CATEGORY 82 AUSTRALASIAN DENTIST LINICAL Right from our undergraduate degree through to any postgraduate education that we undertake, we should always be putting our patient safety and results as being of paramount importance. We set out for a pleasant experience for our patients so that they keep coming back to see us, but also so that they tell their friends and family about us. And we all want to sleep well at night, knowing that we did the best that we could without worrying about the heath and safety of our patients. I am sure you are like me too. That is why I use the ATP approach, and why you should too. This is particularly important with cosmetic injectable procedures. So what is the ATP approach? Anatomy. When we first begin our education at university, we seemingly undertake anatomy wondering why we need to know it. It is only a little later on that you understand the relevance of that level of education. Then as you career progresses, sometimes we take it for granted that we learnt anatomy as we continue on in “autopilot” mode, doing what we have always done. Whenever we learn a new skill, as well as hone our already established skillset, it is important that we always reflect back on the patient anatomy. After all that is what we are dealing with. This is particularly important when we are performing cosmetic injectable treatments. When it comes to the face, there are four components of anatomy. ANATOMY Part one: Vertical fifths The most balanced faces and results are when the vertical fifths of the face are of equal width.We look at this orthodontically, but we should also look at this when we are considering enhancement of the face. Asymmetry in one of the fifths will lead us to see that “something is not quite right”, and we want to balance it out. The nasal alar should lie below the medial canthus of each eye for perfect balance. The most lateral fifth extends from the lateral helix of the ear to the lateral canthus of the eye. The next two fifths are represented by the eyes (medial canthus to lateral canthus). Of course there are racial and genetic variations to this “perfect” ideal of balanced fifths, but having some kind of reference helps us to identify where one fifth is wildly different to the other side. Part two: Horizontal thirds The face can also be divided horizontally into three parts. Before we define this, let’s point out some important landmarks. The trichion is the hairline, and defines the most superior border of the face.The nasion is the bridge of the nose, and is the midline bone depression between the frontal bone and where the two nasal bones meet. The trichion and nasion define the borders of the upper horizontal third. The next third runs from the nasion (or bridge of nose) to the sub-nasale, which is sub-nasal, as it’s name suggests, is the point where the nasal columella joins the upper lip. So essentially the length of the nose makes up the middle horizontal third. The lower third therefore runs from the sub-nasale to the menton, or the lowest point of the chin / mandibular symphysis. Where one of the thirds is too short, we may consider orthodontic treatment, maxillofacial surgery or dermal filler to extend the third that is lacking. They are all equally valid, with proper discussion and consenting with the patient. Part three: Depth of Anatomy So now we have looked at the superficial components or surface anatomy, now we need to consider depth. Where is the deficiency for the patient? And when I am thinking about enhancing the deficiency, what structures are of importance in the area? An area that is a frequent concern for patients is the jawline area. Patients dislike the excess draping that occurs through life, where the jawline definition is lost. Indeed, itmay have never beenpresent in the case of a severe class II orthodontic malocclusion. So some options that we might present to the patient may again include orthodontics and maxillofacial surgery. But what options do we have that are non-surgical and present a short timeline for our patient. We have of course dermal fillers, where we can add to the jawline in key areas to improve both the projection of the chin in both the vertical and horizontal plane, but we can also add to the mandibular border and gonial angle. When we do this, it is vital that we reconcile the structures in the plane we are thinking of injecting. If we remember back to the first year of anatomy back in dental school, we should recall that the facial artery passes over the mandibular border in the antegonial notch, which can be palpated by running your index finger along the jawline. So when we use dermal filler, it is so important that we avoid the facial artery. So how do we do this? We need to keep the dermal filler in the subcutaneous plane. Where the facial artery is deep, we must treat the patient superficially, and vice versa. We can use imaging devices such as laser guidance (which I love and use in my practice) or ultrasound. However ultrasound in particular has a steep learning curve and cannot be learnt in one day. Whilst useful where there are complications and in highrisk areas of the face, the use of ultrasound is certainly not the new standard, despite the misinformation that is sometimes spread by those with financial incentive to do so. I would recommend that you invest in studying an anatomy-based injecting course, to understand the areas of risk in the face. This is too important to ignore. You must know this when you inject. We understand this intimately when we undertake a local anaesthetic block. We must also recognise and appreciate the anatomy when you inject filler or toxin. Part four: Movement When I first studied cosmetic injectables, the dynamic movement of the face was not discussed at all. But as time has gone on, this is an area that is now recognised as being of high importance in the aesthetic zones. For this component of anatomy, we Why every cosmetic practitioner should be using the ATP approach By Dr Giulia D’Anna, BDSc, MRACDS, FIADFE, Grad. Dip. Derm. Ther, Cert IV TAE, Grad. Cert laser giulia@dermaldistinction.com.au Dr Giulia D’Anna
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