Introduction

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1 Introduction

Jean Carruthers, Alastair Carruthers

Summary and Key Features

• Volumization is the key to aesthetic success with facial fillers

• Changes in the concept of beauty, visualization of age-related changes in the face, and validated assessment scales have aided in achieving optimal outcomes

• Reversers and better pain management have enhanced augmentation procedures

• The future holds great promise and expectation for fillers as both drug and delivery vehicle

We have come full circle in the aesthetic approach to the face with soft-tissue-augmenting agents. The volumizing effect of the first filler – autologous fat – was studied over a century ago when it was harvested and inserted into the face. With the development of synthetic fillers, such as hyaluronans, calcium hydroxylapatite, poly-l-lactic acid, and silicone, it became possible to inject fillers specifically into different tissue layers, although still using a two-dimensional approach along visible linear lines, folds, and wrinkles. The emergence of fillers with superior lift capabilities, while still maintaining the desired position, opened the door to the concept of volumizing as not only a possibility but also the accepted norm for achieving optimal aesthetic results, in addition to more superficial filler placement.

In addition to the manufacture of tissue-friendly, long-lasting fillers, we have become aware of more etiologic detail about the anatomical structure of facial aging. Computed tomography (CT), magnetic resonance imaging (MRI) scans, and anatomical cadaver dissection have allowed us to visualize accurately the underlying bony structures, the facial fat pads, and the changes in the overlying facial skin. Studies of a new, descriptive language of age-related facial changes with sequential photographic facial scales have been published, demonstrating their value in improving communication not only with our patients in our clinics, but also with each other as we work toward better treatments, often in multiple research centers simultaneously.

Patient-reported outcomes (PROs) have become the standard for assessing treatment outcomes from the client’s point of view. Published validated questionnaires, such as the Facial Line Outcomes (FLO) and Self-Perception of Age (SPA), can be used easily in the clinic as well as in the research setting. Several validated PROs are used both by patients and by the treating and evaluating physician – such as the Lip Fullness Scale (LFS) and Look and Feel of the Lips (LAF) scale, as well as the severity scales for Perioral Lines at Rest (POL), Perioral Lines at Maximum Contraction (POLM), and Oral Commissure Severity (OCS). Aesthetic medical research has introduced a new outstandingly important paradigm – the patient’s opinion – into the worlds of medical treatment and research.

Mathematical evaluation of facial beauty has also been helpful in trying to achieve the outcomes desired in all cultures. Most interestingly, although there is a trend toward ‘average’ beauty, there is some differentiation between cultures. Whereas the concept of ‘phi’ and the Fibonacci numbers has been well studied in Caucasian actresses and models, the same precepts do not necessarily hold in subjects of Asian ancestry. The Buddha believed the beautiful female face should be ‘round like the moon’ with rosebud lips, connoting fertility and purity respectively. By contrast, the ‘Marquardt mask’ (a model of the ideal human face constructed from the ‘golden ratio’) seems to fit the more heart-shaped Caucasian face. Asian and African lip fullness and proportion also diverge from the Caucasian standards of beauty – in which the upper lip is often about two-thirds the size of the lower – with equal fullness of both upper and lower lips.

Local anesthesia for facial injections has largely evolved away from trigeminal nerve blocks (which also relax the muscles of facial expression, making the end point harder to judge). Instead, topical anesthesia applied directly to the skin and adding lidocaine, or lidocaine with epinephrine, to the filling agent effectively manages pain in most areas of the face. The addition of saline to dilute the filler decreases cohesiveness, allowing for smooth delivery and the ability to distribute the product evenly by gentle massage.

Reversibility has also become a cornerstone of facial filler injections. Hyaluronidase is an enzyme that will catabolize any hyaluronic acid (HA) filler, sometimes within 24 hours. New classes of fillers may be produced with custom-made ‘erasers’ in the future. Post-treatment bruising can now be treated immediately using intense pulsed light at moderate settings (4(10)4, 560 nm filter, four passes), which allows the bruise to be absorbed within 24–48 hours instead of 7–10 days.

Lastly, Voorhees and Glogau have pointed out that fillers used to be considered devices, rather than drugs. However, the concept of fillers as mechanical lifting agents has been joined by the recognition of filling effects on the daily metabolism of the skin. We know now that cross-linked HA increases collagen deposition around the filler, leading to long-term correction. Moreover, we have all noted the increased luminosity of the skin in cheeks augmented by HA. Many of us have considered using fillers as vehicles to deliver drugs, cosmeceuticals, and stem cells that could affect the elasticity, turgor, and texture of aging skin into the subcutaneous space.

The past century has seen an explosion of development of new fillers and their global acceptance by a patient population that would rather look restored and younger without the trauma and downtime of surgery. Indeed, the introduction of non- or minimally invasive injectable procedures represents a significant shift in the approach to facial rejuvenation. According to the American Society of Plastic Surgeons, the use of filling agents increased by 144% between 2000 and 2008 in the USA, from fewer than 700 000 to 1.6 million procedures performed – a figure that increased by an additional 11.3% by 2010. This trend is expected to continue: through 2013, worldwide sales of dermal fillers are expected to expand by more than 8.4% per year on average (from nearly $800 million in 2008 to more than $1.1 billion) in 2013.

Further reading

American Society of Plastic Surgeons. Report of the 2009 statistics. National Clearinghouse of Plastic Surgery Statistics. Online. Available www.plasticsurgery.org/News-and-Resources/2009-Statistics.html, 2010. 12 October 2011

American Society of Plastic Surgeons. Report of the 2010 statistics. National Clearinghouse of Plastic Surgery Statistics. Online. Available www.plasticsurgery.org/News-and-Resources/2009-Statistics.html, 2010. 12 October 2011

Carruthers A, Carruthers J, Hardas B, et al. A validated lip fullness rating scale. Dermatologic Surgery. 2008;34(suppl 2):S161–S166.

Carruthers A, Carruthers J, Hardas B, et al. A validated marionette lines rating scale. Dermatologic Surgery. 2008;34(suppl 2):S167–S172.

Carruthers A, Carruthers J, Hardas B, et al. A validated crow’s feet rating scale. Dermatologic Surgery. 2008;34(suppl 2):S173–S178.

Carruthers A, Carruthers J, Hardas B, et al. A validated hand grading rating scale. Dermatologic Surgery. 2008;34(suppl 2):S179–S183.

Carruthers JDA, Glogau R, Blizter A, the Facial Consensus Group Faculty. Advances in facial rejuvenation: botulinum toxin type A, hyaluronic acid dermal fillers, and combination therapies: consensus recommendations. Plastic and Reconstructive Surgery. 2008;121(suppl):S5–S30.

Carruthers J, Carruthers A, Monheit GD, et al. Multicenter, randomized, parallel-group study of onabotulinumtoxinA and hyaluronic acid dermal fillers (24-mg/mL smooth, cohesive gel) alone and in combination for lower facial rejuvenation: satisfaction and patient-reported outcomes. Dermatologic Surgery. 2011;36(suppl 4):2135–2145.

Carruthers J, Flynn TC, Geister TL, et al. Validated assessment scales for the mid face. Dermatologic Surgery. 2012;38:32–332.

Fagien S, Carruthers J. A comprehensive review of patient reported satisfaction with botulinum toxin type A for aesthetic procedures. Plastic and Reconstructive Surgery. 2008;122:1915–1925.

Medical Insight. Facial injectables: maintaining volume as the economy recovers. Online. Available www.miinews.com/marketStudies/facial_injectables_0611/, 2010. 12 October 2011

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