Facial Assessment and the Shape Lift Technique
There are many filler products in the market and patients can easily get overwhelmed. Even for physicians and practitioners, we are taught different injection techniques by various pharmaceutical and filler companies. The choice of filler product and injection technique is very important, but ultimately depends very much on our patient assessment. This means to say that no particular facial area is always treated with the same filler or technique. Experienced practitioners will be able to conduct a thorough assessment to decide the appropriate filler and technique to use.
Here I will discuss some of the considerations when we assess our patients
1. Whether the area is dynamic or static
The face is dynamic and moving all the time. However not the entire face moves equally. The mid-section of the face i.e. around the mouth and eyes is the dynamic area whereas the outer section is relatively more static. This means that we need to choose a dynamic filler in the mid-section of the face, and a more static filler in the outer face. Using a static filler in a dynamic area of the face can cause the filler to clump up and become lumpy.
2. The amount and quality soft tissue cover
Soft tissue cover refers to the amount of fat and skin quality over the area to be treated. In individuals with more fat and better-quality skin to cover, we can use “harder” fillers. These “harder” fillers give better projection and generally can give longer lasting results. On the other hand, those with little fat tissue may not be able to camouflage the “hard” filler so well and these may appear lumpy.
3. The importance of the facial support and ligamentous structures
The face is supported by ligaments and many of them are located in the outer part of the face. This means that the temples and area under the cheekbones contribute significantly to the structural support of the face. With age, as the temples and area under the cheekbone becomes hollow, the resultant weakened structural support leads to the nasolabial and jowl fat to sag and the formation of the nasolabial folds and marionette lines. In order to restore the lost volume and structural support, we can introduce filler to the temple and area under the cheekbone. This will lift up the sagging nasolabial and jowl fat and reduce the nasolabial folds and marionette lines.
*One common issue we encounter with young ladies is the excessive use of botox in the jaw muscle for jaw slimming. The weakened jaw muscle reduces the structural support of the face and they may notice that the jowl fat becomes more prominent.
Location of the ligaments providing structural support to the face (Pepper and Baker. Local Flaps: Cheek and Lip Reconstruction. JAMA Facial Plast Surg. 2013;15(5):374-382)
When the area beneath the cheekbones become hollow with age, the superficial nasolabial and jowl fat will sag downwards. (Salti G, Rauso R. Facial rejuvenation with fillers: The dual plane technique. J Cutan Aesthet Surg 2015;8;127-33)
Placement of filler under the cheekbone provides structural support and helps lift the nasolabial and jowl fat pad (Adapted from Hamra ST. Building the Composite Face Lift: A Personal Odyssey. Plast Reconstr Surg. 2016;138:85-96)
4. Cultural norms and individual preferences
Asians typically prefer a slimmer and sharper V-shaped face. We achieve this with a combination of jaw muscle botox and chin filler. For those with strong cheekbones (that give the appearance of a wider face), we can place filler in the temples and below the cheekbone to camouflage them. Whereas for Caucasians, they prefer stronger and broader features and a squarer shaped jaw. We can add filler to the cheekbone and jawline to further accentuate these features.
It boils down to practitioners to take the time to understand what results an individual is looking for. Many times, we encounter patients who have brought along a photo of their perfect cheekbone or lips. Common requests include wanting luscious lips or a much higher nose bridge. These may not be suitable as we must keep in mind that all the facial features have to come together in harmony, and it may not look aesthetically pleasing to have one feature stand out too much over the rest.
Shape Lift Training by Dr Allen Huang, Taiwan Plastic Surgeon
I had the opportunity to learn from Dr Allen Huang, who is a prominent Taiwanese plastic surgeon on his Shape Lift assessment technique. We used the restylane range of fillers in this training session. What I found refreshing about this training was that it focused on facial assessment. Most other training sessions focus solely on injection techniques. While technique remains crucially important, the same injection technique cannot be applied to all patients. A good assessment allows modification of the technique, which includes varying the filler product used, the position of the injection points, and the volume of filler injected at each point. The Shape Lift assessment allows injectors to build on and use the appropriate technique to treat individual faces after careful assessment.
Some of the key takeaways of the training include
1. Refinement of the undereye and tear trough region
The undereye and tear trough are challenging areas even for the experienced injector. It is important to evaluate the undereye region both at rest and during dynamic movements of the face. Dr Huang explained his assessment for our patient subjects and evaluated which points to fill, and at which depth. Certainly, some patients will achieve better results with superficial filling whilst others do better with deep filling, and often times, we may need to use a combination of fillers for best results.
2. Structural support of the lateral (outer face) with filler
As mentioned earlier, filling the temple and area under the cheekbone helps to provide structural support and lift the jowl and nasolabial fat, reducing the nasolabial folds and marionette lines. However not everyone is suitable for this. In some instances, filling the area below the cheekbone will make the face wider, which is not typically a desired outcome in Asians. Dr Huang explained and demonstrated to us how to assess which individuals will have good results with this technique.
3. Treatment of mid-cheek groove
Many people are bothered by this mid-cheek groove that run down from the tear trough through the mid-face. This groove is formed by a strong ligament of the face attached to the skin. Dr Huang showed us his assessment of this groove, explaining to us which patients will benefit from filler injection and which will not. Some patients will benefit from loosening this ligament by a procedure called subcision, followed by superficial placement of a “soft” filler like restylane vital light.
The Midcheek groove (Pepper and Baker. Local Flaps: Cheek and Lip Reconstruction. JAMA Facial Plast Surg. 2013;15(5):374-382)
Certificate presentation by Dr Allen Huang
The doctors and the restylane team
Dr Allen Huang assessing the patient and me doing the injection