Foundation course in dermal fillers hf

FOUNDATION
DERMAL FILLERS
LEE WALKER BDS MFDS RCPSG
MJDF RCS ENG

 Many factors affect how we age:
 Things we can control (extrinsic ageing) such as:
 Lifestyle
 Diet
 Excessive exposure to sunlight
 And some things we have less control over (intrinsic ageing):
 Skeletal re-modeling
 Fat redistribution and loss
 Changes in muscle mass and strength
 Genetics
 Disease
THE AGEING FACE

 Visual changes:
 Textural
 Loss of elasticity
 Vascular & pigmented lesions
 Rhytides (lines and wrinkles)
 Change in skin colour
 Histopathological changes:
 Thickening of the stratum corneum
 Reduction of dermal collagen
 Reduction in hyaluronic acid
 Decreased sebum production
 Dilation of blood vessels
FACIAL AGEING

 New York’s Metropolitan museum of art used
a camera to trace where a person’s eye look
when they see a picture of a face
 We look at the eyes
 We look down to the mouth and then
 We look back to the eyes before looking
around the outline of the face
 This creates a central ‘facial triangle’
making it the key feature of the face and
Leonardo da Vinci knew the shape of the
face was more important than lines or
wrinkles nearly 500 years ago!
THE ‘SCIENCE’ OF BEAUTY

 The features of the young looking
face are described by curves or arcs
 Fullness in the lateral brow
that softly curves into the lateral
eye canthus then softly curves
outward on the upper cheek to
curve in again just above the mouth
 The ‘Ogee’ curve - a single or
double soft ‘S’ curve of the face
 A ‘young-looking’ face has round
contours, high cheekbones and a
well-defined jawline with smooth
curves from the cheeks to the edge
of the nose, without hollows.
THE CURVES OF THE YOUNG FACE

 Over time the curves of the face
start to change
 The forehead and brow drop to give a
hooded or tired appearance to the
eyes
 Eyes become less prominent
 Lines and creases develop
 Volume is lost from the cheeks
 Lines around the mouth and nose
deepen
 Skin becomes loose and lower
around the neck forming ‘jowls’
THE CURVES OF THE AGEING FACE

 Studies by Rajiv Grover (2006) suggest that about 7 years before
any effects of gravity are seen there is a gradual LOSS of volume
particularly from the cheek area between 38-40 years of age -
making the face less ‘heart shaped’ and more ‘square’
and changing the ‘facial triangle’
WHY DO THESE CHANGES HAPPEN
GRAVITY OR VOLUME LOSS?
Grover R. Coleman SR, (March 2006). Am Aesthetic Surgery Journal

 The face has deep facial fat that is
separated from the superficial facial fat
 The ‘distribution’ of these pads of fat
changes as a result of weight loss and
as we age
 Sometimes it can accumulate giving the
impression of permanent puffiness,
particularly under the eyes
 More often, it thins and lowers, leading to
deep creases and sunken cheeks
 One very important fat pad in facial
aesthetics is the ‘Malar’ fat pad
CHANGES TO THE DISTRIBUTION OF
FACIAL FAT
Adapted from Rohrich and Pessa (2007)

REDISTRIBUTION OF FACIAL FAT
In the younger face
the Malar fat pad
sits high giving a full
and rounded cheek
In the ageing face the
Malar fat pad drops lower
and inwards which
reduces the eye
prominence and deepens
the nose to mouth lines
(nasolabial folds)

CHANGES IN SKELETAL STRUCTURE
 Reduction of facial height, maxilla,
mandible, loss of teeth
 Orbits increase in size with remodelling
and bone loss over zygoma
 Maxilla decreases in size compounding
inferior displacement of malar fat and
accentuating nasolabial fold
 Maxillary resorption leads to loss of
support for upper lip contributing to
perioral wrinkling
 General coarsening of bony
prominences, especially at sites of
muscle attachment

 Just tightening the skin (ie a face ‘lift’)
without addressing the underlying soft
tissue layers can produce an unnatural
pulling and stretched effect
 To correct the signs of volume loss you
need to understand the effects of fat
distribution AND the effects of gravity
and their relationship with the facial
skeleton and underlying anatomy
 Madonna at the age of 50 showing
why a youthful appearance is all about
the facial triangle, curves and ‘volume’
CORRECTING THE SIGNS OF VOLUME
LOSS
Courtesy New York Magazine Aug 2008

www.lipdoctor.co.uk Professional Beauty North
GOLDEN RATIO (PHI)
The golden ratio is a mathematical law known by many names,
which include the: golden proportion, golden mean, golden cut,
divine proportion, extreme and mean ratio, phi or Ф (the 21st
letter of the Greek alphabet). It can be expressed in many ways,
including numerically, geometrically, in length, area, volume,
distribution, beauty, consciousness and creation itself.

PHI IN IDEAL HUMAN FACE
 Length of face…width of face
 Lips and eyebrows…length of nose
 Length of face…tip of jaw and eyebrows
 Length of mouth… width of nose
 Width of nose… distance between nostrils
 Distance between pupils… between eyebrows

FIBONACCI SERIES
 In the 12th century, Leonardo Fibonacci discovered a
mathematical series that is found throughout nature. Starting
with 1, each new number in the series is simply the sum of
the two before it.
 1, 1, 2, 3, 5, 8, 13, 21, 34, 55, 89, 144, 233, 377, 610, 987…

GLOGAU CLASSIFICATION OF AGEING

FITZPATRICK SKIN CLASSIFICATION

www.lipdoctor.co.uk Professional Beauty North
WRINKLE SEVERITY RATING SCALE

THE PERIORAL AREA
 The perioral region includes the lips,
chin, philtrum, lower cheeks and
jawline
 The mouth is an area of high muscle
activity, from talking, eating and
facial expressions
 The mouth is a sensual area and
plays an important part in the
attractiveness of the face
 Aging in the perioral region can lead
to a sad or displeased look to the
face

PERIORAL WRINKLES
JOWLS
DIMPLED CHIN
MARIONETTE
LINES
LABIOMENTAL
CREASES
PRE-JOWLS SULCUS
AGEING OF THE PERIORAL AREA

• The lips are muscular membranous folds surrounding the
anterior part of the oral cavity
• The lips are a delicate area to inject due to:
– High muscle activity
– High sensitivity due to a high density of neurons
– Rich vascularisation
– If there is an adverse event or a mistake, it is immediately visible
• They swell markedly when bruised, cut or hit and react
unpredictably
• Lipocytes are less prominent than in other facial regions and the
orbicularis oris muscle greatly influences the shape of the lips
• The dry mucosa of the lip is much thinner than the dermis in the
rest of the face. This makes it less suitable for injection
– The submucosal layer under the dry mucosa is the preferred injection site
CONSIDERATIONS FOR TREATMENT OF
THE PERIORAL AREA

THE LIPS
 The lips are muscular membranous folds
surrounding the anterior part of the oral
cavity
 This tissue comprises both mucosa and skin
and has a complex anatomy
 The lips are the most variable features of
the face
 Unlike the eyes and nose the lips have no solid
structure on which to attach
 There are a multitude of muscles that stretch
and move the mouth in various motions

ANATOMY OF THE PERIORAL AREA
Oral commissure – corner
of the mouth
Vermilion border – the
juncture where the lips
meet the surrounding skin
of the mouth area
Labium superius oris –
upper lip
Mentolabial sulcus –
an inverted U-shaped crease
across the lower lip
Labium inferius oris –
lower lip
Vermilion zone –
the typically reddish area
within the vermilion borders
Cupid’s bow – the
vermilion border of the
upper lip
Tubercle – the fleshy protuberance
located in the centre of the upper lip
Philtrum or philtral groove –
the vertical groove extending
from the tubercle to the nasal
septum
Philtral columns –
well-demarcated central fat
compartments existing in the
upper lip, superficial to the
orbicularis oris muscle
Drake RL et al. Gray’s Anatomy for Students. Churchill Livingstone; 2005.

• The skin of the lip forms the border between the
exterior skin of the face, and the interior mucous
membrane of the inside of the mouth
• The vermilion has:
– A dry component (visible when lips are closed)
– A wet component (visible when the lips are parted)
• The colour of the vermilion ranges from red to brown
based on the pigmentation of the individual
– In individuals with light skin colour, the lip skin contains
fewer melanocytes so the blood vessels are visible
giving the lips their red colour
– With darker skin this effect is less prominent
SKIN CHARACTERISTICS OF THE
PERIORAL AREA

• The skin of the lip has 3−5 cellular levels, which is very
thin compared with skin of the face which has up to 16
layers
• The lip mucosa is susceptible to dehydration as:
– Does not retain water in the same way as other skin tissue
– Contains no sweat glands
• Lip fullness varies greatly between individuals
SKIN OF LIPS DIFFERENT TO REST OF
FACE

• The strong support of the teeth and bones is
essential to support the shape and volume of
the lips
• The shape of the perioral region is supported
by the scaffold of bone provided by the
maxillae and mandible and the upper and
lower dentition
TEETH

UNDERLYING STRUCTURES: MUSCULATURE
Zygomaticus minor –
raises the upper lip to
expose the front teeth
Zygomaticus major–
draws the angle of the
mouth upwards and
sidewards as in
smiling
Modiolus –
anchoring point of
muscles that move
the corners of the
mouth
Mentalis – raises and
protrudes the lower lip
and pulls the skin of the
chin up as in pouting
Depressor labii
inferioris – pulls the
lower lip down
Depressor anguli oris –
draws the angle of the
mouth sideways and
downwards
Orbicularis oris –
closes the lips and
makes them
protrude,
compresses lips
against the teeth,
shapes lips during
speech
Levator labii
superioris – raises
the upper lip
Levator anguli oris
– draws the angle of
the mouth
sidewards and
upwards
Drake RL et al. Gray’s Anatomy for Students. Churchill Livingstone; 2005.

• The facial nerve
(cranial nerve VII) is
responsible for
control of the
majority of the facial
muscles, including
those in the perioral
area
• The buccal and
mandibular branches
control the perioral
muscles
Temporal
branch
Zygomatic
branch
Facial nerve
Cervical
branch
Mandibular
branch
Buccal branch
UNDERLYING STRUCTURES: INNERVATION

AGE RELATED CHANGES IN APPEARANCE
 Aging changes can be particularly noticeable around the lips
There is a loss of lip volume;
there may also be apparent
thinning of the lips in people
who have lost teeth
The superficial lip tissues
undergo distension and begin
to droop
The vermilion border becomes
larger, longer, and thicker at the
corners of the mouth
The philtral columns become
less defined and the Cupid’s
bow flattens
Wrinkles develop in the skin
around the lips and the outline
of the lips becomes sunken
The lips become more vertical
and receded
The orientation of the labial
aperture changes with a
drooping of the lateral
commissures
The upper lip lengthens and the
projection of the upper lip is
lost, reducing the visibility of the
vermilion regions

Loss of underlying support causes
the lips to become more vertical
and receded
• Superficial changes reduce volume and fullness:
– Epidermis thinning
– Dermal thinning (and loss of collagen, elastin and
hyaluronic acid)
• Tissues become less extensible and elastic due to:
– Repeated mechanical stresses
– Weakening of the orbicularis oris muscle
• Loss of support from the underlying tissues from:
– Changes in dentition
– Atrophy of the bone, muscles and subcutaneous
tissue
CAUSES OF AGE RELATED CHANGES IN
LIP

Orbicularis oris
• Thinning of the skin and subcutaneous tissues
causes increased wrinkling of the lips and
surrounding area
• These changes are most obvious in people
who have pursed their lips repeatedly, such as
smokers
• Deep wrinkles across the vermilion border
cause ‘lipstick bleeding’
• The ordinary actions of the orbicularis oris
accentuates these wrinkles
PERIORAL WRINKLES

 Jowls develop when the jawline loses its
firmness, due to weakening of retaining
ligaments, loss of skin tone and sagging of
skin and subcutaneous fat
 Jowls make the lower face appear wider
JOWLS

Depressor anguli oris
• A drooping appearance of the perioral area is a
characteristic sign of aging
– This is caused by the anguli oris muscle pulling the
commissures down
• Together with photoaging and age-related loss
of collagen and subcutaneous fat around the
mouth, this can create a frowning and
disapproving appearance
• Deep grooves can also appear from the edge of
the mouth to the jaw
– These are called marionette lines because they
resemble the jaw of a wooden puppet
MARIONETTE LINES

• A dimpled chin, with a peau d’orange or
‘orange peel’ effect, results from:
– Loss of collagen and subcutaneous fat in the
chin
– Repeated lifting of the chin by the mentalis
muscle
• Mental creases are deep crescent-shaped
grooves between the bottom of the mouth
and the point of the chin
Mentalis
DIMPLED CHIN AND MENTAL CREASES

SUMMARY
 The lips are an area of high muscle activity, and are the most
variable feature of the face
 Aging brings loss of volume and elasticity in the perioral area
with loss of support from underlying bone and subcutaneous
fat
• Key areas of concern for patients are:
– Perioral wrinkles (due to thinning of the skin
and loss of skin tone)
– Jowls (due to weakened ligaments, loss of skin
tone and and sagging)
– Marionette lines (due repeated muscle action
and loss of collagen and subcutaneous fat)
– Dimpled chin and labiomental creases (due to
loss of collagen and subcutaneous fat and
muscle action)

 Glycosaminoglycan
 Consists of repeated disaccharide units
 Hydrophillic properties attract water into extracellular matrix
and increase skin turgor
 Gradually degraded so filler longevity increased by cross
linking with 1.4-butanediol diglycidyl ether
 Used be ferived from avian sources (rooster combs eg
Hyalform)
 Now made from bacterial fermentation
HYALURONIC ACID

HYALURONIC ACID CHEMICAL STRUCTURE

G PRIME
Measure of elastic modulus or viscoelasticity

JUVEDERM
2*1.0ml 2*1.0ml
24mg/ml

EMERVEL V RESTYLANE
Rzany, B 2011

 Listen to client
 Fillers are only 1 tool
 Discuss price
 Discuss possible adverse events
 Avoid psychological issue patients, BDD
 Anaesthesia
 Assess and treat in an upright position
 Use a mirror
 Start with a biodegradable filler
 Don’t inject too little or too much filler
 If something goes wrong be accessible and understanding
GENERAL TIPS

 Concentration of HA
 Cost
 Cross-linking
 Degree of cross-linking
 Quantity of HA cross-linked versus uncross-linked
 Type of cross-linking technology used
 Duration of correction
 G’ (elastic modulus)
 Hydration level of product in the syringe
 Presence of lidocaine
 Required needle size for injection
 Sizing technology
 Syringe
 Design of syringe Size
 size
CONSIDERATIONS WHEN CHOOSING A
HYALURONIC ACID FILLER

 A—Assess the patient
 a. Which areas show aging or asymmetry?
 b. Which areas can be easily corrected?
 c. Imagine how the patient will look if various areas are corrected.
 d. Determine the best areas of injection and proceed to next step.
CHOOSING APPROPRIATE FILLER

 B—Budget
 a. Determine the patient’s financial budget.
 b. Determine the patient’s time budget.
 c. Refine plan in your mind about which areas are most important to
treat.

 C—Considerations
 Learn more about the patient.
 What bothers the patient most?
 Ask about prior experience with fillers.
 Are there any religious restrictions?
 Can the patient return for future treatments?
 Does the patient have an event coming up?
 Is the patient on anticoagulants?
 Are there any concerns about outcome?

 D—Device
 a. Assess pros and cons of available fillers.
 b. Match attributes of fillers to what was learned in steps A, B, and C.
 c. Choose the appropriate device.
 d. Discuss the plan with the patient.

 Angle of attack
 30 deg deep dermis
 20 deg mid
 5-10 deg superficial dermis
 Visibility of needle
 Colour and outline superficial
 Outine only mid
 No outline deep
 Should be able to feel resistance when advancing needle, if
no resistence then you’re likely to subcutaneous
HOW DEEP ARE YOU?

MARIONETTES BOTULINUM TOXIN AND
FILLER

 Filler complications are events that should not occur after
treatment and can be avoided with proper technique and
material selection.
 Complications can be categorized as
 Immediate
 Early
 Late
onset events
(Rzany B 2004)
COMPLICATIONS OF DERMAL FILLERS IN
THE PERIORAL TISSUES

 Under/over correction
 Implant visibility
 Tyndall effect
 Nodules
 Immediate hypersensitivity
 Anaphylaxis reported with bovine collagen (Mullins RJ 1996)
 Vascular compromise
 Glabella
 Alar triangle
 By direct injection into vessel or pressure of excessive swelling/filler
on vessel
IMMEDIATE ONSET COMPLICATIONS (0-2
DAYS)

 Persistent nodules
 Localised accumulation
 Inflammatory
 Infective
 Reactivation of herpes (esp lips)
 Atypical infections (eg mycobacteria)
 Angioedema
EARLY ONSET COMPLICATIONS (3-14
DAYS)

 Persistent erythema/telangiectasia
 Granulomas
 Foreign body reaction
 Type 4 hypersensitivity ? Foreign proteins ?biofilm
 Permanent fillers eg PMMA
 Nodules from PLLA (Sculptra, from poor mixing, incorrect placement)
 Migration
 Silicone
 Lesley Ash
DELAYED ONSET COMPLICATIONS (>14
DAYS)

 Blanching
 Blue-grey mottling
 Pain
 Massage
 Hyalase (if HA and don’t bother with allergy test)
 Warm compresses
 GTN paste
 Aspirin/heparin
 If tissue breakdown antibiotics and wound management
IMPENDING NECROSIS

 Nodules
 Massage
 Hyalase
 Injections of saline (Ellanse PLLA)
 Red, fluctuant
 Antibiotics
 I+D, C+S
 Clarithromycin and Ciprofloxacin for biofilm
 Granulomas
 Hyalase if HA
 Injections steroid/5-FU
 CONSULT A COLLEAGUE
NODULES/GRANULOMAS

 Obtain informed consent
 Know your own abilities/limitations
 Explain risks, complications and limitations of
procedure/product
 Discuss any off label uses
 Appropriate antisepsis/hand washing/skin prep
 Clinical photograpy, don’t inject without a photo
 Avoid injecting large amounts of product
 Know your anatomy
 Avoid important neurovascular structures
 Aspirate before injection
AVOIDING COMPLICATIONS

 Enzyme to dissolve miss-placed HA filler
 Can resolve HA granulomas
 Derived from goat testicle (Hyalase)
 Allergy test required, small dermal injection on forearm and check
for allergic reaction after 30mins)
 1500u in vial, mix with 1ml saline
 Inject into filler in 0.05ml aliquots
 Filler dissolves almost instantly, best after 48 hours
 Review/refill 1-2 weeks
HYALURONIDASE

 Consultation
 Facial assessment
 Skin prep
 Injection markings
 Photography
 Injection techniques
 RECORD KEEPING
 Post treatment advice
PRACTICAL SESSION

 Photography
 Assessment of outcome
 Procedure for top ups
 Any other issues raised by delegates
2 WEEK FOLLOW UP SESSION

Foundation course in dermal fillers hf

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