Botox or filler for NL/angularis ori area & sunken cheeks?

My NL/risorius/angularis ori area gets overbuilt easily. NL lines are pronounced & extend down around curve of my mouth. also have very sunken cheeks. I look very gaunt with jowls. I asked my injectionist (a nurse practitioner) for botox around mouth area where overbuilt- she said no, recommended filler in cheek area instead. I've tried restylane, juvederm extra, and Perlane in NL. Never lasts long & quickly gravitates south making jowls & NL pouches worse. Recommendations? I’m south of Boston

Doctor Answers 8

"The Nonsurgical 3D Vectoring Lift" Works Well For Nonsurgically Improving Early Sagging And Jowling

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Without good photos, I can only address your concerns in general terms. However, treating the nasolabial folds directly these days, if required at all, is usually done after addressing other changes in the face that actually have led to their formation. This requires a little explanation.

Fortunately, over the last decade our understanding of how our skin ages has undergone a revolution. Whereas once the visible signs of facial and neck aging were attributed exclusively to skin laxity or looseness, today, we know that the sagging, drooping, wrinkling, textural alterations, etc that characterize the passage of time are a result of a number of anatomical and physiological events. These include loss in the quality and quantity of collagen and elastic fibers, largely due to years of accumulated sun exposure and other environmental damage; an increase in facial expression muscle activity (hyperkinesis); loss of facial volume (due to decreases in fat, bone, cartilage and muscle); weakening of the retaining ligaments that suspend and hold the skin and underlying tissues in place; and the fragmentation and downward displacement--due to the effects of gravity--of the fat compartments that are responsible for giving fullness, smoothness, and youthful contour to the face and neck. The result of this gravitational pull on compromised, devolumized facial tissue is that the face loses its youthful triangular shape and takes on a more boxy look as the jowls and neck sag.

Today, we can address many aging skin changes nonsurgically in a matter of minutes with little or no downtime. For muscle overactivity, we have neuromodulators, such as Botox, Dysport and Xeomin. For roughness, textural changes, skin dullness and mottled pigmentation, we have topical prescription medications, chemical peels, medical microneedling, etc. For fine wrinkles, we have fillers and for deeper furrows and volume loss, we have developed volumizing injectable fillers. And, for sagging skin and apparent laxity, we have the Nonsurgical 3D Vectoring Lift.

A vector describes a magnitude and direction of force. Aging skin is characterized by a negative downward and inward vector of sagging. To counter this, surgeons traditionally pulled skin upward and outward--i.e. using a positive vector. The key difference between the outcomes of traditional surgical correction and nonsurgical 3D vectoring, both of which lift upwards and outwards, is the Nonsurgical 3D Vectoring Lift's additional corrective dimension of ‘forward projection’. This 3D effect is the result of volumizing with the use of injectable agents designed for this purpose, such as Radiesse, Voluma, Restylane SQ, and Stylage XXL.

The Nonsurgical 3D Vectoring Lift is predicated upon the fact that the face and portions of the neck differ in their degree of mobility. The region directly in front and behind the ears is a fixed, denser, relatively immobile area, in contrast to the mid-cheek region (hence the greater tendency of this region to sag with the passage of time). These anatomical differences are exploited in the Nonsurgical 3D Vectoring Lift by making the fixed areas serve as anchoring points for the mobile tissues.

In determining the positive vectors for the mid to lower face, the tissues that require lifting are identified by pulling the skin directly in front of the ears in a direction perpendicular to the area that requires correction. If the pulling results in lifting of the desired tissue, then the vector has been correctly identified and is then marked in accordance with 3D vectoring protocol. A similar approach is used in the region of the bone in back of the ear when dealing with neck laxity. One the proper vectors are marked, the volumizing agents are injected in a series of radiating bands that serve as support struts to the skin and that impart the necessary 3D outward projection--the lift--that distinguishes and defines this nonsurgical approach. The high viscosity and elasticity of the volumizing fillers serves to hold and re-support the overlying tissue and restore more youthful contours.

Although volumizing fillers are reabsorbed over time, they do promote new, native collagen synthesis, which may continue to provide structure, firmness and improved skin quality while continuing to lift tissues. A typical Nonsurgical 3D Vectoring Lift of the face takes about fifteen minutes to perform. Bruising and swelling tend to be minimal, and most people can return to work or social activities immediately following treatment.

In a nutshell, what all this means is that by directly treating the smile lines by simply filling them is merely treating a "symptom," rather than directly addressing the "disease." Consultation with a board certified aesthetic physician with extensive experience and expertise in nonsurgical facial volumization would be strongly advised.

New York Dermatologic Surgeon
4.9 out of 5 stars 33 reviews

Consider deeper injections

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Hi MollyFatCat,

Good diagram!  I don't know where the injector is placing the filler, but in general I try to place the filler as close to the buccal fat pad pocket as possible.  I use a microcannula for filler injections.  When filling hollowness below the cheekbone AKA gaunt appearance, I am trying to fill the deeper buccal fat pad pocket which is adjacent to the cheekbone, and under the zygomaticus smiling muscles.  I am trying to keep the surface skin of the face thin, and build a deep and solid foundation which fills the "valleys" but not the peaks (the cheek bones.)   I suspect the zygomaticus muscles and the natural buccal fat pad pocket helps to keep the filler in place and keeps it from sliding down.  In general, the skin of the cheek feels smooth and you cannot feel the filler, since it is injected deeply where the natural "baby fat" AKA buccal fat pad was lost or diminished.   

If the filler is injected directly under the skin where the hollow below the cheekbone is located, this filler will be very obvious and you can feel the filler directly in the skin.  I have injected using this technique, and for some reason it does seem to go away quickly and does not stay in place.  I have tried it several times in the past.  It appears to be filled when the patient leaves the office, but when I see them in follow up, the hollowness/indentation reappears.

I suspect if it is injected over the zygomaticus muscle, it may migrate downwards towards the nasolabial fold and perhaps make it even heavier.  The zygomaticus muscles are connected to the nasolabial, so if the filler is under these muscles it helps to keep the filler "tucked in," instead of over the muscles which may account for the additional heaviness and "overbuilt" description you used.

I also agree with the other doctors, that it is difficult to answer your question accurately without photos, but some of your description and diagram seemed to be similar to some of the experiences I have had in the past, so I wanted to at least give some of my thoughts.


Dr. Yang

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George Yang, MD
New York Facial Plastic Surgeon
4.8 out of 5 stars 35 reviews

Botox or Filler

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Though it is impossible to make accurate recommendations without an in person consultation, I have found that addressing sunken cheeks first can make the overall facial appearance better after which other areas like the nasolabial folds and pre-jowls can be addressed more effectively, if needed at all.  I have been very happy with the results of Voluma, which is a Juvederm product that was recently FDA approved for volumizing the cheeks and can last up to 2 years.  I suggest speaking with your injectionist about whether Voluma may be right for you, or if you feel like your current provider isn't achieving the look you're hoping for, seeking a consultation with another physician or highly experienced nurse injector for their recommendations.

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Facial Aging and Fillers

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It is very difficult to give an opinion without a photo.  I suggest seeking a cosmetic dermatologist or plastic surgeons advice, one who has a lot of experience in using fillers for facial augmentation and contouring.  It seems you need more permanent/long-term fillers and possibly surgical interventions.  Radiesse and Sculptra may be good options for you to fill out hallows, and reshape your jawline.  But you may need other fillers to help with the countours and finetuning of smaller lines around the mouth.  Fat injections may also be an option.  A formal consultation with a more experienced injector is what is needed.  I wish you the best of luck, Dr. Emer.

Jason Emer, MD
Los Angeles Dermatologic Surgeon
4.8 out of 5 stars 207 reviews

Fillers for gaunt face with jowls and prominent modeolus

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What you are describing is due to normal loss of bone and fat as we age. You might be most happy with a volume recontouring approach. Fillers can be injected in areas of the peripheral face and upper cheeks where the volume loss is greatest. Your lax skin will then drape over a more normal volume and there should be less laxity and jowling.  Injecting more into the areas around the mouth might create a simian look and will not correct the jowling or prominence around the mouth.

Sheryl D. Clark, MD
New York Dermatologist
4.7 out of 5 stars 10 reviews

Filler issues

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Without seeing you in person it is difficult to say but sometimes fat injections may be better because they can last longer and be permanent.  Good luck.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Gaunt face/NL folds

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It is difficult to accurately assess your areas of concern without a photo but it sounds as though you have a lot of volume loss of your face. This loss will give you that "gaunt"appearance and will make your nasolabial folds appear more prominent. In fact, using a filler such as Voluma to your upper cheeks will likely improve your NL folds without using much filler to the NL folds. Voluma may be a nice choice since this filler is indicated to last up to 2 years. Additionally, a product such as Sculptra would be very helpful to address overall facial volume loss and your "gaunt" appearance. Sculptra is considered a volumizer and not a filler, and these results will again last around 2 years. Sculptra builds your own collagen over a period of months. I recommend consultation with a board certified dermatologist experienced in the use of these products. Best wishes.

Kristin Baird, MD
Longmont Dermatologic Surgeon
4.6 out of 5 stars 11 reviews

Filler in cheeks not Botox

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Often the lines around the mouth and jowls are a symptom of loss of cheek volume.   Without photos of your face it's difficult to tell exactly what you have going on. 
The newest filler, Voluma, is made for cheek filling and lasts up to two years. This may be the right option for you. Botox is not the best option for your issue. 
Sometimes a lfft is the only way to correct excess skin.  Find a physician in your area for a consultation to review all of your options to make an informed decision. 

Lee P. Laris, DO
Phoenix Dermatologist
4.8 out of 5 stars 16 reviews

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