ArtiCle | fACiAlAeSTHeTiCS | to completely correct with volumisation will overfill the
face. Close attention to facial diagnosis helps to prevent over-treatment. examine the face systematically in a three step
process. firstly, assess the quality of the skin itself, considering the thickness of the dermis, the elasticity, and the firmness. look for evidence of sun damage as UV light destroys elastin in the skin. Badly sun-damaged skin often has significant absolute skin laxity7
. Secondly, examine volume loss, starting
superiorly, with the temples and zygomatic arches, and work inferiorly across the malar region, submalar region, lateral mid-face, lower face and jaw line. Note the volume loss in each area as mild, moderate or severe. finally, look at the evidence of gravitational forces on the skin such as jowls and pre-jowl sulcus, lack of jawline definition, and nasolabial folds. By careful examination, the unique ratio of absolute and relative skin laxity at play in the patient’s face can be estimated, and predictable results are achievable with the 3D vectoring approach.
3D vectoring Gravitational pulls on weakened and structurally undermined and devolumised facial tissue results in the inferior and medial displacement of tissues. Traditionally, surgical correction lifts the skin superiorly and laterally. in a 3D vector facial lift, the difference from the traditional surgical approach is that by volumising with CaHA, as well as superior and lateral correction, another dimension — forward projection — is added to the correction. A vector, by definition, is a measure which describes both a magnitude and a direction. The negative vector is a way of quantifying the diagnosis of visible ‘sag’ or ‘pull’ in skin tissue. if the tissue is sagging, then the negative vector is estimated and a counter-balancing positive vector is created by the judicious placement of volumising product. The ageing face is downwardly mobile; however,
certain areas of the face are more mobile than others. The face is traditionally divided into upper, mid and lower zones. However, for the purposes of 3D vectoring, the face is usefully considered as three vertical zones8 (Figure 1). These three zones highlight important anatomical differences between facial areas. S1 and S3 are relatively fixed areas of the face, and help to preserve identity as the face ages and soft tissues move. in particular, S3 is useful as an anchoring point that holds the more mobile tissues of S2 in a lifted position. The greater the tissue laxity in the central zone (S2), the greater the need to begin near the base of the tragus (laterally, S3) to help anchor the tissue. The face is composed of distinct fat compartments,
and the composition of the fat in these compartments varies9
. importantly, fat contained in S3 is more dense
and less mobile than fat in S2. Age-related laxity in supporting ligaments, such as the zygomatic and malar ligaments, contributes to a ‘bowing’ of S2 between the fixed zones of S1 and S3.
26 ❚ September 2011 |
prime-journal.com
Figure 1 Vertical sectors S1 (fixed), S2 (mobile), and S3 (fixed) map out the fixed and mobile areas of the face
The correction of negative facial vectors involves
the careful placement of volume anchored in fixed zones (S3), which lift and hold the mobile tissues of S2 in a superior and lateral position. The complete technique involves a whole-face approach. Volumisation of the temples and the zygomatic arch, where volume replacement is possible while maintaining natural contours, provides lift to the mid and lower face and recreates youthful structural ratios. The temple area is volumised subdermally, while CaHA is placed supraperiosteally along the zygomatic arch. for the mid-face and lower face areas, positive vectors
are identified firstly by selecting tissues to be lifted (e.g. jowls) and applying the simple techniques outlined below. Next, a line is drawn superiorly/laterally, and perpendicular to the jowl. This line represents the vector that produces the jowl. By leaving a neat band of CaHA anchored in the fixed zone, the tissues are lifted by the superior lateral volumisation, and held and supported by the high viscosity and elasticity of the CaHA10
. Over time, as the carboxymethyl cellulose
carrier gel is reabsorbed, collagen neogenesis is stimulated, which provides structure and firmness, and improves the quality of the skin and continues to lift tissues4, 5, 6
.
Cannulae The use of micro-atraumatic cannulae in medical aesthetics is relatively new. The theory is that the blunt end of the cannula will tend to push tissue
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