Mr Adrian Richards describes how the ‘A-lift’ can help aesthetic practitioners master natural-looking results
The A-frame concept
The concept of the ‘A-lift’ is one that we use to train our team at Aurora Clinics, and four of our trainers also include this in our training programmes for our delegates at Cosmetic Courses. It was a concept we created which we find helps us to focus on the important facial areas requiring treatment, resulting in natural and long-lasting rejuvenation for the patient. The ‘A-lift’ is based on the A-frame concept, a basic structure which is shaped as a letter ‘A’ and designed to bear a heavy weight, regularly used in construction.1 An example could be two wooden beams connected at a 45 degree angle, with a bar across the middle for extra support in order to prevent the legs from bowing out.
We find that the A-frame concept helps us focus on three of the four aspects of facial ageing; volume loss, active lines and gravity changes. As we age, our face shape inverts from a triangle with its apex facing downwards into one with its apex upwards and its base downwards (Figure 1). To counter this ageing triangle inversion we focus our treatments in a similar pattern – the A-frame. The A-frame subdivides the face into treatment focus areas which lie along the limbs of the extended A. In addition, the cross line of the A ends outside the triangular limbs of the A. To obtain a natural harmonious pan- facial rejuvenation, we ask our practitioners and delegates in training to focus their treatment on these areas.
The A-frame zones (Figure 2)
The limbs of the A-frame lie along the facial areas we believe should be treated in order to achieve a natural facial rejuvenation. Over-treatment of one area with insufficient focus on another can produce an unnatural appearance. In my experience, almost 100% of my male and female patients in their 50s would like to look like they did 5 to 10 years previously. However, only a small number of these patients choose to have treatments that can achieve this. There are multiple reasons that could influence these choices, however, amongst patients I have spoken to, a major factor is a fear of looking unnatural. By adopting the A-frame technique, my staff and I believe we can achieve natural-looking results for our patients. The apex of the A is located above the glabella. When looking at the face, we naturally tend to focus on the eyes and area between them, and less on the peripheral area of the face. Many of my patients who have had their prominent ears corrected have reported that their friends and family could not identify what had changed following the procedure. While their friends and family knew they looked different, often slimmer as prominent ears tend to widen the face, they did not realise it was the ears that had changed. Following the shape of the A-frame downwards, we reach the cheeks, nasolabial folds, oral commissures, marionette lines and, finally, jowls.
I will now detail how I target these areas in my ‘A-lift’ treatment protocol.
The ‘A-lift’ treatment technique
Adopting the ‘A-lift’ technique, the glabellar is treated in most cases with our standard five-point toxin pattern. This involves a single sub-cutaneous injection over the procerus and two sub-cutaneous injections into each corrugator. There is very little sub- cutaneous fat in this area between the skin and underlying muscle. In our experience, a sub-cutaneous bleb of toxin will diffuse downwards into the muscle. Since we have been teaching sub-cutaneous placement, we have noted that it is more comfortable for the patient, produces less bruises and trauma and reduces the risk of toxin diffusion into orbit, which can result in weakness of the eye muscles. Working downwards, the next focus areas lie at the ends of the extended transverse limb of the A-frame – the cheeks. Some faces are less asymmetrical than others, and we feel it is very important to assess patients thoroughly and record their level of facial symmetry prior to any treatment. In most cases, there is only one opportunity to obtain a picture prior to the patient having undertaking a treatment. Where possible, we ask our patients to bring in pictures of themselves over the years. This allows us to assess their facial volume changes over time. Our aim is restore their youthful volume, not add more volume than they ever had as this can produce an unnatural appearance.
We then assess the volume loss within each of the fat compartments of the cheek and aim to restore the loss with a standard cheek augmentation. In my clinics, we prefer to use a cannula to deliver the product, as we believe this gives us more control whilst minimising trauma. For many years, my colleagues and I have found that facial rejuvenation with fat transfer is a popular technique, and this is predominantly performed with cannula rather than needle.
Further down the face, our next areas of focus, along the limbs of the A-frame, are the nasolabial regions. Again our preference is to treat these areas, together with the oral commissures and marionette lines, with cannula rather than needle. The benefits to this technique are that only a single point of entry is required and less trauma is produced with the blunt-ended cannula.
Care is taken in the nasolabial, oral commissure and marionette areas to avoid adding too much volume. As mentioned previously, transfer of volume from the upper to the lower face is a feature of facial ageing. Excess volume in the lower face can age a patient’s appearance, rather than encourage rejuvenation. Most of our patients treated in accordance with the A-frame principles will also have toxin treatment to the depressor anguli oris (DAO) muscle. Relaxing this depressor muscle at the corner of the mouth produces an anti-ageing anti-gravity upturn of the mouth, lessening the amount of dermal filler required.Care is taken to avoid toxin affecting the depressor labii inferioris (LAO), which lies medial to the DAO. Inadvertent relaxation of this muscle will cause the centre of the lip, rather than the corners of the lip, to move upwards, producing an unnatural appearance. The base of the A-frame lies below the jowls, and we use a three-point sub-cutaneous injection technique one centimetre below the jaw line and jowls. Again our preference is to use a moderate dose of toxin in this region, reducing the downward pull of the platysma on the jowls.
While each face is different, they all have some degree of asymmetry and each requires a bespoke treatment plan
When training our team of practitioners in clinic or delegates on our courses, we ask them to focus on the A-frame structure and adopt the ‘A-lift’ technique in practice. While each face is different, they all have some degree of asymmetry and each requires a bespoke treatment plan. By using the A-frame principles, we believe that we can achieve natural pan-facial rejuvenation with our aesthetic treatments. This helps to avoid the unnatural over-treated appearance we see so often, which is often cited as a major reason for potential patients delaying or avoiding aesthetic treatment.
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