25 Dermal Fillers
Soft-tissue augmentation, commonly referred to as dermal filler treatment, reduces facial lines and improves contour defects by temporarily restoring volume to the dermis and soft tissues through the use of injectable products.1 With the use of appropriate techniques and volumes, dermal filler treatments can enhance appearance in a subtle, natural way. Treatments require short recovery times and can be safely performed in the outpatient setting.2,3
Dermal filler treatments have become the second most commonly performed minimally invasive cosmetic procedure in the United States, according to statistics from the American Society for Aesthetic Plastic Surgery.4 The popularity of this procedure is largely due to increased patient demand for less invasive cosmetic treatment options and to recent product innovations that have prolonged treatment results.
Numerous dermal fillers (DFs) are available, each varying in composition, duration of action, palpability, ease of administration, complications, and other factors.5 In addition to the provider’s knowledge of DF products and injection skill, an appreciation for aesthetic facial proportions and symmetry is required to achieve desirable outcomes. Injection of dermal fillers has a steeper learning curve than botulinum toxin injections and requires practice to achieve desirable results.6 This chapter is intended to assist aesthetic providers in getting started with products and techniques that consistently achieve good results and have a low risk of complications. The focus is on the use of hyaluronic acid DF products for the FDA-approved treatment of nasolabial folds (NLFs).
Alternative therapies for the treatment of facial lines and wrinkles include botulinum toxin for dynamic wrinkles, and skin resurfacing procedures such as microdermabrasion, chemical peels, and laser (nonablative and ablative) treatments for static lines. Severe wrinkling with laxity may be better addressed with surgical treatments, such as face-lifts, than with dermal fillers.
Dermal filler products can be categorized based on their duration of action as either short acting (less than 4 months), long acting (6 months to 1 year), semipermanent (1 to 2 years), and permanent (2 years or more) (see Table 25-1).7–9
Injectable hyaluronic acid (HA) products are one of the most versatile dermal fillers currently available. HA is a naturally occurring glycosaminoglycan in the dermal extracellular matrix that provides structural support and nutrients and, through its hydrophilic capacity, adds volume and fullness to the skin. Commercially available HAs vary in formulation, concentration, and degree of cross-linkage, which affects their duration of action as well as postprocedure risks of swelling and bruising.10,11
Facial wrinkles and folds of the lower two-thirds of the face commonly treated with dermal fillers are shown in Figure 25-1. Arterial and venous supply for these areas is shown in Figure 25-2. The lateral nasal artery is a noteworthy vessel for NLF treatments. It is found at the junction of the facial artery and angular artery, and is the main vascular supply for the nasal tip and ala. It is located 2 to 3 mm superior to the nasal alar groove.12
Hyaluronic acid dermal fillers are supplied in individual prepackaged syringes ranging from 0.4 to 0.8 mL based on the manufacturer. Syringes are typically stored at room temperature (up to 25°C or 77°F) prior to use, and the specific manufacturer package insert guidelines should be followed. Shelf-life ranges from 6 months to 1 year.
CAUTION: Blanching during injection indicates that blood flow to the treatment site has been compromised, either by injecting too much filler into the dermis or injecting intravascularly. Discontinue injecting, massage the area until the tissue appears pink, and institute other measures outlined in the Complications section later in the chapter if indicated.
The goal of NLF treatment with dermal fillers is to soften NLFs without full effacement. The NLF is a natural facial contour and full effacement gives a simian appearance and is not aesthetically pleasing. In addition, undertreatment with small volumes may not yield a visible change to the NLF.
Figure 25-5 shows a grading scale for the severity of NLFs. Patients with mild, moderate, and severe NLFs are candidates for dermal filler treatments. Deep folds with excess laxity may have less satisfactory outcomes with dermal filler treatments and may require surgical interventions for significant improvement.