Dina Anderson, MD is a Clinical Instructor at Mount Sinai Medical Center in New York, where she is also in private practice.
The term “volumizing” was first used in the aesthetic community around the time of the approval of Sculptra Aesthetic (Galderma) in the early 2000s. Since then, it's become a popular buzzword often associated with the use of fillers. Now, with the recent approval of Juvederm Voluma XC (Allergan), volumization has officially entered the aesthetic lexicon. Even dermatologists fresh out of residency appear to have a basic understanding of the concept and perhaps some elementary competence with the various techniques used to volumize the face. So what, exactly, does it mean to “volumize” with fillers? Now that the market has expanded and our use and understanding of these agents is evolving, perhaps it is fitting to reflect on what these terms mean and how they translate into practice.
VOLUMIZING VERSUS FILLING
When toxins were first introduced in aesthetic medicine, it didn't take long for brand recognition to take hold. Seemingly everyone knew about Botox Cosmetic (Allergan), even those individuals who never have been treated or considered the procedure. The evolution of fillers has been quite different. With more products available and less brand recognition, the public perception of fillers likely derived from the term “filler” itself. For many patients and even physicians, fillers were used quite literally to fill areas, such as fine lines and wrinkles, as well as for lip augmentation.
“Filling” represents an elementary perspective of how these products should be used to enhance facial appearance. As the market expands and physicians discover newer, subtler uses for these varying agents, one can more appropriately consider the breadth of what these products can accomplish. In short, volumizing is about seeing the face in three dimensions, rather than chasing lines and filling wrinkles. It is about understanding the architecture of the face and enhancing it in subtle ways to accentuate certain areas, while respecting individual variations in facial shape.
BETTER INFORMED, BETTER OUTCOMES?
Accompanying the trend from “filling” to volumizing has been a greater public awareness about non-invasive aesthetic procedures. Patients are generally more informed about certain modalities and agents when they arrive at your office. Rather than simply identifying a need and a desired outcome, many patients have specific products in mind at the consultation. This can be both good and bad for physicians; good in the sense that patients require less hand-holding through the explanation and treatment process, but potentially bad in that they may have preconceived notions about their needs and unrealistic outcomes from a lay beauty article or television show that led them to your door in the first place.
However, a more significant concern is that despite more information being available about various fillers and injectable agents, we are also still seeing the same images of “bad work” reproduced on a wider scale. In other words, some patients and physicians still believe that more is better. Additionally, they may also think that volumizing is just another term for filling. The result of this mindset is often blown-up faces and features that are out of proportion with the rest of the face. This “puffer fish” look is a newer version of the sausage-shaped upper lip that was widely popular a decade ago. Therefore, as physicians, we should be mindful of the pitfalls of “filling” and try to think more globally about the face—even if we have the right notion of volumizing, it can still be taken too far.
SUBTLE BUT SIGNIFICANT
Importantly, volumizing is not just about anti-aging. Nor should it be performed to achieve a result that is blindingly obvious to others. The appropriate mindset is therefore to make adjustments to accentuate certain features based on the symmetry of one's face. Indeed, patients want to look youthful, but it is important to place that desire in a certain perspective. A 70-year-old patient, after all, isn't going to look 30 years younger with any invasive or non-invasive procedure we can offer. Thus, in order to frame the patient's expectations appropriately, I often request that they bring a photo of themselves from five years ago (at most 10 years). A picture allows you to see the specific patient when s/he had more bone structure, less subcutaneous tissue loss, and more collagen elasticity. This provides a sense of a treatment goal, after which you can employ any number of injectable agents to achieve.
Regardless of a patient's age, it is important to keep expectations realistic and the goals for treatment subtle but significant. For female patients, that means pursuing an overall goal of softening of angles and achieving a subtle change in volume rather than blowing out every line or erasing every hollow. Men should be kept masculine, with a square jaw and enhanced medial cheek fullness. A 45-degree angle showing lateral raised cheekbones to the preauricular region is just as feminizing and inappropriate as arching a male brow with toxins.
COMMUNICATION AND EDUCATION
If subtle, significant volumizing results are your goal, arguably the most important step is educating the patient and conveying a vision of the end result that s/he not only understands but also desires. Additionally, it's important to establish whether the patient wants a gradual onset (in which case a natural collagen stimulator like Sculptra may be beneficial) or something along the lines of immediate gratification with a product like Juvederm Voluma XC. In any event, we have many agents available to help us achieve varying effects of volumization, with results lasting years instead of months.
As more volumizers become available in the US, it is incumbent upon clinicians to understand the subtle differences between the different products and how each has unique components. Some are more effective when placed in the subcutaneous level, others more deeply in the supraperiosteal plane. With this knowledge, we can more readily meet our patients' treatment expectations, more broadly embrace volumizing agents, and give a deeper understanding for what they can achieve to make our patients reflect the scientific understanding of our work and artistic vision of our hands.