The Aesthetic Consult for Dermal Fillers – Planning for Success
Current Options and Selection of Appropriate Fillers
Over the past 20 years, the field of facial rejuvenation has grown and changed tremendously. Most patients who walked through a plastic surgeon’s office in 1988 were offered surgery and nothing else. Today, the trend is toward customized programs that utilize surgical and nonsurgical options, along with skin care programs designed to suit each patient’s needs and wishes. The approach to each treatment plan is individual, with many tools and techniques available to achieve successful and satisfying results. With the availability of more tools, the artistry of the field has improved so that patients can be offered a range of procedures that can produce subtle to substantial changes in their facial appearance.
Changes in Facial Rejuvenation Treatment
There has been a significant shift in the past two decades in facial rejuvenation treatments. In 1988, surgery was the single treatment available to patients seeking facial rejuvenation, and surgical procedures were aggressively performed on specific areas around the eyes, mouth, and chin to tighten sagging skin. Brow-lifts were performed using a traumatic coronal procedure, and many deep-plane and composite face-lifts were performed. Facial lipoatrophy was not addressed at all. Overall, the results were less than optimal, the risks were higher, and recovery time was longer than it is today.
In 2008, facial aesthetic procedures are much less aggressive and produce better outcomes.1 A conceptual change in the approach to facial aesthetics has occurred, with a shift in focus from face-lifts to volume restoration (Table 1), as experience has shown that atrophy in the midface and other regions is responsible for the most pronounced appearance of aging.
Table 1. Comparison of Treatment Options For Facial Rejuvenation: 1988 vs. 2008
|Mostly surgical options||Customizing surgical & non-invasive procedures|
|Aggressive face-lift||Short-flap face-lift|
|Aggressive eyelid surgery with a high rate of complications||Fat- and muscle-preserving eyelid surgery; better pre-operative analysis; volume restoration|
|Coronal brow-lift||Endoscopic brow-lift|
|Midface & facial lipoatrophy not addressed||Multilevel fat grafting; injectables; endoscopic midface-lift; implants|
|Aggressive skin resurfacing||non-ablative laser resurfacing (fractional laser resurfacing), skin care regimen, portrait plasma, judicious chemical peels|
Understanding Facial Anatomy
It is important for plastic surgery nurses to understand the facial anatomy in order to better treat their patients. The skin rests on the surface of layers of nerves, muscles, and ligaments that determine facial contours and control expression. One of these layers, just below the skin, is the superficial muscular aponeurotic system (SMAS), which envelopes the entire musculature of the face (Figure 1). The SMAS is extremely important to comprehending the facial aging process.
The SMAS form a delicate network across the face, connecting to both the muscles and skin.2 The facial nerve has five branches that go to the forehead, eye, midface, lower face and neck muscles, all of which impact on facial expression (Figure 2). Beneath the SMAS lie the retaining ligaments and underlying muscles that define the facial contours. Certain areas such as the pre-jowl sulcus, the nasolabial fold, and the zygomatous region are more likely to show signs of aging.
The concept of fat distribution in the face has changed in recent years. A study by Rohrich and Pessa confirmed the observation made by many practicing surgeons that subcutaneous fat in the face lies in distinct subcompartments that do not allow for significant shifting.3 Over time, however, these fat deposits begin to lose volume, causing hollows and troughs to form between the compartments and contributing to the sagging appearance of the skin. In looking at Figure 3, which shows the compartmentalization of fat around the orbital area, it is easy to see how lipoatrophy of this area is involved in the aging appearance of the upper and lower eyelids.
What Is Beauty?
The concept of facial beauty is one that has remained relatively constant over thousands of years: It is a concept of symmetry, along with high, arched cheeks; an angular jaw; full volume in the cheeks and eyes; and a strong presence in terms of the overall face. Gaunt, hallowed cheeks and sunken eyes are perceived as making someone look less attractive and older. Currently, the practice of plastic surgery may lean toward volumizing in order to compensate for atrophy, as facial fullness is very important to the concept of beauty.
An article in the August 2008 issue of New York Magazine explored the notion of the “new new face” where volumizing and fullness have taken the place of the more traditional tightening and shrinking type of facial surgery that was popular in the 1980s and 1990s. The article, which is subtitled “Out with the gaunt and tight, in with the plump and juicy,” cites examples of Madonna and Demi Moore as women who have had more novel, combined volumizing procedures. Observers can only note with admiration that they have had “something” done, although it is difficult to tell what that might have been. These “restuffed” faces are compared to the tight, harsh, reshaped faces of stars of the past all of whom came away from their procedures looking quite different than they had before, rather than recapturing a more youthful version of their own appearance. As the article points out, the current beauty trend seems to be a search for “baby fat,” which is equated with a youthful look.
Source: Van Meter J. About-Face. New York Magazine. August 2008. Available at: http://nymag.com/news/features/48948/
Aging and the Face
The pathophysiology of aging is the result of multiple processes, including loss of skin elasticity, facial atrophy resulting from fat shrinkage and bone resorption, gravitational laxity of the muscles, and dynamic processes in the muscles involved in facial expression that contribute to age lines. Over the course of a lifetime, these processes all increase the appearance of wrinkles; expression lines around the nose, mouth, eyes, and forehead; a heaviness of the eyelids; thinning lips; and sagging skin all over the face, particularly in the areas of the jowls, chin, and neck. Environmental factors such as sun exposure, smoking, and poor diet can accelerate the aging process.
The goal of facial rejuvenation treatment is to reduce these signs of aging in ways that are natural in appearance and have a lasting impact. Today’s treatments are remarkably successful in achieving these goals, as long as the patient has realistic expectations and is well prepared for the surgery and recovery afterward. For this reason, the consultation is extensive and thorough.
Optimizing the Patient Consultation
The consultation provides information in two directions: It educates the patient about the procedures, risks, and requirements for recovery, while providing the aesthetician or physician with an understanding of the patient’s goals and readiness for the procedures. Given the broad range of aesthetic tools and procedures available, the patient needs to understand that each practitioner has a unique approach to treatment, and that there are many options available.
A crucial aspect of the initial consultation is a complete analysis of the face, which provides important information for the development of a treatment plan. People who are born with good bone structure often benefit most from rejuvenation surgery. Most patients will need a fairly comprehensive treatment plan that addresses aging while compensating for less-than-perfect structural elements. These patients often have a heightened awareness of a single flaw and subsequently believe that correction of the offending issue will miraculously address other aging issues. For instance, a patient may request a rhinoplasty without realizing that the single correction will then draw attention to a weak chin. It is the plastic surgeon and nurse’s function during the consultation to help patients see how each element of the face can be enhanced or improved to achieve the results they are anticipating. Simply explaining this to patients can help them make appropriate and satisfying decisions, both financially and aesthetically.
When consulting about injectable treatments, it is important to inform patients about potential off-label uses of products, especially in the United States. For example, botulinum toxin (Botox® ) is only indicated for use on the glabella region above the brows, but currently is used off-label to treat crow’s feet and lines on the forehead. Additionally, patients should be realistically prepared to understand how many units of Botox® may be needed to achieve the results they are expecting, and what the outside costs might be.
The Facial Examination
It is important for any facial rejuvenation practitioner to examine the proportions of the face in order to develop a treatment plan. Issues such as mandible weakness or temporal atrophy can affect the appearance of the whole face. In profile, you want to look at the forehead, midface, and lower face in equal fashion to assess not only the individual characteristics of the facial structure, but also to identify natural asymmetry and age-related changes. This assessment should be shared with patients to help them understand how the procedures they are requesting will or will not address these issues.
For a global facial assessment, the face is viewed in thirds (Figure 4). The upper third is traditionally considered the eyes and forehead, and today it seems more appropriate to include primarly the upper eyelids and brow in this region. The lower eyelids, cheeks, nose, and nasolabial fold fall into the middle third. The lower third includes the jowls, chin, neck and the prejowl sulcus, located just in front of the chin. Each of these regions has special considerations for treatment.4 Some patients may require only regional treatment plans, while others should be viewed globally for a successful rejuvenation plan.5 Overall, however, it has become clear that volume repletion must be a primary consideration for any patient looking for facial rejuvenation.
Ultimately, the goal of facial rejuvenation treatment is to create harmony without creating any major discrepancies.
Facial rejuvenation plans include three primary types of treatments:
- Surface procedures to improve the appearance of the skin;
- Noninvasive (nonsurgical) options aimed at volumizing; and
- Contouring and rejuvenation surgery (formerly performed as a “face-lift”).
The impact of aging on the skin is substantial: It loses elasticity, and expression lines go from being dynamic (as when smiling) to static (and permanent). The effects of sun exposure, smoking, and dietary choices on the pigment and texture of the skin, as well as natural flaws and skin tone, need to be considered in any rejuvenation program. While it may not be the primary concern of plastic surgery nurses, it is important for skin care to be included in the treatment plan to ensure the most successful outcomes for patients, and to help them maintain their results.
The area of the midface has received a great deal of attention in recent years as facial contouring techniques have improved and expanded with the use of injectable volume enhancers.6 This region is particularly susceptible to large-scale, age-related changes resulting in a general flattening of the midface with increased shadowing and areas of concavity that give a gaunt appearance. A Facial Lipoatrophy Panel convened in 2006 to examine the causes of such facial changes related to aging attributed it to “loss of facial fat due to aging, trauma or disease, manifested by flattening or indentation of normally convex contours.”7 For treatment purposes, the group recommended assessment of these changes by measuring three criteria―contour, bony prominence, and visibility of musclature―according to a proposed grading scale of increasing severity from 1 to 5, while noting that assessment of facial lipoatrophy is both subjective and qualitative.
Treatments to restore midface volume loss are achieved using an increasing range of injectable fillers, which are minimally invasive (Table 3).8 Patients can have the procedures done in the office and usually return to work the same day without noticeable scarring or bruising. These products can be classified as neurotoxins, short-, medium-, and long-term fillers, and permanent fillers.
Table 3. Injectables:
- Botulinum toxin type A (Botox Cosmetic)
- Short-term Fillers: Last 2-3 months
- Bovine and human-derived Collagen (CosmoDerm, CosmoPlast™ )
- Intermediate-term Fillers: Last 3-12 months, include mostly hyaluronic acids used for lip enhancement and the tear-trough
- Hyaluronic acids (Restylane, Perlane, JuvÈderm)
- Porcine Collagen (Evolence)
- Long-term Fillers: Last 1 year or more
- Calcium hydroxylapatite (Radiesse™)
- Injectable poly-L-lactic acid (Sculptra™)
- Permanent Fillers: should only be placed by experienced and qualified surgeons
- Polymethylmethacrylate microspheres (Artefill™)
- Silicone (ADATO™ SIL-ol 5000, SilikonÆ 1000)
Surgery may become part of a plastic surgery treatment plan for a number of reasons. Many patients have specific flaws or weaknesses in facial contouring that require more substantial restructuring of the support structures with facial implants or procedures such as rhinoplasty. Midface implants may also be necessary in cases of severe lipoatrophy to support volume-enhancing injectable products. [Dr. Azizzadeh: Can you please specify locations for these types of implants?]
Given the extensive range of products now available, and the many ways they can be used, it is important to make sure facial rejuvenation patients are well prepared for their procedures in order to meet their expectations. The patient consultation is a crucial part of the overall treatment. In our office, a first consultation is conducted by the nurse, who gathers all of the information needed to develop a treatment plan. As the treating physician, I repeat much of the same information with the goal of fully informing patients of the benefits and risks of chosen procedures. This patient preparation process contributes greatly to the success of the procedures we perform.
1. Fedok FG. Advances in minimally invasive facial rejuvenation. Curr Opin Otolaryngol Head Neck Surg. 2008;4:359-368. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18626256?
2. Ghassemi A, Prescher A, Riediger D, et al. Anatomy of the SMAS revisited. Aesthetic Plast Surg. 2003;27:258-264.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/15058546?
3. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219-2227.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/17519724?
4. Carruthers JD, Glogau RG, Blitzer A; Facial Aesthetics Consensus Group Faculty. Advances in facial rejuvenation: botulinum toxin type a, hyaluronic acid dermal fillers, and combination therapies—consensus recommendations. Plast Reconstr Surg. 2008;121(Suppl 5):5S-30S.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/18449026?
5. Klein AW. Soft-tissue augmentation 2006: Filler fantasy. Dermatol Ther. 2006;19:129-133.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/16784511?
6. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial fat compartment; Plast Reconstr Surg. 2008 Jun;121(6):2107-12. http://www.ncbi.nlm.nih.gov/sites/entrez
7. Ascher B, Coleman S, Alster T, et al. Full scope of effect of facial lipoatrophy: A framework of disease understanding. Dermatol Surg. 2006:32;1058-69.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/16918569?
8. Downs BW, Wang TD. Current concepts in midfacial rejuvenation. Curr Opin Otalaryngol Head Neck Surg. 2008;4:335-338.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/18626252?