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Perioral and Lips Enhancement

General Principles
Facial aging progresses as the result of both intrinsic and extrinsic contributing
factors. Over time, loss of subcutaneous fat, gravitational changes due to loss
of elasticity, and remodeling of bony and cartilaginous structures lead to visible
signs of aging. All portions of the face do not age simultaneously. With age,
repetitive muscle activity leads to fine lines that eventually become
hyperdynamic wrinkles, which may deepen and ultimately remain apparent
even when the muscles are at rest. Photodamage and smoking both accelerate
these changes, with photoaging being the single most important contributor to
the appearance of aging skin, including its texture and pigmentation.
Ana¬tomic challenges must be considered in a comprehensive strategy for
perioral rejuvenation, and aging affects the lower face at all levels from the
bone to the epi¬dermis. Due to the numerous factors contributing to the visible
signs of aging, facial rejuvenation is likely to be best served by a multipronged
approach that include; movement control, recontouring, and volume
restoration. In order to prescribe an appropriate treatment plan, it is essential
to have a thorough understanding of both perioral anatomy and perceived signs
of aging.

Lower Face and Perioral Anatomy

Before reviewing the more popular treatments for perioral rejuvenation, an
understanding of the anatomy and the aging process is warranted. The perioral
region has classically been defined as the area located between the subnasale
and menton or the lower third of the face. Laterally, the perioral region
occupies the middle three fifths of the face. The perioral region is bounded by
the nasolabial creases supero-laterally, the labio-mental crease caudally, and
the nasal base cephalically. Within this region, the upper lip projects more
anteriorly than the lower lip and occupies approximately one third of this area.
Key landmarks in the region are the philtrum, philtral columns, cupid’s bow,
vermillion border, nasolabial folds, and labiomental folds. The lower third of the
face is divided again into thirds, with the upper one-third extending from the
subnasale to the stomion and the lower two-thirds extending from the stomion
to the menton. The oral commissure lies within a vertical plane drawn from the
medial limbus of the iris. The lips should meet on repose. The muscles of the
perioral region are arranged in distinct patterns, and there are various
classification systems. Group I muscles enter the modiolus, which is the area of
convergence for the tendinous fibers of muscles entering the lip. Group II
muscles enter the upper lip, and Group III muscles enter the lower lip. The
orbicularis oris, levator anguli oris, depressor anguli oris, risorius, zygomaticus
major, incisivus superioris, incisivus inferioris, and buccinator muscles comprise
the Group I muscles. Group II muscles enter the upper lip as a flat sheet, and
their fibers run at right angles to the fibers of the orbicularis oris. These
muscles include the levator labii superioris, levator labii superioris alaeque nasi,
and zygomaticus minor. Group III muscles include the depressor labii inferioris,
mentalis, and platysma muscles. As a group, these function opposite to the way
the Group II muscles work for the upper lip. The nasolabial fold is produced by
four muscles: levator anguli oris, levator anguli superioris alaeque nasi,
zygomaticus major, and zygomaticus minor. The labiomental fold is produced
by depressor anguli oris and the mandibular ligament.

A key anatomic feature of the upper lips is the Cupid’s bow complex, formed by
two high points of the vermillion joined by a V-shaped depression centrally. The
upper lip usually has 75% to 80% of the lower lip volume with raised philtral
ridges. Ideally, in the youthful face, the upper lip projects minimally more
anteriorly than the lower lip. The lower lip shows fullness in the central portion.
The white roll refers to the raised line of skin that separates the cutaneous and
red lip; it is prominent in youth. Aesthetically, 2 to 3 mm of the upper incisors
may show in repose, but the full length of the incisors should show while
smiling. Sensory innervation of the upper lip comes from the superior labial
and superior alveolar nerves, which are divisions of the infraorbital branches of
the maxillary (V2) nerve. The mandibular (V3) divisions of the trigeminal nerve
give rise to the inferior alveolar nerve, of which the mental nerve is the branch
supplying the lower lip and chin. Blood supply is derived from the inferior and
superior labial branches of the facial artery. The angular artery (off of the distal
facial artery) extends along the pyriform aperture and gives off branches. An
understanding of the perioral region’s structural anatomy allows the surgeon to
choose the most appropriate and long-lasting treatment, whether that is
surgery, soft tissue fillers, fat grafting, skin resurfacing, or some combination of
these techniques.

Perioral Imperfections
A careful examination of the perioral region may disclose one or several flaws.
The area should be examined thoroughly to catalog these deformities first,
although the majority of lip atrophy occurs with aging, hypoplastic lips can also
be present in young patients. For these patients, the goal is to augment or
increase volume. Second, patients could present with a descended stomion or
elongated upper lip. Assessment of facial proportions is critical to identifying
this imperfection. Third, it is important to make note of prominent radial
wrinkling of both lips, which can be particularly noticeable on the upper lip. The
physician should differentiate between dynamic lines (which appear only or
mostly on animation) and static lines (which are present constantly). Fourth,
patients may have a “downturned” or sad appearance to the creases and folds
in the oral commissure area. Fifth, the depth of the nasolabial crease is
important, and any asymmetry should be noted.
With the patient smiling, the amount of maxillary incisor show should also be
checked. Again, an optimal amount of incisor show is 2 to 3 mm. Less tooth
show is suboptimal, and more than 3 mm can be displeasing. The amount of
tooth show changes with age, and an inadequate tooth show should be
corrected to rejuvenate the face. Patients with excessive incisor show can be
referred to as having a “gummy smile.” These patients expose a broad strip of
maxillary gingiva above the teeth when smiling. This exposure could be due to
excess maxillary length or may be the result of a short or hypoplastic upper lip.
Correction of this exposure involves lip augmentation, maxillary intrusion
osteotomy, or lip lengthening with or without augmentation, depending on the
dysmorphology. Another cause of a gummy smile is hyperfunction of the lip
elevators, which can be surgically corrected through lip elongation with or
without rhinoplasty to correct the anterior nasal spine and depressor septi nasi
muscles. In addition, delayed passive eruption is a developmental problem of
the teeth, which can result in an excess amount of gum covering the dental
crown. This is particularly evident in dynamic motion. Gingivectomy and
vestibuloplasty can correct this, and these are usually performed by a cosmetic
dentist or oral maxillofacial surgeon.

Who Need Perioral Enhancement?

Despite the cardinal role played by perioral aesthetics in facial youthful
appearance, minimal attention has been paid in the literature to correcting
dysmorphologies of this region. There are two categories of patients who seek
aesthetic improvement in the perioral area. In the younger patient, lip
augmentation, lip shortening, or lip elongation can be applied singularly to
enhance and harmonize the appearance of this area. In the older patient, skin
changes (including dynamic and static lines), the tilt of the oral commissures,
and lip ptosis all play a major role. Aging also may result in dyschromias.
Volume loss and gravity can lead to an exaggerated depth of the nasolabial
creases or marionette lines. The lips become thin, losing “crispness” in their
white roll and philtral columns, and the surrounding skin loses its subcutaneous
fat, allowing accentuation of the fine wrinkles resulting from repetitive
orbicularis oris action. Ptosis of the malar fat pads lateral to the nasolabial
creases combined with thinning of the skin over the creases draws attention to
the aging perioral area, making depth over the nasolabial crease an issue to
contend with during treatment. Because traditional rhytidectomy techniques
often do not sufficiently address the perioral area, patients may be disappointed
postoperatively about an imbalance of the face or insufficient improvement.
Recognizing the changes that occur with aging in the perioral area and
subsequently exercising the options available to rejuvenate the lower face are
necessary to providing optimal facial harmony. The muscular balance is more
complex than in the upper face with major muscles working sometimes as
agonists and sometimes as antagonists. Any shift with treatment can adversely
affect the functioning of the entire facial area and compromise functions of the
perioral musculature, such as facial expression, oral sphincter, and articulation
inducing unwanted effects frequently cosmetically and functionally distressing.

Neuromodulator Botulinum Toxin A (BoNT A)

To define the lower face treatment plan, a thorough clinical examination must
be performed, including the evaluation of the dynamic interaction between
muscles. In-depth questioning of patients must be conducted to clarify patient’s
treatment goals. The following new treatment approaches are part of current
practice: treatment of several areas of the face at the same or subsequent
sessions, treatment combining fillers, treatment of masseter muscle
hypertrophy, and preventive treatment of lines and rhytides. As part of the
multimodal treatment approach, botulinum toxin improves efficacy and extends
the longevity of temporary fillers. Its combination with various aesthetic
procedures (laser treatments, chemical peels, and surgery), before and while
the improvement effects of these treatments are expected to occur, helps to
maintain a less mobile dermis, and may produce a more uniform improvement
of the treated areas.

1. Nasolabial Angle and Repositioning of the Nasal Tip

An acute nasolabial angle can lead to a droopy nasal tip. Muscles involved in
this condition are the paramedian part of the nasalis muscles: the transverse or
compressor part (also known as compressor naris), constricting the nostril, and
the depressor septi nasi, shortening the height of the upper lip and drawing the
nasal tip toward the upper lip. The levator labii superioris alaeque nasi muscle
also contributes to the elevation movement of the upper lip and nasal ala, and
retracts the nasolabial angle. Onabotulinum injections into the depressor septi
nasi (at the level of the bone nasal spine) can provide a small benefit. However,
Prof Moawad warned not to expect, or lead patients to expect, very marked
morphological changes and to restrict treatment to patients with a
hyperdynamic nasal tip.

2. Dilated Nostrils
Dilated nostrils, not aesthetically pleasing, are caused by the contraction of the
dilator naris muscle, the alar part of the nasalis muscle, in certain situations of
anger or emotional upset, with increase in breathing efforts during mild
exercise (to reduce resistance to flow of air) and also as a habit. Onabotulinum
has rare indications: anatomical abnormalities related not to aging but to the
hyperactivity of the dilator muscle or specific pinched nostrils cases secondary
to surgical rhinoplasty. Treatment is geared to the nostril dilator muscles and
leads to relax nostrils for 3-4 months and keep the cartilage graft in a good
position in the nostril.

3. Marionette Lines, Upturn of the Oral Cimmisures(Depressor Anguli

Oris)
The depressor anguli oris (DAO) is a very important muscle that influences the
way we are seen by other people. The (DAO), extending inferiorly from the
modiolus to attach into the inferior margin of the mandible on the lateral aspect
of the chin. It can usually be easily palpated when the patient is asked to
contract this muscle. In addition, platysmal bands can increase this downward
effect. Constant hyperactivity might lead to deep furrows or Melomental folds
drawing down the corners of the mouth, which will lead consequently to an
overall sad, slightly depressed impression and have traditionally been treated
with soft-tissue augmentation alone. An anatomo-morphological study showed
that the optimum injection point is situated at the inferior third of the DAO,
below the mental foramen. It is safer to inject very superficially, more
externally, and lower to avoid any effect on the DLI muscle. Since the DAO
overlies the depressor labii inferioris (DLI), direct injections lead to usually
asymmetrical paresis. Instead, we inject 3 to 5U at the level of the mandible
but at its posterior margin, close to the anterior margin of the masseter, which
will significantly weaken, rather than paralyze, the muscle. Injections should be
done bilaterally in a point above the mandibular angle in an imaginary line that
follows the direction of the nasolabial groove. In case of preexisting
asymmetries, doses are adjusted accordingly on each side. The combination of
soft-tissue augmentation and BTX-A injected into the DAO will lengthen the
duration of the augmentation. Moreover, some individuals have congenital or
acquired unilateral weakness of the depressor anguli oris muscle, resulting in
an inability to depress the corner of one side of the mouth. In this case as well,
botulinum toxin treatment of the partner muscle restores functional and
aesthetic balance.

4. Mouth Frown
It is important to remember that the effect of BTX-A on one muscle often has
an effect—positive or negative—on another. A good example of this is the
‘‘mouth frown,’’ the permanent downward angulation of the lateral corners of
the mouth, which is caused by the action of the DAO and the upward motion of
the mentalis. We have found that attempts to weaken the DAO or mentalis
alone, while appropriate in some individuals, is ineffective or associated with
unacceptable side effects in others. We currently inject both muscles at the
same time—3U of BTX-A into each DAO and into each side of the mentalis, to a
total of 12U in a female patient—which produces a subtle, synergistic effect.
However, this technique should only be used in patients who have experienced
the effects of BTX-A injections elsewhere, and who are aware of the aim of
treatment and its possible outcomes.

5. Lip and Perioral wrinkles

The lips and the perioral region have an important role in the aesthetic balance
of the face. The perioral muscles act in concert to achieve the extraordinarily
complex movements that control facial expressions, eating, and speech. During
aging, the lateral portions of the lips recede, resulting in a ‘‘rosebud mouth.’’ At
the same time, the distance between the columella and the vermilion border of
the upper lip increases and the substance of the vermilion rolls inside,
producing the thin and disappointed lips that are characteristic of old age.
Perioral muscles, responsible for the perioral wrinkles, are the levators and
depressors with close anatomical interdependence and important functions. The
orbicularis oris is a circular muscle with upper and lower lip contributions and
deep and superficial fibers. Its primary function is the direct closure of the lips;
deep fibers apply lips to the alveolar arch close to the teeth and bring lips
together, while contractions of superficial fibers protrude lips forward. By
exerting a constant pull on the upper and lower lips, this muscle ultimately
forms outwardly radiating perioral lines, sometimes called lipstick lines or
smokers’ lines. Dense vertical perioral rhytides are often associated with the
lengthening of the cutaneous upper lip during aging. These vertical lines can
result from heredity, photodamage, playing a musical instrument that requires
embouchure, or even whistling. Patients often are disturbed by the increased
vertical length of the cutaneous lip and by the radial upper lip lines that can
cause lipstick to bleed upward from the lip and blur the outline of the lip.
Vertical lines of the upper lip are a strong sign of aging. Even when using an
injectable filler some of these lines might remain. This area is delicate to treat
because surrounding muscles are involved in key body functions (mastication,
deglutition, and articulation of sounds) and in facial expressions, and because
the lips are quintessential to the appearance of the lower face.

The modiolus is the insertion site of six perioral muscles interweaving their
fibers at the angle of the mouth: The zygomaticus major originates from the
lateral aspect of the malar bone, and with the levator, and oris acts to dilate
the mouth and elevate the labial commissures bilaterally to smile and
unilaterally to sneer. The levator labii superioris and zygomaticus minor insert
onto the skin at the melolabial fold and in the orbicularis oris muscle fibers of
the upper lip and together they help dilate the mouth, retract and Evert the
upper lip, and deepen the nasolabial sulcus. The risorius dilates the mouth and
widens the rima oris. The depressor anguli oris dilates the mouth and
depresses the labial commissures bilaterally to frown. The buccinators muscle,
a deep lateral muscle, pulls back the angle of the mouth and flattens the cheek,
holding it to the teeth during chewing. The depressor labii inferioris originates
from the platysma and inserts onto the skin of the lower lip. This muscle is
partially responsible for dilating the mouth and depressing and everting the
lips.

Treatment of lips and perioral area is indicated to prevent lip aging damages
and dynamic lip rhytides. Vertical aging lip rhytides or smokers’ lines, amenable
to treatment with onabotulinum, are one of the most common areas for which
patients request treatment. A hyperactive orbicularis oris muscle is partly
responsible, but other muscles play a role. This procedure is rarely carried out
in isolation but in association with other treatment modalities. Key patient
management considerations are, when the upper part of the orbicularis oris
muscle is treated, it is advised to also treat its lower part to balance the
proprioception of decreased muscular contraction strength, including during
reflex contractions. One must be cautious of not altering muscle function.
Patient selection is critical: abstain from treating singers, musicians and,
generally speaking, all patients who make intense use of their perioral muscles.
Caution must be exercised in case of tall superior lips.

The aim of treatment of the upper and lower lip is a reduction of these
unsightly wrinkles. Carefully measuring the sites to balance on either side of
the columella or the lateral nasal ala. Appropriate patients must be chosen
carefully, as those who play wind instruments or professional singers/speakers
are not ideal candidates. It is essential that BTX-A injections should achieve the
desired cosmetic result with the minimum dose without any functional
discomfort. BoNT A Injections points should be done at the vermillion border,
parallel to the lips and at least 1.5 cm away from the mouth corners. The total
dose should be distributed in four to six points, being four at the upper lip and
two at the lower lip. Low doses and superficial injections are preferred to avoid
functional impairment of the lips. The patient is asked to pucker, and the areas
of muscle contraction adjacent to the lines are marked. The recommended
concentration is 1.0 to 2.5 U/0.1 mL, and volumes of 0.025mL or less are
injected per site. The injection is made either intramuscularly or
subcutaneously, just above the muscle. Small doses (1–2U per lip quadrant)
are usually sufficient to weaken the orbicularis oris without causing a paresis
that could interfere with elocution and suction, especially when used in
combination with a soft-tissue augmenting agent.

6. Facial Asymmetry
Correcting facial asymmetry may appear an almost miraculous application of
onabotulinum, particularly for patients who cannot undergo (or do not desire)
major surgical procedures Asymmetries may be caused by bone elements or
soft tissue, or originate from neurological or muscular causes. The two latter
categories can be classified into hyperfunctional (e.g. hemifacial spasm) or
hypofunctional (e.g. facial palsy). BTX can be used for the correction of
asymmetries of neurological or muscular origin. In hemifacial spasm, repeated
clonic and tonic facial movements draw the facial midline over toward the
hyperfunctional side. Botulinum toxin relaxation of the hyperfunctional
zygomaticus, risorius, and masseter allows the face to be centered at rest.
Hypofunctional asymmetry, such as after a unilateral seventh nerve paresis
(Bell’s palsy), can be alleviated by botulinum toxin treatment of muscles on the
normofunctional side. For zygomaticus muscle BoNT A is injected at the
intersection of the line passing through the external canthus and the modiolus
and of the horizontal line passing through the columella nasi. 1=2U/side
subcutaneous injection (depth of 2–3 mm) at a 30_ angle upwards and
outwards alongside the muscle axis. Injections of only 1 to 2U of botulinum
toxin in the zygomaticus, risorius, and orbicularis and 5 to 10U in the masseter
are sometimes required. Likewise, some patients have congenital or acquired
weakness of the DAO, resulting in the inability to depress the corner of one side
of the mouth; chemodenervation of the partner muscle restores functional and
aesthetic balance. Some patients have asymmetric jaw movement. We have
found that an intraoral injection of 10 to 15U of botulinum toxin into the
internal pterygoid on the hyperfunctional side can relax the jaw and relieve
discomfort during masticating and elocution. For physicians not thoroughly
comfortable with facial surface anatomy, we recommend injection through an
EMG system. Treatment should be implemented carefully, with low doses, and
stepwise.

7. Asymmetric Smile
Injections of BoNTA are a simple, noninvasive, and safe way to correct
asymmetric smile. Asymmetric smile can be the result of hyperkinesis of the
depressor labii inferioris m. or a segmental weakness of the levator labii
superiors m. The number of points and total doses are defined individually
according to the muscle involved. Results become evident in less than 5 days,
and the effects last from 4 to 5 months after the first treatment. In subsequent
treatments, it is recommended to reduce the doses, and the results last usually
longer.

8. Risorius muscle (labial paracommissural wrinkles)

Surgical or traumatic lesion of the orbicularis oris or the risorius muscle can
result in the mouth being pulled off center by the unopposed action of the
partner muscles in the normally innervated side. Botulinum toxin
chemodenervation of the risorius immediately lateral to the corner of the mouth
on the normally innervated side will recenter the mouth when the face is in
repose. The risorius is responsible for smiling or grimacing. If hyperdynamic, it
may result in an unwanted or unintended negative expression. Treatment of the
thin labial paracommissural wrinkles must be careful and limited to patients
with tonic skin and dynamic wrinkles not related to sun damages. 2U/side at
2cm on a horizontal line from the corner of the mouth is injected deep in the
subcutaneous (3-4mm) with injection angle 30 . This is followed with high fluid
hyaluronic acid fillers in thin layer with cross hatching technique 2 weeks later.

9. MENTAL CREASE and Dimpled or “cellulitic” Chin (“peau d’orange”)

The mentalis muscle raises the chin, produces a deep horizontal groove (mental
crease), between the lower lip and the prominence of the mandible, elevates
and protrudes the lower lip, and elevates the skin of the chin. These facial
animations express sadness, anger, disdain, or doubt. Over time, collagen and
subcutaneous fat loss in the chin, loss of definition around the mandible, in
conjunction with the hyperactivity of the mentalis, cause a pebbled appearance
with skin wrinkles called ‘‘peau d’orange’’ (orange skin or pebbly chin or
dimpled chin) and contribute to the exaggeration of the mentalis crease. Soft-
tissue augmentation in the mental crease has proven largely unsatisfactory,
with visible beading and overall poor results. Softening of the mental crease
can be achieved by injecting the mentalis, just anterior to the point of the chin.
We inject 3 to 5U into each side of the midline under the point of the chin, just
anterior to the bony mentum, rather than injecting centrally. Care is taken not
to inject at the level of the mental crease, since this will also weaken the lower
lip depressors and orbicularis oris and cause serious adverse effects that can
persist for six months or more, depending on the dose. Again, as in the perioral
area, weakening, rather than paralysis, is the aim of treatment.

10. Gingival smile (Gummy) (GS)

Of all the human facial expressions, the smile is probably the most pleasing and
the most complex in terms of meaning. Although it has long been the motive
for artistic and philosophical debates, the smile, from an anatomic and
physiologic standpoint, is the result of the exposure of the teeth and gums
during the contraction of the muscle groups in the middle and lower thirds of
the face. The smile itself and the aesthetics of the smile are influenced by 3
components: teeth, gums, and lips. An attractive smile depends on the proper
proportion and arrangement of these 3 elements. The upper lip should
symmetrically expose up to 3 mm of the gum and the gum line must follow the
contour of the upper lip. The exposure of more than 3 mm of the gum during
the smile is known as gingival or gummy smile (GS). Excessive display of
gingival tissue during smile is an aesthetically unpleasant condition known as
‘‘gummy smile’’ or ‘‘show’’, partially related to the hyperactivity of the upper lip
elevator . Muscle involved in the appearance of gummy smile includes LLSAN,
levator labii superioris alaeque nasi; ZM, zygomaticus major; ZMi, zygomaticus
minor. For some patients. Excessive gingival exposure may be anterior (Major
gum exposure ([3 mm) in area between canine teeth, posterior (Major gum
exposure ([3 mm) posterior to canines, with normal exposure (3 mm) in
anterior region, mixed (Excessive gum exposure in both areas(anterior and
posterior), or asymmetric (Excessive or more apparent gum exposure on one
side only)and each one has variable degree of involvement of different
muscles..

GS represents an aesthetic disorder and therefore various correction methods

are proposed, including gingivoplasty, orthodontic treatment, orthognathic
surgery, and bone resection. As they are highly complex procedures involving
moderate to severe morbidity, high cost, and considerable time, they have
become less frequently recommended. By contrast, the use of botulinum toxin
(BT) represents a simple, fast, and effective method for the aesthetic correction
of GS. The use of BT for the treatment of GS can be considered remedial (when
the cause of GS is exclusively muscular), adjuvant (when there is an
association of causes and indication of additional treatments such as lip
augmentation or orthodontic devices), or palliative (when definitive surgical
treatment is recommended). Careful case selection, BTX-A may be an effective
treatment alternative for patients with excessive gingival display caused by
hyperactive lip elevator muscles. For this purpose, a dose of 2.5 units BTX-A
should be injected at two sites per side (a total of four sites) in both
overlapping points of the right and left LLSAN and LLS and the LLS and
zygomaticus minor (Zm) muscle sites. These three muscles converged on the
area lateral to the ala. The three vectors passed near a triangular region
formed by three surface landmarks. The center of this triangle, named the
‘‘Yonsei point,’’ was suggested as an appropriate injection point for BTX-
A. Owing to muscle interplay in this area, conservative treatment is essential.
Limit treatment indications to cases with a formal request of patients,
presenting with levator labii muscle hyperactivity and lips with short height,
having undergone a thorough orthodontic and morphologic evaluation prior to
treatment. The adverse events most commonly reported after application of BT
to fix GS are ptosis or stretching of the upper lip (‘‘joker-like’’ smile),
asymmetric smile, and difficulty smiling or chewing.

11. Masseters and lower face reshaping

The masseter, one of the four muscles involved in mastication, closes the jaws
during chewing. Masseter hypertrophy, an asymptomatic enlargement of one or
both muscles, may lead to a square jaw contour. Whether it is congenital or
acquired, a developed masseter muscle makes the face look wider. This is bad
for women esthetically, because a square face gives a masculine image. From
the view of an esthetic standard, it is more desirable for the bigonial distance
(width of lower face) to be narrower than the bizygomatic distance (width of
mid-face). The classical standard bigonial to bizygomatic ratio was 9:10, but a
narrower bigonial distance has become preferred in recent years. The size of
the mandible, the volume of muscle that surrounds the mandible, and the
subcutaneous fat tissues determine the width of the lower third of the face. In a
case of overdeveloped mandible, it can be corrected by bone resection, and
excessive fat tissues can be removed by liposuction. However, if the main
factor is masseter hypertrophy, a treatment for the masseter muscle itself is
essentially needed. The masseter muscle is divided into superficial and deep
portions. The former is larger than the latter and located outside the latter.
Varying degrees of success have been reported for some of the treatment
options for masseter hypertrophy, which range from simple pharmacotherapy
to more invasive surgical reduction.

Injection of botulinum toxin type A into the masseter muscle is generally

considered a less invasive modality and has been advocated for cosmetic
sculpting of the lower face Treatment of masseters muscles with onabotulinum
is quite safe and indicated in two types of conditions: (i) a therapeutic
indication for bruixism and (ii) an aesthetic indication aiming at facial
triangulation. For both morphologic and aesthetic indications, several
consecutive treatment sessions are required to obtain masseters muscle
hypotrophy. In general, the injection is given to the thickest region of the
masseter muscle. However, it can be more easily delivered if a few reference
lines are defined by palpation. Before injection, the anterior and posterior
margins of the masseter muscle are identified by palpation. Then, a rectangular
area is designated by linking the lower border of the mandible, the ear lobe–
mouth corner line, and the anterior and posterior borders of the masseter.
Injection must be given to three different points that are 1.5cm away from the
border of the mandibular angle, i.e. one point where the muscle is thickest and
two other points that are located anterior and posterior to the center in a
triangular manner. The center point must be given 50% of the normal dose.
Then, two points located anterior and posterior to the center must be given
25% each. If patients undergo the injection during clenching, they will feel
more pain than during the resting state. Accordingly, patients should be relaxed
prior to the treatment.

12. Botox Treatment of Bruxism

Bruxism, a diurnal or nocturnal para-functional activity that includes tooth
clenching or grinding, can result in several orofacial lesions, such as tooth wear,
periodontal lesions, temporo-mandibular joint disorders and muscle pain.
Although several therapeutic modalities have been employed, including oral
splint, medications and behavioral approaches, none has been reported to be
fully effective. Taken together, botulinum toxin injections can reduce the
frequency of bruxism events, decrease bruxism-induced pain levels and satisfy
patients’ self assessment of the effectiveness on bruxism. Botulinum toxin
injections are equally as effective as nocturnal oral splint for bruxism.
Furthermore, botulinum toxin injections at a dosage below 100 U of the
masseter or temporalis muscles for otherwise healthy patients are safe.

13. Platysma (Vertical Bands and Horizontal Lines)

Volume loss and sagging represent the main damages in the lower face and
neck with loss of subcutaneous fat, gravitational changes because of loss of
skin elasticity, downward pull exerted by platysma muscles, and remodeling of
bony and cartilaginous structures. These changes lead to ptosis and jowls
formation with loss of chin and jaw line definition and to accentuation of
horizontal and radial neck lines. Platysma is a broad, thin, and superficial
muscle covering the neck’s anterolateral aspect. Contraction of the entire
platysma complex produces a slight wrinkling of the neck skin in an oblique
direction, pulls the skin overlying the clavicle upward and its anterior portion
the thickest part of the muscle, depresses the lower jaw, depresses slightly the
lower lip, partially opening the mouth, and pulls mouth commissures downward
and laterally. In the course of the aging process, horizontal (necklace) lines
form on the neck, and the platysmal bands become more prominent because of
persistent platysmal activity to support the sagging neck and mouth floor
structures, and to loss of skin tone and elasticity. The distinct submental and
subplatysmal fat depositions also play a role in the aging pathophysiology of
the neck. Banding occurs with aging and changes in the submental space. Its
contraction may result in horizontal wrinkles and vertical bands, not only in the
cervical region, but also in the décolleté area. Although most of neck wrinkles
are related to photoaging and skin laxity, BoNTA can be an efficient and safe
treatment to neck aging. It acts by producing a partial paralysis of the anterior
part of the platysma m., softening the vertical platysmal bands. Ideal patients
for this indication should have a thin and good skin elasticity, and little or no fat
or sagging skin.

a) Vertical Bands
Injections should be placed into the deep dermis and not subcutaneously as the
risk of hitting deep venous perforations or other cervical muscles increases as
injections are situated in more profound planes. Usual number of injection
points is 2–12 bands and 10–30 units for total starting dose.

b) Horizontal Neck Lines

Two or three horizontal necklace lines of skin indentation often grace the
slightly younger, chubbier neck. These lines are caused by the superficial
musculoaponeurotic system attachments in the neck. We feel that the simplest
approach is to ‘‘dance’’ along the lines injecting small doses of botulinum toxin
over multiple sites. Aliquots of 1 to 2U are injected in the deep intradermal
plane at approximately 1-cm intervals along the horizontal neck lines to soften
and erase them. We usually inject no more than 15 to 20U of botulinum toxin
for horizontal lines per treatment session. If the neck is gently massaged
afterward, the skin usually does not bruise.

Onabotulinum works on hyperactive muscles lines, i.e., on platysmal bands.

Because of a highly variable efficacy, patient selection is critical: patients must
have retained a satisfactory skin elasticity in the neck and have only minimal
descent of submental fat. Young patients respond much better to treatment
because of the integrity of their retaining ligaments; similarly patients having
undergone lower facial surgery with residual banding are good candidates.
When injecting the neck with botulinum toxin, to prevent injury to important
blood vessels, nerves, and deeper cervical structures and to minimize
complications, it is important to avoid the pharynx and sternocleidomastoid
area and to keep injections superficial. Too deep injections may affect
infrahyoid muscles causing dysphagia or dysphonia. Similar unwanted effects
and anterior neck muscle weakness may be seen with too high doses. The
treatment of the platysma muscle with botulinum toxin has no proven lifting
effect on the facial contour, is inefficient on neck horizontal lines, does not
improve skin laxity and fat deposits, and is not a substitute for surgery.

14. Nefertiti lift (Jawline)

Although there is well-documented evidence for the efficacy of BTX-A in the
correction of platysmal bands, little work has been performed to explore its
potential role in rejuvenation of the jawline. To date, effects in this area have
been reported as a consequence of platysmal banding treatment and are
inconsistent. Hesitancy to explore treatment may be because of evidence of a
greater, more durable response to the toxin in the lower facial muscles as well
as reports of increased potential migration and subsequent side effects.
However, BoNT A injection at the jawline (Nefertiti lift) is a minimally invasive,
effective and acceptable alternative for those patients seeking an effective way
to push back surgery.
15. The wrinkles soothing of Intradermal Injection of BoNT A
Recently, through personal experiences, some Asian physicians have noted a
face-lifting effect observed after intradermal injection of BTA to the mid- and
lower face. The effect has been claimed to be caused by increased collagen
synthesis. BTA showed moderate but significant wrinkles soothing effect on the
lower face for 8 weeks at least without prominent side effects. There are two
possible mechanisms behind this process including blockade of facial expressive
muscles and neocollagen synthesis.

Perioral Soft Tissue Augmentation

Traditional rejuvenation techniques relied on surgical excision of skin, muscle,
and fat. Further advances in lifting procedures, specifically, the superficial
musculoaponeurotic system lift and midface lift, allowed significant
improvements in volumetric repositioning and contouring of the aging face but
did not address soft-tissue atrophy. Lifting atrophied tissues improved contour,
but overall facial volume was not restored. New techniques for volume
restoration have resulted in treatment moving toward a global, 3-dimensional
and multi-site approach comprising muscle relaxation, filling, and volumizing.
As a result, both two-dimensional dynamic and three-dimensional volumetric
anatomical changes need to be treated to achieve consistent, effective, and
aesthetically desirable results : botulinum toxin handles the dynamic changes
by immobilizing the muscles responsible for hyperdynamic facial lines,
smoothing, and shaping the face; volumetric changes can be handled surgically
or treated with nonsurgical reshaping (tightening) or refilling (dermal fillers or
fat grafting. S

Surgeons have better appreciated the need for volume restoration of the lower
face and perioral area as part of an overall rejuvenation strategy. With years of
clinical experience in face and neck aesthetic treatment, the widespread use of
onabotulinum and soft-tissue fillers has brought a better understanding of the
components of lower face aging and of the muscular balance, and has
profoundly affected its clinical management. There are several categories, of
patients that require volume restoration to correct their defects. The primary
patient who ages by a diffuse loss of facial fat without any apparent residual
skin is an ideal candidate. These people look like someone let the air out of the
tire and the skin hangs only because of a relative excess.

Autologus Fat Grafting, Microlipoinjection, Fat Transfer

Why Autologus at/collagen is superior to synthetic materials?

Autologous fat grafting meets all of the fundamental criteria of ideal
augmentation materials: availability, low antigenicity, minimal donor morbidity,
reproducible, predictable results, and avoids non-auto graft disease
transmission or incompatibility, not likely to illicit immune response, least
reported complications and longer survivability. Considering these facts,
autologous fat transfer provides a very appealing resource for soft tissue
volume augmentation in both small and large volumes. Prof. Moawad and many
others insist on the dynamic unique quality of fat as it will age as we age. This
unique quality of fat is perfect in soft tissue augmentation since facial
structures changes as we age and a permanent filler will be out of proportion if
used. Furthermore, fashion and trends changes, and what is accepted now as
beautiful may be not accepted at all later on. The best of all is fat grafting is
forgivable while the mistake of permanent filler is permanent!!! ,” Prof Moawad
says. Although many surgeons have approached fat grafting as the only correct
method to rejuvenate the face (and have demonstrated wonderful results by
doing so), Prof Moawad contend that fat grafting can serve more effectively as
a complement to other rejuvenation techniques. Prof Moawad advocate using
the appropriate combination of procedures to arrive at the most targeted
solution to the problem at hand. Using fat grafting as a complement to
traditional rejuvenation procedures can possibly enhance patient satisfaction
and reduce morbidity associated with aggressive fat grafting alone. For
example, fat grafting could then be combined simultaneously with face-lifting to
enhance the midfacial, periorbital, and prejowl depression to attain an overall
improved aesthetic result. We have had extensive experience with facial fat
grafting. The only relative drawback of fat injection has been the resoption of
some of the fat graft, and often unpredictable volume maintenance. There are
multiple variables that ultimately impact the survival of fat grafts in various
anatomical regions of the face. Through recent improvements in procurement,
processing, and infiltration, autologous fat has become reliable once again. In
my opinion the Disputes about longevity and the technique variation has
postponed the announcement of fat as the perfect filler, added Prof. Moawad.

Nevertheless, its use remains relatively limited compared to commercial fillers,

although few fillers display the versatility, endurance, and safety profile of
autologous fat. It also appears that surgically trained and oriented cosmetic
practitioners are far more likely to use fat, and often as a complement to other
surgical procedures such as face–neck lifts and blepharoplasty. In sheer
numbers, less surgically aggressive dermatologists, and now a wide array of
non-surgically trained “cosmetic practitioners” – not to mention non physician
“extenders” such as physician assistants and nurse practitioners, and even
simple registered nurses – inject the bulk of commercial filler. While synthetic
fillers can smooth out wrinkles and folds, it cannot restore fullness that is
naturally lost as fat and bone diminish and it is not for everyone. Some
individuals are allergic to synthetic materials and may develop an allergic
reaction. Furthermore, synthetic materials can not be used in large quantities
to restore facial deformities due to high cost, making fat grafting a much more
desirable and economical treatment option.

Who is the Best Candidate for Fat Graft? (Patient Selection)?

Autologous fat transfer has come to be recognized as an important, if not
indispensable, tool in the facial aesthetic surgeon’s armamentarium. A simple
analogy to understand the benefits of fat grafting is looking at a full and ripe
grape that becomes prune-like (wrinkled, puckered) over a period of time like a
convex, youthful face that undergoes contraction and involution with age.
Rather than remove what appears to be redundant tissue and transform that
raisin into a pea, perhaps it would be better to re-inflate that tiny raisin back
into a grape. Fat grafting could be considered ideal for those areas where you
really need a lot of filler, such as in those patients who have full-face
lipoatrophy. Individuals who are allergic to bovine collagen (animal origin) or
other synthetic materials, but want youth-enhancing results, are good
candidates for fat transplantation.

Patient selection plays a vital role in success or failure of any procedure. It

never pays to operate on patients with unrealistic expectations, as they are
never satisfied with the outcome. It is vital to have detailed history including
their past, personal, and psychiatric history. In people with severe depression,
facial outlook acts only as a part of the problem and probably will only help but
not treat the cause of depression. It is noticed during consultation that some
patients are not sure what the most appropriate procedure is for them. For
those and others the procedure should be explained to them in nonmedical
terms, along with its potential complications and alternatives. An ideal
candidate will be an individual in good health, with no active or preexisting
medical condition, who is not on any immunosuppressive or anticoagulation
therapy, and who has realistic expectations. The transfer of autologous fat into
atrophic facial areas (either localized or diffuse) can restore a sense of balance
and youth. However, one should avoid producing an appearance that is “pan-
hypertrophied,” a result of planing the atrophic areas to the level of the
hypertrophic areas. Microliposuction of certain hypertrophic areas (such as the
jowls and the area lateral to the nasolabial fold) can be valuable in reducing the
prominence of the fat in these areas. Patients should be encouraged to return
to and maintain an ideal body weight. Grossly overweight patients with
abundant hypertrophic facial areas, for reasons already described, are very
poor candidates for autologous fat transfer.

How Does Fat Transfer is Done?

Fat transplantation is performed at MSI, on an outpatient basis, and usually
under local anesthesia. Medication to alleviate any pain will be given one hour
prior to the procedure if needed. The entire procedure generally takes one
hour. Fat transfer is a two-step process, involving extracting fat cells from a
body site containing sufficient subcutaneous adipose tissue, serving as an
appropriate source for donor site (area where fat is extracted). Generally, fat is
extracted from the abdomen, buttocks, thighs or knees, and re-injected
beneath the skin in areas where cosmetic correction is needed.

a) Fat Extraction
First the donor site is injected with tumescent anesthesia, making the process
of fat extraction painless. Then a small incision is made, and fat is withdrawn
using a micro-cannula (instrument used in liposuction procedure). Unlike
liposuction, fat is not withdrawn with an aspirator machine, but rather with a
syringe under significantly lower pressure. The syringe method of harvesting fat
appears to be the most gentle method for removing suitable fat for reinjection.
After adequate anaesthesia of the donor site, the cannula (attached to the
syringe) is inserted into the fat. The plunger of the syringe is pulled to create
negative pressure within the fat. The cannula is then moved in a back and forth
motion several times in the same area. This maneuver is repeated in a radial
fashion until the entire donor site is lipo-sculptured, or sufficient fat is obtained.

b) Fat Injection
Before fat can be re-injected, it must be processed in order to get viable fat
cells. Fat is centrifuged (rapidly spins liquid down), separating pure fat tissue.
Blood, lidocaine or other material is completely removed; avoiding exposure of
delicate fatty tissue to chemicals or mechanical damage is essential. Fat is then
injected with a small syringe after the area is anesthetized or numbed with
Emla cream, with or without local infiltration of lidocaine. Use of blunt cannulas
throughout the infiltration procedure can minimize hematoma formation and
thereby aid fat-cell viability. In addition, blunt infiltration cannulas limit the
potential for nerve damage, as tissue planes are followed more naturally and
less traumatically disturbed. Besides direct injection of the three proposed entry
sites with local anesthesia, almost all of the anesthetic should be delivered with
the same blunt infiltration cannula used for fat infiltration to minimize
hematoma and swelling prior to starting injection of the fat. The three ports of
entry. Each of these ports of entry is made with a stab incision using a standard
18-gauge needle through which the blunt cannula can be inserted for both
anesthetic delivery and fat infiltration. Placing only tiny parcels of fat – either
3–5 passes per tenth of a cubic centimeter (in unforgiving areas) or a full tenth
of a cubic centimeter per pass (in more forgiving areas). It is injected in a
manner described as “weaving” or “layering” in small amounts in order to
achieve desired cosmetic effect, especially when treating large areas. Prof
Moawad believes fat should be injected into tiny pearls or strands of fat in
targeted depths of the skin or muscle. These tiny pearls have a sufficient blood
supply, permitting the transferred fat cells to survive in their new recipient site.
It is important for the surgeon to visualize the depth of infiltration basically into
the following three zones: Deep (immediately supraperiosteal), Intermediate
(in the musculo-fascial layer) and . Superficial (in the subcutaneous plane) For
the supraperiosteal plane, the nondominant hand can be used to provide tactile
feedback during infiltration and to guide supraperiosteal placement. In addition,
the dominant hand can feel that the cannula tip is gently neighboring the bony
surface. For the intermediate and superficial planes, the cannula passage is less
precise and the surgeon must simply visualize that the cannula is passing
through the central thickness of the soft tissue or more superficially.

Fat Grafting By Anatomical Site

a) Ant Cheek, Lateral Cheek and Malar Septum

When diagramming the face, the cheek may be divided into four areas: (1) the
central malar area or cheek “apple,” (2) the lateral zygoma, (3) the buccal
hollow, and (4) the lateral cheek. The anterior cheek, which often exhibits a
linear depression that runs supero-medially down infero-laterally and which
corresponds with the ligamentous malar septum. The cannula is passed from an
incision that is supero-lateral to the malar septum so that the cannula can
break through the malar septum in a perpendicular orientation to it. Individuals
exhibit varying degrees of resistance when the cannula passes through the
malar septum. The goal is to place fat in the malar septal depression and on
either side of it to raise the anterior cheek along with the unsightly depression.
Generally, 2–3 cc of fat can be placed into the intermediate and superficial
planes. The deep plane can also be addressed, but the surgeon need not hug
the bony contour. A generous tenth of a cubic centimeter per pass can be
undertaken with impunity. Starting with an incision lateral to the nasolabial
fold, 5- to 7-mL threads of fat may be placed around the zygomaticus muscle
and through the subcutaneous fat. Frequently, a second incision will be placed
lateral to the zygomatic arch to cross hatch the area and deposit the optimal
amount of fat in the deep central cheek, forming a 3-dimensional lattice.The
surgeon should be careful in aggressively enhancing the anterior cheek in men,
as this characteristic can be somewhat feminizing. The lateral cheek is more
easily elevated in continuity with the anterior cheek from an infero-medial
position. The bony zygomatic arch can serve as a helpful guide over which the
fat can be placed. The placement of 2–3 cc of fat into the lateral cheek can be
undertaken with a generous tenth of a cubic centimeter per pass into all tissue
depths but again the cannula need not pass immediately in the supraperiosteal
plane.

b) Buccal Recess
The buccal recess can be quite hollow with aging and can be even more
exacerbated by augmenting the cheek above. The buccal hollow can
accommodate a generous amount of fat on the order of 5–8 cc without
difficulty. Placement of fat is into the intermediate and superficial tissue
planes. If the entry site is too proximal to the buccal region, the more distally
as an alternative or together in a cross-hatching fashion in the buccal area, the
fibrous network makes fat transplantation difficult. Therefore, care must be
taken to thread 3 to 5 mL of fat in small aliquots, cross-hatching, fanning, and
paying particular attention to blend fat past the medial aspect of the parotid
fusion line to prevent an apparent tissue “bunching” when the patient smiles
and prevent the patient from looking too full and cherubic in the central cheek.

c) Nasolabial and Labiomental Folds

The treatment of the nasolabial fold with fat injection requires the release of
the dermal attachments creating the fold. We advocate the use of the V-
dissector cannula (Byron Medical) for this purpose. The V-dissector device
allows one to infiltrate small fat aliquots while simultaneously releasing the
fibrous attachments to the nasolabial fold. Typically, 2 to 3 cc of fat is injected
per side in a fan-like distribution. The majority of the fat is placed beneath the
crease and medially, blending into the cutaneous portion of the upper lip. When
performing fat grafting to the nasolabial fold in conjunction with a face lift, it is
unnecessary and often detrimental to carry the face-lift dissection across the
nasolabial fold. A more limited dissection tends to minimize facial flattening,
ecchymosis, and potential bleeding. Similarly, in treating the labiomental
crease, the fat is pulled through the crease from an incision site either lateral or
medial to the crease, often filling up the entire pre-mentum to support the
lower lip. Typically, each crease takes 1 to 2 mL of fat per side.

d) Lips and Marionette lines

Volume augmentation to the lips is an important component of facial
rejuvenation. Nevertheless, the ideal treatment for thin, atrophied lips has yet
to be discovered. The key to successful fat grafting to the lips remains an
understanding of aesthetic principles to restore shape and a soft/natural result.
The upper lip is associated with greater fullness centrally and near the
commissures, whereas the lower lip is associated with increased fullness
paramedially. An important aspect of lip augmentation is maintaining the
“sensuous” feel of the lip. Soft lips have a significant role in intimate
expression; therefore, the lips should feel as natural as possible once healing is
complete. This is one of the major advantages of injecting autogenous
materials.

An 18-gauge needle is used to create a small stab incision at the lateral

commissures, through which the 18-gauge blunt cannula can be easily placed.
It is important in micro-lipoaugmentation of the lip that a blunt cannula be used
to avoid laceration of the labial vessels and resultant hematoma. Fat is
deposited as the cannula is being withdrawn to prevent inadvertent injection
into a vessel. Injecting with the right hand, the upper lip is injected from the
patient’s right commissure and the lower lip is injected from the patient’s left
commissure. This allows the left hand to control the recipient lip and guide the
cannula to the desired level. Conceptually, successful microlipotransfers create
multiple, isolated droplets of fat, not puddles or lakes of fat. Keeping this
concept in mind will help maximize the number of fat cells, achieving
vascularity and therefore viability. Fat can be layered into the muscle of the lip,
and into the vermillion borders. The best lip eversion and shortening of the
cutaneous lip is achieved by entering the lip through an incision lateral to the
nasolabial fold. Droplets of fat are placed from under the mucosa up to the
vermillion. The lower lip can be addressed the same way by making an incision
lateral to, or in the line of, the labiomental crease. Overfilling the lip results in
protracted swelling and downtime and is therefore avoided. Instead, the lip is
filled until a visual endpoint is reached, which usually requires 0.5 to 2 mL per
lip.

Autologous fat grafts to the lips can have excellent results but are limited by
more variability in their persistence and prolonged edema and ecchymosis (2-
3 weaks)when compared with their use in other recipient sites. However, we
have found improvements in postoperative edema resulting from the use of a
smaller, 20-gauge side-port injection cannula (Storz). A minimum of two fat
transfer sessions are planned for each patient and spaced approximately 3–6
months apart. Patients are informed that between 15 and 50% of the fat on the
average will survive with each treatment; necessitating a series of treatments
to achieve the desired results. However, occasionally the “take” is surprisingly
good, and for that reason, the patient is often encouraged to augment the lips
if they are also doing other areas of the face so that they may share the
recovery time. Typically, the lower lip tends to maintain its volume to a greater
degree than the upper lip. A combination of fat transplantation and mucosal
advancement (FATMA) have been used to correct inversion and both augment
the lips as well as control the shape and these have had more permanent
results than those of fat transplantation alone.

Fat is also injected into the marionette depressions below the corners of the
lips. It is important to inject very small quantities of fat, 0.25–0.5 mL at a time,
in multiple areas. However, the increased morbidity and variable persistence of
fat grafts in the lips, Prof Moawad relied heavily on hyaluronic acid as an
alternative in this region. The ease of infiltration, shorter recovery, and an
excellent safety profile are the main advantages of the hyaluronic acid fillers.
Unfortunately, their longevity is limited to 4 to 5 months.
e) Prejowl Sulcus and Jawline
The prejowl sulcus is an important area to augment to achieve a more youthful
facial contour but also to enhance a face-lift result by straightening the jawline
further with fat enhancement. Fat should be infiltrated into all three tissue
planes described previously with a generous tenth of a cubic centimeter per
pass without difficulty. We generally start with 3 cc. It is important to
conceptualize the prejowl sulcus three-dimensionally with fat placed along the
anterior border of the mandible, the inferior border of the mandible, and the
transition between these two borders. Doing so will provide a more even and
complete fill of the prejowl depression. Additional fat can be feathered into the
mental sulcus and anterior chin as aesthetically mandated.

f) Mandible and Chin

The jaw line is filled not only in the anterior plane, but also in the inferior plane
by wrapping fat around the mandible. This area is approached through multiple
incision sites perpendicular to the mandible, fanning laterally and inferiorly so
the fat ends 1 cm below the bony border on the superior portion of the neck.
According to Prof Moawad’s experience, this not only delineates the jawline, but
appears to “borrow” skin from the neck. The submental area and prejowl sulcus
are filled in the same manner, forming a sling to support the chin and separate
it from the uppermost portion of the central neck. The jaw line and chin can
take as much as 20 mL of autologous fat,

Immediate Postoperative Care

As no actual incisions are made, there is no need for any suturing of the entry
sites. Also, no dressings for the body or face are required either. Simply head
elevation and icing are sufficient to expedite the recovery process. The patients
are discharged after adequate postoperative observation.

The Retention of Fat Graft

Fat grafting can achieve long-lasting results. Patients are informed
preoperatively that fat surviving should be long-lasting if not permanent. Fat
survives best in areas with little to no movement that leads to better
revascularization. This has been observed in the malar, periorbital, superior
nasolabial fold, and parasymphysial regions. In contrast, fat grafts to areas with
significant motion, such as lips and marionette lines, have diminished survival
and typically require secondary injections. Touch-up sessions can be performed
at 3 months postoperatively if additional volume is desired using a previously
frozen fat. After performing thousands of fat transfer procedures, Prof Moawad
has found that retention varies in different parts of the face. Fat seems to
“take” and do best where fat atrophy is the problem, like the cheek, periorbital
area, and mandible. When fat is used to replace bony remodeling or mucosal
atrophy (both occur in the perioral area), the retention can be unpredictable.
Despite improvements in fat grafting technique, there remains an element of
variability with the use of autologous fat. Patients desiring further correction in
low retention areas often benefit from additional augmentation with hyaluronic
acid, or calcium hydroxylapatite; however, these small-volume fillers, in Prof.
Moawad’s opinion, cannot replace the dramatic tissue shifts and volumizing
achievable with structural augmentation with fat

New Trends in Fat Grafting

The future of autologous fat transplantation may lie in stem-cell research,
specifically adipose stromal cells. Mature tissues, such as adipose contain some
amount of stromal cells. Stem cells are smaller, more resilient cells that may be
more viable than their mature fat cells. Stem Cells are capable of differentiation
to mature fat cells. Developing technology to expand out clones of adipose
stromal cells would provide a source of filler material for patients that do not
have adequate fat for transfer. Other future research endeavors include the
development of pre-adipocyte transplants, hormonal manipulation of fat grafts,
and the use of growth factors added to harvested tissue in an attempt to
increase survival of transplanted adipocytes.

I. Stem cell-enriched fat grafting or Cell Assisted Lipotransfer (CAL)

The concept of regenerative medicine, using the body’s own stem cells and
growth factors to repair tissue, is an alternative therapeutic strategy for
damaged tissue repair. In particular, adipose adult stem cells (ASCs) have been
used as a cell source for adipose tissue engineering because they could be
readily differentiated into adipocytes with specific induction factors. It has been
suggested that the pre-adipocytes and adipose stromal cells are the cells that
are the most likely components of surviving grafts. These cells are more
resistant to trauma and have lower metabolic requirements compared to
mature adipocytes. Adipose tissue–derived stem cells (ADSCs) can be
commonly obtained from adipose aspirates after conventional liposuction. Cell
assisted fat transfer ASC-poor fat is converted to ASC-rich fat by supplementing
with cells freshly isolated from the adipose tissue during preparation of the
injectable material. The procedure of ASC-enriched fat grafting had excellent
feasibility and safety. Results indicate that ASC graft enrichment could render
lipofilling a reliable alternative to major tissue augmentation, such as breast
surgery, with allogeneic material or major flap surgery. Furthermore, ADSCs
and their secretory factors show promise for application in cosmetic
dermatology, especially in the treatment of skin aging.

II. Fat Graft and Platelet Rich Plasma (PRP) or Stem Cell Fat Transfer
In our experience, one of the most important influences of grafting adult
lipocytes plus stimulation of the very rich mesenchymal stem cells found within
adipose tissues is the addition of platelet-derived factors added to the
harvested graft materials prior to graft placement. The PRP is added to the
autologous graft materials in an approximate ratio of 10% in small volume
cases and 0.5–1% of the total graft prepared for large volume
transplantation. PRP enhances the survival and quality of fat grafts. Although
several mechanisms may be responsible for this result, the most important
mediator of the survival of fat grafts is induction of angiogenesis. PRP contains
mitogenic and chemotactic growth factors important in angiogenesis, including
VEGF and EGF. These factors promoted angiogenesis during the growth of the
fat. A second potential mechanism by which PRP enhances fat graft survival is
greater proliferation of adipose stromal cells (ASCs) or stimulation of ASCs to
differentiate into adipocytes. PRP treatment increases graft weight and volume
and improves graft quality in small and large volume applications.

III. Collagenase digested Fat Transfer

Collagenase is used to dissociate the connecting fibrils between the fat cells in
fat lobules to create a suspension of fluid containing smaller clusters of digested
fat cells. Using this method, the fat is transformed into a fat cell suspension
that can be injected using small gauge syringes. The harvested fat was
centrifuged at 1,500 9 g for 3 minutes. Cellular debris at the bottom was
drained, and the oil layer was removed using a sterile pad. The remaining fat
layer was mixed with collagenase type II. These technique are used to improve
longevity of the transplanted fat due to increase surface area contact with
nutrient bed. The digested fat can pass through small-bore (25- to 27-gauge)
needles which is less traumatic and allow for a more precise delivery into the
superficial layer of the skin, such as the dermis to treat superficial wrinkles and
scars.

IV. Autologus Collagen Micro-injections

While injectable bovine collagen, and other synthetic materials, can smooth out
wrinkles, it is not for everyone. Some patients are allergic to bovine collagen,
or may develop an allergic reaction over time. Alternatively, autologus collagen
is a safe, natural and non-allergenic material. Several techniques are applied to
extract autologus collagen from fat; adding sterile, distilled water to extracted
fat, breaking it down by mechanical manipulation to render it in a non-viscous
form, and centrifuge (spin) it at 1000 revolutions per minute to separate the
oily infranate composed of triglycerides that allows fat extracted to be injected
through a small gauge needle intradermally. Material collected is injected
through a 25-gauge needle into the papillary dermis to correct fine lines and
wrinkles and superficial scars. As in fat transfer, longevity of results may
depend on multiple injections

V. Nanofat Grafting
A special multiperforated harvesting cannula of 2 mm with 1-mm side holes is
used to harvest microfat globules that was mechanically emulsified after
rinsing. Emulsification of the fat was achieved by shifting the fat between two
10-cc syringes connected to each other by a female-to-female Luer-Lok
connector. After 30 passes, the fat changed into an emulsion. At the end of the
fragmentation process, the fat became liquid and took on a whitish appearance.
After this emulsification process, the fatty liquid was again filtered over the
sterile nylon cloth and the effluent was collected in a sterile recipient ,which is
called nanofat graft. A yield of 1 ml of nanofat per 10 ml of lipoaspirate can be
expected. Because of the reduced number of viable adipocytes in the emulsified
fat, the filling capacity of nanofat is obviously very limited. Injection with sharp
needles ranged from 22 gauge (subdermal) up to 27 gauge (intradermal)
is used to treating superficial wrinkles in the perioral area or more to improve
the quality of the skin. Injection was performed until a yellowish discoloration
of the skin showed up. The mechanism for this regenerative effect on damaged
skin remains unknown. However, the presence of a large number of good
quality mesenchymal stem cells, may improves elasticity is presumably a
consequence of increased collagen and elastin synthesis and remodeling.
In fact, it may be questioned whether a nanofat transfer actually is a “fat
grafting” procedure, as adipocytes did not survive the emulsification process.
The major effect of nanofat injection is probably a stem cell activity. Likewise,
nanofat injection might rather be considered as an in vivo tissue-engineering
process. It might be logical to discard the dead adipocyte fraction from the
nanofat and to inject the purified stromal vascular fraction only. However,
isolating the stromal vascular fraction out of the nanofat before injection in
routine clinical cases would be time consuming, complicated, and expensive.
Besides, it requires specific laboratory equipment and experience. Moreover, it
is known that apoptotic cells release cytokines and attract macrophages that
induce growth factors and play an important role in regeneration of the
damaged tissue. Thus, co-injection of fragmented adipocytes might have a
stimulating effect on stem cell differentiation and tissue regeneration.

Liquid Face lift or Soft Dermal Fillers

GENERAL Consideration
Despite the success of facial fat grafting in many areas of the face, plastic
surgeons must be familiar with the use of alternative fillers. Increasingly,
dermal fillers are being used in lieu of structural fat grafts to add volume to the
aging face. Recently, numerous injectable fillers have been marketed as
alternatives to facial fat grafting, with various claims of clinical
efficacy. Although there are many soft tissue fillers by trade name, they can
generally be categorized into temporary fillers (collagen, hyaluronic acid and
calcium hydroxylapatite) and permanent fillers (polymethylmethacrylate,
silicone and hydrophilic polyalkylimide. The substance used is largely dependent
on the practitioner’s comfort, location, and patient’s desired outcome. In the
perioral region, these fillers are quite useful for replacing volume loss, which is
otherwise quite difficult to address. Deep nasolabial folds, labiomental folds,
thinning lips, and fine perioral rhytids can all be addressed by various fillers.
Unfortunately, many practitioners are using fillers not only to address facial
volume loss but also to compensate for gravitational and skin elasticity
changes. The “over-injection” of fillers can yield disappointing and unnatural
results.

Soft Dermal Fillers: The Products

a. Hyaluronic Acids
Of the available hyaluronic acid (HA) fillers, Restylane (Medicis, Scottsdale, AZ)
was the first to receive approval by the FDA (in December 2003) for the
correction of moderate to severe facial wrinkles and folds, such as nasolabial
folds. Restylane has an HA concentration of 20 mg/mL with a particle size of
400 um, making it a more viscous product than the FDA approved animal-
derived HA with 6 mg/mL HA. Restylane operates as an effective dermal filler
by physically stretching dermal fibroblasts, which induces de novo collagen
formation while inhibiting the breakdown of existing collagen. Juvederm, a
similar non–animal-based HA with a slightly higher concentration of HA (24
mg/mL) and more extensive cross-linking, was approved by the FDA in June
2006. The additional cross-linking is thought to increase longevity, and recent
reports have shown this product to persist up to 12 months. Whereas the HA
particles in Restylane are uniformly shaped, Juvederm particles are randomly
shaped. This is postulated to be responsible for Juvederm’s smooth gel-like
consistency. Some physicians describe this product as flowing from the syringe
with more ease and fluidity and causing less bruising. Much like the rivalry
between Coke and Pepsi, there are those who prefer the alternate brand.
Additionally, Juvederm was approved by the FDA in thinner (Ultra) and thicker
(Ultra Plus) versions for greater injection subtlety and variety. With greater
particle size and a slightly higher percentage of cross-linking than Ultra,
Juvederm Ultra Plus is designated for deeper, volumizing injections. Perlane
(QMed, Eatontown, NJ), a thicker, larger-particle version of Restylane, was
approved by the FDA in January 2007. Perlane differs from Restylane only in its
particle size (940 vs 1090 um), although the concentration of HA remains
constant in both products (20 mg/mL).

The hydrophilic nature of HA allows it to maintain its shape using the body’s
own moisture. One gram of HA can bind up to 6 L of water. As a component of
the extracellular matrix, intrinsic HA functions include space filling, lubrication,
shock absorption, and protein exclusion. Over time, the injected hyaluronic gel
is slowly absorbed by the surrounding tissues and disappears by a process
called isovolumetric degradation. As the HA gradually degrades, each molecule
binds more water and, eventually, the same volume can be maintained with
less HA. This provides a natural appearing volume correction and cosmetic
persistence until the product is almost completely degraded

The chemical and molecular composition of natural HA is conserved throughout

all living organisms; therefore, HA fillers do not possess species or tissue
specificity. This means that there is a negligible potential of eliciting humoral or
cell-mediated immune reactions. Restylane, Perlane, and Juvederm are HA
dermal fillers derived from bacterial fermentation in cultures of a Streptococcus
species. Because these products are not of animal origin, there is almost no risk
of contamination with animal allergens, pathogens, or xenogenic disease during
the manufacturing process.

Calcium Hydroxylapatite
Radiesse (Bioform Medical, San Mateo, CA) was approved by the FDA in
December 2006 for the correction of facial wrinkles and folds, such as
nasolabial folds, and for the correction of facial lipoatrophy associated with HIV.
Radiesse is composed of calcium hydroxylapatite (CaHA) microspheres (25–45
_m) surrounded by a 70% methylcellulose carrier that dissipates quickly in
vivo, leaving the CaHA microsphere as a scaffolding to promote collagen in-
growth. Radiesse has a good safety record and stimulates only minimal foreign
body reaction secondary to the spherical shape of the product, which incites
less inflammation then an irregularly shaped product. Granulomatous reactions
and migration of the product are unlikely. The calcium and phosphate minerals
comprising Radiesse microspheres are the same as found in bone. The product
is faintly visible on radiographs but has not been reported to obscure
radiographic interpretation. After implantation, this product is slightly more
malleable than HA. Additionally, the same volume goes further, because a
lower volume of CaHA is needed to fill the same defect as compared with HA.
Importantly, CaHA is not recommended for lip augmentation, because an
unacceptable number of labial nodules have been reported from the product
clumping together.

How to Choose the Most Appropriate Filler?

a) The Product side
We have had experience with the use of large-particle, crosslinked hyaluronic
acid (Perlane, Medicis, Scottsdale, Ariz.; Juve´derm, Allergan, Irvine, Calif.),
smaller particle, non–cross-linked hyaluronic acid (Restylane, Medicis,
Scottsdale, Ariz.), calcium hydroxylapatite (Radiesse, BioForm Medical, San
Mateo, Calif.), and poly-L-lactic acid (Sculptra; Dermik Laboratories, Berwyn,
Pa.) for soft-tissue augmentation in the face. In addition to longevity profile,
the physical characteristics of these injectable fillers ultimately determine their
suitability for a particular anatomical region. Considering the numerous filler
types and brands currently available in Egypt and worldwide, deciding which
facial filler to use, when to use it and why, can be a complex process. With a
solid understanding of filler products, appropriate filler selection, prudent
patient selection, and proper injection techniques, the aesthetic surgeon can
expect satisfied patients with effective volume correction.
Properties of hyaluronic acids, that are important in de-termining their clinical
performance include; the concentration of hyaluronic acid and the degree of
cross-linking which affect longevity and stability; gel hardness, which helps
determine flow

properties, the extrusion force required, the structure and stiffness of the
finished product; and the degree of gel swelling, or ability to resist dilution,
which also influences longevity. For example, hyaluronic acid fillers of lower
viscosity are recommended, particularly for initial treatment. Further fluidity
can be increased by dilution (3:1) with lidocaine 1% or saline.

Despite the temporary nature of HA based dermal fillers and the requirement of
repeated treatments, it is a treatment that appeals to patients due to its ease
of application, efficacy, minimal downtime, and noninvasive nature. In regions
of good skeletal support and relatively thick overlying skin, such as the
nasolabial fold and the glabellar crease, Prof Moawad favor the use of Radiesse
and large-particle hyaluronic acid (Perlane and Juve´derm) because of their
longevity. As larger particle size suspensions, Perlane and Juvederm Ultra Plus
have less total surface area subject to attack by the body, and are theoretically
more resistant to degradation. Because these products are thicker, Juvederm
Ultra Plus and Perlane are designed to be injected deeper into the dermis or
subdermis for volume correction and contouring capabilities

Problems with reversible fillers such as Hyaluronic acid can be easily treated
with Hyaluronidase to dissolve or remove undesired or insufficient volume may
be addressed by adding more product, but irreversible fillers cannot easily be
removed. On the other hand, problems with irreversible fillers are much more
difficult to manage, especially if vital structures have been treated. Therefore,
Prof. Moawad strongly recommends that they not be considered as a first-line
choice and should be used only by clinicians with substantial training and
experience with these filler agents. Even in the best hands, complications may
occur, and this calls for extreme caution, especially when injecting the product
around vital facial structures

b) The Patient side

The choice of which filler to use and when to use it is primarily dependent on
the patient rather than the product. Smart patient selection exponentially
enhances aesthetic results and patient satisfaction. The following are some
important questions to consider when determining which filler to use.
Nevertheless, in thin-skinned individuals or in superficial creases, we prefer
small particle hyaluronic acid (Restylane). In addition, we favor hyaluronic acid
products as an alternative to fat in the nasojugal groove because of the thin
nature of the overlying skin. Similarly, hyaluronic acid remains our treatment of
choice for thin, atrophied lips. For larger-volume augmentation, as in the malar
region, autologous fat remains the best filler.

1. What has or has not Made the Patient Happy in the Past?
If a patient has been pleased with their current filler regimen, there is no
reason to change the filler unless there is significant cosmetic or safety
advantage to using a different product. It is not recommended to re-administer
a product with which the patient has been previously dissatisfied. In this
situation, it is best to attempt an alternate treatment or product or simply not
to retreat at all. Realistic patient expectations are paramount to all successful
injection procedures.

2. Does the Patient Demand either Permanent or Reversible Products?

Certain patients insist on treatment with a permanent filler although a
temporary filler may be the more judicious recommendation. If the patient is an
appropriate candidate with significant temporary filler experience, a permanent
filler may be an option. In contrast, patients new to filler therapy are best
treated with reversible, nonpermanent agents. As such, the patient and
physician have flexibility in terms of treatment volume, repetition, reversibility,
and ability to modify and customize the outcome as needed.

3. Can the Patient Tolerate Downtime?

Patients who cannot tolerate excess post treatment downtime are not ideal
candidates for larger semipermanent volumizer and fat transfer procedures.
These treatments are placed deeper in the dermis with larger-gauge needles
and can result in more significant bruising and swelling. For patients who
require rapid recovery, the thinner HA products or even collagen based
products may be better choices.

4. Is the Patient Undergoing Simultaneous Surgery?

For the patient who is undergoing surgery simultaneously, fat transfer is often
an excellent option. It is abundant and easy to harvest while the patient is
under anesthesia. Additionally, fat transfer usually involves more downtime
than the off-the-shelf injectable products and most patients undergoing surgery
are expecting at least a week of recovery time.
5. Is the Patient older?
Older people tend to have a minimized immune response to a foreign body
injection. Therefore, a permanent product, which may cause an intense
inflammatory response in a younger patient, is more appropriately offered to an
older person. Additionally, in the event of a complication requiring skin excision
of the permanent product, it is easier to camouflage a scar in the expected
creases of an older patient’s face than in the mildly blemished to unblemished
thicker skin of a younger patient.

6. Is the Patient’s Skin Thick or Thin?

Thick skin tends to better accept the deep semipermanent volumizers, resulting
in a better outcome and greater longevity. Thin skin can appear lumpy when
injected with thicker HA products. Often, a customized treatment using 2 or 3
different products on the same patient in different areas can achieve optimal
correction.

Filler Consultation and Treatment Decisions

Experienced patients may know exactly what they want in terms of
perioral enhancement, but many patients “leave it up to the doctor” as to what
to do. It is extremely important to deliver what the patient desires if it is in fact
rational or possible. Some patients have unrealistic expectations, and when
altering the perioral area with long-lasting fillers it is imperative to “do the right
thing.” It is helpful to take before and after pictures to show patients average
treatments. The absolute key to learning about fillers is to be conservative. I
tell my patients that injecting fillers is a sculpting process and not a single
treatment. All patients are rescheduled for a 2-week follow-up. At this follow-
up, it is decided if any touch up is needed or if any asymmetries exist and if the
patient is satisfied. Furthermore, it must be decided in advance (usually in the
informed consent) on who will pay for any touch-up or re-injection.

In general, when performing a consult for fillers, the doctor should determine
what exactly the patient wants and select the appropriate filler. The patient
should be instructed about the positive and negative effects of the filler, and
the recovery and longevity should also be discussed. Overselling a result or
longevity can cause problems, so it is always preferable to be realistic. When
addressing nasolabial folds, I explain that fillers will not eliminate the folds, but
rather will blunt them. I further explain that adults would look unnatural if they
had no nasolabial folds. One problem that exists with lips, folds, and wrinkles is
when the patient will not purchase the adequate amount of filler to do the job.
Fillers are obviously expensive, but underfilling an area will usually disappoint a
patient. In my experience, a single syringe may suffice to augment an upper lip
and possibly a portion of the lower lip. If both lips need attention, then tow
syringes are probably necessary. Similarly, it is a rare situation where a single
syringe of filler will augment two nasolabial folds. This must be explained to
patients or they may be unhappy or feel that the treatment did not work.

It is prudent to attempt to uncover the patient’s expectations, anxieties, or

distress as well as potential misinformation that may derive from the
experience of friends or from other sources, such as magazine articles. These
discussions also provide an opportunity for the practitioner to identify patients
who may not be suitable candidates for treatment and to foster a long-term
plan with those who are. Some practitioners suggested asking patients to bring
photographs of themselves dating back 5 to 10 years to help guide the
treatment plan and establish realistic goals. One of the most important
recommendations is to photograph all areas of the face and not just those
undergoing treatment. Having a number of views available can help in the
accurate assessment of the face and can be useful to show to patients when
they return with questions or issues with their treatment. Photographs can also
be used to document outcomes

FILLERS Selection by Defect Present and Anatomical Region

The goal is to find the best match for the patients’ problem with the optimal
choice of filler therapy. Judicious diagnostic skills, combined with an in-depth
understanding of filler materials and their properties, will yield successful
treatment outcomes. Because the unique characteristics of the recipient site
play an integral role in determining both the choice and the efficacy of a given
filler, it is helpful to categorize fillers selection by anatomical region. In
addition, recipient sites can be further separated into two broad groups: those
that are amenable to groove or crease effacement, such as the nasolabial fold
and glabellar crease; and those that require volume enhancement, such as the
malar region, jaw line, and the lips.

1. Fine Etched Lines: Autologous Collagen based fillers

To erase fine, superficially etched facial lines, such as those along the upper
and lower cutaneous lips, HA fill¬ers should be injected into the superficial to
mid dermis a product that cant not show through the skin. When we are
already using an HA filler designed to be injected into the mid to deep dermis,
for rejuvenation of deeper rhytides, we prefer to use the remaining portion of
the HA filler for superficial rhytides. By diluting it with lido¬caine in a 1:1 ratio;
the diluted product can then be injected into the superficial to mid dermis using
the serial puncture microinjection technique with a low risk for nodularity, to
correct fine lines and superficial rhytides. The consistency of collagen-based
products makes them an excellent treatment for this circumstance.
Unfortunately, their longevity (8 to 12 weeks) is not ideal. Althernatively, the
collagen digested fat, autlogus collagen and nonofat can pass through small-
bore (25- to 27-gauge) needles, which allow for a more precise delivery into
the superficial layer of the skin (intradermally), to treat superficial wrinkles and
scars.

2. Superficial Facial Lines and Creases: Restylane and Juvederm Ultra

For medium-depth fine lines and creases, HA products can achieve excellent
results. The product is placed just beneath the dermis to provide lasting and
predictable results. When treating superficially, make sure the product is placed
in the deep dermis. Superficial placement may be visible through the skin,
worsening the patient’s appearance.
3. Deeper Facial Lines, Folds, and Creases: Perlane, Juvederm Ultra
Plus, Radiesse, and Fat
For deeper lines and creases, the more robust volumizers, such as the larger
particle HAs and CaHA, can effectively fill deeper facial lines and crevices.
These products are injected deep in the dermis or subdermis to fill the defect
completely.

4. Lip Augmentation: Restylane and Juvederm

Successful lip augmentation requires significant skill and aesthetic expertise.
Thinner HAs to define the vermilion border and lift the oral commissure
while,larger volumizing HAs can be used for creating a full pouty lip.

5. Midface and Lower Face Volume Enhancement: Radiesse, Perlane,

Juvederm Ultra Plus, and Fat
These products nicely replace volume in the midface, cheeks, and prejowl
sulcus. Newer intraoral injection techniques greatly decrease pain,
posttreatment ecchymoses, and edema. The product is placed deeply in the
subcutaneous tissues and along the supraperiosteal plane. After injection, the
product is manually molded to achieve the desired contour. Large volumes of
product are necessary in order to appreciate the enhancement
Is Injecting Dermal Fillers Painful?
a) Anesthesia
Pain control is important in any practice, but especially in an elective cosmetic
practice. Pain is a subjective experience, each individual’s need for pain relief
should be assessed. Pain is influenced by injection site, tissue plane of
injection, needle size, condition, pain perception as well as filler properties.
Several methods for pain control during the aesthetic procedure are available
and combinations of these procedures can be useful in some situations.

The application of ice is the easiest and most common topical method of
providing a temporary, localized anesthetic effect. However, the effect is short-
lived and may need. Facial cooling systems provide a longer-lasting
effect. Placing an ice cube or two in a clean surgical glove and then allowing
the patient to hold it over the planned area of injection for 1 to 2 minutes is
usually adequate. The same ice can be used immediately post-treatment to
help reduce bruising and edema. Caution is advised to not overexpose the skin
to the cold, because a burn might result.

Almost everyone uses topical anesthesia, but the use of local anesthesia is
variable. Commercial topical agents formulated with lidocaine, tetracaine,
and/or betacaine are effective pain management tools. These agents achieve
their anesthetic effect through the reversible blocking of nerve conduction at
the application site. They are applied to the skin for 15–60 min prior to the
procedure and can significantly moderate the pain experienced.

The next level of control is achieved with local infiltration of anesthetic,

generally with small-bore (30- or 32-gauge) needles. This technique may be
used to either numb the needle-insertion sites or to achieve a zone of
anesthesia where the filler will be placed. Caution must be exercised in regard
to the total amount of anesthetic used because tissue distortion may occur,
which may affect the ultimate cosmetic outcome. In some individuals, effective
pain management for dermal filler injections may require the use of regional
nerve block anesthesia.

Nerve blocks is performed by injecting an anesthetic agent around a nerve root,

which then produces an anesthetic effect in the distribution area of the nerve
treated. Nearly complete anesthesia may be achieved with little effort or time,
although there is still a possibility of tissue distortion and nerve blocks are
limited by the distribution of the sensory nerve being numbed. Personally, I use
local anesthetic blocks or infiltrations for all lip enhancements but not usually
for skin injection unless the patient’s skin is sensitive to topical anesthetics. On
presentation, the patient is put in a consult room and topical anesthesia is
applied. If the patient is scheduled for nasolabial fold or skin wrinkle
augmentation, no additional anesthesia is used unless the patient is too
uncomfortable. For lip injection, I use infraorbital and mental nerve blocks or,
more commonly, local anesthetic infiltration in the upper or lower anterior
vestibule from cuspid to cuspid region.

Injectable anesthetic choices include lidocaine, with or without epinephrine,

which are both painful upon injection due to acidic nature of the agent.
Epinephrine in the anesthetic may help to reduce bruising; however, if
epinephrine is included, the anesthetic effect may persist for 8 to 10 hours. This
can be an uncomfortable experience for many patients because of the lack of
oral sensation and can reduce oral competency. Septocaine articaine
hydrochloride 4% with epinephrine (Septodont Inc, New Castle, DE) is favored
by many dentists and is an excellent alternative to lidocaine. Even with its
epinephrine content, its duration of effect is limited to 2 hours. Additionally, the
Septocaine has a higher pH, thereby minimizing the burning sensation upon
injection. This can be blunted by placing a topical intraoral anesthetic, such as
Denti-Care topical anesthetic gel, with 20% Benzocaine (Medicom, Lachine,
Québec, Canada) to alleviate the discomfort associated with mucosal
injections. Caution is recommended to prevent direct injection of the neural
foramen

A Septocaine ampule is placed into a stainless steel dental injector syringe with
a 27-gauge, 1.25-in needle (Kendall Tyco Healthcare Group LP, Mansfield, MA).
A cotton-tipped applicator with topical local anesthesia is placed on the buccal
or gingival labial sulcus for 3 to 5 minutes (Denti-Care topical anesthetic gel).
The needle is placed just above the canine at a 30° angle up to the canine
fossa, with the bone of the anterior maxillary wall just lateral to the nasal–alar
insertion. The needle is directed down to the bone and approximately 0.3 mL of
anesthesia is injected. Distraction devices, such as a vibrating massager placed
on the maxillary eminence, can significantly minimize injection discomfort.
Injections are made bilaterally to achieve anesthesia to the entire upper lip
within about 2 minutes. Alternatively, the injections can be accomplished
transcutaneously. This technique is easier and more reliable when first learning
nerve blocks, but it is also associated with a greater discomfort to the patient.
For lower lip anesthesia, following retraction of the lower lip, the second
premolar is located and the needle is inserted into the gingivolabial sulcus,
about 0.5 in beneath and onto the bone of the mandible. Approximately 0.2 mL
of anesthetic is injected bilaterally to anesthetize the entire lower lip and chin
area. Because mandibular injections are slightly more painful then the maxillary
injections, a distraction device placed on the mentum will significantly blunt
pain perception. Some physicians utilize a micro–nerve block technique, in
which small aliquots of anesthetic are injected along the mucosal border of the
lip near the gingival sulcus. Microblocks have the advantage of not producing as
deep a regional anesthetic. However, this technique may take longer to perform
and the potential for incomplete anesthesia is greater

b) Needles and Microcanula

Dermal fillers may be injected using either a hypodermic needle or blunt-tip
microcannula. Needles may be preferred for correcting lines and wrinkles, while
cannulas may be preferred for volume correction. Needles have the advantage
of extreme precision of movement, the possibility of deep intradermal injection,
and a requirement for smaller injection volumes. Disadvantages include pain,
bruising, and possible vessel laceration. Cannulas cause less trauma, pain, and
bruising and allow a large area to be treated at the chosen injection depth.
Disadvantages are that intradermal injection is not possible, specific training in
the technique is required, and unless in the hands of experts, a greater volume
of product is generally used. The needles and syringes used depend on both
individual technique/preference and specific application. Prof
Moawad recommends 31- gauge needles with a short hub (30-U insulin
syringe), 29-gauge, half-inch to 1-inch needles (0.30-ml syringe; BD Medical,
Franklin Lakes, N.J.), tuberculin syringes with 30 or 32-gauge needles, and the
hubless, 30/31-gauge system. Calcium hydroxylapatite is generally injected
with a 30-mm-long 27 gauge or 19-mm-long 28 gauge inner diameter needle
or a 25 or 27 gauge variable length microcannula. A range of injection volumes
is provided in this document and it is suggested that technicians with
experience with needles use volumes at the lower end of the range and those
with experience in cannulas use volumes at the higher end of the range

How the Soft Fillers are Injected?

To achieve successful filler treatments, there are a variety of different
techniques used including threading, serial droplet, and fanning methods

a) Linear Threading
Linear threading is a method of injecting a continual line of filler while keeping
the syringe moving forward or backwards. This is the same mechanism used
when putting a line of toothpaste on a tooth brush. The full length of the needle
is advanced along the wrinkle or fold to create a tunnel for filler placement.
Injection can be anterograde ‘the push-ahead technique’ as the needle is
advanced or retrograde as it is withdrawn. Anterograde delivery may displace
small blood vessels, but retrograde delivery allows more uniform placement,
the preference being largely operator-dependent. Linear threading is best for
the nasolabial folds and vermillion contour.
b) Serial Puncture
Serial puncture is another technique and involves injecting separate beads or
boluses of fillers in a similar means as decorating a cake with medallions from a
frosting injector. Serial puncture techniques are good for filling in gaps or fine-
tuning small areas. When using serial puncture techniques, it is important to
keep the filler beads close together so as not to have a bumpy appearance. The
skin is pulled taught to stabilize the defect and multiple boluses of filler are
delivered along the defect line. The injection sites should be close enough to
form a continuous smooth bead; however, small gaps can be moulded with
massage. It can lead to beading and a dull needle, necessitating multiple
needle replacements. This method is best utilized for treating the glabellar
creases and for placement along the inferior orbital rim in treating periorbital
hollows, acne scarring, shallow forehead rhytids, and philtrum enhancement
and nonsurgical rhinoplasty. This technique is commonly mentioned with
silicone injection.

c) Serial Threading
Serial threading uses elements of both techniques and is useful in wider folds.
In this technique, the needle is inserted to its hub, taking care that the needle
is in the very deepest portion of the dermis or in the subdermal tissues. If the
skin dimples down with downward pressure on the needle, then the needle is in
the dermis. If the needle can be visualized through the skin, then it is too
superficial and will generally not produce an aesthetically pleasing effect. If
there is little resistance to the needle and the product upon injection, then the
needle is in the subcutaneous tissue.

d) Fanning /Cross hatching

The fanning and cross-hatching techniques are variations of linear threading
that allow filling of larger defects or facial contouring. In the fanning technique
a single needle puncture allows ‘fan-like’ placement of successive linear threads
by radially changing the needle direction. Cross-hatching delivers linear threads
in a predetermined grid by multiple punctures. The fanning method is the
preferred manner for achieving superior, natural appearing, and longer-lasting
results. However, the amount of product that is used is dependent on the depth
of the crease, the patient’s desired outcome, and the patient’s financial
preferences. The fanning method is appropriate for placement of the product in
the immediate subdermis or subcutaneous tissues. It is very difficult (if not
impossible) to perform the fanning technique in heavily resistant dermal
tissues. Because the subdermal tissues are less resistant, allowing for more
diffusion, more product is usually needed for complete correction with fanning
as compared with other techniques. In the fanning method, the needle is placed
just below the dermis at a 30° angle with the bevel position irrelevant. The
needle is passed back and forth under the fold, extending approximately 2 mm
lateral to 2 mm medial to the fold. The product is deposited both as the needle
is inserted and withdrawn, filling in an approximately 4-mm wide band of
product with the fold in the center. The product should be deposited slowly and
steadily. In most patients, it will take at least 1 mL of filler per fold to achieve a
satisfactory result. It is important to achieve complete correction but to stop at
the desired cosmetically appealing endpoint and refrain from overcorrection.
Results tend to improve over the next couple of weeks as inflammation
subsides and as the product “settles” into the fold. . Both techniques are useful
in the malar region and oral commissures.

e) Antegrade/Retrograde
It is common to use the anterograde technique along the vermilion border,
where the material will run along the potential tissue space with little or no
additional movement of the needle tip. This can help verify the proper depth of
placement for the needle tip. Other advantages of an anterograde approach is
that it may yield a softer forward movement through tissues, blunting the
impact of the sharp needle tip, pushing vessels out of the way of the advancing
needle, and reducing the probability of bruising. It is also possible to inject a
small amount of hyaluronic acid filler moving forward to blunt the dissection
and to inject additional filler as the needle is withdrawn if a greater volume of
correction is needed. Those who prefer the retrograde injection technique
believe that injecting slowly as the needle is withdrawn helps avoid
intravascular injection of filler. This technique is often chosen for very soft, thin,
or vascular areas, such as below the eyes or the malar region. In these areas, it
is especially important to avoid tissue trauma; with a fine needle, it is thought
that when the material flows as the needle is withdrawn, additional tracks or
dissection planes are not created. This may be preferred when injecting areas
with named vessels. Regardless of the technique used, it is essential to inject
slowly and gently to avoid tissue tears

Dermal filler Rejuvenation of the Lower Face

1) Volume Restoration of Mid Face

The fat pads in the cheek area are among the largest in the face and their
atrophy leads to the slackening of this large expanse of skin and eventual
ptosis. Because of the underlying skeletal support, the malar region is an
excellent region for volumetric highlighting. The principal cause of age-related
changes in the malar region is soft-tissue atrophy and to a lesser extent
gravitational descent. Therefore, the principal goal of soft-tissue fillers in this
region is to restore overall volume and contour rather than to fill a particular
depression. Reconstitution of the malar fat pads is part of a global face
approach that re-establishes an aesthetic convex shape to the face and will also
flatten the nasojugal and nasolabial folds. Prof. Moawad believe that volume
restoration of the mid face is the first essential step in the global
approach. Although, autologous fat grafting represents the ideal replacement
for lost volume in the malar region however, alternative volumetric fillers such
as Radiesse or a thick HA gel such as JU4 or Voluma , should be considered
when fat grafting is not an option. JU4 is recommended for more minor defects
at a dose of 0.4–0.8 mL per side, while Voluma is recommended where there is
more significant volume loss at a dose of between 2 and 5 mL per side.
Restylane Sub-Q (the largest particle size in the hyaluronic acid facial filler
range at 1000 particles/ml) is an effective alternative to fat transfer for mid-
facial augmentation and contouring.

Each product should be injected deeply under the orbicularis muscle, and both
under or in the malar fat pad and subocularis oculi fat. In treating the nasojugal
groove, I use Juve´derm Ultra or Restylane. Tear troughs’ formed by the naso-
jugal fold can be corrected with filler but achieving good results in this area is
challenging. The area should be anaesthetized with topical cream to avoid
distortion of the soft tissues and ice should be used for vasoconstriction to
reduce ecchymosis. The patient should be seated upright to prevent
gravitational movement of the orbital fat pads and to best delineate the area of
correction. Pre-septal injection of filler by linear threading along the orbital rim
avoids exacerbation of the pseudoherniation of orbital fat that creates the
original deformity. The area should be gently massaged after injection to
ensure even distribution. A good correction can last up to 2 years owing to the
relative immobility of the area can be effective when fat grafting is not an
option

Above the ala-tragus line CaHA should be injected supraperiostally, while below
the ala-tragus line injection should be at least deep dermally to the junction
with the subcutis. In both cases, a 1:1 correction factor should be used, no
overcorrection is needed, with treatment best being administered over two
sessions, depending upon individual patient characteristics and requirements.
The number of total injections can be minimized by threading multiple tracks
through one puncture with fanning dispersal of material in different directions.
By restoring structural support and fullness to the malar and infraorbital region,
CaHA can diminish the shadowing effect associated with aging of this
region. The material should then be massaged or molded to desired effect.
Care should be taken not to inject CaHA into the soft tissue above the orbital
rim as contraction of the orbicularis oculi may cause clumping of particulate
materials. For treating small malar smile lines. I use hyaluronic acid filler, but
not BoNTA alone because of the risk of a stroke-like appearance and/or an
inability to smile. To develop a posterior cheek vector a fixed point starting at
the zygomatic arch and in the direction of the jowls using a retrograde fanning
technique to target this posterior cheek region

2) Non Surgical Nose Job

A recent use of dermal filler is in nonsurgical ‘injection’ rhinoplasty to enhance
nasal profile and correct asymmetries whether congenital, traumatic, iatrogenic
or due to aging. Discreet volumetric changes in the fronto-nasal angle, nasal
dorsum and nasolabial angle lead to significant differences in our perception of
the nasal aesthetic. Injection augmentation of a deep radix will soften the
fronto-nasal angle and may disguise a prominent rhinon and dorsal
cartilaginous hump. Medial linear subcutaneous threading of the bony and
cartilaginous dorsum will narrow a broad nose, and lengthen a shortened nose.
Saddle nose deformity and/or upper lateral collapse may be disguised with
injection superficial to perichondrium. An underprojected tip may be built up by
supratip injection followed by moulding to the desired aesthetic result. Nasal tip
ptosis is addressed with single puncture injection into the collumellar base to
open the nasolabial angle. This angle may be opened further with injection of 2
units of Botox into the depressor septi muscle. Asian patients may benefit from
small amounts of filler in the bridge of the nose, which may also soften the
appearance of the epicanthal folds. Functional internal valve collapse may be
addressed with an endonasal ‘spreader’ injection of calcium hydroxylapatite
(Radiesse) into the apex of the internal nasal valve. Fluid HA can be injected
through a thin 30 G needle with no anesthesia needed. Enhancement is
immediate and lasts a long time, depending on the injected HA. However, it is
important to note that excessive filling of cartilaginous dorsum irregularities
may cause supra-tip deformation. In our experience the correction can last up
to 2 years with Restylane, and 3 years with Radiesse, probably because of the
relative immobility of the midface. Dilated nostrils: Nostril reshaping can be
performed by weakening the dilator nasi with small doses of botulinum toxin.
Botulinum toxin injections into the levator labii superioris alaeque nasi and into
the dilator nasi can help to narrow nasal flare, while expansion of nasal flare
can be performed using HA products.

3) Volume Restoration of the Lower face

Aging, volume loss and gravity cause descent of facial soft tissue, leading to
down-turned oral commissures and development of marionette lines
exacerbated by the action of depressor anguli oris. Descent of the malar fat pad
leads to deepened nasolabial folds and a prejowl sulcus and loss of jawline
definition is exacerbated by mandibular resorption. Selective correction with
site appropriate filler can restore volume and ‘lift’ the lower face nonsurgically.
Full rejuvenation of the lower face involves the control of muscle movement as
well as the restoration of volume. In many cases, neither BoNTA nor hyaluronic
acid filler alone will provide optimal results. It is critical to know the
musculature and its complex interactions in this area. Poor treatment planning
and reliance on skin landmarks may lead to asymmetries and other suboptimal
outcomes. Prof Moawad stressed that many patients complain about the
appearance of their lips, and a substantial degree of education may be needed
to help them understand the value of treating the entire lower facial region. In
general, the perioral area should be managed conservatively, with follow-up
visits scheduled to assess the need for additional treatment

4) Lips and Labial rhytides

Orbicularis oris action causes development of perioral rhytids, and age-related
atrophy leads to volume loss, flattening of the cupid’s bow, loss of vermillion
contour and convexity of the pout on profile view. In evaluating the patient’s
lips, a judgment should be made in terms of the length of the lower third of the
face in relationship to the upper two thirds of the face (rule of thirds). The
normal vertical distance of the upper lip should be approximately 10 mm and of
the lower lip 12–14 mm. The length from the columella to the vermillion border
of the upper lip should be noted. In some patients, this length is excessive and
would be ideally shortened with a lip lift. The relationship of the lower lip to the
upper lip should be evaluated. In general, the lower lip should have 25% more
volume or fullness than the upper lip. The shape of the upper lip should have
fullness of the Cupid’s bow and should have two definite anatomical mounds at
the highest point of the Cupid’s bow on each side of the midline. The lower lip
should have more subtle mounds on either side of the midline.

Lip augmentation is an increasingly popular procedure, and esthetic

practitioners are continually challenged to devise techniques suited to meet
individual patient requirements. However, to achieve a more youthful perioral
area, it is important to consider shaping the lips, not just simply adding
volume. There are several aspects to be considered when rejuvenating the lips
such as redefining the vermillion border, replenishing lost volume, and degree
of poutiness. Hyaluronic acid fillers are ideal for replenishing volume loss and
re-establishing a pleasing esthetic look comprising well-proportioned and
voluminous lips, while rhytides around the lips can be treated with small doses
of botulinum toxin to weaken the lip sphincter and smooth the wrinkles.
Interestingly, it has been found that treatment of the lips and the perioral area
is more frequently performed to prevent the effects of lip aging and for
treatment of dynamic lip rhytides in conjunction with other forms of esthetic
treatments. It is important to exercise caution during treatment to avoid
overcorrection. Restylane lipp and Surgilips are quite suitable while Radiesse is
not recommended in the lips because of an increased incidence of visible and
palpable granuloma formation in this region

Patients with thin lips, regardless of filling technique, are always going to have
somewhat thin lips. It is difficult to change the size of the lip, and lip
augmentation with any material merely enhances the natural lip shape. There is
a definite limit to how much augmentation can be performed in any given lip
before the results look unnatural and distorted. Asymmetries of the lip,
associated with smiling, can be improved upon but not resolved with lip
augmentation. It is important to observe the patient when smiling and in
repose.

Despite the sensitivity of the lips, it is now relatively easy to administer many
injections into this area due to surgeons using tiny 30 and 31 gauge needles, as
well as incorporation of topical or injectable anesthesia into treatment
regimens. Newer volumizing products containing lidocaine reduce the need for
use of conventional anesthetic techniques and so are recommended. Anti-
herpes preventative treatment can be used if required. If treatment is still
painful, a local infraorbital and mental block with 2% lidocaine and 1 : 100 000
epinephrine is advised. In this area, swelling and bruising are more frequent
than elsewhere.

I. White Roll Outline and Cupid’s Bow Area

The goal here is to accentuate the white roll and Cupid’s bow area to provide
definition, especially in the “lazy M” region. Since the lip does not have an
organized epidermis–dermis complex, the filler is actually being injected into
the potential space just under the mucosa. This pertains more to the “outlining
of the lazy M,” while augmenting the white roll. In this space, the filler should
flow freely with little syringe resistance, and there is generally antegrade fill
and sometimes retrograde fill as well. When in the correct space, the filler will
flow and not “well up” as a lump. If the filler is too superficial, there will be
considerable pressure on the syringe plunger, the tissue will “well up” as a lump
of filler, and there will be no forward flow. Starting at the commissure, the
needle is advanced along the vermillion line. Retrograde linear threading in the
subdermis enables filler hydrodissection and augmentation of the vermillio-
cutaneous border. On the other hand, if the filler is placed too deeply, it
spreads out and does not provide the desired “roll” effect. In other words, if
you are attempting to make a roll outline, you want to be in the potential space
just under the lip mucosa at the vermilion–cutaneous junction. Severe
blanching may be a sign of a too superficial injection and can disrupt the
vascularity, causing tissue loss.
II. Volume Restoration (Deep Injection)
If the surgeon is trying to add volume to the lips, then a deeper injection is
warranted to provide pout and to generally make the lip larger from within. This
can be done in addition to white roll augmentation or as an isolated procedure.
To increase the general lip volume, the needle is inserted deeper into the lip, in
about the outer one-third to one-half of the lip thickness. With this technique, I
usually inject at the wet–dry line and use the linear threading technique, where
I am injecting on the way out. Frequently, I will confine most of the injection to
the central one-third of the upper and lower lips and taper the filler as I extend
to the commissure. Some patients look better with the middle one third
augmented (what I call the kissing part of the lip), whereas others can use
augmentation out to the commissures. Again, it is better to err on the
conservative side as you can always add more.

III. Phitral Column Augmentation

Esthetic lips usually have a well-developed philtral complex. The philtrum is
distinct and the paired philtral columns are well defined. I feel that this is one
of the most undertreated areas when performing lip augmentation. Basically,
the filler is injected intradermally to accentuate the existing columns or make
new ones. The philtral column is frequently triangular with the apex under the
nostril and the base at the central portion of Cupid’s bow at the vermilion–
cutaneous junction. I pinch this area while injecting to corral the filler in the
desired area and maintain the triangular shape. Besides the lips, other perioral
wrinkles can be simultaneously injected.

5) Nasolabial Folds
The nasolabial folds represent the second most requested filler treatment. As
the deepening of the nasolabial folds begins by the third decade, it is often the
first sign of aging that a patient sees and wants fixed. As most people age, the
nasolabial folds deepen and are frequently a driving force in a patient’s decision
to have face-lift, laser, or other surgical procedures. Correcting the nasolabial
folds is essential for counteracting cheek ptosis and the incidence of marionette
lines, which both have an impact on jawline profile. One main problem that
must be discussed with potential filler patients for nasolabial fold treatment is
the fact that the folds will not “go away.” Failure to fully explain the anticipated
result will lead to a disappointed patient and doctor. I explain to all patients
that nasolabial folds are a natural part of facial aging, and an adult without any
nasolabial folds would look abnormal, as would an infant with a mustache. I
further explain that our goal in treating nasolabial folds is to blunt them, not
eliminate them. I tell the patient they are a valley and we want to make them
less deep. The goal for the treatment of the nasolabial fold is to diminish the
depth of the crease. The effacement of the nasolabial fold can be performed
with the widest array of fillers because of the thickness of overlying skin and
underlying skeletal support from the maxilla. The key to successful treatment of
the nasolabial fold is to accurately diagnose the cause of the deep fold. Some
portion of the nasolabial fold is attributable to gravitational descent of the
overlying cheek, and another portion is attributable to soft-tissue atrophy. To
determine the amount of fold that is attributable to soft-tissue atrophy versus
gravitational descent, we use a manual displacement test. The cheek is pulled
superolaterally. If gentle manual displacement results in significant effacement
of the nasolabial fold, the use of soft tissue fillers alone will probably not be
effective. However, soft tissue fillers are also quite effective in treating the
nasolabial crease due to soft tissue atrophy. The next most critical factor is
letting the patient know that it will probably take multiple syringes of filler to
make a difference. Fillers are expensive, and many patients only desire a single
syringe to split between both nasolabial folds. For all but the most minor folds,
this is an insufficient amount. In my experience, most patients will require at
least 2 syringes to make a difference and it may take up to 4 syringes for deep
folds.

Because of its improved longevity profile, Radiesse is our first choice of

injectable filler in the nasolabial fold. Radiesse has a firm, robust character once
injected and is therefore highly effective in treating men with thicker skin.
However, care must be taken to avoid superficial injections of Radiesse because
of the possibility of contour irregularities. An important drawback to the use of
Radiesse is relatively increased discomfort when compared with other
injectables. Hyaluronic acid is also effective in the nasolabial crease. We have
had particular success with the use of longer-lasting, large-particle hyaluronic
acid products: Perlane and Juve´derm. We have found these agents to be
comparable to Radiesse in this region. Lastly, we reserve smaller particle
hyaluronic acid (Restylane) for shallow nasolabial creases and for small touch-
ups

Although I rarely inject the lips without local anesthesia, I rarely use local
anesthesia for nasolabial folds or other skin injections. I generally apply topical
anesthesia for 10 minutes prior to injection. If this is not sufficient, then
infraorbital blocks or mucosal local anesthetic infiltration is performed
intraorally on the mucosal side of the nasolabial folds. A significant and
common mistake, especially with the novice injector, is to inject in the very
center of the nasolabial fold. Since various tissue planes merge in this area,
injecting filler material in the center of the fold can cause the filler to migrate
laterally. If this happens, one can actually make the nasolabial fold bigger! In
order to control the flow and location of the filler in the nasolabial fold, the filler
should be injected slightly medial to the actual fold. The filler can also be
massaged into the center of the fold. A cannula rather than a needle can be
used for HA filler administration at all stages. Filler is injected using a
retrograde linear threading technique along the line of the fold with a half-fan
at the bottom of the fold because of more volume deficiency in this area. To
flatten the fold, a ladder of radial retrograde linear threading is made
perpendicular to the fold. Good results can be obtained with malar
augmentation, which improves nasolabial folds as well. This is one area where I
commonly use linear threading and then fill in the gaps with serial puncture.

It is important to note that while volume restoration to the midfacial does not
eliminate the need to treat nasolabial folds, it does significantly decrease the
severity stage. It is important that augmentation of the proximal nasolabial
folds with fillers is performed with caution as there is a risk of vascular
compromise of the angular artery. Again, when using hyaluronic acid fillers,
significant swelling usually ensues immediately, so it is important not to
overcorrect the folds as it becomes difficult to tell what is filler and what is
swelling. I have all filler patients return in 2 weeks for follow-up and possibly
touch-up. Taking preinjection digital pictures is also important when injecting
fillers anywhere. Patients forget what they looked like and pictures are
necessary to truly evaluate a result.

6. Other Wrinkles of the Perioral Area

Perioral rhytids are filled with mid-dermis serial puncture can be injected
separately, but care must be used not to create “speed bumps” along the lip.
The marionette lines (mandibulolabial folds) are frequently injected by
intradermal linear threading. Radial fanning injections in an upward direction
may be required to fill marionette lines. Filling depressed commissures can also
be accomplished, but in my opinion, it requires a large volume of filler and
frequently does not meet the patient’s expectations. Sometimes, face-lift
surgery is required to pull the jowls and related tissues in a posterior–superior
vector, which can make a difference in perioral facial folds. The mentolabial fold
is sometimes augmented to improve lower facial esthetics. Correction of the
melomental fold can best be treated using a combination of botulinum toxin
and HA fillers, which together provide an adjunctive effect. HA fillers should be
administered 2 weeks after the botulinum toxin injection but, again, it is
important to avoid overcorrection.

Until recently, patients tended to request that treatment is limited to the

nasolabial folds and lips; however, it is now possible to take a more global
approach by incorporating jugal wrinkle correction into the overall treatment
plan. Treatment of jugal wrinkles should be performed using a combination of
HA fillers and botulinum toxin, which together have a synergistic effect. Prejowl
suclcus is injected at the intersection of jawline and the vertical line descending
from the outer edge of the nostril. . As mentioned previously, a retrograde
linear threading technique is used for submandibular and lateral mandibular
placement. It is suggested to use of a cannula and combined treatment
comprising botulinum toxin into the risorius muscle and HA filler in the cheek
wrinkles. However, it should be noted that this is an emerging technique with
little evidence current available in the literature on the treatment of cheek
wrinkles.

7. Chin
Slight recession of the chin can alter the appearance of the entire face.
Injections into the chin to alter its projection may provide dramatic
improvements in an individual’s appearance. Remodeling of the chin,
particularly the lateral regions that become hollow with aging, shows some
benefits by reshaping the oval facial outline or jawline. HA fillers are also useful
for smoothing the appearance of chin implants, particularly in the transition
area between the implant and soft tissue layer. The skin over the chin implant
may dimple, and this can be addressed using approximately botulinum toxin
into the mentalis. Dermal fillers should be injected using a needle or cannula,
although HA fillers with a long duration can be injected using serial puncture or
linear threading techniques.

8. Upper Jawline
The upper zones of the jawline require injection of CaHA at the dermal-
hypodermal junction or deep dermis using a retrograde fanning technique. As
mentioned previously, the choice of injection depth will depend on whether
using a needle or cannula and also on the thickness of the dermis.
Recommended insertion points are at the posterior cheek (“posterior cheek
vector”) and cheekbone.

9. Lower Jawline
The jawline is the defining feature of the lower face, but with age gradually
takes on a more square appearance compared with the oval of youth. For
correction of the oval in the lower jawline, To recontour the jawline, CaHA can
be injected along the periosteum of the inferior mandible. The usual point of
insertion is the inferolateral mandibular border. A retrograde linear threading
technique is used for submandibular and lateral mandibular placement. Radial
fanning injections from the same point of insertion can also be conducted if
required whether using a needle or cannula and also on the thickness of the
dermis. Recommended insertion points are at the mandibular angle and prejowl
sulcus.

10. Parotid Masseteric Hollow

The mandibular angle corresponds to the junction of the vertical and horizontal
components of the mandible. In certain cases, a longer-lasting result can be
achieved by inserting the needle at insertion at mandibular angle and injecting
in retrograde linear and fanning techniques orientated toward insertion points
zygomatic arch point to achieve a more valgus projection of the mandibular
angle. This three-dimensional volumetric approach reduces tension in the cheek
(increased collagen network) and creates more harmonious facial volumes.

11. Earlobe Volume

With age, the earlobes sag and develop creases. Irregularities in the ears are
seen as impediments to overall esthetic beauty. Treatment comprises the use
of fillers and resurfacing of the vertical rhytides immediately anterior to the ear
and earlobe, while HA fillers can be used to fill sagging earlobes and rejuvenate
appearance. Women who have had repairs due to earrings pulling through and
tearing the earlobe can benefit from the tissue expanding effects of hyaluronic
acid filler. Injection should be via a 27–30G needle using a combination of
serial threading and serial puncture. The filler can be injected directly into the
lobe and massaged into place to avoid lumping and to provide fullness to the
lobe; however, care should be taken to respect the overall esthetic appearance.
Treatment effects are very long-lasting, which may be due to the lack of
movement and metabolic activity in this region.

Post-procedure Considerations
The typical protocol for postprocedure care involves immediate placement of ice
onto the injected areas to reduce and limit tissue edema and bruising. The
subject should be advised to refrain from massaging or manipulating the
treated areas for at least 24 h as this can disturb the position of the filler.
Exposure to extensive sun or heat should be minimized for approximately 24 h
after treatment or until any initial swelling and redness has resolved. Some
consensus members also advise subjects to remain upright for the remainder of
the day and to sleep with their head elevated to reduce the degree of edema.
Post-treatment photographs may be taken as soon as the injections have been
completed and the washable markings removed. In the consensus members’
respective practices, follow-up visits are typically scheduled 2 to 3 weeks later,
with a further visit at 2–3 months for optional touch-up treatments if required

Adverse Events
The duration and severity of adverse events associated with CaHA are
comparable to those seen with hyaluronic acid fillers and are mainly volume
and technique related rather than associated with the material itself. Some
reactions occur immediately after treatment, whereas some have a delayed
onset. Similar to other dermal fillers, the principal side effects are redness,
swelling, and bruising. A number of steps can be taken to minimize these
adverse effects, including avoiding all blood thinningmedications starting 1
week prior to the procedure, staying out of the sun as long as swelling persists,
avoiding vigorous exercise during the first 24 h to avoid raising blood pressure,
keeping the head elevated throughout the procedure and for 24 h after, and
avoiding massaging the area other than that performed by the clinician
immediately after injection. Bruising can be further limited by a slow injection
technique with small aliquots of product, use of blunt cannulas and limiting the
number of skin punctures during the injection process using the linear
threading or fanning technique. As with any procedure that breaks the surface
of the skin, dermal filler injections are associated with a risk of infection. To
minimize this risk, the injection site must be sterilized with an effective topical
disinfectant, the needle and syringe safely removed from sterilized individual
packaging, gloves worn throughout the procedure, and care taken that the
needle is not contaminated during the procedure. A new syringe must be used
for each subject.

Dermal filler injections can lead to reactivation of herpes virus infections. If the
treatment is targeting the mouth area and the individual has a history of cold
sores, prophylactic treatment with valaciclovir (500 mg BID for 3–5 days) can
be started prior to injection to reduce the likelihood of this occurring. If the
individual has not received prophylactic treatment, but infection is recognized
early, valaciclovir at a dose of 2 g BID for 1 day should be given. Foreign body
granulomas are extremely rare, but can occur with all injectable dermal fillers,
usually after a latent period of several months to years after injection.
Inadvertent injection into a nerve or blood vessel is also a rare complication of
dermal filler procedures. Several papers highlight the treatment steps that
should be taken if these events occur

The Best Marriage, OnabotulinumtoxinA, Dermal Fillers and Volumizers

Traditionally, rejuvenation of the lower face has primarily focused on replacing
volume loss in areas such as; the nasolabial folds, marionette lines, mental
crease, oral commissures, and fine lines of the cutane¬ous lips. The benefits of
combined OnabotulinumtoxinA and HA filler treatments were highlighted,
particularly the beneficial synergistic effects of combined treatments that can
result in up to 50% improvement compared with using the products
individually. These combination leads to a rapid, temporary correction with a
weak morbidity and at reasonable treatment costs. This approach restores both
dynamic and static wrinkles and volumes, and enables a decreased quantity of
HA to be injected. Notably, the combination of BoNTA and hyaluronic acid filler
appears to increase the longevity of the outcomes, an issue of importance to
patients. Furthermore, this combined treatment may be used as preventative
treatment in younger patients. As he approach aging globally, Prof Moawad
recommends using a combination of OnabotulinumtoxinA and HA filler
administered to restore mouth corners, jawline, nose, ears and chin in the
lower face. Both BoNTA and hyaluronic acid fillers are integral to multimodal
approaches to facial rejuvenation and enhancement that include light and laser
techniques as well as topical treatments such as cosmeceuticals. Together,
these approaches can help clinicians and patients achieve highly satisfactory
outcomes.More than ever, patient education and counseling are essential when
developing a comprehensive treatment plan, so that patients can make
informed decisions about their treatment choices.

a) For the Midface, the most apparent effect of aging is the loss of volume.
Thus, hyaluronic acid fillers play a central role, with BoNTA treatment serving
as an important adjunct depending on the specific treatment plan. A key step in
facial rejuvenation of the midface is the restoration of volume in the malar
region. By treating this area with hyaluronic acid fillers, clinicians can provide a
more youthful, rounded area that will affect how other areas of the face, such
as the tear troughs and nasolabial folds, are subsequently treated. Importantly,
optimal results depend on using sufficient volume, and patients may need to be
educated that undertreatment is likely to lead to an unsatisfactory outcome.

b) In the Lower Face, both BoNTA and hyaluronic acid fillers are important
because rejuvenation involves control of muscle movement as well as
restoration of volume. Detailed treatment planning is essential, to avoid
asymmetries and poor outcomes. Knowledge of the musculature and its
complex interactions is crucial. Treating the perioral area is central to the
aesthetic outcome of the lower face, but treatment should be initiated
conservatively, with follow-up visits for additional treatments.

Energy Based Perioral Skin Rejuvenation/Tightening

The perioral region is like a barometer of chronologic and environmental age for
which patients often seek cosmetic rejuvenation. It is important for the patient
and physician to under¬stand the types of defects that can be improved using
noninvasive techniques and those that require a surgi¬cal approach. Anatomic
changes occurring in this region caused by ageing include; changes in skin
texture, tone, laxity, or pigmentation. A variety of energy based
technology are available for perioral enhancement , such
as dermabrasion, light, IPL radiofrequency, ultrasound and laser resurfacing.

What is Energy Based Skin Rejuvenation (EBSR)?

EBSR involves a variety of popular methods to rejuvenate, tighten and
resurface the face. It include non ablative lasers, intense pulsed light (IPL)
,Light emitted diode (LED) with or without photodynamic therapy
(PDT), fractional laser, radiofrequency, and ultrasound. In non-ablative tissue
tightening, the epidermal injury is minimized, and thermal energy is directed
into the reticular dermis and subcutis, where immediate tissue contraction and
delayed remodeling are believed to collectively cause skin tightening. The
attractive features of non-ablative skin tightening are limited post-procedure
healing time, ability to return to work or social engagements, reduced risk of
adverse events compared with ablative resurfacing or lifts procedures, and less
need for physician oversight. For all these reasons, more patients are
appropriate candidates for non-ablative skin rejuvenation than for ablative or
surgical skin tightening.

1. Non Ablative Lasers

Initially, the Q-switched Nd:YAG laser at 1064 nm, either alone or in
combination with a carbon particle solution, was shown to induce some dermal
remodeling. Then came the visible lasers such as the pulsed dye laser (PDL)
and the pulsed 532-nm potassium titanyl phosphate (KTP) laser, alone or in
conjunction with the 1064-nm neodymium yttrium aluminium garnet (Nd:YAG)
laser. These wavelengths have been found to improve skin signs of photoaging,
specifically; 532nm targets blood vessels and superficial pigmentation and
rhytides, and 1,064nm targets deeper dermal blood vessels and pigmentation.
The low-fluence QSNY laser of 4. J/cm2 and a repetition of rate of 5Hz with
spot size of 4mm using two passes at a 2-4weaks interval, was shown to be
safe an effective treatment for dark lip due to melanin excess. Reticular veins
in the perioral areas from 1 to 3 mm were treated with long pulsed Nd YAG
laser with 180–200 J/cm2, 3 mm spot size and a 25–50 ms pulse width
depending on the vessel size; 1 mm vessels were treated with a 25 ms pulse
width and 2–3 mm vessels were treated with a 50 ms pulse width. The
treatment goal was to achieve immediate blanching of the vessels which
normally requires one to two passes. The vessels were treated from distal to
proximal without overlap.

The use of aforementioned lasers for dermal remodeling has been largely
replaced by the longer wavelength infrared lasers, which more effectively target
the mid dermis, resulting in more consistent mild improvement in rhytides. The
prototype of nonablative rejuvenation is the infrared Nd:YAG laser at 1320 nm
(CoolTouch; Mesa, Calif)and, more recently, the diode laser at 1450nm
(Smoothbeam; Wayland, Mass) and the erbium:glass laser at 1540nm. They
are more effectively target the mid dermis, resulting in more consistent mild
improvement in rhytides. Patients should be advised that the results are less
dramatic than those obtained with ablative resur¬facing and multiple
treatments may be required.

2. Non Ablative Light Rejuvenation (Photofacial or Fotofacial)

Photo facial is a generic term for a skin treatment that uses some kind of light-
based technology. Photo facials (sometimes called foto facials) have a number
of different uses, but are mostly used for treating brown spots, broken
capillaries, and boosting collagen. The two main types of technology used for
photo facials are LED (light-emitting diode) and IPL (intense-pulsed light).

I. Light Emitted Diode (LED)

An LED photo facial is a very gentle treatment that uses narrow spectrum light
to boost collagen, which creates plumper, younger-looking skin or to kill the
bacteria that causes acne. LED photo facials are painless, cool and relaxing, and
(unlike IPL or laser treatments) carry no risk of burning. Light-emitting diode
photomodulation uses coded pulses of low energy, non laser, non thermal light
energy to stimulate mitochondrial activity, increase collagen and fibroblast
production, and decrease collagenase. LEDs reduce the appearance of fine lines
and wrinkles, as well as improving the appearance of photodamage induced
large pores. Through the process of LED Photomodulation, LED Light can both
corrects skin appearance and helps minimize signs of aging over time. The best
results come after a series of photo facial treatments. To begin, a series of six
treatments with one-to two weeks between is recommended. After that,
maintain with a treatment every month or two. It is offered a stand-alone
treatment or faster results as a part of more comprehensive rejuvenating MSI
Peel.

II. Intense Pulsed Light (IPL)

An IPL photo facial delivers a bright blast of light (500-1200nm) at very high
energy levels through a hand-held device. Filters may be placed to exclude
shorter wavelengths, thereby preferentially targeting various chromophores.
The advantage of IPL is its ability to target both melanin and hemoglobin
resulting in global improvement in dyspigmention and vascularity. In addition,
it induced collagen remodeling with modest effect. An IPL photo facial is the
better choice if you have brown spots, broken capillaries or overall redness of
the face. The term ‘‘photo rejuvenation’’ was coined in describing the global
improvement in multiple parameters of photoaging. The use of IPL has led to
modest clinical improvement in rhytides, although pigment and vascular
abnormalities of photo damaged skin show dramatic improvement. The
combination of IPL with RF leads to a syner-gistic effect, resulting in further
improvement of wrinkles and skin texture accompanied by a reduction of skin
laxity. IPL has been the most effective light source used in conjunction with
aminolevulinic acid (ALA) to improve skin signs of photoaging in photodynamic
therapy.

Photo facials work best in conjunction with a regular skin care routine. After
each treatment, patients can return to normal activities. The skin will be slightly
pink when you leave, but easily covered with makeup. After the initial series of
treatments, additional Fotofacial sessions are recommended once every 3 to 4
months to maintain results. It can be offered as a stand alone treatment or
mostly as a part of more comprehensive rejuvenating MSI.

III. Photodynamic Therapy or PDT

Photodynamic therapy (PDT) involves the use of photochemical reactions
mediated through the interaction of photosensitizing agents, light, and oxygen
for rejuvenating the skin and treat acne. Photodynamic therapy is a 2-step
procedure. In the first step, the plant photosensitizer (mild reaction) or ALA
(moderate to severe reaction) is applied to the skin and it is allowed to be
taken ups. The second step involves the activation of the photosensitizer in the
presence of oxygen with a specific wavelength of light (infrared light, IPL, Laser
or LED (blue, red or combination). Once delivered, the targeted tissue absorbs
the light’s energy. Photodynamic therapy works best for improving any type of
sun-damaged.
3. Non Ablative Rradiofrequency (NARF)
In an effort to increase penetration depth and strive towards collagen shrinkage
and skin tightening, radiofrequency wavelengths have been recently employed.
Radiofrequency devices utilize electrical energy to transfer heat energy to the
dermis at relatively low temperatures. These devices typically are not intended
to resurface the skin but rather to induce thermal damage to dermal collagen
while sparing the epidermis. Resistance and the resultant degree of thermal
damage is determined by the depth and composition of the treated tissue.
Because RF energy uses an electrical current rather than a light source, it does
not affect epidermal melanin; therefore, patients of all skin types, including
darker skin types and those with a predisposition to develop post-inflammatory
hyperpigmentation may be treated with RF. Radiofrequency devices produce
electrical energy that heats the dermis without plume and at relatively low
temperatures. Radiofrequency devices can be classified into several
configurations based on the method by which the electrical current passes
through the tissue. The first type to be introduced was monopolar RF, which
applies energy to tissue via a single electrode tip and a grounding plate. Bipolar
RF applies energy to tissue via 2 points on the tip of a single probe, and
penetration depth is estimated at half the distance between the electrodes.
Tripolar RF devices recently were introduced; this technology utilizes a multiple
electrode configuration to heat superficial and deep skin layers simultaneously.
Fractional RF also is a novel technology in which bipolar RF energy is delivered
via a minimally invasive approach using a microneedle electrode assembly.

a) MONOPOLAR RF
Monopolar systems deliver current using one electrode that contacts the skin
and another that acts as a grounding pad. The electrode contacting the skin
delivers the electric current to the skin. The epidermis is spared by contact
cooling hat the tip of treating head. The FDA initially approved monopolar RF
devices to treat periorbital wrinkles. Since then, they have been used to treat
laxity of the forehead, cheeks, nasolabial folds, marionette lines, jawline, and
neck. The low level multiple passes approach necessitate 4-6 sessions every
one to two weeks. The procedure can be repeated every one year as needed to
maintain the results. Noninvasive skin tightening treatment of the perioral
area is best indicated for patients with mild to moderate dermatochalasis,
reasonably good skin tone, and minimal tissue ptosis. Ideal candidates for this
noninvasive treatment either do not want or do not need skin lifting surgery. In
general, younger patients who do not want or do not need a very marked
change in their perioral appearance, or patients who have previously
undergone skin lifting who are noticing a gradual recurrence of skin laxity are
the best candidates for monopolar radiofrequency (RF) skin tightening.
Contraindications include implantable medical devices such as pacemakers and
defibrillators and active dermatologic conditions such as collagen vascular
disease and autoimmune diseases. Everybody is a good candidate for RF, but it
is of special significance to whom do not like invasive surgical intervention, and
who is still young for surgery.

b) Bipolar RF
The main difference between bipolar and monopolar RF is the configuration.
The bipolar configuration consists of two active electrodes placed a short
distance apart overlying the intended treatment area. The current flows
between the two electrodes. The depth of penetration is approximately half the
distance between the two electrodes. The major limitation of this configuration
is the depth of penetration. The monopolar device achieves high penetration of
the emitted current, which serves as its main advantage and also its major
drawback, which is associated pain. The bipolar configuration is not as
penetrating but provides more-controlled distribution of energy and less pain.

Bipolar RF devices are frequently combined with light-based technologies,

termed electro-optical synergy (ELOS). Functional aspiration controlled
electrothermal stimulation(FACES) is another system used with the bipolar
device that uses a vacuum to maximize and control penetration of the electric
current. The mechanism of action for simple bipolar RF devices is similar to
that of monopolar RF devices. The electric current generates heat as it travels
through the skin and meets resistance from the tissue. This heat causes
collagen shrinkage, an inflammatory response, and fibrous septa contraction in
the dermis. Bipolar RF has been employed for a lengthy and continually
expanding list of indications, including skin laxity, wrinkles, vascu¬lar lesions,
dyschromia, cellulite, and body tightening.

The ELOS system uses the synergistic effects of light and RF-based devices.
The light energy is used to preheat the target tissue through photothermolysis,
which lowers the tissue’s impedance. The lower impedance makes the tissue
more susceptible to the RF component so that it is selectively targeted.
Therefore, lower levels of energy of the light and RF component are needed to
produce the desired effect with fewer side effects. The optical component also
targets fibroblasts, blood vessels, and dyschromias. ™.This combination has
been shown to induce tissue contraction and effects on laxity, rhytides, and
other aspects of photodamage. A major drawback of this therapy, however, is
that it requires numerous treatments at 2- to3-week intervals, which may
ultimately achieve only mild to moderate improvement. RF devices the Polaris™
and ReFirme™ from Syneron™ utilize bipolar RF at the ends of laser systems
(780–910nm diode for the Polaris and 700–2000nm infrared light for the
ReFirme

Pellevé can deliver monopolar or bipolar RF depend¬ing on the handpiece used

and is FDA approved for the treatment of mild to moderate facial wrinkles and
rhytides in Fitzpatrick skin types I to IV. In contrast to Thermage, treatment
with Pellevé does not require anes¬thesia or external cooling of the skin. A
treatment gel ensures proper coupling of the device, and the Pellevé electrodes
are moved in a circular pattern over the skin with 3 to 4 passes that raise the
skin temperature to 42°C.

c) Fractional RF
Fractional RF is a newer nonablative approach. There are two ways to deliver
fractional RF. Whereas some devices (Matrix RF device; Syneron, Medical Ltd)
use electrodes, others use an array of microneedles arranged in pairs between
which bipolar RF energy is delivered (ePrime system; Syneron Medical Ltd).
Another system Miratone FRF system (Primaeva Medical, Inc.,Pleasanton, CA)
using a microneedle electrodearray. The fractionally delivered energy creates
zones of affected skin adjacent to unaffected areas. The treated areas have
resulting thermal damage in the deep dermal collagen, which stimulates would
healing, dermal remodeling and new collagen, elastin, and hyaluronic acid
formation. The unaffected areas located in between affected areas initially
maintain skin integrity but, in the long term, serve as a reservoir of cells that
promote and accelerate wound healing. ractional RF has been demonstrated to
induce improvement in skin texture and reduced wrinkles in both abdominal
and facial skin. Other than pain and tran¬sient erythema, no adverse events
were reported. A new device has been developed that combines fractionated
optical energy with a 915-nm diode combined with a fractionated bipolar RF.
This integrated system targets the epidermis and superficial dermis. By using
the RF component synergistically, less energy is used to heat the collagen in
the deep dermis and stimulate new collagen formation and contraction (Matrix
eLaser; Syneron, Irvine, CA).

How Does Non Ablative Radiofrequency (NARF) Works?

Radiofrequency devices deliver volumetric and uniformheating to the deep
dermis with simultaneous surface cooling of the skin. Unlike lasers, which
target specific chromophores based on the principle of selective
photothermolysis, radiofrequency generates heat based on a tissue’s natural
resistance to the movement of electrons within a radiofrequency field. When
applied over a period of time, thermal energy contracts and thickens collagen
fibers, disrupts hydrogen bonds, and alters the conformation of the collagen
triple helix. It also induces a more prolonged wound-healing effect that is
associated with sustained remodeling, reorientation, and formation of new
collagen bundles over subsequent months, resulting in effective skin
rejuvenation with minimal recovery time. The understanding of the clinical and
histologic changes induced by monopolar RF advanced through the work of Prof
Moawad and his colleagues. At MSI we treated participants with Glogau
classification I to II facial wrinkles and reported increases in mean collagen
types I and III as well as newly synthesized collagen. We also observed higher
levels of mean collagen and a lower level of mean elastin at 3 months post-
treatment compared to immediately post-treatment, which they attributed to
continued dermal remodeling. Participants demonstrated statistically significant
improvements in skin tightening in the periorbital area and forehead. Although
the results of RF are not as dramatic as a facelift, over 90% of patients obtain
noticeable tightening of the treated areas and it never looks “pulled.” These
devices are used for noninvasive treatment of periorbital rhytids, as well as
thermal lifting of the face, neck, and brows. Human eyelids can be safely
treated with monopolar RF energy delivered via a novel 0.25 cm2 treatment tip.
Effectiveness at shrinking eyelid skin was at best mild to moderate.
nPretreating patients with botulinum toxin type A (Botox) 2 weeks before a
therma-lifting procedure helps to promote relaxation of the muscles that
depress the brow and the lower face, decreasing resistance to collagen
contraction and allowing for more efficient collagen remodeling.

d) Non Ablative Infrared Light

There are different approaches to heating up the dermis to effect clinical skin
tightening. The first is by radiofrequency energy and the second infrared non-
ablative heating device (Titan, Cutera, Inc., Brisbane, CA) with epidermal
cooling. The device emits a broadband light spectrum between 1,100 and 1,800
nm effective in achieving mild to moderate gradual clinical improvement in the
treatment of facial and neck skin laxity. Although the initial tightening may be
impressive to patients, it is often temporary. More importantly, the heating
initiates progressive collagen remodeling over the next several weeks and
months resulting in gradual skin tightening and reduction of skin laxity. The
procedure is associated with minimal downtime and is safe for use in darker
skin, Types IV and V. The StarLux IR delivers fractionated energy through the
hand piece of the device, which emits light in the range of 850 to 1350nm to
the deep dermis, again targeting water as the principal chromophore along with
its mechanism of action and infrared absorption depth. Several treatments are
required with this device for successful collagen remodeling to be achieved. The
SkinTyte also utilizes light energy in the range of 800 to 1400nm. It works
through a sophisticated cooling mechanism as well, with pre- and post-cooling
during the actual treatment. Clinical results of this device show tissue
tightening

e) Focused Ultrasound (Ulthera)

An alternative to light-based sys¬tems is the use of intense ultrasound.
Ultrasound energy has specific characteristics that may increase its suitability
for skin tightening. It is widely believed that energy delivery to the deeper
subcutaneous layers of the face, or even the superficial musculo-aponeurotic
system. Intense ultrasound works as follows: an ultrasound field vibrates
tissue, thus creating friction between molecules, which absorb mechanical
energy that leads to secondary generation of heat. Overall, selective
coagulative change is effected within the focal region of the beam but other
tissue proximal and distal to the focal region of the ultrasound field is
preserved. Notably, the intense ultrasound used for skin tightening (Ulthera
System, Ulthera Inc, Mesa, AZ) is different from ultrasound devices designed
for lipolysis. The skin tightening ultrasound penetrates 4 to 5 mm into the facial
skin and delivers focal, intense pulses (20-50 milliseconds long) that cause
localized thermal injury, and instigate the tissue repair cascade. Deep skin
layers are targeted and heated to stimulate the growth of collagen, which
gradually lifts the skin in 3-4 months. It is currently used for a non-invasive
eyebrow lift and can be used to return definition to the jawline and improve the
area under the chin. A single ultrasound treatment of the forehead produced
on average brow height elevation of slightly less than 2 mm. The ultrasound
treatment can be quite effective to non-invasively rejuvenate the face; it is best
performed using light pain medication to increase comfort during the
treatment. It is suggested to repeat the treatment every 2-3 years to maintain
the results.

Who Is Good Candidate for Non Ablative Skin

Rejuvenation/tightening?
Patients with mild, moderate, and severe rhytides and photodamage are
candidates for nonablative technology; however, patient expectations must be
handled directly. Patients who are concerned about risk and recovery and are
willing to accept minimal efficacy in exchange for minimal risk are the ideal
candidates for nonablative approaches. The advantage of virtually all
nonablative devices and techniques is that postoperative care is unnecessary.
Immediately postoperatively, minimal erythema and edema resolves within
several hours. The majority of patients can apply makeup and return to normal
daily life immediately following treatment
Pulsed dye, KTP, and IPL treatment are minimally painful require no anesthesia.
Topical anesthesia is the mainstay for pain control during nonablative
resurfacing using the 1320-, 1450-, and 1540-nm devices. Multiple treatments
numbering roughly 5 are administered every 3 to 4 weeks. The infrared lasers,
such as the 1320-nm Nd:YAG and 1450-nm diode are operated at the highest
tolerated fluence to insure success. Erythema and minimal edema is the desired
clinical endpoint regardless of laser system used, and also appears to be
directly correlated with clinical outcome. Treatment with insufficient energy
produces little if any wrinkle reduction or scar improvement. Cold packs may be
applied immediately after laser treatment to alleviate any further discomfort.
No discomfort should be expected once the laser treatment is concluded.

IPL devices and combination differ dramatically between systems; however, all
require the application of cold aqueous gel and one to multiple passes in each
treatment session. A series of 5 to 6 or more treatments are typically used. RF
treatment techniques vary depending on the device being used. The patient is
grounded using a grounding pad for monopolar RF; for bipolar RF and the novel
unipolar RF system, this is not necessary. A coupling fluid or aqueous gel is
used with the treatment tips of the devices. Recently, the approach of low
Fluence /multiple passes radiofrequency devices have been optimized to no
anesthesia is needed.

f) Ablative Laser Resurfacing (ALSR)?

Although fillers and implants can rejuvenate the perioral area, nothing can
come close to the impact that aggressive CO2 skin resurfacing has on this area.
Cosmetic surgeons can put all the filler they want in a patient’s lips and it will
indeed make the lips bigger and the stretch from the filler may hide some
rhytids. No filler, however, can cut through decades of skin aging like CO2 laser
resurfacing can. The aging skin is frequently a sallow color and, especially in
the perioral area, can take on a pebbly appearance from actinic damage. Solar
lentigos and other actinic and age induced lesions are also quite common, in
addition to dreaded vertical lipstick lines.. I never laser the perioral area as a
solitary cosmetic unit. I feel that one can get away with solitary periorbital laser
skin resurfacing, because the periorbital areas are recessed and blend in when
confined to the skin within the bony orbit. The perioral area is quite different. I
have seen too many patients treated at other offices with isolated perioral
resurfacing, and they end up with a very apparent distinction between the
treated and nontreated areas. A laser “milk mustache” is not uncommon.
Because of this, I always perform a full face laser when treating the perioral
area, to minimize the color disparity and blend the areas.

Who Need Ablative Laser Skin Resurfacing?

The optimal candidate is a patient with Fitzpatrick skin types I to IV with
photodamage and moderate postoperative expectations. Of import, perioral and
periorbital rhytides, which are resistant to face lift procedures, are highly
amenable to laser resurfacing. Fine rhytides, particularly in the periorbital,
perioral, and cheek areas may be completely eradicated with laser resurfacing;
deeper creases are also improved, probably secondary to a general tightening
effect. Rhytides and creases upon active movement and facial expression, such
as in the glabella and nasolabial folds, tend to be more resistant to laser
resurfacing and better addressed combination of neurotoxins and fillers.
Contraindications to ALSR include a history of keloids or connective tissue
diseases. Diseases with koebnerizing features, such as psoriasis or vitiligo, are
considered relative contraindications.

Does Ablative Laser Skin Resurfacing Need Skin Preparation?

Preoperative regimens used to improve outcome from laser resurfacing include
the use of tretinoin, which appears to speed healing after laser resurfacing. skin
type III or darker pigmented skin types are usually started on topical bleaching
agents, such as hydroquinone, before resurfacing shown to reduce the risk of
post-inflammatory hyperpigmentation. All patients, regardless of whether they
have a history of herpes labialis, receive prophylactic oral antivirals, such as
acyclovir, starting 1 day before resurfacing and continuing for 10 days
postoperatively or until reepithelialization is complete. Oral antibiotics, such as
dicloxacillin or azithromycin, are prescribed routinely to reduce the chance of
secondary bacterial infection. Some physicians recommend. In addition, a 3- to
4-day course of systemic corticosteroids preoperatively may be prescribed to
reduce the significant edema.

Is Ablative Laser Skin Resurfacing Painful?

The CO2 laser typically produces more discomfort than the Er:YAG laser. For
localized treatment of individual cosmetic units, such as the periorbital and/or
perioral areas, local anesthesia is sufficient. Topical anesthetic agents, such as
lidocaine and prilocaine cream (EMLA cream) are used for superficial laser
procedures, namely the shortpulsed Er:YAG laser. For full-face laser
resurfacing, a combination of topical and systemic agents is usually employed.

How Does Ablative Laser Skin Resurfacing Done?

In CO2 laser resurfacing for rhytides, a first ‘‘pass’’of non-overlapping and
vaporizing laser pulses is performed, followed by gentle yet thorough wiping of
the desiccated debris with saline-soaked sponges. The skin surface then reveals
a pink hue, representing partially denatured papillary dermis. Dry gauze is used
to remove any water remaining on the skin, which may absorb laser energy and
block its targeting of dermal tissue. A second laser pass is then performed, and
subsequent passes result in progressive yellowing and visible tissue contraction.
In a typical resurfacing session, passes are made over the entire treated area.
Subsequent passes are concentrated on high points of scars or shoulders of
rhytides. In order to blend or soften lines of demarcation, the feathering of
borders is performed with low-pulse energy and density. The end point of
treatment is the effacement of tissue irregularities and visible wrinkles.

How Do I Look Like after Ablative Laser Skin Resurfacing?

Edema, exudation, and sloughing of thermally denatured collagen occur during
the first 1 to 3 days. Edema is often most severe on the second and third
postoperative days and treated with ice packs, head elevation at night, and, if
severe, oral corticosteroids. Cool compresses are used and wet debridement is
performed throughout the first week. Continued 0.25% acetic acid, normal
saline, or cool tap water soaks are followed by the application of petroleum jelly
or healing ointment. Acetaminophen (paracetamol) with or without codeine
phosphate or hydrocodone can alleviate discomfort. During the first few weeks
after resurfacing, patients will often complain of pruritus, which is usually self-
limited and controlled by antihistamines and mild topical corticosteroids. There
is also evidence that exogenous intake of estrogens improves outcome
following ablative resurfacing. After reepithelialization, there is a variable period
of erythema ranging from 1 to 4 months, which is easily camouflaged with a
make-up containing green foundation. Sun avoidance after laser resurfacing for
the entire period of post-laser erythema should be stressed to the patient to
reduce the risk of postinflammatory hyperpigmentation. As with most cosmetic
procedures, patient expectations are the most important determinant of patient
satisfaction with the outcome.

What are the Results of ALSR?

Although traditional ablative laser resurfacing was able to achieve results for
skin tightening, which rivaled surgical correction, the side effects of several
months erythema and swelling, long-term risks of prolonged dyspigmentation
and potential scarring significantly limited the application of this technology. In
the resultant wound-healing cascade, fibroplasia and neocollagensesis were
evident in the treated areas. Downtime with the CO2 laser typically lasted
about one week or more, and depending on the device and the aggressiveness
of the clinician utilizing the device, potential adverse effects became more
widespread. These potential adverse effects included pain, edema, persistent
erythema, infections, postinflammatory hyperpigmentation, and the most
problematic of all, hypopigmentation following the ablative procedure, seen in
some patients two years following the laser surgery.

g) Fractional Skin Laser Resurfacing (Non Ablative/Ablative)

FT was developed as a way for laser surgeons to get closer to ablative laser
resurfacing clinical outcomes with less patient downtime and fewer overall
adverse events. Simply stated, FT is the production of an injury pattern to the
skin with skip areas repeated over and over again, which, as they heal,
promote an improvement in the tone and texture of the skin, in lines and
wrinkles, in pigmentary concerns including melasma, and in scars, especially
acne and traumatic scars. The concept of fractional emission of light into
microscopic zones of injury contrasts with traditional ablative skin resurfacing
using a CO2 or erbium laser, in which a flat beam induces a confluent, uniform
patch of epidermal or dermal injury. After a 48- to 72-hour phase of acute
thermal damage, a phase of re-epi¬thelialization and repair starts, which is
mediated by the adjacent columns of intact tissue. In this 30-day phase, the
areas of thermally ablated tissue are repopulated by fibroblast-derived
neocollagenesis and epidermal stem cell reproduction. Based upon these
mechanisms of action nonablative FP holds great promise in both treatment of
skin textural abnormalities (acne scarring, rhytides, and skin mottling
associated with photoaging) as well as pigmentary variation (melasma,
hyperpigmented scars, lentigines, and dyschromia). One of the significant
advantages of nonablative FP is the low incidence of adverse side effects.

Fractional thermolysis (FT) can be divided into several classifications. The

easiest has been to classify FT devices into nonablative and ablative FT laser
systems. This classification was “easy” at the beginning when only several
devices were available. It is now a little more complex, especially among the
ablative laser systems, thus new terminology seems prudent at this time.
Ablative FT laser systems originally were divided into classifications based on
laser type: CO2, Er:YAG, or yttrium-scandium-gallium-garnet (YSGG, 2790nm).
What has changed is that different ablative FT laser systems emit light
differently, with penetration depths that may be considered “superficial” and
others that may be considered “deep.” Thus a new classification system seems
prudent at this point. ablative FT lasers has been classified into “micro-ablative
FT laser systems,” which would include those lasers that produce epidermal and
dermal damage to a depth less than 750 microns, and “deep dermal ablative FT
laser systems,” which would include those lasers that produce damage beyond
750 microns in the skin.

I. Non Ablative FP Lasers (NAFP)

Indications for nonablative FP include mild to moderate acne scarring;
dyschromia; fine wrinkling and texture changes associated with photoaging on
the face. The non ablative FP systems include; Fraxel restore 1550nm, Fraxel
refine 1410nm, Affirm 1440nm, StarLux 1540, Matisse 1540nm,
Dermablate1540nm, Mosaic 1550nm and Sellas 1550nm. Theses nonablative
devices produce minimal patient discomfort. Some patients may require a
topical anesthetic prior to the procedure and/or forced cool aircooling during
the procedure. After treatment most patients notice erythema and some
edema, which can last for up to 48 hours following the treatment, followed by
skin desquamation for several more days. With all nonablative fractional
devices, there is usually a need for multiple treatments to achieve the final
result.Most contend that 4 to 6 treatments are required to attain the given
desired outcome for the majority of clinical indications.

II. Ablative FT Lasers (AFP)

It is used for ablative skin rejuvenation, and therefore it was obvious also to
utilize this laser in a fractionated manner for treating rhytids, fine lines and for
skin resurfacing Ablative .Fractional carbon dioxide (CO2, 10,600 nm)
photothermolysis such as Fraxel re:pair, Reliant DEKA Smartxide DOT Ellipse
Juvia (Hørsholm, Denmark), Lasering USA Mixto SX, and Lutronic are now
available. The Er:YAG laser operates at a wavelength (2940 nm) where tissue
water absorbs maximally. The Ablative fractionated Er:YAG laser (2,940 nm)
(Pixel, Alma Lasers) was designed to overcome the homogenous pattern of
thermal damage created using standard erbium-doped yttrium aluminum
garnet (Er:YAG) by creating microscopic thermal zones (MTZs) with sparing of
tissue surrounding each wound.
The degree of improvement with ablative fractionated resurfacing significantly
surpasses that of the original prototype nonablative fractionated devices, with
only slightly longer downtimes and similar low side effect profiles. This mode of
resurfacing produces improvements in the skin signs of photoaging
(improvement moderate to severe rhytides, dyschromia and skin mottling, and
other texture abnormalities) analogous to that only previously achievable with
traditional ablative resurfacing or even greater because of the pattern of
thermal ablation, which provides deep dermal penetration not be achieved
safely with traditional ablative devices. Furthermore, the rapid recovery times
seen with fractionated CO2 laser marks a significant improvement over
traditional CO2 and Er : Yag laser resurfacing because of the differences in
mechanisms of wound healing. Traditional ablative laser wounds heal by
migration of stem cells from hair follicles. In contrast, with fractional ablative
resurfacing, re-epithelialization occurs more rapidly because of migration of
neighboring cutaneous stem cells.

h) Ablative Plasma Skin Resurfacing

Plasma skin resurfacing. A novel device for performing ablative resurfacing has
been developed which works by passing radiofrequency into nitrogen gas. The
‘‘nitrogen plasma’’ causes rapid heating of the skin with limited tissue ablation
and minimal collateral thermal damage. Differences between plasma skin
resurfacing and laser skin resurfacing techniques include lack of chromophore
dependency and maintenance of the structural integrity of treated tissue after
delivery of plasma energy. After the delivery of plasma energy to the skin,
there are resulting zones of thermal damage and thermal modification (similar
to ablative skin resurfacing). The zone of thermal damage is ultimately
sloughed, while the zone of thermal modification recovers. Maintenance of an
intact epidermis overlying the area of injured tissue appears to support shorter
healing times relative to ablative skin resurfacing techniques. The more
aggressive the treatment—that is, the higher the fluence—the more impressive
the results. The only plasma skin resurfacing device commercially available is
produced by Rhytec Inc., Waltham, MA. This device is cleared by the FDA for
cosmetic improvement for treatment of facial and nonfacial areas for rhytides.
Until recently, this device had not been formally evaluated for its safety and
efficacy in treating the eyelids. Results appear to be similar to gentle CO2 and
Er:YAG laser resurfacing.

HA Fillers or BTX-A With Laser or Light Modalities

Laser or light treatments used in combination with der¬mal fillers and/or BTX-A
allows for more global aesthetic improvement in facial aging. Patients
undergoing noninvasive facial rejuvenation often prefer to have multiple
cosmetic procedures performed at one time to minimize downtime. However,
concerns have been expressed regarding the combination of dermal fill¬ers
with laser or light therapies because the heat generated in the dermis could
possibly reduce the efficacy or lead to more rapid degradation of dermal fillers.
Although there is no substantial evidence that energy based technology will has
determintal effect on fillers, some practitioners prefer to perform filler injections
following long pulsed lasers or radiofrequency or wait several days. For
example, the use of nonablative lasers, intense pulsed light, or radio-frequency
when used immediately after BoNTA treatment does not reduce the efficacy of
BoNTA treatment. Indeed, BoNTA plus laser treatment increases the extent and
longevity of improvement compared with laser treatment alone. In addition,
BoNTA plus intense pulsed light improves outcomes over intense pulsed light
alone when the crow’s feet are treated. Similarly, radiofrequency, lasers, or
intense pulsed light can be used safely and effectively in combination with
hyaluronic acid filler to treat nasolabial folds and perioral rhytides. Given their
experience, the faculty cautioned that edema from other treatments, such as
fractional laser therapy, could distort the anatomy, which could affect filler
placement and potential migration of neurotoxin. Therefore, any multimodal
treatment plans should take such effects into consideration.
Topical Agents, Chemical Peels, and other Considerations

a) Cosmeceuticals
Topical agents can be used in conjunction with other modalities. Although
topical retinoids remain the gold standard for photoaging, many patients are
unable to tol¬erate them around the eye. One such trend is the development of
natu¬ral antioxidants such as niacinamide. Antioxidants are the largest
category of cosmeceutical ingredients incor¬porated into topical treatments and
will likely remain so for the next several years. They can be divided into 3 main
categories: carotenoids, flavonoids, and polyphe¬nols. The carotenoids are
derivatives of vitamin A and thus are components of many cosmeceuticals
because of their similarity to retinoids. The flavonoids are aro-matic compounds
with antioxidant and UV-protection properties. Commonly used flavonoids in
cosmeceu¬ticals include soy, milk thistle extract, and ginkgo. The polyphenols
represent a subset of flavonoids and include common cosmeceutical ingredients
such as green tea, pomegranate, and grape seed extract.

b) Mesolipolysis
The injection of phosphatidylcholine (250 mg/5 ml) into the fat pads is a simple
office procedure popularly used in subcutaneous injections for fat
dissolution. Especially jowls, and submental localized fat deposition. After 5
minutes of applying an ice compress to the infra-orbital skin, 0.5-inch, 30-
gauge needle was used to inject 0.4 mL of phosphatidylcholine approximately
0.5 cm deep into the un-anesthetized area. An ice compress was then
reapplied immediately after the procedure for 10 minutes. Patients were
instructed to remain upright for at least 4 hours after the procedure, not to
engage in any vigorous physical activity for the rest of the day, and to sleep
with their heads elevated to the height of at least two pillows the night of the
treatment. Patients were evaluated every two weeks with maximum 5 sessions.
Pain, erythema and swelling were observed to temporary and mild.

c) Chemical Peels
For patients with minimal laxity or those unwilling to accept the risks of
surgery, other strategies such as chemical peeling have been employed.
Chemical peeling is often used to treat fine lines , mild superficial scarring, sun
spots, age spots , freckles, melsasma , and dull texture. Generally, fair-skinned
and light-haired patients are ideal candidates for chemical peels. Darker skin
types may also experience good results depending upon the type of skin
problem encountered. Before the peel, Prof. Moawad might prescribe bleaching
agents, tretinoin, sun-blocks and moisturizer at least 4-6 weeks before
chemical peel for those patients with pigmentation or dark skin.

Chemical peeling involves the application of a chemical agent to the skin to

induce controlled destruction or exfoliation of old skin and stimulation of new
epidermal growth with more evenly distributed melanin. When peel agents
reach the dermal layer, important wound-healing activities occur that cause
skin remodeling and skin smoothing, which are both anti-aging benefits.
Superficial peels are recommended to treat a variety of superficial conditions
involving the epidermis and superficial dermis, including: mild actinic damage,
superficial wrinkling, dyschromia, actinic keratoses, and active acne. Since the
effect is cumulative, a series of peels is recommended. Superficial peels can be
used on patients with any skin type, require minimal or no recovery time, and
are rarely associated with adverse reactions or complications. Medium-depth
peels are used primarily to treat severe dyschromia, moderate rhytidosis,
moderate to severe skin laxity, moderate to severe photoaged skin and actinic
keratoses. Although the results are more dramatic than with superficial peels,
there is a post-peel recovery time of at least five days as well as the necessity
for post-peel home care

At the time of treatment, the skin is thoroughly cleansed with an agent that
removes excess oils, and the eyes and hair are protected. A chemical solution is
applied to the skin that causes it to “blister” and eventually peel off. Prof.
Moawad may recommend a superficial or, medium chemical peel. He favor the
medium-depth peel, the combination peel, and repeated lighter peeling
regimens. He will select the proper mix of chemicals such glycolic acid, salicylic
acid, lactic acid, TCA, PCA, Phytic acid, or Jessner solution. Prof Moawad will
individualize the strength of these chemical agents to match your skin type and
degree of sun damage offering his patients more than 10 programs. Most
patients experience a warm to somewhat hot sensation that lasts about five to
10 minutes, followed by a stinging sensation. A deeper peel may require pain
medication during or after the procedure. Depending upon the type of peel, a
reaction similar to a sunburn occurs following a chemical peel. Superficial
peeling usually involves redness, followed by scaling that ends within three to
seven days. Medium-depth and deep peeling may result in swelling and the
presence of water blisters that may break, crust, turn brown and peel off over a
period of seven to 14 days. Following any skin peel, it is important that you
avoid any exposure to the sun. Your new skin is very sensitive and susceptible
to injury. Prof. Moawad will prescribe a proper home skin care treatment
program that included cleansers, moisturizers, and sunscreens with or without
anti-aging or bleaching agents to ensure proper healing and maintain the result
of your peel. Following a chemical peel, your new skin will be tighter, smoother
and may be slightly lighter than it was before surgery. Results of chemical peels
may also be enhanced our by new laser/light-based rejuvenation techniques.

Emerging Trends
The shift from a two-dimensional focus to a three-dimensional approach to
minimally invasive facial rejuvenation has reinforced the idea of creating overall
facial harmony and balance, within the confines of cultural, ethnic, and gender-
related goals and ideals. With this approach comes an appreciation of the need
for substantial volumes of hyaluronic acid filler to achieve optimal outcomes.
This often entails substantial patient education, to ensure realistic expectations
and to foster a commitment to longer-term maintenance with sufficient product
to provide a high degree of satisfaction. In tandem, it is now recognized that
relaxing the muscles of the lower face can play an important role in
combination with fillers. In addition, BoNTA treatments, begun at earlier ages,
can aid in line prevention. Resurfacing with light/laser treatments or chemical
peels, along with line management, volumizing, and recontouring, has proven
to be both safe and effective. Not to be neglected are topical treatments, such
as cosmeceuticals, to protect against photodamage, aid in retexturing of the
skin, and serve as an important adjunct to other aesthetic products and
procedures. A variety of products are available, and many patients can benefit
from their clinician’s advice on these products to minimize the risk of
hypersensitivity reactions while maximizing benefit. An effective sunblock is
considered one of the most important topical agents that patients can use. In
addition to protecting against photoaging, sunblock may also help prevent
hyperpigmentation after other aesthetic treatments. Despite general awareness
of the need for sun

Conclusion
As more cosmetic patients are opting to defer or avoid surgery in favor of
noninvasive modalities, the dermatol¬ogist has the potential to be at the
forefront of perioral rejuvenation. The number of minimally invasive aesthetic
products and procedures has burgeoned in the last several years. In concert,
clinicians have continued to expand and refine their techniques to provide their
patients with optimal outcomes and a high level of satisfaction. Neurotoxins,
fillers, lasers, RF devices, chemical peels, and cosmeceuticals can all be used as
part of a global strategy to address the dimensions of the aging perioral area.
Proper patient selection and management of expectations are critical to the
success of any cosmetic intervention. It has also become apparent that,
although it is necessary to discuss regions of the face individually, treating
areas of the face in isolation does not yield the best possible outcomes for
patients. It was stressed that treatment of any one area may have a
considerable effect on other areas that should be evaluated as treatment
progresses.
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