LAS VEGAS When using dermal fillers, think of yourself as an artist with a palette of colors, using this one here and that one there.

"There is no ideal filler for all occasions; we need to have a range of fillers," said Dr. Alastair Carruthers, who, with his wife Dr. Jean D.A. Carruthers, pioneered the cosmetic use of botulinum toxin A. "You must always match the patient with the indication and the filler."

At the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery, he went on to discuss his approach to treating specific anatomical areas with various dermal fillers:

▸ Glabella. For this area "you have to inject the frown line superficially, so you want a product that is relatively thin," said Dr. Carruthers, who practices dermatology in Vancouver, B.C.

"Good old Zyderm was wonderful in this area, but you don't want to inject anything that is likely to cause vascular occlusion." For the glabella, he will typically use Restylane, Juvéderm Ultra, or Evolence Breeze in conjunction with Botox.

▸ Infraorbital hollow. He called this area the most difficult to treat consistently well. Even a tiny overcorrection can cause bumps.

"My advice is to always undercorrect," he said. "Always inject supraperiosteally. Hyaluronic acid fillers are great in this area." Diluted Evolence Breeze is another option.

▸ Malar/zygomatic area. For this area, the optimal filler depends on the patient's aversion to risk. Radiesse is going to provide the patient with the best value for the money, "but you're going to get bruising and swelling," said Dr. Carruthers, who is also with the department of dermatology and skin science at the University of British Columbia in Vancouver.

"You're also going to get bruising and swelling to a lesser degree with hyaluronic acid fillers. So for the individual who has a dinner party that night, I would use Evolence."

▸ Cheeks. This is a challenging area to treat from a technical standpoint, but the results for patients with HIV-associated lipoatrophy can be striking. Dr. Carruthers likes to use Radiesse, hyaluronic acid fillers such as Juvéderm Ultra Plus or Perlane, or Evolence.

▸ Nasolabial folds. Since any dermal filler works well in the nasolabial folds, Dr. Carruthers uses "whatever I have in the syringe. I will always be treating other areas and will use the filler I'm already using in the nasolabial folds."

If someone comes in saying that they want their nasolabial folds corrected, "always look at their cheeks to see if they need improvement there as well," he suggested.

"Also, don't overdo it. We've all seen individuals who have seen their nasolabial folds corrected spectacularly. Babies have nasolabial folds. The nasolabial fold is a natural thing; you can soften it but don't try to get rid of it."

▸ Lips. This is another challenging area to treat, one "where you make or lose your reputation in your area of practice," Dr. Carruthers said.

He recommends avoiding the use of permanent fillers in the lips and those that cause fibroplasia, including AlloDerm, and products that contain Gore-Tex.

"Why? Because the lip is so mobile. Even with the soft fillers we put into lips you can still get problems," Dr. Carruthers explained during his presentation. "Be conservative and cautious, and don't try to overtreat the lips."

He said that he uses Evolence Breeze about 70% of the time for correction of the lips. He also uses Restylane and Juvéderm Ultra.

▸ Marionette lines. The area requires a relatively stiff filler such as Juvéderm Ultra Plus, Perlane, or Evolence. Even with these products, however, the results may not be optimal.

"You have to accept that fillers do not hold well in the marionette area," he said. "You should be injecting right down to the jaw line if you're attempting to improve this area."

▸ Chin. When adding volume to this area, be mindful of the branches of the facial artery. "Stay superficial where the facial artery crosses the mandible," he recommended.

Dr. Carruthers noted that bruising is most likely to occur when the dermatologist injects into the lateral part of the chin. To minimize bruising, he recommends injecting posterolaterally from the central chin.

Fillers he uses for the chin include Radiesse, Juvéderm Ultra Plus, Perlane, or Evolence.

Dr. Carruthers disclosed that he is a consultant and performs research for Allergan Inc., Merz GmbH & Co., and Biform Medical Inc.

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A patient is shown before receiving Radiesse for lipoatrophy of the cheeks, which can be challenging to treat.

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Noticeable results can be seen in the patient's cheek area after treatment with one syringe of Radiesse. PHOTOS COURTESY DR. ALASTAIR CARRUTHERS

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'There is no ideal filler. … You must always match the patient with the indication and the filler.' DR. CARRUTHERS

Primer on Fillers Emphasizes Variety, Artistry