The Art of Biostimulation: A Journey into PMMA Volumization
There is a unique product in the world of aesthetic medicine, one that stands apart from the rest. It is called Bellafill, and its core is composed of polymethyl methacrylate, or PMMA, suspended in bovine collagen. This is not just another filler; it is the only filler the FDA has approved to last for five years. In reality, its effects stretch far beyond that timeline. It is also the sole filler approved for treating acne scars. When you introduce Bellafill into the body, something remarkable happens: your own tissues respond to the PMMA microspheres by creating a natural collagen reaction. The body cannot break down these spheres, which means the volume you create is truly long-lasting.
This substance is incredibly versatile. I use it in the temples, in the mid and lateral cheeks, along the nasolabial folds, and in the marionette lines. I love it along the jawline. The result is a very natural appearance with remarkably little swelling. The bovine collagen component actually contributes to less bruising and less swelling than many other fillers. There is one crucial difference, however: because of the bovine collagen, a skin test is required to rule out the small—approximately one in two hundred—risk of an allergic reaction.
The Acne Scar Solution: Understanding the Mechanism
When it comes to acne scarring, Bellafill is specifically approved for rolling acne scars. The technique I use involves first subcising the tethering below the scar, then injecting into the dermis. Studies have shown that roughly 0.1 cc of filler is used per scar on average, and typically two treatments are needed per scar. A single syringe can therefore treat approximately eight scars, each requiring a double session. Of course, acne presents in multiple forms—ice pick and boxcar scars, for instance—and I use a multi-modality approach including Infini, TCA cross, and laser resurfacing to address all dimensions of the scarring.
The Top-Down Assessment: Mapping the Canvas
When I evaluate a patient, I always go from the top down. We assess volume loss in the forehead, the supraorbital area, and the temple region. Then we move to the cheek area, the nasolabial folds, the marionette lines, and even the preauricular area. Volume loss also appears along the jawline. After a full assessment, we plan a comprehensive treatment that includes the temples, cheeks, nasolabial folds, marionette lines, jawline, and the preauricular area, as well as targeted work on the acne scarring itself. This patient has had Bellafill before, so we are ready to proceed.
The Temple Technique: Precision with Cannulas
I prefer to use cannulas for safety. For the temples, I use a 23-gauge Softfil cannula. I start by creating a pilot hole midway between the brow and the hairline along the zygoma, going through the dermis with the needle. When inserting the cannula, I always hold it from the hub and advance beneath the vessels. This is the safest approach. I go all the way to the temple fusion line and perform a retrograde injection. I place about half a syringe—0.4 cc—of Bellafill here, using a fanning technique. A little goes into the supraorbital area, and then beyond the temple fusion line toward the hairline. The key is not to overload; you put in small aliquots. There is a lot of vascularity here, so gentleness is paramount. If done correctly, there should be no bleeding, no bruising.
On the other side, I repeat the same process. I use the larger cannula because Bellafill can clog smaller ones. I advance gradually, staying beneath the vasculature, between the deep temporal fascia and the superficial temporal fascia. I lay a little filler along the supraorbital rim, which gives a subtle brow lift. The cannula tells you where to go; if you feel any resistance, you stop and redirect. Constant movement is essential for safety.
Cheeks, Preauricular Area, and the Jawline
For the mid cheek, I use a similar pilot hole. The skin here is thicker due to acne scarring, so I use a gentle twisting technique for insertion. I always have an assistant provide distraction—a vibration device and cold therapy help immensely. I inject along the periosteum, constantly moving while I inject. This is the safest way. For the preauricular area, which often becomes deficient after a facelift, I create another small insertion point, use a milking motion to locate the pilot hole, and then inject retrograde. Moving from the mid cheek to the lateral cheek provides a lifting effect and restores volume.
The nasolabial folds require the most attention because of the angular vessels near the nasal ala. I stay underneath these vessels and constantly move as I fill. A full syringe is often needed here. The marionette area follows, and half a syringe is usually sufficient. The preauricular area is contiguous with the temple fat pad, so if you are addressing the temple, you must address this zone as well. It pulls up the lower face, helping the marionette lines and the jawline.
For the jawline, I use cannulas again. The vessels at the angle of the mandible are critical; I stay ahead of them. I enter the preperiosteal plane, lower than the jaw itself, and perform a retrograde injection. This creates a firmer, more defined jawline and a strong angle—something essential for beauty. The prejowl sulcus is a bit less comfortable, but it completes the line.
The Transformation Through Volumization
Something interesting happens when you volumize a patient with Bellafill: the acne scarring itself often becomes less noticeable. In fact, many older patients complain of new acne scarring, but it is actually old scarring that has become more prominent due to volume loss. So, a key principle is that you must volumize the face before you directly treat the scars. This is why I often combine the treatments.
For the rolling acne scars, I use cannula subcision. This involves popping up the scars from their tethering below. Recent studies have shown that cannula subcision yields better outcomes and higher patient satisfaction compared to the traditional Nokor needle technique. The Bellafill contains lidocaine, which keeps the patient comfortable throughout.
The Final Picture
After completing the temples, cheeks, nasolabial folds, marionette lines, jawline, and preauricular area on one side, we repeat the process on the other side. The total volume used is typically around six syringes for a comprehensive session. The patient is calm, comfortable, and the result is immediate: the nasolabial folds are softer, the marionette lines are lifted, the jawline is straighter, and the overall face has a refreshed, natural volume. The key is to let the cannula guide you, to never fight resistance, and to always respect the anatomy. This is the art of Bellafill—a long-lasting, natural-looking solution to both volume loss and the persistent challenge of acne scarring.