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The aging face: global approach with fillers and neuromodulators.


The goal of treating the aging face is to restore facial balance and modify shadows. A facial evaluation should focus on areas of volume loss and opportunities to use neuromodulators (eg, botulinum toxin A) and the use of fillers. A thorough understanding of facial anatomy, including muscles, nerves, bone, and fat pads, is essential for effective and safe treatment.


Aging face; botulinum toxin A; fillers; neuromodulators


As we age, bone and fat volume in the face and neck naturally decrease. Furthermore, rotational descent of the face occurs with aging, contributing to a lengthening of the face and the creation of lines, folds, and shadows. Youthful faces often have a heart-shaped pattern, but with age the face becomes more oval (elongated) or square (broadened, bottom heavy). For example, a baby's face has a shape similar to an inflated beach ball, round and unlined. But the muscular atrophy, photodamage, and fat atrophy that occur with aging lead to an appearance more like a wrinkled, deflated beach ball.

In the midface, aging often increases fat in the lower areas and decreases volume in upper areas. The bone also resorbs and remodels. Resorption is common in the frontal bone, contributing to a convexity of the bone and ptosis of the brow. Resorption of the zygomatic angle makes the angle more acute, and the malar fat pad sags medially and creates or worsens the nasolabial fold. Other changes that contribute to the appearance of aging include periorbital hollowing, marionette lines, submalar hollowing, and periocular rhytidosis.

The goal of treating the aging face is to restore facial balance and modify shadows. For example, the infraorbital fat pad tends to protrude as people age. Part of the cosmetic problem caused by this change is the shadow that the pad creates; filling below the protruding pad can reduce this shadow and create a more youthful appearance. The facial evaluation, therefore, should focus on areas of volume loss and opportunities to use neuromodulators (eg, botulinum toxin A) and the use of fillers.

Neuromodulators and the Aging Face

Injections of neuromodulators relax specific muscle groups and can reduce wrinkles and improve cosmesis. There are several common facial targets for neuromodulators. The forehead is a complex region with corrugator muscles that adjust brow height and volume. The pattern of movement of these muscles varies by individual, and several patterns have been described (Figure 1). The most common is the V pattern, which can be addressed with neuromodulator injections in the procerus medial corrugators and lateral corrugators. The inverted omega pattern involves medial contraction of the corrugators and often includes the nasalis muscles. Neuromodulator injections should be focused centrally. The omega pattern involves the frontalis and procerus muscles, and injections focus on the central areas. The U-shaped pattern typically responds well to treatment and may need less neuromodulator. Finally, the converging arrow patterns typically involve deep central lines on the forehead. When treated with neuromodulators, this pattern often shows the greatest improvements.

Other facial sites for neuromodulators include the masseter muscles. Hypertrophy of the masseters may occur even in young patients, contributing to a bottom-heavy facial appearance. Injection of these muscles can ameliorate this hypertrophy.

Fillers and the Aging Face

Neuromodulators can improve cosmesis of the forehead by relaxing muscles that contribute to folds and wrinkles. But volume loss can also contribute to poor cosmesis. For example, an arched eyebrow is generally considered more youthful and attractive; fillers can be used in the forehead to achieve this arched or rounded appearance. The safest zone for the injection of fillers in the forehead is in the mid-forehead at the level of the periosteum, which can help avoid an intra-arterial injection. A typical volume for this application is 0.1 to 0.2 mL of filler per site, with 3 or 4 injections per side, followed by blending by hand to achieve the desired look. Blending is easy in this region because the filler is injected on the periosteum.

Fillers can also be used to increase brow height. Caution should be exercised when injecting filler into the brow, and a cannula may be safer than a needle. The general approach involves injecting at the lower margin of the brow from the peak of the brow and continuing laterally. The temples are another site that may benefit from application of fillers. Injection should be performed 1 cm above the orbital rim and 1 cm medial to the temporal fusion plane, with a finger pressed behind the needle to prevent the filler from flowing into the hairline. Up to 1 mL of filler per side may be needed to eliminate shadows. Injecting filler in this spot is generally quite safe.

A youthful orbit is characterized by a long, flat, and full eyelid, with the upper lid concealed by skin. The bony orbit is not visible. With aging, the orbit loses volume and becomes more skeletonized. The typical finding with age is called the A-frame deformity. Fillers can be used to replace this volume loss, although injecting in this area requires advanced technique, and use of a cannula is recommended. Small volumes of filler (eg, approximately 0.1 mL) are usually sufficient to rectify A-frame deformities.

The midface is one of the most important areas to address in aging. The focus should be on the cheek, lower lid, and submalar area. A common finding that occurs with aging is the malar crease, which occurs as fat in the cheek begins to sag. It is important not to add filler below the malar crease, as this may produce an unnatural appearance. Injections of filler from the bottom of the malar crease upward and in the anteromedial and lateral cheek can ameliorate this crease, as well as the nasolabial fold. Using this approach, injections in the nasolabial fold may not be necessary. The medial and lateral lid-cheek junction will also be addressed when the midface is corrected.

Filler can be added to the medial and lateral tear trough by injecting one or two small boluses (approximately 0.1 mL) near the periosteum and massaging the gel up to the medial canthus. Both medial and lateral tear troughs must be addressed. Lateral scleral show of the eye (analogous to a downturned corner of the mouth) can be lifted with filler. This technique should only be attempted by clinicians with extensive experience injecting filler. To treat lateral scleral show, a small amount of filler can be injected below the lateral canthus to provide lift.

The submalar area can be injected with small amounts of filler (approximately 0.05-0.1 mL per injection) in a grid pattern in the subcutaneous plane (Figure 2).

Finally, in the lower face, areas for fillers include the marionette lines, chin apex, and the pre- and post-jowl sulci. However, some patients who complain about jowls actually have protrusion of the submandibular gland. This protrusion can usually be managed with application of neuromodulator (eg, 5-8 units botulinum toxin A on each side), often with rapid resolution.

In summary, use of fillers and neuromodulators is an effective strategy for the treatment of age-related facial changes. A thorough understanding of facial anatomy, including muscles, nerves, bone, and fat pads, is essential for effective and safe treatment.


Shaw RB Jr, Kahn DM. Aging of the midface bony elements: A three-dimensional computed tomographic study. Plast Reconstr Surg. 2007:119:675-681.

Nowell Solish, MD, FRCP(C), Assistant Professor, University of Toronto, Toronto, Ontario, Canada

Dr Solish has received an honorarium for his participation in this activity. He acknowledges the editorial assistance of Josh Kilbridge, medical writer, and Global Academy for Medical Education in the development of this continuing medical education journal article.

Nowell Solish, MD, FRCP(C): ConsultantlGruntlResearch Support: Allergan. Inc., Galderma Laboratories, L.P.. Indeed Labs. Inc., Merz, Revance Therapeutics, Inc., Valeant.

Address reprint requests to: Nowell Solish, MD. 66 Avenue Road. Suite 1, Toronto, Ontario M5R3N8:

Caption: FIGURE 1

Patterns of Corrugator Movement and Sites for Neuromodulator Injection

Caption: FIGURE 2

Two Techniques for Submalar Injection of Filler


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Author:Solish, Nowell
Publication:Dermatology News
Article Type:Report
Date:Sep 1, 2016
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