FPSAM - Roundtable 2021 - 3

EXPERT PANEL DISCUSSION
Dr. Cotofana: The way to address this is to camouflage
the change in volume and surface projection.
Therefore, when you detach this area, and detach this
ligament to some extent, you create a slide-over space
and then you volumize the area anterior to the labiomandibular
sulcus, and readjust to the volume posterior
to the sulcus.
If I may also add-understanding that because there
is this sulcus, there is a change in subcutaneous architecture;
if you understand this, then you will know
in which plane to apply the product and which product
to apply, because, as we discussed already, having a
very rigid product in this area might be good for volumizing,
but it will not give the natural appearance.
One must always have the combinations between a
volumizing effect and the natural mobility of the respective
tissues.
Dr. Dayan: Okay, so what about this scenario: often,
patents will ask for the corner of the mouth to
be lifted or turned up. If you had an adhesion
pulling the corners of the mouth down, do you
recommend a certain plane to try to lift those corners
up? For example: should we go perpendicular,
or should we go parallel? As you know, there are
some doctors who go parallel and thread, and some
doctors who go perpendicular to it to build a buttress.
What are your thoughts, Dr. Cotofana?
Anatomically, is there an advantage to one way
over the other? Can you also comment on the nasolabial
fold which I believe is of similar anatomy?
Dr. Cotofana: When you want to adjust this area, we
also need to consider the safety aspects. The reason
why coming from laterally is easier than coming from
inferior is because laterally you have a nice layer of
subcutaneous fat, which you do not have medially.
So, coming from laterally, it is easier to stay in the
subdermal plane, and then when you advance toward
that respective area, exactly below the corner of the
mouth, then you feel a little bit of resistance when
you pop through that adhesion and then you just do a
little bit of subcision and then you place the product
there and when you detach the skin and you revolumize,
then you can reposition. The nasolabial
fold is very similar.
Dr. Dayan: I greatly appreciate what you mentioned
about the subcision aspect. I believe it's a big part of
what I do when I treat that area and realize that I'm
able to be successful in getting the corner of the
mouth up. Dr. Fabi, when you are injecting around
the corner of the mouth, do you have a specific
technique that you prefer to utilize, specifically for
enhancing the corners of the mouth and marionette
lines, and do you have a certain product of the
Galderma/Restylane brands that you prefer?
ª 2021 by American Academy of Facial Plastic and Reconstructive Surgery, Inc.
Dr. Fabi: I am successful with getting the corners of
the mouth to come up, and I like to use Defyne because
I do believe that a lot of the changes that we are seeing,
especially with oral commissures, are a function of
what Dr. Cotofana mentioned with respect to the ligament.
I usually start by building the chin first and then
work my way up and bridge the chin with the oral
commissure, as these anatomic areas do not live in
vacuums but are intimately associated with one another.
I like to use Restylane Defyne in both areas.
Dr. Dayan: Dr. Rosengaus, can you speak to your
preferred technique? Is there a role for NASHA,
or is it all XpresHAn, as you mentioned, for the
marionette lines and into the oral commissures?
Dr. Rosengaus: It is a very good question, Dr. Dayan.
In fact, I have published an article on the topic titled
The Happy Face Treatment: Treatment for Oral
Commissures and the Marionette Lines.1 Based on this
anatomy, we use subcision, which is the main differentiator;
then we design the space for the product because
as Dr. Sebastian said, there is a very scarce layer
of superficial fat-so you have these myodermal attachments
that you must clear away, because, if you
don't, you will still have the lines, the planes, the folds,
and the irregularities. This is very important to note
because we move all these areas all the time.
Dr. Dayan: Dr. Durairaj, I am wondering if you use
a similar technique. Can you also comment on
where you begin your procedure?
Dr. Durairaj: I typically will start by analyzing facial
shadows. I think 50% ofwhat we do in filler treatments
is creating highlights and improving dark shadows.
I like to go right directly into the marionette fold initially,
and I love Dr. Rosengaus's technique with the
Happy Face-I read the article-it's very good, and I
do provide a vertical buttress of support directly at the
oral commissure. I like to place 0.1 cc bolus of filler
directly within the oral commissure, almost to the
point where it is slightly visible. I think it is an area that
we grossly undertreat. We treat the body of the lips and
ignore the corners of the mouth. To make up for this, I
place that little droplet, and it almost acts as a cushion
of support between the upper lip and the lower lip and
it allows the lips to rest upon something. It supports the
modiolus of the mouth. I treat the marionette fold directly,
followed by lateral angular lift going in an
upward direction, and that initial bolus at the oral
commissure. That seems to work well.
Dr. Dayan: Dr. Fabi, can you talk a little bit about
your approach to the lips? Has your approach
changed over the recent past? I would like to delve
a bit deeper into this topic.
3
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