Let Balance, Aesthetics Guide Volume Replacement

Volume replacement can give an aging face some lift, but it’s not for everyone, according to Dr. Mark G. Rubin.

In a woman with a round face, for example, adding volume to the lower half of the face can create a fuller, heavier appearance rather than a more youthful appearance, he said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

"We all agree that volume loss is a significant part of aging, but without attention to facial balance and aesthetics, the results of volume replacement can be less than satisfactory," he added, noting that when it comes to facial contouring, an understanding of balance and aesthetics becomes more important than technique.

One important concept to keep in mind is the "triangle of youth," said Dr. Rubin who practices dermatology in Beverly Hills, Calif. He explained that a triangular face is more youthful, which is why volume that promotes roundness can have the opposite effect, even if the volume tends to smooth wrinkles.

Creating a triangular shape by providing fullness and prominence of the cheekbone – as long as it isn’t overdone – can create a youthful, attractive look, he said.

The aging lower half of the face has volume loss in several areas, including the medial cheek/nasojugal groove, the central cheek, the nasolabial folds, the marionette lines, and the prejowl area.

Volume replacement in the marionette lines and at the jaw line can be particularly effective.

In the marionette fold, one technique that can be useful is building a layer of support to push up on the descending cheek, thereby camouflaging its leading edge.

"Sometime you need to add a little support into the lateral lower lip, as well as the horseshoe of the modiolus," he said. "Remember, as you push up on the corner of the lip, that you can accidentally create or aggravate fullness laterally."

Adding filler to the upper vermilion border can also support this approach by tightening the lip and providing some lift to the corner, thereby helping reduce the puffiness created by treating the upper marionette area.

Volume at the jawline can also provide a more youthful look, but keep in mind that the two areas of apparent volume loss – the pre- and postjowl – are actually normal areas, whereas the skin in between has descended, Dr. Rubin explained. Filling these pre- and postjowl pseudodepressions will provide something of an optical illusion, making the jowl look less prominent. Similarly, adding volume at the prejowl sulcus can reduce the sagging appearance of the jowl.

However, a patient with a round face may not be a good candidate for this approach. "Too much volume at the prejowl sulcus in a patient with a round face will make the face look fat," he explained.

Also, in some patients the smoothing of the jaw line may look good on profile, but it can have a masculinizing effect by widening the lateral face when viewed head on.

As for the cheeks, not all "deflate" in the same way, and thus not all will benefit from volume replacement. In those with central cheek hollowing, volume can be very effective in creating a more youthful appearance, as well as in tightening loose skin.

A number of filler options can be considered, including hyaluronic acid (HA) fillers, poly-L-lactic acid, calcium hydroxylapatite, and polymethyl methacrylate (PMMA).

"But for first-time patients, or if you are learning your way, don’t underestimate the value of a reversible filler," he said.

As with the use of neurotoxins, the approach to using fillers can vary without necessarily affecting the outcome. Various physicians have their own preferences for products and injection techniques, yet almost everyone seems to be able to achieve the intended aesthetic goal, he explained.

"So I don’t think the ‘what’ is that important. It’s knowing the ‘where’ and the mastering of an injection technique that means more," he said.

In fact, Food and Drug Administration trial data for most fillers suggest that they are more similar than dissimilar in terms of efficacy, longevity, and adverse effects. Still, although conventional wisdom suggests that particle size, concentration, or lift should affect the final result, and thus in theory there should be one product that is best for each location, there is a lack of agreement.

In Dr. Rubin’s experience, however, HA, PMMA, and calcium hydroxylapatite fillers can have a slight rippling effect when they are injected in areas of soft tissue, such as the central cheek.

"It’s hard to make a smooth contour across 6-8 cm when you are injecting droplets or linear filaments of a filler," he said, noting that poly-L-lactic acid seems to create a smoother contour in that area.

When injecting over bony areas, HA products and calcium hydroxylapatite are acceptable, because the defects are generally smaller and there is less surface area on which to see ripples.

Dr. Rubin is a consultant for Medicis. He also has been involved in FDA clinical trials for Restylane, Perlane, and Artefill. SDEF and this news organization are owned by Elsevier.

Volume replacement can give an aging face some lift, but it’s not for everyone, according to Dr. Mark G. Rubin.

In a woman with a round face, for example, adding volume to the lower half of the face can create a fuller, heavier appearance rather than a more youthful appearance, he said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

"We all agree that volume loss is a significant part of aging, but without attention to facial balance and aesthetics, the results of volume replacement can be less than satisfactory," he added, noting that when it comes to facial contouring, an understanding of balance and aesthetics becomes more important than technique.

One important concept to keep in mind is the "triangle of youth," said Dr. Rubin who practices dermatology in Beverly Hills, Calif. He explained that a triangular face is more youthful, which is why volume that promotes roundness can have the opposite effect, even if the volume tends to smooth wrinkles.

Creating a triangular shape by providing fullness and prominence of the cheekbone – as long as it isn’t overdone – can create a youthful, attractive look, he said.

The aging lower half of the face has volume loss in several areas, including the medial cheek/nasojugal groove, the central cheek, the nasolabial folds, the marionette lines, and the prejowl area.

Volume replacement in the marionette lines and at the jaw line can be particularly effective.

In the marionette fold, one technique that can be useful is building a layer of support to push up on the descending cheek, thereby camouflaging its leading edge.

"Sometime you need to add a little support into the lateral lower lip, as well as the horseshoe of the modiolus," he said. "Remember, as you push up on the corner of the lip, that you can accidentally create or aggravate fullness laterally."

Adding filler to the upper vermilion border can also support this approach by tightening the lip and providing some lift to the corner, thereby helping reduce the puffiness created by treating the upper marionette area.

Volume at the jawline can also provide a more youthful look, but keep in mind that the two areas of apparent volume loss – the pre- and postjowl – are actually normal areas, whereas the skin in between has descended, Dr. Rubin explained. Filling these pre- and postjowl pseudodepressions will provide something of an optical illusion, making the jowl look less prominent. Similarly, adding volume at the prejowl sulcus can reduce the sagging appearance of the jowl.

However, a patient with a round face may not be a good candidate for this approach. "Too much volume at the prejowl sulcus in a patient with a round face will make the face look fat," he explained.

Also, in some patients the smoothing of the jaw line may look good on profile, but it can have a masculinizing effect by widening the lateral face when viewed head on.

As for the cheeks, not all "deflate" in the same way, and thus not all will benefit from volume replacement. In those with central cheek hollowing, volume can be very effective in creating a more youthful appearance, as well as in tightening loose skin.

A number of filler options can be considered, including hyaluronic acid (HA) fillers, poly-L-lactic acid, calcium hydroxylapatite, and polymethyl methacrylate (PMMA).

"But for first-time patients, or if you are learning your way, don’t underestimate the value of a reversible filler," he said.

As with the use of neurotoxins, the approach to using fillers can vary without necessarily affecting the outcome. Various physicians have their own preferences for products and injection techniques, yet almost everyone seems to be able to achieve the intended aesthetic goal, he explained.

"So I don’t think the ‘what’ is that important. It’s knowing the ‘where’ and the mastering of an injection technique that means more," he said.

In fact, Food and Drug Administration trial data for most fillers suggest that they are more similar than dissimilar in terms of efficacy, longevity, and adverse effects. Still, although conventional wisdom suggests that particle size, concentration, or lift should affect the final result, and thus in theory there should be one product that is best for each location, there is a lack of agreement.

In Dr. Rubin’s experience, however, HA, PMMA, and calcium hydroxylapatite fillers can have a slight rippling effect when they are injected in areas of soft tissue, such as the central cheek.

"It’s hard to make a smooth contour across 6-8 cm when you are injecting droplets or linear filaments of a filler," he said, noting that poly-L-lactic acid seems to create a smoother contour in that area.

When injecting over bony areas, HA products and calcium hydroxylapatite are acceptable, because the defects are generally smaller and there is less surface area on which to see ripples.

Dr. Rubin is a consultant for Medicis. He also has been involved in FDA clinical trials for Restylane, Perlane, and Artefill. SDEF and this news organization are owned by Elsevier.

Volume replacement can give an aging face some lift, but it’s not for everyone, according to Dr. Mark G. Rubin.

In a woman with a round face, for example, adding volume to the lower half of the face can create a fuller, heavier appearance rather than a more youthful appearance, he said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

"We all agree that volume loss is a significant part of aging, but without attention to facial balance and aesthetics, the results of volume replacement can be less than satisfactory," he added, noting that when it comes to facial contouring, an understanding of balance and aesthetics becomes more important than technique.

One important concept to keep in mind is the "triangle of youth," said Dr. Rubin who practices dermatology in Beverly Hills, Calif. He explained that a triangular face is more youthful, which is why volume that promotes roundness can have the opposite effect, even if the volume tends to smooth wrinkles.

Creating a triangular shape by providing fullness and prominence of the cheekbone – as long as it isn’t overdone – can create a youthful, attractive look, he said.

The aging lower half of the face has volume loss in several areas, including the medial cheek/nasojugal groove, the central cheek, the nasolabial folds, the marionette lines, and the prejowl area.

Volume replacement in the marionette lines and at the jaw line can be particularly effective.

In the marionette fold, one technique that can be useful is building a layer of support to push up on the descending cheek, thereby camouflaging its leading edge.

"Sometime you need to add a little support into the lateral lower lip, as well as the horseshoe of the modiolus," he said. "Remember, as you push up on the corner of the lip, that you can accidentally create or aggravate fullness laterally."

Adding filler to the upper vermilion border can also support this approach by tightening the lip and providing some lift to the corner, thereby helping reduce the puffiness created by treating the upper marionette area.

Volume at the jawline can also provide a more youthful look, but keep in mind that the two areas of apparent volume loss – the pre- and postjowl – are actually normal areas, whereas the skin in between has descended, Dr. Rubin explained. Filling these pre- and postjowl pseudodepressions will provide something of an optical illusion, making the jowl look less prominent. Similarly, adding volume at the prejowl sulcus can reduce the sagging appearance of the jowl.

However, a patient with a round face may not be a good candidate for this approach. "Too much volume at the prejowl sulcus in a patient with a round face will make the face look fat," he explained.

Also, in some patients the smoothing of the jaw line may look good on profile, but it can have a masculinizing effect by widening the lateral face when viewed head on.

As for the cheeks, not all "deflate" in the same way, and thus not all will benefit from volume replacement. In those with central cheek hollowing, volume can be very effective in creating a more youthful appearance, as well as in tightening loose skin.

A number of filler options can be considered, including hyaluronic acid (HA) fillers, poly-L-lactic acid, calcium hydroxylapatite, and polymethyl methacrylate (PMMA).

"But for first-time patients, or if you are learning your way, don’t underestimate the value of a reversible filler," he said.

As with the use of neurotoxins, the approach to using fillers can vary without necessarily affecting the outcome. Various physicians have their own preferences for products and injection techniques, yet almost everyone seems to be able to achieve the intended aesthetic goal, he explained.

"So I don’t think the ‘what’ is that important. It’s knowing the ‘where’ and the mastering of an injection technique that means more," he said.

In fact, Food and Drug Administration trial data for most fillers suggest that they are more similar than dissimilar in terms of efficacy, longevity, and adverse effects. Still, although conventional wisdom suggests that particle size, concentration, or lift should affect the final result, and thus in theory there should be one product that is best for each location, there is a lack of agreement.

In Dr. Rubin’s experience, however, HA, PMMA, and calcium hydroxylapatite fillers can have a slight rippling effect when they are injected in areas of soft tissue, such as the central cheek.

"It’s hard to make a smooth contour across 6-8 cm when you are injecting droplets or linear filaments of a filler," he said, noting that poly-L-lactic acid seems to create a smoother contour in that area.

When injecting over bony areas, HA products and calcium hydroxylapatite are acceptable, because the defects are generally smaller and there is less surface area on which to see ripples.

Dr. Rubin is a consultant for Medicis. He also has been involved in FDA clinical trials for Restylane, Perlane, and Artefill. SDEF and this news organization are owned by Elsevier.