Choosing dermal fillers that align with the Art Codes Framework

When considering what makes a female face beautiful, we previously discussed how every face is made up of Defining Points, Defining or Inverse Lines, and Connecting Planes, and these differ between male and female faces. You can also learn more about how the Art Codes Framework for patient consultation addresses aesthetic diagnosis, empowering clinicians to analyse and create a specific diagnosis around these points.

To use dermal filler products to balance and harmonise facial features and proportions, we must understand their different properties. Some will be optimal for projecting while others will help to define and connect planes, all thanks to their rheology, or properties including the elasticity, viscosity, and cohesivity of the hyaluronic acid gel that defines softer or stronger outcomes and aesthetic results.

In this blog, Dr Tim Pearce will discuss choosing dermal filler products that align with the goals of the Art Codes Framework to consider the Defining Points, Defining or Inverse Lines, and Connecting Planes of the face.

How do you choose the right dermal filler for a specific area, based on its rheological properties?

The rheological properties of dermal filler products are somewhat debated within the medical aesthetic sphere. The biggest issue with filler rheology is that it is a measurement of various states of the hyaluronic acid gel outside of the body. However, we place it in the tissue and it interacts intimately with multiple different molecules that also have rheological properties.

This interaction ultimately forms the outcome for the patient, the degree of projection or the achieved definition, for example. Extrapolating how much of the real-world outcome is comparable to the properties shown in the laboratory is difficult. We can only work with what we see in front of us, asking the question; does it look like it is projecting? When you see the patient again in six months, has the result maintained the projection or is the product all gone? This lived experience with your patients will help you to determine which dermal filler products are behaving as you anticipated based on their published rheological properties.

I always say, do not ask me to recommend the best filler; there is no such thing. I advise all aesthetic clinicians to become experts at understanding their dermal filler brand/product of choice. Once you understand the product – your tool – you will use it appropriately for each patient to create a beautiful result; that’s the skill. I think it takes at least two years to get to know a product; and to understand it slowly over time.

The hydrophilic or water-attracting properties of a dermal filler product are perhaps the most important for me.

What is the difference between FDA-approved and CE-marked dermal fillers?

Hundreds of dermal filler brands and products are widely available in the UK; I would not say you can create amazing results for patients with any product because the quality and rheology vary significantly, despite compliance with European CE-marking that we also acknowledge in the UK.

However, I would suggest that you cannot go wrong by sticking with dermal filler brands and products that are also FDA-approved in America*, which includes most of the big names (from major pharmaceutical companies) who we have heard of for many decades in the UK, simply because they have undergone more clinical testing for both efficacy and safety, including long-term analysis.

* Note: there are some differences in specific product names and branding.

European CE marking is a more limited approval standard because it does not review data on human interaction or long-term aesthetic results. Compliance is like that of manufacturing a toothbrush in a factory, looking at the use of approved materials, and processing in a clean environment because the filler products are classified as medical devices, rather than medicines or drugs, which would undertake more rigorous testing, as is the case for dermal fillers in the USA.

What factors would influence the choice of filler product for blending a Connecting Plane versus projecting a Defining Point?

Connecting Planes tend to be more mobile and softer, often with no bone underneath or a shallow area of tissue above the bone, as with the forehead. Therefore, we must choose a filler product on the soft end of the scale – soft to intermediate – to maintain a smooth result without bumps that can move naturally. These products are also appropriate for the superficial treatment of fine lines and creases.

With a Defining Point, we seek the opposite of soft, it must be a stronger product to hold the projection and definition.

There are two ways you can create subtle transitions within connecting planes. The first is placing the filler product deep so you do not see the outline of the product, using needle-on-bone injection techniques. The second is to use a soft product for superficial injection so that it blends naturally within the tissue, allowing the blending or transitioning of one point to the other.

How can different dermal fillers be used in a layering technique to achieve a full-face transformation?

To achieve a full-face transformation using the Art Codes Framework, product layering is a useful strategy, especially when presented with patients who have extreme concerns, such as significant volume loss, where there is a need for increased stability in the outcome, which cannot be optimally achieved with treatment focused solely within a single tissue layer.

Depending on the area being treated, this approach may include an initial focus on periosteal injections to create support at the bone level, followed by a more superficial approach rising through the tissue layers including cannula or intradermal injections, for example.

Certain structures, like the chin, can benefit from a ‘tower’ technique of layering dermal filler products, starting with injecting on the periosteum, then within the subcutaneous fat, and into the dermis to create definition and a three-dimensional shape.

Similarly, your injection technique is a balance between avoiding risk and achieving good results. The key factor is product placement – where the filler is likely to go in probabilistic terms, and then, how you can perhaps influence that further by altering the angle of your injection and product delivery – bevel up or bevel down.

A risk-aware approach, making small adjustments to lower the likelihood of complications, ultimately improves safety and results.

Using the Art Codes Framework to evaluate your patients will guide your choice of dermal filler products and your placement

The biggest take-home message is to understand what you are trying to create. You should run through the Art Codes assessment on all your patients, every time you see them. Consider the Points, Lines and Planes on their face, what they look like, and when you last treated them. Over time, you will make better and better decisions on what works to treat each patient and optimise their results.

Take good before and after pictures and look back at them every time, you will learn so much faster than people who do not use photographs.

If you have any questions or other topics for discussion, you can find Dr Tim Pearce on Instagram.

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