PEER-REVIEW | COMBINATION THERAPIES |
fat and bone atrophy cause a loss of prominence in the mid-facial area. These are the vectors of facial ageing and soft tissue ptosis, and in the post-menopausal period these changes become more visible owing to hormonal changes, and creating a greater appearance of age as a result. The lower eyelid and tear trough area can be
challenging to treat in facial rejuvenation. While lower eyelid bags are one of the most common reasons that patients present for treatment, a separate entity known as a tear trough deformity may occur in conjunction with lower eyelid bags (or alone). The osteocutaneous ligament, also known as the tear
Figure 1 Different types of tear trough
such details as bone structure, where changes to this
level can cause resorption of soft tissues, which can become dry as a result of low levels of oestrogen. With this in mind, it is essential to consider how low
levels of oestrogen can influence facial contours, and particularly the perioral skin and lips during menopause and post-menopause, and to consider how aesthetic practitioners can adapt their techniques for the correction of tear trough deformities.
Anatomical considerations Correction of the skeletal framework is one of the most important goals in facial rejuvenation. Areas with a strong predisposition to resorption include the temporal area and the mid-facial skeleton, particularly the maxilla and the pre-jowl sulcus of the mandible. Depending on the age of the patient and her individual
Correction
of the skeletal framework is one of the most important goals in facial rejuvenation.
features, the facial contour will inevitably change due to: ■ Ptosis ■ Loss of elasticity, firmness, and radiance ■ The migration of localised fat (double chin) ■ Wrinkling ■ Deepening of temporal areas ■ Bone resorption ■ Deepening of the temporal fossa ■ Depression of eyebrow line. Without doubt, ageing of the lower eyelid and tear
trough area is very much influenced by the changes that take place in facial fat tissue. In younger patients, the cheek fat pad tends to be dense and abundant. With age,
Table 1 Indications for surgical and non-surgical correction
INDICATIONS SURGICAL TREATMENT NON-SURGICAL TREATMENT
Severity of the tear trough II–III degree of severity I–II degree of severity with surface changes and unaesthetic look
Grade of fat hernias of the Expressed
lower eyelid Oedema of the lower eyelid Common
52 ❚ March 2013 |
prime-journal.com Non-expressed Rare
trough ligament, is placed between the palpebral and orbital parts of the orbicularis oculi muscles. With ageing, there is a gradual tissue migration as a result of gravitational ptosis, changing the quality and location of the facial fat pads, as well as muscle spasm and a weakening of the ligaments that create the tear trough. It is the authorsÕ opinion that the degree and intensity of this ptosis should determine the choice of invasive or non-invasive approaches to correction. Therefore, the choice of patient treatment algorithm
(i.e. surgical or non-invasive correction) will help the aesthetic practitioner to achieve an optimum result and not compromise short-term results.
the method with incorrect and
Effects of hypoestrogenism Beginning during the pre-menopause period, and continuing during menopause and post-menopause with declining levels of oestrogen, some degenerative changes take place with regard to the epithelium and connective tissues (especially hyperkeratinisation). This is accompanied by a decrease in function of the salivary glands (hyposalivation). These considerations are especially important with
regard to the lips. The lips are divided into the mucous membrane (internal) and skin (external). The vermilion is the transition zone between the skin and mucous membrane. The submucous layer at the vermilion border is absent. A large number of tiny salivary glands are located on the border between muscular layer and mucous membrane. The vermilion border is covered with multiplayer squamous keratinised epithelium, while the buccal vestibule is covered with squamous non- keratinised epithelium. The vermilion mucous border and mouth changes are the first clinical signs of menopause. These considerations resulted in the authors starting
the IMPACTç (Integral Menopausal Patient Anti-aging Cosmetic Treatment) Concept investigation.
Materials and methods Every woman will experience three stages of hormonal reorganisation known as pre-menopause, menopause, and post-menopause. All bodily tissues undergo changes during these periods, as previously described, including bone, muscle and fat. Treatment options to correct such aesthetic changes will generally include hyaluronic acid fillers, fat grafting, skeletal implants, and fat transposition.
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