submitted by Daniel A. Sterling, MD, FACS

Would liposuction help nasolabial folds and jowling?

Part of facial aging is the development of nasolabial folds and jowling.  The reason for this is that as we age our soft tissue descends from its youthful location on the underlying supportive skeletal frame.  Along with the descent of the facial tissue, there is usually a loss of volume as the facial fat tends to atrophy with age.  This is the reason why facial fillers are used readily as well as fat grafting to reproduce some of the fullness of youth and to give an overall better contour.  Liposuction is not routinely performed for nasolabial folds and is only partially successful in improving jowls.  Depending upon the severity and degree of nasolabial folds, marionette lines and jowling, a number of different interventions can be performed.  For the lesser and intermediate of these, facial fillers or fat grafting can be performed with excellent results.  The most severe problems can only be helped by a face lift which can also be combined with fillers and fat grafting at the same time to greatly improve all of these areas.  In any case, we are very fortunate to have many options to offer patients and women can expect to get an excellent result with any number of them.

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Submitted by Dr. Daniel A. Sterling

I am interested in having facial fillers, however, I do not do well with numbing agents such as Lidocaine. I would like to have my lips and nasolabial creases done. Is it possible to have the procedure done using a topical?

Not all fillers require “numbing agents” such as Lidocaine.  We used topical agents that work in some cases by temporarily freezing the area and others that work by numbing the area.  Although nerve blocks are still used infrequently when larger procedures are required, topical agents in most cases will provide more than adequate local anesthetic effect. 

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There are times that the patient is unhappy with the changes that take place after facial filler is used. In addition, certain facial fillers may show a blue tint when placed in the lower eyelids (Tindall Effect).

It is for this reason that many plastic surgeons do not like to use the more permanent facial fillers. This way there is a limited amount of time before temporary facial fillers disappear.

The group of facial fillers belonging to the family of hyaluronic acid fillers lend themselves well to removal by using the enzyme hyaluronidase. The facial filler disappears within about one hour after injecting the enzyme. The facial fillers belonging to this group are Juvederm Ultra, Juvederm Ultra plus, Perlane and Restylane. The Tyndall effect disappears almost immediately when hyaluronidase is injected.

Radiesse is almost impossible to remove because it does not dissolve with any of the known enzymes. Radiesse can be molded for about 2 weeks after injection, smoothing out the surface if any lumpiness is present.

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Chickenpox scars are generally difficult to correct. The scar tissue tends to cause the  pock scar to retract into the deeper tissues, and the scar tissue itself often needs to be released surgically to allow the pock scar to elevate. This can be enhanced by placing a small button of facial filler such as Juvederm, Perlane or Restylane beneath the scar tissue to maintain the elevation. After the scar has been released and elevated, most of the elevation should remain. Any time scar revision is done, some scar will always remain, though it is expected that the scar will be improved.

Facial fillers have an excellent safety record, and can be used for both young and old patients.

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Facial fillers can be used on other parts of the body besides the face. Plastic Surgeons can fill out depressions almost anywhere on the body. The texture of the skin will help determine the type of facial filler used. Facial fillers used in other locations tend to last a similar amount of time as when used on the face. It is best to repeat the application before the facial filler disappears completely.
Some depressions of the body are associated with a moderate amount of scar tissue, especially after trauma. In order to fill out the depression surgery may be needed to correct the scar. When this is done, fat is usually mobilized from adjacent areas to fill out these depressions.

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Some people (mostly women) have considerable muscular activity involving the lips. This often results in lip lines. When pursing the lips (kissing movement) deep furrows are often noted. When we correct lip lines, separate injections of facial filler are first injected into the deep furrows, followed by more superficial injections just beneath the lip lines. Sometimes a chemical peel or dermabrasion is used after the facial filler to get the best result.

Botox helps minimize muscular activity and this helps maintain the facial filler for a longer period of time. Botox is used mostly for frown lines, forehead wrinkles and crow’s feet.  .The combination of Botox and facial filler is very helpful for long term (1-2 years) correction of frown lines.

Botox is used sparingly, if at all, in the lips, because of the undesired effect of changing the facial expressions and smile. Though the combination of Botox and facial filler will last longer than either one alone, it is always important to discuss this with the patient first. If the combination is used, only a small amount is used to get feedback from the patient. If the patient is happy with the combination treatment, this can then be continued in the future.

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Not only do certain facial fillers last longer than others, but the same facial filler may last a variable amount of time within the same patient. It is known that increased facial movement causes more rapid disappearance of facial filler. Certain areas of the face have greater motion, such as the area around the lips, and this area may show quicker disappearance of the facial filler. In contrast the areas along the sides of the nose and the cheek bone area have less facial movement and therefore the same facial filler will last a longer time.

Radiesse is probably the longest lasting facial filler of the group of temporary fillers. Artefill is considered to be in the more permanent category of facial fillers. Studies of Juvederm Ultra Plus are showing durations of up to one year. Perlane is known to last about 4 to 6 months and Restylane about 3 to 6 months. Collagen lasts only about 3 months.

One way to decrease motion is to inject Botox at the time of facial filler injection. This is especially effective in the frown lines where the combination of Botox and facial filler can last 1-2 years. Another area that lends itself well is the combination of Botox and facial filler in the marionette lines. Here too increased duration of results can be expected.

It is always best to have additional facial filler before all the filler disappears. In this way a steady state of enhancement can be maintained. Different fillers can be used together. For example the upper parts of the lip can be filled with Radiesse including the nasolabial creases, whereas the vermillion is better enhanced with Restylane or Juvederm Ultra.

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A new study published in Plastic and Reconstructive Surgery (v.121 pp.289-304) shows that Juvederm Ultra Plus lasts one year or more when injected into the nasolabial folds.

81% of 87 subjects were noted to have continued improvement during this time frame. When repeated touch up treatments were given, the volume of Juvederm Ultra Plus was less than the amount originally required, showing a lingering effect of the product.

Facial fillers have become mainstream for the many baby boomers who want to maintain their youthfulness, and avoid major surgery. Juvederm Ultra Plus is FDA approved and manufactured by Allergan Corporation. It belongs to the group of hyaluronic acid fillers which have a long safety record. Previous thoughts on this filler were that it lasts 6-8 months or more. This new information shows that Juvederm Ultra Plus lasts longer than previously thought.

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Facial aging often presents itself with considerable lower facial aging. The type of aging shown in the accompanying figure does not lend itself to a face lift because we are dealing with a patient that has loss of volume, and any amount of tightening will not correct the aging problems as shown around the mouth. In addition the lips show the usual thinning that comes with aging.

Fortunately there are a variety of FDA approved facial fillers that can be injected to restore the depleted volume of fat, to plump out the wrinkles around the mouth, and restore the natural more youthful lip volume.

Lip lines are very common, more so in women, and may appear as early as the 30’s. This is often accompanied with thinning of the lip vermillion (red purple area) of the upper and lower lips. The facial fillers of choice are the FDA approved hyaluronic acid fillers such as JUVEDERM™ Ultra Injectable Gel , JUVEDERM™ Ultra Plus Injectable Gel , Restylane®, and Perlane® for the vermillion and the same fillers and or Radiesse® for the upper and lower lips above and below the vermillion. These fillers give a youthful appearance to the lips without appearing overdone. Radiesse® (our choice) and the other facial fillers can also be used to fill the sunken cheeks near the corners of the mouth, as well as the chin, marionette lines, and nasolabial creases.

BOTOX® Cosmetic is helpful in eliminating the platysma bands.

The accompanying photograph is representative of many of the patients we see in our practice. The use of properly selected facial fillers injected conservatively and BOTOX® Cosmetic helps restore a more youthful appearance.

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Perlane®, a hyaluronic acid facial filler was approved by the FDA on May 4, 2007. Perlane® is similar to Restylane® for volume restoration of the face, but has a larger molecule than Restylane® and is therefore more effective for deeper wrinkles and depressions of the face. Perlane® also lasts longer (about 6 months to 1 year) than Restylane (about 4 to 6 months).

A large European and Canadian experience with Perlane has been shown to be safe and effective.

Perlane is commonly used for the following conditions:

• Wrinkle correction
• Diminishing worry lines, smile lines, crow’s feet, marionette lines at corners of the mouth, and smoker’s lines
• Lip enhancement
• Reducing the severity of nasolabial folds
• Chin augmentation
• Filling cheek depressions
• Redefining lip border
• Softening acne scars

Other, less common, uses for Perlane® filler include:

• Filling hollows under the eyes
• Creating a temporary eyebrow lift
• Correcting facial depressions caused by fat loss
• Softening the appearance of jowls

Before and After Photographs: Perlane® Facial Filler

Left Photograph: Before treatment of Nasolabial folds. Right Photograph: After treatment. Individual results may vary. Photographs courtesy of Medicis Aesthetics.

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We know have available a new product called Juvederm Ultra for the correction and enhancement of lips and Juvederm Ultra Plus for the correction of deeper folds and wrinkles.

In the past, we were more limited to the correction of superficial wrinkles and lip lines by using collagen, Restylane and Radiesse. Restylane, which is a hyaluronic acid facial filler comes as a larger molecule under the name of Perlane, suitable for deeper injections to correct deeper folds and for longer lasting improvement of lip volume but is only available through Canada. Radiesse is generally used little or not at all in the lip because of the problem of nodule formation.

Juvederm Ultra  and Juvederm Ultra Plus is a similar larger hyaluronic acid molecule and is now available in the United States and is approved by the FDA. This new facial filler gives us an added modality for the correction of deeper folds and to achieve longer-lasting lip enhancement. Often lip lines can be improved not only by injecting facial filler superficially into the lip lines, but also by enhancing the volume of the lip.

Juvederm injectable gel employs its unique manufacturing process to provide the highest concentration of cross-linked hyaluronic acid of any currently available hyaluronic acid dermal filler for long-lasting results. This advanced manufacturing process also creates a smooth consistency gel that flows consistently and easily into the skin and provides a smooth, natural look and feel.

The use of Restylane dates back to 1997 and has a long history of use primarily in Europe. It was not approved by the FDA until 2003, and since then, has had widespread use in the United States.

Radiesse is approved for a number of medical conditions including facial bone augmentation, and has been used off-label in America since 2003 for wrinkle treatment. Radiesse was FDA approved on 12/27/06 for the long lasting correction of moderate to severe facial wrinkles and folds such as the nasolabial folds. Radiesse also has clearance status in Europe, Canada and Latin America for facial esthetics. There is both a large European and American experience with this product.

Restylane tends to last about four to six months which is longer than collagen (2-3 months) and does not require allergy testing. Radiesse lasts about one to two years and also does not require allergy testing. Both facial fillers tend to last longer when Botox is injected which diminishes muscular movement. The concomitant use of Botox is especially helpful in the frown lines, and can be used sparingly in the lips.

The injections of both Restylane and Radiesse are made more comfortable with the use of local anesthesia. Any patient with a history of cold sores (herpes simplex) should be pre-treated with an antiviral agent such as Valtrex for one to two days before using Restylane or Radiesse. Restylane is a non-animal stabilized hyaluronic acid filler. It works by attracting water. The water plus the injected gel maintains the volume injected.

Restylane is hyaluronic acid which is a natural complex sugar found throughout all living organisms that retains water – absorbing more than 1,000 times its weight – and adds volume to the skin’s surface. In addition, hyaluronic acid binds with collagen and elastin and transports essential nutrients to these fibers. The triple combination of collagen, elastin and hyaluronic acid provides structure, elasticity and volume to the skin and contributes to its overall appearance.

The key ingredient in Radiesse is 30% calcium hydroxylapatite in a 70% gel consisting of cellulose, glycerin and sterile water. The calcium  microspheres remain in place to act as a scaffold that allows the in-growth of fibroblasts that lay down collagen. In this way Radiesse stimulates the body to produce new collagen.  This maintains the injected volume for a longer period of time.

Of the 9.2 million non-surgical procedures performed in the United States in 2004, nearly 900,000 involved soft-tissue augmentation using Restylane. Currently, there is a vast worldwide experience with both Restylane and Radiesse.

Juvederm, manufactured by Allergan, is the latest facial filler that will become available in early 2007.

A prospective patient recently emailed us and wanted to verify that Juvederm is superior to Restylane. Both products are hyaluronic acid which attracts water; therefore, helps with volume fill and hydration.

The clinical study involving Juvederm compared Juvederm to Zyplast (collagen), but not to Restylane. Juvederm was the favored drug over collagen. No data exists comparing Juvederm to Restylane.

Of concern is that Juvederm contains less hyaluronic acid than Restylane (24 mg/ml versus 20 mg/ml). Whether or not the longevity of Juvederm will be comparable can only be determined by future controlled scientific studies. Until then, we are dealing with more hype than science.

I recently read an interesting article on the use of Botox and facial filler for marionette folds. Until recently, there was little that could be done for marionette folds. With the advent of facial fillers such as Radiesse, Restylane and fat grafting, these depressions below the corners of the mouth could be filled in, at the same time elevating the drooping corners of the mouth (oral commissures).

The article, which appeared in the September/October 2006 issue of the Aesthetic Surgery Journal, describes the aging anatomy of the depressor muscles of the corners of the mouth (depressor anguli oris) and the benefits of combining a small amount of Botox (3 to 4 units) and facial filler. It has been our experience, that whenever possible, it is helpful to combine Botox and facial filler in that the two treatments together prolong the effects of improvement. An added benefit for the use of Botox in this area is that the depressor muscles to the corners of the mouth are weakened, allowing the angles of the mouth to move into a more favorable upward position.

"D" in the illustration is the depressor anguli oris responsible for turning down the corners of the mouth and is also implicated in the development of marionette folds.

The following before and after photographs show the benefit of Radiesse facial filler for the correction of marionette folds. More complete correction and longer-lasting results can likely be achieved by combining this treatment with Botox injections.

We recently had the privilege of a trainer who came to our office to spend an afternoon teaching us advanced techniques of facial filler injections. This gave us an opportunity to understand new concepts for the use of a product that we have considerable experience with.

Radiesse is manufactured by Bioform and is a long-lasting, temporary facial filler. We spent the afternoon understanding how to build up the midface. Midface collapse is a particularly vexing problem in plastic surgery. The many surgical techniques available to restore mid-face volume speak to the frustrations that plastic surgeons have rebuilding this area. The mid-face is the zone between the eyes and the nasolabial folds and from the sides of the nose to the cheekbones. As the fat in this area collapses and migrates downward, the nasolabial folds become more prominant and the mid-face flattens. This is one of the early signs of facial aging.

By injecting Radiesse into this area, the mid-face is enhanced which at the same time helps lift the nasolaial folds.l

Though our patients were swollen at the end of the procedure due both to the injection of local anesthesia and Radiesse, all of us could see the transformation that was in the making. Though we worked long hours that day, we were elated to have yet another application of this effective facial product.

Every third person suffers from oral herpes simplex infections of the lips, also known as "cold sores." Cold sores are not a sign of a recently acquired herpes simplex infection but instead a reactivation of herpes virus particles already living in your body. Cold sores occur when latent herpes simplex virus particles, which have been lying dormant ("asleep"), become reactivated.

Although experts still don't know all of the ways the herpes simplex virus particles can be activated, some of the things that can cause a cold sore include:

• Stress, tiredness or being "run-down"
• A cold, fever or the flu
• Exposure to the sun
• Hormonal changes, such as from menstruation or pregnancy
• Trauma, such as shaving, cuts, dental work, or facial cosmetic surgery
• Implantation of any facial filler such as Restylane or Radiesse

Therefore, any patient with a history of prior infections should be pre-treated with Valtrex or Acyclovir for 1 to 2 days before the injection of facial fillers.

Restylane versus Radiesse and Lip Nodules

The September issue of the Plastic and Reconstructive Surgery Journal has an interesting supplement on facial fillers. The collective experience of many physicians is presented.

The section on lip enhancement deals with the pros and cons of Radiesse and Restylane facial filler as used for lip augmentation.

I have had excellent results using both Radiesse and Restylane; however, I have concerns about reports that show a small percentage of lip nodules after the use of Radiesse. I like Radiesse because it lasts longer; therefore, less frequent injections are needed. Though Radiesse takes longer for the swelling to disappear, and for the first few weeks the lips may be somewhat unnatural with more of a firm quality, this settles down and becomes soft. It is thought that the normal muscular activity of the lips causes the Radiesse to bunch up in a small group of patients forming lip nodules.

These lip nodules usually respond to massage, though at times need to be either broken up with a fine needle followed by massage; injected with dilute steroids; or excised (removed surgically). This does not appear to be a problem when Restylane is used.

It is further thought that using a smaller amount of Radiesse in 2 to 3 sittings, massage at home for 2 to 3 weeks, and being careful to limit lip movement for 2 to 3 weeks appear to reduce the incidence of lip nodules after Radiesse injections.

For those patients who do not want to take the risk of lip nodules, it is advised that Restylane be used.

Regardless of the facial filler used, we watch our patients carefully after the procedure so that we can add more facial filler on a timely basis. We do not want the lips or any other area to return to starting levels, rather it is better to add more facial filler as the effects of Restylane or Radiesse begin to wear off.