I Don’t want fillers! I’ll look bloated and fake!

That seems to be the most common retort whenever the mention of fillers come into the conversation with the uninitiated. And you can’t blame them for this reaction, what with the many bad examples coming from Hollywood and those around us.
The crux of the issue is the initial understanding (or lack thereof) of the dynamism of facial anatomy in the past, and the effect it had on injection techniques. The study and discovery of facial anatomy has been a gradual one, with greater insight coming over the past few years. From the layers that define the various regions of the face, to the effect each layer has in different states of motion or rest – the unravelling of all these little nuances has allowed for a clearer understanding of how, and when, the face should be touched up.

The face was previously seen as a persistently deflating and sagging entity, and treatments as such were put in place to reverse just that. Face lifts without proper volumisation created wind-swept appearances, accentuated by the unmanaged hollowness. Fillers came into play but were used incorrectly, with large volumes pumped in to re-inflate fat. This produced the classic over-filled faces that we, unfortunately, still see today.

The Structure of the Face

The structure of the face is complex, but from a bird’s eye view is an elegant and simple, and can be thought of as a tent, with an overlying canvas and a deeper strut for support:

The top 3 layers, comprising of the skin, superficial fat, and superficial muscular system form the canvas of the face. This is what you can pinch with your fingers and is supported by the next layer.


The deeper layer, consisting of a deeper fat and bone, provide rigid support for the layers above.The dynamics of the two are different, and play differently to facial ageing and expression.

The Ageing Face

Ageing brings with it several changes, and these changes are different in the different layers of the face. Understanding the dynamics that each change brings about has allowed a better understanding of how and what should be done for each patient.

As we age, the following occurs:The skin thins as we lose elasticity and collagen. This produces the fine wrinkling and crepe skin associated with age.

The superficial fat becomes looser and seemingly enlarged, bringing about the sagging and heaviness of the face.

The muscular system loses tension and the face begins to sag visibly.

Deep Fat loses volume and becomes sparse, reducing support to overlying structures.Bone resorbs, further reducing support and adding to the hollowing of the face and loss of definition.

The visible changes from ageing happen when the above occur simultaneously, and what one sees is a collective result of all the above interactions –

Areas around the eyes age first as overlying tissue is thin, and bony resorption is readily seen. Hollowing and then under eye fat bulging is seen.

ii.) The midface (the front of the cheek) then begins to show hollowing, with a flattening of the cheek and show of underlying ligaments of the cheek

iii.) The sides of the face start to fall due to poor structural support and increasing upper layer laxity, producing characteristic nasolabial folds and marionette lines

iv.) The bony chin and jawline also resorb, creating a flattened and under-projected chin and more obtuse jawline. This further worsens jowling as support is further lost

Other similar changes occur at the forehead, temples, nose, and so on. The most important thing to know is that underlying structural support is diminishing, while overlying tissue tends to get heavier and more lax.

How does this change the way we do things?

The understanding of the above dynamics of the face has, over the years, changed the way we inject and the types of products available for facial augmentation.

Filler companies have produced a wider variety of fillers, each with their own viscoelastic properties – ie how stiff and firm each product is.

The aim essentially is to resupport the face where structural support has been lost (with harder fillers), blend areas with poor superficial tissue coverage (softer fillers), and rehydrate the skin where texture is poor (the softest of the lot, typically known as skinboosters).Strategically placed fillers in the right areas offer optimal effect for minimal amounts of filler injected, and the product is not a changed and overblown version of you, but rather you in a more harmonious, younger state.

How does that tie in with facial dynamism?

The above gives the rationale for our approach, but the face has some further intricacies worth noting.The face exists itself as a highly dynamic and interdependent structure, with the above layers behaving differently as you move:

 

The superficial layers above bulge in response to the contraction as one moves, such as in smiling. This produces the natural cheek flare as one laughs. Any filler product placed in this area will accentuate with movement.

The deeper layers, however, remain rigid and do not move. Fillers placed in this layer, used judiciously, do not cause bulging or excessive and unnatural fullness to the face. This dictates the necessary use of less rigid and more flexible fillers for the superficial tissue to produce a more natural, less bloated result.

TL;DR

Facial anatomy is complex, and much light has been shone in only more recent years on the intricacies of its structure and interactions.

As filler companies respond by producing more suitable products for the different areas of the face, so do we as practitioners necessarily understand and respond by changing the way in which we choose to rejuvenate the face.The art of facial rejuvenation with filler-based techniques is an ever evolving one, both academically as well as clinically for each individual practitioner. As we pull away from the techniques of old, we hope to restore the optimism in the benefits that fillers can provide.