Presentation made at the MIPSS meeting, Marbella 2022 by Dr. Gabriela Casabona.
Systematic Approach to Minimally Invasive Facial Rejuvenation, by Gabriela Casabona.
What is the importance of being systematic in your approach for facial rejuvenation?
Systems are very important. I started to recognise the importance of a systematic approach many years ago when I began changing my toxin injections. Getting comfortable with a technique is so much easier - human beings are creatures of habit, we go with what we know, can already do, and quite often take the easier path. We can easily opt to use the same automatic technique for every individual. So, to tailor-make something is not as natural for us, it is out of our comfort zone. To get out of that comfort zone is when the magic happens - for each patient, we have to restart, think again, and apply something different. This raises the question as to whether there is a way to find a pattern or system for a customised approach? So then I learned how important it was to do this, because nowadays we also have all the artificial intelligence and machines to learn these algorithms and create patterns - what is the importance of being systematic, of bringing patterns? What we do is art, yes, a part of it is art, but every single painter or sculptor who studied their craft learned the basics and techniques before they could develop that art. You have to start somewhere, so asking the right questions is the first, most important thing - I have always believed that. So, I will introduce you to the following, important steps. Knowing your patients, understanding complexities, regions versus treatments, what to choose, where to start, combinations and anatomy, safety vs effectiveness.
What does the patient really want?
“People talk without speaking, and others hear without listening!”
To find out what a patient wants can be really difficult. Sometimes a patient comes to you with a request, but they don’t know how to exactly translate what they want - so I have to learn to communicate suing a common ground in these instances. How can I really understand and extract what my patient really wants from what they have said?
During a summer academy in Austria at a workshop for upper third facial rejuvenation, I had an experience with a model, who was a doctor. She explained to me that she wanted the MINIMUM amount of toxin; very very very little. During her combination treatment I showed her a scale on static lines of the forehead and asked the model where she saw herself at that time, and where she wanted to see herself according to that scale. Before treatment she pointed at the number 4 (on a scale of 0 - 4), to which I agreed. When I asked where she would like to see herself, she pointed at the scale relating to 0. This patient wanted the maximum effect without having to have the treatment necessary to achieve it. Had I gone along with her words, she would not have been happy with the outcome. This shows how far we can be from a perspective if we are not analyzing what the patient wants effectively. It is so important to translate the patient correctly. We normally go from where I am going to treat, to the product I am going to use and how I am going to use it. But we forget three things that add complexity to our treatments:
Self perception - the patient that has an incorrect perception of their reality, good or bad is irrelevant, but we need to recognise what their self perception is to be able to gauge their wants. Is this a difficult candidate for aesthetic treatments?
Expectations - patients with high expectations are more complex to treat than those with low expectations.
Severity - We must take this into account before applying a technique or product - we can’t take the same technique, independent of the severity, and just change the amount of product required. Sometimes these small details can interfere with the outcome if not addressed properly.
Step 1. Expectations…one patient I did injectables for complained about her eye bags which I treated with fillers. Her main component was lack of volume and skin quality so I decided I could inject her. But she wasn’t happy with the outcome, why? Her main goal was not in fact what I thought it was - what she really wanted fixed was the bar code - so she wasn’t happy and it was my fault as I had not understood her. So I continued to treat her but there’s a limit to what I can do here, I cannot achieve a grade 0 using the procedures she was comfortable with. This is why I like to use images, and scales to be able to really see what a patient is expecting. To really understand and know what their expected outcome is. They have to point out what they are expecting, and then my job is to aim to achieve that outcome. What they say and what they point to can be very different things! This process also helps with recognising their self perception, where they see themselves on the scale is indicative of how they perceive their appearance, which could be very different from what we see.
Another patient said she was not happy with her jowling (post treatment) but actually she was unhappy with her marionette lines. If you are treating laxity, for example, you have to take photos of before and after to be able to measure effectively at a particular angle. To standardize this I ask the patient to use their hand and rest their head on it, then remove it for the photo - keep a record.
Step 2. What are other complexities I found? The levels, skin quality, physical conditions, high expectations - all this made that patient more complex. Another patient has skin problems, skin quality issues, physical conditions, and high expectations. Learning to deal with complex patients is essential, and complex does not always equal severity.
What I have learned by observation is that we can adjust and we can understand what to do when having a mild or severe patient in terms of layers and treatments. Every treatment can treat a different layer, I can use HA, for example, in almost all the layers, energy based devices to others, so I have to understand which layers to treat with which treatments. I realized that when a patient has a problem with skin quality - this is a game changer in priority - treat this first, always. HA, lasers, PRP nano-fat, whatever the treatment - treat the skin quality first.
When using injectables, and you have a bad level of skin quality, It’s like a balloon effect - take a balloon, inflate with six puffs of air, tie it up…it’s tight, shiny, elastic, beautiful - in a week you release that air and then see if you can blow that balloon to the same tensity with the same 6 puffs of air. Not a chance, you’ll need at least double. It is the same with the skin. If you have loose skin of bad quality, that is not tight and does not give back energy to the bone, you are going to have to fill it more and more.
Muscles of the mimic can be treated differently - I may sometimes block the muscle force (at muscle level) or maybe I will simply smooth the connections in between the muscle and the skin (by injecting above the muscle). Do I want to treat inside the muscle to block the function? Or do I want to treat it superficially just to block the connection and not the function?
I need to recognise that the same HA can behave differently depending on the layer in question, and take advantage of this.
Step 3. Treat the layers. In the face, you often have to treat different layers in order to use less product. If you try to create a skin effect by only injecting the bone you will have to inject much more product.
Understand the difference between the bolus and the retrograde. The bolus itself apparently has the same lifting effect as a retrograde, but if you massage a retrograde injection it will almost dissolve in the tissue. And the bolus stays where it is - so if you want to create a lifting effect with the filler, don’t use retrograde, you have to use bolus. If you start using retrograde, and I remember when I was a speaker promoting a product, other doctors were using so much more product than I was - they were using 3 times more product. Why? Because they were using retrograde that has a smaller lifting capacity than when you use a bolus.
Biostimulators: Technique makes a difference in the diffusion; I want to diffuse the biostimulator but if you use a needle you have very little diffusion, no matter the type you have used, the biostimulator will be concentrated along the needle injection. Whereas if you use a cannula you will be able to distribute everywhere - so technique is vital to outcome.
Step 4. Where to treat. Once you understand the severity, what the patient wants, their expectations, etc., you know which layers are involved; whether it is a bone problem, a fat problem, a skin problem, what are the problems that need to be treated, which procedures you need to use in each layer, whether I need to combine treatments or not - where do you start?
When a neck angle patient comes in, I would usually start with the chin, but because of the severity of the neck angle I need to bring a holistic approach - how do I give support to the lateral face so that I can get a better design, a tighter jawline, and so that I can use less product on the chin - I see that this is not only a chin problem but a combination. So what I did was grade her, understand what she wanted and the level of improvement she desired. So instead of treating her only on the lower face, I treated 3 regions to get the result she wanted.
How did I get to this? Go beyond the area they’re complaining about and treat multiple regions of the face to give the effect you want to achieve. Especially if they are 3 - 4 on the scale. This is the result I achieved for her. Using only fillers and microfocused ultrasound, fillers in the points shown, using the posterior temple to give support to the jawline definition angle of the mandible. Where to treat is important so choose your regions according to the severity. If a patient has a high expectation or an added complexity you add a region to their treatment.This is how I classify my patients, it depends on whether they are mild, moderate or severe as to how many regions I treat.
Step 5. Patient combination procedures; after looking into 3000+ patients in 19 years, I understood that the jowling was only treated with one or two procedures, but if I have a severe jowling, I would treat 2 - 3 regions with 2 -3 procedures. The more severe, the more areas I treat, with more procedures. A mild case may only be the region shown. If more severe I go beyond and use combined procedures to get where I need to go.
First things first - it is vital, when a combination of procedures is in play, to prioritise each treatment accordinlgy. If I am correcting a chin or a nose, for example, as well as lip fillers,I would not do the lip first. The chin and nose are landmarks for the lip and how it looks, if they are being changed they should be changed first. The lip can then be addressed.
Step 6. How to treat? I never realized how many decisions I made before taking a cannula and injecting a patient - the cannula size, the product, is it bolus or retrograde? how far do I inject? which layer am I going to? - there are more than 15 decisions to make before beginning the treatment itself.
How to treat is a very important factor - what will I use? How many syringes will I need? What amount am I injecting for each bolus? So those are the things that are severity dependent on the amount and the sessions and the technique is goal dependent, so I want to loft, I want to contour, what am I doing with this particular patient. Am I using bolus, mini bolus or retrograde injections?
The next question is the amount, how many syringes of filler am I using? If there are more than 6 syringes in one session, the session would be divided into more than one. Choose the depth of the toxin injection according to the goal; are you blocking the muscle or simply smoothing the skin? Choose your filler technique according to the goal; lift or contour or smooth?
Customize your treatments, don’t be too automatic when you do things, don’t lose the view of the different needs, muscle mass and symmetries each patient has. Choose safety first, always. There is no 100% safe place for any procedure on the face in my opinion, but there are more effective places to put procedures, so we bear in mind what we already know, what means lateral face and medial mid face behave differently with different procedures, so we must correct something medial by starting laterally, note the effect, and then go medial. Keep the results with the least amount possible.
Don’t forget areas - the posterior temple is an area we don’t see, we don’t see an immediate effect, because we are not trying to affect the temple itself, though it can have a great effect on many other areas of the face - I personally love the posterior-superior temple to achieve an effect on the brow and the interior temple. I love the posterior-inferior temple to get an effect on the mid face and also the lower face. Whenever I don’t have space on the bizygoma to expand more, I go for the posterior-inferior temple to give support, for example. To create the foxy eye effect on the brow, I used the posterior-superior temple. These combined procedures create a more natural, holistic look. If you treat only one area, the trouble area, the rest of the face can look worse. You are smoothing just one area and creating a gap between there and the rest.
Skin quality is a game changer - for one patient I treated her skin quality (in order to inject life into it) six months prior to injecting her with fillers. The amount of product, I had previously calculated, intended to use on her during a teaching session, was completely different to what I actually used. Her skin quality had improved so significantly in the 6 months I only needed to use ⅔ of what I had planned.
Take home messages -
Try to understand what the patient wants objectively
Take quality before and after pictures with correct positioning
Be aware of complexity points that can interfere with the outcome
Start by impact zones - towards a holistic approach
The more severe the condition, the more regions to combine; starting from top to bottom
The more severe a condition, the more procedures you need per region: start from deep to superficial unless bad skin quality)
Choose technique according to the layer and the goal
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