May 2018 #PRSJournalClub: “Cheek Volumization and the Nasolabial Fold”

by Ara A. Salibian, MD (@AraSalibianMD)
Resident Physician
Hansjörg Wyss Department of Plastic Surgery
NYU School of Medicine


The May #PRSJournalClub focused in on an exciting new study in this month’s @PRSJournal entitled “Cheek Volumization and the Nasolabial Fold”. The study objectively analyzed positional and volumetric changes in the nasolabial fold and cheek after injection of cheek fillers to assess the effect of cheek filling on perioral rejuvenation. The authors interestingly found that filling the cheek did not translate to traction forces on the nasolabial fold traditionally thought to be associated with improvements in nasolabial fold contour.

On May 20th, study authors Dr. Donald S. Mowlds (@DonaldMowldsMD) and Dr. Val Lambros (@Vallambros) from the Department of Plastic Surgery at the University of California, Irvine answered questions from around the world and provided further insights into the fascinating results of their study in a discussion hosted by @PRSJournal on #Facebook.

Click here to read the study as well as view this month’s comprehensive collection of #PRSJournalClub articles.

Fillers are widely used in Plastic Surgery as well as in multiple other specialties. However, the subtleties of their effects on facial contour and volume are still being elucidated. Cheek fillers have been perceived by both patients and providers to improve the contour of the nasolabial fold. Different explanations for this observation have been offered, with the main theory being that skin tension secondary to cheek expansion creates a superior vector of pull on the fold and adjacent structures. The authors of this paper sought to determine whether a true “lift” of the nasolabial crease and fold occurred after cheek filling using three-dimensional photographic analysis.

In this study, cheek expansion was analyzed before and after injection of one to three cc of filler (Voluma; Allergan, Inc., Dublin, Ireland) over the cheekbones in 77 patients. The authors used three-dimensional images of the face taken immediately before and immediately after injection, as well as at other different time points after injection to analyze the subtle effects of filler placement on cheek volume and contour as well as on nasolabial crease, nasolabial fold and nasojugal crease. By animating pre- and post-injection images, Dr. Lambros and Dr. Mowlds were able to dynamically analyze these changes. Furthermore, spatial mapping of the translation of facial pores allowed the authors to directly quantify the amount and vector of skin movement secondary to filler injection.

Interestingly, the authors found that placement of filler consistently resulted in outward expansion of the skin from the center of the injection site. Analysis of pre- and post-injection images showed no planar motion of the nasolabial tissues secondary to cheek filler injection. The injections increased the surface area of expansion but did not create traction forces on the skin remote to the site of injection, contrary to the proposed theories on nasolabial lift. As other studies have suggested that nasolabial fold appearance may improve after cheek filling, the authors propose that these perceptions may be due to a more global improvement in facial appearance or a smoothening of the cheek transition in patients with nasojugal crease hollowing. These landmark findings critically add objective, quantifiable evidence to our understanding of the perceived effects of filling the face.

The article and the implications of its results were discussed in another fantastic #PRSJournalClub podcast. This month’s podcast hosted special guest moderator Dr. Vu T. Nguyen, Assistant Professor at the Department of Plastic Surgery at the University of Pittsburgh.  As usual, she was joined by PRS Resident Ambassadors Francesco Egro (@FrancescoEgro ), Nikki Phillips (@DrNikkiPhillips), and Ira Savetsky (@IraSavetskyMD).

The panel brought up excellent points on changes in approaches to facial rejuvenation to include filling the face and the ability of three-dimensional photography to capture subtle changes in facial contour and volume. Great points were brought up by all discussants on individualizing surgical and non-surgical facial rejuvenation, collaborating with patients to promote shared-decision making for these procedures and staging trial lidocaine injections and actual filler injections.

You can listen to this great podcast below!

On May 20th, PRS Journal hosted a fantastic interactive #PRSJournalClub discussion with Dr. Lambros and Dr. Mowlds on #Facebook! Questions were fielded from all over the world in what became a phenomenal discussion on the nuances of facial fillers and their effects on facial aesthetics. Discussion points included the use of alternative methods of imaging for evaluation of filler outcomes and techniques of utilizing three-dimensional photography for assessing facial contour and volume. The authors further detailed their approach to cheek fillers and methods of analyzing the aging face. The discussions also further addressed the misconception of “lifting” the face with fillers as well as the evolution and future of non-surgical methods of facial rejuvenation

Check out some of the great discussions from Sunday below! 

This May #PRSJournalClub article (as well as other Journal Club selections from May), selected classic pairings and videos, and the entire Facebook Q&A are archived on PRSJournal.com at the following link: https://journals.lww.com/plasreconsurg/pages/collectiondetails.aspx?TopicalCollectionId=335.

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