Dr. Zins

Mr. Shelley

FACING FACTS The first step in facing injectable fillers' limitations is through a further understanding of the aging face. While controversy has existed as to whether changes of midface aging, such as elongation of the lower eyelid caused by infraorbital hollowing, flattening of the malar eminence, and increased prominence of the nasolabial fold, are caused by gravitational migration of the cheek fat, or if it is due to fat atrophy, one study in Plastic and Reconstructive Surgery found gravity to be the primary culprit.

Dr. Trokel

As research continues to fully comprehend aging's true impact on the face, cosmetic consumers should be educated about what injectable fillers can and cannot do, according to Dr. Owsley. "Most patients have a hidden, unrealistic agenda [about what injectable fillers can do for them] and they may not be happy long term with fillers alone," he states.

GUIDED BY THE CONSUMER Even as efforts to further study and collect objective data on injectable dermal fillers continue to gain steam, the liquid face lift is winning the popularity race even without long-term evidence.

"More and more of my colleagues are going toward the surgical dermatology route," Dr. Owsley tells Cosmetic Surgery Times. "It's the consumer that ultimately controls what treatment they accept and the majority will try injectables — but the pendulum swings back and forth."

Additional evidence that the liquid facelift concept is here to stay is the formation of The Liquid Face Lift Association. Founded in February of last year, the non-profit association of licensed physicians is dedicated to elevating standards in liquid facelift, dermal filler and botulinum toxin medical practices. Physician members (currently 150) are required to have performed at least 1,000 documented dermal filler procedures, with the average member having performed over 5,000 of these procedures.

"The first phase of our mission was to further educate consumers, with the second phase to educate physicians," says Kyle Shelley, director, Liquid Face Lift Association, Oklahoma City. "Our members are dedicated to educating the consumer."

While not affiliated with any medical device company, the Association is in constant communication with the dermal filler companies, especially as it relates to new guidelines and applications, explains Mr. Shelley. "Most of today's physicians did not learn about the new advanced dermal fillers in school. There are a lot of techniques and applications that you can do with these, but it's very important that the physician further their education with as much hands-on information as possible," Mr. Shelley states.

While the debate over the extent to which dermal fillers can successfully deliver a "liquid facelift" rages, there is little question of their utility in certain patient populations. Younger patients are ideal candidates for fillers such as Restylane, Perlane and Macrolane, all notable not only for their efficacy, but also for their safety profiles which shows each to be proven and consistent. Yet, as a patient ages, the capability to effectively treat the aging face with dermal fillers alone begins to narrow, in Dr. Zins' estimation.

"Most plastic surgeons would agree with the following pronouncement: Facial aging is a combination of skin laxity and soft tissue descent, as well as volume loss; therefore, the best answer [for the aging patient] is not only a volume filler, but also a surgical technique that repositions soft tissue to tighten," says Dr. Zins. "Fillers are going to be more effective in young people."

Both Drs. Owsley and Zins contend that the strength of proven plastic surgery procedures, such as the minimally invasive neck lift and the SMAS-platysma bidirectional (deep layer or muscle) facelift will continue to dominate, along with adjunct dermal fillers to sustain long-term effects. For instance, modifications to Dr. Owsley's malar fat pad elevation technique, including markings of the cutaneous insertion of the malar septum being placed at the infraorbital location, has minimized post-operative ecchymosis and edema following the procedure. These markings approximate the caudal margin of the musculus orbicularis oculi, according to Dr. Owsley.

"Dissection under the malar fat pad is performed sharply under direct visualization. Care is taken to stay caudal to the malar septum insertion as marked on the skin. Refinements in the dissection of the midface malar fat pad have not altered the effective repositioning achieved. By leaving the malar septum intact, the amount of post-operative edema and ecchymosis is less than formerly associated with the dissection over the infraorbital orbicularis," writes Dr. Owsley in a recent publication. Patients were able to resume their usual activities and employment after a recovery period of 10 to 21 days — but to what percentage of contemporary cosmetic patients is that timeframe "acceptable"? Is there a middle ground for the middle face?

INJECTION INNOVATIONS This trend for quick results is leading many cosmetic surgeons to innovate ways in which dermal fillers augment other minimally or non-invasive procedures to gain the same effects of the full facelift. One procedure built on this theory is the "Y Lift." Named after the resulting "Y" effect of harmonious facial proportions, the Y Lift consists of strategically marking the face to fit a moldable form customized for each patient. Through a proprietary specialized instrument, the face is elevated and held in its new position through the cheek forms and with the use of Juvéderm.

"By using a specialized instrument that creates a miniscule hole that is typically placed at the top of the midface region, I can access the deeper layers of tissues to not only lift the face, but to also sculpt and create cheekbones, define and recreate the jaw line and restore the neck to its youthful appearance," states Yan Trokel, M.D., D.D.S., creator of the Y Lift and director of The YAN Center for Corrective and Cosmetic Surgery, New York City. "I have performed hundreds of the Y Lift with a very high success rate. Complications are few, and the results last up to two years with touch-ups of Juvéderm throughout that period." The Y Lift has not yet been published in a peer-reviewed journal, but data are currently being collected for future review.

For now, each patient who seeks a liquid facelift — or other new techniques — should be presented with the best, objective data not only on dermal fillers, but also on the longer-lasting plastic surgery procedures that are proven to offer long-term results, contends Dr. Owsley.

In sum, "The ideal way to correct facial aging today is through the combination of a surgical procedure plus augmenting with dermal fillers," says Dr. Zins.

REFERENCE

Owsley JQ, Roberts CL. Some anatomical observations on midface aging and long-term results of surgical treatment. Plast Reconstr Surg. 2008;121:258-268.

FOR MORE INFORMATION
Liquid Face Lift Association
http://www.liquidfacelift.com/