INTRODUCTION TO DERMAL FILLERS :
THE CURRENT TREATMENT STRATEGY IN
ASIAN FACE
Dermato-venereology Update Nusantara 2019
Semarang, 28th-30th June 2019
Syarief Hidayat
INTRODUCTION
• Dermal fillers have been increasingly used in facial esthetic
procedures.
• Filler is one of semi- invasive treatment to against the aging
process
• (2011) 1.6 million/ year 2.4 million (2015)
• Its use will increase further as we refine the concept of aging
• However, there still a lack of recommendation/ clinical
evidence or expert consensus report for Asian faces
Hema et.al. Global Aesthetics Consensus: Hyaluronic Acid Fillers and Botulinum Toxin Type A—Recommendations for Combined Treatment and Optimizing Outcomes in Diverse Patient Populations. Plast Reconstr Surg.. 2016
May;137(5):1410-23
Wu et.al. Consensus on Current Injectable Treatment Strategies in the Asian Face. Aesthetic Plast Surg. 2016 Apr;40(2):202-14.
ASIAN VS WESTERN
• HA fillers are used more commonly and extensively in
young Asians than in young Western patients.
• The objective is different
• WESTERN improve AGING process
• ASIA ESTHETIC
• reshape and recontour facial features/ structural
deficiency
Consensus on Current Injectable Treatment Strategies in the Asian Face. Woffles T. L. Wu. 2016. Aesth Plast Surg. P 1-13
ASIAN VS WESTERN
• ASIA ESTHETIC
• Reshape and recontour facial features/ structural
deficiency by:
• Reduce sub-orbital hollow area
• Correct ‘‘flatness’’ of facial area
• Improve projection of the nose and chin
Consensus on Current Injectable Treatment Strategies in the Asian Face. Woffles T. L. Wu. 2016. Aesth Plast Surg. P 1-13
ASIAN VS WESTERN
• The structural and anatomical features are specific
• Asian differ from Western in facial aging,
• Hence the need of unique esthetic treatment
strategies for each populations
Consensus on Current Injectable Treatment Strategies in the Asian Face. Woffles T. L. Wu. 2016. Aesth Plast Surg. P 1-13
Philippines Japan Indonesia
Korea Indonesia China
India
Ethiopia America
THE AGING AND BONE LOSS
THE INSIGHT FOR THE CLINICIAN
Age-related bony changes are mainly in the periorbital and midcheek zones, including the superomedial and inferolateral aspects of the orbit,
the medial suborbital and piriform areas of the maxilla, and the prejowl area of the mandible.
Arrows indicate the areas of the facial skeleton susceptible to resorption with aging. The size of the arrow correlates with the amount of resorption.
Mendelson B, Wong CH. Changes in the facial skeleton with aging: Implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg. 2012;36:753–760.
THE FAT COMPARTMENTS AND AGING PROCESS IN HUMAN FACE
THE FACEMAP OF DERMAL FILLER
Alloplastic Volumizing Augmentation of Midface and Mandible Sections : Chapter 32. Edward O. Terino et.al. 2017. Plastic surgery key
MALE VS FEMALE
MAN VS WOMEN
• A man’s Skeleton is larger, its surfaces rougher and the edges are
more angular
• Women’s skeleton has a more pronounced zygoma and
zygomatic arch
• Divided into 3 parts : Upper, Middle and Third
• Zygomatic Prominence is attractive in women
GALADARI, H. 2017. Soft Tissue Augmentation: Principles and Practice, Springer Berlin Heidelberg.
MAN VS WOMEN
• Augmentation of the chin in women is mainly in the midpoint and
extends laterally to no more than a line drawn vertically down from
the nasal ala.
• In men, Chin augmentation extends to a vertical line drawn down
from the corners of the mouth
• Men’s jaws appear more angular and more prominent Create a
stronger : Masseteric
• Consider not to perform filler to augment the angle of jaw in
women VERY MUSCULAR JAW
GALADARI, H. 2017. Soft Tissue Augmentation: Principles and Practice, Springer Berlin Heidelberg.
ABSORBABLE (TEMPORARY) MATERIALS
• Hyaluronic acid : Juvederm, Restalyne, Prevelle Silk, Hylaform, Belatero
• Calcium hydroxylapatite ( CaHA) : Renu CE 0086
• Poly-L-lactic acid (PLLA): Sculptra 101
Food and Drug Administration. Dermal filler treatment. 2018. U.S. Department of Health and Human Services
NON-ABSORBABLE (PERMANENT)
MATERIALS
• Polymethylmethacrylate beads (PMMA
microspheres) non-biodegradable,
biocompatible, man-made polymer :
bellafill
• Polyacrylamide gel (PAAG) non-
biodegradable, non-resorbable sterile
watery gel 2.5% cross-linked polyacrylamide
and non-pyrogenic water
Food and Drug Administration. Dermal filler treatment. 2018. U.S. Department of Health and Human Services
FDA REGULATION IN DERMAL
FILLER
• Correction of moderate to severe facial wrinkles and skin folds on
nasolabial folds
• Non-absorbable material ONLY for the correction of nasolabial
folds and cheek, acne scars >> 21 years
• Restoration and/or correction of the signs of facial fat loss
(lipoatrophy) in HIV
• Lip and cheek augmentation and correction of contour
deficiencies
• Hand augmentation
Food and Drug Administration. Dermal filler treatment. 2018. U.S. Department of Health and Human Services
THE FDA HAS NOT APPROVED DERMAL
FILLERS TO:
• Increase breast size (breast augmentation)
• Increase size of the buttocks
• Increase fullness of the feet
• Implant into bone, tendon, ligament, or muscle
• The FDA has not approved injectable silicone for large-scale
body contouring/ enhancement
Complications embolism (blockage of a blood vessel),
stroke and death
Food and Drug Administration. Dermal filler treatment. 2018. U.S. Department of Health and Human Services
UNAPPROVED DERMAL FILLERS
Juvederm Ultra 2, 3 or 4, because these products are not
approved for use in the U.S (FDA)
The FDA has NOT approved liquid silicone or silicone gel for
injection to fill wrinkles or augment tissues anywhere in the
body.
Food and Drug Administration. Dermal filler treatment. 2018. U.S. Department of Health and Human Services
ASIAN PERSPECTIVES
• Asian facial concepts and trends over the past four decades
they do not want to look Western, BUT they wish to look like good-
looking Asians, within their own ethnic esthetic boundaries.
• Anterior projection of the forehead, brows, and midface (medial
cheeks and nose) is a common goal.
Woffles et.al. Consensus on Current Injectable Treatment Strategies in the Asian Face. Aesth Plast Surg. 2016.
ASIAN PERSPECTIVES
• The aims of facial esthetic treatment in Asians are:
• to achieve clear, youthful, and fair skin;
• an oval facial shape with smooth facial contours;
• large expressive eyes with clearly defined palpebral creases;
• and an esthetically pleasing, structural definition of the nose, chin,
eyebrows, and cheeks adequately projected midline features
• When treating aging patients, the focus of treatment should involve the
whole face, NOT ONLY certain aspects, because it will affect the
overall balance and proportions of the face.
Woffles et.al. Consensus on Current Injectable Treatment Strategies in the Asian Face. Aesth Plast Surg. 2016.
UPPER FACE INTERVENTION
• Most patients prefer a natural look, with a smooth
forehead
• Upper face volumization : achieve optimal smoothness
and anterior projection of the forehead and upper face
• Older women want a smooth, contoured forehead
without temporal hollows.
Woffles et.al. Consensus on Current Injectable Treatment Strategies in the Asian Face. Aesth Plast Surg. 2016.
MIDFACE TREATMENT
• Asians are less prone to photoaging, they generally have fewer
wrinkles bunny lines and under the eye lines = MAIN CONCERN
• Younger Asian main treatment: volumization medial cheek,
nasal shape and chin contour
Woffles et.al. Consensus on Current Injectable Treatment Strategies in the Asian Face. Aesth Plast Surg 2016.
MID-FACIAL AUGMENTATION
• Asian faces are typically wider, shorter, and flatter than Western
faces, and this central concavity most common complaints
• Deep augmentation of the cheek can result in profound changes
in all areas of the mid and lower face, and is recommended
before augmenting the tear trough or nose
• Common correcting nasolabial folds, or filling the perioral region
Nark-Kyoung Rho et.al. Consensus Recommendations for Optimal Augmentation of the Asian Face with Hyaluronic Acid and Calcium Hydroxylapatite Fillers. 2015. American Society of Plastic Surgeons Journal.
TEAR TROUGH AUGMENTATION
• TEAR TROUGH = bulging of orbital fat and deepening of the orbital
rim groove (aging of the lower lid and cheek)
• Midface augmentation often improves the appearance of the tear
trough : first step in a panfacial treatment approach
• Overfilling the area often disrupts the lid-cheek junction : More
unnatural appearance
Nark-Kyoung Rho et.al. Consensus Recommendations for Optimal Augmentation of the Asian Face with Hyaluronic Acid and Calcium Hydroxylapatite Fillers. 2015 American Society of Plastic Surgeons Journal
LOWER FACE AUGMENTATION
• Most Asian women desire an inverted triangle shape, a
slender chin and jaw.
• Square lower face is esthetically undesirable among
Asian women
• Chin retrusion is a common feature of the Asian face ↑
treatment in the chin area with fillers.
Nark-Kyoung Rho et.al. Consensus Recommendations for Optimal Augmentation of the Asian Face with Hyaluronic Acid and Calcium Hydroxylapatite Fillers. 2015 American Society of
Plastic Surgeons Journal.
CONCLUSION
• A reflection of different patient’s demographics, anatomical
morphology, and ethnicities defines THE IDEA OF BEAUTY
• Understanding of the characteristic anatomy and morphology of
Asian face is crucial
• Combination treatment strategies are often required to optimally
address the complexity of Asian patients esthetic concerns.
THANK YOU
“Beauty is not in the face; beauty is a light in the heart.” ― Kahlil Gibran.
Frontal View Lateral View
BLOOD VESSELS OF THE HEAD AND NECK
THE ANATOMY OF BLOOD VESSEL
Schematic drawing of anatomy, distribution, and connections between the ophthalmic and facial arterial systems. (Used with
permission from Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, Lazzeri S. Blindness following cosmetic injections of the
face. Plast Reconstr Surg. 2012;129:995–1012.)
THE LEVEL OF EVIDENCE AND CONSENSUS
RECOMMENDATION
Evidence was based on the Oxford Centre for evidence based medicine hierarchy
Hema et.al. Global Aesthetics Consensus: Hyaluronic Acid Fillers and Botulinum Toxin Type A—Recommendations for Combined Treatment and Optimizing Outcomes in Diverse Patient Populations. Plast Reconstr Surg.. 2016 May;137(5):1410-23.
Chang D (2017) The Safety and Efficacy of Midface Rejuvenation in Asians with Hyaluronic Acid Dermal Fillers, High Intensity Focused Ultrasound and Thread lift. Cosmetol & Oro Facial Surg 3: 125
