Midface descent strikes in 60s, 70s

Aspen, Colo. - The key to addressing midfacial descent and overall fat loss in patients in their 60s and 70s is staging treatments appropriately and matching patient expectations, according to experts who offered solutions at Cosmetic Boot Camp, held here.

“In the sixth and seventh decades,” says Wendy E. Roberts, M.D., “men and women have different issues. But what we’re really addressing is midfacial descent. In men in particular, it leads to a heavier cutis” that often creates very prominent nasolabial folds. Other common concerns in men of this age group include prominent frontalis wrinkles, says Dr. Roberts, a dermatologist in private practice in Rancho Mirage, Calif.

“The most important take-home point in the sixth and seventh decades is that you can’t do it all in one session,” Dr. Roberts says.

Patients in this age group require significant volume, she adds, so she sets a global price for her “liquid facelift.”

Addressing midfacial descent

Starting at the midface, she performs tear trough rejuvenation with Juvéderm XC (hyaluronic acid/HA, Allergan) or another HA.

“I do a retrograde injection at the tear trough. And I like to visualize the cannula when I’m injecting this area - I like to see the depth at which I’m injecting,” Dr. Roberts says. She performs these injections in two stages: superficially with HA and, in some severe cases, periosteally with microdrops of diluted Sculptra (poly-L-lactic acid/PLLA, Valeant Aesthetics).

With Sculptra, Dr. Roberts injects a deep subcutaneous depot at the temporal fossa.

“I give a robust amount both in the temporal fossa and in the deep dermal subcutaneous malar prominence, which will lift that area. I also like to work in the hairline area, in the deep plane, directing the Sculptra upward to again achieve some midface lifting. Injecting this area is great for women because their hair covers the injection sites,” she says. Typically, Dr. Roberts also uses another injection point in the center of the zygomatic/cheek area.

Mary P. Lupo, M.D., says that in her experience, Sculptra injections in this area don’t cause pain - until the next day, when patients feel soreness chewing or opening their mouths widely. She and Dr. Roberts agree that massaging the area right after treatment helps minimize this discomfort. “We must prepare patients for this, and talk them through it,” says Dr. Lupo, who is a New Orleans-based dermatologist in private practice.

Selecting the right HA

For the canine fossa, which also features thicker skin in males, Dr. Roberts often chooses Perlane (HA, Medicis) or Radiesse (calcium hydroxylapatite, BioForm/Merz). “We need that lift and G prime.”

Perlane is slightly easier to mold than Radiesse, she says, which can be important around the oral commissure, a high-motion area. In contrast, “Radiesse can get a little bulky in the commissure area,” although it’s well suited for the top of the nasolabial folds, where thicker skin necessitates a more robust filler.

The angular artery passes through the nasolabial fold area, Dr. Roberts says, “And with Radiesse, you cannot aspirate. So I use very slow injections. The key is not to place too much volume here too quickly.”

Typically, she places three injection points that form a triangle slightly below the edge of the nostril. After these vertical injections, Dr. Roberts carefully cross-hatches the remaining length of the nasolabial fold, injecting small depots very superficially to provide lift. Massage follows the injections in this area.

Some patients also benefit from a layer of Belotero (HA, Merz) just above the cross-hatched injections of Radiesse, running essentially parallel to the nasolabial fold, Dr. Roberts says.

“Belotero works well for superficial etched vertical cheek rhytids,” she says. As a further hedge against the dynamic motion here, “I take a multilevel approach; I start deep, then raise the fold through more superficial injections.”

Accentuating the positive

Jonathan Sykes, M.D., says he bases his filler recommendations on the patient’s age and amount of existing facial fat. A 67-year-old female patient he treated had a higher right eyebrow, which he says commonly comes with lower-lid ptosis on the same side, plus a thinner upper eyelid. But overall, he adds, this patient had an attractive facial bone structure he wanted to accentuate rather than obscure. Dr. Sykes is director, facial plastic and reconstructive surgery, University of California-Davis, and a Cosmetic Boot Camp co-director.

This patient’s treatment involved PLLA injections along the mandibular line, Juvéderm around the mouth and in selected rhytids, plus diluted Restylane (HA, Medicis) in the periocular area to lift the ptotic lid, all performed under local anesthesia mixed with epinephrine for vasoconstriction.

Dr. Sykes says he typically dilutes a vial of PLLA with about 2 cc of lidocaine without epinephrine, and about 7 cc of sterile water. “I always start with an injection from the side, using a 1.5 inch, 25-gauge needle,” injecting on bone along the mandibular line. When performing these injections, “You must know where the masseter is, because the facial artery lies at the front of the masseter.”

He also injected this patient’s preauricular sulcus. In this area, “We must be more careful because there is no deep plane - we are not injecting on bone.” Therefore, he injects smaller amounts, more superficially, in this area. He also injected PLLA in a vertical line up toward the ear, then into the pyriform aperture to reach the medial fat pad of the cheek.

“This is the only injection I perform perpendicular to the skin, because I want to know exactly where I’m injecting,” Dr. Sykes says. When injecting the upper cheek, he adds, “At no time do I inject the eyelid, which is only 400 to 500 µ thick.” All told, he typically injects two vials of PLLA per session; this patient required five vials total.  

For the tear trough, Dr. Sykes says he injected small amounts of Restylane diluted 50:50 with saline, also on the bone and slightly above it (using progressively smaller amounts for the more superficial injections).

“The closer you put the product to the dermis, the more effect you’ll see, but you’ll also see more complications,” he says. To lift this patient’s ptotic lower lid, he adds, “I injected a little closer to the lid than I normally would.”

Next, he injected undiluted Juvéderm Ultra around the patient’s mouth, starting just below the corners of mouth (subcutaneously) to correct a slight downturn here. Regarding injection volumes, he generally uses one to 1.5 syringes total around the mouth.

Additionally, Dr. Sykes injected a little more HA to slightly plump this patient’s lower lip. In such areas, “It’s important to get a feel for what your patients want. This patient made it clear that she would rather have a wrinkle or two than look unnatural.”

Disclosures: Dr. Lupo is a trainer and clinical investigator for Allergan, and a trainer for Medicis/Valeant, but has no ownership interests in these companies. Dr. Roberts is a consultant, speaker and/or advisory board member for Valeant, Allergan, L'Oreal, Neostrata, Skin Medica, TopMD and Theraplex. Dr. Sykes has received research support from Kythera, and is an advisory board member for Allergan and a speaker for Merz and Valeant.