- Filler technique in lieu of facelift is discussed in the surgeon's own words
In our recurring feature, First-Person Surgical, we hear the surgeon's own voice relate the heuristic techniques and lessons learned that only time in the surgical suite can teach. In this issue, CST has partnered with The Johns Hopkins University School of Medicine and the National Cosmetic Network to bring you one surgeon's injection techniques for facial rejuvenation, a companion piece to the six-part, live-procedure CME video series, "Excellence in Nonsurgical Procedures."
Some of my plastic surgery colleagues express surprise when I tell them that I do virtually no facelifts anymore — maybe one or two a year. I still perform neck lifts, but unless a patient has severe skin laxity, I prefer to approach facial rejuvenation as recontouring of the face — filling in the infraorbital perinasal hollows, adding cheek prominence and making a variety of improvements to the very important perioral area.
Why have I adopted this approach to rejuvenation? Like many others in our field, I've been greatly influenced by the work of Dr. Sydney Coleman who teaches that a hollow face is an old face, and faces that are broad with full cheeks look youthful. Further, I've observed that traditional techniques often do not address a very important component of facial attractiveness: a cheerful or pleasant facial expression. This is particularly applicable to the perioral area, where pulled down corners of the mouth, thin lips and vertical wrinkles often do more than make a person look older — they also send a negative emotional message. In addition, softening nasolabial folds and marionette lines, addressing the area around the mouth where it appears to "cave in," and restoring the lip-to-chin balance all make a huge difference in creating a pleasing and youthful appearance.
MULTIPLE MODALITY APPROACH In recent years, I've adopted a multiple modality approach to perioral rejuvenation. I generally start with minimally invasive treatments, which may include the following:
CosmoDerm (Allergan; Irvine, Calif.) (human-based collagen implant), which can be used for superficial perioral wrinkles
Juvéderm Ultra (Allergan), which is comparable to Restylane, for enhancing the lip vermilion
Juvéderm Ultra Plus (Allergan), which is a more highly crosslinked hyaluronic acid designed for deeper wrinkles such as nasolabial folds
Botox (Allergan) to decrease hyperkinetic lines and address lateral depressions of the mouth.
Ultimately, I may suggest other therapies, with longer-lasting results, such as the Erbium laser and fat grafting.
PATIENT EVALUATION After eliciting from the patient precisely what bothers him or her, I evaluate both negative and positive facial features. First, I look for things that make the patient look old, sad or tired, as well as asymmetries that I may, or may not, be able to correct. Second, I look for things I want to retain and emphasize — perhaps a lovely jaw line. It's important to share these observations with the patient and to thoroughly explain both the goals and limitations of the selected procedures.
Most of my patients are very receptive to the idea of injectable therapies. For those who have concerns about whether soft tissue fillers might distort or change their appearance, I sometimes will let them "try out" a more volumized look using a noncrosslinked hyaluronic acid, which lasts only about three weeks. Many physicians are not aware that this is available and quite inexpensive.