Injectables and Fillers in Male Patients Jess Dhaliwal, MD , Oren Friedman, MD* Traditionally, in facial plastic surgery, male pa- tients were known to focus on function over form. Men typically did not consider rejuvenation surgery until they had advanced changes associ- ated with aging, and it was often coupled with a functional concern. However, over the last sev- eral years, this conservative approach seems to have changed. Although men still comprise less than 10% of patients who undergo cosmetic surgery, the number of men seeking minimally invasive, nonsurgical procedures has increased by 722% since 1997. 1 Motives include the desire to be more competitive and youthful in the work- force, the growing social acceptability of cosmetic procedures, and increased awareness of nonsur- gical options. Men may be discouraged from pursuing facial surgical procedures for several reasons (eg, re- covery time, surgical scars, need for camouflage, time off work). Minimally invasive procedures offer instant results without mandatory downtime or scars. The ability to return to work immediately is a distinct advantage. The most powerful nonsurgi- cal tools for aesthetic surgeons include botulinum toxin type A (Botox) and dermal fillers. Fillers and injectables do not require anesthesia or lifestyle changes, such as weight loss or smoking cessa- tion, and are therefore attractive alternatives to more aggressive interventions. In 2006, Botox was the most common nonsurgi- cal procedure for men. Hyaluronic acid (HA) augmentation was found to be the third most com- mon nonsurgical aesthetic procedure for men. The trend has been away from collagen fillers in favor of HA, calcium hydroxylapatite (CaHA), and poly- L-lactic acid (PLA) augmentation. 1 The popularity of dermal fillers and injectables will likely continue to increase as surgeons gain more experience and products become more refined. AGING The changes associated with aging follow a pre- dictable pattern. Over time, the epidermis and subcutaneous tissues become thinner, mostly because of the effacement of the dermal- epidermal junction and loss of collagen, elastin, and HA. Gravity contributes to the descent of sub- cutaneous fat and drooping of the eyelids, nose, lips, and cheeks. Fat atrophy can lead to hollowing in the orbital, temporal, and buccal spaces. De- mineralization of the facial skeleton causes a loss of facial height and a weakening of the chin. Extrin- sic factors, such as smoking and sun exposure, accelerate these changes and lead to pigment irregularity and coarse skin. The optimal use of fillers and injectables requires an understanding of the aging face syndrome (Fig. 1). This process begins during the third decade (age 20s) and is caused by the gradual weakening and atrophy of various facial support structures. During this decade, the eyebrows begin to descend. During the fourth decade, excess eyelid skin laxity appears, glabellar frown lines form, and the nasolabial folds become more prominent. During the fifth decade, rhytids deepen and periocular (crow’s feet) and perioral wrinkles become more noticeable. During the sixth decade, deepening of the rhytids continues, along with descent of midfacial fat, which leads to jowl forma- tion and a worsened appearance of the nasojugal fold. During the seventh decade and beyond, skin laxity and fat resorption continue to dominate, which exaggerates the aforementioned changes. Department of Otorhinolaryngology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA * Corresponding author. E-mail address: [email protected] (O. Friedman). KEYWORDS Injectable fillers Cosmetic surgery Plastic surgery Aesthetic surgery Facial Plast Surg Clin N Am 16 (2008) 345–355 doi:10.1016/j.fsc.2008.03.002 1064-7406/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved. facialplastic.theclinics.com
Transcript
Injectables and Fillersin Male Patients
Jess Dhaliwal, MD, Oren Friedman, MD*
KEYWORDS� Injectable fillers � Cosmetic surgery � Plastic surgery� Aesthetic surgery
ics.
com
Traditionally, in facial plastic surgery, male pa-tients were known to focus on function overform. Men typically did not consider rejuvenationsurgery until they had advanced changes associ-ated with aging, and it was often coupled witha functional concern. However, over the last sev-eral years, this conservative approach seems tohave changed. Although men still comprise lessthan 10% of patients who undergo cosmeticsurgery, the number of men seeking minimallyinvasive, nonsurgical procedures has increasedby 722% since 1997.1 Motives include the desireto be more competitive and youthful in the work-force, the growing social acceptability of cosmeticprocedures, and increased awareness of nonsur-gical options.
Men may be discouraged from pursuing facialsurgical procedures for several reasons (eg, re-covery time, surgical scars, need for camouflage,time off work). Minimally invasive procedures offerinstant results without mandatory downtime orscars. The ability to return to work immediately isa distinct advantage. The most powerful nonsurgi-cal tools for aesthetic surgeons include botulinumtoxin type A (Botox) and dermal fillers. Fillers andinjectables do not require anesthesia or lifestylechanges, such as weight loss or smoking cessa-tion, and are therefore attractive alternatives tomore aggressive interventions.
In 2006, Botox was the most common nonsurgi-cal procedure for men. Hyaluronic acid (HA)augmentation was found to be the third most com-mon nonsurgical aesthetic procedure for men. Thetrend has been away from collagen fillers in favorof HA, calcium hydroxylapatite (CaHA), and poly-L-lactic acid (PLA) augmentation.1 The popularityof dermal fillers and injectables will likely continue
Department of Otorhinolaryngology, Mayo Clinic, 200 Fi* Corresponding author.E-mail address: [email protected] (O. Friedman).
Facial Plast Surg Clin N Am 16 (2008) 345–355doi:10.1016/j.fsc.2008.03.0021064-7406/08/$ – see front matter ª 2008 Elsevier Inc. All
to increase as surgeons gain more experience andproducts become more refined.
AGING
The changes associated with aging follow a pre-dictable pattern. Over time, the epidermis andsubcutaneous tissues become thinner, mostlybecause of the effacement of the dermal-epidermal junction and loss of collagen, elastin,and HA. Gravity contributes to the descent of sub-cutaneous fat and drooping of the eyelids, nose,lips, and cheeks. Fat atrophy can lead to hollowingin the orbital, temporal, and buccal spaces. De-mineralization of the facial skeleton causes a lossof facial height and a weakening of the chin. Extrin-sic factors, such as smoking and sun exposure,accelerate these changes and lead to pigmentirregularity and coarse skin.
The optimal use of fillers and injectables requiresan understanding of the aging face syndrome(Fig. 1). This process begins during the thirddecade (age 20s) and is caused by the gradualweakening and atrophy of various facial supportstructures. During this decade, the eyebrowsbegin to descend. During the fourth decade,excess eyelid skin laxity appears, glabellar frownlines form, and the nasolabial folds become moreprominent. During the fifth decade, rhytids deepenand periocular (crow’s feet) and perioral wrinklesbecome more noticeable. During the sixth decade,deepening of the rhytids continues, along withdescent of midfacial fat, which leads to jowl forma-tion and a worsened appearance of the nasojugalfold. During the seventh decade and beyond,skin laxity and fat resorption continue to dominate,which exaggerates the aforementioned changes.
To augment the structures weakened by aging, theideal filler must possess several qualities: it mustbe nontoxic and noncarcinogenic; it should notmigrate from the injection site; the consistencyshould allow for use with a small needle; and itshould be easy to inject. It also should be painlessand cause minimal skin changes at the injectionsite, and the results should last for a long time.Most important, it must be biocompatible andproduce only a minimal inflammatory response.Currently, no filler fulfills all of these criteria.
Fig. 2. Techniques for filler placement.
PATIENTASSESSMENT
During the prefiller evaluation, several importantquestions should be answered. A good historyshould include allergies, current medications(particularly anticoagulants and antivirals), pasthypertrophic scars/keloids, and any prior facialprocedures. A physical examination is necessaryto look for evidence of prior fillers or cosmeticsurgery. If the glabella, brow, or periocular areasare part of the treatment plan, it is essential tolook for evidence of preexisting brow ptosis.Injectables or fillers that are used frivolously inthe context of brow ptosis could have adverseconsequences.
It is also imperative to ask about a history of coldsores. If the patient has a history of herpes simplexvirus, many physicians prescribe antiviral prophy-laxis. One physician survey reported thatpractitioners commonly prescribed one of tworegimens: (1) valacyclovir, 500 mg before theprocedure and 500 mg 12 hours after the proce-dure, or (2) the same regimen, with an additionalprescription in case of an outbreak.2
TECHNIQUES FOR FILLER PLACEMENT
Four techniques have been described for fillerplacement: serial puncture, linear threading, fan-ning, and cross hatching. Serial puncture is a tech-nique in which small aliquots of filler are injectedinto multiple puncture sites (Fig. 2). During linear
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threading, the needle forms a tract and the filler isinjected as the needle is withdrawn (Fig. 3). Linearthreading can also be combined with serial punc-ture. The fanning technique is a modification of lin-ear threading; instead of completely withdrawingthe needle, it is reintroduced in another vector(Fig. 4). In the cross-hatching technique, filler isinjected in linear threads at right angles approxi-mately 5 to 10 mm apart (Fig. 5).2 Fanningand cross hatching are considered advancedtechniques.
Fig. 4. Techniques for filler placement.
TYPES OF FILLERS
Nearly 20 fillers are Food and Drug Administration(FDA) approved for cosmetic use. Each filler hasparticular indications and is intended for injectionin specific levels of the dermis or hypodermis(Fig. 6). The following section describes in detailmany of the more commonly used fillers.
Collagen
The first widespread commercial fillers, collagenproducts are the standard by which many newerfillers are judged. Collagen fillers remain the moststudied, although their popularity has waned sig-nificantly with the introduction of HA.
Collagen fillers offer the advantage of localanesthesia because they are mixed with 0.3% li-docaine. The anesthetic component also de-creases the activation of eosinophils, which maydecrease bruising.3 Another advantage collagenfillers may have over HA fillers is in their use alongfine lines; two collagen fillers, Zyderm 1 (Allergan,Irvine, California) and CosmoDerm 1 (Allergan),are indicated for use in the superficial dermis. Re-stylane Fine Lines (Medicis Aesthetics Incorpo-rated, Scottsdale, Arizona), an HA filler, has notyet been FDA approved.
The main disadvantage of bovine collagen fillersis that they require skin testing, which can delaytreatment by 1 month. Up to 5% of patients willhave a hypersensitivity to bovine collagen. Manycollagen products also require overcorrection
Fig. 3. Techniques for filler placement.
because the saline component of the filler gets ab-sorbed quickly. Results typically last between 3and 6 months.
Three bovine collagen fillers are FDA approved:Zyderm 1, Zyderm 2, and Zyplast (Allergan).Zyderm 1 has 35 mg/mL of collagen. It is injectedin the superficial dermis and is used for superficialrhytids (periocular, perioral), lip augmentation, andacne scars. It requires an overcorrection of 150%to 200%.4
Zyderm 2 has 65 mg/mL of collagen. It is in-jected into the middermis and is used for deeperrhytids and lip augmentation. It requires an over-correction of 100% to 150%.4
Zyplast has 35 mg/mL of collagen that is crosslinked. It is injected into the deep dermis and is
Fig. 5. Techniques for filler placement.
Fig. 6. Planes of injection. Each filler is intended forinjection into specific levels of the dermis andhypodermis.
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used for nasolabial folds, marionette lines, anddeep rhytids. Overcorrection is not necessary.4
Zyplast is not advised for use in the glabellar com-plex because it presents a risk for necrosis.
In 2003, a family of human-derived collagenfillers grown from a single fibroblast cell line wasintroduced, obviating the need for skin testing. Itincludes three products: CosmoDerm 1, Cosmo-Derm 2, and CosmoPlast (Allergan). The indica-tions are similar to the bovine-derived productsmentioned earlier.
Micronized Human Cadaveric Dermis
The use of micronized human cadaveric dermis, orCymetra (LifeCell Corporation, Branchburg, NewJersey), has also been described for soft tissueaugmentation. It is freeze dried and reconstitutedin the office with lidocaine. Cymetra does notrequire skin testing and should be injected at thedermal-subcutaneous junction. However, its usein cosmetic procedures is limited by its largeparticle size, which requires a larger needle(23 gauge). Results last for 2 to 6 months.
Hyaluronic Acid
HA fillers have quickly become the most popularfillers on the market. Since the FDA approval ofRestylane (Medicis) in 2003, the number of HA pro-cedures in men has risen to more than 73,000 peryear.1 Currently, several HA fillers are approved forcosmetic use: Restylane, Perlane (Medicis), Hyla-form (Allergan), Hylaform Plus (Allergan), Captique(Allergan), Juvederm Ultra (Allergan), and Juve-derm Ultra Plus (Allergan).
HA is highly conserved between mammalianspecies, a property that makes it nonimmunogenic.HA also maintains its volume longer than collagenbecause it is extremely hydrophilic. HA moleculesbind more water as surrounding molecules aredegraded, allowing it to maintain its volume evenas it is metabolized.2 Researchers have demon-strated that HA works by stretching fibroblastsand inhibiting collagenase, which stimulates colla-gen production and prevents its breakdown.5
Although HA fillers possess many ideal qualities,their main disadvantage is that they do not containlocal anesthetic. Some practitioners also believethat HA fillers are too viscous for use in fine linesand superficial augmentation.6
All HA fillers are indicated for moderate to se-vere wrinkles. Restylane, Hylaform, Captique,and Juvederm Ultra should be injected in themid- to deep dermis. Perlane should be injectedat the junction of the deep dermis and superficialsubcutis. Perlane, Hylaform Plus, and JuvedermUltra Plus have formulations that are indicatedfor deeper rhytids. Overcorrection is not requiredfor any HA filler. However, if overcorrection occurs,hyaluronidase, a pharmaceutic enzyme, can beused to degrade the filler. Results last for 6 monthsor longer.
Restylane, Perlane, Juvederm, and Captiqueare derived from bacterial cultures of Streptococ-cus equi. Hylaform is composed of HA derivedfrom rooster combs. Studies have demonstratedlonger-lasting results with HA fillers, comparedwith collagen.7,8 Restylane and Perlane havebeen shown to have higher efficacy and satisfac-tion, compared with Hylaform.9,10 Captique andHylaform are produced using the same process,and the literature pertaining to Captique is derivedfrom that of Hylaform.6
Juvederm is the newest HA filler. Although threeformulations are FDA approved, only two, Juve-derm Ultra and Juvederm Ultra Plus, are currentlymarketed in the United States. Juvederm hasa smooth, gel-like consistency and higher concen-trations of HA, compared with other fillers. A re-cent study comparing Juvederm with Zyplastfound increased patient satisfaction and improve-ment at 24 weeks.11 Juvederm is touted to last upto 1 year. These favorable qualities have beenreported by some studies; however, clinical expe-rience and long-term data are limited becauseJuvederm was only FDA approved in 2006.
Calcium Hydroxylapatite
Approved by the FDA for cosmetic purposes inDecember 2006, CaHA, or Radiesse (BioFormMedical, San Mateo, California), is a synthetic,
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semipermanent filler composed of CaHAmicrospheres in a water-based gel carrier. Afterinjection, the gel carrier dissolves and the micro-spheres act as a matrix for fibroblasts and newcollagen growth. Eventually, the microspheresthemselves are metabolized into calcium andphosphate ions.12 CaHA is approved for moderateto severe wrinkles around the nose and mouth andfor HIV-associated lipoatrophy. Results last for upto 1 year.
CaHA should be injected at the dermal-subcuta-neous junction, typically with a 27-gauge needle.Overcorrection is not necessary. In a recent studyof 117 subjects comparing human collagen withCaHA on moderate to deep nasolabial folds,CaHA was found to have greater patient satisfac-tion and longevity at 6 months. The patients servedas their own controls, with collagen injected onone side and CaHA on the other. However, edemaand ecchymosis were significantly more commonon the CaHA-treated side.13 Company-sponsoredstudies from Europe have also shown CaHA to bebetter than HA-based fillers at 12 months.14
The use of CaHA for lip augmentation is contro-versial because studies have suggested a 5% to15% risk for nodule formation.12
Poly-L-Lactic Acid
Approved by the FDA in 2004 for HIV-associatedlipoatrophy, PLA, or Sculptra (Sanofi-Avantis,Bridgwater, New Jersey), differs from other fillersin that it is a dermal stimulator. After injection,PLA is resorbed over the first week. PLA worksby stimulating a foreign body reaction that inducescollagen deposition. Over time, the tissue reactionleads to increased dermal thickness. Multipletreatments are typically required at 2-to 4-weekintervals.
PLA should be reconstituted with sterile water,but some practitioners advocate the addition oflidocaine. After preparing the filler, it must sit for2 hours before injection. It should be injectedwith a 26-gauge needle at the level of the deepdermis or subcutaneous plane. PLA is typicallyused to correct the appearance of sunken cheeksor temporal hollowing. The main notable sideeffect is the delayed development of subcutane-ous papules.15
Polymethylmethacrylate
Although historically known as a component ofbone cement and other medical implants, polyme-thylmethacrylate (PMMA) has found a novel use asa permanent soft tissue implant. Approved bythe FDA in 2006, ArteFill (Artes Medical, Inc., SanDiego, California) is composed of nonresorbable
PMMA microspheres (20% of total volume) sus-pended in a gel of bovine collagen (80% of totalvolume) with 0.3% lidocaine. After injection, thefiller collagen is absorbed and the PMMA micro-spheres are fixed into place by native fibroblastsand collagen. Skin testing is required because ofthe bovine collagen component. The implantshould be injected at the junction of the dermisand subcutis. Overcorrection should be avoided.Instead, the area should be gradually correctedin two or three sessions over several months.16,17
Currently, ArteFill is indicated for nasolabial foldcorrection, but has been used ‘‘off label’’ in othersites (glabella/perioral complex). It is not recom-mended for individuals with thin skin.
A recent study looking at a 5-year follow-up of119 patients after PMMA implants for nasolabialfold correction found most patients (90%) to besatisfied with the cosmetic outcome. The mainadverse event was ‘‘lumpiness’’ in 10 patients,with most rating it as mild. Two patients werenoted to have granulomatous reactions, one ofwhich required excision of the implant.16
A recent case report from Europe reported aninterferon-triggered, sarcoidosis-type reaction toPMMA implants in a woman who had hepatitis Cwho was on interferon therapy. The lesions wereeventually treated with allopurinol and facial re-constructive surgery.18
Liquid Injectable Silicone
The use of silicone as a permanent filler has beenthe subject of controversy. Liquid silicone has FDAapproval for use by ophthalmologists for retinaldetachment, but it is also used off label for cos-metic purposes. Many experienced injectors relyon injectable silicone for various procedures, in-cluding permanent lip augmentation, correctionof rhinoplasty irregularities, and augmentationalong fine rhytids (periorbital, periocular). Facialsilicone injections represent an advanced proce-dure that should be performed only by those withvast experience with injectables. Further discus-sion about liquid injectable silicone is beyond thescope of this article.
Autologous Fat Transfer
The use of autologous fat as a dermal filler haswaxed and waned in recent years. In theory, ithas many of the qualities of an ideal filler becauseit is inexpensive, nonimmunogenic, and easyto harvest. However, unpredictability, question-able persistence over time, and ability toachieve a smooth contour have been cited asdisadvantages.
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Recently, autologous fat transfer has experi-enced a definite surge in popularity. Lipocontour-ing has been used for nasolabial folds, lipaugmentation, corrections of rhytids, and cheekand mandibular augmentation. Fat transfer hasallowed surgeons to recreate the oval shape ofthe face through deep injections over the malareminence. It has also been used to correct jowlingthrough injections along the mandibular line.
The optimal technique for harvesting and trans-planting fat has been debated. No standard tech-nique currently exists. In general, fat can beharvested from the outer thigh, buttocks, or flankareas using direct excision or suction aspirationunder low pressure. It is generally processed bywashing or centrifugation. It is injected at therecipient site in the subperiosteal, epiperiosteal,or subcutaneous planes. Small volumes of fat areadvocated to optimize fat survival.19,20
The most serious complication associated withautologous fat transplantation is acute arterial em-bolism. To avoid this, many investigators suggestusing a blunt-tipped cannula and aspirating beforeinjection.19
BOTULINUM TOXIN TYPE A
The cosmetic use of Botox is the most commonnonsurgical procedure in men.1 Initially approvedby the FDA for treatment of glabellar frown lines,Botox (Allergan) is now routinely used off label invarious facial sites. The combined use of Botoxand dermal fillers is thought to give longer-lastingresults than when each is used independently.
Botox is a neurotoxin that blocks the release ofacetylcholine at the neuromuscular junction. It iscontraindicated in patients who have neuromus-cular disorders, those who are pregnant or nurs-ing, and those taking aminoglycosides, calciumchannel blockers, or quinines. Results typicallylast for 3 to 6 months.
Reloxin, the first alternative to Botox in theUnited States, is slated to hit the market in 2008.It is in the final stages of FDA approval and isthought to offer greater diffusion than Botox.
CLINICAL APPLICATIONS
The availability of alloplastic injectable fillers hasincreased dramatically over the last 10 years.Although ongoing research and technologicadvances continue to produce new trends, thefundamental aesthetic principles for the applica-tion of dermal fillers will likely remain unchanged.The following sections focus on the different areasof the face that are often treated with injectablesand fillers.
UPPER FACE
Among the areas of greatest concern for men arethe forehead and eyebrow subunits. Aging leadsto several prominent changes in the area, many ofwhich can be corrected with dermal fillers and Bo-tox. Frontalis hypertrophy occurs as a compensa-tory mechanism to counteract the downward pullof gravity and the brow depressors. The static anddynamic forces in this area counteract each otherand accentuate glabellar and forehead rhytids.21
Glabellar Complex
To appreciate the effects of aging on the glabella,one must understand the underlying muscleactions in this area. Horizontal glabellar wrinklesresult from contraction of the procerus muscle.Vertical frown lines result from repeated contrac-tion of the more laterally located corrugator super-cilii. Inspection of the glabellar complex at rest andwith activity helps determine the ideal treatmentregimen.
If wrinkles are present only with muscle activity,Botox may be an adequate treatment and mayprevent or delay future development of rhytids. Ifwrinkles are present at rest, effective treatmentwill require the use of fillers, in addition to Botox.
The standard protocol for Botox in the glabellarcomplex involves 4 units (U) in five injection sitesfor a total of 20 U. However, a prospective, dou-ble-blind, randomized study conducted in 2005advised that 40 U should be the starting dose formen.9 The higher dose did not lead to increasedcomplications. Typically, one midline injectionshould target the belly of the procerus. Two injec-tions extending over each aspect of the medialbrow should target each corrugator. The medialcorrugator injection should be at least 1 cm overthe bony supraorbital ridge to prevent blepharop-tosis (Fig. 7).
The proper use of dermal fillers in this area re-quires the practitioner to be cognizant of therare, but serious, complications of tissue necrosisand blindness from arterial embolization. Theseadverse events are thought to occur secondaryto excessive filler placement in an area with limitedcollateral circulation and retrograde embolizationfrom accidental pressurized injection into a vessel.Linear threading or serial puncture can be used inthe area. The filler should not be injected under anyback pressure and the area should be checked forcapillary perfusion after the procedure.21
Frontalis Region
Forehead wrinkles are most commonly treated offlabel with Botox. The frontalis muscle is the only
Fig. 9. Treatment of the lateral brow. An ‘‘X’’ indicateswhere Botox should be injected. Conservative dosingavoids eyelid ptosis from diffusion into the levatormuscle. The needle illustrates application of a dermalfiller. Note the location of the lacrimal gland.
Fig. 8. Treatment of forehead rhytids. An ‘‘X’’ indicateswhere Botox should be injected. Injections should beat least 1.5 to 2 cm above the brow to avoid ptosis.The needle illustrates application of a dermal filler.
Fig.7. Treatment of the glabellar complex. An ‘‘X’’ indi-cates where Botox should be injected. The medial cor-rugator injection should be at least 1 cm above thebony supraorbital ridge to prevent blepharoptosis.
Injectables and Fillers in Male Patients 351
brow elevator. As with the glabella, practitionersmust be aware of brow ptosis. Careful evaluationsbefore the procedure can identify those patientswho already have some degree of ptosis, alongwith those who compensate for brow ptosis withcontraction of the frontalis. Administering Botoxinjections to those patients should be done withcaution.
The typical protocol for Botox in this areainvolves four to six injections of Botox spaced1 cm apart. Injections should be at least 1.5 to2 cm above the brow to avoid ptosis (Fig. 8). TheBotox should be dosed according to the degreeof improvement necessary. Typically, 2 U are in-jected per site.
Lateral Brow
The use of dermal fillers to augment the lateralbrow has also been described. Because of thecharacteristically thin skin in this area, an appropri-ate filler should be selected. Matarasso andcolleagues2 described a technique of using0.2 to 0.3 mL of Restylane per side. The superolat-eral margin of the brow is filled using an antero-grade threading technique (Fig. 9).
The lateral brow may also be gently lifted withBotox injections into the lateral aspect of the orbi-cularis oculi muscle (see Fig. 9). This proceduremust be performed with caution by experiencedinjectors, to avoid complications. Eyelid ptosiscan result if Botox diffuses through the orbital sep-tum toward the levator muscle. A peaked andunattractive brow (or ‘‘joker appearance’’) mayalso occur in cases of unrecognized lateral fronta-lis hypertrophy because of the unopposed pull ofthe frontalis once the lateral brow orbicularis isinjected.21
Botox injections near the lacrimal gland (ie, lat-eral brow elevation, periocular rhytids) can leadto the temporary complication of dry eyes. Thisfinding has been borne out in the author’s experi-ence and also in studies documenting worsenedSchirmer test results after Botox injections.22,23 Itis thought that Botox may interfere with autonomiccholinergic transmission to the lacrimal gland.
Periocular Rhytids (Crow’s Feet)
Excessive contraction of the orbicularis oculi mus-culature (ie, squinting, blinking) leads to periocular
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rhytids, or ‘‘crow’s feet.’’ In addition to eyelid clo-sure, the orbicularis is also the most powerful de-pressor of the brow.24
The main consideration when injecting Botox inthis area is to avoid the pretarsal and preseptalportions of the orbicularis musculature. In general,the injections are placed at least 1 cm from the lat-eral orbital rim (Fig. 10). Care should also be takento avoid medial injections in the zygomaticusmajor musculature. Some practitioners advocate10 to 15 U per side,24 whereas others claim thegenerally accepted dose is 12 U per ‘‘crow’sfoot.’’25
When using dermal fillers along the thin periorbi-tal skin, small aliquots should be used to avoidcontour irregularities. Serial puncture or linearthreading can be used to deposit the filler.
Infraorbital Folds
Studies have shown that 2 to 4 U of Botox, 3 mmbelow the ciliary margin, are effective for under-eye rhytids. However, treating this area widensthe palpebral apertures. Overly aggressive paraly-sis of the lower lid orbicularis can also lead toa droopy eyelid and excess scleral show.24,25 Dif-ficulty with eye closure may ensue, which can leadto ineffective protection from soap and water andsecondary eye irritation.
Infraorbital Hollowing (‘‘Tear Trough’’Deformity)
The use of dermal fillers for treatment of infraorbitalhollowing has been increasing as a viable
Fig. 10. Treatment of periocular rhytids. An ‘‘X’’ indi-cates where Botox should be injected. Injections aregenerally placed at least 1 cm from the lateral orbitalrim. The needle illustrates application of a dermalfiller.
nonsurgical option. Knowledge of the anatomyand the changes associated with aging is essen-tial, to prevent complications.
Soft tissue changes involving the nasojugal foldmedially and the arcus marginalis laterally contrib-ute to the tear trough deformity. The use of colla-gen, autologous fat, PLA, and hyaluronans haveall been described to treat the area. The plane ofinjection is critical for lasting results and forpreventing palpable nodules or blue-gray skin dis-coloration. Fillers should be injected in the subor-bicularis plane just above the periosteum (Fig. 11).
Hirsch and colleagues26 described one ap-proach for HA fillers to the area. Using a long(1-inch) 30-gauge needle, the filler is injected ina lateral to medial direction. The needle is ad-vanced to the plane between the orbicularis oculimuscle and periosteum. Small aliquots (between0.2 and 0.4 mL) of filler are injected. Care is takennot to injure the infraorbital nerve or the infratro-chlear vessels adjacent to the nasal bone. The filleris injected under low pressure in the submuscularspace, preventing retrograde embolization intoa periorbital artery.
LOWER FACE
The most common procedures involving the lowerface include correction of nasolabial folds andmarionette lines. Aging not only causes soft tissuechanges, but also leads to bony resorption, whichresults in a loss of mandibular height. Autologousfat transfer and other soft tissue fillers have beenused to strengthen the mandibular line. Other
Fig.11. The tear trough deformity.
Fig.12. DAO. An ‘‘X’’ indicates where Botox should beinjected. Injections should be avoided superiorly andmedially. The needle illustrates application of a dermalfiller.
Injectables and Fillers in Male Patients 353
procedures in the lower face include cheek aug-mentation, particularly in those patients whohave HIV-associated lipoatrophy. Dermal fillersand Botox can also be used to correct flatteningof the upper lip, chin dimpling, and perioral rhytids.
Nasolabial Folds
This region is the most-studied area for filler place-ment. It is generally safe, even for inexperiencedpractitioners. Overcorrection should be avoidedand the filler should be injected in the correct planeto avoid a ‘‘sausage’’-type appearance. The lon-gevity of dermal fillers can also be compromisedby excessive facial movements in this area. Thisprocess of resorption is one reason autologousfat in the nasolabial fold has been met with somedissatisfaction. Serial puncture and linear thread-ing are commonly used techniques for correctplacement.
Radial Lip Lines
Superficial rhytids around the lips are more com-monly treated in women. Filler selection is impor-tant because of the superficial nature of therhytids. Botox has also been used in this area;however, oral incompetence and drooling areimportant risks to be considered, especially inpatients who rely heavily on speaking or pursingtheir lips (ie, singers and musicians). Generally,conservative dosing (1 U) per injection in eachquadrant of the lip above the vermillion border isadvised.24,25 Fillers injected in this area can beapproached using a linear threading technique,beginning at the white roll.
Downturned Oral Commissures(‘‘Marionette Lines’’)
Contraction of the depressor anguli oris (DAO)muscle can give a sullen appearance. Termed‘‘marionette lines,’’ the area can be treated witha combination of Botox and fillers. The DAO origi-nates from the oblique line of the mandible andinserts at the oral commissure. Asking the patientto frown can isolate the DAO. Injection of a fewunits of Botox in each DAO can raise the oral com-missure by 1 to 2 mm at rest (Fig. 12).25 To avoidthe complications of asymmetric smile and oralincompetence, the injections should be avoidedsuperiorly and medially. Fillers and autologous fatare typically used in the triangular area at the oralcommissures created by the marionette lines.2
Cheeks
Generally considered an area that requires experi-ence, cheek augmentation can be performed with
dermal fillers. Cross hatching or fanning can beused. Autologous fat can also be used in a mannersimilar to that of a cheek implant. Because of theincreased incidence of ecchymosis, ice and mas-sage are recommended in this area.
Lip Augmentation
Primarily considered a procedure for women, lipaugmentation can be performed successfullywith fillers. Augmentation can be performed alongthe vermillion border, lip body, and oral commis-sures, depending on the overall goal of the proce-dure. Small needles should be used to assureprecision (ie, 30 or 32 gauge), and the nondomi-nant thumb and index finger should stabilize thearea being injected.2
Chin Dimpling
Chin dimpling occurs because of contraction ofthe mentalis muscle and regional skin changes.Botox and dermal fillers can be used to correctthis deformity.25
Acne Scars
Dermal fillers have also been used successfully toimprove the cosmetic appearance of acne scars.Generally, subcision is performed first, using a nee-dle to sever any tethering fibrous bands, followedby injection of the filler. The appropriate selectionof the filler is critical because injections are usuallyperformed superficially.
CONTRAINDICATIONS AND COMPLICATIONS
In general, fillers are contraindicated in patientswho have multiple severe allergies or sensitivity
Dhaliwal & Friedman354
to the individual components of fillers, and inpatients who are pregnant or breastfeeding.
Important principles for all injections includeaspirating before injection and avoiding forcefulor pressurized injections. The plane of injection iscritical to avoiding overlying skin changes.
Bruising, erythema, and ecchymosis areexpected complications after fillers. They are tran-sient and usually subside within 2 weeks.
Among true complications, nodules and granu-lomas are commonly discussed. Nodules appearin the first several weeks after injection and areusually single and well circumscribed. Granulomasappear much later, often 6 months to years afterthe procedure. Both nodules and granulomasrespond to intralesional steroid injections.27 Surgi-cal excision should be reserved for persistentnodules and granulomas.
Injection necrosis is a rare complication, withmost case reports involving the glabella after colla-gen fillers. Tissue viability can be compromisedby vascular compression by filler, by vesselobstruction, or by direct vessel injury during theprocedure.
The glabella is vulnerable because of limited col-lateral circulation. A typical presentation of glabel-lar necrosis is immediate painless blanching orbruising of the injection area. Two to 3 days later,the skin changes to dusky or black, with eventualeschar formation. Necrosis can be preventedin this area by aspirating before injection,injecting superficially and medially, and avoidingovercorrection.28
SUMMARY
The use of injectables and fillers will only increasein popularity. Although an ‘‘ideal’’ filler remains elu-sive, several fillers currently on the market provideinstant, predictable results, with few complica-tions. A thorough knowledge of the regional anat-omy, techniques for injection, and properties ofindividual fillers can make fillers and injectablesa rewarding part of any aesthetic practice.
ACKNOWLEDGMENTS
The authors would like to acknowledge JohnHagen for providing the illustrations in this article.
REFERENCES
1. American Society for Aesthetic Plastic Surgery 2006
statistics. Available at: http://www.surgery.org/down
