Case Study: Full-face Rejuvenation

Dr Jeremy Isaac explores his tips for facial restoration using the TEOXANE range of dermal fillers

Assessment, ageing and anatomy This 48-year-old peri-menopausal patient presented to my clinic because she felt reserved and self-conscious about her appearance, wanting to look fresher and younger. She had undergone no previous aesthetic treatments in the past and there were no contraindications found following a medical consultation. The face was assessed using a global full-face approach. It was clear that the forehead, temples, mid-face and jawline were all showing the paradigm of ageing. The upper face appeared quite skeletal with temporal hollowing and there was the presence of decent, deflation and disproportion in the mid-face. Through dermal filler treatment, the aim was to achieve an overall softening of the face, developing feminine curves rather than sharp angles. The goal was a natural, subtle accentuation and avoiding abnormal exaggeration, our patient’s greater fear. I always begin treatment from the upper face, working through to the lower face. It is important to ensure the upper face is supported and elevated first as it has a direct impact on the anatomy and appearance of the mid-face. I then augment the mid-face before the lower face.

Technique and product selection I choose the Teosyal RHA dermal filler range for their rheology. The genesis of the resilient hyaluronic range is to mimic natural hyaluronic acid. The TEOXANE range is the first resilient hyaluronic acid dedicated to facial dynamics2 and has an unparalleled viscoelastic region making the hydrogel very dynamic. The consequence is the gel is capable of stretch and compression with excellent biomechanical endurance, enabling it to mimic the natural movements of the face. They also have an excellent safety profile, and all the products in the range are approved by the US Food and Drug Administration.1 For this treatment, I used both needles and cannulas. I believe it is important for practitioners to be able to use both instruments to achieve a multi-layer approach. To access the superficial fat for example, you need a cannula to ensure you are in the correct tissue plane and when targeting the deep fat compartments of the face, then a needle or cannula could be used to access these anatomical landmarks. I started with deep compartments and used the whole of the Teosyal RHA toolbox. By placing the right product in the right plane we were going to get the right outcome. A total of 7.8ml of product was used to get this outcome (Figure 1). RHA 4 was used in the mid-face and multi-layered into the deep and superficial compartments. The target for the injection was the anterior mobile face and the lateral aspect of the periauricular area. The volume loss of ageing seen in the temple, jawline, pre-jowl sulcus and chin were addressed using RHA 4. RHA 3 was used in the marionettes and RHA 2 was injected into the body of the lips. RHA 1 was used to augment the depleted upper cutaneous lip with a cannula and the perioral rhytids effaced using a flat blanching technique. In her review, the patient said she was very happy with the outcome. She’s got so much more confidence because of having this treatment, saying she feels she can face the world again. In my assessment, I deemed no further dermal filler treatment was necessary.

Top tips for success It is important to understand the patient’s list of priorities when it comes to treatment and know what they want to achieve for their final outcome. Don’t rush your treatments because hyaluronic acid products react differently amongst individuals and consequentially, you may not need as much product as you may think. As hyaluronic acid takes on 1,000 times its weight in water, underestimate what you think you may need and then review. Remember, it is better to do a touch-up than overtreat and have to electively dissolve the product. Finally, for excellent aesthetic outcomes, it is essential to understand the anatomy and the stage of ageing of the patient to have a skillset of techniques to address the patient’s concerns and products with rheological properties you can trust within the targeted tissue. Each product has different characteristics and acts differently so choose dynamic products above the SMAS and more static products for the deep fat compartments for a natural outcome.

Before After Dr Jeremy Isaac practises at Wish Skin Clinic in Port Talbot. He is a country expert for Teoxane and is a national trainer for Teoxane and Aesthetic Medicine Pathways. He is on the JCCP training and education committee and is a founder of MAP-IQ. Qual: BDS, MSc (CosMed), PGCert (MedEd), LDS, RCS

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Teoxane.com/uk

REFERENCES

1. US FDA, Premarket Approval (PMA), Teoxane, 2022. <https:// www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pma.cfm> 2. Faivre J, et al. Advanced Concepts in Rheology for the

Evaluation of Hyaluronic Acid-Based Soft Tissue Fillers.

Dermatol Surg. 2021 Jan.

BOCOUTURE® is the only toxin that can be transported and stored prior to reconstitution without the need for cold chain1–3

FEEL GOOD LOOK GOOD

Bocouture® (botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials*. Prescribing information: M-BOC-UK-0432. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of botulinum toxin. BOCOUTURE should only be administered by an appropriately qualified healthcare practitioner with expertise in the treatment of the relevant indication and the use of the required equipment, in accordance with national guidelines . The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Total recommended standard dose is 20 units. 4 units into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 4 units injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 10 units to 20 units is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 2 units, 3 units or 4 units is applied per injection point, respectively. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with ageing or photo damage). In this case, patients may not respond to botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with botulinum toxin hypersensitivity, amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare - exaggerated muscle weakness, dysphagia, aspiration pneumonia). Hypersensitivity reactions have been reported with botulinum toxin products. Glabellar Frown Lines: Common: headache, muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: eyelid oedema, dry eye, injection site haematoma. Upper Facial Lines: Very common: headache. Common: hypoaesthesia, injection site haematoma, application site pain, application site erythema, discomfort (heavy feeling of frontal area), eyelid ptosis, dry eye, facial asymmetry, nausea. For a full list of adverse reactions, please consult the SmPC. Overdose: May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Legal Category: POM. List Price: 50 U/vial £72.00, 50 U twin pack £144.00, 100 U/vial £229.90, 100 U twin pack £459.80. Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany. Date of Preparation:August 2021. Further information available from:. Ground Floor Suite B, Breakspear Park, Breakspear Way, Hemel Hempstead, Hertfordshire, HP2 4TZ Tel: +44 (0) 333 200 4143

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard for the UK. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

*Botulinumtoxin type A, purified from cultures of Clostridium Botulinum (Hall strain)1 References: 1. BOCOUTURE® (incobotulinumtoxinA) Summary of Product Characteristics. Merz Pharmaceuticals GmbH. 2. Vistabel® (onabotulinumtoxinA) Summary of Product Characteristics. Allergan Ltd. 3. Dysport® (abobotulinumtoxinA) Summary of Product Characteristics. Ipsen Ltd. M-BOC-UK-0443 Date of Preparation: December 2021