"Panfacial structural filling causing volume replacement provides lift and contour. Then fine-tuning can be achieved with superficial fillers and other modalities," said Dr. Mandy, volunteer professor of dermatology, University of Miami, FL.

Options for structural semipermanent filling include one of the biodynamic fillers, calcium hydroxyl apatite (Radiesse, BioForm Medical) or poly-L-lactic acid (Sculptra, Sanofi-Aventis), a large molecular weight crosslinked hyaluronic acid, or autologous fat.

However, an important point of caution when using a filler material in the area of the malar eminence is to pay attention to the amount injected in order to avoid causing lower eyelid and malar edema. Dr. Mandy postulated that this complication can arise with the use of too much filler, which leads to stretch and tensioning of the malar septum and subsequent obstruction of lymphatic flow. He noted that it occurs rarely but is very distressing to patients and may be difficult to manage.

Panfacial structural filling is most often combined with botulinum toxin type A (Botox Cosmetic, Allergan), but other modalities can be used, including resurfacing and radiofrequency tightening procedures. Many patients also need multilevel filling with injections of both a structural filler and a superficial filler that will provide rhytid filling.

The superficial filler category includes the various collagen products, of which porcine collagen (Evolence, OrthoNeutrogena) is the newest. Porcine collagen has a number of advantages, as it requires no refrigeration or skin testing, and it is associated with very little postinjection reactivity. However, dermatologists should recognize there are several caveats for its use, and training is required.

"The material should be injected with very low pressure and into the dermis. You should see the outline of the needle, but not the "blue" color, and then you know the injection is in the right place," Dr. Mandy said.

Injection too superficially leads to irregularities, and massage immediately postinjection is also important to prevent lumping. Due to a risk of lumping, porcine collagen should not be injected into the lips. DT