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Facial Shaping With Fillers (printer-friendly)

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cme.medscape.com

This article is part of a CME/CE certified activity. The complete activity is available at:
http://cme.medscape.com/viewprogram/30402

Facial Shaping With Fillers CME/CE


Rebecca Fitzgerald, MD
Published: 07/21/2009

Slide 1.

Hello, I'm Dr. Rebecca Fitzgerald. I'm a dermatologist in private practice in Los Angeles, California, associated with
UCLA (University of California, Los Angeles) Medical Center. Welcome to this MedscapeCME Video Lecture, "Facial
Shaping With Fillers."

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Slide 2.

We've had fillers for quite some time now, but with fillers such as collagen, facial shaping wasn't really a possibility.
Those fillers were used more to fill a line or a small fold. Even hyaluronic acid can be used to address folds but not in
substantial volume.

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Slide 3.

As we've begun to see an explosion on the market of new fillers, we have gained the ability to do a little bit of
contouring and volumizing with these new agents. We're going to spend some time today talking about facial shaping
and looking at not just local lines and folds but trying to see the face as the complex 3-dimensional interlocking puzzle
that it is, and see those lines and folds as the first visible signs of an underlying process.

Slide 4.

Who are we treating with these agents? Everybody. The population is getting older, and we're beginning to figure out
that even though getting older is somewhat inevitable, looking older can be a little bit optional. We're staying in the
workforce longer.

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Slide 5.

I think that nonsurgical rejuvenation is something that really lends itself well to people in the workplace because they
just don't want any downtime.

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Slide 6.

We're not doing something that's all that radically different from what we've done with surgery. We're trying to tighten
the skin and fill up the volume loss underneath the skin. So it's really on a spectrum. But we're finding that if we start
earlier, we can do that very effectively with nonsurgical methods, and that's what we'll talk about today.

Slide 7.

What are some of the indications and limitations of replacement fillers? You can use as much as you want at any one
time. It's a shorter learning curve. It's very cost effective for mild volume replacement. It's the only thing that you can
use in the lips, and that's the most requested area for treatment. But these agents have a bit of a limited longevity,
lasting 12 to 36 weeks.

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Slide 8.

The stimulatory fillers cannot be used in any amount desired at one sitting. These are done through multiple treatment
sessions, and the results are not immediate. So it's not an "event filler." This isn't something that you want to use for a
patient who has a wedding or a reunion coming up in a couple of weeks. But the tradeoff is duration -- these are more
of a long-haul fix. Optimal results with these fillers are a little more technique-dependent, but they can correct
significant volume loss, tighten the skin, and the duration is about 12 to 36 months.
What are we treating? Let's review a little bit of the current literature on aging.

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Slide 9.

I think it's very well accepted now that volume loss -- more so than gravity -- is at the root of what we're seeing in the
aging face. If you put a bunch of long-stemmed tulips in a vase on Monday, they all stand up. If you look at the same
vase on Friday, they all begin to hit the counter. Gravity hasn't changed at all between Monday and Friday, but the
hydration state of the flowers has changed. What happens to those flowers at about 8 days happens to us over about 8
decades very slowly. What's happening isn't happening in just one tissue but in multiple structural layers in the face: in
the skin, in the fat and the muscle underneath the skin, and in the craniofacial support that's holding all that soft tissue.
Those changes are happening not independently but interdependently between tissues. Although the sequence of
those changes is somewhat predictable, the pace of those changes is very individual between different patients and
even between tissue layers within the same individual.
Those changes lead to the morphologic changes that we see in the aging face, in terms of the topography of the face
and how it reflects or shadows light, and in terms of the shape, the balance, and the proportions of the face. That's
what I want to spend a little bit of time on today.

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Slide 10.

If you draw a line through the center of her face, you can see that her left side is much more volumized than her right
side. That volumized side of her face looks a little bit younger than the right side. She's got more of a convexity to her
temple on the left than the right. Her cheek has a little bit more anterior projection. Her face is an oval shape on the
volumized side and a little bit less of an oval shape on the less volumized side. Interestingly, on the side with volume,
there's no distinction between the temple, the lid, and the cheek. It all blends together as one flowing thing. On the side
with less volume, you can make out a very distinct entity of a temple, a lid, a lid-cheek junction, and a cheek. I think
that what we're trying to do with these volumizers is bring back the left side of the face.

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Slide 11.

We can apply what we've learned from very extreme changes to less extreme changes in order to have the ability to
intervene earlier. If you look at the top picture, you can see that he's lost a great deal of volume in the preauricular area
and in his mid-face. His face is literally becoming a little too small for his skin. You begin to see that slackened skin
collect underneath his jaw line and his neck. As you revolumize that face, it begins to pull that skin back up.
If you then look at a typical 45-year-old female face that presents very commonly in a cosmetic office, and you look at
her face in the same way that you look at his, you begin to realize that she's losing volume in exactly the same way,
and that her face is becoming a little too small for her skin. The slackened skin is falling off of that smaller face, and if
you revolumize that face you can pick that skin back up. If you start early with volumizers, it's a very possible thing to
do without a lift and without a laser. In very extreme cases, where much more laxity is present in the skin, it's probably
not possible.

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Slide 12.

This is a nice example of that principle. This looks almost like a mother and daughter. The only intervention is
volumizers. Interestingly, in this patient, the folds and lines have not been treated as isolated entities but as symptoms
of an underlying global process. In the after picture, she still has a nasolabial fold, perhaps even more pronounced than
the one before she was treated, but she still looks significantly younger because the topography of her face and the
shape of her face looks like that of a younger individual.
Let's go through some of the structural changes that are happening in the skin, the fat, and the bone. Then let's look at
how those influence the morphology of the face.

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Slide 13.

If you look at this patient, he's 66 years old on both sides of his face. But on the driver's side window [side of his face],
where he's received a lot more chronic sun -- he's a truck driver -- that skin has lost the ability to adjust to the
underlying volume loss in his face. You begin to see herniation and a bigger fold that you don't see on the other side.

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Slide 14.

A recent study showed a very fascinating piece of information that fibroblasts have to leverage themselves and hold
onto mature collagen and stretch a bit in order to make new collagen. [1] If they can't do that, and they begin to involute,
not only do they not make new collagen, but they begin to make collagenase. So you begin to enter into a selfperpetuating vicious cycle -- the more collagen you lose, the more collagen you lose. Intervening early will probably
make a very significant difference.
What about the soft tissue underneath the skin? For a long time, it was just assumed that fat was in one big sheet
underneath the skin. Over the last year, research has shown that that fat is, in fact, compartmentalized in very, very
well-demarcated, well-demarginated areas and compartments on the face -- about 9 of them. [2]

Slide 15.

If you look at the cadaver on the far left, you see the deep medial cheek fat pad where we almost always see a
nasolabial fold form. You can really change a lot in a face by treatment of this area, and we'll talk about it again in a
minute. If you look at the temporal and the preauricular fat on the cadaver to the far right, you can see that there's an
enormous amount of volume in that fat compartment. As that volume is lost, you can see a huge change in the face.

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Slide 16.

If you look at this patient, she's got a pretty decent craniofacial skeleton, but her skin looks like it's hanging off of her
face. Does she really need a facelift, or can you lift that sagging skin by replacing the volume where it's been lost in her
temple and her preauricular area? Well, surprisingly, you can.

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Slide 17.

I think that this study has given us nothing less than a blueprint of where to fill the face. [3] They took a cadaver, filled a
syringe with saline, put it in that deep medial cheek fat pad, and infused the saline into that compartment. Not only did
they get projection of the cheek, but it also effaced the under-eyelid bag and the nasolabial fold.
What would happen if you took the same approach with a volumizer on a patient? The same thing -- you'll get anterior
projection of the cheek, which will then, secondarily, efface the lower lid back and the nasolabial fold. Also, that anterior
projection will gravity-proof that face because inflated tissue is not as subject to the downward pull of gravity. You'll
take her back to that fresh vase of flowers on Monday instead of Friday.

Slide 18.

Underneath the skin and the fat is the craniofacial skeletal support. Is that changing, too? Recent evidence shows that
there are some very dramatic changes in the craniofacial platform as we age. In this study, Shaw and Kahn [4] at
Stanford [University, Palo Alto, California] took 60 patients (twenty 20-year-olds, twenty 40-year-olds, and twenty 60year-olds) and did CTs and looked for statistically significant differences in the bony volume in these different age
groups and found remarkable changes. If you look at the circled areas, you can see that it is no wonder we develop
"11s" in our glabellar fold -- there's nothing supporting that overlying soft tissue. The lateral projection of the cheekbone
really, really diminishes. If you look at that whole maxilla, you can see that a tremendous amount of bony volume and
support is lost. You can see that the pyriform aperture remodels and becomes much larger. If you think of the face as a
table and a tablecloth, where the craniofacial skeletal support is the table and the soft tissue (in terms of fat and
muscle and the skin that wraps around the whole thing) is the tablecloth, with no support underneath that soft tissue,
it's going to begin to fold and sag.

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Slide 19.

If you look at this young patient -- he looks for all the world like a lipoatrophy patient -- but this is not a soft-tissue
defect in this patient. He's a congenital craniofacial hypoplasia patient. Just putting in implants, where you've just seen
the loss on that previous CT, along that zygomatic arch, along the pyriform aperture, and along the mandible has really
made a difference in his facial shape and the support for that soft tissue.

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Slide 20.

What if you used an injectable filler and did the same thing that you see with those craniofacial implants and placed it
along the zygomatic arch, along the pyriform aperture, and the canine fossa, and the maxilla, and along the mandible?
Can you give a little support to someone who has ample soft tissue and great tone in their skin but not enough
craniofacial support to hold all of that soft tissue? Well, it turns out that you can.

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Slide 21.

If you look at what's happening to us as we age, it seems that there's a certain opportune time in life when there's just
enough craniofacial hard tissue support for all the overlying soft tissue, and we grow into that place from infancy and
grow away from it with age.

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Slide 22.

At that golden time, we have some very predictable proportions in our face. [5] If you look at very standard facial shape
and proportion measurements, drawing a line along the side of the head and through both the lateral and the medial
canthus, you can see that in the 5 vertical fifths, in the upper third of the face, we should be 1, 2, 3, 4, 5 eyes across
in the upper third of our face. And if you look at the face in horizontal thirds, you can see that in that lower third of the
face there's a golden Fibonacci ratio of one third to two thirds between the lip and the chin. Those proportions become
lost with aging.
If you look at any artist's instruction on how to draw a face, they tell you to start with an upside-down egg, which is 5
eyes across in the upper third and tapering to a heart shape in the lower third of the face.

Slide 23.

In fact, that facial shape has been considered an icon of beauty for a very, very long time.
In the same article that was just referenced before, in New York Magazine in August of '08, [6] there was a very
interesting article on facial aging. They took each of these 4 cultural icons of beauty and morphed them into 1 new face
-- all considered extremely beautiful faces.

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Slide 24.

Interestingly, they all have an oval heart-shaped face with a one-third to two-thirds proportion in the lower third of the
face. What they all also have is nasolabial folds. I think we spend a great deal of time with our fillers trying to get rid of
nasolabial folds. So what I want to focus on today is facial shape and proportions and what that does to the topography
and the contours of the face, rather than individual folds.

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Slide 25.

Facial shape and proportions, in fact, have a very, very big impact on some of the key characteristics of attractiveness.
This was a very well-done and very thorough review of 100 years of literature on what (without even thinking about it)
spontaneously tells us whether whoever's walking in front of us is attractive or not attractive. [7] These 4 things
[youthfulness, sexual dimorphism, averageness, symmetry] emerge consistently. All have some genetic advantage.
Youth is obvious. Sexual dimorphism -- we have 2 sexes so that we have to mix genes with every new generation in
the species, so those sexes need to recognize one another. Prototypicality or composites probably indicate some
genetic mixture. In other words, if you get a puppy from the pound, they're less likely to get hip dysplasia than a
purebred Lab. Symmetry is probably some indicator of developmental stability.

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Slide 26.

If you look at this patient, he came in saying, "You know, Doctor, I don't really like this [indicating lines in the glabella],
and I don't really like this fold [indicating the nasolabial fold]." So we fixed the "11s" in his glabella with a little botulinum
toxin, and we used a little calcium hydroxylapatite in the folds. Does he look better? Marginally. What's the problem? If
this is what bothers him, why is fixing it not as gratifying as you would imagine it to be?

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Slide 27.

Look at his facial shape. He's certainly not 5 eyes across in the upper third of his face. He's not an upside down egg.
His head is shaped a little more like a peanut.

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Slide 28.

If you address that and put a little bit of convexity back into those temples, you can make a surprising difference in a
face.

Slide 29.

If you look at her, addressing not just the shape of the face but also addressing that proportion that's lost in the lower
third of the face and taking it from not quite 50:50 back to not quite one third to two thirds, you can really make a
younger and more beautiful version of the same face.

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Slide 30.

That proportional change is done with supraperiosteal injections in an area of the maxilla that's been termed Ristow's
space -- in this canine fossa, pyriform aperture area. You can see in this example how deep injections there push the
soft tissue out and away from the craniofacial skeleton, which reshapes the lip without touching the lips.

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Slide 31.

Putting a little bit down on the mandible lengthens that chin. The two taken together can really adjust those proportions.

Slide 32.

Treatment -- looking at the face as a whole -- whether you fix the nasolabial fold or not, can bring back the 3 primary
arcs of youth: convexity of the forehead, the ogee curve of the cheek, and that long uninterrupted line of the jaw.

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Slide 33.

This is a patient who went to see a doctor and asked to get nasolabial fold correction with a filler and then doctorbounced and came into my office and said, "Oh, well, you know, I got that fixed, but I don't really feel like I look any
better." I think that happens a lot. I think that patients are unaware that temples matter or facial shape matters. In fact, if
you bring it up to them, they say, "Oh, you know, I just put my hair over that. That doesn't bother me. This is what
bothers me." I think it's incumbent upon us to know that those are the first obvious visible signs of an underlying global
process, and that if we address that process, we can really get very sophisticated results.
Again, if you look at her picture, you can see that without fixing individual lines and folds, you have really addressed
facial shape and contours and made her look 10 to 15 years younger -- or at least like a younger, more rested version
of herself.

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Slide 34.

Temples make a difference even in a very full face; just becoming 5 eyes across again can bring a lot of youthfulness
back to that face.

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Slide 35.

It's not even just an age issue. Even in a relatively young patient, a 35-year-old, if there isn't enough soft tissue to
cover the bone of that craniofacial skeleton, they look sort of gaunt and harsh. Just filling over the whole thing softens
the face a great deal.

Slide 36.

I think the mistakes that we all made when we first started using fillers were to focus on only one area of the face. This
"cheeks-on-a-stick" look is something I know I did when I first started using fillers. I would imagine that all of us have. I
think that looking at the face as a whole and blending that back into a facial shape and proportion that looks a little bit
more prototypical is much more attractive. The other common example is to put a pair of 25-year-old lips on a 55-yearold face. It didn't take any of us long to find out that that's not a very attractive result at all.

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Slide 37.

What are some of the things that we need to watch out for with these fillers? There are some very common adverse
events that are common to all fillers. If you put a needle in a face, you can get edema and bruising. There have been
rare reports of granulomas with all fillers, and there have also been rare reports of Mycobacterium chelonae infections
with all injectables. Most of these have been traced to tap water, so it's a good idea to clean the face with alcohol
before doing any injectables. Biostimulatory fillers can produce papules and nodules if they are placed too superficially
or in or through hyperkinetic musculature around the eyes or around the lips. Replacement fillers can compromise
vascular flow in the supratrochlear, supraorbital, or area of the angular artery if a great deal of that bulking agent is
placed in an area where the vascular flow doesn't have a lot of corollaries.

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Slide 38.

Superficial placement is undesirable with any filler. Hyaluronic acids shine back as a blue gel if you place them too
superficially. Biostimulatory agents make neocollagenesis that shows up in the top layer of the skin. I think that
superficial placement is a hangover from the collagen days, when you sacrificed longevity of the product if you placed it
too deeply. It's not only unnecessary now but undesirable.

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Slide 39.

I think the most important issues in technique with replacement fillers are to be careful to not put a large amount of a
bulking filler in a small area where you can compromise blood flow of the supratrochlear, supraorbital, or angular artery.
In this case, the patient was treated with hyaluronidase, and the whole condition resolved very quickly.

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Slide 40.

With stimulatory fillers, I think the important issues in technique are to avoid placement in hyperkinetic muscles, to avoid
superficial placement, and to avoid overcorrection. Overcorrection can be done by putting in too much of a stimulator
too soon and getting too vigorous of a response.

Slide 41.

In summary, clarify the patients' desires and expectations. Are they looking for a quick fix for a reunion or a wedding in
a couple of weeks, or are they in this for the long haul? Do they want something that's done in a stepwise fashion that
will then last for 1 or 2 years? Try to look at the degree of aging present in all thirds of the face, and look at the volume
loss -- not just in the skin and the soft tissue but also in the underlying craniofacial support. Consider the entire facial
shape and balance and understand the indications and limitations of all the products so that you can choose what you'd
like to use.
Realize that we all have our own individual stamp on aging, and there is, therefore, no one algorithm that can be used
to treat every face that presents in front of you. The trick is to learn how to read each individual face.
At this time, I'd like to take a look at a few patients and analyze their faces and make some choices as to what
procedure might offer them the best result.

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Slide 42.

Post-Assessment: Measuring Educational Impact


Thank you for participating in the CME activity. Please take a few moments to read the following cases and complete
the questions that follow to help us assess the effectiveness of this medical education activity.

Case #1: A 34-year-old woman presents for an aesthetic consultation. She has noticed the initial changes
of facial aging and feels that she doesn't look young and fresh anymore. She would like to deal with these
aging-associated changes early so that she can hopefully avoid aggressive procedures later in life. On
examination, you note early volume loss in the midface, especially the cheeks. She also has glabellar
rhytides. Her skin has generally good elasticity and tone, and she has few pigmentary changes associated
with photoaging. The patient is somewhat tentative about volume replacement procedures because she is
worried that she will not like the outcome and will be "stuck" with the results. She has a college reunion
coming up in 3 weeks.
Which treatment course would you recommend?
Injection of a hyaluronic acid replacement filler to the cheeks; botulinum neurotoxin A injections to
the glabellar area
Biostimulatory filler injections to the mid-face; botulinum neurotoxin A injections to the glabellar area
Botulinum neurotoxin A injections to the glabellar area followed in 2 weeks by fractionated ablative
laser treatment
Botulinum neurotoxin A injections to her lower face
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Case #1 continued: The patient opts to undergo hyaluronic acid replacement filler injections to the
cheeks because hyaluronic acid injections are reversible with the injection of hyaluronidase, and the
results last 12-36 weeks. She also has botulinum neurotoxin A injections to her glabellar area. She returns
in 5 months and states that she was happy with the results of the replacement filler procedure but would
like results that last longer than 1 year.
Which of the following would you recommend at this point?
Recommend injections of a biostimulatory filler to the midface area, and continue treatment with
botulinum neurotoxin A
Recommend continued treatment with a hyaluronic acid filler, but increase the volume of filler
injected during each treatment and increase the frequency of treatments. Continue treatment with
botulinum neurotoxin A
Recommend injection of a porcine collagen-derived filler to her cheeks

Case #1 continued: The patient and you opt for poly-L-lactic acid injections for long-lasting volume
replacement and continued treatment with botulinum neurotoxin A.
As you obtain informed consent to treat this specific area, you warn her about the following potential
adverse effects:
Nodules, bruising, swelling, pain
Potential vascular occlusion to the glabellar area resulting in necrosis
MRSA infection
Teratogenicity

Which of the following patient types would not be a candidate for a biostimulatory dermal filler?
Patients who are not in a hurry for results and want a treatment that will last approximately 2 years
Patients with mid-face volume loss
Patients with thin lips who wish to have a more voluminous appearance to their lips

Case #2: A 54-year-old man presents to you stating that he is unhappy about the creases between his
nose and his mouth and the deep wrinkles in his forehead. He has moderate photodamage, significant
nasolabial folds, prominent glabellar rhytides, and volume loss in his temples. He would like to see some
immediate results but does not want to have to return often for repeat treatments.
Which one of the following treatment plans would be most appropriate for this patient?
Hyaluronic acid injections to correct the nasolabial folds; botulinum neurotoxin A injections to the
glabellar region
Calcium hydroxylapatite injections to correct the nasolabial folds; botulinum neurotoxin A injections
to the glabellar region
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Bovine-derived collagen injections to correct the nasolabial folds; botulinum neurotoxin A injections
to the glabellar region

Case #2 continued: The patient returns for follow-up in 4 weeks. His nasolabial folds and glabellar lines
have improved significantly, but you and the patient agree that his overall appearance is only marginally
better.
Which of the following would you do at this point?
Inject the temples with a biostimulatory filler to help restore the ideal "upside-down egg" shape of a
youthful face
Recommend cheek implants to permanently restore mid-face volume
Perform microdermabrasion to improve the texture of his skin
Inject Ristow's space with large volumes of hyaluronic acid

When injecting a biostimulatory filler into the temple area, which of the following would be the preferred
technique
Inject superficially in a fanning pattern, being careful to avoid the temporal artery
Inject deeply and slowly below the temporalis fascia, placing the product as a bolus
Inject deeply and slowly in a cross-hatch pattern
Save and Proceed

This activity is supported by an independent educational grant from Dermik Laboratories.

This article is part of a CME/CE certified activity. The complete activity is available at:
http://cme.medscape.com/viewprogram/30402
References

1. Fisher GJ, Varani J, Voorhees JJ. Looking older: fibroblast collapse and therapeutic implications. Arch Dermatol.
2008;144:666-672. Abstract
2. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg. 2007;119:2219-2231. Abstract
3. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg.
2008;121:2107-2112. Abstract
4. Shaw RB Jr, Kahn DM. Aging of the midface bony elements: a three-dimensional computed tomographic study.
Plast Reconstr Surg. 2007;119:675-681. Abstract
5. Azizzadeh B, Murphy M, Johnson C. Master Techniques in Facial Rejuvenation. Philadelphia, Pa: Elsevier; 2006.
6. New York Magazine. About-Face. August 11, 2008. Available at: http://nymag.com/news/features/48948/.
Accessed July 9, 2009.
7. Bashour M. History and current concepts in the analysis of facial attractiveness. Plast Reconstr Surg.
2006;118:741-756. Abstract

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Facial Shaping With Fillers (printer-friendly)

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Authors and Disclosures


As an organization accredited by the ACCME, MedscapeCME requires everyone who is in a position to control the
content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME
defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months,
including financial relationships of a spouse or life partner, that could create a conflict of interest.
MedscapeCME encourages Authors to identify investigational products or off-label uses of products regulated by the US
Food and Drug Administration, at first mention and where appropriate in the content.
Author
Rebecca Fitzgerald, MD

Clinical Instructor, UCLA Department of Medicine, Los Angeles, California; private practice, Los Angeles, California
Disclosure: Rebecca Fitzgerald, MD, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: sanofi-aventis/Dermik Laboratories
Served as a speaker or as a member of a speaker's bureau for: sanofi-aventis/Dermik Laboratories; Allergan, Inc.;
BioForm Medical, Inc
Editor
Kristin M. Richardson

Scientific Director, MedscapeCME


Disclosure: Kristin M. Richardson has disclosed no relevant financial relationships.
Nurse Planner
Laurie E. Scudder, MS, NP

Accreditation Coordinator, Continuing Professional Education Department, MedscapeCME; Clinical Assistant Professor,
School of Nursing and Allied Health, George Washington University, Washington, DC; Nurse Practitioner, School-Based
Health Centers, Baltimore City Public Schools, Baltimore, Maryland
Disclosure: Laurie E. Scudder, MS, NP, has disclosed that she has no relevant financial relationships.

2009 MedscapeCME.

Contents of Facial Shaping With Fillers


[http://cme.medscape.com/viewprogram/30402]
All sections of this activity are required for credit.
1. Facial Shaping With Fillers
[http://cme.medscape.com/viewarticle/705977]
2. Skill-Building Video: Early, Prophylactic Treatment of a 31-Year-Old Woman
[http://cme.medscape.com/viewarticle/706013]

http://cme.medscape.com/viewarticle/705977_print

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3. Skill-Building Video: A Woman Concerned About Nasolabial Folds and Diminished Chin Projection
[http://cme.medscape.com/viewarticle/706015]
4. Skill-Building Video: A Woman With Significant Volume Loss
[http://cme.medscape.com/viewarticle/706016]

This article is part of a CME/CE certified activity. The complete activity is available at:
http://cme.medscape.com/viewprogram/30402

CME/CE Information
CME/CE Released: 07/21/2009; Valid for credit through 07/21/2010
Target Audience
This activity is intended for dermatologists, plastic surgeons, and nurses who are involved in aesthetic procedures.
Goal
The goal of this activity is to review facial anatomy, facial aging, and available dermal fillers in order to develop
individual treatment plans for facial shaping.
Learning Objectives
Upon completion of this activity, participants will be able to:
1.
2.
3.
4.

Assess a patient's candidacy for facial shaping with the use of injectable soft-tissue augmentation agents
Apply findings about facial anatomy to develop evidence-based treatment strategies for facial shaping
Differentiate the clinical attributes of the available injectable soft-tissue augmentation agents
Develop aesthetic treatment plans that incorporate injectable soft-tissue augmentation agents to maximize
aesthetic outcomes and minimize aesthetic effects

Credits Available
Physicians - maximum of 1.25 AMA PRA Category 1 Credit(s)
Nurses - 1.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)
All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of
participation.
Physicians should only claim credit commensurate with the extent of their participation in the activity.
Accreditation Statements
For Physicians

MedscapeCME is accredited by the Accreditation Council for Continuing Medical Education


(ACCME) to provide continuing medical education for physicians.
MedscapeCME designates this educational activity for a maximum of 1.25 AMA PRA Category 1 Credit(s) .
Physicians should only claim credit commensurate with the extent of their participation in the activity.
Contact This Provider
For Nurses
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Medscape, LLC is accredited as a provider of continuing nursing education by the American


Nurses Credentialing Center's Commission on Accreditation.
Awarded 1.25 contact hour(s) of continuing nursing education for RNs and APNs; 0.0 contact hours are in the area of
pharmacology.
Contact This Provider
For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted
above. For technical assistance, contact CME@medscape.net
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There are no fees for participating in or receiving credit for this online educational activity. For information on
applicability and acceptance of continuing education credit for this activity, please consult your professional licensing
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This activity is designed to be completed within the time designated on the title page; physicians should claim only
those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete
the activity online during the valid credit period that is noted on the title page.
Follow these steps to earn CME/CE credit*:
1. Read the target audience, learning objectives, and author disclosures.
2. Study the educational content online or printed out.
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