Many patients seek treatment for superficial ageing—smoothing wrinkles and boosting volume. But a multidimensional approach is better able to target the deeper, underlying source of volume loss. Dr Danny Vleggaar describes the use of poly-L-lactic acid, calcium hydroxylapatite and fillers for deep tissue regeneration
In aesthetic medicine, regeneration can mean creating tissue, or restoring, mimicking or suggesting a younger state. Even if you inject an instant filler deep into the tissue, you suggesting the presence of a structure or tissue that isn’t there anymore, therefore regenerating a new face.
So to understand why we’re regenerating the face, we need to know where we’ve come from. The first fillers were fat transplants, followed by bovine collagen in the 70s and 80s, hyaluronic acids, calcium hydroxylapatite and poly-L-lactic acid. But we used these products in lines or wrinkles in a two dimensional fashion and tried to smooth out the surface. We were very focused on the superficial ageing component or, in other words, dermal ageing or photoageing.
However, we started to realise that a smooth surface wasn’t the fountain of youth. For a youthful appearance, you need other elements—projection, volume, contour and continuity. It’s much more complicated than just a smooth exterior.
Patient selection is very important for deep tissue regeneration. If you discuss the treatment with a patient, many still have the classic idea of facial rejuvenation, which targets superficial and dermal ageing, so they still complain about lines and wrinkles, pigmentation and telangiectasias. We therefore need to advise them about the importance of global facial treatment to restore the deeper progressive loss of volume—that’s what will eventually restore a youthful look.
It’s important that your patient is counselled in the three dimensional rejuvenation process. Older patients need to know that what they see on the outside is the tip of the iceberg. The philosophy of three dimensional treatment is to treat the whole face, restore balance and not to overdo one area at the cost of another, with the aim of creating a natural, younger looking face.
In younger patients, you can treat isolated areas. You don’t necessarily need to provide a three dimensional projecting treatment. However you will see weak areas in younger patients too—this can be pan-facial or isolated. You try to improve on existing youthful qualities. At a certain age, you need to go into pan-facial rejuvenation to get a natural looking result. Your treatment has to suggest that there is ample bone, deep fat, nice curves and contours, reflections of light and arcs of youth. It’s an illusion; that bone and fat is long gone.
For example, a patient might have a very weak skeletal structure. Their soft tissues are poorly supported and projected by this structure. You could use PLLA to create collagen on the periosteum to mimic the presence of prominent bone masses. You can then get a balanced and refreshed effect without touching any lines or folds, or augmenting soft tissue—you can just push it away from the skeletal platform.
A pan-facial approach in this case would be important. You couldn’t just give the patient cheeks or cheekbones, as that wouldn’t fit with the rest of the face. So three dimensional regeneration is not so much about touching soft tissue, but more about touching the table that the tissue is supported by and upon where it sits.
Lateral eyelid ptosis may becaused by temple flattening and even concavity, which can affect the position of the lateral upper eyelid. This would be a typical patient for deep three dimensional sculpting. By injecting in the temple area, you can pick up some of the lateral ptosis. You can also improve facial length by injecting on the mandible. There are many robust and cohesive products that can expand the surface on the mandible and push tissue away.
While surgeons used to use solid implants historically for pathology, craniofacial hyperplasia or maxillary hyperplasia, injectables are now often used in cosmetic cases. All pathologies are projected on the cosmetic situation. You’re either born with strong or weak skeletal features, or simply skeletal features that are remodelled over time, which affects the position of the soft tissue.
There are significant differences between the male and the female face. Male and female skull shapes are different, which have consequences for the position of the soft tissue. If you perform deep tissue regeneration, you have to place the deep volume—whether a product or stimulation—in the most prominent areas for both men and women.
The focus points in a patient are very similar to where surgeons historically placed their implants. We therefore mimic the implant with an injectable, and we can do this because it is a non-pathological state. For three dimensional regeneration, try not to micromanage a face. Patients often like to direct our attention to a small line, wrinkle or nasolabial fold and, while understandable, you need to see it from a larger perspective.
In an HIV patient for example, nasolabial folds are a symptom; a sign of a compromised dermis, loss of elasticity, bone loss in the upper jaw and a loss of deep medial cheek fat with aged skin that can’t rewrap any more around a smaller, deeper volume.
Whether you’re using PLLA, PMMA, calcium hydroxylapatite or one of the more robust instant fillers, there are no-go areas. We don’t target highly dynamic areas such as the lips, the thin area of the eyelids or the tear troughs. We focus on bony prominences where we can inject the product in a stable position and mimic the presence of either deep fat compartments or bone.
There have been cases of blindness or unilateral visual impairment with injectables in the periorbital region. However, although dramatic, these adverse events are rare. According to some authors, 90% of adverse events are dependent on technique, skill or knowledge, so it’s important to know the anatomy. There are all kinds of anastomoses in the periorbital region and they’re not always predictable. There is a lot of anatomical variation.
If you don’t want to risk visual impairment in a patient, don’t inject in the temples. Don’t inject in the periorbital region. Don’t inject in the glabella region. Don’t inject in the nose. It could happen anywhere, even in the nasolabial fold.
However, we are more or less in control. If you know the course of an artery, you would inject perpendicular to that artery and not in the stream of the artery. When you want to inject, you do a reflux manoeuvre to make sure you’re clear. Take your time, position your needle in the target area and then you check.
With every product that we have ever injected, we can find cases of blindness or visual impairment. The majority of these have been caused by fat injections and most injection sites were in the mid-face. There has been a case of visual impairment from poly-L-lactic acid and that was in the temples. Other cases have involved hyaluronic acid, calcium hydroxylapatite or collagen and have been in the mid-face.
For issues with hyaluronic acid, we luckily have hyaluronidase. You can get a central retinal artery occlusion from hyaluronic acid—this doesn’t mean hyaluronic acid is a bad product, it’s a wonderful product. But for deep injections in certain areas, you have to keep in mind that certain things just don’t go.
With calcium hydroxylapatite fillers, be aware of local vascularisation for deep injections. Again, it’s extremely rare—there have only been 30 or 40 cases over the last few decades, but it’s a severe adverse event. It shouldn’t stop you from doing injection treatments, just make sure you know the anatomy. Never force a product in and always use a low pressure and a low velocity injection technique.
Evaluate your skills
So why are we still doing these deep injections? We started to realise that facial flatness and concavity is aesthetically displeasing, and even if you have a smooth surface and beautiful skin, it doesn’t look nice. It doesn’t look youthful. An adequate skeletal foundation is the first thing that you need to get a beautiful, refined facial mask.
The efficacy, safety and optimal outcome of three dimensional rejuvenation depends on two factors: whether the patient really needs it and your skills. If you’re not comfortable in certain areas, don’t do it. It doesn’t mean you can’t ever do it, but get the training, look up articles, memorise the anatomy and evaluate the risk benefit of treating these areas according to your own comfort zone, knowledge and skill.
We want to try and keep treatment very general with three dimensional cosmetics, rather than highlighting one area. I try to balance most products over the face in equal amounts. With PLLA, I build a scaffold on the periosteum. After three treatments, you can get wide mature bands of collagen on the periosteum which mimic the presence of bone.
Where I don’t want to mimic the presence of bone, I could mimic the presence of deep or ample filled deep fat compartments. If I inject in the mid-face, I try to suggest the presence of an ample filled deep medial cheek fat compartment which can be the primary determination of a youthful and projecting mid-face.
In the younger patient you can treat isolated areas. It doesn’t have to be three dimensional, you can provide a simple correction to the lid-cheek junction or the tear trough—while this is a normal anatomical border cleft in the muscle, it can become cosmetically displeasing. Very small amounts of hyaluronic acid in that area will do the trick.
With brow issues, you can inject a small amount under the brow and in the temples, on the tail of the brow and the lateral upper eyelid.
When you have to do more treatment, you can start to combine products. You can use hyaluronic acid in the periorbital region and tear trough, botulin toxin around the eyes and a solid base of poly-L-lactic acid on the periosteum to mimic strong skeletal features and in the mid-face to mimic deep fat.
In female patients with a masculine-looking face, there can be competition between the bigonial width and the bizygomatic width. The easiest way to treat this is with a neuromodulator in the maseter muscle to restore the ratio of bigonal bizygomatic width. To get the bizygomatic width wider than the bigonial width, and a more feminine face, you have to put a lot of volume in the temples. So always think about balancing ratios of the face with multiple modalities like neuromodulator and fillers.
On the other hand, the male face should have a strong jaw and high cheek bones. There is a huge competition between bigonial width and bizygomatic width. You can put a lot of volume in the mid- and upper face to get that larger and wider, but the easiest thing is to inject botulin toxin in his masseters. So keep in mind, three dimensional treatment can do wonderful things for patients, but you don’t always need it. Use your common sense and do a thorough analysis of a face and try to find out the most strategic and efficient way to achieve your goals.
If you have a younger patient with a disturbed lateral contour with depression and prominences, loss of bone in the mid-face, and loss of deep cheek fat,. you can give injections on the periosteum in those crucial areas of the zygoma and mid-face, around the piriform aperture.
You might have a male patient with no issues with the soft tissue, just not enough bone—or perhaps a configuration of the skeletal platform which is more typical for a female. You shouldn’t use too much to augment soft tissue because this may round out his face. If you put volume in the right place, you can accentuate his cheek bones and bizygomatic width, and give him a little more mandible prominence. Don’t make the bigonial width wider than the mid-face width.
Don’t touch the soft tissue or treat his tear troughs. That’s not the real reason he’s coming to you; he’s coming because he looks feminine. If you treat his tear troughs, he won’t be pleased. So aim to provide deep volume and you can get that typical male look—high cheek bones, strong jaw, with a maximum bizygomatic width and a small increase of the bigonial width.
If you’re treating the temple, for example, try to inject gradually and take your time. Every time you reposition, do a reflux manoeuvre—pull the plunger and inject very slowly. The temple fossa is a huge basin and its upper border is the frontal fusion line. If you were to use poly-L-lactic acid, use a 25G 1.5 inch needle with a slow approach. Slowly fill the whole temple fossa with a layer of the product, which will eventually form a layer of collagen, popping the temple out and making the connection from the relatively stable convexity of the lateral upper forehead to the zygoma.
Inject close to the periosteum, under the deep temporalis fascia, so it’s still in the temporalis muscle. There are some arteries running there. They’re getting smaller and are more in the periphery, but make sure you always reflux and take your time. If you try to inject but can’t get a product out of your needle, don’t inject. You may be in a vascular structure.
If you’re giving redefinition of the lateral jaw line, stay above the parotid fascia. Don’t go through the parotis. I inject in this area subdermallywith a little antegrade flow—hydrodissection. For me, this works like a cannula, so I don’t use cannulas. With this approach, a slow dissection with continuous injection of a watery product with a needle works like a cannula. I don’t see any difference in bruising or site-specific adverse events like erythema.
It’s a very easy one stick approach of the mandible. Women tend to have a lot of bone loss on the central mandible. The male mandible, in contrast, tends to become more prominent I don’t want to thicken the outside—we don’t inject soft tissue with collagen stimulators anymore. I go just in front of the edge of the mandible, through the insertion of the depressor labii inferioiris and straight behind the muscle aiming for the roots of the elements. Inject around 0.3ml under the mucosal fold on the periosteum of the mandible which immediately pushes that whole soft tissue layer forward and works as effectively as soft tissue thickening.
The angular artery which runs alongside the nose needs some care. I like to do a long distant approach with the long needle starting 2-3cm lateral from the nasal alar. The artery can be superficial so pull the nose up and try to slide underneath and slowly inject around the piriform aperture. Once you position the needle, do a thorough check by pulling the plunger—if there’s no blood, then inject 0.3ml. Every time you reposition that needle, try to pull that artery up because there’s a lot of anatomical variation. It may be coiled. You can give 1-3 depots around the pyriform aperture—the effect is that it will shorten the upper lip, undeepen the nasolabial fold and rotate the nose slightly forward.
Three dimensional aesthetics can be very effective with selective use of fillers in the mid-face, piriform aperture, mandible and the temporal area. These have been defined as key areas for facial rejuvenation—subtle improvements or changes can have enormous consequences for the outcome and a fantastic rejuvenating effect.
Ensure you are well skilled. Know the anatomy. Know where the arteries are running and try to do site-specific corrections and always work carefully and slowly While intravascular compromise is rare, the risk is not zero so make sure you know the anatomy and feel comfortable in certain anatomical regions.
Dr Danny Vleggar works in private practice in cosmetic dermatology in Geneva, Switzerland