Dr. Anthony BenedettoWhen performing facial rejuvenation treatments in cosmetic patients, it’s time to take a “whole face” approach using various cosmetic tools to achieve not only excellent aesthetic outcomes but also more natural-looking results in facial rejuvenation. That’s according to Anthony Benedetto, D.O., F.A.C.P., clinical professor, department of dermatology, University of Pennsylvania School of Medicine, and medical director of the Dermatologic SurgiCenter, Philadelphia. Dr. Benedetto spoke at the annual meeting of the North American Clinical Dermatologic Society in 2014.
“In order to more effectively modify the static changes, clinicians should approach the face as a whole and address all aspects of the aging face, and not only ‘fill’ the lines that one sees,” he says.
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The static changes that occur over time in the aging face involve varying degrees of volume loss, including skin atrophy and reduced elasticity, fat atrophy and decent into the lower face, as well as muscle, soft tissue and bone mass loss. In addition, the dynamic changes that occur are a result of chronic muscle movement in the face, which results in wrinkling of the overlying skin over time.
“Not only do we have to address the static changes, but we also need to understand the dynamic and interaction of the involved muscles and facial expressions in nonverbal communication to better treat the aging face as a whole,” Dr. Benedetto says.
In This Article
Dr. Benedetto’s Filler Choices
The Facial Aging Process
Natural aging or intrinsic aging is a continuous process that normally begins during the third decade of life. During this process, Dr. Benedetto says collagen production slows within the skin and elastin has less “spring.” This, together with extrinsic aging, results in a three-dimensional aging process that not only involves a thinning of the epidermis and dermis, but also numerous other changes. These changes include:
- More prominent bony landmarks
- The indentation of periorbital areas and temples
- Diminishing support of the mid- and lower face
- Deepening and elongation of the nasolabial folds, creating marionette lines, which are enhanced by the decent of the corners of the mouth
- Enlargement of the jowls and pre-jowl sulcus
- Thinning and elongation of the lips
- Ptosis of the nasal tip
- Chin recession
The underlying fat compartments in the face are distinctly separated from each other by fibrous connective tissue, Dr. Benedetto says, and the shifting of the facial fat pads over time also significantly impacts and typically characterizes the aging face.
“In a young face, the boundaries between the compartments are not obvious but smooth in outline, and as we age, the cosmetic units become more obvious,” he says. “This is what enhances the bony appearance of the face after all the thinning and loss of soft tissue. However, the face does not age evenly because changes occur in different compartments at different rates or times as the patient ages, causing subtle changes over time, which slowly but surely define an older-looking face.”
Filler Factors
While collagen was the preeminent cosmetic tool of its time in facial rejuvenation decades ago, continued research has borne numerous other dermal fillers composed of hyaluronic acid (HA), polylactic acid (PLA) and calcium hydroxylapatite (CaHA). Approximately 95% of dermal filler treatments today are performed in the mid- and lower face, Dr. Benedetto says, not just to fill wrinkle lines, but to replenish and recontour this region.
“Many of the state-of-the-art filler products available today can help us significantly modify and augment the aging face, allowing us to treat beyond the forehead and glabellar lines and nasolabial folds, such as the lateral brows and temples, the tear trough and the perioral area. We can now much more aesthetically define and augment lips, soften and elevate oral commissures, eliminate marionette lines and pre-jowl sulci, and even augment and sculpt the chin,” Dr. Benedetto says.
Numerous factors should be considered when choosing the appropriate filler for the different target regions of the face, he says, most important of which include the individual characteristics of a given filler product, such as its degree of crosslinking, concentration, gel hardness (G prime), cohesivity, viscosity and biologic effect.
“The longevity of effect as well as the distribution of the product underneath the skin are also important factors to consider when choosing the ideal filler for a given location. While the filler should be easy to inject, it should also be elastic but firm to the correction,” Dr. Benedetto says.
Dr. Benedetto’s Filler Choices
Dr. Benedetto’s Filler Choices
Depending on the patient and the correction to be made, CaHA-based products are Dr. Benedetto’s dermal filler of choice when filling and rejuvenating the lateral malar and malar area, submalar cheek, nasolabial folds, nasal defects, nasal tip, scars from acne or trauma, marionette lines, mental crease as well as augmentations of the chin and jawline.
Dr. Benedetto says he often chooses HA fillers for the correction of forehead and glabellar lines, lateral brow and temple, periorbital area including the tear trough, earlobes, radial lip lines, oral commissures, lip enhancement and horizontal necklines. He likes to reserve PLA filler treatment for the temple and malar areas, as well as in the nasolabial folds and jawline.
A Holistic Approach to Rejuvenation
A Holistic Approach to Rejuvenation
Each part of the face has a specific area where certain fillers are more appropriate. According to Dr. Benedetto, each filler has its place and should be chosen according to the target region of the face and the aesthetic correction and outcome you are trying to achieve. Creating the “perfect” face is in the eyes of the beholder, he says, and achieving good aesthetic outcomes depends on the physician and his or her sense of symmetry, proportion and balance.
“When enhancing and rejuvenating the upper face, some physicians may overlook the indentation often occurring in the temple area in elderly patients because they are too focused on filling lines and less focused on addressing the areas of volume loss,” he says. “When directly comparing the face of a younger and older patient, the indentation seen at the temple area is very obvious and the correction one performs with fillers there can be very dramatic.”
Dr. Benedetto says he combines different cosmetic tools when performing whole face rejuvenation, often starting with botulinum toxin injections to relax and redrape the targeted area, and then follow-up with filler treatments a few weeks later to replenish, reshape and recontour the region treated. If the patient requires or desires more, he may continue with laser skin resurfacing therapy for a complete whole face rejuvenation approach.
Performing maintenance treatments is also important for upholding results achieved at the culmination of the whole face rejuvenation treatment plan, Dr. Benedetto says. Not only will the intrinsic aging process continue, but the filler and botulinum toxin products injected will slowly degrade and wear off, requiring touch-up treatments.
“The three main areas to be addressed in rejuvenation of the aging face are the shape and position of the brows, the volume and shape of the lips and the texture of the skin, and the volume of the underlying subcutaneous compartment. A base knowledge of facial aesthetics, aging and anatomy will assist trained clinicians to adequately determine a course of treatment for the patient seeking aesthetic enhancement,” Dr. Benedetto says.
Disclosures
Dr. Benedetto reports no relevant financial interests.
