Invited Discussion

Dr. Biesman has written an overview of the nonanimal stabilized hyaluronic acid (NASHA) fillers. Restylane is approved by the Food and Drug Administration as a dermal filler for the correction of soft tissue contour deficiencies. Streptococcal bacterial fermentation is used to produce the Restylane. Marketed in the United States and Canada by Medicis, Restylane is a medium viscosity glycosaminogylcan, and very versatile as a mid to deep dermal filler. An expanded spectrum of NASHA fillers is awaited to be able to fill more superficial dermal lines as well as to use more deeply as a facial contouring substance.

In addition to the treatment of facial wrinkles, I find that Restylane is useful for filling the lips and for deeper facial contouring periorbitally and periorally.

With aging, the pink lip tissue involutes, rolling in toward the mucosa. The natural, more youthful profile of the lip may be reestablished by rolling the pink part of the lip outward (Fig. [1]). The vermillion border may also be defined with injection of Restylane into the potential space along the lip line. Although augmentation here will also balloon out the fine vertical wrinkles at the lip edge, it is important not to let the substance advance into the white part of the lip, as an unnatural ridge appears making it evident that the filler is present. The lip may also be augmented to a larger, fuller size if desired, even in a young patient. At times, the patient would like to change the balance of the upper and lower lip, or change the contour of the lip. For example, the bow of the lip may be either emphasized or blunted as desired. In augmenting and pushing the upper lip upward and outward, the distance from the upper lip to the nose is decreased to achieve a more youthful spacing. The profile of the lips from the side view is also more projected to correct the flattened profile of aged lips (Fig. [2]). Rather than filling individual lines as has been typically done in the past with bovine and human collagens, Restylane is useful for establishing contour with more diffuse and even application. In filling the tissue, many of the fine lines are ballooned out and effaced. It is important not to overcorrect the soft tissue defect with Restylane. Conversely, if insufficient substance is used, an undercorrection will result, and the patient may be dissatisfied. Thus, undercorrection is also to be avoided, and the patient needs to be prepared to have additional vials added until they are satisfied with the correction. At the point that correction is achieved, the fill lasts approximately 6 months but may vary with technique of injection, depth of injection, movement in the area, and the individual patient. Residual static rhytid effacement following dynamic rhytid treatment with Botox may have longer-lasting combined effect than using either treatment alone.

Figure 1 Flow the Restylane forward in small aliquots, rolling the pink lip outward.

Figure 2 (A) Before Restylane. (B) After Restylane, lips and lateral column support.

The perioral area may be further treated by vertically raising the corners of the lips to achieve a pleasant upturn with vertically oriented columns of Restylane. Botox in combination can relax the depressor muscle to the corner of the lip. A deeper injection at the depression in the jaw line can visually correct the appearance of jowls in subtle cases. As the nasolabial folds are treated, fill directed on the more medial aspect of the fold will push the fold out and avoid adding to the fold.

The periorbital area may be treated with Restylane by depositing a small aliquot of material along the superolateral orbital rim to subtly lift the tail of the brow and take up redundant skin over the fill. The hollow along a tear trough deformity or lack of soft tissue over the inferior orbital rim at the trailing edge of the malar fat pad may be augmented (Fig. [3]). After flowing the substance forward along the rim, Restylane may be gently massaged if necessary to the desired contour. In the periorbital area I avoid superficial injection of Restylane due to the thin nature of the skin. Knowledge of orbital anatomy is mandatory when using a filler in the area around the eye.

Figure 3 (A) Tear trough hollow before Restylane. (B) Hollow filled with Restylane; supraperiosteal placement.

Dermal fill and facial contouring with Restylane in combination with Botox to relax dynamic rhytids, laser resurfacing to treat textural rhytids, and surgery to improve structural involution allows for even more individualized three-dimensional sculpting and treatment of patients desiring aesthetic rejuvenation. I look forward to an even broader spectrum of NASHA fillers as they become available to expand the palette of fillers for facial contouring.