A New Wrinkle & Fold Grading System for Facial Volumization and Restoration

PURPOSE: Volume replacement procedures are commonly performed as part of more comprehensive facial cosmetic surgery. However, currently available wrinkle grading systems do not characterize the severity of folds and creases in relation to the broader condition of the local facial zone. This creates a communication gap between physicians and patients regarding facial analysis and expectations for optimal patient outcomes associated with facial volume restoration. The purpose of this study was to develop a new grading scale for the evaluation of facial folds and creases to optimize patient outcomes in facial volumization and restoration that also will calculate the appropriate amount of dermal filler required to create specific facial corrections.

DESIGN:

• (A) Patient and physician inter views were completed where the replacement procedure was described and the patient's face was evaluated and photographed;
• (B) The procedure was completed on one side of the patient's face, and the completed side photographed;
• (C) The second half of the procedure was completed and second side of the face was photographed. The amount of filler and the type was predetermined by understanding the length-depth and width of the folds treated combined with the volume loss in that zone.
  

SUMMARY: Based upon treatment and analysis of over 250 patients (age 35-70), an easy-to-use grading system was developed for facial evaluation associated with facial volumization and restoration procedures. This system has 5 levels of severity which specifically address length, width and depth of folds and creases, as well as volume loss in different facial zones including the glabella, nasolabial fold, marionette and pre-jowl sulcus. In addition, recommendations for amounts of dermal filler that will be required for each procedure are also provided. Of the patients evaluated, 10-12% were Level 1 patients; 25-30% were Level 2 patients; 30-40% were Level 3 patients; 25-30% were Level 4 patients; and 10-12% were Level 5 patients.

Although this grading system has been developed for all zones of the face, this presentation will focus upon the use of the grading system for treating the marionette and prejowl sulcus zones of women.

CONCLUSIONS: The practical application of this grading system has been to increase patient awareness, which has helped to set appropriate patient expectations concerning outcomes. In addition, this grading system will allow practitioners to properly evaluate the length, width and depth of the crease or fold plus the amount of volume loss in each facial zone so they can inject the appropriate amount of dermal filler for each specific procedure performed.

METHODS:

STATISTICAL METHODS:

• Table 1 shows the suggested initial filler amounts for treating the marionette and prejowl sulcus zones.
• The average age of the patients was 52.0 ± 8.4 years (range 35 to 82 years).
• Table 2 shows the distribution of severity levels in the patient population.
• Table 3 shows the average amounts of filler (Perlane, Restylane, and total of both) used to treat patients in each severity level.

CORRECTION RESULTS: The majority of patients achieved a 75% correction relative to baseline severity. Specifically, the correction results for the 100 female patients were as follows:

• 50% correction: n=23
• 75% correction: n=76
• 100% correction: n=1

Figure 2 shows the marionette and prejowl sulcus zones of a level 3 patient before and after treatment.

Figure 2. Marionette and prejowl sulcus zones of a level 3 patient before treatment (A) and six weeks after treatment with 3 mL of Restylane/Perlane (1.5 mL per side) (B).

STATISTICAL RESULTS:

• Table 4 summarizes the association of age, severity level, and filler amounts with outcome (ie, the percent facial correction from baseline).
• Patients with ≥75% correction differed significantly from those with 50% correction.
• When adjusted for age, the total amount of filler used was 78% lower among patients with ≥75% improvement compared with patients with 50% improvement (odds ratio = 0.22; 95% Confidence Interval, 0.10-0.48; P = .0002).
• These results imply that a greater degree of improvement after treatment is found among patients with lower baseline severity as indicated by a younger age, a lower average level of severity, and a smaller amount of filler used.