Using injectable fillers for midface rejuvenation

Abstract

Treatment aimed at preventing and reversing the facial aging process has grown in popularity. The aging midface is defined by classic deepening of the nasolabial folds, formation of marionette lines around the mouth, and significant atrophy of deep facial fat. While surgical options have been investigated with satisfactory and long-lasting results, nonsurgical alternatives such as soft tissue fillers are a safe and effective strategy for facial rejuvenation. This review focuses on a variety of injectable fillers available for the treatment of the aging midface, including hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid, and polymethyl methacrylate. Mechanism of action, relevant anatomy, indications/contraindications, technique, and any evidence of efficacy and safety are described. The benefits of injectable fillers include reduced patient discomfort and shorter recovery times. Understanding the advantages and limitations of injectable fillers for midface augmentation can allow providers to counsel and treat patients seeking care appropriately.

Keywords

Hyaluronic acid / midface / nasolabial fold / mouth / aging / face / fillers

References

[1] Gilhar A,Karry R.Ageing of human epidermis: the role of apoptosis, Fas and telomerase.Br J Dermatol2004;150:56-63

[2] Varani J,Rittie L.Decreased collagen production in chronologically aged skin: roles of age-dependent alteration in fibroblast function and defective mechanical stimulation.Am J Pathol2006;168:1861-8 PMCID:PMC1606623

[3] Suwabe H,Kajiwara H,Tsutsumi Y.Degenerative processes of elastic fibers in sun-protected and sun-exposed skin: immunoelectron microscopic observation of elastin, fibrillin-1, amyloid P component, lysozyme and alpha1-antitrypsin.Pathol Int1999;49:391-402

[4] Gierloff M,Buder T,Açil Y.Aging changes of the midfacial fat compartments: a computed tomographic study.Plast Reconstr Surg2012;129:263-73

[5] Boehm LM,Hettinger P.Facial aging: a quantitative analysis of midface volume changes over 11 years.Plast Reconstr Surg2021;147:319-27

[6] Tower J,Paskhover B.Longitudinal analysis of superficial midfacial fat volumes over a 10-year period.Aesthetic Plast Surg2018;42:995-1001

[7] Rohrich RJ,Savetsky IL.Prediction of facial aging using the facial fat compartments.Plast Reconstr Surg2021;147:38S-42S

[8] Owsley JQ Jr.Midface lift of the malar fat pad: technical advances.Plast Reconstr Surg2002;110:674-85; discussion 686-7

[9] De Cordier BC,Al-Hakeem MS.Rejuvenation of the midface by elevating the malar fat pad: review of technique, cases, and complications.Plast Reconstr Surg2002;110:1526-36; discussion 1537-40

[10] Barrett DM,Wang TD.Facelift controversies.Facial Plast Surg Clin North Am2016;24:357-66

[11] Hamra ST.The deep-plane rhytidectomy.Plast Reconstr Surg1990;86:53-61; discussion 62-3

[12] Abraham RF,Williams EF 3rd.Thread-lift for facial rejuvenation: assessment of long-term results.Arch Facial Plast Surg2009;11:178-83

[13] Saylan Z.The S-lift: less is more.Aesthet Surg J1999;19:406-9

[14] Tonnard P,Monstrey S.Minimal access cranial suspension lift: a modified S-lift.Plast Reconstr Surg2002;109:2074-86

[15] Chang S,Rohrich RJ.A systematic review of comparison of efficacy and complication rates among face-lift techniques.Plast Reconstr Surg2011;127:423-33

[16] Kim BJ,Lee Y.Development of facial rejuvenation procedures: thirty years of clinical experience with face lifts.Arch Plast Surg2015;42:521-31 PMCID:PMC4579162

[17] General and Plastic Surgery Devices. FDA executive summary general issues panel meeting on dermal fillers. Available from: https://www.fda.gov/media/146870/download. [Last accessed on 2 Aug 2021]

[18] Petchngaovilai C.Midface lifting with botulinum toxin: intradermal technique.J Cosmet Dermatol2009;8:312-6

[19] Chang SP,Chen WY,Chen PL.The wrinkles soothing effect on the middle and lower face by intradermal injection of botulinum toxin type A.Int J Dermatol2008;47:1287-94

[20] Kimura K.Facial tightening effects, following focused and radial acoustic wave therapy assessment, using a three-dimensional digital imaging.Lasers Surg Med2021;53:630-9 PMCID:PMC8246538

[21] Sasaki GH.Early clinical experience with the 1440-nm wavelength internal pulsed laser in facial rejuvenation: two-year follow-up.Clin Plast Surg2012;39:409-17

[22] Kwon HH,Park KH.A novel combination regimen with intense focused ultrasound and pressure- and dose-controlled transcutaneous pneumatic injection of hypertonic glucose solution for lifting and tightening of the aging face.J Cosmet Dermatol2018;17:373-9

[23] Ozgentaş HE,Spira M,Shenaq S.A comparison of soft-tissue substitutes.Ann Plast Surg1994;33:171-7

[24] Papakonstantinou E,Karakiulakis G.Hyaluronic acid: a key molecule in skin aging.Dermatoendocrinol2012;4:253-8 PMCID:PMC3583886

[25] Toole BP.Hyaluronan: from extracellular glue to pericellular cue.Nat Rev Cancer2004;4:528-39

[26] Meyer LJ.Age-dependent changes of hyaluronan in human skin.J Invest Dermatol1994;102:385-9

[27] Kim JE.Hyaluronic acid fillers: history and overview.Facial Plast Surg2011;27:523-8

[28] Hinderer UT.Malar implants for improvement of the facial appearance.Plast Reconstr Surg1975;56:157-65

[29] Oranges CM,Haug M,Schaefer DJ.Universal and ethnic-specific considerations on facial rejuvenation: where do you inject your fillers?.Plast Reconstr Surg Glob Open2016;4:e842 PMCID:PMC5010333

[30] Maio M, DeBoulle K, Braz A, Rohrich RJ; Alliance for the Future of Aesthetics Consensus Committee. Facial assessment and injection guide for botulinum toxin and injectable hyaluronic acid fillers: focus on the midface.Plast Reconstr Surg2017;140:540e-50e

[31] Raspaldo H,Niforos FR.Global, 3-dimensional approach to natural rejuvenation: part 1 - recommendations for volume restoration and the periocular area.J Cosmet Dermatol2012;11:279-89

[32] Arsiwala SZ.Simplifying injectables for volumetric rejuvenation of face.J Cutan Aesthet Surg2018;11:51-9 PMCID:PMC6128161

[33] Salti G.Facial rejuvenation with fillers: the dual plane technique.J Cutan Aesthet Surg2015;8:127-33 PMCID:PMC4645140

[34] Tan M.Midface volumization with injectable fillers.Facial Plast Surg Clin North Am2015;23:233-42

[35] Weiss RA,Bank D.Effectiveness and safety of large gel particle hyaluronic acid with lidocaine for correction of midface volume deficit or contour deficiency.Dermatol Surg2016;42:699-709

[36] Monheit G,Joseph JH,Dover JS.Efficacy and safety of two resilient hyaluronic acid fillers in the treatment of moderate-to-severenasolabial folds: a 64-week, prospective, multicenter, controlled, randomized, double-blinded, and within-subject study.Dermatol Surg2020;46:1521-9

[37] Jones D.Volumizing hyaluronic acid filler for midface volume deficit: 2-year results from a pivotal single-blind randomized controlled study.Dermatol Surg2013;39:1602-12

[38] Few J,Paradkar-Mitragotri D.A multicenter, single-blind randomized, controlled study of a volumizing hyaluronic acid filler for midface volume deficit: patient-reported outcomes at 2 years.Aesthet Surg J2015;35:589-99 PMCID:PMC4482214

[39] Kerscher M,Kravtsov M.Effectiveness evaluation of two volumizing hyaluronic acid dermal fillers in a controlled, randomized, double-blind, split-face clinical study.Clin Cosmet Investig Dermatol2017;10:239-47 PMCID:PMC5498678

[40] Prager W,Kerscher M.Patient-reported outcomes following split-face injection of 2 volumizing fillers in the upper cheeks.Plast Reconstr Surg Glob Open2017;5:e1412 PMCID:PMC5682159

[41] Ahn MS.Calcium hydroxylapatite: Radiesse.Facial Plast Surg Clin North Am2007;15:85-90, vii

[42] Jacovella PF.Use of calcium hydroxylapatite (Radiesse®) for facial augmentation.Clin Interv Aging2008;3:161-74

[43] Marmur ES,Goldberg DJ.Clinical, histologic and electron microscopic findings after injection of a calcium hydroxylapatite filler.J Cosmet Laser Ther2004;6:223-6

[44] Yutskovskaya Y,Leshunov E.A randomized, split-face, histomorphologic study comparing a volumetric calcium hydroxylapatite and a hyaluronic acid-based dermal filler.J Drugs Dermatol JDD2014;13:1047-52

[45] Berlin AL,Goldberg DJ.Calcium hydroxylapatite filler for facial rejuvenation: a histologic and immunohistochemical analysis.Dermatol Surg2008;34 Suppl 1:S64-7

[46] Berri N,Fares Y.Polyethylene oxide and silicon-substituted hydroxyapatite composite: a biomaterial for hard tissue engineering in orthopedic and spine surgery.Adv Biomed Res2018;7:117 PMCID:PMC6124219

[47] Pajor K,Kolmas J.Hydroxyapatite and fluorapatite in conservative dentistry and oral implantology-a review.Materials (Basel)2019;12:2683 PMCID:PMC6747619

[48] Cohen JT.Voice outcome after vocal fold injection augmentation with carboxymethyl cellulose versus calcium hydroxyapatite.J Laryngol Otol2020;134:263-9

[49] Graivier MH,Busso M,Narins RS.Calcium hydroxylapatite (Radiesse) for correction of the mid- and lower face: consensus recommendations.Plast Reconstr Surg2007;120:55S-66S

[50] Jansen DA.Evaluation of a calcium hydroxylapatite-based implant (Radiesse) for facial soft-tissue augmentation.Plast Reconstr Surg2006;118:22S-30S, discussion 31S-3S

[51] Fitzgerald R,Yang PT.An approach to structural facial rejuvenation with fillers in women.Int J Womens Dermatol2019;5:52-67 PMCID:PMC6374711

[52] Palermo EC.Calcium hydroxyapatite for face. In: Costa AD, editor. Minimally invasive aesthetic procedures. Cham: Springer International Publishing; 2020. p. 487-97. PMCID:PMC6467620

[53] Loghem JV,Werschler WP.Calcium hydroxylapatite: over a decade of clinical experience.J Clin Aesthetic Dermatol2015;8:38 PMCID:PMC4295857

[54] Smith S,McClaren M.A randomized, bilateral, prospective comparison of calcium hydroxylapatite microspheres versus human-based collagen for the correction of nasolabial folds.Dermatol Surg2007;33 Suppl 2:S112-21; discussion S121

[55] Sadick NS,Roy D.A multicenter, 47-month study of safety and efficacy of calcium hydroxylapatite for soft tissue augmentation of nasolabial folds and other areas of the face.Dermatol Surg2007;33 Suppl 2:S122-6; discussion S126-7

[56] Bass LS,Busso M.Calcium hydroxylapatite (Radiesse) for treatment of nasolabial folds: long-term safety and efficacy results.Aesthet Surg J2010;30:235-8

[57] Rayess HM,Hanba C.A cross-sectional analysis of adverse events and litigation for injectable fillers.JAMA Facial Plast Surg2018;20:207-14 PMCID:PMC6145786

[58] Sickles CK,Gross GP.Poly-L-lactic acid. In: StatPearls. StatPearls Publishing; 2020.

[59] Cabral LRB,Gimenez RP.Effect of hyaluronic acid and poly-L-lactic acid dermal fillers on collagen synthesis: an in vitro and in vivo Study.Clin Cosmet Investig Dermatol2020;13:701-10 PMCID:PMC7533910

[60] Rotunda AM.Poly-L-lactic acid: a new dimension in soft tissue augmentation.Dermatol Ther2006;19:151-8

[61] Galderma. Sculptra aesthetic injectable poly-L-lactic acid. 2020. Available from: https://www.galderma.com/us/site-s/g/files/jcdfhc341/files/2020-11/782347%20Sculptra%20Aesthetic%20IFU.pdf. [Last accessed on 2 Aug 2020]

[62] Vleggaar D,Lorenc ZP.Consensus recommendations on the use of injectable poly-L-lactic acid for facial and nonfacial volumization.J Drugs Dermatol JDD2014;13:s44-51

[63] Bartus C,Daro-Kaftan E.A decade of experience with injectable poly-L-lactic acid: a focus on safety.Dermatol Surg2013;39:698-705

[64] Lowe NJ,Lowe P,Patnaik R.Injectable poly-l-lactic acid: 3 years of aesthetic experience.Dermatol Surg2009;35 Suppl 1:344-9

[65] Bauer U.Optimizing injectable poly-L-lactic acid administration for soft tissue augmentation: the rationale for three treatment sessions.Can J Plast Surg J Can Chir Plast2011;19:e22-7 PMCID:PMC3269336

[66] Butterwick K.Injectable poly-L-lactic acid for cosmetic enhancement: learning from the European experience.J Am Acad Dermatol2009;61:281-93

[67] Salles AG,Gimenez R,Ferreira MC.Evaluation of the poly-L-lactic acid implant for treatment of the nasolabial fold: 3-year follow-up evaluation.Aesthetic Plast Surg2008;32:753-6

[68] Narins RS,Brandt FS.A randomized study of the efficacy and safety of injectable poly-L-lactic acid versus human-based collagen implant in the treatment of nasolabial fold wrinkles.J Am Acad Dermatol2010;62:448-62

[69] Brandt FS,Baumann L.Investigator global evaluations of efficacy of injectable poly-L-lactic acid versus human collagen in the correction of nasolabial fold wrinkles.Aesthet Surg J2011;31:521-8

[70] Brown SA,Baumann L.Subject global evaluation and subject satisfaction using injectable poly-L-lactic acid versus human collagen for the correction of nasolabial fold wrinkles.Plast Reconstr Surg2011;127:1684-92

[71] Hyun MY,No YA.Efficacy and safety of injection with poly-L-lactic acid compared with hyaluronic acid for correction of nasolabial fold: a randomized, evaluator-blinded, comparative study.Clin Exp Dermatol2015;40:129-35

[72] Narins RS.Minimizing adverse events associated with poly-L-lactic acid injection.Dermatol Surg2008;34 Suppl 1:S100-4

[73] Haneke E.Managing complications of fillers: rare and not-so-rare.J Cutan Aesthet Surg2015;8:198-210 PMCID:PMC4728901

[74] Solomon P,Zener R.Facial soft tissue augmentation with Artecoll®: A review of eight years of clinical experience in 153 patients. Can J Plast Surg 2012;20:28-32. PMCID:PMC3307678

[75] Morhenn VB,Gallo RL.Phagocytosis of different particulate dermal filler substances by human macrophages and skin cells.Dermatol Surg2002;28:484-90

[76] Lemperle G,Busso M.Soft tissue augmentation with artecoll: 10-year history, indications, techniques, and complications.Dermatol Surg2003;29:573-87; discussion 587

[77] Elson ML.The role of skin testing in the use of collagen injectable materials.J Dermatol Surg Oncol1989;15:301-3

[78] Cohen SR.Artecoll: a long-lasting injectable wrinkle filler material: report of a controlled, randomized, multicenter clinical trial of 251 subjects.Plast Reconstr Surg2004;114:964-76; discussion 977-9

[79] Gold MH.Optimizing outcomes with polymethylmethacrylate fillers.J Cosmet Dermatol2018;17:298-304

[80] Salles AG,Gemperli R.Complications after polymethylmethacrylate injections: report of 32 cases.Plast Reconstr Surg2008;121:1811-20

[81] Cohen S,Monheit G.Five-year safety and satisfaction study of PMMA-collagen in the correction of nasolabial folds.Dermatol Surg2015;41 Suppl 1:S302-13

[82] Limongi RM,Borba A.Complications and management of polymethylmethacrylate (PMMA) injections to the midface.Aesthet Surg J2016;36:132-5

[83] Keller G,Antunes MB,Magill CK.Midface lift: panel discussion.Facial Plast Surg Clin North Am2014;22:119-37

[84] Jacono AA,Lavin TJ.Nonsurgical facial rejuvenation procedures in patients under 50 prior to undergoing facelift: habits, costs, and results.Aesthet Surg J2017;37:448-53

[85] Ransom ER,Jacono AA.Persistent improvement in lower eyelid-cheek contour after a transtemporal midface lift.Aesthetic Plast Surg2012;36:1277-82

[86] Pascali M,Bocchini I.Midface-lift patient satisfaction: a 5-year follow-up study.Indian J Plast Surg2016;49:329-35 PMCID:PMC5288907

[87] Shtraks JP,Yu D.Investigation of the longevity of the endoscopic midface lift.JAMA Facial Plast Surg2019;21:535-41 PMCID:PMC6802057

[88] Pontius AT,Williams EF 3rd.Midface injectable fillers: have they replaced midface surgery?.Facial Plast Surg Clin North Am2013;21:229-39

[89] Hufschmidt K,Foissac R.The infraorbital artery: clinical relevance in esthetic medicine and identification of danger zones of the midface.J Plast Reconstr Aesthet Surg2019;72:131-6

[90] Khan TT,Mettu P,Woodward JA.An anatomical analysis of the supratrochlear artery: considerations in facial filler iInjections and preventing vision loss.Aesthet Surg J2017;37:203-8

[91] Gatherwright JR,Katira KM.Three-dimensional changes in the midface following malar calcium hydroxyapatite injection in a cadaver model.Aesthet Surg J2015;35:NP169-75

[92] Casabona G.Blood Aspiration Test for cosmetic fillers to prevent accidental intravascular injection in the face.Dermatol Surg2015;41:841-7

[93] Hojjat H,Lucas J.Public perception of facial fillers.Facial Plast Surg2019;35:204-9

[94] DeLorenzi C.Complications of injectable fillers, part 2: vascular complications.Aesthet Surg J2014;34:584-600

[95] Sito G,Sommariva R.Vascular complications after facial filler injection: a literature review and meta-analysis.J Clin Aesthetic Dermatol2019;12:E65-72 PMCID:PMC6624005

[96] Beleznay K,Humphrey S.Avoiding and treating blindness from fillers: a review of the world literature.Dermatol Surg2015;41:1097-117

[97] Biskupiak J.Economic analysis of "liquid" versus surgical face-lift: are large-volume facial soft tissue filler injection treatments a viable alternative to rhytidectomy?.Facial Plast Surg2010;26:296-302

[98] Kaufman-Janette J,Cox SE,Smith S.Efficacy and safety of a new resilient hyaluronic acid dermal filler, in the correction of moderate-to-severe nasolabial folds: a 64-week, prospective, multicenter, controlled, randomized, double-blind and within-subject study.J Cosmet Dermatol2019;18:1244-53 PMCID:PMC7384057

[99] Food and Drug Administration: Summary of safety and effectiveness data (SSED). Available from: https://www.accessdata.fda.gov/cdrh_docs/pdf17/P170002B.pdf. [Last accessed on 8 Aug 2021]

[100] Rzany B,Hartmann M.Efficacy and safety of 3 new resilient hyaluronic acid fillers, crosslinked with decreased BDDE, for the treatment of dynamic wrinkles: results of an 18-month, randomized controlled trial versus already available comparators.Dermatol Surg2019;45:1304-14

[101] Niforos F,Cavallini M.VYC-12 injectable gel is safe and effective for improvement of facial skin topography: a prospective study.Clin Cosmet Investig Dermatol2019;12:791-8 PMCID:PMC6817835

[102] Sparavigna A.Efficacy and tolerance of an injectable medical device containing stable hybrid cooperative complexes of high- and low-molecular-weight hyaluronic acid: a monocentric 16 weeks open-label evaluation.Clin Cosmet Investig Dermatol2016;9:297-305 PMCID:PMC5044990