology. 2004;208(4):307–313. https://doi. ►► What does G prime describe?
org/10.1159/000077838
►► Describe the advantages of using a cannula over a
Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek
facial layers, spaces, and the mid cheek segments. Clin sharp needle
Plast Surg. 2008;35(3):395–404. https://doi.org/10.1016/j. ►► When treating the lips of a more mature female,
cps.2008.02.003
Mendelson B, Wong CH. Changes in the facial skeleton with aging:
what other areas should be considered?
implications and clinical applications in facial rejuvenation.
Aesthet Plast Surg. 2012;36(4):753–760. https://doi.org/10.1007/
s00266-012-9904-3
Mendelson B, Wong CH. Anatomy of the aging face. 2013. http://
tinyurl.com/y88l4myf (accessed 18 September 2017) Key points
Pavicic T. Calcium hydroxylapatite filler: an overview of safety and ►► There is a huge variety of fillers available and all vary
tolerability. J Drugs Dermatol. 2013;12(9):996–1002
in their safety and effectiveness. Hyaluronic acid
Raspaldo H. Volumizing effect of a new hyaluronic acid sub-
dermal facial filler: a retrospective analysis on 102 cases. fillers are widely recognised as the safest available
J Cosmet Laser Ther. 2008;10(3):134–142. https://doi. ►► There are many factors to consider when using
org/10.1080/14764170802154607
Rohrich R, Pessa J. The fat compartments of the face: anatomy fillers to treat patients, including the ageing process
and clinical implications for cosmetic surgery. Plast Resconstr and product choice. Injectors should have an
Surg. 2007;119(7):2219–2227. https://doi.org/10.1097/01.
prs.0000265403.66886.54 understanding of both filler properties and their
Salti G, Rauso R. Facial rejuvenation with fillers: the dual plane appropriate injection techniques
technique. J Cutan Aesthet Surg. 2015;8(3):127–133. https://doi. ►► The Global Ranking Scale is a useful tool to facilitate
org/10.4103/0974-2077.167264
an effective consultation process
Segura S, Anthonioz L, Fuchez F, Herbage B. A complete range
of hyaluronic acid filler with distinctive physical properties ►► The approach to using dermal fillers has changed
specifically designed for optimal tissue adaptations. J Drugs from filling lines to considering the face more
Dermatol. 2012;11(1 Suppl l):S5–8
Sundaram H. Going with the flow: an overview of soft tissue filler
globally and addressing multiple areas
rheology and its potential clinical applications. 2011. http://
tinyurl.com/jgssx2a (accessed 14 September 2017)
Taub AF, Sarnoff D, Gold M, Jacob C. Effect of multisyringe
hyaluronic acid facial rejuvenation on perceived age. Dermatol
Surg. 2010;36(3):322–328. https://doi.org/10.1111/j.1524- Vleggaar D, Fitzgerald R, Lorenc ZP et al. Consensus
4725.2009.01436.x recommendations on the use of injectable poly-L-lactic acid for
Thornton MJ. Estrogens and aging skin. Dermatoendocrinol. facial and nonfacial volumization. J Drugs Dermatol. 2014;13(4
2013;5(2):264–270. https://dx.doi.org/10.4161%2Fderm.23872 Suppl):S44–S51

Would you like to see your article published in

the Journal of Aesthetic Nursing?
Send your clinical, professional and practice management ideas
© 2017 MA Healthcare Ltd

to the editor or tweet us @JAestheticNurse

Email: natasha.devan@markallengroup.com
Phone: 0207 501 6780

Volume 6 Issue 8 ► October 2017 ► Journal of AESTHETIC NURSING 413

Downloaded from magonlinelibrary.com by 194.066.072.104 on June 5, 2018.