Dermal Fillers: Rebuilding the Face

In this section, we will talk about

• Dr Hyland’s 5-S system for facial analysis: Shape, Symmetry, Sagging, Sculpting, and enhancing Specific Features-Lips, Nose, Chin
• How Hyaluronic acid- based fillers are used to Restore Volume & Recontour (shape) the face;
• How to Enhance Beauty and create a more Masculine or Feminine appearance
• The use of collagen- stimulating fillers to increase dermal thickness for areas with very thin crêpey skin eg. hands; and the use of Platelet Rich Fibrin Matrix (PRP or PRFM) for treating fine lines, and improving skin texture

Dermal Fillers: 3 broad categories

1. Volumizing and Shaping fillers, have a firm gel consistency and are comprised of cross-linked hyaluronic acid. They address Sagging, Shaping , Sculpting and enhancing Specific facial features (nose, chin, lips)- eg Juvederm, Restylane 
2. Collagen- stimulating fillers such as Sculptra are used to increase dermal thickness in patients who have lost subcutaneous fat and have very thin crêpey skin. With the exception of Radiesse, they do not have a firm gel consistency, and thus cannot be used to shape the face or enhance specific features: also their effect evolves over time and 2-4 treatment sessions 
3. PRP /PRFM is derived from the patients own blood, (see Selphyl), and is used for its regenerative qualities to improve skin texture and small defects such as fine lines or small atrophic scars. Some physicians have used it with varying degrees of success for hair thinning. The effects are subtle, and often several treatment sessions are required

Dr Hyland’s 5-S System of Facial Analysis:

• Shape & Symmetry
• Sagging & Sculpting
• Specific Features

1. Shape:

There are 5 basic face shapes; Round, Square, Rectangular, Oval and Heart-shaped; square or rectangular tend to be associated with masculinity: oval or heart-shaped more feminine. Botox & Fillers can be utilized to alter the shape of the face:

Botox in masseter muscle slims and elongates a square or rectangular face;(feminizing)

conversely, filler at the angle of the jaw will square off the face (masculine ideal)

Emphasizing the cheekbones and creating a more pointed chin with filler, slims and elongates a round face and converts an oval to a more feminine triangular shape- see section on sculpting and enhancing specific features

To create a strong masculine appearance, the emphasis should be on creating a rectangular or square face with emphasis on a strong jawline and prominent, more rounded, (vs pointy) chin. Juvederm Volux is particularly good for working in this area

Chiselled jawline, emphasizing angle of jaw, and a strong, rounded chin

1. Symmetry: Everyone is asymmetrical !!! The right side of your face is not a mirror image of the left side – one side-usually the (L)- is broader and flatter, and will have deeper/more noticeable nasolabial folds.This is inherent to the bone structure of the face, and although we can adjust the placement of filler in the cheeks to minimize the discrepancy,and make adjustments in eyebrow height with Botox- it can never be 100% corrected
2. Sagging

As discussed in a previous section, (The 5-Rs of Facial Rejuvenation) the primary role for fillers in facial rejuvenation is to rebuild the mid face following volume loss and sagging that is the result of deep fat compartment shrinkage and bone resorption

Change in shape of face with volume loss; face becomes flatter with noticeable sagging

The fat pads of the mid face are responsible for the full, rounded appearance that we associate with youth. Much like a padded hangar, when these fat pads shrink, the face looks flatter as the skin that was stretched over them falls into folds- the nasolabial folds on either side of the nose, marionette lines that arise from the corners of the mouth, and jowls– which are skin folds hanging down below the jawline.

With increasing age, the bones of the midface undergo gradual resorption, adding to hollowness and baggy skin under the eyes, flattening and puckering of the upper lip; and the fat pads of the temple shrink which further compromises support to the skin of the periocular (eye) area:

Typical zones of bone resorption in face; eye sockets, upper and lower jaw and chin

 

 

Real Life: Lazer Room Case; Before and after Revolumizing of mid face

Volume loss of mid face& temples results in hollow cheeks, droopy eyelids and bags under the eyes: restoring volume to temples helps raise the eyebrows, improve area under the eyes, and refilling mid face fat compartments adds to the rejuvenating effect.This patient was treated with Sculptra; the collagen -stimulating effect being responsible for the improvement in skin quality

Addressing Sagging: Restoring Volume Loss & Symmetry

Sculpting Cheeks and Jawline: Recontouring, Beautifying

 

Depending on the extent and location of the deep fat loss, this may require several sessions of 2-4 syringes of a firm gel HA filler eg Juvederm Voluma; typical zones of fat loss are the midface fat compartments, temples, under eye (tear troughs) area; at the same time , we address symmetry, keeping in mind that one side may require slightly more volume restoration than the other or a slightly different distribution of filler:

 

Zones for placement of filler

O Session 1 Restoring Volume to mid face, addressing Sagging

• placing strategic deposits of filler along the cheek bone (zygoma ), and
• restoring volume to the mid face fat compartments

O Session 2: Addressing residual Sagging & Symmetry.

• Filler is placed at the angle of the jaw, the sides of the face,

and along the front of the jawline to disguise jowls

• Temples and tear troughs are treated to improve brows and bags under the eyes

O Session 3: Sculpting the face to create a more Masculine or Feminine Appearance

• Chin & Jawline– correct a retroceded chin;enhance feminine or masculine appearance
• Cheeks – sculpted diagonally to create a more trianglar(feminine ) face; laterally to create a squarer, more masculine shape

• Retroceeded chin: a weak, or retroceeded chin can often be improved with dermal fillers, and in the process a more defined jawline is created; the angle of the jaw and chin are squared off to create a stronger, more masculine look; if femininity is the desired effect, the chin should be more pointed , less emphasis placed on the angle of the jaw
• Brows- Arched brows are a feminine trait (Botox); males tend to have lower, more horizontal brows;subtle placement of filler along lateral brow can emphasize masculinity
• Lips- fuller, slightly everted lips with sharp definition of Cupids bow are femininizing

Enhancing Specific Features

Non-surgical Rhinoplasty (Nose Job)

Dermal fillers can be used to improve the appearance of broad-flat-tipped nose or to improve the profile of a nose with a bump; It cannot straighten deviated septae, and should be avoided if the patient has had previous surgery, as that may alter the anatomy of the blood supply. A tiny dose of Botox can be used to improve a hooked nose

Lips : Pre-treatment Assessment – 4Ps

 

Optimal results are obtained when we do a careful pre-treatment assessment

1. Proportions -Width of lips in relation to the face; Upper to Lower Lip ratio
2. Projection- Are the lips everted ( turned out) vs inverted (typical of old woman)

eversion/inversion of lips

1. Facial Profile – convex, straight or concave?We need to assess lower jaw,chin and bite

1. Peripheral structures – Chin, Teeth, Muscles – have a major impact on the appearance of the lips

Facial Profiles: Convex can be associated with retroceeded chin ( micrognathia) or overbite (malocclusion); Concave profile could be connected to prognathia (prominent chin), underbite (malocclusion of teeth ); or with increasing age, a combination of bone resorption in the mandible & maxilla, tooth loss and muscle imbalance results in overclosure of mouth and a decreased distance between tip of nose and the chin

If a patient has a orthodontic isue, eg overbite or protruding upper teeth- attempts at lip augmentation make make their appearance worse by increasing the protrusion of their upper lip

Muscle imbalances may require treatment with Botox or fillers – eg overactive DAO muscle pulling down the corners of the mouth; an overactive mentalis muscle may result in “witches chin” and make it difficult to evert the lower lip; and puckering of the upper lip is a result of overactive orbicularis oris muscle

 

Lazer Room Cases

DAO muscle plus lip augmentation Smokers lines treatment plus lip augmentation

Treatment:

Lip Augmentation : 3-Ps- Pencil Outline, Plump & Project (Evert)

1. The Pencil outline– similar to using a lip pencil- is accomplished by using a cannula inserted at the corner or commisure of the lip and placing a small line of filler along the vermillion border of the upper and lower lip , reinforcing the commisures and helping to create a slight upturn in the corners, and giving a nice sharp outine to the Cupids Bow.
2. Plumping is by injection into the cushions of the lips– top and bottom – allowing for normal movement – see function below.
3. Projection – or eversion – is accomplished by injecting along the wet/dry border of the lip and in the Philtrum. A tiny dose of Botox may help relax the muscle above the upper lip (lip flip technique)

Good Results are dependent on 4 factors: Proportion, Profile; Function, Feel

1. It is important that the lips remain in Proportion to the face and retain normal upper/lower lip proportions- (ie too big an upper lip will look disprortionate and odd);
2. When seen in Profile– side view- the top lip should not protrude in front of the bottom lip
3. They should be Functional-ie able to pucker (pronounciation, drinking from a straw, and kiss)
4. They should Feel smooth, not lumpy

2 Collagen- enhancing fillers– such as Sculptra, Radiesse boost collagen synthesis in the dermis ( middle layer of the skin) and PRP/PRFM (platelet rich fibrin matrix –which is derived from the patient’s own blood)- – are used to improve skin thickness and texture: but, except for Radiesse, they lack the firm gel consistency required to rebuild facial architecture. They are used in cases of extreme emaciation– loss of subcutaneous fat -and for hand rejuvenation, where the skin has become very thin and crêpey

 

Lazer Room Hand Rejuvenation Before/After with Radiesse