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    New filler options facilitate 'three-dimensional' approach to facial aesthetics


    Dr. Waldorf
    New York — As filler products change, so do the aesthetics that guide their use, says Heidi A. Waldorf, M.D., director of laser and cosmetic dermatology, Mount Sinai School of Medicine, New York.

    "The modern approach to soft-tissue augmentation is based on a three-dimensional approach rather than the old two-dimensional approach," Dr. Waldorf says. Rather than filling or resurfacing individual lines and wrinkles, "A three-dimensional approach relies on looking at the facial shape as a whole, noting where the patient has lost structure and volume and replacing that volume to achieve more natural contours and appearance," she says.

    Evaluating patients in a three-dimensional manner requires not just looking at them from the front, she says, but also from 45- and 90-degree angles, as well as taking follow-up photos from these angles.

    "Patients often complain about the nasolabial folds and marionette lines because that's what they see head-on when they look in the mirror," Dr. Waldorf says. "We need to educate patients that these lines are not just wrinkles based on use." Rather, such wrinkles appear because faces lose volume in the form of fat, bone and dentition as they age, she says.

    In rebuilding lost deep fat and bone structure, "Some of the common areas that have been previously overlooked are the temples, the preauricular sulcus and the jawline," Dr. Waldorf says.

    Additionally, she says patients who are concerned about bags under their eyes often try various topical creams and lotions, to no avail. "The reason they have bags or dark circles is because they have a tear trough, that distinct margin between the fat pad of the lower eyelid and the cheek," she says. "By lifting the tear trough and building up the zygoma and malar area, you can, in a very natural way, reduce the appearance of these dark circles and bags without making people look puffy."

    Easy does it

    It's also critical not to go to extremes, Dr. Waldorf says. "I always discuss with my patients that we want them to look natural, like a more youthful, rested version of themselves," she says. "We're trying to avoid the telltale 'filler freaks' such as the duck lips, or the monkey mouth, which occurs when you completely efface the nasolabial folds. We don't want people to have a globe-like head — it should still have contours. And we don't want someone to look like a rhino, with huge cheeks coming straight from under their eyes and an apparent horn — the nose — sticking out in the middle."

    Generally, Dr. Waldorf says, the goal is to approximate as closely as possible the standard proportions of what's considered the ideal face. "Most of us don't have those ideal proportions," she says. "However, while keeping in mind that there may be asymmetries on the patient's face that the patient likes because they provide individuality, don't accentuate those. If anything, go closer toward symmetry."


    John Jesitus
    John Jesitus is a medical writer based in Westminster, CO.

    Derm Pulse
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