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“The Role of Fillers in Facial Implant Surgery”

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“The Role of Fillers in Facial Implant Surgery” Clinics Reuiew Articles FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Minimally Inuasiue Procedures in Facial Plastic Surgery EDITOR Theda C. Kontis CONSULTING EDITOR J. Regan Thomas MAY 2013 The Role of Fillers in Facial Implant Surgery William J. Binder, MDa-*, Karan Dhir, MDb, John Joseph, MDa'c KEYWORDS Facial implant surgery • Cheek augmentation • Malar augmentation Facial alloplastic implants 1 Chin implant • Chin augmentation • Facial fillers Facial rejuvenation • Facial augmentation KEY POINTS • Achieving optimal, long-lasting results in facial rejuvenation requires knowledge of how the aging process affects all levels of the face including the skin, soft tissue, and underlying bone structure. • Facial fillers and alloplastic implants are 2 methods commonly used to achieve the goal of volume enhancement for rejuvenation of the face. It is important to understand the appropriate use of each technique either as a sole modality or in conjunction with each other to attain optimal aesthetic results. • Although minimally invasive soft-tissue augmentation procedures such as fillers have effectively improved the midface treatment paradigm, chin augmentation with alloplastic implantation remains the mainstay of treatment of microgenia. Dr Joseph demonstrates midface facial filling with Sculptra and discusses his preparation of the ® materials for tear trough and midface injection in a video that accompanies this article. TREATMENT GOALS USING FILLERS AND In contrast, rates of midface alloplastic implant IMPLANTS procedures have increased at a measured pace during the past 2 decades because of the intro- Augmentation of the midface and chin with allo- duction of "less-invasive" techniques such as plastic implants has been performed with in- injectable facial fillers and fat transfer.43 Alloplas- creasing frequency during the past 4 decades tic implantation of the chin remains the optimal and offers a long-term solution for augmenting choice for projecting and repositioning the soft skeletal deficiencies, restoring facial contour irreg- tissue envelope, whereas facial fillers have gained ularities, and rejuvenating the face.1'2 Specifically, popularity in rejuvenating the aging midface.5 This chin augmentation with alloplastic implantation is more recent reliance on less-invasive surgical and the fastest growing plastic surgery trend among nonsurgical rejuvenation procedures has mini- all major demographics. The media have also mized the key role of the skeletal structure compo- well publicized the advantages of this technique, nent of the aging midface. However, rather than which has been characterized as "chinplasty" in replacing surgical augmentation techniques, mainstream magazines, further heightening the fillers can enhance the ability to use midface im- awareness of both the aesthetic and psychological plants more effectively to achieve long-term benefits of treating microgenia.3 rejuvenation. No financial disclosures. V3 a Department of Head and Neck Surgery, University of California, Los Angeles, 120 South Spalding Drive, Suite o 340, Beverly Hills, CA 90212, USA;b Department of Head and Neck Surgery, Harbor-University of California, Los Angeles, 120 South Spalding Drive, Suite 340, Beverly Hills, CA 90212, USA; c Department of Head and u Neck Surgery, University of California-Harbor, Los Angeles, 9400 Brighton Way, Suite 203, Beverly Hills, CA CD 90210, USA * Corresponding author. CO E-mail address: [email protected] CD Facial Plast Surg Clin N Am 21 (2013) 201-211 U http://dx.doi.0rg/10.1016/j.fsc.2013.02.001 re 1064-7406/13/$ - see front matter © 2013 Published by Elsevier Inc. 202 Binder et al The Process and Effects of Aging in the Face exhibits deficiencies in skeletal structure such as a negative vector of the infraorbital rim. Successful rejuvenation of the aging face entails a multidimensional approach to correct the volu- metric changes involving the skin, deep soft Midface Rejuvenation tissue, and bony skeleton.6~! The specific goals for midface rejuvenation are to8'9 • Integumentary changes such as epidermal thinning, decrease in collagen, loss of skin 1. Add contour to the upper midface or malar area elasticity, and deep tissue volume loss repre- 2. Restore cheekbone fullness and reduce sub- sent the hallmarks of soft-tissue changes in malar hollows the aging face.6 3. Soften the nasolabial and marionette folds • With advancing age, fat in the malar, buccal, 4. Reduce the vertical descent of the jowl temporal, and infraorbital regions atrophies 5. Smooth out facial lines and wrinkles and produces volumetric changes. • Fat atrophy extends beyond the subcuta- Initially, facial rejuvenation techniques were neous level and affects the deeper soft tissues tailored to improve skin laxity alone. In the along with the fat pad of Bichat. With con- 1980s, Binder first introduced midface alloplastic tinued wasting of the fat pads and loss of augmentation as an independent method for volu- fascial support, these areas become progres- metric enhancement of the aging face.2 Augmen- sively ptotic due to gravitational effects. tation not only enhances the facial skeleton but • The malar fat pad, suborbicularis oculi fat, also achieves a suspensory effect that redistrib- and orbicularis oculi muscle descend inferi- utes the soft tissue in a more favorable position. orly, exposing the infraorbital rim, and pro- By restoring lost facial soft tissue volume and duce an elevation or "mound" lateral to the increasing the anterior projection of the area, nasolabial fold and exaggerate its depth. midface augmentation reduces midface laxity, • The nasolabial and nasojugal folds deepen, restores facial contour, and decreases the depth leading to cavitary depressions and hollow- of the nasolabial fold. This result can be accom- ness in the submalar regions. plished with implantation alone and in combination • These changes may also flatten the midface with a rhytidectomy procedure, whereby augmen- and eventually unmask the underlying bony tation can soften the sharp angles and depres- anatomy. sions of the aged face, rendering a more natural postoperative result.8'9 For these patients, aug- Over time, the progressive cumulative effects of menting the bony scaffold of the malar or maxillary aging transform the once full, angular, youthful regions improve the fundamental base for sus- face into a predictably rectangular (or pear- pending the facial tissues. This emphasis on shaped) face, which appears longer in configura- volume restoration continues to represent a key tion, aged, and fatigued.8 contribution to facial rejuvenation. Most soft-tissue deficiencies in the aging mid- Later, less-invasive soft-tissue volume restoration face are localized within the recess referred to as techniques such as fat transfer and injectable facial the "submalar triangle," an inverted triangular area fillers were developed to restore soft-tissue volume of midfacial depression bordered superiorly by the loss in the midface.10" '2 Facial fillers are safe and prominence of the zygoma, medially by the nasola- effective; require a short learning curve; and over bial fold, and laterally by the body of the masseter the more immediate term, are cost-effective for muscle. The aging midface exhibits a "double treating mild to moderate soft-tissue volume loss. convexity" curvature caused by weakening of the Numerous specialties have adopted their use in lower eyelid orbital septum and consequent pseu- the office setting, and often commercially produced doherniation of the lower orbital fat pads.2'8'9 fillers do not require a physician for their administra- Age-related morphologic skeletal changes, well tion. Fueled by increased public knowledge result- described by Shaw, must also be considered ing from direct consumer marketing and during the preoperative consultation. Overall, the advertising, facial fillers have proliferated in both aging face is characterized by the resorption of numbers and types during the past few decades. bone along the orbit, midface, and mandible, Originally, soft-tissue fillers such as collagen were which leads to a reduction in the skeletal frame- used to smooth out superficial changes such as work and laxity of the overlying skin. The net result epidermal and dermal rhytids. Over the years, of these topographic changes can make an other- diverse types of fillers offering longer duration times wise healthy person appear gaunt.6'7 These and improved standards of safety and immunoge- changes are further compounded if the patient nicity have been introduced to restore volume and Facial Implants & Fillers 203 contour to the aging face. Fillers are now used to of volume loss contributed by both soft-tissue and treat nasolabial folds, lips, atrophic scars, the skeletal changes must be evaluated individually for glabella, forehead, and Marionette lines. Thicker each patient to maximize the benefit of multiple versions of hyaluronic acid-based fillers, calcium treatment modalities. hydroxyapatite (Radiesse), and biostimulating fillers such as poly-L-lactic acid (Sculptra) and polymethyl- methacrylate (Artefill) have also been used for Chin Augmentation enhancing the volume of the midface, mental, and The goal of chin augmentation is to reposition and mandibular regions.12'13 Relying on minimally inva- rotate a rigid soft-tissue envelope to a more sive techniques as a sole procedure, however, projected position along the inferior border of the may harbor inherent limitations that frequently result mandible. The procedure should
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