Artefill is the first and only FDA approved wrinkle filler in the United States.  As cosmetic surgeons, we have waited a long time for a safe product such as Artefill to become available to our patients.  Although there have been other products on the market (such as silicone and Medpor, etc) none have been FDA approved and none have had the safety heritage of Artefill’s predecessor – Artecoll. 

Artefill is essentially a mixture of purified Bovine collagen as well as Polymethylmethacrylate (PMMA) microspheres in an 80:20 ratio.  There is also 0.3% Lidocaine (anesthetic solution) mixed with the collagen for added patient comfort.  The collagen portion resorbs over several weeks but the PMMA micro-spheres remain and become encapsulated by the body as a permanent “filler.”  Most patients will require two or three treatment sessions spread about four to eight weeks apart in order to achieve the final desired result without “over-filling.”

The treatment initially involves a simple skin test to ensure that the patient is not allergic to the Bovine collagen component of Artefill.  If after a month, no signs of allergic reaction are seen then the treatment can be performed safely.  The skin test involves placement of 0.1cc of Artefill test mixture under the skin of the forearm in the same manner as a PPD (T.B. test).

The FDA has approved Artefill for wrinkle reduction of the Nasolabial folds (deep lines extending from the sides of the nostrils to the corners of the mouth).  Although the FDA approval is for correction of the nasolabial folds, Artefill can also be used for the correction of other deep facial lines.  Artefill should not be used around the eyes, in the lips, or in superficial lines.  However, it can be used for permanent tissue augmentation such as for malar (cheek) augmentation in place of a malar or submalar implant or in place of fat injection or even a mid-face lift.  It can also be used to augment the chin or the pre-jowl area in place of implants. 

The cost is higher than traditional fillers such as Restylane or Collagen but given its permanent nature, Artefill is cost effective overall with a cost per syringe that is only slightly higher than that of Radiesse (another filler that lasts about 12-18 months). 

First, I want to clarify some terminology. The "prejowl" area is exactly as it sounds. It is the area lateral to the chin but medial to the "jowls", so basically it is an area between the chin and jowls. The most common aesthetic defect affecting this area is a lack of fullness making the chin look too pointy. The treatment includes "filling" the area with fillers such as Restylane or Radiesse, using pre-jowl implants such as the "Mittleman prejowl implant" or using fat grafting in the area. All are valid options. With Artefill, the new permanent filler recently approved  by the FDA, the options are even more abundant.

Now the other issue is "jowling" or "jowls." This refers to fullness or sagging in the area of the jowls. The gold-standard treatment is a "traditional" lower facelift and the reason I place the word "traditional" in quotes is that if you have done your homework you will appreciate and possibly be overwhelmed by the fact that there are numerous approaches, incisions, dissection techniques and extents and methods for carrying out a "traditional" facelift.   No two surgeons do a facelift the same way – almost.

Some patients, especially younger patients with very minimal jowls and good skin tone, can benefit from a "mini" type lift and delay undergoing a more extensive facelift for many years. Again, there are many variations of "mini lifts" as well.  

Liposuction of the jowls can be carried out very conservatively and it is somewhat effective. However, there are risks associated with it and, given the very slight benefits, it may not be the best option by itself.

As the appearance of the "aging face" is a result of tissue and volume loss, replenishment of this "volume" using fat grafting or fat transfer is a valid option. The same can be achieved with fillers or implants. As the area under the skin is "filled", it "pulls" on the more dependent lower areas and in effect "lifts" the skin and jowls.

If you decide to go with a min-lift, you can expect a 5 to 7 day recovery for the edema, bruising and "rippling" to substantially subside despite what the advertisers of “weekend facelifts” and other marketing hype today would make you believe. Unfortunately, men cannot use makeup for cover-up and camouflage but they generally heal faster due to the nature of male skin with an abundant presence of hair follicles and sebaceous units.  Women can easily use makeup to cover the slight bruises that may persist beyond the first few days and go about their daily routines after a mini-lift. There usually is not much pain or swelling associated with mini-lifts although each patient may have a different experience. A very important consideration is incision placement, especially in men since again men cannot cover scars with makeup.   The proper placement and location of incisions are much more important than the length of the incision in assuring that the scars are hidden and camouflaged well. 

Many patients today are on diets or have weight loss goals in mind as part of their overall “makeover.”  I usually recommend reaching your "target weight" before undergoing any kind of a "lifting" procedure.  If you are going to lose more than 15lbs, then the skin will loosen back up once the weight is gone and you may need another "tuck-up" procedure prematurely.

As far as the neck, a neck lift with or without a cheek lift (which would make it essentially a facelift) is the gold standard for the treatment of a heavy neck with loose skin and extra fat tissue commonly known as the "turkey gobbler neck".

However, neck liposuction in younger patients or combined with submentoplasty (where the platysma muscle is imbricated or sutured in the mid-line, creating a nice, tight "corset" with removal of a little bit of skin medially under the chin as opposed to laterally with a neck/facelift) is a valid alternative in someone with a moderate size neck. (In very large, heavy necks, a neck lift is still the preferred choice.)

Unfortunately, the highly-marketed modalities, such as Thermage and Contour lifts / thread lifts to name a few, do not properly or permanently address the aging neck and are often a disappointment.

Until now, the best and only proper way to address an aging neck was a neck lift.  It is a fantastic surgery but it is “over kill” in the majority of non-obese patients.  The ideal neck lift patient has a large neck or a neck with lots of extra fat or lots of extra skin.  A neck lift creates a beautiful jaw line and a nicely-sculpted and natural-looking neck with long-lasting results.

The ideal candidate for submentoplasty is a patient who is relatively within their ideal weight to height ratio with moderate loose skin and fat who wants a nicer neckline.  This 45-minute “mini neck lift” provides exactly the proper amount of “surgery” for such patients.  The results are significant yet natural.  There is almost no pain and the only downtime is associated with the post-op bruising which can readily be covered with make-up.  The results are real and long lasting and do not rely on sutures or wires and the procedure is relatively quick and safe.   What allows this procedure to stand apart from almost anything else out there today is the use of a very small hidden “T” incision under the chin which allows removal of excess skin and fat as well as muscle tightening through this one-inch incision that is well hidden and inconspicuous.   Patients often return to work within 5 days and the cost is about half of what a neck lift would be.  However, proper patient selection is key to achieving the best results.  This procedure is amazing but it is not for everyone.

With every new procedure there is a wave of followers creating a new “trend.”  The fact is, if there is abundance of loose skin and sagging tissue on the face and neck then these areas have to be "lifted" to a more youthful position and then the excess must be judiciously excised - hence a facelift of some sorts.

If there is decent of tissue with loss of volume then "filling" the areas will lift things and harmonize the face and replenish fullness.  Incidentally, implants or fillers will give a similar result in many instances.

Occasionally the best result is achieved with a combination of these modalities.  For example some patients look amazing and youthful a few weeks after a facelift but then notice some areas of "aging" again fairly soon after surgery as the swelling subsides. In such a patient, "filling" with a filler or fat at the time of surgery would have resulted in a better long-term aesthetic outcome. Each patient is different so each patient requires a somewhat unique approach - to some extent.

Many patients are interested in obtaining fuller more youthful cheeks.  Some have lost this fullness due to sagging tissue and loss of tissue volume as result of age.  Other have never had the ideal cheek or malar fullness as a result of genetic bony and soft tissue variations.

Options are numerous and depend on the patient’s age and anatomy.  Implants made in various shapes and sizes are great options.  Fat injection done in a series of 2 to 3 sessions will also result in naturally appearing fuller cheeks.  Fat can also be injected to the naso-labial folds at the same time if needed in older patients.  Filler injections although viable, were not cost effective until now.  Artefill, the first permanent “filler” approved by the FDA is a fantastic option for augmentation of the cheeks and effacement of the naso-labial folds.  Mid-face lift is also another option best used in older patients who have deep naso-labial folds and show inferiorly and medially descended cheeks.  This procedure may be combined with fat injection, filler injection or even cheek implants. 

The ultimate goal is achieving a triangular face (with the base located between the cheeks and the apex at the chin).  This “inverted triangle” is associated with youth rather than the “rectangular face” associated with aging.