Dermal Fillers for Facial Harmony: An Introduction

Demonstration of filler treatment to nasolabial folds, the ideal practice site for beginners.

It is human nature to seek beauty in the world around us, including among our fellow human beings. When it comes to the human visage, symmetry is key to facial harmony and the highly sought after perception of youth. Armed with these demands from patients, dentist Altamiro Flávio, DDS, set out to expand his practice into esthetics with the use of botulinum toxin and dermal fillers. After the 2018 release of his book Botulinum Toxin for Facial Harmony, he wrote a companion volume titled Dermal Fillers for Facial Harmony exploring dermal fillers to increase soft tissue volume. To learn more about the applications of botulinum toxin in dentistry, check out our interview with Dr Flávio: Botulinum Toxin for Facial Harmony: How this Unconventional Treatment Can Expand Your Practice.

Botulinum Toxin for Facial Harmony: How this Unconventional Treatment Can Expand Your Practice

Unlike botulinum toxin, which is administered through intramuscular injection, facial fillers must be injected into the fat—which already serves as a natural filler—to avoid muscle damage. There are two possible fat layers for this injection site, which are separated by a layer of muscle: superficial and deep. In most cases, the target for fillers is the superficial layer, as placing fillers under muscle runs the risk of repeated muscle contractions flattening its newly fabricated volume. Superficial injection sites provide three advantages: (1) a position above the muscle avoids impacting muscular function; (2) a smaller volume of filler is necessary at this depth because it does not have to push the muscle to the surface, only the outermost dermis and epidermis of the skin; and (3) it can be injected at this depth in relation to the larger blood vessels. That said, the skin below the eyes is extremely thin. To avoid complications of an injection in this delicate area, it is the only region where it is advisable to inject filler deep under the muscular plane.

Fillers have two main purposes: to occupy space in the soft tissue and to stimulate collagen production for increased tissue volume. The two most important characteristics of filler gel are its viscoelasticity (shape retention) and cohesivity (ability to stick together), thereby maintaining a major “lift” effect when force is applied. While durability is important, permanence is not recommended in most cases. Facial topography changes over time, while filler does not, so permanent fillers will lead to an unnatural facial appearance. The ideal filler is long-lasting yet reversible, biosafe, biodegradable, biocompatible, nonimmunogenic, low allergenic, molecularly stable, and—most importantly—effective.

The hyaluronic acid (HA) filler, a natural polymer created by the body’s cells, meets all these requirements. Introduced in 2003 after nearly 150 years of experimentation with a wide variety of materials, it has become the industry standard. HA is found in the umbilical cord, suggesting that its use may create favorable conditions for regeneration and growth. The examples in Dr Flávio’s book use HA fillers due to their excellent record of effectiveness, practicality, and safety. In addition, HA fillers can be stored without refrigeration for up to 2 years due to their relatively stable molecular composition.

There is no one-size-fits-all approach for facial fillers. Different fillers should be used for different parts of the face, taking into account the depth and blood supply of the area in question. To achieve proficiency in dermal filler injection, Dr Flávio is a firm believer that practice makes perfect. He recommends clinicians practice on cadavers as much as possible. In the video above, he demonstrates treatment on nasolabial folds (commonly known as “laugh lines” among patients), which present the ideal practice site for beginners. This area is a common complaint of older people seeking filler treatment, but it can usually only be observed during smiling among the young. It can begin to show around age 30, and while it remains a top esthetic concern for patients, it should not be a priority for clinicians. Instead, Dr Flávio advocates that clinicians focus on the marionette lines, which show in the older population of 50 and up and are a much more obvious sign of aging. Treatment for these two areas is so similar that practicing on the nasolabial folds is just one way up-and-coming dentists are learning to curate beauty to meet their patients’ needs.

Filler treatment for nasolabial fold and marionette lines. (a) Pretreatment smile. Notice the lower lip asymmetry, lower gummy smile, and eyebrow asymmetry. (b) Posttreatment smile after botulinum toxin injection to correct the asymmetries and gummy smile. (c) Injection sites marked. (d) Frontal view after botulinum toxin treatment but before filler treatment. (e) Frontal view after filler treatment. (f) Injection sites marked. (g and h) Profile views before and after filler treatment. The use of filler made the nasolabial fold smoother and eliminated the marionette lines. (i) Demarcation of areas around the marionette lines. The filler should be injected using a 22G or 23G cannula with one single filament or several filaments. The ideal depth is 3 mm. If a good result is not observed at the end of the treatment, a subcision followed by the injection of a filler may be used. The patient should be informed that subcisions usually cause bruising.

Altamiro Flávio, DDS, graduated from the Federal University of Goiás College of Dentistry in 1990 and went on to become a specialist in dental prostheses at the Federal University of Uberlândia in 1992. In 2010, he created a continuing education course called “A Smile for Each Face,” which included topics such as facial analysis, digital planning, dental anatomy, direct and indirect veneers, restorations, botulinum toxin, facial fillers, and viscosupplementation. He continues to teach courses like this all over the world, and he also teaches the specialization course in restorative dentistry at the Brazilian Association of Dentistry in Goiás. Dr Flávio is an accredited member of the Brazilian Society of Aesthetic Dentistry and a founder of the Brazilian Society of Botulinum Toxin and Facial Implants. He maintains a private practice in Goiânia, Brazil.

Dermal Fillers for Facial Harmony
Altamiro Flávio

In our esthetics-obsessed culture, patients are becoming more aware and demanding of dermal filler treatments. Yet all too often we hear news stories of botched procedures or anesthesia gone wrong. This book walks you through how to incorporate dermal fillers into your clinical armamentarium, starting with the basic characteristics of the materials and advancing to the injection techniques and clinical indications for their use. The author includes such fine detail as whether to use a needle versus a cannula and why you must understand the precise tissue layers of the face in order to effectively deliver this nuanced treatment. In step with its sister volume, Botulinum Toxin for Facial Harmony, the book focuses on facial analysis as a crucial step in determining appropriate treatment, a philosophy that is carried through the entire book. An entire chapter is devoted to clinical cases illustrating the various facial regions and their appropriate filler applications, clearly demonstrating how to use the techniques presented to optimize esthetics and facial harmony. Supplemental material and videos are available via QR code for additional learning.

176 pp; 228 illus; ©2019; ISBN 978-0-86715-821-2 (B8212); $148 Special preorder price! $118
Available September 2019

Contents
1. Facial Anatomy
2. History, Classification, and Characteristics of Fillers
3. Injection Planes and Techniques
4. Complications
5. Facial Analysis for Dermal Filler Injections
6. Facial Anesthesia for Filling Procedures
7. Facial Regions and Possible Filler Therapies

This article was written by Sarah Mondello, Quintessence Publishing.

©2019 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.