Fillers Changing Cosmetic Approach

LAS VEGAS — The new approach in the cosmetic treatment of the aging face is to look beyond simply using fillers for wrinkles and to think about restoring volume in the upper face and cheeks, Dr. W. Philip Werschler said.

"We are moving from using fillers as wrinkle and line fillers, to facial shaping agents," said Dr. Werschler, at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "And we divide the face into facial treatment zones in which certain facial shaping agents might be more suited."

A young face, from below the eyes, has an inverted triangle shape with the broad base of the triangle extending across from the top of the malar zygomas and the point extending down to the muscularis mentalis of the chin. As the face ages, the volume descends. Jowls form and muscle atrophies, and the face takes on an upright triangle shape with the sides framed by the marionette lines and the top at the narrowing of the nasal bone, said Dr. Werschler, who has a private dermatology practice and conducts research in Spokane, Wash.

In a recent study, researchers performed dissections on the faces of 30 cadavers, and found that the subcutaneous fat in the face is divided into distinct compartments. Malar fat, for example, is divided into three compartments. The researchers also suggested that the different compartments of fat in the face probably change differently with age, with the divergent fat pads changing location and proportion (Plast. Reconstr. Surg. 2007;119:2219-27).

A short while ago, there was a limited repertoire of fillers, said Dr. Werschler. One could use a temporary filler (bovine collagen) or a permanent filler (silicone). Now there is a broad palette of fillers, with properties that defy easy classification, such as poly-L-lactic acid (Sculptra) and calcium hydroxylapatite microspheres (Radiesse). Poly-L-lactic acid can be molded and shaped under the skin for a short while after injection, while calcium hydroxylapatite stimulates collagen growth around the implanted material and persists for over a year. Both can be used to build volume and they last much longer than collagen.

A "facial shaping artist" will plan out the rejuvenation procedure by taking into account the different properties of fillers, he said. The plan should be informed by the triangle concept, and by the concept that the face has three zones. The top zone extends roughly from the hairline to the upper eyelids. The middle zone goes roughly from the eyebrows to the upper lip. The bottom zone falls roughly from the base of the nose to include the anterior neck.

The goal should be to create balance and symmetry within each zone, and balance and proportion between the zones. The treatment concept embracing these ideas is known as RAVE, or regional aesthetic volume enhancement.

Many simply look to reduce nasolabial folds, oftentimes injecting too much and concentrating on just that one area. Patients may have fewer lines, but they can lose balance and proportion between the zones and can end up looking like "someone who has just stepped off the set of 'Planet of the Apes,'" he said.

"You have to look at facial balance," Dr. Werschler said. "Our approach now has to be more about global balance of the face. Lines and wrinkles do not necessarily define someone's age."

Dr. Werschler has served as a consultant to many companies, including Sanofi Aventis, maker of Sculptra, and BioForm Medical Inc., maker of Radiesse.

LAS VEGAS — The new approach in the cosmetic treatment of the aging face is to look beyond simply using fillers for wrinkles and to think about restoring volume in the upper face and cheeks, Dr. W. Philip Werschler said.

"We are moving from using fillers as wrinkle and line fillers, to facial shaping agents," said Dr. Werschler, at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "And we divide the face into facial treatment zones in which certain facial shaping agents might be more suited."

A young face, from below the eyes, has an inverted triangle shape with the broad base of the triangle extending across from the top of the malar zygomas and the point extending down to the muscularis mentalis of the chin. As the face ages, the volume descends. Jowls form and muscle atrophies, and the face takes on an upright triangle shape with the sides framed by the marionette lines and the top at the narrowing of the nasal bone, said Dr. Werschler, who has a private dermatology practice and conducts research in Spokane, Wash.

In a recent study, researchers performed dissections on the faces of 30 cadavers, and found that the subcutaneous fat in the face is divided into distinct compartments. Malar fat, for example, is divided into three compartments. The researchers also suggested that the different compartments of fat in the face probably change differently with age, with the divergent fat pads changing location and proportion (Plast. Reconstr. Surg. 2007;119:2219-27).

A short while ago, there was a limited repertoire of fillers, said Dr. Werschler. One could use a temporary filler (bovine collagen) or a permanent filler (silicone). Now there is a broad palette of fillers, with properties that defy easy classification, such as poly-L-lactic acid (Sculptra) and calcium hydroxylapatite microspheres (Radiesse). Poly-L-lactic acid can be molded and shaped under the skin for a short while after injection, while calcium hydroxylapatite stimulates collagen growth around the implanted material and persists for over a year. Both can be used to build volume and they last much longer than collagen.

A "facial shaping artist" will plan out the rejuvenation procedure by taking into account the different properties of fillers, he said. The plan should be informed by the triangle concept, and by the concept that the face has three zones. The top zone extends roughly from the hairline to the upper eyelids. The middle zone goes roughly from the eyebrows to the upper lip. The bottom zone falls roughly from the base of the nose to include the anterior neck.

The goal should be to create balance and symmetry within each zone, and balance and proportion between the zones. The treatment concept embracing these ideas is known as RAVE, or regional aesthetic volume enhancement.

Many simply look to reduce nasolabial folds, oftentimes injecting too much and concentrating on just that one area. Patients may have fewer lines, but they can lose balance and proportion between the zones and can end up looking like "someone who has just stepped off the set of 'Planet of the Apes,'" he said.

"You have to look at facial balance," Dr. Werschler said. "Our approach now has to be more about global balance of the face. Lines and wrinkles do not necessarily define someone's age."

Dr. Werschler has served as a consultant to many companies, including Sanofi Aventis, maker of Sculptra, and BioForm Medical Inc., maker of Radiesse.

LAS VEGAS — The new approach in the cosmetic treatment of the aging face is to look beyond simply using fillers for wrinkles and to think about restoring volume in the upper face and cheeks, Dr. W. Philip Werschler said.

"We are moving from using fillers as wrinkle and line fillers, to facial shaping agents," said Dr. Werschler, at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "And we divide the face into facial treatment zones in which certain facial shaping agents might be more suited."

A young face, from below the eyes, has an inverted triangle shape with the broad base of the triangle extending across from the top of the malar zygomas and the point extending down to the muscularis mentalis of the chin. As the face ages, the volume descends. Jowls form and muscle atrophies, and the face takes on an upright triangle shape with the sides framed by the marionette lines and the top at the narrowing of the nasal bone, said Dr. Werschler, who has a private dermatology practice and conducts research in Spokane, Wash.

In a recent study, researchers performed dissections on the faces of 30 cadavers, and found that the subcutaneous fat in the face is divided into distinct compartments. Malar fat, for example, is divided into three compartments. The researchers also suggested that the different compartments of fat in the face probably change differently with age, with the divergent fat pads changing location and proportion (Plast. Reconstr. Surg. 2007;119:2219-27).

A short while ago, there was a limited repertoire of fillers, said Dr. Werschler. One could use a temporary filler (bovine collagen) or a permanent filler (silicone). Now there is a broad palette of fillers, with properties that defy easy classification, such as poly-L-lactic acid (Sculptra) and calcium hydroxylapatite microspheres (Radiesse). Poly-L-lactic acid can be molded and shaped under the skin for a short while after injection, while calcium hydroxylapatite stimulates collagen growth around the implanted material and persists for over a year. Both can be used to build volume and they last much longer than collagen.

A "facial shaping artist" will plan out the rejuvenation procedure by taking into account the different properties of fillers, he said. The plan should be informed by the triangle concept, and by the concept that the face has three zones. The top zone extends roughly from the hairline to the upper eyelids. The middle zone goes roughly from the eyebrows to the upper lip. The bottom zone falls roughly from the base of the nose to include the anterior neck.

The goal should be to create balance and symmetry within each zone, and balance and proportion between the zones. The treatment concept embracing these ideas is known as RAVE, or regional aesthetic volume enhancement.

Many simply look to reduce nasolabial folds, oftentimes injecting too much and concentrating on just that one area. Patients may have fewer lines, but they can lose balance and proportion between the zones and can end up looking like "someone who has just stepped off the set of 'Planet of the Apes,'" he said.

"You have to look at facial balance," Dr. Werschler said. "Our approach now has to be more about global balance of the face. Lines and wrinkles do not necessarily define someone's age."

Dr. Werschler has served as a consultant to many companies, including Sanofi Aventis, maker of Sculptra, and BioForm Medical Inc., maker of Radiesse.