CATEGORY 62 AUSTRALASIAN DENTIST LINICAL Mr Bryan Mendelson, a Melbournebased plastic surgeon published a landmark paper in 2012, which really changes the landscape when it came to cosmetic injectable treatments. Up until that time, dermal filler enhancements were problem-focused. If a patient had a line, filler was used to inject the line. This meant that the diagnosis and real-root cause of the problem was never addressed. However since the publication, practitioners that assist their patients with dermal filler cosmetic injections should be looking at all the layers of the skin and face, before providing treatment. As dentists, this should go without saying as we regularly assess a patients face in our day-to-day treatments, particularly when we are determining whether a patient requires orthodontic treatment. Let’s look at the main areas of the face and the changes that occur in each layer. The bone layer As we age, our facial bones undergo a series of changes that contribute to the visible signs of aging in the face. These changes can include bone resorption, or the loss of bone tissue, and changes in bone density and shape. Bone resorption occurs naturally as we age, and it can lead to a loss of support for the skin and soft tissues of the face. This can result in a loss of volume, sagging skin, and changes in the overall facial contour. The bones of the forehead, cheekbones, and jawline are particularly affected by bone resorption, and these changes can contribute to a more aged or tired appearance. Changes in bone density and shape can Treating the multiple layers of the face also contribute to the visible signs of aging in the face. As we age, the bones of the face canbecome thinner and less defined, which can lead to the development of wrinkles and fine lines. The shape of the face can also change as a result of bone changes, with the jawline becoming less defined and the cheeks appearing sunken or hollow. The eye sockets become enlarged, the nose aperture widens, providing less support and the zygomatic arch loses volume and projection. Similarly the maxilla and mandible undergo bone change, more so if there is a loss of teeth along the journey of life. To address the effects of bone changes on the aging face, there are several cosmetic treatments available. Dermal fillers can be used to restore volume and definition to areas that have been affected by bone resorption. Typically a cosmetic injector will use a high g-prime or cohesive filler to enhance and replicate the bone, down on the periosteum. It is important that the correct filler is used with respect to the anatomy so that the filler volume is visible, but that is looks natural and blended with the face. The deep fat layer Over time, one of the most significant changes is the loss of fat volume in the face, including the deep fat pads. The deep fat pads of the mid face, are located deep within the cheeks and are responsible for giving the face its fullness and youthful appearance. There are three main fat pads, these are the medial and lateral Suborbicularis occuli fat (SOOF) and the deep medial cheek fat. These cheek fat pads lose around 20% of their volume between the ages of 30 years of age and 60 years of age, leading to flattening and descent of the tissues. As we age, the deep fat pads shrink and descend, resulting in a loss of volume and sagging of the mid-face. This can lead to the development of deep nasolabial folds, marionette lines, and jowls, which can make us appear older and more tired. To address the loss of volume in the deep fat pads, various cosmetic treatments can be performed. Dermal fillers can be injected into the specific fat pads of the deep cheek to restore volume and lift the midface. It is important again that the cosmetic injector understands the anatomy of the area intimately, as there are large vessels and neuromuscular bundles located in the region that need to be protected. Similar to the dermal fillers that might be used on the periosteum, the fillers used in this area need to be cohesive, have a high G-prime and resistance to deformation. Superficial fat pads Superficial fat pads are the layers of fat that lie just beneath the skin, and they also play an important role in the ageing process of the face. As we age, the superficial fat pads can shrink and migrate, leading to a loss of volume and changes in the contours of the face. Unlike the deep fat pads, the superficial fat pads are less tightly bound to the face, and will redistribute fat to the lower parts of the face including the nasolabial fat pad and the superficial jowl fat pads, further exaggerating the changes that occur with ageing. The superficial fat pads lose approximately 10% of their volume between the ages of 30 and 60, so we need to also consider enhancement in this layer too. Replacing volume in the superficial fat pads is generally directed toward the medial and middle superficial fat pads, and is best done using a cannula. A cannula is a Dr Giulia D’Anna By Dr Giulia D’Anna
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