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 Categories
- 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
- 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
- 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
- Addressing Sagging
- Sculpting Cheeks and Jawline
- Specific Features
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
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.
Change in shape of face with volume loss; face becomes flatter with noticeable 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.
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
3. Addressing Sagging
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 fillers
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
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
4. Sculpting Cheeks & Jawline
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
5. Enhancing Specific Features
1. Non-surgical Rhinoplasty (Nose Job)
Dermal fillers can be used to improve the appearance of a 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
2. Lip Enhancement
Optimal results are obtained when we do a careful pre-treatment assessment – Proportions,Projection, Profile, Peripheral structures .
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
3. Facial Profile – convex, straight or concave?We need to assess lower jaw,chin and bite
4. Peripheral structures – Chin, Teeth, Muscles – have a major impact on the appearance of the lips
With increasing age, a combination of bone resorption in the mandible & maxilla, tooth loss and muscle imbalance results in a decreased distance between the tip of the nose and the chin
If a patient has an orthodontic issue, eg overbite or protruding upper teeth- attempts at lip augmentation will increase 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 can be a result of an overactive orbicularis oris muscle (smokers).
Lazer Room Cases
DAO muscle plus lip augmentation Smokers lines treatment plus lip augmentation
Lip Augmentation- Treatment- 3Ps: Pencil (outline), Plump, Project
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.
Plumping is by injection into the cushions of the lips– top and bottom – allowing for normal movement – see function below.
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
- 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);
- When seen in Profile– side view- the top lip should not protrude in front of the bottom lip
- They should be Functional-ie able to pucker (pronounciation, drinking from a straw, and kiss)
- They should Feel smooth, not lumpy
Dermal Fillers for Ear Lobes
Frequent wearing of heavy dangling earrings can stretch earlobes, leading to an unattractive appearance. Dermal fillers can help rebuild the ear’s structure and plump up the lobe area. It only takes a few minutes to restore sagging earlobes with hyaluronic acid fillers such as Juvederm.
However, if the earlobes have been torn or stretched to an extreme degree with ring-like structures in the lobe, surgical reconstruction may be required
Hands are one of the first areas to give away your age; the skin becomes thin and crepy, revealing the underlying blood vessels, plus the effects of sun-damage– brown spots- become noticeable in the 50s- and pre-cancerous lesions such as actinic keratoses- in the 60s and 70s. (See section on Brown spots for treatments – IPL, laser, cryotherapy and topical agents)
Collagen – stimulating fillers such as Radiesse will help thicken the dermis and disguise the prominent vessels; see illustration below of Lazer Room case
Lazer Room Hand Rejuvenation Before/After with Radiesse (results may vary)
Sculptra * Individual Results May Vary
What is Sculptra?
Sculptra is made from Poly-L-Lactic acid, a compound commonly used in surgical sutures for its collagen-stimulating properties. It is mostly used for pronounced facial volume loss due to subcutaneous and deep facial compartment fat loss. This can occur in association with rapid weight loss, as well with aging. It was the first filler to be approved by the FDA and Health Canada for severe localised loss of fat tissue related to HIV
Areas which can be treated include the cheeks, nasolabial folds, jawline, chin, marionette lines and temples.
One of the interesting side benefits of this product is its phenomenal ability to rejuvenate the skin, rendering it baby-soft, smooth and glowing, due to its powerfully stimulating effect on collagen production.
How Does It Differ from Fillers Such As Juvederm?
Sculptra differs in its onset of action to Juvederm. Immediately following injection, the volume loss is replenished; over the next few weeks, the initial effect diminishes, to be followed by a third phase coinciding with the stimulation of natural collagen in which the volume is gradually regained.
Because of this 3 -stage response, a full Sculptra treatment is usually administered over 2-4 sessions, spread out over a 2-6-month period. The end result will last in excess of 2 years. It is commonly referred to as the Liquid Facelift in France.
Sculptra effects are a result of diffuse dermal thickening; they are subtle and gradual – developing over many months: it is not possible to achieve the same degree of definition, sculpting or shaping with Sculptra that one sees as an immediate effect of hyaluronic acid fillers such as Juvederm
SELPHYL (PRfm Platelet-Rich FiBRIN MATRIX)
forehead lines before and after Selphyl *Individual Results Will Vary
Selphyl takes a leap forward into regenerative medicine by harnessing the power of your own biology (in this case the growth factors attached to your own platelets) to stimulate the growth of new skin cells to fill in small hollows, scars and fine lines of the face, neck and hands. Read more here
Selphyl For Neck Rings * Individual Results May Vary
Unlike conventional dermal fillers, no foreign material is injected into your body. in a simple 4 stage process, a small amount of your own blood is withdrawn, spun in a centrifuge to separate the red and white blood cells from the serum containing your platelets. The serum is then activated to produce Platelet Rich Fibrin Matrix (PRFM), which is then injected back into the areas requiring correction. Typically, fine lines, atrophic acne scars, horizontal neck rings, backs of the hands, or creases on the chest wall, and as an adjunct in full-face resurfacing. Some clinicians are using it for hair thinning, in conjunction with low-level diode lasers, but multiple sessions are required.
Over the next 6-12 weeks, your body will do the rest regarding tissue repair and cellular growth. Collagen production will proceed to fill in the hollows and lines naturally. The advantages of this process are virtually no chance of allergic reaction; gradually emerging natural results; and – because it is your own tissue vs. a foreign substance which could be broken down by enzymes in the body- long lasting effects!!
The advantages of this process are:
- Virtually no chance of allergic reaction
- Gradually emerging natural results
- Because it is your own tissue vs. a foreign substance which could be broken down by enzymes in the body you will have a long- lasting result.
Selphyl adapts the natural process of wound healing for cosmetic indications
Q. What Happens When We Cut Ourselves?
A. A gap is created in our skin, we bleed, the blood clots, and over a period of weeks, the body creates new cells to fill in the gap and knit the edges of the wound together.
Q. Why Do We Stop Bleeding?
A. The platelets in our blood clump together, producing fibrin, which, together with the platelets, forms the clot, or plug to stop the bleeding.
This Platelet-Rich Fibrin Matrix (aka the “clot”) forms the scaffold over which new cells (eg. fibroblasts, epidermal cells and vascular cells) grow, eventually filling in the gap and remodelling the skin to heal the wound.
Q. What Triggers This New Cellular Growth?
A. At least 7 major growth factors attached to platelets have been identified to be responsible for tissue repair.
Platelet Rich Fibrin Matrix (PRFM) has been successfully used in other clinical applications such as:
- Oral-Maxillofacial Surgery (e.g. implant surgery)
- Sports Medicine (eg. tendon repair)
- Wound Care
Frequently Asked Questions
Are There Any Contraindications to PRFM (Selphyl)?
PRFM injections are contraindicated to the following
- In areas of a localized infection.
- In persons subject to hypertrophic scarring (keloids).
- In persons with auto-immune disease.
- If anaemia is present.
- In persons with intrinsic disorders of platelets or clotting function (eg. Factor V Leiden).
- In persons taking medications that may affect platelet function (eg. ASA, Anti-Inflammatory Medication, Plavix, Warfarin etc).
- In pregnant or breast-feeding women.
Q. What Kind of Cosmetic Results Can I Expect from Selphyl Treatments?
A. Results are subtle, and evolve slowly; several treatments may be required to achieve the desired clinical effect, and it is not indicated for volume loss or facial sculpting; rather it is an alternative to low-viscosity hyaluronic acid fillers eg Volite, Restylane fine lines, for fine lines of the face & neck, small atropic scars and an adjunct to boost the effect of microneedling or resurfacing lasers.
Q. Is There Risk of Fibrotic Tissue Forming In The Skin After Injection?
A. Currently, there are no reports regarding hardening/lumps or bumps. A slow release of growth factors occurs over time, which would disfavour the formation of a fibrous mass; The PRFM itself has a gelatinous structure, which will be resorbed over time, as the new epithelial cells grow.
Q. What Is The Vampire Facelift?
A. The Vampire Facelift was a term coined by the American media to describe a technique used by some plastic surgeons to mix the patient’s platelets or mesenchymal stem cells with fat cells extracted from their body during liposuction and re-inject it in the midface to create a lift , much as we now use volumizing fillers such as Radiesse or Voluma.