Lower-face rejuvenation options abound

"Treatment must be tailored to the problems of the specific patient. There is no one-size-fits-all remedy for lower facial/neck aging," says Roberta Sengelmann, M.D., assistant professor of dermatology and otolaryngology and director of the Center for Dermatologic and Cosmetic Surgery at Washington University School of Medicine.

According to Dr. Sengelmann, the key elements to aesthetically improving the lower face and neck can be stratified into the five Rs: relaxing, restoring, resurfacing, redefining, and redraping.

Dr. Sengelmann accomplishes relaxation of hyperdynamic muscles of the face and neck bands with botulinum toxin A.

"Most of the muscles we seek to treat in the midface have some deleterious tugging effects on the mouth. These perioral muscles, which provide function to the mouth but also elevate, depress and purse the lips, can create asymmetries if at all out of balance," she tells Dermatology Times.

In these locations, she notes, botulinum toxin can harmonize the facial musculature as well as soften wrinkles.

However, she says, "the tricky thing about the mid/lower face and neck is that these are very functionally important areas, as opposed to the upper face, where wrinkling one's brow carries little functional significance. The ability to orate, masticate, phonate and swallow and more is all dependent on musculature that resides below the nose and above the clavicles. Treatment with botulinum toxin in these areas must be precise, symmetrical and conservative."

Dr. Sengelmann notes that dermatologic surgeons must have a thorough grasp of the functional anatomy before undertaking treatment, because these muscles are all juxtaposed, and interrelated with the superficial muscular aponeurotic system (SMAS).

Because working in this area requires advanced techniques, she advises physicians with little experience in injecting botulinum toxin to master the more forgiving area of the upper face first.

Restoring volume

To restore volume, Dr. Sengelmann employs various fillers, fat transplantation, poly-L-lactic acid and implants. The fillers she likes best for rejuvenating the perioral area including the lips, marionette lines, nasolabial folds and prejowl sulcus, she says, are human collagen and hyaluronic acid (HA).

As far as which HA to choose, Dr. Sengelmann says that to achieve the most substantial lift, she chooses Restylane (Medicis/QMed), whereas for a softer filling of the pink lip she will choose Hylaform (Inamed) or Captique (Inamed) when possible. She also frequently uses calcium hydroxyapatite for areas requiring a substantial and longer-lasting lift at the angles of the mouth, marionette lines and nasolabial folds, as well as expanded polytetrafluoroethylene (PTFE) implants for permanent augmentation in lips and nasolabial folds.

Dr. Sengelmann reserves fat and poly-L-lactic acid for areas where volume enhancement is needed, as opposed to fold or crease improvement.

"One of the most critical aspects of rejuvenating the mouth is to elevate the corners or angles of the mouth," Dr. Sengelmann says. "That's a commonly overlooked area. Whether one chooses Cosmoplast (Inamed) Restylane or Radiesse (BioForm Medical, Inc.) matters less than how one uses it. Fillers can be chosen based upon duration of action: three-to-four-months, four-to-six-months, 12-to-18-months or permanent."

She generally recommends that new patients start with a temporary filler, usually human collagen, before embarking on treatment with a more durable one so they can get accustomed to how it feels. Also, side effects of swelling and bruising are minimal when using a collagen product, which makes for positive first experiences for patients.

"Technique is ultimately more important than the product chosen. If one is an elegant user of any of these products, one is going to create smooth, natural, beautiful lips."