How does the face age?

How does the face age?

The face ages through what I call the “3 D’s – decent, deflation, and demarcation. UV damage to the skin, loss of collagen in the dermis, loss of subcutaneous fat, and loss of bone density contribute to the 3 D’s. It is important to understand what is wrong before beginning a treatment regimen. A therapeutic technique must address the underlying anatomic basis for the cosmetic problem.

It is useful to break the face down into 3 aesthetic regions. The upper third includes the hairline to the glabella (brows), the middle third includes the glabella to the nose, and the lower third from the nose to the chin.

Aging changes in the upper third include brow ptosis (droop), glabellar creases between the brows, and forehead rhytids (wrinkles). A surgical brow lift is often needed to correct brow ptosis. However, in mild cases of brow ptosis, Botox can provide an excellent brow lift without the down-time of surgery. Botox works very well for forehead and glabellar creases. Sometimes, a dermal filler such as Restylane or Juvederm is needed to fill in persistent glabellar creases.

Aging changes in the middle third of the face include baggy and excessive eyelid skin, eyelid ptosis (droop), puffy or sagging lower lids. These changes are best addressed surgically through an upper and lower lid blepharoplasty. In some patients, hollowing of the lower lids occurs with demarcation of the lower rim of the orbit (eye socket) or a depression near the side of the nose called a tear trough deformity. These patients are best served by adding volume to this area with dermal fillers. Prominent nasolabial folds (laugh lines) are also treated very effectively with dermal fillers. Nasal tip ptosis (downward pointing of the nose) develops due to loss of structural support around the nasal alae. Again, dermal fillers work very well at correcting this deformity by increasing volume and support in this area.

Aging changes to the lower third of the face include jowls (pronounced melolabial folds) and loss of lip volume. Loss of lip volume presents as lip ptosis (curling in of the lips) with loss of the vermillion (red) border, a poorly defined “cupid’s bow”, and loss of the upper and lower “pillows”. Fine vertical lines become more prominent. Dermal fillers are ideal choices for correcting both melolabial folds and lip enhancement.

What are dermal fillers and how do they work?

Dermal fillers are injectible, soft tissue implants that can be permanent, semi-permanent, and temporary. They are used to replace lost volume after age or disease-related bone, fat, and collagen loss. They can be used in many different aesthetic regions throughout the body, especially the face and hands. This discussion will focus on the application of dermal fillers to the face.

Permanent fillers, such as silicone, are rarely used in the face. At first it may seem like the most economical way to go. However, a well placed filler today becomes a not-so-well placed filler years later as the face changes shape. A permanent filler is not easy to remove.

Semi-permanent fillers can last 1-2 years and have some important uses in the face. Examples include Radiesse and Sculptra. Radiesse is a calcium hydroxylapetite in an aqueous carrier. It is used for precise placement in deep tissues where bone loss has occurred. It is particularly effective along the jaw bone, nasolabial folds, and along the inferior rim of the orbit (eye socket). Sculptra is polymerized lactic acid, similar to the material used for skin sutures (Vicryl). It is the opposite of Radiesse, in that it is used for non-precise large-area volume enhancement. It does have a small, but real risk of allergic reaction.

Temporary fillers are by far, the most commonly used fillers in the face today. Collagen filler was quite popular for awhile,but only lasts 3-6 months and has a risk of allergic reaction. Collagen has largely been replaced by the hyaluronic acids (HAs). Hyaluronic acid is a naturally occurring substance and is found in the eye, joints, and skin. HAs are safe, have a very low incidence of allergic reaction, and typically last 6-12 months. Restylane/Perlane and Juvederm Ultra/Ultra Plus are examples of HAs. Restylane and Juvederm Ultra have smaller molecular structures, which is more effective in filling in finer lines, and building volume and definition in the lips. Perlane and Juvederm Ultra Plus have larger molecules, and thus more “horsepower” in building volume and filling deeper lines.

What are the different types of anethesia used for dermal filler injections?

Dermal filler injections are second only to Botox in popularity for non-surgical facial rejuvenation. There are a number of different ways to provide anesthesia during dermal filler injections. These include ice, topical anesthetic, dental blocks, and local anesthetic mixed with the filler itself. The choice of anesthetic depends on the type of filler used and the area of injection. This discussion will focus on the hyaluronic acid fillers, namely Restylane/Perlane and Juvederm Ultra/Ultra Plus.

Topical anesthetics include 2% lidocaine gel and a triple anesthetic gel composed of 20% benzocaine, 6% lidocaine, and 4% tetracaine, (BLT gel). I find the BLT gel is more effective that the lidocaine gel alone. Dental blocks with 3% Polocaine are painlessly given with a tiny 30 gauge needle to anesthetize the upper and lower lips and peri-oral region. Recently, clinicians have started mixing small amounts (0.2-0.3 cc) of 2% lidocaine with epinephrine with the hyaluronic acid gels with high patient satisfaction. Medici, the maker of Restylane/Perlane has introduced a pre-packaged mixture of 0.3% lidocaine with Restylane/Perlane in Europe. It is not available in the US, yet.

Glabellar creases, lateral sub-brow fat augmentation, nasolabial folds (laugh lines) and melolabial folds (frown lines) respond well to either pre-injection icing or topical anesthetic gel. Tear trough (depressions on the inside corners of the lower lids) injections typically require anesthetic to be mixed with the filler in addition to icing. Lip augmentation and injections to the outer corners of the mouth almost always require a dental block for adequate analgesia.