Features
Contouring the male face
Dr Derek Jones passes on his experience of treating men with an array of fillers
I start every filler lecture with anatomical slides of high-risk structures, and that is vascular anatomy. Anyone picking up a filler syringe must know it inside and out, like the back of your hand. The facial artery supplies the blood to the face, breaking off on the lower lip, into the inferior labial artery, into the superior labial artery, travelling up along the course of the nasolabial fold. All of these present high-risk for vascular occlusion.
This network connects the dorsal nasal artery to the supratrochlear artery. If you inject your filler into any point along this and occlude the vessel, you can get a watershed vascular occlusion that affects a portion of or the entire network, manifested an an immediate white blanching of tissue followed by a retiuculated purple-blue erythema. There are increasing case reports secondary to intravascular occlusion with fillers; that’s why we have to know where these vessels are, where they run, and we have to be respectful of them so that we don’t create any mischief.
We have much data on Restylane, Juvederm and Belatero. Studies show that when you reach optimal correction with hyaluronic acid and retreat in 6–12 months, you need less volume for optimal correction, and the corrections start to persist for longer periods—often 18–36 months. HAs are long-lasting with repeat treatments.
HAs are “erasable”. I use many fillers—they all have a role—but I particularly like hyaluronic acid because I sleep well at night. If I have a problem I know I can erase it with hyaluronidase. If I have an unfortunate intravascular accident, which can happen to even the best of us, I have hyaluronidase in my cabinet that I can use to flood the area and resolve it.
We use Vitrase in the USA; the one common here is Hylase. When using hyaluronidase, you need to have some awareness of the difference between fillers. It takes more Vitrase to dissolve Juvederm than it does Restylane. That doesn’t mean one product persists longer than the other. But if you’re using Juvederm and you’re trying to erase it, it’s going to take twice as much hyaluronidase than Restylane.
From my clinical experience, each tenth of a cc of Juvederm that I estimate I want to dissolve, I use 10 units of Vitrase; and for each tenth of a cc of Restylane that I estimate that I want to dissolve, I use five units. The hyaluronidase works well and breaks the cross links immediately. You often see the hyaluronic acid fading away before your eyes.
HAs are great for male lips. You must be careful not to over-volumise them. I never use calcium hydroxylapatite or polylactic acid. Lips are for hyaluronic acid only; it’s a much softer, more supple product and you can erase it.
HAs work nicely for tear troughs. Many practitioners want to treat tear troughs, but they are the most technically complex area to treat. I get many referrals because of my experience with hyaluronidase. Most people come to my clinic with an over-volumised tear trough.
I inject on a deep plane through this area, going in at a 90-degree angle with, generally, a 32-gauge half-inch needle. You don’t want to put it too superficially. You need to go just a little inferiorly to the trough into the sub-orbicularis oculi fat and place it properly, usually in an epiperiosteal location.
If there’s any mid-facial atrophy in the cheek, you have to address this before you treat the tear trough; otherwise you’ll create a sausage effect that is basically buttressing out over a hollow cheek, and that’s a no-no. Often by just restoring cheek atrophy, you can make eyes look better.
HAs can treat the ear lobes. One patient had a little line in the ear that bothered him. I put .4 ccs of HA in each ear lobe and he was thrilled.
I always pay attention to what bothers patients. I give them the mirror and ask them. I may have all sorts of ideas about what I want to do, but I really try to incorporate their primary complaint foremost, without doing any harm.
Radiesse is a one-year filler, and we have histologic studies showing that. Calcium hydroxylapatite is visible in CT and X-ray and does not obscure underlying structures or pathology. It is FDA-approved for the nasal labial fold in HIV facial lipoatrophy. HIV facial lipoatrophy patients can take much volume.
For more advanced stage two lipoatrophy, the average optimal correction using Radiesse is about 13cc; our silicone studies suggest
about the same. You’re not going to make patients happy with a smaller amount. Part of what we need to do as good cosmetic injectors is to be able to estimate how much volume someone will need.
Radiesse is a robust product. There are probably a disproportionate number of vascular accidents with Radiesse because novice injectors are using it and injecting it too rapidly, getting into vascular structures. I use a lot of it in my own practice. Inject it very slowly. I use a linear retrograde technique, using a long needle. If you’re injecting as you pull back, you have much less chance of injecting straight into an artery.
Cannulas are becoming much more popular these days. I’m still mostly a needle injector, but I would certainly seek experience with cannulas when injecting Radiesse because it may be less risky. Never inject it into the lips; never inject it into the glabella, which is a high risk area for necrosis; and never inject it into the tear trough.
Sculptra is a subtle volumiser.
You have to do multiple treatments and I would say do not inject this product superficially. It is not an intra-dermal injection, it’s a SubQ injection. You want to make sure that you reconstitute with 5cc or more using a linear threading technique.
I’ve done a significant amount of work with the HIV lipoatrophy community. I was among a group of authors who published data on 77 patients treated with liquid injectible silicone using micro-droplet technique, 2cc per treatment at monthly intervals, until we got optimal correction. (Derek H Jones MD, Alastair Carruthers MD, David Orentreich MD, Harold J Brody MD, Mei-Ying Lai MS, Stanley Azen PhD, Gregory S Van Dyke MD, PhD. “Highly Purified 1000-cSt Silicone Oil for Treatment of Human Immunodeficiency Virus-Associated Facial Lipoatrophy: An Open Pilot Trial,” Dermatologic Surgery, Vol 30, Iss 10, pp 1279–1286, Oct 2004.) The treatment worked beautifully. You have to go slowly with the micro-droplet technique using highly purified 1000-cSt silicone. I do find this to be absolutely the best treatment for HIV facial lipoatrophy.
We have recently followed up with about 135 of these patients. Extremely good results were evident at five years or more. We have had four patients who have developed some subcutaneous induration, which is expected with any permanent filler. Luckily we’ve been able to treat it quite nicely with intralesional cortisone with 5-flourauracil.
Dr Derek Jones is an associate professor of dermatology at UCLA and director of the Skin Care and Laser Physicians clinic of Beverly Hills. W: skincareandlaser.com
