This is the golden age for minimally invasive cosmetic procedures.  Who would have ever thought 15 years ago, that procedures done in the office in a matter of 20-30 minutes could result in demonstrable improvements in one’s appearance with results lasting, in some cases, a year or more?  Without the need for downtime, anesthesia, or significant costs, cosmetic procedures have flourished, with many people who never would consider enhancements, “dipping their toe” in these procedures.  The concept of “preventative maintenance” has spurred the younger generation to start earlier, with smaller, less dramatic, but noticeable procedures as well.

At the forefront of the wave of cosmetic enhancements are dermal fillers.  When Restylane was FDA approved in 2003, a revolution in the field was born.  Although the main focus was to improve the nasolabial folds, the “smile” lines, in its inception, the broad “off label” use of it, along with subsequent FDA approval of other fillers, treatments have spread to just about every area of the face.  There are now about a dozen dermal fillers on the market, with the majority of them based on hyaluronic acid, a naturally occurring substance that is found in skin and joints.  Hyaluronic acid fillers (Restylane, Perlane, Voluma, Juvederm, Belotero) provide a soft, very well tolerated fill, with an extremely safe profile.  There is also a level of security knowing that these fillers are generally completely reversible, using the widely available enzyme, hyaluronidase, that can dissolve hyaluronic acid, in minutes to hours.

Although less popular, it must be mentioned that there are other dermal fillers which are FDA approved, each with their own niche market.  Radiesse is composed of microspheres of calcium hydroxyapatite, and is known as a very robust filler, that has a very high G prime, a measure of it’s lifting ability.  Sculptra is composed of Poly L Lactic Acid (PLLA), also naturally occurring as a sugar in the body, and is known as a collagen stimulator.  Its use is for global, long lasting, volumization of the face.  The longest duration FDA approved filler is Artefill.  It is composed of microspheres of Poly Methyl Methacrylate (PMMA) which is a synthetic molecule.  Artefill is considered a permanent filler and works as a collagen stimulator, similar to Sculptra.

The understanding of the aging face has made great strides in the last decade.  It is now widely understood that loss of volume is the primary cause of the aging face.  Leading this volume loss is the shrinking of the multiple fat pads of face, primarily of the cheek and periorbital area.  This is why aging often begins to show around the eyes.  Gravity contributes to our aging problems and often manifests itself by the descending of these fat pads. Relegated to a less relevant problem than 15 years ago, is the aging related to excess skin.  Plastic Surgeons have tightened loose skin for decades during facelifts, often leaving people appearing skeletonized and hollow, but without wrinkles.  It is now understood that most of the redundant skin can be improve with proper volumization of the offending fat pads, and most facelifts incorporate this during surgery presently.  (In the author’s opinion, most of the patients undergoing the knife could have had their concerns addressed using a combination of fillers and skin tightening devices.)

The common manifestations of volume loss are:

  1. Temporal hollows
  2. Loss of cheek volume
  3. Tear trough deformity
  4. Excessive crows feet and forehead lines
  5. Low hanging eyebrows
  6. Hollowness of the eye (orbit)
  7. Jowls
  8. Poorly defined jawline
  9. Small lips
  10. Dropping of nasal tip
  11. Lip lines (smokers lines)
  12. Corners of mouth dropping causing sad look
  13. Saggy neck
  14. Elongation and narrowing of the face

All the above mentioned aging effects can be improved with dermal fillers.  Expertise is required to recognize exactly what areas need to be treated to replenished the lost volume, while still maintaining a natural appearance.  It’s been shown that the brain can recognize less than a 1mm change in brow position.  When corrections are not done properly, it is very easy for the brain to catch it.  Poor corrections of the lips probably stands out in most people’s memory, where they are either too full, out of proper proportion, or there was poor attention to landmarks.

Experienced dermal filler injectors are no longer “chasing lines”, the symptom of aging.  The goal is to lift and replenish lost volume by addressing the cause of the aging of the face.  Of note, even the neck’s problems can be improved by properly injecting the face.  Choosing a doctor that has experience in recognizing the areas affected by volume loss and has the knowledge and expertise to improve those areas is essential for optimal patient outcomes.


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