Amy Taub, MD: Hi. I'm Dr Amy Taub. I'm an assistant professor of dermatology at Northwestern Feinberg School of Medicine and the founder of Advanced Dermatology in Lincolnshire and Glencoe, Illinois. Welcome to the program titled The Aesthetic Game Show: How Would You Approach These Patients?

Joining me today are Mary Lupo, who is a clinical professor of dermatology at Tulane School of Medicine and founder of the Lupo Center for Aesthetic and General Dermatology in New Orleans, Louisiana. As well as Dr Steve Yoelin who is in private practice in Newport Beach, California. He's a board-certified ophthalmologist.

Welcome to our audience. We're going to do something really fun for the next 30 minutes or so. We're going to have a quickfire program. We've got a countdown timer and just two minutes to answer each question. We're going to see if we can get the key information across in that short time. Let's get started.

Mary, let's start with you. If you were seeing this patient in your office for a consultation, what do you notice about her appearance and how would you approach an improvement in her aesthetic appearance?

Mary Lupo, MD: The first thing I would do would be to set realistic expectations. This person by some argument could be a surgical candidate for a facelift, but I do think that most of the patients who come to our practices are looking for nonsurgical options. There are many for this patient, but they have to be done in concert. The first thing that I would make note of is she has profound loss and dissent of certain of her fat pads really causing a drooping of the lower face, accentuating the marionette area and giving her profound, deep nasolabial folds.

I would do a global rejuvenation with something like a Sculptra® (poly-L lactic acid) pan-facial accentuating the lateral cheeks and the jawline. I would put a little hyaluronic acid filling, either Restylane® or Juvederm® directly in the nasolabial fold, but I would make sure that I had something very deep in that canine fossa.

For that, I usually do a bolus of Sculptra®. I like this because it's a liquid. I go all the way down to the bone. I reflux. What I find is that it will actually give me a little bit of shortening of that very long distance between her nose and her upper lip. I would be very judicious with a little fill in the body of her lip. I would avoid the vermilion border because that could potentially roll her lips inward a little bit more. I would put some thicker HA filler, not just in her prejowl sulcus, but I would also put some at the very lateral superior aspect of her zygoma in what is sometimes called the V1 and V2 position [Narukar 2016]. I would put that on the bone as well as some prejowl sulcus. I actually counterpoint that with a little directly midline in the chin. Because if you put it in the prejowl only, you can square off the chin in a female and you want angularity. You want to have a triangulation. I go from this point in the cheek, in this V1, V2 area, and I accentuate this and making sure to address some areas in the jawline and the area that some people call the angle of the jaw, either on the bone or in the deep subacute plane.

Dr Taub: This is actually my patient. Let's talk about what I did and then let's see if Steve has anything to add. Now, this is actually from quite a while ago. She was part of a study that I published to look at full-face hyaluronic acid filler. I agree with you Mary completely that Sculptra® would be a good choice, but in her case I was trying to show a reduction in apparent age with a significant amount of hyaluronic acid filler [Taub 2010]. Three syringes of Restylane® Lyft (hyaluronic acid with lidocaine) at the time and three syringes of Restylane® were used in her and possibly one or two more. It was six to eight syringes. Clearly it took quite a bit of volume. I injected her along the bone both medially and laterally along her zygoma. I did exactly what Mary just said, went down into this pyriform fossa all the way down to bone, straight down and pulled back to make sure that there was no blood entering the needle. I used the thicker, which would either be Restylane® Plus (hyaluronic acid with lidocaine) now or Juvederm® Voluma (hyaluronic acid with lidocaine) or if we get others we might have those. Then I also did use Restylane® in her marionette and some in her chin. I did use Restylane® all the way in her upper lip. I did actually fill her lips slightly.

At that time, I was not treating the angle of her mandible, but I would absolutely recommend that to be done. The very last thing I did was little bit of top off on her nasolabial fold just to see if we could, because it was such an etched increase as you see. I left some of it there because I really thought that trying to improve it 100% would not really look very nice or appropriate.

Steve Yoelin, MD: I think you made a nice point of demonstrating that this patient needed a fair amount of product. Keep in mind each of those syringes is just a fifth of a teaspoon. It sounds like you use six to eight syringes, but this patient needed six to eight syringes. I'd like to build on some of the points that were made earlier is that midface augmentation was probably the most important part of this rejuvenation process and then working in a way downward.

I think the symptoms that patients complain about like nasolabial folds and marionette lines are just that. The problem oftentimes is elsewhere. I think by addressing the problem like you did, you're just going to get a better result as you work your way towards the nasolabial folds, the lips and the marionette lines.

Lastly, and I think Mary you touched upon this, is that the patient has a long upper lip, which is really a challenge to treat. Treating that piriform aperture or that's the area just adjacent to the ala with bolus of whatever product you like whether it's Sculptra® or hyaluronic acid, what you'll end up doing is you probably are able to shorten the distance between her columella and her upper lip, which I think is very important.

Another option, and I think Amy you did this, is by augmenting the tip of her chin and by elongating her lower portion of her face or her chin, it puts that upper lip in perspective [Bueller 2018].

Dr Taub: All right, let's move on. All right, Steve, if you could take a look at this patient and let us know what you think you would do to treat her and what you would tell her in your consultation?

Dr Yoelin: It's her nasolabial folds that are very prominent here and then her marionettes or the beginning of her marionettes. Her lips are beautiful. I think it's important even comment on that. If a patient has, as you go through the assessment, it can be a little bit awkward at times. I think if they do and all patients do have features that are quite beautiful, you should call them out. I think it's important to do that during your assessment.

I would treat the nasolabial folds. We've talked about that in the past. There's a host of different products you could use. I typically start from the superior portion of the fold and work my way inferiorly. You could use Juvederm® Ultra (hyaluronic acid) or Juvederm® Ultra Plus (hyaluronic acid with lidocaine). You could use Restylane-L® (hyaluronic acid with lidocaine) if you wanted. You could even stack products if you choose to with a firmer product or a heavier product if you will more deeply placed and maybe a lighter product more superficially.

The marionettes to me are not that robust. All you really want to do here maybe is support the lateral portion of her lips. Again, if you choose, you could use a medium of strength if you will, or thickness product. Juvederm® Ultra or Juvederm® Ultra Plus would work really well here. You use Restylane® Refyne (hyaluronic acid with lidcaine), Restylane® Defyne (sodium hyaluronate) if you want. You could use Restylane-L®. You can even use Juvederm® Vollure (hyaluronic acid) if you choose to do so.

Dr Lupo: This is a lovely woman. She reflects a large portion of my patient population down here in New Orleans. She's a skin type five. She was beautiful everywhere except her nasolabial folds. She actually got this result with two syringes of Juvederm® Ultra Plus.

But, I agree with Steve. I could get the same result with a Restylane® Lyft. I could also get this result with Radiesse® (hydroxylapatite). I find that skin of color patients because the skin is thicker are often patients that are excellent candidates for that calcium hydroxyapatite filler. I personally always use a cannula with that. In fact, when I'm doing nasolabial folds, the cannula is my treatment of choice [Hexsel 2012]. The angular artery is there. I think one needs to be very, very careful, inject slowly.

I also feel that the beauty of using a cannula in patients like this is you can fan it and actually allow your cannula to perform a little bit of a dermal subcision, if you will, which I think also stimulates some collagen repair and gives a nice result. I think this is an example of sometimes patients do need the simple things and choose your product and use your technique and know your anatomy and you can give them excellent results.

Dr Taub: Mary, I want to pick up on one thing that you said. Different skin types and different genders have different quality of skin as she pointed out. A lot of times skin of color, especially skin type five and six, is a little thicker. It tends to be more forgiving, but sometimes you need a little bit more volume. Just like with men too. Men, you're not going to approach a man with nasolabial folds like this with a very thin filler because you won't get anywhere. Maybe it's more important the actual thickness or robustness of the filler.

Okay move on. I'm going to take this one. What I see here is a male, and he's got etched in forehead lines that are going horizontally. Even though he's at rest, I can see that he's got at least a moderate amount of glabellar prominence. And I can't really see his eyelids, but I'm going to assume that he doesn't look like he has a lot of ptosis of his forehead. So, I'm hoping that by treating his glabella and his forehead with botulinum toxin, I'm going to be able to improve these lines with the caveat that because of the fact that they're deeply etched in, they probably will not go away 100%, and they will just be softened, and the patient needs to know that before we start. And that also we don't want to put in so much that it could actually cause brow ptosis [King 2016].

More recently, I have been using very fine, what I call the fine fillers, could be Restylane® Silk (hyaluronic acid with lidocaine) or Juvederm® Volbella (hyaluronic acid). I really have a lot of experience with Volbella, which I like for these lines, but obviously that would be secondary. If he had a lot of ptosis in his brow, such that it didn't seem safe to put enough toxin in his forehead to really make a difference, I would probably propose that solution to him. Alternatively, not commonly used, but if none of those were appropriate, we might consider CO2 resurfacing. So Steve, what do you think about this patient?

Dr Yoelin: What the patient has is static lines, and I think you described that earlier is static lines don't really go away, if you will, when you're treating your patients with toxins. Over time they will, and even during that first treatment you might reduce your static clients to some degrees, but it probably would take several treatments in order to get these lines to be effaced with toxins alone. I think that conversation needs to be had with the patient. That's number one. Then number two, I think if you're going to treat these horizontal forehead lines almost invariably, you should always treat the glabella too because if you don't weaken the depressors of the brow, then I think these brows will descend [King 2016].

Other piece too, it's a male patient and I think oftentimes male patients may want, not always, but oftentimes they may want maybe a more subtle outcome. And so you're probably going to use a little bit less in the forehead than you might normally use with a female patient to maintain movement. But also, I think it's more appropriate to have that movement in a male patient. So that being said, then it may take him a little bit longer to reach his goal. So again, it's about managing expectations. Initially, I agree, I think this is a toxin patient because the dynamic lines have turned to static lines.

Now the question is, in terms of safety, the blood vessels that you're concerned about are the super orbital and the super trochlear. And I think where these lines are, especially those two main horizontal lines, the blood vessels have become more superficial, but they're perpendicular. They are running perpendicular to those horizontal lines, and they don't really run in the dermis. So that's why using a lighter filler that you outlined is really important and making sure that the product is placed superficially. And I wouldn't overfill these lines, I would just tell this patient, "Listen, it took me awhile to get them, it's going to take you a while for them to go away, and so if you're patient with us, I think we'll get you a satisfactory result over time."

Dr Taub: Well, Mary's the maestro here. Mary, what did you do to get this phenomenal result?

Dr Lupo: So, I'm rather proud of the fact that way back in 2004 I had male patients coming in for Botox® (onabotulinumtoxin). So, that was what I did here, and the reason I submitted this for y'all's consideration is I wanted to take home a few points. And that is that you can improve static lines with neuromodulators. And Steve made the point that with repeated use, these static lines will get better. This is 20 days later, the amount of improvement that you get.

But at the end of the day, the most important thing is as Steve said, you want to treat some of the depressors. And in his case, if you notice he doesn't have any eleven's, so I just put some in his procerus. He did not have any brow or lid ptosis at rest, and the rest was little micro injections of Botox across the entire forehead. So, this is a good result. Sometimes I tell people that perfect is the enemy of good. And what I mean by that is if you blast this forehead with too much neuromodulator of any type, you run the risk of making those lines look better but dropping the brow. So, I prefer to give people what I call a first base or a second base hit rather than swing for a home run and strike out completely.

Dr Taub: So, let's look at this patient. Steve, you're the ophthalmologist in the group, so you can probably appreciate the anatomy even more precisely than Mary or I. Could you tell us how you would treat this patient?

Dr Yoelin: So what you have, what I see here is just what looks like to be dynamic lines. This is a pretty easy patient to treat in that whatever toxin you choose, we have four to choose from here in the United States, Jeuveau™ (prabotulinumtoxinA), Botox®, Dysport® (abobotulinumtoxinA) and Xeomin® (incobotulinumtoxinA), and it really is up to you and your personal choice of what toxin that you'd like to use here. But if you're going to use something like Botox®, you probably could use around 12 units around each eye. That's the FDA-approved dose. Ironically, Botox® so far is the only product that has approval for crow's feet, but you can use other products if you choose to do so.

And the way I space my injections, there's usually one injection just lateral to the lateral canthus, about a finger breath lateral to the lateral canthus, and then one injection about a centimeter higher along the orbital rim another four units or so. And what I oftentimes do, once I've injected the lateral canthus, and just above the lateral canthus, if you will, those two injection sites were about 8 units of Botox®, assuming we're going to use Botox®, I'll use a little bit less product as I move my way inferiorly along that orbital rim. And in this case, this particular patient has some activity underneath her eye too. So, there's orbicularis fibers that are active there too. So, if you choose to, you can even inject smaller amounts of product in the pretarsal obicularis along the lash line. And what that will do is a couple things, it'll help efface some of those dynamic lines that you see underneath her eye.

Now, that being said, let's assume that those lines are static in nature and we weren't able efface them very well with toxin. What you could do is with a lighter filler, and we've talked about them already, whether it's Juvederm® Vobella, Belotero Balance® (hyaluronic acid) or Restylane® Silk, on a cannula, underneath the skin surface above orbicularis, what you can do is put a sheet or a lake of hyaluronic acid just underneath the skin surface with a cannula, you can get a needle too, but they tend to bruise a lot, and create a barrier between the skin and the underlying orbicularis oculi muscle and that will help efface these lines too. So those are the things that I see. I'm kind of curious what the rest of the group thinks.

Dr Taub: Well Mary, I want to hear what you actually did because we're looking at the date of the first picture and this is six years later. So either you've been treating her with a neuromodulator for six years to show that she has stayed in good condition. Or, she does look very refreshed in other ways. So my guess is you've used a laser and/or fillers?

Dr Lupo: I knew my laser pal Amy would pick up on that. So I submitted this because I like to show long-term results. Plastic surgeons like to say that they make 10-year differences in patients and they do very quickly. But we make 10-year differences in our patients who are methodically and in a disciplined fashion seeing us at regular intervals. Those of us who do nonsurgical rejuvenation.

And this is an example of intermittent neuromodulator. In her case, it was Botox® and I did little micro injections. This is a full smile as was the previous one. And the reason she looks good so long with just a little, and this was a total of 10 units of Botox to this eye, to each eye, 10 units, is because she got an Active FX™ Fractional CO₂ one time to stimulate collagen production. Gave her a little bit of tightening of that upper eyelid that I think was important to her, improved her general photo damage in that area.

The lower aspect of the orbicularis oculi is the most difficult to obliterate with neuromodulators alone. Because you have the dynamic contribution of the zygomaticus major muscle pushing the cheek up and crinkling those lower crow's feet. So you really can't, in a dynamic fashion, totally efface those. I do agree and use a low molecular weight, maybe a hyper blended hyaluronic acid with a little added lidocaine to make it even thinner. And I do put a pool of that between the deep dermis and the obicularis.

Dr Taub: All right. Let's move on to this patient and I will give you a hint. Just like what Steve said, we're going to build on this idea of doing multiple modality or at least more than one modality of treatment. Mary, if you saw this lady in your office, what would you reach for first and how would you approach it?

Dr Lupo: I would absolutely pull out my Fraxel on this patient and do a dual because her overall skin integrity needs to be improved and it will help with some of the fine lines. She has that very long philtral column and we need to make sure that we're building up that canine fossa to give the illusion of a little bit of a lip lift.

I would start initially with two vials of Sculptra® done to pan facial. I would do it all along her zygoma. I would do anterior to her ear one along the jaw line toward the ear and then one perpendicular just anterior to the ear and give an L shaped sculpture injection. I do it on myself.

And find that that gives a great little lift and helps to support. I don't particularly like the HA fillers in that vast area of the lateral inferior cheek and along the jaw line except if I'm along the jaw bone. That area that is called the diffuse V4 region often sinks in and makes you appear gaunt as you get older. And Sculptra® enhances this area without bulking it up.

I do like a long the zygoma, I like the more robust HAs. You can use Restylane® Lyft or you can use a Juvederm® Voluma there. And in the nasal labial fold I would either go with Restylane® or with Juvederm® either Ultra or Ultra Plus. I think it's important to address her a marionette, pre jowl area. And again, as I emphasize on the first patient, you want to get the tip of the chin in order to give a little bit of an angularity there so you don't square off a woman's chin.

Dr Taub: So this patient actually had a tissue tightening procedure called, which is broadband lights and you could have done it with radio frequency or ultrasound as well. And she had a particularly excellent response to it and we did do her full face, not her eyelids.

We also put in toxin into her glabella and the forehead and she had about three syringes of filler. This was a long time ago. I totally agree with you now. I think I would have considered starting with Sculptra. And I think this is also a good example of the fact that we have many, many tools now in our toolbox. You can approach these things in many different ways, which in some times actually gives us a little bit of too much complexity in our consults.

Dr Yoelin: The only thing I might add is this is when you're assessing your patients, I think it's helpful to look at them and look at the shape of their heads.

Now, I think when she started she had more of a, maybe it's an oval or maybe even a rectangular head, and I think in a perfect situation, female heads should be either oval or heart like, in general [Goodman, 2015]. I think when we think of males, we think of rectangles and maybe even trapezoids with the wider portion of the trapezoid being a lower third of the face. That being said, let's just say this patient really was more of a rectangle when you started.

But as you look at the after photo, what you've done is you ovalized her face. Which is so much more attractive, much more appealing, and I think that's sort of the theme that you need to think about, especially when you're thinking about dermal fillers or collagen stimulators.

Dr Taub: All right. I think we have time for one more. When I look at her, I see this sad eye, this angular vector going from her medial face to the outside of her face. Sometimes people call this negative vector approach. Also, I may be wrong but I feel like she's already had some filler because her cheeks look a little full. So I'm a little puzzled by this. Actually, the first thing I thought of when I saw this patient is even though she doesn't have a lot of photo damage, I would like to see what CO2 resurfacing would do for her. Because I really feel like she has some kind of laxity that is hard to describe. She needs to have a lift, and I don't really see that I might not be able to give it to her with just filler alone because I might overfill her, make her look unnatural. But if I had to do filler alone, I would say I would definitely work on her medial zygoma and possibly give her a little bit more lip. See if we could lift the lip up because that's a very long lip. Maybe a little bit lateral because she still has some loss of volume, just inferior to the lateral campus, and she also has terrible volume loss in her temples which is really noticeable. You want to get her lateral cheeks because she's falling inward. Maybe that would pick her up and a little in her chin. So, I'm going all over the place, but I probably ultimately would maybe do a little bit in our lateral face, a little bit in her medial face if we're talking about filler, and then try to lift up her lip. So, what did you do, Mary?

Dr Lupo: You're very good, Amy. You're right. She had been injected and maybe it doesn't show on the photograph, but especially on her left side in her superior medial zygoma, she actually has some unattractive overfill that was actually accentuating a lot of the aging elsewhere. And she was just being treated without a plan, if you will. So, what I did was I did a combination of a little bit of Sculptra® and just two syringes of Juvederm® Ultra. The thing I think that really made the difference is she got one Fraxel Dual. So, if you look at the time period, she really hadn't had enough of the Sculptra® time for it to fully evolve, I think all of the improvement that you're seeing right now is from the two syringes of Juvederm® Ultra and the Fraxel dual.

Dr Taub: Where did you put the Juvederm® Ultra?

Dr Lupo: Sometimes I call this to my patient my pixie dust treatment, and this is where I do little micro injections in various strategic points. And she had so many areas injected with that two CCs, I had to write them down, so I will read it. She had just the peak of her nasal labial fold in the canine fossa. She did not have the entire nasal labial fold. She had her chin and she had her jaw line laterally injected to give her a little bit of a lift. She had a little bit in the inferior aspect of what I call the V2 and the V1 position. In other words, I injected her out here to give a little bit of a lift here. In other words, not on the superior part of the zygomata.

Her cheek bone was actually pretty good, but it was very narrow, so I put a little underneath. Went under and injected and I did use a needle right on the bone there, and then she got a little bit at the angle of her jaw, which you can't really appreciate. So, she really got little micro injections of anywhere to 0. 1 to at most 0.2 to any one area, usually more like 0.05-0.1 in a lot of different areas. And her lips were pretty good and I think that her lips look better because of the canine fossa being treated and the marionette and the chin being treated.

Dr Yoelin: What strikes me is that you were able to get a result like this with two CC's of Juvederm® Ultra. I think that's phenomenal. Interestingly, you used Ultra and you got a great result when you injected superperiostial but I'm going to ask you this, could you have used another product and-

Dr Lupo: Oh, gosh, yeah.

Dr Yoelin: You could have and for the superperiostial injections, there's a host of them I'm thinking of, but what would you have chosen if you didn't use Ultra?

Dr Lupo: Juvederm® Ultra+, Restylane® Lyft, Restylane® L, you could probably use Revanesse® Versa (hyaluronic acid). Belotero®, probably not. Probably a little too thin. That is one of the areas I tend not to use Radiesse® unless I'm all the way on the bone. I still like the security of noting that if my needle moves a little bit and I get a little bit of a blanch, no matter what I can instantly reverse it. So, I'm very conservative in that canine fossa. Interesting, the only place that she had the sculpture done was in her temple and that's why her temples really hadn't changed that much because she was here for her second temple injection for this visit. But I wanted you to see what a Fraxel Dual and two syringes of Juvederm® Ultra could do.

Dr Taub: Towards the end of the program, we're getting more and more advanced, which of course is nice. I wish we had all day to talk because I'm having a wonderful time talking to my colleagues and enjoying it immensely. So, I'm sad to have to stop but let's turn to you, Steve. What do you think that the audience has learned as a result of this program or what do you hope that they're taking home from this?

Dr Yoelin: I think the most important thing, and we talked about it throughout the program, is safety first. I think it's super important that we don't put our patients at undue risk, and I think the way you do that is understand underlying anatomy. And we talked a little bit about anatomy here, but I think it's a very valuable tool is to really understand what's going on below the skin's surface. And when you're poking somebody, whether with a needle or with a cannula, I think it's extremely important you know what vital structures are close to the tip of that needle or cannula at all times.

So, safety first and then I think Mary did a really nice job. I'm talking about managing patient expectations. Some of these patients had, virtually all of them, had exceptional results and sometimes that's just not the case. And so, I think maybe painting a picture of realistic expectations is very important. And then maybe most important of all is don't stop learning. You don't learn how to do this in your residency or fellowship typically.

Dr Lupo: I would say that the takeaway when you talk to the three of us is... I’ve actually given an entire lecture at Cosmetic Bootcamp called, "It's not the filler, it's the floor." And what I meant by that was it's not the product, it's who's injecting the product. I think you can get great results with many products. The most important thing is that you are getting trained, that you do your homework, that you're learning the anatomy, that you get tutored by someone who's an expert to help you show you the ropes, either in residency or after residency.

Dr Taub: I think that we actually touched on most of the every day things that many patients come into our office with. Certainly, there are always going to be rare things or less common things, but these types of things that we covered probably covers 80% of the type of thing we see in our day to day work with aesthetic patients. And we gave you some food for thought, especially how to manage fillers for some basic areas like a nasal labial fold, the marionette line, the cheeks, but more importantly how to visualize what you see. How to think about the solutions and how to prioritize them. That's really important going forward because if you don't do everything at once, you can always say to your patient, "We can start with this and then we'll see how that goes and then we'll start with something else."

Some patients are very willing to do that and sometimes that's a good thing to do when you're starting out so that you can really learn what's going to make the difference and then be, like Steve said, learning always. I don't think a day goes by that I don't change my filler approaches or think about after I've read a paper or go to a meeting that I need to think about something that I wasn't thinking about before or being more careful. So, you have to also change your technique as you learn more and you want to learn as much as you can. So, I hope that everybody enjoyed this program. Please continue on to answer the questions that follow and complete the evaluation, and I want to say thank you again.

This is a verbatim transcript and has not been copyedited.