My First Approach to Facial Sculpting or Injectable Agents

The ability to mold and shape the human face with injectable material has been one of the most dramatic advances in the field of cosmetic medicine over the last 10 years. Each year numerous companies strive to develop products that are safe and effective, as well as long lasting, in bringing volume back to the face. My first experience with returning volume to the face was over 15 years ago with a product called Cymetra, which was essentially frozen human collagen. Those early experiences taught me a great deal about how to appropriately restore volume to the face. The products now available are numerous and quite varied in their composition, and also in their uses and duration.

Problems with inexperienced doctors

Unfortunately, many people think it is a very simple thing to place a syringe full of material into the face and push the plunger. Many inexperienced doctors will mistakenly place new volume at the depth of creases such as the nasolabial folds and the fold between the corners of the mouth and the chin. While there may be some benefit to moderate injections into these areas, injection of a significant amount of material to some of these areas will result in a very odd appearance, and has given rise to names such as the “duck look.” When a patient has been “ducked” it means that too much volume has been injected into her lip or injected above her lip, which causes them to protrude, giving her the appearance of a duck. The “chimpanzee look” can appear with too much volume placed around the lip in the central part of the lower part of the face, which can result in a very unattractive fullness to the upper lip between the nose and the upper line of the red portion of the lip.

We have also seen new variations of such complications. I recently had a patient come to see me who had been seeing a famous dermatologist in Manhattan. The patient had been having more and more volume placed in the temporal area to the point that we came up with a new descriptor, the “orangutan look.” While these terms may seem somewhat humorous, to the patient these conditions can be significantly distressing. I have patients self referred from cosmetic medicine providers who were placing volume inappropriately. After I inform them that the mistakes are either difficult, or virtually impossible to fix, to a person they wish they had seen a board-certified surgeon in the beginning.

In essence, a potential consumer needs to understand that the placement of volume in the human face means we are placing replacement material for what has been lost naturally. Therefore, the people best qualified to know how to place this material are those people who actually operate surgically in the face and understand it intimately from an anatomic standpoint. A doctor who spends every day in the operating room knowing how to avoid injuring someone in surgery is going to be a lot better at knowing how to avoid injuring or deforming somebody when they place injected fillers into your face. In my opinion, a medical provider who either does not operate in the region or operates only on teeth and gums should not be placing replacement volume in anyone’s face. However, that is a personal opinion and may not necessarily reflect the opinion of the state medical or dental board.

Revolumization

In regards to appropriately volumizing a face, many years ago I started a program I call “revolumization,” where we are returning volume to the face. Deep creases aren’t the result of the creases actually deepening; they are usually due to the surrounding skin deflating, just like taking the air out a balloon. The skin starts to overlap the deep crease and makes it appear deeper. In order to adequately treat these areas not only do you have to put a small amount of filler in the crease, but you also need to fill up the surrounding areas again. To do that I place very widespread amounts of filler throughout the cheek and jaw line area in order to essentially blow the balloon back up. This can be tricky because we don’t want to reach the same amount of volume that patients had in their 20s because an overly full face at age 45 is not going to look appropriate, whereas at age 25 it was the norm.

In general, faces tend to become less round and more linear as we age, so when I return volume to the face I try to do it in appropriate symmetrical fashion, distributing volume throughout the temporal areas, cheeks, jowls, hollows of the cheeks, nasolabial folds, folds in the corners of the mouth, and sometimes in the area below the eyes. The area below the eyes needs special attention and in my opinion should only be injected with very low viscosity material such as Prevelle. This should only be done by a very experienced injector and only after he has come to know the patient’s face well, having performed other prior injections elsewhere on the face.

Fillers and their uses

In our practice, we tend to use Juvederm more than most other fillers. There are very specific situations for other fillers. Sculptra is an excellent filler when used appropriately for overall volume correction in patients who have significant volume deficiencies from nutritional problems, excessive dieting, or other types of wasting conditions. Sculptra has been an excellent revolumizer and I like the fact that it stimulates collagen growth. Juvederm XC, Restylane, and Voluma are used in various areas of the face depending on the situation and depending on the anatomic region. I tend to use Voluma more in the mid-face region, Juvederm XC in more peripheral areas, and Restylane more in the lips where a very fine delivery is required.

No doubt new fillers will be coming out every year and I am sure we will find some amazing technology that will continue to safely provide our patients with this wonderful benefit of revolumizing their faces. However, patients need to use an experienced provider that understands the anatomy of the face, so that they can have their volume restored with a natural look in a safe manner.