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General Principles
Facial aging progresses as the result of both intrinsic and extrinsic contributing
factors. Over time, loss of subcutaneous fat, gravitational changes due to loss
of elasticity, and remodeling of bony and cartilaginous structures lead to visible
signs of aging. All portions of the face do not age simultaneously. With age,
repetitive muscle activity leads to fine lines that eventually become
hyperdynamic wrinkles, which may deepen and ultimately remain apparent
even when the muscles are at rest. Photodamage and smoking both accelerate
these changes, with photoaging being the single most important contributor to
the appearance of aging skin, including its texture and pigmentation.
Ana¬tomic challenges must be considered in a comprehensive strategy for
perioral rejuvenation, and aging affects the lower face at all levels from the
bone to the epi¬dermis. Due to the numerous factors contributing to the visible
signs of aging, facial rejuvenation is likely to be best served by a multipronged
approach that include; movement control, recontouring, and volume
restoration. In order to prescribe an appropriate treatment plan, it is essential
to have a thorough understanding of both perioral anatomy and perceived signs
of aging.
A key anatomic feature of the upper lips is the Cupid’s bow complex, formed by
two high points of the vermillion joined by a V-shaped depression centrally. The
upper lip usually has 75% to 80% of the lower lip volume with raised philtral
ridges. Ideally, in the youthful face, the upper lip projects minimally more
anteriorly than the lower lip. The lower lip shows fullness in the central portion.
The white roll refers to the raised line of skin that separates the cutaneous and
red lip; it is prominent in youth. Aesthetically, 2 to 3 mm of the upper incisors
may show in repose, but the full length of the incisors should show while
smiling. Sensory innervation of the upper lip comes from the superior labial
and superior alveolar nerves, which are divisions of the infraorbital branches of
the maxillary (V2) nerve. The mandibular (V3) divisions of the trigeminal nerve
give rise to the inferior alveolar nerve, of which the mental nerve is the branch
supplying the lower lip and chin. Blood supply is derived from the inferior and
superior labial branches of the facial artery. The angular artery (off of the distal
facial artery) extends along the pyriform aperture and gives off branches. An
understanding of the perioral region’s structural anatomy allows the surgeon to
choose the most appropriate and long-lasting treatment, whether that is
surgery, soft tissue fillers, fat grafting, skin resurfacing, or some combination of
these techniques.
Perioral Imperfections
A careful examination of the perioral region may disclose one or several flaws.
The area should be examined thoroughly to catalog these deformities first,
although the majority of lip atrophy occurs with aging, hypoplastic lips can also
be present in young patients. For these patients, the goal is to augment or
increase volume. Second, patients could present with a descended stomion or
elongated upper lip. Assessment of facial proportions is critical to identifying
this imperfection. Third, it is important to make note of prominent radial
wrinkling of both lips, which can be particularly noticeable on the upper lip. The
physician should differentiate between dynamic lines (which appear only or
mostly on animation) and static lines (which are present constantly). Fourth,
patients may have a “downturned” or sad appearance to the creases and folds
in the oral commissure area. Fifth, the depth of the nasolabial crease is
important, and any asymmetry should be noted.
With the patient smiling, the amount of maxillary incisor show should also be
checked. Again, an optimal amount of incisor show is 2 to 3 mm. Less tooth
show is suboptimal, and more than 3 mm can be displeasing. The amount of
tooth show changes with age, and an inadequate tooth show should be
corrected to rejuvenate the face. Patients with excessive incisor show can be
referred to as having a “gummy smile.” These patients expose a broad strip of
maxillary gingiva above the teeth when smiling. This exposure could be due to
excess maxillary length or may be the result of a short or hypoplastic upper lip.
Correction of this exposure involves lip augmentation, maxillary intrusion
osteotomy, or lip lengthening with or without augmentation, depending on the
dysmorphology. Another cause of a gummy smile is hyperfunction of the lip
elevators, which can be surgically corrected through lip elongation with or
without rhinoplasty to correct the anterior nasal spine and depressor septi nasi
muscles. In addition, delayed passive eruption is a developmental problem of
the teeth, which can result in an excess amount of gum covering the dental
crown. This is particularly evident in dynamic motion. Gingivectomy and
vestibuloplasty can correct this, and these are usually performed by a cosmetic
dentist or oral maxillofacial surgeon.
2. Dilated Nostrils
Dilated nostrils, not aesthetically pleasing, are caused by the contraction of the
dilator naris muscle, the alar part of the nasalis muscle, in certain situations of
anger or emotional upset, with increase in breathing efforts during mild
exercise (to reduce resistance to flow of air) and also as a habit. Onabotulinum
has rare indications: anatomical abnormalities related not to aging but to the
hyperactivity of the dilator muscle or specific pinched nostrils cases secondary
to surgical rhinoplasty. Treatment is geared to the nostril dilator muscles and
leads to relax nostrils for 3-4 months and keep the cartilage graft in a good
position in the nostril.
4. Mouth Frown
It is important to remember that the effect of BTX-A on one muscle often has
an effect—positive or negative—on another. A good example of this is the
‘‘mouth frown,’’ the permanent downward angulation of the lateral corners of
the mouth, which is caused by the action of the DAO and the upward motion of
the mentalis. We have found that attempts to weaken the DAO or mentalis
alone, while appropriate in some individuals, is ineffective or associated with
unacceptable side effects in others. We currently inject both muscles at the
same time—3U of BTX-A into each DAO and into each side of the mentalis, to a
total of 12U in a female patient—which produces a subtle, synergistic effect.
However, this technique should only be used in patients who have experienced
the effects of BTX-A injections elsewhere, and who are aware of the aim of
treatment and its possible outcomes.
The modiolus is the insertion site of six perioral muscles interweaving their
fibers at the angle of the mouth: The zygomaticus major originates from the
lateral aspect of the malar bone, and with the levator, and oris acts to dilate
the mouth and elevate the labial commissures bilaterally to smile and
unilaterally to sneer. The levator labii superioris and zygomaticus minor insert
onto the skin at the melolabial fold and in the orbicularis oris muscle fibers of
the upper lip and together they help dilate the mouth, retract and Evert the
upper lip, and deepen the nasolabial sulcus. The risorius dilates the mouth and
widens the rima oris. The depressor anguli oris dilates the mouth and
depresses the labial commissures bilaterally to frown. The buccinators muscle,
a deep lateral muscle, pulls back the angle of the mouth and flattens the cheek,
holding it to the teeth during chewing. The depressor labii inferioris originates
from the platysma and inserts onto the skin of the lower lip. This muscle is
partially responsible for dilating the mouth and depressing and everting the
lips.
Treatment of lips and perioral area is indicated to prevent lip aging damages
and dynamic lip rhytides. Vertical aging lip rhytides or smokers’ lines, amenable
to treatment with onabotulinum, are one of the most common areas for which
patients request treatment. A hyperactive orbicularis oris muscle is partly
responsible, but other muscles play a role. This procedure is rarely carried out
in isolation but in association with other treatment modalities. Key patient
management considerations are, when the upper part of the orbicularis oris
muscle is treated, it is advised to also treat its lower part to balance the
proprioception of decreased muscular contraction strength, including during
reflex contractions. One must be cautious of not altering muscle function.
Patient selection is critical: abstain from treating singers, musicians and,
generally speaking, all patients who make intense use of their perioral muscles.
Caution must be exercised in case of tall superior lips.
The aim of treatment of the upper and lower lip is a reduction of these
unsightly wrinkles. Carefully measuring the sites to balance on either side of
the columella or the lateral nasal ala. Appropriate patients must be chosen
carefully, as those who play wind instruments or professional singers/speakers
are not ideal candidates. It is essential that BTX-A injections should achieve the
desired cosmetic result with the minimum dose without any functional
discomfort. BoNT A Injections points should be done at the vermillion border,
parallel to the lips and at least 1.5 cm away from the mouth corners. The total
dose should be distributed in four to six points, being four at the upper lip and
two at the lower lip. Low doses and superficial injections are preferred to avoid
functional impairment of the lips. The patient is asked to pucker, and the areas
of muscle contraction adjacent to the lines are marked. The recommended
concentration is 1.0 to 2.5 U/0.1 mL, and volumes of 0.025mL or less are
injected per site. The injection is made either intramuscularly or
subcutaneously, just above the muscle. Small doses (1–2U per lip quadrant)
are usually sufficient to weaken the orbicularis oris without causing a paresis
that could interfere with elocution and suction, especially when used in
combination with a soft-tissue augmenting agent.
6. Facial Asymmetry
Correcting facial asymmetry may appear an almost miraculous application of
onabotulinum, particularly for patients who cannot undergo (or do not desire)
major surgical procedures Asymmetries may be caused by bone elements or
soft tissue, or originate from neurological or muscular causes. The two latter
categories can be classified into hyperfunctional (e.g. hemifacial spasm) or
hypofunctional (e.g. facial palsy). BTX can be used for the correction of
asymmetries of neurological or muscular origin. In hemifacial spasm, repeated
clonic and tonic facial movements draw the facial midline over toward the
hyperfunctional side. Botulinum toxin relaxation of the hyperfunctional
zygomaticus, risorius, and masseter allows the face to be centered at rest.
Hypofunctional asymmetry, such as after a unilateral seventh nerve paresis
(Bell’s palsy), can be alleviated by botulinum toxin treatment of muscles on the
normofunctional side. For zygomaticus muscle BoNT A is injected at the
intersection of the line passing through the external canthus and the modiolus
and of the horizontal line passing through the columella nasi. 1=2U/side
subcutaneous injection (depth of 2–3 mm) at a 30_ angle upwards and
outwards alongside the muscle axis. Injections of only 1 to 2U of botulinum
toxin in the zygomaticus, risorius, and orbicularis and 5 to 10U in the masseter
are sometimes required. Likewise, some patients have congenital or acquired
weakness of the DAO, resulting in the inability to depress the corner of one side
of the mouth; chemodenervation of the partner muscle restores functional and
aesthetic balance. Some patients have asymmetric jaw movement. We have
found that an intraoral injection of 10 to 15U of botulinum toxin into the
internal pterygoid on the hyperfunctional side can relax the jaw and relieve
discomfort during masticating and elocution. For physicians not thoroughly
comfortable with facial surface anatomy, we recommend injection through an
EMG system. Treatment should be implemented carefully, with low doses, and
stepwise.
7. Asymmetric Smile
Injections of BoNTA are a simple, noninvasive, and safe way to correct
asymmetric smile. Asymmetric smile can be the result of hyperkinesis of the
depressor labii inferioris m. or a segmental weakness of the levator labii
superiors m. The number of points and total doses are defined individually
according to the muscle involved. Results become evident in less than 5 days,
and the effects last from 4 to 5 months after the first treatment. In subsequent
treatments, it is recommended to reduce the doses, and the results last usually
longer.
a) Vertical Bands
Injections should be placed into the deep dermis and not subcutaneously as the
risk of hitting deep venous perforations or other cervical muscles increases as
injections are situated in more profound planes. Usual number of injection
points is 2–12 bands and 10–30 units for total starting dose.
Surgeons have better appreciated the need for volume restoration of the lower
face and perioral area as part of an overall rejuvenation strategy. With years of
clinical experience in face and neck aesthetic treatment, the widespread use of
onabotulinum and soft-tissue fillers has brought a better understanding of the
components of lower face aging and of the muscular balance, and has
profoundly affected its clinical management. There are several categories, of
patients that require volume restoration to correct their defects. The primary
patient who ages by a diffuse loss of facial fat without any apparent residual
skin is an ideal candidate. These people look like someone let the air out of the
tire and the skin hangs only because of a relative excess.
a) Fat Extraction
First the donor site is injected with tumescent anesthesia, making the process
of fat extraction painless. Then a small incision is made, and fat is withdrawn
using a micro-cannula (instrument used in liposuction procedure). Unlike
liposuction, fat is not withdrawn with an aspirator machine, but rather with a
syringe under significantly lower pressure. The syringe method of harvesting fat
appears to be the most gentle method for removing suitable fat for reinjection.
After adequate anaesthesia of the donor site, the cannula (attached to the
syringe) is inserted into the fat. The plunger of the syringe is pulled to create
negative pressure within the fat. The cannula is then moved in a back and forth
motion several times in the same area. This maneuver is repeated in a radial
fashion until the entire donor site is lipo-sculptured, or sufficient fat is obtained.
b) Fat Injection
Before fat can be re-injected, it must be processed in order to get viable fat
cells. Fat is centrifuged (rapidly spins liquid down), separating pure fat tissue.
Blood, lidocaine or other material is completely removed; avoiding exposure of
delicate fatty tissue to chemicals or mechanical damage is essential. Fat is then
injected with a small syringe after the area is anesthetized or numbed with
Emla cream, with or without local infiltration of lidocaine. Use of blunt cannulas
throughout the infiltration procedure can minimize hematoma formation and
thereby aid fat-cell viability. In addition, blunt infiltration cannulas limit the
potential for nerve damage, as tissue planes are followed more naturally and
less traumatically disturbed. Besides direct injection of the three proposed entry
sites with local anesthesia, almost all of the anesthetic should be delivered with
the same blunt infiltration cannula used for fat infiltration to minimize
hematoma and swelling prior to starting injection of the fat. The three ports of
entry. Each of these ports of entry is made with a stab incision using a standard
18-gauge needle through which the blunt cannula can be inserted for both
anesthetic delivery and fat infiltration. Placing only tiny parcels of fat – either
3–5 passes per tenth of a cubic centimeter (in unforgiving areas) or a full tenth
of a cubic centimeter per pass (in more forgiving areas). It is injected in a
manner described as “weaving” or “layering” in small amounts in order to
achieve desired cosmetic effect, especially when treating large areas. Prof
Moawad believes fat should be injected into tiny pearls or strands of fat in
targeted depths of the skin or muscle. These tiny pearls have a sufficient blood
supply, permitting the transferred fat cells to survive in their new recipient site.
It is important for the surgeon to visualize the depth of infiltration basically into
the following three zones: Deep (immediately supraperiosteal), Intermediate
(in the musculo-fascial layer) and . Superficial (in the subcutaneous plane) For
the supraperiosteal plane, the nondominant hand can be used to provide tactile
feedback during infiltration and to guide supraperiosteal placement. In addition,
the dominant hand can feel that the cannula tip is gently neighboring the bony
surface. For the intermediate and superficial planes, the cannula passage is less
precise and the surgeon must simply visualize that the cannula is passing
through the central thickness of the soft tissue or more superficially.
b) Buccal Recess
The buccal recess can be quite hollow with aging and can be even more
exacerbated by augmenting the cheek above. The buccal hollow can
accommodate a generous amount of fat on the order of 5–8 cc without
difficulty. Placement of fat is into the intermediate and superficial tissue
planes. If the entry site is too proximal to the buccal region, the more distally
as an alternative or together in a cross-hatching fashion in the buccal area, the
fibrous network makes fat transplantation difficult. Therefore, care must be
taken to thread 3 to 5 mL of fat in small aliquots, cross-hatching, fanning, and
paying particular attention to blend fat past the medial aspect of the parotid
fusion line to prevent an apparent tissue “bunching” when the patient smiles
and prevent the patient from looking too full and cherubic in the central cheek.
Autologous fat grafts to the lips can have excellent results but are limited by
more variability in their persistence and prolonged edema and ecchymosis (2-
3 weaks)when compared with their use in other recipient sites. However, we
have found improvements in postoperative edema resulting from the use of a
smaller, 20-gauge side-port injection cannula (Storz). A minimum of two fat
transfer sessions are planned for each patient and spaced approximately 3–6
months apart. Patients are informed that between 15 and 50% of the fat on the
average will survive with each treatment; necessitating a series of treatments
to achieve the desired results. However, occasionally the “take” is surprisingly
good, and for that reason, the patient is often encouraged to augment the lips
if they are also doing other areas of the face so that they may share the
recovery time. Typically, the lower lip tends to maintain its volume to a greater
degree than the upper lip. A combination of fat transplantation and mucosal
advancement (FATMA) have been used to correct inversion and both augment
the lips as well as control the shape and these have had more permanent
results than those of fat transplantation alone.
Fat is also injected into the marionette depressions below the corners of the
lips. It is important to inject very small quantities of fat, 0.25–0.5 mL at a time,
in multiple areas. However, the increased morbidity and variable persistence of
fat grafts in the lips, Prof Moawad relied heavily on hyaluronic acid as an
alternative in this region. The ease of infiltration, shorter recovery, and an
excellent safety profile are the main advantages of the hyaluronic acid fillers.
Unfortunately, their longevity is limited to 4 to 5 months.
e) Prejowl Sulcus and Jawline
The prejowl sulcus is an important area to augment to achieve a more youthful
facial contour but also to enhance a face-lift result by straightening the jawline
further with fat enhancement. Fat should be infiltrated into all three tissue
planes described previously with a generous tenth of a cubic centimeter per
pass without difficulty. We generally start with 3 cc. It is important to
conceptualize the prejowl sulcus three-dimensionally with fat placed along the
anterior border of the mandible, the inferior border of the mandible, and the
transition between these two borders. Doing so will provide a more even and
complete fill of the prejowl depression. Additional fat can be feathered into the
mental sulcus and anterior chin as aesthetically mandated.
II. Fat Graft and Platelet Rich Plasma (PRP) or Stem Cell Fat Transfer
In our experience, one of the most important influences of grafting adult
lipocytes plus stimulation of the very rich mesenchymal stem cells found within
adipose tissues is the addition of platelet-derived factors added to the
harvested graft materials prior to graft placement. The PRP is added to the
autologous graft materials in an approximate ratio of 10% in small volume
cases and 0.5–1% of the total graft prepared for large volume
transplantation. PRP enhances the survival and quality of fat grafts. Although
several mechanisms may be responsible for this result, the most important
mediator of the survival of fat grafts is induction of angiogenesis. PRP contains
mitogenic and chemotactic growth factors important in angiogenesis, including
VEGF and EGF. These factors promoted angiogenesis during the growth of the
fat. A second potential mechanism by which PRP enhances fat graft survival is
greater proliferation of adipose stromal cells (ASCs) or stimulation of ASCs to
differentiate into adipocytes. PRP treatment increases graft weight and volume
and improves graft quality in small and large volume applications.
V. Nanofat Grafting
A special multiperforated harvesting cannula of 2 mm with 1-mm side holes is
used to harvest microfat globules that was mechanically emulsified after
rinsing. Emulsification of the fat was achieved by shifting the fat between two
10-cc syringes connected to each other by a female-to-female Luer-Lok
connector. After 30 passes, the fat changed into an emulsion. At the end of the
fragmentation process, the fat became liquid and took on a whitish appearance.
After this emulsification process, the fatty liquid was again filtered over the
sterile nylon cloth and the effluent was collected in a sterile recipient ,which is
called nanofat graft. A yield of 1 ml of nanofat per 10 ml of lipoaspirate can be
expected. Because of the reduced number of viable adipocytes in the emulsified
fat, the filling capacity of nanofat is obviously very limited. Injection with sharp
needles ranged from 22 gauge (subdermal) up to 27 gauge (intradermal)
is used to treating superficial wrinkles in the perioral area or more to improve
the quality of the skin. Injection was performed until a yellowish discoloration
of the skin showed up. The mechanism for this regenerative effect on damaged
skin remains unknown. However, the presence of a large number of good
quality mesenchymal stem cells, may improves elasticity is presumably a
consequence of increased collagen and elastin synthesis and remodeling.
In fact, it may be questioned whether a nanofat transfer actually is a “fat
grafting” procedure, as adipocytes did not survive the emulsification process.
The major effect of nanofat injection is probably a stem cell activity. Likewise,
nanofat injection might rather be considered as an in vivo tissue-engineering
process. It might be logical to discard the dead adipocyte fraction from the
nanofat and to inject the purified stromal vascular fraction only. However,
isolating the stromal vascular fraction out of the nanofat before injection in
routine clinical cases would be time consuming, complicated, and expensive.
Besides, it requires specific laboratory equipment and experience. Moreover, it
is known that apoptotic cells release cytokines and attract macrophages that
induce growth factors and play an important role in regeneration of the
damaged tissue. Thus, co-injection of fragmented adipocytes might have a
stimulating effect on stem cell differentiation and tissue regeneration.
GENERAL Consideration
Despite the success of facial fat grafting in many areas of the face, plastic
surgeons must be familiar with the use of alternative fillers. Increasingly,
dermal fillers are being used in lieu of structural fat grafts to add volume to the
aging face. Recently, numerous injectable fillers have been marketed as
alternatives to facial fat grafting, with various claims of clinical
efficacy. Although there are many soft tissue fillers by trade name, they can
generally be categorized into temporary fillers (collagen, hyaluronic acid and
calcium hydroxylapatite) and permanent fillers (polymethylmethacrylate,
silicone and hydrophilic polyalkylimide. The substance used is largely dependent
on the practitioner’s comfort, location, and patient’s desired outcome. In the
perioral region, these fillers are quite useful for replacing volume loss, which is
otherwise quite difficult to address. Deep nasolabial folds, labiomental folds,
thinning lips, and fine perioral rhytids can all be addressed by various fillers.
Unfortunately, many practitioners are using fillers not only to address facial
volume loss but also to compensate for gravitational and skin elasticity
changes. The “over-injection” of fillers can yield disappointing and unnatural
results.
The hydrophilic nature of HA allows it to maintain its shape using the body’s
own moisture. One gram of HA can bind up to 6 L of water. As a component of
the extracellular matrix, intrinsic HA functions include space filling, lubrication,
shock absorption, and protein exclusion. Over time, the injected hyaluronic gel
is slowly absorbed by the surrounding tissues and disappears by a process
called isovolumetric degradation. As the HA gradually degrades, each molecule
binds more water and, eventually, the same volume can be maintained with
less HA. This provides a natural appearing volume correction and cosmetic
persistence until the product is almost completely degraded
Calcium Hydroxylapatite
Radiesse (Bioform Medical, San Mateo, CA) was approved by the FDA in
December 2006 for the correction of facial wrinkles and folds, such as
nasolabial folds, and for the correction of facial lipoatrophy associated with HIV.
Radiesse is composed of calcium hydroxylapatite (CaHA) microspheres (25–45
_m) surrounded by a 70% methylcellulose carrier that dissipates quickly in
vivo, leaving the CaHA microsphere as a scaffolding to promote collagen in-
growth. Radiesse has a good safety record and stimulates only minimal foreign
body reaction secondary to the spherical shape of the product, which incites
less inflammation then an irregularly shaped product. Granulomatous reactions
and migration of the product are unlikely. The calcium and phosphate minerals
comprising Radiesse microspheres are the same as found in bone. The product
is faintly visible on radiographs but has not been reported to obscure
radiographic interpretation. After implantation, this product is slightly more
malleable than HA. Additionally, the same volume goes further, because a
lower volume of CaHA is needed to fill the same defect as compared with HA.
Importantly, CaHA is not recommended for lip augmentation, because an
unacceptable number of labial nodules have been reported from the product
clumping together.
properties, the extrusion force required, the structure and stiffness of the
finished product; and the degree of gel swelling, or ability to resist dilution,
which also influences longevity. For example, hyaluronic acid fillers of lower
viscosity are recommended, particularly for initial treatment. Further fluidity
can be increased by dilution (3:1) with lidocaine 1% or saline.
Despite the temporary nature of HA based dermal fillers and the requirement of
repeated treatments, it is a treatment that appeals to patients due to its ease
of application, efficacy, minimal downtime, and noninvasive nature. In regions
of good skeletal support and relatively thick overlying skin, such as the
nasolabial fold and the glabellar crease, Prof Moawad favor the use of Radiesse
and large-particle hyaluronic acid (Perlane and Juve´derm) because of their
longevity. As larger particle size suspensions, Perlane and Juvederm Ultra Plus
have less total surface area subject to attack by the body, and are theoretically
more resistant to degradation. Because these products are thicker, Juvederm
Ultra Plus and Perlane are designed to be injected deeper into the dermis or
subdermis for volume correction and contouring capabilities
Problems with reversible fillers such as Hyaluronic acid can be easily treated
with Hyaluronidase to dissolve or remove undesired or insufficient volume may
be addressed by adding more product, but irreversible fillers cannot easily be
removed. On the other hand, problems with irreversible fillers are much more
difficult to manage, especially if vital structures have been treated. Therefore,
Prof. Moawad strongly recommends that they not be considered as a first-line
choice and should be used only by clinicians with substantial training and
experience with these filler agents. Even in the best hands, complications may
occur, and this calls for extreme caution, especially when injecting the product
around vital facial structures
1. What has or has not Made the Patient Happy in the Past?
If a patient has been pleased with their current filler regimen, there is no
reason to change the filler unless there is significant cosmetic or safety
advantage to using a different product. It is not recommended to re-administer
a product with which the patient has been previously dissatisfied. In this
situation, it is best to attempt an alternate treatment or product or simply not
to retreat at all. Realistic patient expectations are paramount to all successful
injection procedures.
In general, when performing a consult for fillers, the doctor should determine
what exactly the patient wants and select the appropriate filler. The patient
should be instructed about the positive and negative effects of the filler, and
the recovery and longevity should also be discussed. Overselling a result or
longevity can cause problems, so it is always preferable to be realistic. When
addressing nasolabial folds, I explain that fillers will not eliminate the folds, but
rather will blunt them. I further explain that adults would look unnatural if they
had no nasolabial folds. One problem that exists with lips, folds, and wrinkles is
when the patient will not purchase the adequate amount of filler to do the job.
Fillers are obviously expensive, but underfilling an area will usually disappoint a
patient. In my experience, a single syringe may suffice to augment an upper lip
and possibly a portion of the lower lip. If both lips need attention, then tow
syringes are probably necessary. Similarly, it is a rare situation where a single
syringe of filler will augment two nasolabial folds. This must be explained to
patients or they may be unhappy or feel that the treatment did not work.
The application of ice is the easiest and most common topical method of
providing a temporary, localized anesthetic effect. However, the effect is short-
lived and may need. Facial cooling systems provide a longer-lasting
effect. Placing an ice cube or two in a clean surgical glove and then allowing
the patient to hold it over the planned area of injection for 1 to 2 minutes is
usually adequate. The same ice can be used immediately post-treatment to
help reduce bruising and edema. Caution is advised to not overexpose the skin
to the cold, because a burn might result.
Almost everyone uses topical anesthesia, but the use of local anesthesia is
variable. Commercial topical agents formulated with lidocaine, tetracaine,
and/or betacaine are effective pain management tools. These agents achieve
their anesthetic effect through the reversible blocking of nerve conduction at
the application site. They are applied to the skin for 15–60 min prior to the
procedure and can significantly moderate the pain experienced.
A Septocaine ampule is placed into a stainless steel dental injector syringe with
a 27-gauge, 1.25-in needle (Kendall Tyco Healthcare Group LP, Mansfield, MA).
A cotton-tipped applicator with topical local anesthesia is placed on the buccal
or gingival labial sulcus for 3 to 5 minutes (Denti-Care topical anesthetic gel).
The needle is placed just above the canine at a 30° angle up to the canine
fossa, with the bone of the anterior maxillary wall just lateral to the nasal–alar
insertion. The needle is directed down to the bone and approximately 0.3 mL of
anesthesia is injected. Distraction devices, such as a vibrating massager placed
on the maxillary eminence, can significantly minimize injection discomfort.
Injections are made bilaterally to achieve anesthesia to the entire upper lip
within about 2 minutes. Alternatively, the injections can be accomplished
transcutaneously. This technique is easier and more reliable when first learning
nerve blocks, but it is also associated with a greater discomfort to the patient.
For lower lip anesthesia, following retraction of the lower lip, the second
premolar is located and the needle is inserted into the gingivolabial sulcus,
about 0.5 in beneath and onto the bone of the mandible. Approximately 0.2 mL
of anesthetic is injected bilaterally to anesthetize the entire lower lip and chin
area. Because mandibular injections are slightly more painful then the maxillary
injections, a distraction device placed on the mentum will significantly blunt
pain perception. Some physicians utilize a micro–nerve block technique, in
which small aliquots of anesthetic are injected along the mucosal border of the
lip near the gingival sulcus. Microblocks have the advantage of not producing as
deep a regional anesthetic. However, this technique may take longer to perform
and the potential for incomplete anesthesia is greater
a) Linear Threading
Linear threading is a method of injecting a continual line of filler while keeping
the syringe moving forward or backwards. This is the same mechanism used
when putting a line of toothpaste on a tooth brush. The full length of the needle
is advanced along the wrinkle or fold to create a tunnel for filler placement.
Injection can be anterograde ‘the push-ahead technique’ as the needle is
advanced or retrograde as it is withdrawn. Anterograde delivery may displace
small blood vessels, but retrograde delivery allows more uniform placement,
the preference being largely operator-dependent. Linear threading is best for
the nasolabial folds and vermillion contour.
b) Serial Puncture
Serial puncture is another technique and involves injecting separate beads or
boluses of fillers in a similar means as decorating a cake with medallions from a
frosting injector. Serial puncture techniques are good for filling in gaps or fine-
tuning small areas. When using serial puncture techniques, it is important to
keep the filler beads close together so as not to have a bumpy appearance. The
skin is pulled taught to stabilize the defect and multiple boluses of filler are
delivered along the defect line. The injection sites should be close enough to
form a continuous smooth bead; however, small gaps can be moulded with
massage. It can lead to beading and a dull needle, necessitating multiple
needle replacements. This method is best utilized for treating the glabellar
creases and for placement along the inferior orbital rim in treating periorbital
hollows, acne scarring, shallow forehead rhytids, and philtrum enhancement
and nonsurgical rhinoplasty. This technique is commonly mentioned with
silicone injection.
c) Serial Threading
Serial threading uses elements of both techniques and is useful in wider folds.
In this technique, the needle is inserted to its hub, taking care that the needle
is in the very deepest portion of the dermis or in the subdermal tissues. If the
skin dimples down with downward pressure on the needle, then the needle is in
the dermis. If the needle can be visualized through the skin, then it is too
superficial and will generally not produce an aesthetically pleasing effect. If
there is little resistance to the needle and the product upon injection, then the
needle is in the subcutaneous tissue.
e) Antegrade/Retrograde
It is common to use the anterograde technique along the vermilion border,
where the material will run along the potential tissue space with little or no
additional movement of the needle tip. This can help verify the proper depth of
placement for the needle tip. Other advantages of an anterograde approach is
that it may yield a softer forward movement through tissues, blunting the
impact of the sharp needle tip, pushing vessels out of the way of the advancing
needle, and reducing the probability of bruising. It is also possible to inject a
small amount of hyaluronic acid filler moving forward to blunt the dissection
and to inject additional filler as the needle is withdrawn if a greater volume of
correction is needed. Those who prefer the retrograde injection technique
believe that injecting slowly as the needle is withdrawn helps avoid
intravascular injection of filler. This technique is often chosen for very soft, thin,
or vascular areas, such as below the eyes or the malar region. In these areas, it
is especially important to avoid tissue trauma; with a fine needle, it is thought
that when the material flows as the needle is withdrawn, additional tracks or
dissection planes are not created. This may be preferred when injecting areas
with named vessels. Regardless of the technique used, it is essential to inject
slowly and gently to avoid tissue tears
Each product should be injected deeply under the orbicularis muscle, and both
under or in the malar fat pad and subocularis oculi fat. In treating the nasojugal
groove, I use Juve´derm Ultra or Restylane. Tear troughs’ formed by the naso-
jugal fold can be corrected with filler but achieving good results in this area is
challenging. The area should be anaesthetized with topical cream to avoid
distortion of the soft tissues and ice should be used for vasoconstriction to
reduce ecchymosis. The patient should be seated upright to prevent
gravitational movement of the orbital fat pads and to best delineate the area of
correction. Pre-septal injection of filler by linear threading along the orbital rim
avoids exacerbation of the pseudoherniation of orbital fat that creates the
original deformity. The area should be gently massaged after injection to
ensure even distribution. A good correction can last up to 2 years owing to the
relative immobility of the area can be effective when fat grafting is not an
option
Above the ala-tragus line CaHA should be injected supraperiostally, while below
the ala-tragus line injection should be at least deep dermally to the junction
with the subcutis. In both cases, a 1:1 correction factor should be used, no
overcorrection is needed, with treatment best being administered over two
sessions, depending upon individual patient characteristics and requirements.
The number of total injections can be minimized by threading multiple tracks
through one puncture with fanning dispersal of material in different directions.
By restoring structural support and fullness to the malar and infraorbital region,
CaHA can diminish the shadowing effect associated with aging of this
region. The material should then be massaged or molded to desired effect.
Care should be taken not to inject CaHA into the soft tissue above the orbital
rim as contraction of the orbicularis oculi may cause clumping of particulate
materials. For treating small malar smile lines. I use hyaluronic acid filler, but
not BoNTA alone because of the risk of a stroke-like appearance and/or an
inability to smile. To develop a posterior cheek vector a fixed point starting at
the zygomatic arch and in the direction of the jowls using a retrograde fanning
technique to target this posterior cheek region
Patients with thin lips, regardless of filling technique, are always going to have
somewhat thin lips. It is difficult to change the size of the lip, and lip
augmentation with any material merely enhances the natural lip shape. There is
a definite limit to how much augmentation can be performed in any given lip
before the results look unnatural and distorted. Asymmetries of the lip,
associated with smiling, can be improved upon but not resolved with lip
augmentation. It is important to observe the patient when smiling and in
repose.
Despite the sensitivity of the lips, it is now relatively easy to administer many
injections into this area due to surgeons using tiny 30 and 31 gauge needles, as
well as incorporation of topical or injectable anesthesia into treatment
regimens. Newer volumizing products containing lidocaine reduce the need for
use of conventional anesthetic techniques and so are recommended. Anti-
herpes preventative treatment can be used if required. If treatment is still
painful, a local infraorbital and mental block with 2% lidocaine and 1 : 100 000
epinephrine is advised. In this area, swelling and bruising are more frequent
than elsewhere.
5) Nasolabial Folds
The nasolabial folds represent the second most requested filler treatment. As
the deepening of the nasolabial folds begins by the third decade, it is often the
first sign of aging that a patient sees and wants fixed. As most people age, the
nasolabial folds deepen and are frequently a driving force in a patient’s decision
to have face-lift, laser, or other surgical procedures. Correcting the nasolabial
folds is essential for counteracting cheek ptosis and the incidence of marionette
lines, which both have an impact on jawline profile. One main problem that
must be discussed with potential filler patients for nasolabial fold treatment is
the fact that the folds will not “go away.” Failure to fully explain the anticipated
result will lead to a disappointed patient and doctor. I explain to all patients
that nasolabial folds are a natural part of facial aging, and an adult without any
nasolabial folds would look abnormal, as would an infant with a mustache. I
further explain that our goal in treating nasolabial folds is to blunt them, not
eliminate them. I tell the patient they are a valley and we want to make them
less deep. The goal for the treatment of the nasolabial fold is to diminish the
depth of the crease. The effacement of the nasolabial fold can be performed
with the widest array of fillers because of the thickness of overlying skin and
underlying skeletal support from the maxilla. The key to successful treatment of
the nasolabial fold is to accurately diagnose the cause of the deep fold. Some
portion of the nasolabial fold is attributable to gravitational descent of the
overlying cheek, and another portion is attributable to soft-tissue atrophy. To
determine the amount of fold that is attributable to soft-tissue atrophy versus
gravitational descent, we use a manual displacement test. The cheek is pulled
superolaterally. If gentle manual displacement results in significant effacement
of the nasolabial fold, the use of soft tissue fillers alone will probably not be
effective. However, soft tissue fillers are also quite effective in treating the
nasolabial crease due to soft tissue atrophy. The next most critical factor is
letting the patient know that it will probably take multiple syringes of filler to
make a difference. Fillers are expensive, and many patients only desire a single
syringe to split between both nasolabial folds. For all but the most minor folds,
this is an insufficient amount. In my experience, most patients will require at
least 2 syringes to make a difference and it may take up to 4 syringes for deep
folds.
Although I rarely inject the lips without local anesthesia, I rarely use local
anesthesia for nasolabial folds or other skin injections. I generally apply topical
anesthesia for 10 minutes prior to injection. If this is not sufficient, then
infraorbital blocks or mucosal local anesthetic infiltration is performed
intraorally on the mucosal side of the nasolabial folds. A significant and
common mistake, especially with the novice injector, is to inject in the very
center of the nasolabial fold. Since various tissue planes merge in this area,
injecting filler material in the center of the fold can cause the filler to migrate
laterally. If this happens, one can actually make the nasolabial fold bigger! In
order to control the flow and location of the filler in the nasolabial fold, the filler
should be injected slightly medial to the actual fold. The filler can also be
massaged into the center of the fold. A cannula rather than a needle can be
used for HA filler administration at all stages. Filler is injected using a
retrograde linear threading technique along the line of the fold with a half-fan
at the bottom of the fold because of more volume deficiency in this area. To
flatten the fold, a ladder of radial retrograde linear threading is made
perpendicular to the fold. Good results can be obtained with malar
augmentation, which improves nasolabial folds as well. This is one area where I
commonly use linear threading and then fill in the gaps with serial puncture.
It is important to note that while volume restoration to the midfacial does not
eliminate the need to treat nasolabial folds, it does significantly decrease the
severity stage. It is important that augmentation of the proximal nasolabial
folds with fillers is performed with caution as there is a risk of vascular
compromise of the angular artery. Again, when using hyaluronic acid fillers,
significant swelling usually ensues immediately, so it is important not to
overcorrect the folds as it becomes difficult to tell what is filler and what is
swelling. I have all filler patients return in 2 weeks for follow-up and possibly
touch-up. Taking preinjection digital pictures is also important when injecting
fillers anywhere. Patients forget what they looked like and pictures are
necessary to truly evaluate a result.
7. Chin
Slight recession of the chin can alter the appearance of the entire face.
Injections into the chin to alter its projection may provide dramatic
improvements in an individual’s appearance. Remodeling of the chin,
particularly the lateral regions that become hollow with aging, shows some
benefits by reshaping the oval facial outline or jawline. HA fillers are also useful
for smoothing the appearance of chin implants, particularly in the transition
area between the implant and soft tissue layer. The skin over the chin implant
may dimple, and this can be addressed using approximately botulinum toxin
into the mentalis. Dermal fillers should be injected using a needle or cannula,
although HA fillers with a long duration can be injected using serial puncture or
linear threading techniques.
8. Upper Jawline
The upper zones of the jawline require injection of CaHA at the dermal-
hypodermal junction or deep dermis using a retrograde fanning technique. As
mentioned previously, the choice of injection depth will depend on whether
using a needle or cannula and also on the thickness of the dermis.
Recommended insertion points are at the posterior cheek (“posterior cheek
vector”) and cheekbone.
9. Lower Jawline
The jawline is the defining feature of the lower face, but with age gradually
takes on a more square appearance compared with the oval of youth. For
correction of the oval in the lower jawline, To recontour the jawline, CaHA can
be injected along the periosteum of the inferior mandible. The usual point of
insertion is the inferolateral mandibular border. A retrograde linear threading
technique is used for submandibular and lateral mandibular placement. Radial
fanning injections from the same point of insertion can also be conducted if
required whether using a needle or cannula and also on the thickness of the
dermis. Recommended insertion points are at the mandibular angle and prejowl
sulcus.
Post-procedure Considerations
The typical protocol for postprocedure care involves immediate placement of ice
onto the injected areas to reduce and limit tissue edema and bruising. The
subject should be advised to refrain from massaging or manipulating the
treated areas for at least 24 h as this can disturb the position of the filler.
Exposure to extensive sun or heat should be minimized for approximately 24 h
after treatment or until any initial swelling and redness has resolved. Some
consensus members also advise subjects to remain upright for the remainder of
the day and to sleep with their head elevated to reduce the degree of edema.
Post-treatment photographs may be taken as soon as the injections have been
completed and the washable markings removed. In the consensus members’
respective practices, follow-up visits are typically scheduled 2 to 3 weeks later,
with a further visit at 2–3 months for optional touch-up treatments if required
Adverse Events
The duration and severity of adverse events associated with CaHA are
comparable to those seen with hyaluronic acid fillers and are mainly volume
and technique related rather than associated with the material itself. Some
reactions occur immediately after treatment, whereas some have a delayed
onset. Similar to other dermal fillers, the principal side effects are redness,
swelling, and bruising. A number of steps can be taken to minimize these
adverse effects, including avoiding all blood thinningmedications starting 1
week prior to the procedure, staying out of the sun as long as swelling persists,
avoiding vigorous exercise during the first 24 h to avoid raising blood pressure,
keeping the head elevated throughout the procedure and for 24 h after, and
avoiding massaging the area other than that performed by the clinician
immediately after injection. Bruising can be further limited by a slow injection
technique with small aliquots of product, use of blunt cannulas and limiting the
number of skin punctures during the injection process using the linear
threading or fanning technique. As with any procedure that breaks the surface
of the skin, dermal filler injections are associated with a risk of infection. To
minimize this risk, the injection site must be sterilized with an effective topical
disinfectant, the needle and syringe safely removed from sterilized individual
packaging, gloves worn throughout the procedure, and care taken that the
needle is not contaminated during the procedure. A new syringe must be used
for each subject.
Dermal filler injections can lead to reactivation of herpes virus infections. If the
treatment is targeting the mouth area and the individual has a history of cold
sores, prophylactic treatment with valaciclovir (500 mg BID for 3–5 days) can
be started prior to injection to reduce the likelihood of this occurring. If the
individual has not received prophylactic treatment, but infection is recognized
early, valaciclovir at a dose of 2 g BID for 1 day should be given. Foreign body
granulomas are extremely rare, but can occur with all injectable dermal fillers,
usually after a latent period of several months to years after injection.
Inadvertent injection into a nerve or blood vessel is also a rare complication of
dermal filler procedures. Several papers highlight the treatment steps that
should be taken if these events occur
a) For the Midface, the most apparent effect of aging is the loss of volume.
Thus, hyaluronic acid fillers play a central role, with BoNTA treatment serving
as an important adjunct depending on the specific treatment plan. A key step in
facial rejuvenation of the midface is the restoration of volume in the malar
region. By treating this area with hyaluronic acid fillers, clinicians can provide a
more youthful, rounded area that will affect how other areas of the face, such
as the tear troughs and nasolabial folds, are subsequently treated. Importantly,
optimal results depend on using sufficient volume, and patients may need to be
educated that undertreatment is likely to lead to an unsatisfactory outcome.
b) In the Lower Face, both BoNTA and hyaluronic acid fillers are important
because rejuvenation involves control of muscle movement as well as
restoration of volume. Detailed treatment planning is essential, to avoid
asymmetries and poor outcomes. Knowledge of the musculature and its
complex interactions is crucial. Treating the perioral area is central to the
aesthetic outcome of the lower face, but treatment should be initiated
conservatively, with follow-up visits for additional treatments.
The use of aforementioned lasers for dermal remodeling has been largely
replaced by the longer wavelength infrared lasers, which more effectively target
the mid dermis, resulting in more consistent mild improvement in rhytides. The
prototype of nonablative rejuvenation is the infrared Nd:YAG laser at 1320 nm
(CoolTouch; Mesa, Calif)and, more recently, the diode laser at 1450nm
(Smoothbeam; Wayland, Mass) and the erbium:glass laser at 1540nm. They
are more effectively target the mid dermis, resulting in more consistent mild
improvement in rhytides. Patients should be advised that the results are less
dramatic than those obtained with ablative resur¬facing and multiple
treatments may be required.
Photo facials work best in conjunction with a regular skin care routine. After
each treatment, patients can return to normal activities. The skin will be slightly
pink when you leave, but easily covered with makeup. After the initial series of
treatments, additional Fotofacial sessions are recommended once every 3 to 4
months to maintain results. It can be offered as a stand alone treatment or
mostly as a part of more comprehensive rejuvenating MSI.
a) MONOPOLAR RF
Monopolar systems deliver current using one electrode that contacts the skin
and another that acts as a grounding pad. The electrode contacting the skin
delivers the electric current to the skin. The epidermis is spared by contact
cooling hat the tip of treating head. The FDA initially approved monopolar RF
devices to treat periorbital wrinkles. Since then, they have been used to treat
laxity of the forehead, cheeks, nasolabial folds, marionette lines, jawline, and
neck. The low level multiple passes approach necessitate 4-6 sessions every
one to two weeks. The procedure can be repeated every one year as needed to
maintain the results. Noninvasive skin tightening treatment of the perioral
area is best indicated for patients with mild to moderate dermatochalasis,
reasonably good skin tone, and minimal tissue ptosis. Ideal candidates for this
noninvasive treatment either do not want or do not need skin lifting surgery. In
general, younger patients who do not want or do not need a very marked
change in their perioral appearance, or patients who have previously
undergone skin lifting who are noticing a gradual recurrence of skin laxity are
the best candidates for monopolar radiofrequency (RF) skin tightening.
Contraindications include implantable medical devices such as pacemakers and
defibrillators and active dermatologic conditions such as collagen vascular
disease and autoimmune diseases. Everybody is a good candidate for RF, but it
is of special significance to whom do not like invasive surgical intervention, and
who is still young for surgery.
b) Bipolar RF
The main difference between bipolar and monopolar RF is the configuration.
The bipolar configuration consists of two active electrodes placed a short
distance apart overlying the intended treatment area. The current flows
between the two electrodes. The depth of penetration is approximately half the
distance between the two electrodes. The major limitation of this configuration
is the depth of penetration. The monopolar device achieves high penetration of
the emitted current, which serves as its main advantage and also its major
drawback, which is associated pain. The bipolar configuration is not as
penetrating but provides more-controlled distribution of energy and less pain.
The ELOS system uses the synergistic effects of light and RF-based devices.
The light energy is used to preheat the target tissue through photothermolysis,
which lowers the tissue’s impedance. The lower impedance makes the tissue
more susceptible to the RF component so that it is selectively targeted.
Therefore, lower levels of energy of the light and RF component are needed to
produce the desired effect with fewer side effects. The optical component also
targets fibroblasts, blood vessels, and dyschromias. ™.This combination has
been shown to induce tissue contraction and effects on laxity, rhytides, and
other aspects of photodamage. A major drawback of this therapy, however, is
that it requires numerous treatments at 2- to3-week intervals, which may
ultimately achieve only mild to moderate improvement. RF devices the Polaris™
and ReFirme™ from Syneron™ utilize bipolar RF at the ends of laser systems
(780–910nm diode for the Polaris and 700–2000nm infrared light for the
ReFirme
c) Fractional RF
Fractional RF is a newer nonablative approach. There are two ways to deliver
fractional RF. Whereas some devices (Matrix RF device; Syneron, Medical Ltd)
use electrodes, others use an array of microneedles arranged in pairs between
which bipolar RF energy is delivered (ePrime system; Syneron Medical Ltd).
Another system Miratone FRF system (Primaeva Medical, Inc.,Pleasanton, CA)
using a microneedle electrodearray. The fractionally delivered energy creates
zones of affected skin adjacent to unaffected areas. The treated areas have
resulting thermal damage in the deep dermal collagen, which stimulates would
healing, dermal remodeling and new collagen, elastin, and hyaluronic acid
formation. The unaffected areas located in between affected areas initially
maintain skin integrity but, in the long term, serve as a reservoir of cells that
promote and accelerate wound healing. ractional RF has been demonstrated to
induce improvement in skin texture and reduced wrinkles in both abdominal
and facial skin. Other than pain and tran¬sient erythema, no adverse events
were reported. A new device has been developed that combines fractionated
optical energy with a 915-nm diode combined with a fractionated bipolar RF.
This integrated system targets the epidermis and superficial dermis. By using
the RF component synergistically, less energy is used to heat the collagen in
the deep dermis and stimulate new collagen formation and contraction (Matrix
eLaser; Syneron, Irvine, CA).
IPL devices and combination differ dramatically between systems; however, all
require the application of cold aqueous gel and one to multiple passes in each
treatment session. A series of 5 to 6 or more treatments are typically used. RF
treatment techniques vary depending on the device being used. The patient is
grounded using a grounding pad for monopolar RF; for bipolar RF and the novel
unipolar RF system, this is not necessary. A coupling fluid or aqueous gel is
used with the treatment tips of the devices. Recently, the approach of low
Fluence /multiple passes radiofrequency devices have been optimized to no
anesthesia is needed.
a) Cosmeceuticals
Topical agents can be used in conjunction with other modalities. Although
topical retinoids remain the gold standard for photoaging, many patients are
unable to tol¬erate them around the eye. One such trend is the development of
natu¬ral antioxidants such as niacinamide. Antioxidants are the largest
category of cosmeceutical ingredients incor¬porated into topical treatments and
will likely remain so for the next several years. They can be divided into 3 main
categories: carotenoids, flavonoids, and polyphe¬nols. The carotenoids are
derivatives of vitamin A and thus are components of many cosmeceuticals
because of their similarity to retinoids. The flavonoids are aro-matic compounds
with antioxidant and UV-protection properties. Commonly used flavonoids in
cosmeceu¬ticals include soy, milk thistle extract, and ginkgo. The polyphenols
represent a subset of flavonoids and include common cosmeceutical ingredients
such as green tea, pomegranate, and grape seed extract.
b) Mesolipolysis
The injection of phosphatidylcholine (250 mg/5 ml) into the fat pads is a simple
office procedure popularly used in subcutaneous injections for fat
dissolution. Especially jowls, and submental localized fat deposition. After 5
minutes of applying an ice compress to the infra-orbital skin, 0.5-inch, 30-
gauge needle was used to inject 0.4 mL of phosphatidylcholine approximately
0.5 cm deep into the un-anesthetized area. An ice compress was then
reapplied immediately after the procedure for 10 minutes. Patients were
instructed to remain upright for at least 4 hours after the procedure, not to
engage in any vigorous physical activity for the rest of the day, and to sleep
with their heads elevated to the height of at least two pillows the night of the
treatment. Patients were evaluated every two weeks with maximum 5 sessions.
Pain, erythema and swelling were observed to temporary and mild.
c) Chemical Peels
For patients with minimal laxity or those unwilling to accept the risks of
surgery, other strategies such as chemical peeling have been employed.
Chemical peeling is often used to treat fine lines , mild superficial scarring, sun
spots, age spots , freckles, melsasma , and dull texture. Generally, fair-skinned
and light-haired patients are ideal candidates for chemical peels. Darker skin
types may also experience good results depending upon the type of skin
problem encountered. Before the peel, Prof. Moawad might prescribe bleaching
agents, tretinoin, sun-blocks and moisturizer at least 4-6 weeks before
chemical peel for those patients with pigmentation or dark skin.
At the time of treatment, the skin is thoroughly cleansed with an agent that
removes excess oils, and the eyes and hair are protected. A chemical solution is
applied to the skin that causes it to “blister” and eventually peel off. Prof.
Moawad may recommend a superficial or, medium chemical peel. He favor the
medium-depth peel, the combination peel, and repeated lighter peeling
regimens. He will select the proper mix of chemicals such glycolic acid, salicylic
acid, lactic acid, TCA, PCA, Phytic acid, or Jessner solution. Prof Moawad will
individualize the strength of these chemical agents to match your skin type and
degree of sun damage offering his patients more than 10 programs. Most
patients experience a warm to somewhat hot sensation that lasts about five to
10 minutes, followed by a stinging sensation. A deeper peel may require pain
medication during or after the procedure. Depending upon the type of peel, a
reaction similar to a sunburn occurs following a chemical peel. Superficial
peeling usually involves redness, followed by scaling that ends within three to
seven days. Medium-depth and deep peeling may result in swelling and the
presence of water blisters that may break, crust, turn brown and peel off over a
period of seven to 14 days. Following any skin peel, it is important that you
avoid any exposure to the sun. Your new skin is very sensitive and susceptible
to injury. Prof. Moawad will prescribe a proper home skin care treatment
program that included cleansers, moisturizers, and sunscreens with or without
anti-aging or bleaching agents to ensure proper healing and maintain the result
of your peel. Following a chemical peel, your new skin will be tighter, smoother
and may be slightly lighter than it was before surgery. Results of chemical peels
may also be enhanced our by new laser/light-based rejuvenation techniques.
Emerging Trends
The shift from a two-dimensional focus to a three-dimensional approach to
minimally invasive facial rejuvenation has reinforced the idea of creating overall
facial harmony and balance, within the confines of cultural, ethnic, and gender-
related goals and ideals. With this approach comes an appreciation of the need
for substantial volumes of hyaluronic acid filler to achieve optimal outcomes.
This often entails substantial patient education, to ensure realistic expectations
and to foster a commitment to longer-term maintenance with sufficient product
to provide a high degree of satisfaction. In tandem, it is now recognized that
relaxing the muscles of the lower face can play an important role in
combination with fillers. In addition, BoNTA treatments, begun at earlier ages,
can aid in line prevention. Resurfacing with light/laser treatments or chemical
peels, along with line management, volumizing, and recontouring, has proven
to be both safe and effective. Not to be neglected are topical treatments, such
as cosmeceuticals, to protect against photodamage, aid in retexturing of the
skin, and serve as an important adjunct to other aesthetic products and
procedures. A variety of products are available, and many patients can benefit
from their clinician’s advice on these products to minimize the risk of
hypersensitivity reactions while maximizing benefit. An effective sunblock is
considered one of the most important topical agents that patients can use. In
addition to protecting against photoaging, sunblock may also help prevent
hyperpigmentation after other aesthetic treatments. Despite general awareness
of the need for sun
Conclusion
As more cosmetic patients are opting to defer or avoid surgery in favor of
noninvasive modalities, the dermatol¬ogist has the potential to be at the
forefront of perioral rejuvenation. The number of minimally invasive aesthetic
products and procedures has burgeoned in the last several years. In concert,
clinicians have continued to expand and refine their techniques to provide their
patients with optimal outcomes and a high level of satisfaction. Neurotoxins,
fillers, lasers, RF devices, chemical peels, and cosmeceuticals can all be used as
part of a global strategy to address the dimensions of the aging perioral area.
Proper patient selection and management of expectations are critical to the
success of any cosmetic intervention. It has also become apparent that,
although it is necessary to discuss regions of the face individually, treating
areas of the face in isolation does not yield the best possible outcomes for
patients. It was stressed that treatment of any one area may have a
considerable effect on other areas that should be evaluated as treatment
progresses.
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