Video Cosmetic Science of Filling the Face

Dermtube Journal Club from publishers of Practical DermatologyDr. Fitzgerald Video – Cosmetically Filling the Face

Gaining an understanding of what’s happening beneath the surface is key to understanding how to get the results you want from fillers. Done right, the outcomes can be exceptionally natural looking. Done wrong you can waste money and not look at all the way you intended.

In this video, Dr. Fitzgerald explains very important factors in how a dermatologist chooses fillers and how the underlying facial fat compartments determine where fillers are placed and how much is required for best results.

Dr. Fitzgerald was recently invited for an interview by Practical Dermatology’s  Journal Club. Learn new perspectives on aging and how fillers and other injectables can not only correct lines and folds and volume loss but also how early treatment may help prevent them from occurring as rapidly.

Video Transcript – The Science of Cosmetic Fillers

Welcome to this edition of dermtube JournalClub. My name is Josh Zeichner. I’m the Director of Cosmetic and Clinical Research in the Dermatology Department at Mount Sinai Medical Center New York City, and I’m your host. It is my pleasure to introduce Dr. Becky Fitzgerald, who is in private practice in Los Angeles and is a voluntary faculty at UCLA, will be here talking to us about what’s new in cosmetically filling the face. Welcome, Becky.

You know, I think that we’re now beginning to recognize that lines and folds are sort of downstream markers of an overall global process. And as we learn a great deal more about the anatomy of aging, we learn more how to target the processes that lead to the development of those lines and folds.

Hi, Josh. Thanks for having me.

Thanks for being here. So tell me, when we used to fill the face, it used to be about specifically treating lines and folds. How have the current concepts of the aging face changed that?

Sure. You know, I think that we’re now beginning to recognize that lines and folds are sort of downstream markers of an overall global process. And as we learn a great deal more about the anatomy of aging, we learn more how to target the processes that lead to the development of those lines and folds.

Because anatomy sort of informs concepts, and concepts inform techniques, and then techniques determine outcomes. So I think that as we learn more anatomy, we’re more able to target specific areas that then develop into those downstream markers so that we can sort of predict, well, if we put it here, we’ll get this result. And if we put it there, we’ll get this result. And I know that there was a time where we thought, well, here’s a nasolabial fold, and if we put it here, we’ll just pop the nasolabial fold out.

But I think all of us, when we very first started doing fillers, in a young face, you could sort of use one syringe of HA, and that’s exactly what happened. Very predictably, you’d put in one tube of HA and the whole thing would pop out. And then a 60-year-old woman would come in, and you’d put in one tube, and then a second tube, and then a third tube for half price. And you’re thinking, where’s the stuff going? Why isn’t this getting any better? And I think that that’s a lot of what we’re learning.

When a patient comes to see you in the office, what is your approach to evaluating that patient’s aging face?

People are starting to realize that a stitch in time saves nine. And if you do something earlier, it’s easier to fix, and it leads to higher patient satisfaction and doctor satisfaction because they’re easier. And you can use one syringe of HA or one vial of PLLA and make a big difference. And probably just sort of keep lines from progressing as quickly as they otherwise would.

Sure. I think that if you can use some of the new information that we’ve got about the anatomy of aging, that you can approach every face in a much more specific way. You can address that particular face at that particular point in time with what is particularly changing it. So what I like to do is sort of try and look at the skin, fat, muscle, and bone and figure out if it’s kind of a multiple tissue issue, or a one-tissue issue.

If you have a yoga teacher who’s fairly young, or an HIV patient with extreme lipoatrophy who’s fairly young, they usually have a great skeletal support, really good skin, and just no fat in their face. So it’s a very clear cut one tissue issue. But if someone like me walks in, that’s a multiple tissue issue. I’ve got a little bit of skin elastosis, I’ve got a little bit of fat loss and rearrangement. The cranial facial skeletal support that it’s sitting on is changing, and everything’s sort of sliding around on that face. So then you could sort of figure out what needs attention most.

One interesting statistic that I think is worth sharing is that if you look at the American Society of Aesthetic Plastic Surgeons, they’ve sort of kept records on what procedures we’re doing most of, and who’s getting those procedures done. And in the statistics that came out last year, we know that Americans spent about $10.7 billion on cosmetics. We know that about $6.5 billion of that were surgical procedures, and almost $2 billion were nonsurgical procedures.

And of those, mostly injectables, skin care, I think accounted for about $2 billion as well. But baby boomers have really led the pack for many, many years now. People 51 to 64 have been those in the majority seeking treatment. But last year, they were sort of second place to Gen X-ers. So the 35 to 50-year-olds accounted for about 44%, or four million of the procedures done, whereas baby boomers accounted for only 28%.

So people are starting to realize that sort of a stitch in time saves nine. And if you do something earlier, it’s easier to fix, and it’s much more– I think it leads to higher patient satisfaction and doctor satisfaction because they’re easier. And you can use one syringe of HA or one vial of PLLA and make a big difference. And probably just sort of keep it from progressing as quickly as it otherwise would.

There’s an article that Voorhees and Fisher and Wang looked at saying– I think everybody’s familiar with this. This literature came out about five years ago. But the collagen in the skin, the fibroblasts need mature collagen to sort of stretch onto in order to make new collagen. And if they don’t have mature collagen to stretch onto, if that collagen is elastotic and fragmented from age or extrinsic aging, then those fibroblasts not only don’t produce more collagen, they produce more collagenase.

And you get yourself in this sort of deleterious, negative cycle that’s difficult to break. Meaning that once you let yourself get to a certain point of collagen loss, sunscreen’s not really going to help anymore. You could sit in a dark closet, and you’re still going to look like that old lady in Something About Mary before too long because you’re sort of– the collagenase is working faster than the collagen. So anything that gets you out of that cycle makes a big difference. And I think that earlier treatment in Gen Xers may keep us from entering that cycle even longer.

I know that there have been a lot of new techniques that have been reported recently in the literature. Tell us about some of those, different ways that you can actually inject the products.

Yeah. Well, one thing is new tools with which to inject the product. So everybody’s talking about cannulas now. And cannulas are a nice way to put in filler because they seem to be associated with much less bruising and much less swelling and much less trauma. They’re not needleless, in that you still have to use some sort of a pilot needle to make a port through which to put that canula. And they’re a little different the needles because once you put the cannula in, you’re sort of stuck in the plane that you injected it in in the first place. But the flow is very controlled.

I think there’s a French plastic surgeon named Patrick Trevidic who’s got a great video of product, HA product, coming out of a needle and coming out of a cannula of the same size. And the cannula is a much more even stream of product. And that you can literally put five or six syringes of product into a face that’s on fish oil and aspirin and get them out of the office without bruising.

And then we’re hoping that cannulas maybe improve safety. Right now, vascular occlusion is a very rare event, but it’s a terrible event when it does happen. And now that we’re putting fillers in a little bit more deeply, I think we’re seeing a little bit more vascular occlusion. There’s actually a new textbook that Joel Pessa and Rod Rorhich published that came out in December that talks about some of the anatomy of the face and how you can sort of predict underlying anatomy from what you see in the facial topography of the face.

And one very interesting point that they brought up is that creases seem to form over underlying deep vasculature, arterial vasculature. So the angular artery seems to be under the crease that folds at the nasolabial fold. The super trochlear artery is under the 11’s. And it sort of gives us a way to predict where it is and isn’t safe to place deep filler.

Placing superficially under those creases is fine, but if the arterial flow is situated deeply under those creases, then that’s probably not a good idea. We’re hoping that using cannulas will just sort of move those vessels out of the way, rather than pierce them. But that’s not really known. It’s kind of anecdotal right now. We’re going to need more studies to really prove that.

One thing that you can do with cannulas though is feel resistance. So if there’s any resistance to sort of gliding in that cannula, then you may be perforating some sort of membrane. So you might want to just back it up and move it over before you do that. But I’ve been using cannulas for about a year now. And I do have to say that it has been my experience that there’s a great deal less swelling and bruising. And that’s a very welcomed effect by patients.

Now, for the new injector just starting out, would you advise starting with cannulas, or do you think that that’s something really reserved for more experienced injectors?

You know, I think that it’s something that could be adapted by anyone. It’s just a different technique so I think a lot of these techniques, there’s many ways to put the product in. The important thing is where you put the product, and the result that you’ll get from where you put the product. And I think that that’s what I meant by anatomy informs concepts, and concepts determine technique, which determines outcome. But I think where you put it is more important than how you put it in.

I think as long as it’s a safe way to put it in, and that there’s many, many safe ways to do. I would say it’s analogous to playing piano scales. You’re kind of slow when you first start out, but two, three weeks into it, you can really go pretty quickly. So I don’t think it’s a difficult technique. I think it’s just a different way to do it.

I recently saw an article talking about a new tower technique, this idea of putting a buttress in there, into areas where you need it. Tell us about that.

That’s a really interesting technique. It’s based on the premise that if you go from the outside in, you’ve got skin, fat, then muscle that’s encased in fascia that’s mass, deeper fat, and then periosteum and bone. And that there’s not a lot of lateral play between those horizontal layers. So that if you use a vertical technique and place product going in vertically and  injecting as you withdraw, that you’re giving kind of a buttress for those horizontal layers to sort of hold on to each other and not slide as much.

We know that that fat’s compartmentalized now, right? We’ve known that for a while. And we know that there’s superficial compartments above this mass, and deep compartments below this mass. And we know that as those compartments empty, maybe some of that fat goes to the lower area of those compartments.

But they begin to separate, and you begin to see shadows. So I think that technique is reinforcing the integrity of those horizontal layers. And I think that they’re placing it as sort of osteocutaneous ligaments, the zygomaticus, and everywhere that the fascia crosses the bone and connects to the bone, where there’s the orbital retaining ligament–

So those are the key areas.

Those are the key areas, yes.

Great. This concludes another addition of dermtube JournalClub. I’m Josh Zeichner, and I’m your host. Thanks so much for watching Dr. Becky Fitzgerald discuss with us what’s new in fillers. See you next time.