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Spotlight On: Volume Restoration

Look at an array of youthful faces, and they’re bound to have one thing in common: volume. This look of fullness results from skin having the necessary structural support to look smooth and supple, and to reflect light. And while the etiology of volume loss may be attributed to many factors, modern, integrative approaches to volume restoration address both the underlying cause and visible effects.

Volume loss is one of the primary signs of aging. As facial volume naturally diminishes, skin is no longer stretched as tightly over the surface, creating areas marked by hollowing, shadows and folds. Anatomic changes—evidenced by shifts in bone and loss of bony mass—cause skin and soft tissue to drape differently, affecting multiple areas of the face.

The skin itself also suffers from the simultaneous breakdown of existing collagen and the decreased capacity to generate new structural proteins, causing increased laxity and sagging.

One of the first facial areas to be affected, the midface, is comprised of three parts: the zygoma (or cheekbone), the apple, and the submalar hollow, where hollowing occurs. As we lose cheek volume, tissue itself slides down, causing the cheeks to sink and often worsening nasolabial folds.

In addition, women in particular can lose up to 40 percent of their mandible. The eye socket also recedes, causing the orbital area to appear hollow and sunken. The bridge of the nose may lose bone and start to droop slightly with age. And one can’t overlook the temples, which start to create an overall look of gauntness as they deflate, causing a concavity that affects surrounding areas like the eyebrows.

Fat, too, plays an important role in giving the face youthful-looking roundness. Therefore, it stands to reason that lifestyle changes, such as illness, dieting, increased exercise or other causes of extreme weight loss will start to affect facial fullness, typically after a weight loss of 10 pounds or more.

Whatever the cause, comprehensive treatment for volume loss focuses on the end goal of restoration, not augmentation. In fact, we often begin an injectable treatment plan by reviewing a patient’s old photographs to get a better idea of how their facial contours have changed over time.

Volume restoration options fall under two categories: traditional fillers, which literally “fill” shallow areas and folds, and biostimulators, which rebuild the underlying structure of the skin by stimulating the production of collagen.

Filler options have evolved over the years, increasing in both variation and efficacy. Once the only dermal filler option available on the market, collagen fillers—limited by their typically higher risk of allergic reaction—have all but disappeared from the market and have been replaced by more sophisticated options such as hyaluronic acid, or HA, fillers.

Hyaluronic acid truly revolutionized the filler market, as its duration almost doubles that of collagen without a serious risk of allergic reaction. Furthermore, popular hyaluronic acid fillers may be catered to the needs of the patient, and their versatility means they can be used virtually anywhere on the face.

One of HA’s primary benefits is that it can hold up to 1000 times its weight in water, but this also means that HA fillers have the potential to create a doughy or puffy appearance. Because no patient should display the telltale signs of unnatural-looking filler, any unsatisfactory results can be corrected by injecting the treated area with hyaluronidase, an enzyme that dissolves hyaluronic acid.

For those patients with, well, patience, there are poly-L-lactic acid injectables available that offer a gradual way to restore fullness to hollow areas of the face. Rather than fill, they stimulate collagen production deep within the dermis to reinforce the skin’s support structure. It can also thicken the skin up to a centimeter, providing a visible boost to surrounding skin. Results, though not immediate, can last for over two years with a series of treatments.

Like big name brand fillers, they help create scaffolding for new collagen growth; however, they also provide the benefit of instant volume correction. Made of calcium hydroxylapatite, this combination treatment walks the line between filler and biostimulator, delivering instant gratification for those patients that want it while gradually restoring support and volume. It works especially well for defining the jaw line and cheeks.

Recent advancements have improved the overall safety profile of injectable treatments. Blunt-tip cannulas help mitigate risk factors when injecting, as they push nerves and blood vessels out of the way when inserted into the skin, thus lessening the chances of bruising or excessive bleeding caused by piercing a blood vessel.

The future continues to look bright for volume restoration as injectables rise in popularity. I predict a surge in injectables that deliver less swelling, fewer side effects, and improved tolerance overall. I’d also love to see the introduction of more fillers that can be used very superficially or that can actually serve as a delivery system for antioxidants or other agents to improve the health of the skin.

Though no one is exempt from aging, we all have the power to decelerate the process. By addressing some of the primary underlying causes—sun exposure, free radical damage—and taking proactive steps toward restoring the volume and fullness or our youth, we can turn back the clock on how—and when—we age.