As aesthetic medicine increases in popularity, we find an increasing amount of patients who have never previously considered aesthetic enhancement walking through our clinic doors.
One glance at any social media page that promotes filler treatments will quickly show practitioners advertising their ‘natural’ results or priding themselves in the ‘natural enhancement’ their practice performs. This reveals a trend in aesthetics—one which is obvious. The majority of patients want natural outcomes.
As the demand for aesthetic treatments has increased, so too has our knowledge of the facial ageing process. This increased understanding of the anatomy of the ageing face has significantly enhanced our ability to achieve these sought-after natural results. Where previously, fillers would be used to directly treat lines and folds, we are now able to address the cause, and not the consequence, of facial ageing: volume loss and extrinsic skin changes. We achieve this through targeting areas where this volume is first lost. This approach of indirectly treating patients' concerns by addressing cause, rather than effect, is the cornerstone of creating natural results with filler treatments.
This article will address the approach to natural enhancement with filler treatments.
Regional and social preferences
Even though there is science in beauty and ageing, what is considered to be beautiful is still very often subjective. For instance, patient expectations can vary dramatically between regional norms. What is deemed natural to one demographic would not find favour with another. So where do we find the baseline for what is deemed to be natural?
The diagram in Figure 1 demonstrates how patients who seek profile balancing (a treatment modality where the face is approached in profile view and a series of treatments is planned to restore and/or enhance certain ratios) can be beautified to a point within the natural threshold. The same applies for patients seeking facial rejuvenation.
What many patients are concerned by is the practitioner taking them beyond this beautification threshold, and towards a fabricated ideal of beauty that may be culturally accepted, but does not conform to the natural aesthetic.
This gives us two categories of undesirable, ‘unnatural’ end results:
In some cases, we are seeing trends develop within the UK towards a less natural overall look, with some patients requesting more artificial-looking enhancement of their features. However, the majority of patients will request natural enhancement, and will be concerned about having an unnatural outcome due to fear of being judged for their decision to undertake aesthetic treatments. Societal stigma is a key factor that holds many patients back from seeking help from aesthetic practitioners. With time, this is changing, but currently, a significant proportion of patients prefer not to be seen as having had treatment. Therefore, for both beautification and rejuvenation treatments, practitioners must understand how to achieve natural results.
Conservative; medical; surgical
A key tenet for all healthcare professionals to adhere to when treating patients is to do no harm. In aesthetic medicine, this means considering minimally invasive treatments that may be able to address the patient's concerns, before moving to more invasive treatments, as well as informing patients if, in our medical opinion, the treatment they request will not give them a satisfactory outcome.
With regards to considering conservative approaches first, skincare should be the foundation of any consultation in aesthetics. It is our duty as aesthetic practitioners to ensure that the patient is getting the most out of their skincare regimen, and has tried non-invasive solutions, such as skincare, before seeking more invasive treatment.
If conservative approaches have already been tried and have not been successful, we can then consider medical treatments, such as injectables. These should be considered first in terms of bony volume loss, followed by fat (deep then superficial), and then the use of neuromodulators.
Following the schematic in Figure 2 will facilitate natural results because this bony volume loss is the cornerstone of facial ageing. Toxin treatments may not be so necessary after filler treatment (see myomodulation).
Finally, when medical treatments have been found to be unsuitable, surgical treatments should be considered. In those patients who require surgical intervention to achieve their desired outcome, practitioners should be knowledgeable and conscientious enough to refer patients on to their surgical colleagues for specialised surgical intervention. This is an important consideration in maintaining the patient's natural appearance, as the lifting effect of fillers are limited by the fact that their use can sometimes create loss of natural proportions elsewhere in the face.
Consultation
The consultation is, without a doubt, the most important part of the treatment process. Every consultation should include a full and comprehensive history-taking. When taking history from your patients, be sure to understand what their ideas, concerns and expectations of treatment are. Patients will usually present with either one of two complaints: a general complaint, or a request to treat a specific area (e.g. nasolabial fold). Each of these patients require a different approach.
When a patient presents to clinic with a general complaint (for example, the common grievance of ‘I look so tired’, it is up to the practitioner to determine exactly which of the patient's facial features are causing this effect, and in what fashion and order these concerns should be addressed. These types of patients are usually more accommodating of any treatments the practitioner may advise, and will generally be happy to take these recommendations on board. The second type of patient will direct you to a specific trait that is bothering them. The challenging part here is that the patient's perception of his or her needs sometimes do not match with the treatment the aesthetic practitioner finds will give the patient the optimal end result.
As mentioned previously, it is the duty of the aesthetic practitioner to advise patients against any treatments that will leave them either underwhelmed with the results or looking unnatural, and instead inform them about the ideal treatment to address the patient's specific concerns.
Oftentimes, this requires enhancement of the bone or deep tissues where they are deplete in volume due to the natural ageing process, and not directly injecting a nasolabial fold or marionette line. The difficulty in managing these patients lies in the fact that the aesthetic practitioner needs to communicate that they have understood the patient's concern, while at the same time impart their knowledge of why their own proposed treatment plan would benefit the patient more so than to acquiesce to the patient's initial request.
Another patient that the aesthetic practitioner may encounter at some point is the patient who is not concerned with or burdened with the signs of ageing, who simply wants to enhance their lips. In the authors' experiences, these patients can be very aware and afraid of the possibility of overtreatment and the resulting unnatural aesthetic outcomes. Many of these patients assert that they do not want ‘duck lips’ or an overenhanced appearance as a result of treatment. In such patients, it is better to under-treat, especially if it is the first time you are seeing this patient. If the patient then decides they wish to undergo further enhancement, they can do so at a later time. It is important to remember that lip fillers are a medical procedure, and all patients should be given adequate time (in the form of a ‘cooling-off’ period between consultation and treatment) to consider whether they wish to undergo this procedure. Under-enhancing, rather than over-enhancing, allows the patient to fully consider the extent of treatment that they desire (Vuyk and Zijlker, 1995; Harris, 2017).
» It is the duty of the aesthetic practitioner to advise patients against any treatments that will leave them either underwhelmed with the results or looking unnatural, and instead inform them about the ideal treatment to address these specific concerns «
Examination
When assessing the patient, it is important to see them in animation. The aesthetic practitioner can ask the patient to frown, look surprised and smile fully, but the best way to assess them is to watch them closely throughout the consultation. While discussing their concerns, the patient will not be as aware of their facial movements, which gives the aesthetic practitioner a much better perception of the patient's natural expressions.
There exist a number of ways to carry out an aesthetic consultation, and it is recommend that each practitioner identifies the one that works for them and their patients. The two main methods are mirror-assisted consulation or photo-assisted consultation. It is important to be aware that this is many patients' least favourite part of the consultation, as it can be very confrontational for them. It is important that the aesthetic practitioner is understanding of the vulnerability of the patient during this process, and picks their words carefully when addressing the patient's areas of concern.
Both of the above mentioned methods of consultation allow the practitioner and the patient to look together at the patient's face and address specific concerns that the patient may have. This process will also help the practitioner to illustrate more clearly what their ideal treatment plan will entail. This manner of direct visualisation will often help the patient to better understand why certain treatment options will suit their face better.
Treatment
In order to help patients better understand their aesthetic needs, practitioners often find it useful to break down the face into three thirds: upper, middle and lower.
Upper face
The upper face has long been known to be the primary target for botulinum toxin treatments to address wrinkles and fine lines by injecting the three well-known treatment zones: the forehead, glabella and crow's feet.
However, developments in dermal filler treatments in recent years have brought volumising treatments to the upper face as well. Upper face volume replacement can be naturally achieved in the temples through restoring bony convexity of the frontal bone. Judicious use of filler to support the brow in the retro-orbicularis oculi fat (ROOF) pad is also advised. However, these areas are generally best left to experienced injectors, as they have an increased risk of vascular complications due to anastomoses between the internal and external circulations, and the fact that they contain large calibre blood vessels in relatively tight subcutaneous tissues and fascias (Rohrich and Pessa, 2007).
Midface
Treating the midface is an excellent example of how natural results can be achieved by following a structured approach which addresses the sequence of volume loss in the ageing face. Bony resorption to the maxilla and around the orbits will contribute to changes to the midface fat pads and periocular region. In particular, atrophy of the deep medial fat pad is an ideal target to restore natural volume.
The nasolabial fold is the last area to treat in the midface. Obliterating a nasolabial fold is not necessarily an anti-ageing treatment, and can lead to an unnatural appearance if over-treated.
It is important to understand the limitations of rejuvenation through filler treatment. At some point, the laxity of the skin and loss of bone and soft tissue will no longer be manageable by volume restoration, and one must either accept this next stage in the ageing process or refer these patients for plastic surgery, where more invasive procedures might address their concerns. Continuing to treat a patient with dermal fillers, even when this is no longer a suitable treatment option, can lead to suboptimal outcomes, patient satisfaction and an artifical look (Rohrich and Pessa, 2007).
Lower face
Similar to the midface, the lower face provides ample opportunity to address the root causes of facial ageing: bony volume loss, fat pad atrophy and ligamentous laxity. Injectors should initially approach the mandible through supporting key areas of structural loss: the chin, gonial angle and the prejowl sulcus. Following this, treatment along the mandibular line and up the mandibular ramus can be effective for creating definition. Finally, the marionette area and labiomental crease can be treated directly in the subcutaneous plane (Rohrich and Pessa, 2007).
Myomodulation
Improving or diminishing muscle action of the face through filler treatments is increasingly used to create natural aesthetic enhancement. The basis of myomodulation concerns the potentiation of muscle action as the tissue fulcrum improves. As we lose bone and fat volume, certain muscles have a diminished contractile potential, which can be restored through tissue revolumisation (de Maio, 2018). Similarly, filler can be used to splint muscles to inhibit their activity.
In combination, myomodulation techniques can achieve significant indirect aesthetic results through affecting muscle movement (de Maio, 2018).
Conclusion
In order to perform procedures that can achieve natural and desirable results for patients, aesthetic practitioners first and foremost need an in-depth knowledge of facial anatomy. Not only this, but a thorough understanding of how the anatomical compartments of the face interact with each other, and how this changes with ageing, is also required in order to provide optimal results.
This understanding of anatomy needs to be paired with the practitioner's knowledge of available treatment options, techniques and products. It is becoming increasingly obvious that nothing less than the aforementioned holistic approach to rejuvenation and augmentation is the only way of achieving the consistent, natural results our patients desire—and practitioners should pride themselves in delivering.
In a field that is growing exponentially, it is the duty and responsibility of aesthetic practitioners to continue to educate themsevles at a pace that matches the new developments and treatment modalities and techniques that are being discovered with such frequency.
Only in doing so can we protect not only our patients, but also the the specialty we so value, as it continues to mature and find its place among the established fields of medicine.