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Facial Sculpting and Tissue Augmentation
J
EAN D.A. CARRUTHERS, MD,
✽
AND
ALASTAIR CARRUTHERS, MD
†
✽
Department of Ophthalmology and
†
Division of Dermatology, University of British Columbia, Vancouver, British
Columbia, Canada
BACKGROUND. Until recently, deep facial sculpting was exclu-
sively the domain of surgical interventions. Recent advances in
the available array of dermal and subdermal fillers combined
with an esthetic appreciation by both surgeons and nonsurgeons
alike of the positive effect of filling the volume-depleted face have
led to an expansion in the indications for the use of soft tissue
augmenting agents.
METHOD
. Subdermal support of the lateral two-thirds of the
brow, the nasojugal fold, the malar and buccal fat pads, the lat-
eral lip commissures, and the perioral region, including the pre-
jowl sulcus, all restore youthful facial contour and harmony. An
important advance in technique is the subdermal rather than the
intradermal injection plane.
RESULTS. “Instant” facial sculpting giving a brow-lift, cheek-lift,
lip expansion, and perioral augmentation is possible using mod-
ern soft tissue augmenting agents. The softer, more relaxed
appearance contrasts to the somewhat “pulled” appearance of
subjects who have had surgical overcorrections. Treatments can
be combined with botulinum toxin and other procedures if
required.
CONCLUSION. Newer advances in the use of fillers include the use
of fillers injected in the subdermal plane for “lunchtime” facial
sculpting. Using the modern esthetic filler compounds, which are
biodegradable but longer lasting, subjects can have a “rehearsal”
treatment or make it ongoing. Some individuals, such as those
with human immunodeficiency virus (HIV)-related lipoatrophy
or those who desire to obtain a longer-lasting effect, may elect to
use a nonbiodegradable filling agent.
© 2005 by the American Society for Dermatologic Surgery, Inc. • Published by BC Decker Inc
ISSN: 1076–0512 • Dermatol Surg 2005;31:1604–1612.
ALASTAIR CARRUTHERS, MD, AND JEAN CARRUTHERS, MD, ARE CONSULTANTS AND INVESTIGATORS
FOR AND HAVE RECEIVED HONORARIA FROM ALLERGAN INC. AND MEDICIS INC., ARE
INVESTIGATORS FOR Q-MED, INC. AND FERNDALE LABS INC., AND ARE CONSULTANTS,
INVESTIGATORS, AND ADVISORY BOARD MEMBERS FOR BIOFORM MEDICAL INC. ALASTAIR
CARRUTHERS ALSO IS ON THE ADVISORY BOARD OF AND HAS RECEIVED HONORARIA FROM
UNILEVER CANADA, IS ON THE ADVISORY BOARD OF AND IS A STOCK HOLDER OF ARTES MEDICAL,
INC., AND IS AN INVESTIGATOR FOR RICHARD JAMES INC. JEAN CARRUTHERS, MD, IS ON THE
ADVISORY BOARD OF ARTES MEDICAL INC, AESTHERA, AND LUMENIS, INC.
SOFT TISSUE augmentation with injectable filling agents
is commonly used for reducing signs of facial aging. Ini-
tially used mainly in the perioral region, augmentation in
other areas is rapidly increasing in popularity. A novel use
for filling agents is to use their volume-occupying proper-
ties to replace lost subdermal fat and remodeled maxillary
and mandibular bone to elevate the lateral brow, the mid-
face, and the sublabial sulcus and mental contours, among
other areas. The “push-fill” restores the youthful charac-
teristics of the face without “pull” surgery, with less incon-
venience and few complications. Using fillers for facial
rejuvenation requires not only knowledge of specific fillers
but also insight into the process and anatomy of aging.
This article briefly reviews the new facial sculpting con-
cepts for filler use.
Brow Ptosis and Surgical Brow-Lifts
The lateral brow becomes ptotic as the brow fat pad
shrinks in size, and the lateral brow skin becomes elastotic
with chronologic aging, photodamage, and repetitive
action of the depressor fibers of the orbicularis oculi. The
anatomy of brow ptosis has been extensively studied by
Knize,
1,2
and its treatment initially was primarily surgical.
However, a purely surgical lift elevates the tail of the brow
but does not restore its anterior projection. A purely sur-
gical lift is two-dimensional, whereas the filler lift adds the
anterior projection and the third dimension seen in youth
(Figure 1). A variety of complications may be associated
with forehead and brow-lifting procedures.
3
In a recent
retrospective review of 628 patients who underwent endo-
scopic brow-lift, Chiu and Baker found surgery to be less
effective than desired in the majority of patients, with
postsurgical complications, including alopecia, hairline
changes, infected hardware, brow asymmetry requiring
surgical revision, prolonged forehead or brow paresthesia,
frontal branch nerve paralysis, and scalp dysesthesia.
4
Address correspondence and reprint requests to: Jean Carruthers,
MD, Cosmetic Surgery Inc., 740–943 West Broadway, Vancouver,
BC, Canada V5Z 4E1, or e-mail: drjean@carruthers.net.
Dermatol Surg 31:11 Part 2:November 2005 CARRUTHERS, JDA AND A: FACIAL SCULPTING AND TISSUE AUGMENTATION
1605
Complications that may be seen in the filler lateral
brow-lift are both technique and substance related. Ideally,
the needle is bent 45, bevel up, and is gently inserted into
the subdermal space (ie, replacing the brow fat pad) at the
lateral brow cilia. The “push-ahead” technique is used,
allowing the subdermal region to be elevated by the for-
ward movement of dermal filler rather than the tip of the
needle (see Figure 1A). In this manner, bruising is
extremely uncommon. In addition, spending some time
molding the filler gives the best esthetic in terms of sym-
A C
B
Figure 1. (A) Lateral brow-lift using the technique of subdermal insertion of the needle at the most lateral extent of the brow and delivery
of the filler by the push-ahead technique to avoid bruising. (B) Before and after bilateral Restylane brow-lift from the temporal brow to the
supraorbital notch. Note that the brow is more evenly arched and the upper eyelid platform is instantaneously enlarged in the after photo-
graph in both subjects. (C) Filler lifting of the ptotic lateral brow restores the youthful anterior projection of the brow rather than simply ele-
vating it, as with traditional surgical techniques.
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CARRUTHERS, JDA AND A: FACIAL SCULPTING AND TISSUE AUGMENTATION
Dermatol Surg 31:11 Part 2:November 2005
metry and anterior projection. The lumping and bumping
seen with hyaluronan injection in the lips can also be seen
here. It is important to explain to subjects that 2 to 3 days
of mild swelling and prominence of the implant are an
expected part of the immediate local tissue response. Mas-
sage, ice, and oral prednisone 20 to 25 mg/d for 48 to 72
hours may be needed in more reactive individuals. We
believe that highly viscous fillers, such as the hyaluronans,
are ideal for this indication and that autologous fat and the
collagen-based fillers need to be injected using a blunt can-
nula because they are much less viscous and can possibly
embolize the periocular circulation. We have been per-
forming this technique using hyaluronans with 27- to 30-
gauge needles and the push-ahead technique since 2000
and have seen no vascular occlusive phenomena (see Fig-
ure 1, B and C).
Midface
Over the last 10 years, physicians have also focused their
efforts on correcting the aging changes in the midface.
5
Surgical lifting procedures of the midface provide an
esthetic recontouring of the malar region, with more
emphasis on the lower eyelid–cheek continuum and the
projection of the zygomatic ridges. In women, the visual
expansion of the zygomatic midface emphasizes the heart-
shaped esthetic of the classically beautiful female face.
Although advances in cosmetic techniques—such as the
reinforced orbitotemporal lift,
6
combined cheek and mid-
face lift with full-thickness temporal lower eyelid resec-
tion,
7
endoscopic lift,
8–11
midface sling,
12
and malar fat pad
elevation
13,14
—have improved patient outcomes, many
surgical procedures result in prolonged periods of perior-
bital ecchymosis and edema, and consistent and symmet-
ric improvements are still somewhat difficult to achieve, in
particular for the less experienced surgeon.
Complications that may occur in the midface relate to
judgment and marking of facial contours to achieve sym-
metry, multiple needle insertions that may provoke bruis-
ing and failure to use the push-ahead technique, and mold-
ing of the newly placed implant. In the malar area, the
insertion plane is subdermal, and the region needing to be
filled is marked, with the patient’s assistance by holding a
mirror, using a white soft lead eye pencil.
In the nasojugal fold, the filler material needs to be
placed deep to the orbicularis oculi muscle just along the
periosteum at the arcus marginalis so that there is no obvi-
ous cutaneous evidence of filler presence. In this way, the
Figure 2. (A) Anatomic location of subdermal filler placement to restore normal malar convex contour. (B) Zygomaticomalar soft tissue aug-
mentation using non–animal-stabilized hyaluronic acid (Restylane). Note the area to be augmented drawn on the subject using a soft eye-
liner pencil (easily removable) to ensure post-treatment symmetry.
B
A
nasojugal fold is subtly distended and there is no tell-tale
“blue ellipse,” as when the material is placed immediately
subcutaneously. The reason for this is the unique thinness
and delicacy of the periocular skin (Figure 2).
Lumping and bumping are mainly seen with the
hyaluronan fillers. We note very transient similar side
effects in the collagen-based fillers. Similar management of
the situation with pretreatment explanation of the possi-
ble side effects turns them from complications to expected
post-treatment outcomes.
The Aging Face
The pioneering work of Coleman,
15
Amar,
16
Donofrio,
5,17,18
and Berman
19
has led to the principle that age-related
changes in the face may largely be improved by subcuta-
neous autologous fat augmentation and redistribution: the
“sagging” skin associated with age is caused by the atrophy
of subcutaneous fat and loss of remodeled facial bone, as
well as by gravity.
18
Loss of volume—particularly around
the eyes and cheeks—cannot be completely corrected by
traditional surgical procedures. This understanding has led
to the emergence of a new form of rejuvenation: volume
replacement with fillers in the brow and mid- and lower
face, which subtly restores the face to youth (Figures 2 to 4).
Fillers for Facial Contouring
The recent surge in available injectables has shifted the
focus of rejuvenation from surgical procedures, including
use of autologous fat, to those that are more convenient
and associated with fewer complications and little or no
“downtime.” Soft tissue filler injections can be performed
using only topical anesthetic agents and give an instant
result with no downtime. A number of techniques aimed at
restoring lost volume through the use of autologous and
nonautologous fillers have demonstrated that rebalancing
fat distribution or otherwise replacing volume to youthful
proportions can restore the harmonious esthetic of the face.
That it can be performed in a noninvasive manner may
herald the future of facial rejuvenation.
Traditional Fillers
Bovine collagen has long been considered the “gold stan-
dard” in injectable fillers because of its ease of use, avail-
ability, affordability, and convenience. However, the pos-
sibility of allergic reactions to bovine collagen and the
limited duration of effect have stimulated the continual
search for more ideal fillers.
20
CosmoDerm and Cosmo-
Plast (INAMED Aesthetics, Santa Barbara, CA, USA) are
new bioengineered human collagen products approved for
cosmetic use in Canada and the United States; in a study
of 428 patients, no allergic responses were observed.
21
Some believe that autologous fat grafting—a procedure
that has been performed for more than 100 years—repre-
sents the ideal replacement for soft tissue atrophy, replacing
volume and contours lost in the aging process.
22,23
In 1997,
Coleman promoted lipostructure—the placement of small
amounts of fatty tissue in multiple tunnels—for a safe, long-
lasting method of recontouring the face.
15
The fat autograft
muscle injection technique, developed by Amar
16
and based
on Coleman’s technique, involves the injection of adipose
tissue within the muscles of facial expression in intricate
layers of autologous fatty tissue with anatomic patented
microcannulas and has shown improved long-term, esthetic
results for facial rejuvenation.
24
In “fat rebalancing,” Donofrio has shown that replac-
ing “missing” fat with autologous fat gives both a pleas-
ing elevation and anterior projection of the lateral brow—
a return to its youthful contour.
17,18
Each rebalancing
treatment, which addresses all facial areas, makes patients
appear 2 to 5 years younger. Fat is harvested from the
patient, frozen, and transferred in less than 0.1 cc aliquots
under low injection pressures, weaving fat in a cross-
hatched three-dimensional design through the muscle to
the subdermis or, when injected periorbitally, placed con-
servatively deep to the periocular musculature.
18
In total,
patients undergo four to eight transfers over a year.
Although largely technique dependent, potential com-
plications of autologous fat grafting include hematoma,
fat necrosis, infections, vascular occlusion (including
blindness and cerebral vascular accident), and the forma-
Dermatol Surg 31:11 Part 2:November 2005 CARRUTHERS, JDA AND A: FACIAL SCULPTING AND TISSUE AUGMENTATION
1607
Figure 3. Traditional perioral (lip) augmentation using non–animal-stabilized hyaluronic acid (Restylane) (A, before; B, after).
AB
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CARRUTHERS, JDA AND A: FACIAL SCULPTING AND TISSUE AUGMENTATION
Dermatol Surg 31:11 Part 2:November 2005
tion of cysts. Since the variable longevity of contour cor-
rection depends on technique, the amount of fat injected,
and location, improvements in harvesting, handling, and
the injection process may have an impact on positive
patient outcomes.
22
However, the fact remains that autol-
ogous fat grafting demonstrates unpredictable and some-
times temporary results.
25,26
Moreover, harvesting and
reinjecting fat are both significant procedures that are
associated with downtime and the possibility of serious
complications.
Hyaluronic Acid
Hyaluronic acid—a dimeric, cross-linked sugar molecule
consisting of N-acetylglucosamine and glucuronic acid—is
a key structural component of the skin that functions as a
space-filling, structure-stabilizing, and cell-protective mol-
ecule. In cross-linked gel form, hyaluronic acid is
hydrophilic and provides volume to easily fill in larger
folds of skin around the mouth and cheeks (see Figures 2
to 4). Restylane and Perlane (Medicis Inc., Scottsdale, AZ,
USA) are non–animal-stabilized hyaluronic acid gels that
appear to provide durability and esthetic improvement
that are superior to bovine collagen.
27
They may be useful
adjuncts in facial cosmetic procedures
28,29
and rarely cause
an allergic reaction. Restylane was approved for
nasolabial fold augmentation by the US Food and Drug
Administration (FDA) in 2003. Hylaform Plus (Genzyme
Corp., Cambridge, MA, USA) is a naturally occurring
cross-linked hyaluronan obtained from chicken combs;
Hylaform was recently approved for esthetic use by the
FDA (April 2004). The results typically last from 3 to 6
months, depending on the type of cross-linked hyaluronic
acid used. The duration of the hyaluronic acid derivatives
varies significantly, depending on the area injected. For
example, mobile areas, such as the lips and lower
nasolabial folds, have a shorter duration than less mobile
areas, such as the cheeks, zygoma, and chin or those areas
the mobility of which is affected by botulinum toxin.
Complications and Contraindications
The temporary nature of hyaluronic acid—an advantage in
itself—is both the primary advantage and disadvantage for
patients seeking a longer-lasting effect. However, the guar-
antee of eventual dissipation can be a reassurance, espe-
cially to esthetically naive patients who have never experi-
enced facial rejuvenation. Intramuscular or subperiosteal
injections are not recommended because much of the filler
will be absorbed. Likewise, injections into dynamic areas
associated with a great amount of movement, such as
around the mouth, may lead to less satisfactory results
because the motion will encourage absorption.
30
Injection-
related adverse effects—bruising, erythema, pruritis, dis-
coloration—are common and should be described pre-
treatment to the patients as expected sequelae that are in no
way unexpected complications.
Delayed skin reactions have been reported postinjec-
tion.
30
Recent publications have documented intermittent
swelling and granulomatous reactions,
30,31
and the use of
impure or contaminated material can result in infection or
foreign body reaction.
32
However, granulomas often
respond to injected corticosteroids, topical antihistamines,
and digital pressure or manipulation.
30
Silicone Oil
Highly refined and purified silicone oil (Silskin, Richard
James Inc, Boston, MA, USA) is currently the subject of a
multicenter clinical trial.
33
A similar product, Silikon 1000
(Alcon Pharmaceuticals, Fort Worth, TX, USA) has been
successfully used to restore normal contour in human
immunodeficiency virus (HIV)-associated facial wasting.
33
Prior to treatment, individuals bear a stigma on their faces,
which is characteristic of HIV infection. After treatment,
subjects are able to return to normal work and social activ-
ities, having discarded that stigma (Figure 5).
Injectable silicone oil is currently in use, but this is
mainly restricted to indications such as facial wasting
because of the concern over long-term complications. The
remote possibility of silicone granuloma is enough to dis-
courage many physicians from using this agent.
Figure 4. Support and enhancement of the lateral oral commissures
and the creation of the commissural buttress as suggested by Cole-
man.
26
(A) Before and (B) 1 year after Perlane augmentation.
A
B
Polymethylmethacrylate Microspheres
Artecoll (to be marketed in the United States after FDA
approval under the name Artefill; Artes Medical, San
Diego, CA, USA) is a suspension of polymethylmethacry-
late (PMMA) microspheres in 3.5% bovine collagen solu-
tion. It is available in Canada and Europe and successfully
corrects atrophy of the malar fat pad and adjacent subcu-
taneous fat (Figure 6).
34,35
After subdermal (or, in severe
cases, epiperiosteal) injections, the collagen solution even-
tually dissipates, leaving behind the nonbiodegradable
PMMA microspheres. The volume to be injected depends
on the depth and size of the depression; generally, at least
two to four injection sessions are required. Given that the
product (but not the correction) is permanent, one does
not want to overcorrect the defect. Instead, partial correc-
tion, followed by reinjection after a few months, will pro-
duce a smoother, more natural appearance.
Complications and Contraindications
Injections of Artecoll are not recommended for areas of
thin skin (eg, lower eyelid or neck). With lip augmenta-
tion, or in any other areas of repetitive movement, bead-
ing, palpability, and visibility of the implant may occur.
Artecoll facial injections have been reported to cause the
delayed development of granulomatous reactions,
36
and
improper placement intradermally (rather than into the
upper levels of the subdermis) or too aggressive injections
can lead to beading, ridging, and nodule formation and can
cause disfigurement, which is reversible only by surgical
excision.
30
Conservative amounts of Artecoll and a long
interval between injections are recommended.
37
Even with a
conservative approach, granulomas can appear months—
even years—after treatment. Although the incidence is low,
their potential occurrence must be part of the subject’s
informed consent process. They appear to respond to intrale-
sional triamcinolone injections,
30,38
but other treatments,
including surgery, may also be necessary. Contraindications
include allergies to bovine collagen, thin, flaccid skin or
atrophic skin disease, and keloids. Skin testing prior to injec-
tion is mandatory because of the bovine collagen vehicle.
Technique
The injection technique for Artecoll is different from that
used for biodegradable fillers. First, the optimum results
are obtained by subdermal and not intradermal injection
levels. Second, it is unwise to aim for a full correction with
Artecoll because the body responds better by being able to
Dermatol Surg 31:11 Part 2:November 2005 CARRUTHERS, JDA AND A: FACIAL SCULPTING AND TISSUE AUGMENTATION
1609
Figure 5. Repeated sequential purified silicone oil injections using the microdroplet technique restore subjects with chronic facial wasting to
normal appearance and social function (A, before; B, afer).
Figure 6. Artecoll under correction: injection in the subdermal plane to give a stepwise sequential esthetic augmentation (A, before; B, after).
AB
AB
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CARRUTHERS, JDA AND A: FACIAL SCULPTING AND TISSUE AUGMENTATION
Dermatol Surg 31:11 Part 2:November 2005
encapsulate a smaller quantity of product more frequently
(see Figure 5).
Temporal Brow-Lift
The skin is anesthetized with topical LMX 5% or Betacaine
ointment and inspected for the underlying vasculature. The
filler product of choice for each individual is
chosen—usually Restylane or Hylaform Plus for the first
treatment. We prefer to use the hyaluronan fillers in this area
because of the greater tendency of the material to self-
agglomerate and its ability to be gently molded postinjection.
A soft white or colored eye pencil is used to draw the
ellipse into which the filler will be injected (N. J. Lowe,
personal communication of his daughter’s observation,
2003). The needle is bent at a 25 angle, bevel up, pushed
through the skin, and gently advanced into the subdermal
plane. The product is injected by the “push-ahead” tech-
nique so that the filling agent dissects ahead of the needle.
Usually, the initial injection is placed at the temporal end
of the lateral brow cilia, and the injection volume is 0.2 cc.
The needle is withdrawn and reinserted about 7 mm
medial to the first. The product is further injected using the
push-ahead technique to the lateral aspect of the supraor-
bital notch. The usual injection volume is 0.1 to 0.2 cc in
this segment. The product is molded gently to recreate the
natural projection previously created by the brow fat pad,
and ice is applied. An instantaneous lateral brow-lift is
observed (see Figure 1).
Midface Filler Lift
Hypoplasia of the zygoma or midface fat descent and atro-
phy rob the female face of the normal heart-shaped con-
tour. The eye pencil is used to outline the area of the
zygoma, requiring esthetic enhancement. The face is
checked for asymmetry, and photographs are taken with
the periocular muscles relaxed and then dynamic in a
forced smile. Filler is injected into the subdermal space in
each place, and the esthetic benefit is inspected by the sub-
ject in a mirror. Restylane, Perlane, and Hylaform Plus all
work well in this region. Artecoll may also work well, but
a smaller injection volume is used at each treatment, as is
a “top-up” treatment in approximately 6 to 8 weeks. Pho-
tographs, relaxed and with full smile, are taken after the
treatment (see Figure 2). Botulinum toxin type A (BTX-A;
Botox) for the crow’s feet may be injected at the same
treatment session. The combined use of filler and BTX-A
appears to extend the life of the filling agent in this region
as in others.
28,29
Nasojugal Fold Lift
As the ligament of Lockwood relaxes and allows the globe
to sit more inferiorly, the malar fat pad descends and often
appears to “split” along the orbitomalar ligament. The
resulting unmasking of the nasojugal fold gives a “double
bubble” contour to the lower eyelid–cheek continuum.
Injection of a filler deep to the orbicularis oculi and ante-
rior to the arcus marginalis allows a restoration of the nor-
mal sigmoid contour to the cheek lid continuum (Fig-
ure 7).
Perioral Augmentation or Rejuvenation
The perioral region was found on a 2002 consumer survey
performed by Allergan Pharmaceuticals to be of slightly
more concern to the female respondents than the glabella.
The deflation of the vermilion lip with vertically oriented
“lipstick lines,” the downturned mouth corner, and the
deepening melomental fold give a negative, sour, and dis-
appointed emotional projection, even though the individ-
ual may be feeling very positive emotionally (Figure 8).
For many years, the vermilion lip itself has been the
primary esthetic target of the physician experienced with
the use of injectable fillers. However, during a research
project performed using hyaluronans in Vancouver in
2003, Dr. Arnold Klein taught us to expand the lip treat-
ment concept from the center of the frame (the lips them-
selves) to the entire lower facial frame—to the mouth cor-
ners, the melomental folds, the mental groove seen in
tooth-grinders, and the prejowl sulcus. His carefully
thought-out approach was a success in that project
33
and
in our subsequent lip and perioral injections in our prac-
tices (Figure 9).
The order of treatment we use is first to elevate the lip
corners and then the melomental folds, creating a subder-
mal strut of support to lift the lateral commissures (see Fig-
ures 8 and 9).
We extend the inferior portion of the strut laterally to
fill in the prejowl sulcus. Often, using this approach, the
inferior half of the nasolabial fold no longer requires intra-
dermal fill, and we concentrate on the “shadow sulcus” in
the upper nasolabial fold at the lateral border of each nasal
ala (see Figure 9). The key to the injection technique is to
lay down a subdermal deposit of filler material so that the
general contour is reestablished. Layering can be done sub-
sequent to the subdermal sculpting.
Chin (Mental) Implant
Some patients desire a fuller chin so that it projects for-
ward to line up with the lower lip with the face in the
Frankfort horizontal. After photographing the face in the
primary position and right and left lateral gaze, the filler is
injected subdermally into the regions superior and lateral
to the mentum. Typically, 0.2 to 0.4 cc is required per side.
The fill here is a pleasing adjunct for more traditional lip
augmentation.
30
BTX-A is usually injected right at the
point of the mentum into the mentalis, and 3 to 5 U is
injected on each side into the depressor anguli oris.
38
Both
can be injected at the same treatment session if required.
Conclusion
In addition to their benefits in correcting rhytids and folds,
fillers can be used to restore fullness that is naturally lost
as fat and bone diminish from the face with aging, creat-
ing a more harmonious and esthetically appealing visage.
With new techniques and materials, it is often difficult to
decide which procedure or filling agent will provide the
most optimum results with the fewest complications or
side effects. Cosmetic patients—sophisticated con-
sumers—are increasingly dissatisfied with less than ideal
results or procedures that cause considerable interruption
in their daily activities. In addition to a predictable esthetic
outcome, safety and duration are of the utmost impor-
tance. Although the more traditional fillers are still used
widely, newer agents—particularly hyaluronic acid deriv-
atives and PMMA microspheres and collagen agents—
have gained popularity and achieved wider accessibility.
Their space-occupying properties are used to replace lost
subdermal support and then provide brow, midface, and
lower face augmentation with an almost instant enhance-
ment of the projection and profile of the injected area.
Unlike traditional surgical procedures, soft tissue aug-
mentation addresses the increasing demand for less inva-
sive treatments that can give a three-dimensional effect.
Agents such as the hyaluronans may prove to be the ideal
sculptural facial rejuvenation agents, producing a more
natural and youthful countenance with greater safety and
convenience for the esthetic subject.
Dermatol Surg 31:11 Part 2:November 2005 CARRUTHERS, JDA AND A: FACIAL SCULPTING AND TISSUE AUGMENTATION
1611
Figure 8. Treating the complete perioral frame and the vermilion lip
enhances the positive effects of the perioral region.
A
B
Figure 7. (A) Anatomic location of filler in this region is in the vir-
tual space posterior to the orbicularis oculi muscle at the arcus mar-
ginalis. The injector should be able to feel periosteum with the tip
of the needle and to use the push-ahead technique so that the filler
insertion does not cause bruising. (B) Deep soft tissue augmenta-
tion (retro-orbicularis oculi) at the arcus marginalis to elevate the
nasojugal fold.
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3. Tardy ME, Alex J, Hendrick D. Rejuvenation of the aging brow and
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W.B. Saunders; 1999.
4. Chiu ES, Baker DC. Endoscopic brow lift: a retrospective review of 628
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5. Donofrio LM. Fat distribution: a morphologic study of the aging
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Figure 9. Esthetic improvement of the vermilion lip within the entire perioral frame using long-lasting but biodegradable hyaluronan (Resty-
lane) (A, before; B, afer enhancement of lip corners).
A
B
