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Replacing What Was Lost

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Hollowing under the eyes, a loss of prominence in the cheek bones and deepening of the nasolabial folds are among the first signs of aging that bring patients to the plastic surgeon’s door. Each of these concerns relates to changes that occur in the midface as the malar fat pad descends and facial fat begins to degrade. “The whole midface area starts to sag with age,” says David Alessi, MD, of the Alessi Institute for Facial Plastic Surgery in Beverly Hills, California. “You see loss of volume in the area and the malar fat pad descends, deepening the nasolabial fold, flattening the cheek bone area and creating a separate groove beneath the eyelid fat.”

Depending on the degree of volume loss and the patient’s specific anatomy, physicians have a variety of surgical and nonsurgical treatment options available to rejuvenate the midface. Selecting the right procedure for your patients starts by identifying the severity of sagging, and the patient’s desired outcome, budget and tolerance for downtime.

Nonsurgical Interventions

For patients with minor sagging in the midface and deepening of the nasolabial folds, dermal fillers are a cost-effective and popular option. “If someone just has some minor sagging in the midface, then we treat that with fillers,” says Dr. Alessi. “A filler in the nasolabial folds works very well. Fillers in the malar area work very well too.”

Patients who have more severe sagging and deepening of the nasolabial folds require more extensive volume replacement in the malar area.

Achih H. Chen, MD, director of The Georgia Center in Evans, Georgia, cites Radiesse, Voluma XC, Sculptra and Perlane as effective fillers for the midface. He uses Radiesse, injected with a fanning technique, to replace lost volume in patients who don’t want or need surgery. “It is a different injection technique than in the nasolabial fold,” he says. “There are some folks who use the depot technique, where they place the needle right down close to the bone and inject a bolus in that area. I tend to use a fanning technique to feather the filler throughout the soft tissue of the cheek to give a good, uniform augmentation in that area.”

For patients who do not require surgery, John G. Westine, MD, of Delray Plastic Surgery in Delray Beach, Florida, recommends Sculptra. “I’ve been using Sculptra for about 10 years, ever since it was approved for lipoatrophy,” he says. “Initially it was pretty expensive—about $1,200 a vial to patients back in 2005. But it has since become more competitively priced with Galderma. Currently, patients will likely spend around $600 to $800 per vial, so it’s much more popular and less cost prohibitive. Subsequently, I’ve been using a lot more Sculptra for midface and diffuse facial volume loss.”

He notes that Sculptra can cause more temporary bruising than HA-based fillers, especially with superficial fanning techniques. So it is especially important for patients to stay off any medications that may potentially thin their blood, like aspirin, herbal supplements or fish oils. Conversely the deeper bolus-type injections in the temples and the midface do not tend to create much bruising given that the needle can be passed only once to its target.

Image copyright Getty Images.


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