Dr Asad Naqvi presents a full-face case study on an older patient using dermal filler
The full-face approach has been gaining more popularity in aesthetic medicine recently.1 Previously, practitioners would treat an area in isolation, rather than looking at the face as a whole. However, this had the potential to lead to exaggerated features that did not complement the face in its entirety. Since then, education and training surrounding full-facial rejuvenation has increased and we are more aware of looking at our patients from all angles, creating appropriate treatment plans and assessing the patient holistically in our practices.
In this article, I present an example of a full-facial rejuvenation treatment to add volume and correct signs of ageing in my patient.
A 63-year-old female presented to my clinic wanting to regain lost confidence after undergoing chemotherapy for bowel cancer. The treatments had reduced muscle and fat in her face, leading her to have a gaunt, older appearance. The patient is now in remission and has gained some confidence back but wanted to undergo aesthetic treatments to rejuvenate her skin and add volume to her face, resulting in a plumper, healthier appearance.
I had previously treated the patient’s nasolabial folds with dermal filler two years ago and had no concerns regarding her medical history. She is currently undergoing hormone replacement therapy and taking vitamin D tablets. She is a non-smoker and is generally fit and healthy.
During the consultation, the patient noted that she wanted to look younger but natural in her appearance, and her main concerns were regarding her lower face. I used the Galderma Facial Assessment Scale (Figure 1), which is simple to use and has improved my consultation approach.2 The tool allows patients to visualise treatment results and enables a better understanding of a holistic treatment approach.
The assessment is split into five areas: skin quality, facial shape, facial symmetry, facial proportions and contour, as well as animation and emotional expression. The patient is asked to rank these areas based on the scale – one being that you are happy with it, or four being that it needs a lot of improvements.2 Afterwards, I then give my assessment and ranking, and we agree on a rating together based on both our opinions. I always try and make my patient feel better about their rating as most patients tend to put themselves down with their scores, so I either agree with their ranking or lower it.
Once the tool has been completed, both the practitioner and patient can identify the main areas of concern. As a result, the patient can assess their own face, come up with their own conclusions and be more involved in their treatment plan.
Once the main concerns have been established, I advise which areas might benefit from treatments, outlining the costs, product and risks associated. I spend time detailing the risk of necrosis from vascular occlusion and explain that there are two types. The first is an arterial occlusion and the second is a venous occlusion.
The first sign of an arterial occlusion is pain and a change in skin colour, usually a lighter and less red appearance, however, the order in which this happens may vary. An arterial occlusion is usually indicated with the livedo pattern.3 The blood supply from the artery going to the skin or the area of the face stops. Due to the lack of blood, it becomes painful, therefore if pain after a treatment is worsening, rather than improving, this is likely necrosis.
As well as this, the skin may feel cooler with time, and blanching will increase as the blood supply is restricted. If an arterial occlusion is not treated quickly, the area can change to blue/purple with a mottled appearance, and then later black as the skin begins to die. The occlusion can occur within 48 hours after treatment.4
Venous or vascular occlusion can occur when the vein becomes blocked. Unlike arterial occlusion, the skin does not become pale but instead, the area becomes darker with a purple appearance as venous blood pools, like a bruise. The area will begin to swell and become painful.5 I advise my patients to look out for either of these and to contact me on my personal number immediately to treat the complication if it arises.
We agreed that she had wrinkles on her forehead, prominent eyebags, deep nasolabial folds, a hollow marionette area, jowls, small lips and fullness around the submentum which needed addressing. I suggested her preauricular area needed volume, but she said it was not a major concern for her. These concerns were making the patient look tired, saggy and sad in her appearance.
I explained to her the science behind ageing and how gravity contributed to the loss of fat pads and dragging of the skin, along with reduced bone density, pulling everything down and resulting in sagging and jowling. By educating your patients, they are more likely to agree with the treatment plan and understand why you are performing certain treatments.
It is also important to manage the patient’s expectations of treatment outcomes. I explained to the patient that although I am unable to make her look 30-40 again, I can make her look good for her age, which the patient was pleased with.
At the end of the consultation, the patient was happy with the plan to treat the forehead, eyes, nasolabial folds, marionette lines, lips, submalar hollows and jowls. The patient had a cooling-off period and was booked in for treatment six weeks later.
I explained to the patient that the treatment plan could be carried out across a few sessions to achieve a natural appearance as well as allow herself and her family to adapt to the results. However, the patient lived far away and had a distance to travel so we decided to carry out all the treatments in the same session. As I would usually space out the treatments, I had to take extra precautions such as the use of cooling cryo globes to cause vasoconstriction and the use of microtip blunt cannulas, both to manage bruising and swelling.
Before treatment, the patient was given a pre-care and aftercare document to review. She was advised to avoid alcohol for 48 hours prior, and aspirin and non-steroidal anti-inflammatory medications for five days prior. She also listed her medication history to assess if she has any immunosuppressants that can cause delayed healing, remove all makeup, not go to the gym and avoid using saunas or hot tubs on the day before treatment to reduce the effects of vasodilatation.
The patient was against botulinum toxin treatment because she wanted to maintain expressions so we opted for dermal fillers for her forehead, in particular Restylane Vital. I chose the Restylane range as they are less hydrophilic, hence reducing the false ‘full’ look as well as being a reputable brand.
I injected her forehead and glabellar with 1.3ml of Vital, which is a skin booster with some minimal lifting effect. It is a very thin and delicate filler, which can be injected superficially to soften lines. I used a combination of needle and cannula for this area and switched between the two. I then moved onto her eyes and injected 0.4ml each side of Eyelight with a 23 gauge 50mm blunt tip cannula.
Her nasolabial folds were injected with 0.3ml of Lyft in the pyriform fossa between the nostril and top of the nasolabial fold with a needle, and I injected on the periosteum to lift the skin. I always aspirate in the nasolabial fold and glabellar due to the main facial arteries running through these areas.6
For the remaining nasolabial area, I used a 23 gauge 50mm blunt tip cannula where I injected 0.4ml of Defyne in the subcutaneous fat, followed by 0.3ml per side of Refyne subdermally as it is softer and more flexible than other fillers. This is ideal as the patient is more animated through talking and eating in this area.
Moving down towards her lower face, for the marionette lines, I used Defyne with a needle and aspirated. I used a perpendicular technique with 0.4ml each side. In the lips, I injected 0.5ml in the bottom lip and 0.3ml in the top lip using Kysse with a needle, using the vertical tenting technique.
Her jowls were treated with 0.2ml of Lyft in the pre-jowl area onto the periosteum, to lift the skin and fat off the bone. Then, I topped this up with 0.4ml of Defyne to strengthen the jawline. Finally, the submalar area was injected with 1ml per side of Defyne using a cannula. A cannula was used as it was a large area to treat and minimised the risk of bruising.7
I keep aftercare advice scientific and easy for the patient to follow. After any filler treatment, I re-educate my patients on necrosis and remind them about the possible other side effects such as lumps, bruising and swelling.
As well as complication advice, I notify my patients to avoid saunas, hot tubs, sunbeds or long, hot showers for the next two days. The temperature increases patients’ blood flow, causing the swelling and bruising to increase which can make the downtime longer.8
I also advise patients to not apply makeup until the following morning and avoid touching the face for the next six hours to avoid infection or moving the filler. Patients should also be careful with their face for the next five days by avoiding massages, pressing too hard, or having any treatments like dermaplaning or laser hair removal that could irritate the skin. The patient went home with a leaflet outlining all information and complication management.
I saw the patient for a review two weeks post-treatment, giving her time for any bruising and swelling to subside. The patient was very happy with her result and her confidence had been restored (Figure 2). Her lip volume had reduced slightly from the treatment when I reviewed her, but they had held their shape and appeared more voluminous compared to before.
The longevity of the result is difficult to determine as it is dependent on the patients’ age, skin type and lifestyle, so I always give a wide timeframe that the results may last to manage expectations accordingly. I base the timeframe on my own experiences having carried out thousands of filler treatments throughout my career. For this particular patient, I advised that results would last between nine to 15 months, and she was booked in for a follow-up for nine months’ time to retreat if required.
When conducting any assessment, especially a full-facial treatment plan, always give the patient an opportunity to talk and express their concerns to you. The use of an assessment tool has enabled me to open up this conversation more easily with my patients and allow them to become more involved in their treatment journey. As a result, the patient trusts your expertise, and is more confident in undergoing the treatment as they have been educated from the beginning.
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