Facial aging is caused by wrinkling, decreased pigment, and decreased blood supply and loss of underlying fat tissues. A progressive loss of tissue volume due to the loss of subcutaneous fat and bone contribute significantly to facial aging.
Soft tissue fillers can be used to restore a semblance of youth through the replacement of lost tissue volume and the filling and effacement of coarse wrinkles.
●Upper faceGlabellar lines – Deep vertical lines in the glabellar area form as a result of repetitive contraction of the muscles that mediate brow depression. Soft tissue fillers can be used to soften the appearance of these lines. Because of the important role of muscular activity in the creation and exacerbation of glabellar lines, concomitant treatment with botulinum toxin is often beneficial.Horizontal forehead lines – Horizontal forehead lines result from the repetitive elevation of the brow over time. Similar to glabellar lines, placement of a soft tissue filler into deep horizontal forehead lines can diminish their appearance. Horizontal forehead lines may also be improved with botulinum toxin injection.Lateral brow lift and temporal fossa changes – The natural loss of periorbital fat that occurs with aging results in lateral brow ptosis and reduced lateral brow projection. Fillers can be used to elevate the lateral brow and restore its anterior projection.
Temporal fossa wasting – Volume replacement with soft tissue fillers can minimize the appearance of age-related concavity in the temporal area.
Tear trough depression – With aging, pronounced depressions may occur between the rim of the orbital bone and the nasal sidewall due to the relaxation of suspensory ligaments of the eye and the descent of the malar fat pad. This can be difficult to correct surgically. The nasojugal fold has been successfully managed with the injection soft tissue fillers.Cheeks – Hypoplasia of the zygoma and the descent and atrophy of midfacial fat contribute to loss of the heart-shaped contour that is characteristic of the young female face. Injection of soft tissue fillers into the malar area increases anterior projection of the cheek and diminishes the appearance of nasolabial folds, leading to a more youthful appearance.
Nasolabial folds – Nasolabial folds are the most common sites treated with soft tissue fillers. United States Food and Drug Administration approval for many products is limited to use in this area.
Oral/perioral – Vertical perioral wrinkles and mouth frown can be corrected with soft tissue fillers; lip augmentation also can be performed with these agents.
Chin – Melomental folds (marionette lines) and horizontal creases in the chin are amenable to treatment. Fillers have also been used for chin and mandibular augmentation.
Hand rejuvenation – Soft tissue augmentation can camouflage the skin laxity, wrinkling, and prominence of bone that characterize the appearance of the aged hand.Neck and chest – Soft tissue fillers can ameliorate signs of flaccidity, atrophy, and wrinkling in the neck and presternal chest.
In addition to the indications described above, soft tissue fillers may also be used to repair cosmetic contour defects that are unrelated to age. Soft tissue fillers are minimally invasive alternatives to traditional rhinoplasty for patients who wish to avoid surgery. Fillers have also been used to correct post-surgical contour deficiencies and asymmetries in the nose.
THERAPEUTIC APPLICATIONS — Soft tissue fillers play an important role in the correction of defects that result from medical disorders, trauma, or surgery.
- HIV-associated lipoatrophy — Human immunodeficiency virus (HIV)-associated lipoatrophy is the most extensively studied therapeutic indication for injectable soft tissue fillers. Patients present with facial lipoatrophy, characterized by sunken cheeks, bitemporal wasting, and deep nasolabial folds. These features can be stigmatizing and can have a significant psychosocial impact on affected individuals. Treatment has been associated with an improved sense of well-being and a high level of patient satisfaction.
- Scarring — Facial scars, particularly the pitted atrophic scars that often result from acne vulgaris, can be difficult to treat. Soft tissue fillers can improve the appearance of individual scars and overall skin texture. Injectable fillers have also been used to improve depressed scars that result from the treatment of skin cancer, trauma, or other causes.
- Facial asymmetry and soft tissue defects — Facial asymmetry may be congenital or acquired (surgical or traumatic), and can result from bony or soft tissue abnormalities. Soft tissue fillers can be used to restore volume to underlying tissues in a manner that restores symmetry. Patients with trauma-induced lipoatrophy, hemifacial atrophy (Parry-Romberg syndrome), and linear scleroderma (linear morphea) have benefited from treatment with these agents.
- Examples of other defects that have been corrected with soft tissue fillers include mandibular prognathia, surgical or traumatic skull defects, and residual cosmetic defects following cleft palate surgery. Multiple disorders involving the eyelids such as eyelid malposition, lid margin asymmetry, epiblepharon, and paralytic lagophthalmos, as well as loss of periorbital volume in anophthalmic enophthalmos have also been managed with these agents.
- Other — Soft tissue fillers are utilized for medical purposes in nonfacial sites. Examples include nipple contouring and improvement of chest wall defects after mastectomy and breast reconstruction, and treatment of glottic insufficiency (vocal cord dysfunction).