Midface and Perioral Volume Restoration: A Conversation Between the US and Italy

January 2014 | Volume 13 | Issue 1 | Original Article | 67 | Copyright © January 2014

Erin Gilbert MD PhDa and Lucia Calvisi MDb

aSUNY Downstate Medical Center, Brooklyn, NY
bPrivate Practice, Sardinia, Italy

BACKGROUND: There are numerous dermal fillers available to injectors in the US and Europe for the correction of age-related volume loss in the midface and perioral regions. Product availability differs between these two aesthetic markets due to US Food and Drug Administration (FDA) regulatory requirements. The purpose of this study is to discuss differences in filler selection by two practitioners in the US and Europe based upon both stylistic approach and filler availability in each market.
OBJECTIVE: To analyse and discuss the approach to midface as well as lip and perioral volume restoration by two independent dermatologists working in the US and Italy.
METHODS: Seven patients were selected for discussion and divided into two groups: 1) those requiring midface volumization and 2) those undergoing perioral or lip volume replacement. Patients in the midface group were injected with Juvéderm Voluma® XC, Juvéderm® Volift® with lidocaine, Restylane- L®, Perlane-L® or Radiesse®. Patients in the perioral and/or lip group were injected with Juvéderm® Volbella™, with lidocaine, or Belotero Balance™. Patients were photographed before and immediately after injection to evaluate aesthetic outcomes. In each case, filler selection was based upon patient characteristics, anatomical considerations and inherent filler properties.
Results: All patients were extremely satisfied with their treatments. There were no significant immediate or delayed complications following treatment with any of the dermal fillers used.
CONCLUSIONS: Volume restoration in the midface and perioral or lip region can be effectively achieved using a variety of dermal fillers. The dermal filler portfolio available in Europe is exponentially larger than that in the US. Product selection in either market is ultimately the result of the physician’s experience injecting each dermal filler, as well as his or her personal preferences.

J Drugs Dermatol. 2014;13(1):67-74.


Facial appearance is a defining hallmark of identity and self-confidence.1, 2 Changes in skin quality, such as the loss of elasticity and decreased dermal thickness, in addition to alterations in fat pads, muscle, and bone, contribute to structural remodeling in the aging face.3,4 These changes influence self-perception and are often the primary motivation for patients seeking out facial rejuvenation.
In most cases, intrinsic facial aging occurs in a predictable chronological pattern. Loss of volume in the malar, perioral and pre-mental regions is an early and common phenomenon of aging. Volume loss in the periocular area and temples is also commonly observed, especially in cases of weight loss or more advanced facial aging. In this study we present seven case vignettes highlighting volume restoration in the malar and perioral region to illustrate how product selection, in addition to individual techniques, guide our injection practices in two different aesthetic markets.


Midface Volume Replacment

Patient 1 (Juvéderm Voluma® XC)
A 42 year-old woman presented complaining of volume loss in the cheek area due to a rapid reduction in weight after a recent pregnancy. She was not breastfeeding at the time of injection. She had never been treated with any dermal fillers in the deep malar region but had been injected in the nasolabial folds 1 month previously with 1 mL of Volift® 0.5 mL for each nasolabial fold with a threading technique. The patient was injected with Juvéderm Voluma XC, 1 mL per zygomatico-malar zone in microboluses using a serial puncture technique with the supplied 27G x 1” needle in both the deep supra periosteal and deep dermal planes. No topical anaesthesia was needed. The treatment was well tolerated with minimal trauma and no significant post-procedure swelling (Figure 1).
Patient 2 (Juvéderm® Volift® with lidocaine)
A 43 year-old woman presented for correction of the deepening of her nasolabial folds. She had been treated 6 months previously for the same complaint by another physician with hyaluronic acid (1 mL of Restlylane®) without satisfaction. At the time of her visit, she requested a longer-lasting and more natural appearing treatment than the previous one. She was injected with Juvéderm Volift with lidocaine 1 mL (0.5 mL per side using a 30G x ½” needle in the deep dermis with a linear threading technique). Minimal post-injection bleeding was easily controlled (Figure 2).
Patient 3 (Restylane- L®)
A 40 year-old woman presented 5 months after her first dermal