Initially thought to be useful in rejuvenation of the face as a standalone treatment, we now know that to achieve composite rejuvenation of the face, surgery alone is not sufficient.In an ageing face in addition to aesthetic surgery, we require to improve quality of skin, relax hyperactive muscles of the face, modify muscle responses and restore volumes in areas not traditionally subjected to surgery, like the temples, forehead, glabella ,alar bases, lips and chin.
Also, in younger patients they are a good option to rejuvenate and enhance facial features where we are not contemplating surgery.
Botulinum toxin (Botox) also now called Onabotulinum A is a very effective, precise and potent drug to relax muscles in a desired manner to improve appearance of the face of a person. Since it is so precise, it is also used in correction of functional asymmetries of the face, especially milder pareses or residual asymmetry after surgical correction of facial palsy.
It is the injectable of choice for the upper third of the face where in addition to smoothening wrinkles, one can elevate the eyebrows. Botox can even alter their shape in a favorable manner by precisely changing the balance between the elaevators and the depressors of the eyebrows.
In the lower third of the face, it helps shape the jawline by relaxing the platysma, and the prominent angles of the jaw by reducing masseter bulk giving a more tapering look. Nowadays, it is also being used for making the calves and shoulders more slender.
On its own, Botox has the ability, if injected precisely into the depressor septi to improve the shape of the tip of the nose( both pre and post rhinoplasty), the nature of the smile by relaxing the depressors of the angles of mouth, as well as improve a gummy smile among other things.
Mesobotox( or Microbotox as described by Dr Woffles Wu), the now established concept of injecting small amounts of diluted Botox superficially in the skin is effective in giving a smooth appearance to the skin of the forehead , midface,chin and especially the neck by relaxing only the skin attachments of superficial muscles.It also improves prominent pores in the skin by relaxing the erector pili muscles and decreasing activity of the sebaceous glands.
Injectable fillers (now almost always limited to Hyaluronic acid fillers), have seen rapid advances in the physical characteristics of fillers. Changing from thick rigid hydrophilic biphasic gels with a high G prime ,which made it verydifficult to inject as well as to mold, changing to lower molecular weight, intensely cross linked ( vycross technology), monophasic gels with higher cohesiveness, a lower Gprime and a decreased affinity for absorbing water resulting in ease of extrusion through a smaller gauge needle, easy to mold, enabling full correction and reduced deformability.
With these advances in filler characteristics, it is possible to use them as friendly adjuvants post facelift and blepharoplasties to correct, improve residual areas of volume loss in the midface and periorbital region. Post rhinoplasty, they can be usedto correct minor issues.Of use as a trial for confused patients before nose surgery to enable them to make up their minds, or even as a standalone treatment to shape low profile noses are excellent situations to put the best fillers to use.
With increasing awareness of altering favourablythe shape of the face to oval (or as close as possible), the filling of hollow temples, the enhancing of projection to the small chin in the Indian patient, or to restore the loss of chin volume, position and projection with age, injectable fillers with the ability to achieve all of this in a few minutes, without any downtime have become an important tool in the armamentarium of the Aesthetic Surgeon.
The biggest advantage with the HA fillers is that they can be selectively, or completely reversed with hyaluronidase in calculated concentrations. Hyaluronidase preparation in our country is not a human one, and hence dermal sensitivity testing must be done prior to use.
Having stated thus, it should be remembered that safety issues are very important, as various adverse effects have been reported with injectable fillers ranging from inflammatory nodules , to infections, to accidental intravascular injections in the arteries of the face causing skin necrosis over the nose and glabella, as well as loss of vision from occlusion of the retinal artery (more than half of such reported cases are from injectable fat and not fillers). Detailed knowledge of the facial anatomy, including detailed knowledge of the vascular anatomy, coupled with learning safe injection techniques remain the cornerstone of safe and effective filler treatment.
