WAIKOLOA, HAWAII Deep filler injections can address volume loss that occurs in facial bone structure during the aging process, according to Dr. Howard K. Steinman.
"The shape and volume of the maxilla and mandible change with aging," Dr. Steinman said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.
"This significantly contributes to facial age-related cosmetic deformities," he added.
Injecting fillers deep, near the periosteum, can address these issues, he said. Although this has been well documented in plastic surgery literature, it is probably a new concept for most dermatologists.
Dr. Steinman, who is in private practice in Chula Vista, Calif., said that he first became aware of the clinical importance of facial skeletal movement last year at SDEF in Hawaii during a workshop that was led by Dr. William Philip Werschler of the University of Washington, Seattle, and Dr. Danny Vleggaar of the Nouvelle Clinique Vert Pré, Geneva.
"Ever since I discovered this and researched it, it has altered the way that I see my cosmetic patients and how I use fillers," he said. "Understanding these changes often permits more effective correction with less filler volume."
Dr. Steinman described the maxilla as a "ledge of the midface tissues." As the maxilla moves inferiorly and posteriorly, the muscles and other soft tissues attached to it descend. This aging process is in addition to laxity and the loss of fat volume over time. Lateral tear troughs, for example, begin to form as a result of the descent of the maxilla causing enlargement of the orbital rim, in addition to the soft tissue changes.
Putting filler immediately above the periosteum replaces orbital rim that has moved. "You're going to lift up the tissues, and you're going to help redrape and eliminate the lateral tear trough," he said, noting that he routinely does this using Radiesse (BioForm Medical).
When working on nasal labial folds, Dr. Steinman angles the needle down all the way to the periosteum and injects as he pulls back slightlya technique he learned from Dr. Vleggaar.
He imagines a triangle in the corner of the nose and the nasal labial fold.
"I do three injections from the inferior apex of the triangle, injecting superiorly and filling this triangle," he said. "This is a great technique for doing rejuvenation of this fold with very little filler."
The mandible also changes as patients get older, he said. The height of the mandibular shortens, which the muscles and soft tissue attached to the mandible rim have to accommodate for, resulting in "jowling" and the formation of prejowl sulcus.
To correct this problem, he injects deeply along the mandibular rim "bulking it up" as best he can before injecting into the subdermal plane. Again, a small quantity of filler can be used in this procedure, he noted.
With the advent of botulinum toxin type A, said Dr. Steinman "all of us that were 'pre-Botox' in our training suddenly learned to see facial muscles and their cosmetic effects," he said. "They're part of [the] assessment armamentarium."
He predicted dermatologists will start to perceive facial skeletal changes the same way they now perceive facial muscles and will adapt treatments accordingly.
Dr. Steinman disclosed that he had no relevant conflicts of interest.
SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.
Dr.Steinman suggests imagining a triangle in the corner of the nose and nasal labial fold (before, left image). Perform "three injections from the inferior apex of the triangle, injecting superiorly and filling" it (after, right). Photos courtesy Dr. Howard K. Steinman
Facial skeletal changes will be perceived by dermatologists in the same way that facial muscles are now perceived. DR. STEINMAN