It seems to me that the greatest achievement of recent years has not been new technologies, but a change in the minds of aesthetic medicine specialists - from a master wrinkle filler to an artist, a sculptor who has a vision of the beauty and harmony of a woman's face. And the main task is to meet the patient's expectations, on the one hand, and to preserve naturalness and individuality, on the other. I hope the time of "plastic", "pumped", "frozen" faces is over.
There is no one-size-fits-all measure or technique. Everyone chooses certain tools and strokes for themselves: just as an artist uses a certain palette of colors for each painting, so a doctor, assessing a patient's face, selects those methods and drugs that will give a harmonious and beautiful result.
And no meter, no congress will turn a banal "injector" (or, as they say abroad, injector) into a real aesthetic medicine specialist in an instant. So it turns out that you need to collect skills and recommendations, touches of techniques and methods, going through a difficult path of formation.
The series of my articles is just an attempt to share my personal experience with you, with successes and failures. In one of my articles, I already addressed the topic of facial oval correction, but then I focused more on correcting age-related changes in that imaginary line that runs from the temporal region along the protruding points of the cheekbones and gently passes through the cheeks to the rounding of the chin. Correction of the facial oval in this sense naturally included correction of "boulders", eyebrow lifting, lifting of the zygomatic zone, etc. (see the article "Facial Abyss. Hypertrophic and atrophic changes", LNE No. 3(91) / 2015, p. 28-07 - Ed. note) (photo 1).
In today's article, I would like to touch upon the topic of not only anti-aging correction, but also the harmonization of the lower facial line, which runs along the lower mandibular line (photo 2).
As always, I would like to remind you that there is no single measure of "beauty" of facial features and shape. Numerous changes in the trends of beauty assessment in the twentieth century, with all its fluctuations from the recognition of triangular, "cat" face, broad-eyed, pentagonal, etc. as the canon of beauty, only prove the need to preserve individuality and non-template in aesthetic medicine (photo 3 without the bottom two).
However, one of the leading signs of facial aging was, is and will be a change in the contours of the lower jaw, which, in fact, leads to a visual shortening of the lower mandibular line, as well as an increase in the cervical-chin and mandibular angle (Fig. 1). + bottom two of photo 3).
This sign of aging is especially common in women with an initially sloping chin and a short hyoid bone (characterized by a shortened distance between the trachea and the end of the chin) and is exacerbated by age-related atrophy and resorption processes in the temporomandibular joints and the alpine-mandibular joint.
Although the chin slant can usually be compensated for (if it is caused by maxillary prognathia, then this is, of course, an orthodontic correction, but if the peculiarity of the structure of the lower jaw is the introduction of fillers or the placement of a silicone implant), unfortunately, the location of the hyoid is not.
In youth, a fairly sharp cervical-chin angle is maintained due to hypertonicity of the entire platysma mass, but with age, its anterior rods begin to sag, while the lateral ones form even greater hypertonicity, which enhances and accelerates the formation of "boulders" and "blunting", smoothing this angle, and a second chin is formed, sometimes even without significant fat deposits.
Compensation is usually required to be comprehensive. In terms of botulinum toxin, the procedure of the so-called masseter smoothing, i.e. making the face more oval by injecting Dysport into the m. Masseter. In this situation, such a procedure will only aggravate the situation.
We can talk about the injection of botulinum toxin in the Nefertiti neck procedure to compensate for age-related hypertension of the lateral platysma bands for some compensation of the "boulders". This procedure is often combined with the injection of botulinum toxin into the m. Depressor anguli oris, which theoretically should reduce the degree of manifestation of the "boulder" and the lowering of the corner of the mouth, but in my practice I do not see a good result of correcting this point, but the risk of problems due to the spread of botulinum toxin in the m. Depressor labii inferioris is very high. It seems to me that the risk outweighs the possible bonuses.
The use of HA fillers is indicated after the full effect of botulinum toxin has occurred. The introduction of fillers is carried out in several areas, and I will tell you more about this.
The first stage is supraosseous compensation, the injection of a filler into the chin area. On the crest of the chin bone, we place 2 bullae vertically: the volume of the lower one is from 0.5 ml, the volume of the upper one is at least 0.3 ml (when forming the upper bullae, we determine the boundaries of the mucous membrane attachment through the oral cavity and mark this border outside; naturally, the upper bulla should not be higher than this level, because otherwise there is a high probability of embarrassment: during the procedure, you can simply pass through the tissue). The most dense preparations should be used for this procedure, for example, Teosyal Ultra Deep or RHA 4 (Fig. 2).
In the case of older patients who already have a shortened mandibular line, it is possible and even indicated to introduce a bulla of a dense preparation at the corner of the jaw. The bulla in the mandibular angle is placed behind the m attachment. Masseter is quite voluminous - about 0.5 ml (Fig. 3).
Returning to the principle of light and shadow play on the face, I always pay attention to the formation of a depressed triangle in the corner of the mouth and in front of the bulla. I compensate for it with a 27 G cannula 45-50 mm long. At the first stage, we perform a "dry" multiple perforation of the labiomandibular ligament according to the same scheme that will be used to place the filler. This procedure alone will cause a slight correction of the lip-brow fold and "boulder" due to the weakening of this ligament by perforation.
The second stage is the filler correction. According to the same scheme: a puncture is made from the lateral protrusion of the chin and a rather dense, but at the same time well-stretchable preparation is spread with a fan - I use Teosyal RHA 3 or Teosyal RHA 4. The product is spread out in a thin layer wide. It is necessary to feel how the cannula breaks through the labiomandibular ligament when passing the line (photo 4).
The depressive triangle in the corner of the mouth is compensated with a plastic and elastic filler. Any product in the Teosyal RHA line is suitable for this purpose, the doctor makes a choice depending on the severity of depression, skin thickness, subcutaneous fat volume, and the activity of the facial muscles. The correction is carried out with a point needle at the very point of the drooping triangle, the volume of the bulla is 0.2-0.3 ml, after injecting the drug, we perform a good kneading. When administering the drug, it is necessary to control the process of drug administration with a finger through the oral cavity so as not to "fall through" into the oral cavity (Photos 5-7).
However, the most pronounced result is a comprehensive correction that includes surgical threads. I have already given a scheme for placing sutures to correct the oval of the face and described it in the article "Facial Abris" (Fig. 4).
If we talk about the correction of the lower jaw line, the most effective in my practice is the placement of surgical sutures almost from the ear ridge with the exit at two points parallel to the mandibular line. The first point is determined by a 1 cm departure from the lip-chin fold and from the edge of the jaw. The second is located 2-3 cm laterally (Photo 8).
Thus, a fairly pronounced correction and rejuvenation of the lower facial contour is possible using non-surgical methods, with the right combination of techniques and, of course, with a correct assessment of the patient. A patient who has long been indicated for circular facial plastic surgery due to a pronounced excess of tissue and its high stiffness will not be satisfied with the result, nor will the doctor who performed the procedure. Even in fairly "favorable" patients, you should not have high expectations, but in general, the result is quite satisfactory and long-lasting.