Full face treatment: the ideal way for natural facial rejuvenation
face 4/2014
The ageing process leads to atrophy of all tissue layers involved, right down to the bone. It is therefore not enough to fill in individual wrinkles, but rather to restore youthful proportions, which can only be achieved in a multi-stage process using various preparations.
Ageing processes The ageing process does not only take place on the skin, but encompasses all layers up to and including the bone. Fat and connective tissue in particular are subject to age-related degradation.
In the face, a distinction is made between a superficial and a deep layer of fat. As part of the ageing process, there is a loss of volume in the superficial and deep fat compartments. Following the force of gravity, the soft tissue slips caudally. Bony degeneration also begins from around the age of 50. Structural changes in the bone, such as the flattening of the zygomatic bones, enlargement of the orbits and loss of the defined jaw angle, result in the loss of bony support for the overlying soft tissue, which causes the latter to sag as well. Bony changes are also responsible for the pronounced loss of anterior projection.
A scientific study was carried out to investigate how the fat bodies in the face change during the ageing process. Computed tomography images and measurements of cadavers from two age groups (54-75 years versus 75-104 years) were compared with each other.
Age-related migration of the fat compartments
The distance between the fat compartments and the lower orbital rim was greater in the older group than in the younger group. In addition, the sagittal thickness of the lower third of the most important fat compartments in the midface was greater in the older group and the sagittal thickness of the upper third was smaller than in the younger group. The study thus provides the insight that there is indeed a migration of the fat compartments in the midface caudally as part of the ageing process.
The age-related changes described above lead to a change in the shape of the face: the sagging tissue causes the mandibular and chin contours defined in youth to be lost and the lower part of the face to widen. A young face is typically shaped like a downward-pointing triangle with the typical V-shape, whereby the proportions shift as a result of the above-mentioned changes in such a way that this triangle is reversed in old age, with the apex now pointing upwards.
Restoration of youthful proportions
Knowledge of these anatomical changes is a prerequisite for achieving a natural treatment result with the full-face treatment.
Age-related changes in the face can be visualised using vectors. In order to rejuvenate the shape of the face, a lateral/vertical lift in accordance with the vectors and equalisation of the volume to restore the projection are required.
While the restoration of the vectors can be carried out both invasively and minimally invasively, volume can be built up by implanting fillers. Special demands must be placed on the volume fillers used. A volume filler based on calcium hydroxyapatite (CaHA) is particularly suitable for volume substitution due to its physical properties. The CaHA microspheres (30 per cent) with a round, smooth surface (Ø 25-40μm) contained in a gel matrix, a cellulose-based gel made of water and glycerine, stimulate collagen neosynthesis in the long term, so that a dual mechanism of action can be postulated.
Due to its high elasticity, the filler has a high tolerance to stretching and can withstand negative vectors such as gravity and skin laxity. Thanks to its excellent lifting capacity, less volume is required than with a conventional hyaluronic acid filler. In addition to its high elasticity, CaHA also has a high viscosity. Migration is therefore not possible per se. In regions or indications where more distribution is required, this can be achieved by adding lidocaine. This increases patient comfort and makes the treatment more pleasant not only for the user but also for the patient.
A CaHA-containing filler should always be injected retrogradely into the deep dermis or subcutis. Superficial undiluted injection should be avoided as this could result in irregular corrections. Deep, supraperiosteal implantation is also possible, especially if subsequent "fine-tuning" with a hyaluronic filler in the dermis is desired.
Performing cheek augmentation
The cheek and cheekbone region is particularly suitable for volume augmentation. Augmentation of the medial and mid-cranial cheek compartments emphasises the direction of the elevators. The face is given a "friendlier" expression. The volume regain in the zygomatic arch area also results in a nasolabial lifting effect and a secondary tightening of the skin. Augmentation of the middle and caudal-lateral cheek compartments can also lift the marionette lines in addition to a nasolabial lifting effect.
It is helpful for the user to mark auxiliary lines on the face with a white eyeliner pencil before implantation. If, for example, the zygomatic arches are marked, the injection point for the vector technique should be in the centre between these two lines in order to also lift the nasolabial folds.
Another practical guideline runs from the tragus to the ala nasi: the material should be placed supraperiosteally above the line and subdermally or subcutaneously below it. As described above, the volume filler is also suitable for recontouring the jaw-chin line. In this case, it is recommended to inject directly at the jaw angle and along the jawline. The patient shown here underwent a full face approach with the volume filler, whereby both cheeks and the jawline were augmented and the nasolabial folds were filled. As with any filler treatment, the patient should be called in for a follow-up appointment after two to four weeks. At this point, any remaining fine wrinkles can be superficially filled with a low-viscosity hyaluronic acid filler.
Such a comprehensive treatment is possible by combining different procedures. A combination package is now available for the complete treatment of a face. This takes into account the requirements for superficial and deep treatments and contains two packs of a volume filler, two packs of a hyaluronic acid filler and two atraumatic cannulas.
Beautiful lips: The epitome of sensuality
The lips should be included in any rejuvenation treatment, as full lips are seen across cultures as the epitome of youthfulness and sensuality. Among Caucasians, an emphasised philtrum, a finely curved cupid's bow in the shape of a heart contour and a concave upper lip are considered ideal.
By nature, the lower lip is slightly larger than the upper lip. The ideal ratio of upper lip to lower lip for Caucasians is 1:1.6, which corresponds exactly to the golden ratio. Men's lips should not be too full, as full lips symbolise femininity. With increasing age, there is a reduction in lip volume on the one hand and a loss of lip contour and vermillion border on the other.
As the ideas of an "ideal" lip can vary, it is helpful to use standardised scales to assess the current state and to clarify a possible desired state for the patient consultation. As a rule, patients primarily want more volume. However, it is important to keep an eye on the ideal proportions. Only then can beautiful results be achieved.
Lip treatment should also include levelling out radial wrinkles and lifting the corners of the mouth. Radial wrinkles can be filled very well using the so-called blanching technique with a low-viscosity hyaluronic filler. Oral commissures are lifted with an elastic and cohesive hyaluronic filler and thus contribute to a positive facial expression.
Dermal fillers used to treat the lips should optimally adapt and integrate into the tissue. According to a clinical study, monophasic polydensified hyaluronic fillers are clearly superior to both biphasic products containing particles and monophasic monodensified hyaluronic fillers in terms of biointegration. Due to different density zones in the gel, they can adapt particularly well to the surrounding tissue without disrupting its integrity.
Both a sharp needle and a blunt cannula can be used on the lip, with the latter procedure being much more comfortable for patients. Hyaluronic fillers containing local anaesthetics are advantageous, as the lip region is very sensitive to pain.
Blanching technique for the lips
In the blanching technique, a short 30 G cannula and a downward cut are used to inject superficially so that a white discolouration of the skin ("blanching") is visible, similar to earlier collagen implantations. This technique is only possible with a monophasic polydensified dermal filler, as it can be injected very superficially without triggering the dreaded Tyndall effect. It is important that the cannula is only inserted just under the skin. After implantation, the material should then be massaged out. If done correctly, the whitish discolouration will disappear within a few minutes.
There is also a treatment set for lip treatment, which contains two different viscosity hyaluronic acid fillers with local anaesthetic. This set can therefore be used for all lip treatment situations: The more viscous filler is suitable for adding volume to the upper and lower lip area and for lifting the corners of the mouth, while the low-viscosity preparation is also particularly suitable for contouring the lip border and emphasising the cupid's bow and the philtrum.
Conclusion
The most aesthetically pleasing and natural results in facial rejuvenation are achieved with full-face treatments, as youthful proportions can be reconstructed three-dimensionally. Comprehensive anatomical knowledge is required on the part of the practitioner. Full-face treatments are always combination therapies that involve several sessions. In any case, the lips should also be included, as they are an essential feature in the assessment of a "youthful face".
Source: face 4/2014