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Clinical Practice Special Focus

EndyMed 3DEEP

remaining flat. In these cases I add more product to the centre of the lip at the top and bottom, and add a very small amount, around 0.5mls, to the area around the mouth, halfway between the centre of the border and the lateral edge, with more emphasis on the bottom lip, to lift the lip line. For patients with thin, ‘letterbox’ lips it can be difficult to get volume while the mouth is closed. For those patients it can be helpful to show them in a mirror how their lips look fuller when they are in motion.” For barcode lines, Dr Rakus says, “Fillers still achieve good results, but lasers such as Fraxel and Total FX can be highly effective in minimising fine lines and are often used in a combination treatment plan.” Ageing is often associated with a downturned, ‘sad’ mouth, which develops due to descent of surrounding tissue, habitual expressions and loss of volume. The use of botulinum toxin in the lower face, in particular to relax the depressor anguli oris muscles to create lift at the oral commissures is increasingly popular. However, Dr Mervyn Patterson warns that special care must be taken when treating the lower face. “If treatment of the depressor anguli oris is unequal on both sides the smile will be asymmetrical and difficult to correct. Slight diffusion laterally of toxin in the mentalis will affect the depressor labia inferioris which leads to a very unusual looking movement of the lower lip.” Aesthetic nurse Sharon Bennett says, “To avoid asymmetry, when targetting the perioral area and the depressor anguli oris it is important to avoid the orbicularis oris, which would affect the sphincter and closure of the mouth with reduction in ability to pucker, while injections given too medially will affect the depressor labii inferioris between the DAO and the mentalis. This will cause a flattening of the contour of the lower lip, an asymmetric smile and reduction in the ability to purse the lips. You can

I use the tower technique when injecting in the zygomatic arch, placing little towers of one of the thicker fillers, Dr Nick Lowe

Dr Ariel Haus using the Sublime skin tightening system

normally palpate the DAO by getting the patient to contract the muscle for example asking them to pronounce the letter ‘e’.” Dr Mervyn Patterson warns that, “Over zealous orbicularis oris injections impair the ability to pronounce ‘p’s and ’b’s. The correct procedure only lasts about 6 weeks.” Surgeon Adrian Richards adds that excessive relaxation of the depressor anguli oris muscle (DAO) may lead to the elevation of the corners of the mouth. This occurs because of the action of their antagonist levator anguli oris muscles, which elevate the corners of the lip. With less resistance to the levator muscle, the lips can curl up in an unnatural ‘joker smile’. This may be a particular risk with older patients because the philtrum area tends to lengthen with age, which lowers the central part of the upper lip. Says Richards, “The key is to be very conservative and very superficial. I would use 2 to 2.5 units of Botox, and inject just into the skin, allowing the toxin to diffuse into the muscle.” If a patient has a strong platysmal muscle pulling down the angle of the mouth giving jowls and marionette lines, Dr Lowe says, “I inject a maximum of ten units of Botox or equivalent into the muscle, divided equally between the right and left sides of the platysmal bands.” Lower facial ageing may also be caused by volume loss in the mid-face, so don’t ignore the use of lifting fillers injected into the lateral cheek and over the zygomatic bone to lift the lower face and mouth area. Dr Lowe says, “I use the tower technique when injecting in the zygomatic arch, placing little towers of one of the thicker fillers, injected vertically right on the periapical of the zygomatic arch with either SubQ or Voluma. Sculptra treatments can lift the mid-face but it is important to avoid the area around the mouth as it appears that the action of the muscles in this area concentrate Sculptra into small areas, which may result in nodules.” However, Dr Patterson says, “There is only so much lift one can be achieved with fillers, and lifting becomes more difficult with more aged faces without creating an over-inflated look to the cheek. Early intervention is best and patients should be informed when surgery is the best answer to their concerns.” For early signs of jowling, Dr Lowe says a more youthful jawline appearance can be achieved using a hyaluronic dermal filler injected into the indentation just below the chin and before the jowl. “Used in combination with a thicker filler to lift the cheek skin this can be extremely effective, In addition, Nefertiti injections of Botox along the jawline can be effective in cases where the platysmal bands are pulling Aesthetics | February 2014


Aesthetics february 2014  
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