The first thing that I do when a patient comes in for a skin rejuvenation consultation is to try to determine whether they need volume correction, as that is likely to give them a big bang for the buck. I look at all of the areas where volume loss causes aging changes and decide between a targeted filling of a few areas, reduction in specific wrinkles, or a broader volume restoration to larger areas of the face.
Cosmetic Skin Filler Evaluation:

1. The first areas I look at are the corners of the mouth and the creases leading down from the corner of the mouth to the chin. These “marionette lines”, that look make you look like a ventriloquist’s dummy, are the most aging changes. They appear to drag your face down and accentuates neck and jowl looseness. So the first thing I recommend is to fill those in.

2. Then I look at the lips themselves. Often they have lost volume and have radiating lines. I like to plump the lips primarily to treat the lines around the mouth. If I just inject the radiating lines, often the patient will get a “Marge Simpson” upper lip with prominence of the area above the red part of the lip. We will talk more about lips later as they are the area that have potential to look bizarre if not done properly.

3. Next are the nasolabial folds from the side of the end of the nose down to the mouth. If present, they cause a harsh appearance.

4. The cheeks have usually lost volume, causing a flat face and pushing down on everything below them. This area is often neglected in filler treatments.

5. If there are hollows under the eyes causing a tired look, we talk about fillers there.

6. Last is the temples. After the other areas are corrected, if the temples look sunken then we need to address those.

7. After I look at the entire face I decide whether we need to fill in certain areas, usually with a hyaluronic acid filler, or do a more complete, less targeted, overall filling with Sculptra.

There are a bunch of fillers available. These are the most commonly used:

• Hyaluronic Acid Fillers—Juvederm Ultra XC, Juvederm Ultra Plus XC, Restylane-L, Perlane-L
• Poly-L-Lactic acid (PLLA)—Sculptra Aesthetic
• Calcium hydroxyl apatite—Radiesse
• Fat injections
• Polymethylmethacrylate (PMMA) suspended in collagen—Artefill
• Surgical implants

I tend to stick with the hyaluronic acid fillers for targeted area and Sculptra Aesthetic for overall volume improvement. Hyaluronic acid fillers are reversible if needed, and Sculptra is great for overall volume improvement. Fat injections involve removing some of the patient’s fat and injecting it into the area to be filled. It is nice because most of us have a ready supply, but fat injections are more unpredictable with some of the fat not surviving transplantation. Also fat is less precise in placement, and causes a fair amount of swelling especially in the lips. I have seen major swelling last for 3 weeks or more. My patients won’t tolerate that. That said, some physicians do it very successfully.

Juvederm Ultra XC, and Restylane-L are for more superficial placements and Juvederm Ultra Plus XC and Perlane-L are for deeper filling. All 4 have a local anesthetic in them which decreases discomfort. All are sold by the syringe. The hyaluronic acid fillers give immediate improvement that lasts on average 1 year. At one year, more or less, we will do another treatment.

Sculptra Aesthetic is a powder that is mixed with an anesthetic and is for overall improvement. Sculptra is designed to be given over several (average of 3) treatments and lasts on average 2 years. At around 2 years most patients choose to do another treatment. Most patients do not need to do 3 treatments again at that time.

Sculptra (and to a lesser degree the hyaluronic acid fillers) are bio-stimulatory, meaning that they actually cause you to make more of your own collagen so some of the results are lasting. The improvement with Sculptra evolves over a 6 month time period so you gradually look better and better.

Fillers are my favorite procedure because they make such a difference and I enjoy the artistry of sculpting the face. I do all of the filler injections in my office. They are more difficult to get right than you might think. If you see someone and you think “wow, look at those bizarre lips” or if you can tell they have filler injections, they have not been served well. I always work to get a completely natural look, only better.

Sounds like a lot of filler injections. How much do we need?

Next: What is it going to take?