LAS VEGAS There's no one right way to do facial soft tissue augmentation, so success depends on both scientific and artful practice, a panel of experts agreed at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.
The members shared tips and compared their preferences for soft tissue augmentation, beginning with the various fillers they use in their practices.
Dr. Kimberly J. Butterwick does a lot of fat transfers. Most of her patients understand the need to come back for maintenance, so she hasn't used the permanent fillers. "When they come back every 46 months for Botox you can put in your Restylane or your filler. They may also want a light peel at the same time. So I use a lot of the Restylane and Hylaform products because patients like to get all their maintenance at one visit, and do that two or three times a year," said Dr. Butterwick, who practices in San Diego.
"I think patients are looking for bulk implants, not fillers, but the problem with permanent fillers in this country is that we don't have enough experience looking at the adverse eventshypersensitivity, granulomas, and long-term effects. It's not something that I recommend for my patients," said Dr. Neil S. Sadick of Cornell University in New York.
Most patients in his practice are moving on to three-dimensional volumetric filling, with Sculptra probably accounting for the largest increase in share. "Even Radiesse is gaining increasing usage. Patients are looking for something that will last 12 years, which I think is the optimal duration for a given filler," he said.
Dr. Suzan Obagi also avoids permanent fillers. "Patients might say they want something permanent, but I explain to them that, from a safety standpoint, something we can adapt over time" may be better, said Dr. Obagi of the University of Pittsburgh.
For patients who do want something permanent, she does fat transfers. "About 80% of my transfers use fat, and 20% use the other fillers," she said.
When it comes to harvesting fat, she goes to areas where the fat is not likely to fluctuate. "If the patient loses or gains 10 pounds, fat from there is less likely to hypertrophy. For some patients it's abdominal fat; for some patients it's the hips," she said.
After reviewing the literature, Dr. Butterwick says she believes that there is no evidence that fat from one area survives better than from any other, so she also harvests from areas that are least resistant to dietary changes. "I do like the outer thigh; it comes out quickly and is avascular," she said.
In a radioisotope study, "we found no difference in terms of fat aging and longevity from different anatomic sites," Dr. Sadick remarked. People who were thinner had greater fat longevity. For thin patients, he usually harvests from the abdomen and hips.
With thin patients, "there's very little margin for error to avoid indentation," Dr. Obagi pointed out. "I do augmentation in a lot of yoga instructors and marathon runners. Usually you have to go to the buttock, and you have to be very good at your technique." For these patients, she uses a standard cannula because it has more of a blunted tip.
Dr. Butterwick said that "sometimes you have to hunt around and harvest from the arms or from multiple areas. It takes longer, so you might just choose to use Sculptra in that patient."
When the discussion turned to fat contouring in the midface and periorbital area, she suggested that the facial autografting muscle injection system's anatomic approach gives a result similar to the Coleman technique and that "the fat may survive longer because of the proximity to the muscle."
Dr. Obagi uses a modified Coleman technique, as does Dr. Sadick. He said that "the key to success and greater longevity is in layering the fat or filler in different anatomic areas."
With thin patients, such as marathoners, 'there's very little margin for error to avoid indentation.' DR. OBAGI