Full face rejuvenation

Dr Mei Dr Mei discusses full-face rejuvenation: A ‘Cookbook Approach’, or an anatomical assessment?

Full face rejuvenation is a term used when aesthetic clinicians address the facial ageing process. 1When your face ages, the whole face undergoes ageing. It does not necessarily age at the same speed, but all the tissues of your face will age. This includes the skeletal structure, muscles, ligaments, fat pads and skin. 2

Our patients seek aesthetic advice and treatments to combat this ageing, and it is our responsibility as clinicians to treat each patient appropriately.

As the non-surgical rejuvenation specialty progresses, we have begun to see a shift in patient attitudes from previously specifying treatments such as ‘lip filler and Botox’ to patients coming in expressing they want to look fresher, less tired and a better version of themselves. 3From my own experience, the new patients coming to the clinic are, in fact, concerned about the ‘overfilled or unnatural’ look and only request subtle treatments.

Through my own training academy, I have developed a process of teaching to ensure my delegates are able to develop a full face treatment plan based on the patient in front of them and the anatomical variations present, which I believe ensures natural results. Based on the feedback from some of my delegates who have attended other training courses, it would appear that it is still commonplace to teach techniques such as boluses in varying volumes placed in certain positions.

As the non-surgical rejuvenation specialty progresses, we have begun to see a shift in patient attitudes

With this comes a lack of consideration for the anatomy that surrounds it. For example, to enhance the cheeks, three boluses would be placed on the zygomatic arch in boluses such as 0.1 or 0.2, and the temple and midface would not be considered. The enhanced cheek in this situation could be mistaken for the ‘overfilled syndrome’ 4as the face would not be balanced - the temple would look more hollow and the midface flatter. Scrolling through Instagram or Facebook on various clinic pages, you are able to see evidence of such treatment plans.

From my experience, injectors who rely solely on a “cookbook approach” 2and “volumetric systems” may find it harder to achieve natural results, as the treatment plans are more rigid and not necessarily based on a thorough assessment of the patient in front of them. The way a person ages can differ due to race, lifestyle and the environment, even identical twins who are exposed to different environmental factors age differently. 5Therefore, all facial rejuvenation treatment plans must be made based upon the presenting anatomy rather than a specific formula to ensure a natural, holistic result.

FULL FACE REJUVENATION, BASED ON AN ANATOMICAL APPROACH

My patient, age 46, a female with no relevant medical history, came for a consultation wanting to look and feel a bit fresher. She didn’t have any specific requests, apart from wanting to still look like herself and for the treatment to be subtle. Her main concerns were that she would have over-exaggerated features as she had seen on social media. We formulated a treatment plan based on the volume she had lost from the top third, middle third and lower third of the face rather than addressing only certain features of her face. 2

Before selecting a dermal filler, it is important to consider the area of the face to be treated, the skin quality and also the volume loss in this area. Not all dermal fillers are equal, and it is important to select the appropriate filler for the indication you wish to treat. 6

First, I addressed the temples as there was volume loss in the area and increased visibility of the temporal crest. Volume loss in the temple can contribute to a “skeletonised” face, which is a sign of ageing. Addressing the temple can make beneficial changes to the forehead, medial and lateral midface. 7

TREATMENT PROTOCOL

My method of choice was to address the subdermal fatty layer of the temple (layer 2) using a cannula 25g, 50mm with a dermal filler of medium viscosity – Stylage M. I used 1ml per temple with a retrograde fanning technique.

It has been shown that this subdermal fatty layer of the temple is an optimal target for lifting and volumising treatments. There are no major neurovascular structures found in this layer, making it a safer plane to treat. 7

Next, I addressed the midface, lateral cheek and the piriform fossa. In the midface, I used a high g prime filler (Stylage XXL) to treat the Lateral Sub Orbicularis Fat (L-SOOF). I used a 27g 13mm needle and deposited a 0.1ml bolus just above the periosteum.

I then placed a 0.2ml bolus with a needle in the Medial Sub Orbicularis Fat (M-SOOF) and a bolus of 0.2ml at the piriform fossa. 8Iused a total of 0.5ml XXL per side.

The SOOF, when treated, gives the biggest change in surface projection compared to the other fat pads 9, and therefore if this is treated first, less dermal filler should be needed in the other areas. I then reassessed the patient for areas of volume loss and the transition zones of the midface. Using a 25g 27mm cannula, I then addressed the Deep Medial Cheek Fat with a bolus and small linear thread and the lateral cheek fat using 0.5ml of a high G prime filler (Stylage XL).

It has been shown that this subdermal fatty layer of the temple is an optimal target for lifting and volumising treatments

The reason for this was to ensure a smooth transition zone in the midface. For a patient with temporal hollowing, it is important to ensure a smooth transition from the lateral cheek to the temple, as overfilling the lateral cheek can make the temple appear more hollow. 10For the lower face, I treated the chin, pre-jowl sulcus, angle of the mandible and marionette lines.

I used a high G Prime filler (as projection was needed) – Stylage XXL with a 27g, 13mm needle and placed a 0.2ml bolus at the prejowl sulcus and at the angle of the mandible. I placed a 0.1ml bolus at the anterior portion of the chin for a subtle projection. 11Then, using Stylage XL with a 25g, 27mm cannula, I addressed the marionette lines and the anterior jaw and chin to ensure smooth transitions throughout. I used 0.5ml on each side.

NEXT STAGES

Once the main foundations of treatment had been done, I treated the nasolabial folds, lips, and nose. Stylage L with a 25g, 27mm cannula in the mid dermal plane using micro boluses. This area must be treated with caution as this can coincide with the path of the facial artery.9 0.5ml was used on each side. Stylage L is a mild volumiser (lower G Prime than XL and XXL) and was chosen as the area treated did not have significant volume loss. The lips were very difficult to treat due to their volume loss, empty pockets and slight M shape.

I initially placed 0.8ml Stylage S with both a 25g, 27mm cannula and 13mm needle. The plan was then to place 1ml Stylage Lips Plus deeper with cannula to address the volume loss and refine with Stylage S more superficially, 8 weeks post initial treatment.

Lastly, for the nose, I used 0.4ml of Stylage XXL in a B.D. 0.3ml syringe. I used micro boluses and addressed the bridge, the tip and the anterior nasal spine. The nose was considered last, as it was not part of the rejuvenation but instead to balance the side profile. Stylage XXL was chosen for its projection qualities, and it also has reduced swelling due to the lower H.A. content (21mg/g) compared to XL.

The patient was also treated with Azzalure to the frown, forehead and crow’s feet to soften her rhytides. I would expect this patient to continue with a good skincare protocol and would review them in 12 months to see if any additional treatment was needed.

More often than not, at 12 months, the patients are still looking very well and very little, if any, treatment is needed.

REFERENCES

1. Dhillon B, Patel T. A Retrospective Analysis of Full-face Dermal Filler Treatments: Product Choice, Volume Use, and Treatment Locations. J Clin Aesthet Dermatol.2020;13(9):33-40

2. Sydney R. Coleman, MD, Rajiv Grover, BSc, MB BS, MD, FRCS (Plast), The Anatomy of the Aging Face: Volume Loss and Changes in 3-Dimensional Topography, Aesthetic Surgery Journal, Volume 26, Issue 1_Supplement, January 2006, Pages S4–S9

3. de Maio, M. MD Codes™: A Methodological Approach to Facial Aesthetic Treatment with Injectable Hyaluronic Acid Fillers. Aesth Plast Surg 45, 690–709 (2021)

4. Song, T, Facial overfilled syndrome, complications of inappropriate filler delivery 2018. www.prime-journal.com

5. Guyuron, Bahman M.D.; Rowe, David J. M.S., M.D.;

Weinfeld, Adam Bryce M.D.; Eshraghi, Yashar M.D.;

Fathi, Amir M.D.; Iamphongsai, Seree M.D. Factors Contributing to the Facial Aging of Identical Twins, Plastic and Reconstructive Surgery: April 2009 -Volume 123 -Issue 4 - p1321-1331

6. Ramos-E-Silva M, Fonteles LA, Lagalhard CS, Fucci-da-Costa AP. STYLAGE®: a range of hyaluronic acid dermal fillers containing mannitol.

Physical properties and review of the literature.

Clin Cosmet Investig Dermatol. 2013;6:257-261.

Published 2013 Oct 23.doi:10.2147/CCID.S35251

7. Cotofana S, Gaete A, Hernandez CA, Casabona G, Bay S, Pavicic T, Coimbra D, Suwanchinda A, Swift A, Green J.B., Nikolis A, Frank K. The six different injection techniques for the temple relevant for soft tissue filler augmentation procedures – clinical anatomy and danger zones. J Cosmet Dermatol. 2020 Jul;19(7):1570-1579. doi:

10.1111/jocd.13491. Epub 2020 Jun 1. PMID: 32418303

8. Surek CK, Vargo J, Lamb J. Deep Pyriform Space: Anatomical Clarifications and Clinical Implications. Plast Reconstr Surg. 2016

Jul;138(1):59-64

9. Cotofana, Sebastian & Koban, Konstantin & Frank, Konstantin & Green, Jeremy & Etzel, Lucas & Giunta, Riccardo & Schenck, Thilo. (2019). The Surface-Volume-Coefficient of the Superficial and Deep Facial Fat Compartments – ACadaveric 3D Volumetric Analysis. Plastic and Reconstructive Surgery

10. R.Fitzgerald, J Carqueville, P.T.Yang (2019). An approach to structural facial rejuvenation with fillers in women

11. Akinbiyi, Takintope MD; Othman, Sammy BA;

Familusi, Olatomide MD; Calvert, Catherine MD;

Card, Elizabeth B. BS; Percec, Ivona MD, PhD Better Results in Facial Rejuvenation with Fillers, Plastic and Reconstructive Surgery -Global Open:

October 2020 -Volume 8 -Issue 10 - pe2763

DR MEI

Dr Mei is a dentist, with a background in Oral and Maxillo-facial surgery. She runs her own aesthet-ic clinic and training academy and is based in Leeds. She is also a trainer for VIVACY. You can follow her on Instagram @drmei