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3/2/2011
Creative filling techniques rival surgical facelift results
Once used as the go-to tools for filling facial lines and crevasses, fillers are now, for some facelift candidates, replacing the scalpel.
Creative filling techniques rival surgical facelift results

Once used as the go-to tools for filling facial lines and crevasses, fillers are now, for some facelift candidates, replacing the scalpel.

Just call it the "nonsurgical facelift," says Deborah S. Sarnoff, M.D., clinical professor of dermatology, New York University Langone Medical Center, New York.

Embracing fillers' versatility requires a change in thinking, according to Dr. Sarnoff. First-generation fillers were for filling lines, but now, especially with the newer fillers, dermatologists can build volume.


"Particularly women who are underweight and aging, they start to experience bony resorption. Fat and muscle atrophy, and we look deflated," she says.

Dermatologists can restore lost facial bulk with today's more robust fillers, such as calcium hydroxylapatite, (Radiesse, Merz); hyaluronic acid products, such as Perlane (Medicis); or poly-L-lactic acid, Sculptra Aesthetic (Sanofi-Aventis, off-label).

"Done right, using fillers looks natural. There is not a lot of downtime, and, in many cases, it replaces the need for silicone cheek implants. Often, we can achieve the equivalent of a surgical mid-facelift, by volumizing the mid portion of the face," Dr. Sarnoff says.

Facial trends

The trend during the past couple of years, according to Dr. Sarnoff, has been the heart-shaped, or inverted triangle, face.

"We want broader cheek areas, then, to taper to the chin," she says. "Many of our faces become more square-like as we age. One way to restore that balance is to build up the cheek area."


A patient before (left) and six months after the "liquid facelift" with calcium hydroxylapatite, with elevation of the cheeks visible in the "after" image. (Photos: Deborah Sarnoff, M.D.)

The concept of using fillers becomes refined, according to Dr. Sarnoff, when dermatologists use them to build certain vectors of the face.

"You do not just want to volumize indiscriminately," she says.

Dermatologists who attempt facial contouring need an aesthetic eye and proper training on how to augment the bony structures, including the zygoma, malar area and mandible. While male patients, who prefer a sculpted jawline, might require calcium hydroxylapatite filler to build up the posterior mandible, women could achieve a more ideal look with fillers focused in the cheeks, zygoma and preauricular areas, Dr. Sarnoff says.

Dermatologists should skillfully use fillers in thin streams not clumps to provide structure and elevate the skin, she says.

Augmenting the browlift

One sign of beauty in a woman is a high brow. Dr. Sarnoff uses Botox (onabotulinumtoxinA, Allergan) to achieve a chemical browlift, along with a small amount of filler underneath the brow (particularly under the lateral brow) to further elevate the brow.

"I would consider using a thinner filler to elevate the brow and a more robust filler right along the maxilla and mandible to augment those areas. That way, we are putting the more robust fillers deep down, on the bone, to augment the bone and using some of the finer fillers higher up in the subcutis and dermis to support and actually lift and elevate," she says.

Dermatologists can also use the thinner fillers to address the dark, sunken areas of the tear trough, Dr. Sarnoff says.
Benefits and drawbacks

One benefit to using fillers versus a surgical mid-facelift to contour the face is that fillers allow for more customization, according to Dr. Sarnoff. The true surgical mid-facelift does not address the brow and jawline, but fillers can.

There are the obvious advantages to using fillers, including less downtime, pain and bruising than with a surgical procedure.


"You can premedicate with a little Arnica Montana (Boiron), which is a natural herb that helps reduce bruising. And if patients cover any bruises with a liquid foundation or concealer that matches their surrounding skin, there is literally no downtime. You avoid anesthesia, preop testing and a surgical procedure," Dr. Sarnoff says.

Dermatologists can fine-tune what they do with fillers, mixing and matching different types to achieve a particular outcome. In the case of hyaluronic acid fillers, dermatologists can even dissolve the product with hyaluronidase if the patient is not happy with the results.

"The patient can be an active part of this customizing it during the procedure and coming back a week or so later to add some more," Dr. Sarnoff says.

Proper explanation

Dermatologists do, however, need to explain to patients that fillers resorb. Dr. Sarnoff, who says she does not use permanent fillers because of their high rates of complications, tells patients that the results of the longer-lasting fillers can stay around for as long as a year and a half.

"One of the drawbacks is that you have to do maintenance," she says. "It takes a lot of filler to get good results, and that can be quite an expense. We have creative pricing, on a sliding scale, where the price for each syringe goes down after the first few."

While almost anyone is a candidate for a liquid facelift, Dr. Sarnoff says she proceeds with caution when patients are taking blood thinners, and she counsels pregnant patients to wait until after their pregnancies before undergoing treatment.

And Dr. Sarnoff will, in some cases, go beyond just fillers to achieve desired results.

"In my practice, I love to combine fillers with Botox and the fractional CO2 (laser). They are all compatible in one treatment session," she says.

Disclosures: Dr. Sarnoff is a consultant to Allergan and is a clinical adviser and involved in medical education for Merz.

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