Special Feature: Choosing Filler for Younger Patients

Contouring has been a popular makeup technique for several years now.1 With the aim to define, enhance and sculpt the structure of the face, the technique allows individuals, especially popular with young females, to get the perfect snap for their Instagram account. The makeup technique, which involves highlighting and shadowing certain areas to accentuate places that naturally catch the light with concealer or highlighter, peaked in popularity in 2016.1 Although consumer magazines are predicting the trend will die down and become more focused on a natural look,2-4 practitioners suggest that many patients are turning to non-surgical treatments to make their illusion a reality. Aesthetic practitioner Dr Charlotte Woodward explains, “Patient requests for a natural contour are definitely growing and are most popular with younger patients. This is likely associated with the current selfie culture. I also find that patients are requesting a much stronger jawline, chin and other angular features like in the mid-face, something which wouldn’t have been requested previously. People are now becoming more aware that this look can be enhanced with non-surgical treatments.” When these patients present to clinic, one thing that is particularly important, Dr Woodward says, is to take a full-face approach to assessment and treatment. “It’s especially important in younger patients because they don’t usually need rejuvenation; they just want a bit more definition or volume. Quite often, young patients want one area tweaked, but practitioners need to recognise when this may make their face out of proportion, so other areas can be augmented to keep that natural balance,” she explains. To achieve successful facial contouring results, product selection is key, practitioners note, and will vary quite significantly. Aesthetics speaks to practitioners Dr Raul Cetto, Dr Beatriz Molina, Dr Sophie Shotter and Dr Woodward about what products they choose to enhance, contour and augment anatomical areas that are commonly requested by younger patients. Understanding biomimetics “When treating all patients, it’s very important for practitioners to know the rheological properties of each dermal filler they use extremely well. Depending on what you want to achieve you will use different fillers for the different areas across the face, you can’t just have one single syringe and use it in all areas,” explains Dr Molina. Dr Cetto says that this is why dermal fillers are produced to act and behave differently to each other when they are injected. He reiterates, “It’s incredibly important to have different fillers with different properties in your portfolio because every single tissue layer has different biophysical properties. You need to choose a product that will be able to mimic the properties in the layer you are injecting – it’s called biomimetics, where the filler mimics the tissues that it is restoring or replacing.”5 Generally speaking, Dr Cetto says there are five tissue layers that practitioners must consider when choosing their filler (Figure 1).6,7 As an example of how the layers can differ, Dr Cetto says, “The superficial fat layer has type 1 fat, which consists of large adipocytes that are very strong but very malleable and respond well to movement, whereas the deep fat layer, which is attached to the bone, has much smaller adipocytes and provides projection of the overlying tissues and is not subject to movement.8-10 Even though both layers are fat, they have different biomechanical properties so your filler needs to be able to mimic them for natural outcomes and your product will almost certainly need to differ.” Dr Shotter adds, “Without understanding that you need to choose different fillers with different properties according to the area and the depth you are treating, you shouldn’t be going anywhere near a needle, in my opinion. The other crucial factors for selecting products are the patient’s skin type, texture, facial properties, gender, and skin thickness. So, it’s very important to understand how your filler is going to behave in different patients.”

Dr Charlotte Woodward

Epidermis

Dermis

Superficial fat pads

Muscle

Deep fat

Bone

Figure 1: The typical layers of the facial tissues

Dr Cetto notes that for younger patients, practitioners will likely focus on the superficial planes to enhance what is already there, rather than replacing what has been lost in the deep layers. However, he says, that this isn’t essential, and treatment approaches will vary according to individual patients.

Choosing your products

Upper face To contour a forehead that is displaying a lack of convexity, Dr Cetto will use a product that has good strength that can project the overlying tissues. He explains, “It also needs to have some form of malleability and stretch because it’s a tight compartment. I like to place my product with a cannula deep onto the bone and I prefer Teosyal RHA 4. I love the whole Teosyal range because it is designed to behave very similarly and naturally to the tissues.” Dr Shotter’s approach involves using the Juvéderm range. She says, “Because the forehead doesn’t have a lot of tissue, to enhance and contour for younger patients I usually choose Volbella or Volift to achieve gentle projection and shaping rather than using anything too stiff.” Dr Molina adds, “When I am treating the forehead, I like to use a product that is soft and gentle but also malleable that will not be too think or lumpy and give a nice contour. I would usually choose Aliaxin SR to achieve this. I’d inject the product superficially using a 25 gauge TSK cannula,” she says. Dr Molina will use the same filler for the temple and will inject in a fanning technique; she thinks a cannula method is more cost effective as it prevents product wastage compared to using needle in this area. She adds, “If you want to treat using the well-known technique by Dr Arthur Swift for the temple11 then you would use a product with higher G prime. I would either choose Aliaxin EV or Restylane Volyme and inject with a needle deep onto bone.” According to Dr Cetto, there is yet to be consensus from anatomists about how many skin layers there are in the temples, which makes this area tricky in terms of filler placement. “To make the best use of my product in this large area, I will adopt a layered approach using a cannula in layers that are deemed as ‘safe’. I will do my first injection just below the temporal fusion line and behind the lateral orbital rim down to the periosteum using products which will create good projection – like Ultra Deep or RHA 4 – and I will finish by treating the superficial subcutaneous fat, just below the skin,” he says. When Dr Woodward augments the temples, she will choose a strong and firm product. “I like to use either Ultra Deep, Perfectha Subskin, or Ellansé with a needle down to bone to create volume. Whenever there are skin texture issues, I like to use Ellansé where it’s not contraindicated (lips, tear troughs and glabella), as this can improve texture, as well as shape, and augment the area. It’s important to note that this product is not a hyaluronic acid (HA), so it can’t be dissolved, but it can be much longer lasting so this can be very attractive to patients,” she explains. Dr Shotter will use a high G prime product for contouring the temple, which is stiff and provides lift. “I tend to work with a needle in this area, deeply, and try to give a nice lift at the tail of the eyebrow, so I need a product with higher lifting capacity. For this, I will choose Voluma; sometimes I may use a softer product with a cannula in a superficial plane if I need a bit more refinement,” she explains.

Mid-face The mid-face is an area that usually requires several different fillers, according to the practitioners interviewed, depending on the patient and areas for placement. Dr Cetto reminds practitioners that products that are suitable for deep injections will not be suitable for superficial injections or areas with little overlying tissue. “Injecting a deep volumising product with a high G prime into the superficial fat is how you cause that chipmunk cheek because it won’t integrate or move with the tissues,” he emphasises. Dr Cetto likes to use a layered approach when contouring the mid-face. “It’s a much more efficient way of utilising product. I use a deep volumiser, Ultra Deep, and then a superficial volumiser to enhance and contour – RHA 4. Conversely, for older patients, you likely want to focus more on the deep fat pads, which start atrophying,” Dr Cetto says. Dr Molina agrees, adding that for sculpting and contouring, good tissue integration is important. She says, “When I am treating a younger patient who is not showing signs of ageing in their deep layers, I am usually treating the subcutaneous level with a cannula to give me a good artistic shaping of the cheeks and cheekbone with Aliaxin EV because I find I get lovely contours with a natural result – I have also previously used Restylane Refyne for this. If the patient needs a bit of volume and some pillars for support, then I will inject deep with a needle using a high G prime product such as Aliaxin SV, and then I’ll put a lower G prime product over the top for a contouring effect using a cannula.” Aliaxin SV is a new product that is launching in the UK in October, which Dr Molina finds is good for contouring faces, cheekbones, jawlines and chins. “This is because it has good lifting capacities but maintains the softness of the rest of the range,” she explains. If the patient has a flat mid-face, Dr Woodward will inject Perfecta Subskin, Ultra Deep or Ellansé with a needle, deep down to the bone, in the malar groove and the alar triangle. “It’s important to always under-treat when using Ellansé because unlike hyaluronic acid you only get 85% of the results immediately after treatment but will increase over three months,” she notes. She says she will also consider overlaying RHA 4 superficially on top of the deeper injections if

Dr Beatriz Molina

Before After Before After

Figure 2: Before and after cheekbone with Aliaxin SV. Patient treated with 1ml per side.

required. Dr Shotter says that deep injections can look nice on the right young patient. “I find that Voluma, which has a relatively high G prime gives a nice shape to the cheekbone when injected deep. This can make someone look contoured without makeup, which is what many patients are looking for at the moment. To treat the superficial fat pads, I will use Volift,” Dr Shotter explains.

Nose The nose is a common concern for many young patients and, in makeup contouring, it’s possible to add highlights and shadows to alter its appearance.12 When contouring with dermal filler, firstly, Dr Shotter and Dr Cetto note that there is no dermal filler product that is licensed to be used on the nose, so all products are injected off-label. “This means that any practitioner must check with their insurance provider to see if they are covered for doing off-label treatments,” Dr Cetto advises, adding, “As the foundations of the nose are solid tissues, I like to use a product that mimics those characteristics, and for me that is the volumiser Ultra Deep as I can inject small amounts to get a great lift. For a large defect, I will use a short cannula, but for small alterations I will use a needle.” Dr Molina only ever uses cannula in the nose because she feels that it is safer to avoid vascular compromise. Dr Molina treats a lot of noses, and her product of choice can vary according to the patient. “If I want pure projection, like on an Asian nose for instance because they usually have thicker skin and are flatter compared to Caucasians, I will need a product with a high G prime and good lifting capacity. I will usually choose NASHA technology that won’t integrate and will project – Lyft is my filler of choice here, but never for thin skin as it will be visible,” Dr Molina explains, adding, “If I also want some shaping and integration, I will choose Aliaxin EV. Then, for very mild interventions I will choose Aliaxin FL; I have also used Refyne to achieve this.” Lower face Dr Molina says, “I am seeing an obvious trend of patients coming in and actively seeking jawline contouring and augmentation. I will choose my product according to how much lift I deem is necessary for the patient. For example, for a very nice, angled jawline that is very divined I will choose Aliaxin SV. For something softer, especially in females, I will choose Aliaxin EV as you will not need as much projection.” For the jawline and chin, Dr Woodward says she uses a firm product to augment. She will either use Ellansé, Perfecta Subskin or Ultra Deep in the deep layer, then overlay using RHA 4. “It’s deceiving how much product you will need in a chin and jawline to give you a very sharp contour, so make sure patients are aware of this,” she advises. Dr Shotter also likes a filler that won’t move to create a defined appearance. “When you are augmenting the jaw, I look for a product that is very stiff as you will usually be injecting onto the bone to create sharp definition. I am really liking Volux for this because it’s high G prime gives a superior sculpt and really holds its shape in this area,” she says.

Learn what products work best for you Dr Molina highlights that when contouring it’s important to choose products that will achieve natural results, and place these in the correct plane. “I think for the younger patients, it’s the soft fillers that create the most natural contours because it allows the face to move with the patient when they animate,” she says. All practitioners agree that no matter the patient’s age or facial area you are treating, you must always consider your patient’s unique facial features and requirements, area of injection, and depth before you choose your product. “I think looking at the biomimetics – the biomechanical characteristics of the tissues – is a good starting point when you are choosing your fillers,” says Dr Cetto. “Think about what product and treatment approach will suit your patient; it’s not a one size fits all, and this sometimes gets forgotten, especially by junior injectors,” adds Dr Woodward, emphasising, “I have several different filler brands, which have different properties and I think you need to pick what’s right for the patient. I like to give patients a choice, for example some want a reversible HA, but others want a long-lasting product.” Dr Molina reiterates, “Know your product inside-out and challenge yourself to learn about various brands; try a range of products so that you can pick and choose what works best for you. If you only have one filler, or even one brand, you might not be getting the optimum results for you and your injection style, so understand what your style of injecting is, the anatomy, and your patients and, if necessary, get more training to push your boundaries.”

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