Heart of Face™

Facial Rejuvenation using Btx expertise combined
with Injectable Fillers in upper, mid & lower face.

PHILOSOPHY

Any attractive visage has smooth, round contours; high cheekbones; oblique, hollow jowls; and a thin but well-defined jaw line. One can easily see and draw a “triangle of beauty.” The triangle of beauty creates desire on an unconscious level by encompassing two vertical oblique vectors that open to the sky, to the Divine.

The opposite of the triangle of beauty, the reverse triangle, can be found in faces considered to be old or unattractive. In this reverse triangle, the summit is on top and the base is below, with specific components that include drooping eyes and tear trough deformity; lateral eyebrow ptosis; malar descent; a large, jowly, heavy jaw line; and hypertonic contractions of the depressor muscles (which pull down the soft facial components).

To obtain a natural, physiological correction, we must correct properly—step-by-step—each specific anatomical component. Harmony is the key to success in creating a natural look versus one that is excessively modified and ultimately unnatural.

In our opinion, the best way to approach facial rejuvenation in an elegant manner is to learn the anatomy of the face again in detail in order to achieve a comprehensive knowledge. Both dynamic and volumetric anatomical changes need to be thoroughly understood and addressed.(1)

Dynamic changes of the facial musculature can be modified with products that relax lines and smooth and shape the face—botulinum neurotoxin type A (BTX) in upper, mid, lower facial and neck, alone or in combination with injectable fillers.

Volumetric change is another important part of facial rejuvenation. Most often seen in the mid and lower face and neck, volumetric changes can be addressed surgically or non surgically, and can be related to one of two distinct diagnoses:

• 1) reshaping (in cases with adequate volume),where we can deal with BTX to change muscular balances in the upper and the lower face, or Facelift (2),
  2) refilling (in cases of soft tissue loss or inadequate volume), using injectable fillers.
  While it is useful from an academic perspective to look at dynamic versus volumetric changes, the trend currently is toward assessing the face as a whole and using combination therapy (e.g., Btx + fillers) to provide each patient with the best possible outcomes and to recreate that triangle of Beauty.(1)

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ANATOMY

Each layer of the mid-face has its specific influence on facial morphology. Consequently, it is essential to determine which anatomical component is responsible for facial disharmony before selecting the technique used for its correction. Static wrinkles are generated as the result of skin degeneration with age, sun exposure and smoking. The skin layer can be rejuvenated by means of skin resurfacing and dermal fillers.
Fat harmoniously fills the youthful face and specifically the subcutaneous tissue layers, located between skin and muscles, varies in thickness. The eyelids have very poor subcutaneous fat, whereas the malar fat pad is composed of a thick layer of subcutaneous fat extending from the malar eminence to the nasolabial crease: the SOOF (Sub Orbicularis Oculi Fat).
Loss or paucity of subcutaneous fat may lead to a gaunt and unattractive appearance and/or premature ageing. In fact, many of the signs of ageing are due to the loss of subcutaneous fat. The use of subdermal fillers or the implantation of autologous fat acts at the subcutaneous fat level.
Important muscles of expression in the mid-face are: orbicularis oculi, zygomaticus major and minor, levator labii superioris, levator anguli oris and levator labii superioris alaeque nasi. The orbicularis oculi muscle consists of pretarsal, preseptal and periorbital portions.

With ageing, festooning of lower-eyelid skin and muscle may occur over the malar prominence. Repeated contraction of the orbicularis oculi muscle causes crow’s feet, dynamic wrinkles, and intensifies the hollow eyes and tear trough deformity which are amenable to correction with botulinum toxin or surgery.
Hyperactivity of Muscles

Depressor muscles create permanently a facial descent with a central concentric contraction around glabella, nose, mouth and chin. Wrinkles are the consequences of that hyperactivity: Crow’s feet develop by iterative concentric contractions of the orbicularis oculi muscle. Horizontal forehead wrinkles are caused by contraction of the frontalis muscle to compensate for eyebrow ptosis. (5)

DAO (Depressor Angulis Ori) contraction pull down the corner of the mouth, intensifying that reverse triangle.

Hollow eyes & Tear trough deformity Orbicularis oculi muscle adherence to the lacrymal crest, descent of the SOOF (Sub Orbicularis Oculi Fat) and the malar fat pad associated with septum hernia create a medial depression under the eyes: the tear trough deformity.

By acting on each anatomical components we can recreate a natural, attractive,youthful eye contour Nasolabial Fold Pronounced nasolabial folds are due to sagging of the malar fat pad. The nasolabial crease is an invagination of the epidermis into the dermis. Contraction of the zygomatic muscles accentuates the fold during smiling. Treatment may target each component of the prominent nasolabial fold by using dermal/subdermal fillers or fat and by repositioning the malar fat pad.

TECHNIQUES

BOTULINUM TOXIN / Muscular balance:

We recommend to start facial rejuvenation with Btx injections with a very specific cartography for different kind of patient relevant to each own proper static & dynamic anatomy. Btx injections 2 weeks before or 5-6 weeks after injectable fillers.

™Exceptional Btx+Fillers are performed in the same session; in that occasion we must use the dermal filler firstly, then Btx at the end of the session, to reduce the risk of diffusion with injectable fillers and massage time. We can use those two products in the same session because BOTOX® /VISTABEL® is unique & safer. It hits the target into the muscles with less diffusion than the other botulinum toxins of the market (3).

Injectable FILLERS:

Non permanent gels like NASHA(as Softline® & SSoftline Max® , or Juvederm®) are useful to fill the nasolabial folds, hollow eyes, or malar areas. We recommend:
- crossing-injections for the nasolabial folds to obtain an harmonious contour
- deep sub-fat pad and sub-orbicularis oculi muscle’s injections to correct tear trough and malar descent before, during or after Btx injections. We recommend to use Fillers after Btx.

CONCLUSION

An anatomical expertise combined with elegant cleaver technical injections using BTX (Vistabel®) & Dermal Fillers (Softline®) are the paramount to achieve natural harmonious non surgical facial rejuvenation. Dynamic & Volumetric facial modifications help to create a new “heart” of the visage, included in the famous triangle of beauty and serenity.

BIBLIOGRAPHY

• 1. Fagien S., Raspaldo H. “Facial Rejuvenation With Botulinum Neurotoxin: An Anatomical and Experiential Perspective.” Dermasurg 2007 (in press).
• 2. Raspaldo H. “Lifting video-assisted: evolution [Video-assisted endoscopiclifting: development].” Rev Laryngol Otol Rhinol (Bord)1997;118(1):57–64.
• 3. Carruthers JD, Lowe NJ & al. “Botox Glabellar Lines II study group Double-blind, placebo-controlled study of the safety and efficacy of botulinum toxin type A for patients with glabellar lines.”
  Plast Reconstr Surg. 2003 Sep 15;112(4):1089-98.
• 4. Raspaldo H, Giordano Ph., Bettens R. “Midface Enhancement: anatomy & techniques”. In Facial Plastic Rejuvenation-book Hodder Arnold Editor - May 2006.
• 5. Raspaldo H. “Rules of using botulinum toxin in advanced cases.”
  Dermatology Times 2006 August.

VIDEO COLLECTION

• 1. Injection Techniques n°1 (Face & Neck anatomy, patients selection, Btx technical injections for upper & lower face) – Flynn T., Levy J.L., Lowe N. & Raspaldo H. (English & French)
• 2. Injection Technique n°2 (Facial anatomy, patients selection, Vistabel + Softline & Softline Max combined injections for upper,mid & lower face) – Wahl G., Raspaldo H. DRC video Ed. (English & French)
• 3. Techniques d’injection: Vistabel Hydrafill Softline/ Softline Max – Raspaldo H. Allergan France Ed. (French)
• 4. Nasolabial folds & Lips contouring with dermal fillers: Specific technique – Raspaldo H. Intercharm Moscow medical publications. (Russian)
• 5. Voluma injection technique of a new volumetric treatment: How to easily improve facial contours in your office – Raspaldo H. DRC video Ed. (English & French)