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Restoring volume with fillers, combining procedures enhances results

Call it the global approach to facial rejuvenation. After years of attacking the individual lines and wrinkles that many patients loathe, leading cosmetic dermatologists have learned to address their underlying causes with multiple agents and procedures. “Years ago, we just injected the fine lines and wrinkles. We didn’t realize that restoring a youthful look was more about restoring lost volume in other areas of the face,” said Bruce E. Katz, MD, clinical professor of dermatology at the Mount Sinai School of Medicine and director of the Cosmetic Surgery and Laser Clinic at Mount Sinai Medical Center. “That depletion of volume — which results from gradual loss of fat, muscle, and bone — leads to deepening nasolabial folds, marionette lines, and laxity of the jowls. Everything droops because the support structure’s not there anymore. So now we use fillers to restructure the face, to counteract the gravitational changes.” 

Fillers approved by the U.S. Food and Drug Administration include hyaluronic acid (Restylane, Perlane, Juvederm, and Belatero, the most recently approved), poly-L-lactic acid (Sculptra), and calcium hydroxyl apatite (Radiesse). Voluma, a hyaluronic acid widely used in Europe, is expected to reach the U.S. market within the next year or two. In addition, a handful of autologous agents provide other options. Dr. Katz said he uses platelet-rich plasma (PRP), already FDA-approved in wound healing, to restore volume and stimulate stem cell growth. “We’ve used it in the tear troughs, and it’s done very well,” he said. “Not only volume, but texture, luminosity, and pigment are all improved.” Kimberly J. Butterwick, MD, a private practitioner in San Diego who co-authored an in-depth look at autologous fat transfer techniques in Facial Plastic Surgery Clinics of North America (15(2007):99-111), said she can “recycle” as much as 30 to 50 cc’s of fat from a liposuction procedure into a patient’s face. “It’s way too expensive to use synthetic filler in that quantity, but we can use as much fat as we want,” she said. “The longevity isn’t entirely predictable, but I’ve seen some patients for whom the fat has stayed in their cheeks for many years.” (One study cited in Dr. Butterwick’s paper reported 55 percent fat loss within six months followed by negligible loss at nine and 12 months.) [pagebreak]

Combinations that work

While a single injection of neurotoxin or filler is still appropriate in many cases, the experts say that a combination of procedures often yields more natural and longer-lasting results. “We call it the four Rs: relaxing the muscles, refilling the face, resurfacing with lasers, and redraping with either facelifts or skin tighteners like radiofrequency or ultrasound,” Dr. Butterwick said. The multi-pronged approach “is more natural than just using volumizing to fix everything, or just using toxin. The combinations address all the aspects of aging.”

Thanks to the broad variety of approved agents, a combination treatment may involve two fillers, as opposed to a filler and another procedure. “The more I practice, and the more facial analysis I do, I like to combine the non-hyaluronic acid products with the hyaluronic acid products,” said Joseph F. Sobanko, MD, director of dermatologic surgery education and assistant professor of dermatology at the Hospital of the University of Pennsylvania. “For example, for patients who have deepened pre-jowl sulcus and/or deepened melolabial folds, I’ll often split products. I’ll place calcium hydroxyl apatite in a deeper plane — that particular product has a G prime that gives you more of a lift; it’s able to withstand pressures more. But often there are finer rhytids at the oral commissures, and in planes where I don’t feel comfortable injecting the more viscous product. So I’ll overlie the hyaluronic acid more superficially, almost in a tiered or towered pattern. You’re addressing the rhytids in two different ways, and I feel that the results are improved.” For Dr. Butterwick, who said she loves fillers, a common treatment would be “to lift the cheeks and temples with calcium hydroxyl apatite, or a thicker hyaluronic acid, then use a lightweight filler.” The latter may be too soft for lifting, but Dr. Butterwick likes to use it superficially — such as in the tear trough or in fine lines around the mouth — “because it doesn’t cause the Tyndall effect.” [pagebreak]

Combining a filler with a neurotoxin can have a synergistic effect, say the experts. “There’s not a day goes by that I don’t do polytherapy,” said Seth L. Matarasso, MD, clinical professor of dermatology at the University of California School of Medicine in San Francisco. “Putting two to five units of toxin into the depressor anguli oris reduces the pull of that muscle and lifts the corner of the mouth, so you won’t need as much filler, and it makes your filler last longer.” Dr. Matarasso said he uses toxin-filler combinations “in the glabellar area, the marionette line, and the area around the eye. Putting a hyaluronic acid in the inferior ocular sulcus masks that hyperpigmentation. Then if you take a little bit of toxin at the lateral canthal ridge, you get rid of crow’s feet.” Although he may inject filler and toxin in the same anatomical area in one office visit, “what I will not do is put a filler and toxin into the same syringe, and people have been known to do that.” Dr. Sobanko agreed, noting that “when toxin diffuses in the wrong place, you can end up with adverse sequellae. To have a syringe with both filler and toxin being injected in what I would consider a non-targeted way can introduce more side effects than if they were injected individually in separate syringes.”

Although readily admitting that toxins and fillers injected at the same time yield synergistic improvement, Dr. Sobanko said that for patients new to cosmetic treatment, he injects the toxin and filler in separate visits five to seven days apart. “That gives them the ability to see the benefit of each product,” he explained. “I prefer to start them off on a toxin, give them a week or two to see the benefits, and then the rhytid would likely require even less filler, because the muscle has been relaxed, and the filler would likely last longer because that muscular contraction is not expediting the absorption of the filler.”

Targeting the glabella

While many dermatologists treat the glabellar crease with a toxin-filler combination, Dr. Sobanko said he does not inject fillers in that location and, in fact, tries to avoid injecting them in the upper third of the face. “Based on the anatomic depth of the vasculature arising in the supratrochlear and supraorbital area, if you place filler in a subcutaneous plane, the risk for tamponading one of those vessels and/or intravascular occlusion is too high, in my mind, and there have been a number of case reports to show that ischemia and necrosis in the forehead is a serious risk. So I avoid it, though others may feel comfortable with it.” [pagebreak]

Another potential complication in this area surfaced in a patient of Susan H. Weinkle, MD, assistant clinical professor of dermatology at the University of South Florida. The patient presented with double vision after having her glabellar lines treated with a hyaluronic acid filler and a toxin. When a search of the dermatology literature yielded no clues, Dr. Weinkle consulted her husband, an ophthalmologist, to determine the cause. She learned that when using a filler and toxin together in this area, “you have to be aware that if you fill too far medially and inferiorly, and then inject the toxin too low, the toxin can diffuse into the medial canthal region, into this orbital notch, and relax the fibers of the superior oblique muscle,” she explained. “If you relax that muscle in the right eye, when the patient looks to the left, they will have double vision. Now I do this a little more cognitively, being careful when I’m treating the medial corrugator to make sure not to bring the injection too low so that it’s diffused over that orbital rim.”

Success in rejuvenating with fillers depends at least as much on the practitioner as it does on the product, say the experts. For Mary Lupo, MD, clinical professor of dermatology at Tulane University School of Medicine, “it’s not the filler, it’s the filler the person who’s using the product. There’s an art form in understanding the muscles of the face, which is why you get the best results from a board-certified physician in one of the four core specialties [dermatology, ophthalmology, otolaryngology, and plastic surgery].” Her “mantra” as she instructs residents and practicing physicians, she said, is to “think lateral before medial, and think superior before inferior. There’s an over-fascination with the nasolabial folds, but that isn’t what ages the face; it’s the hollowing and downward shift. So when you inject laterally, it lifts more medially, and when you inject superiorly, you lift more inferiorly.” Dr. Weinkle, who said she has been injecting fillers since 1979, agreed that optimal results derive from “the art and skill of understanding the vessels and nerves, and how to maximize the injection. We can talk about which products till the cows come home, but it’s really about the person behind the syringe.”

Editor’s note: Dr. Butterwick serves on the advisory board for Allergan, Merz, and Valeant. She is a principal investigator for Voluma (Allergan) and PurTox (Mentor). Dr. Katz, Dr. Matarasso, and Dr. Sobanko reported no conflicts. Dr. Weinkle is a consultant for Merz, Allergan, Valeant, and Galderma. 

Role of fillers evolves

In the May issue of the Journal of the American Academy of Dermatology, which is honoring the Academy’s 75th anniversary in 2013 by publishing an article each month acknowledging previously published articles that had significant impact on the practice of dermatology, C. William Hanke, MD, MPH, reflected on how much things have changed since he coauthored “Dermal implants: Safety of products injected for soft tissue augmentation” in 1989. The ensuing years have seen the introduction of hyaluronic acid, poly-l-lactic acid, and calcium hydroxylapatite, with nine different agents approved by the Food and Drug Administration between 2003 and 2011. As Dr. Hanke noted, “the clinical trials on the new filler materials and the development of safe and effective injection techniques have been led almost exclusively by dermatologists.”

To read the full article, “Evolution of filler materials in dermatology” (J Am Acad Dermatol 2013; 68:858-9), visit To learn more about the AAD’s 75th anniversary, visit



Role of fillers evolves