Patient satisfaction and great aesthetic outcomes start at the initial consultation, and physicians should carefully examine the facial anatomy to improve their approach to the treatment plan. Deborah D. Sherman, MD, assistant clinical professor at department of ophthalmology at Vanderbilt University and chief executive officer and chief surgeon of Sherman Aesthetic Center, both in Nashville, TN, described the approach she takes and how it can translate across the four core specialties of aesthetic medicine. She shared her insights at the Cosmetic Bootcamp Virtual Meeting on July 11, 2020.
The face has four, almost tectonic, layers—bone, fat pads, muscles, and skin—to consider in an aesthetics analysis, Dr Sherman explained. For these facial layers, aging comes in several parts. Atrophy of the bone reduces tissue support, fat loss and descent on the face leads to an inversion of the “triangle of youth,” habitual expressions such as frowning and smiling lead to repetitive muscle contraction thus fine lines, and skin thins and loses elasticity. Together, these layers contribute to loss of shape, structure, and contour over time.
Dr Sherman recommended assessing a patient with a wide focus, including:
- Signature vs distracting features;
- Facial shape;
- Proportion and symmetry;
- Emotional attributes; and
- Light and shadows.
Further, Dr Sherman discussed how she assesses the patient’s face in thirds: the upper face, the midface, and the lower face.
For the upper face, aesthetic specialists should take close look at the periorbital aging changes. Patients often present with temporal wasting, loss of forehead convexity, brow and eyelid ptosis, lateral canthal dystopia, dermatochalasis, and lid retraction. For example, many patients are concerned with the appearance of tear troughs; although, noted Dr Sherman, aesthetic specialists should consider the root cause of tear troughs carefully. It may be loss of fat in the cheek or imbalance elsewhere that needs to be addressed instead of the tear trough directly.
The midface, explained Dr Sherman, is the first place to show aging. Often, midface aging changes can be seen as early as 30 depending on genetics and external factors. It’s often due to atrophy of the bony skeleton, descent of ptotic cheek fat, and depletion of malar fullness. This area is critical to the triangle of youth, and addressing the midface with fullness often leads to a more youthful appearance.
Last, the lower face is an important factor in attractiveness. As skin laxity increases, creating excess skin and loss of jawline definition, and alveolar bone resorption and depletion of malar and perioral fat occur, these changes cause a negative alteration of appearance and create a look of sadness or displeasure. Patients often want to improve the appearance of their marionette lines or dimpled chin, but cosmetic dermatologists are commonly addressing desires for fuller lips.
“Not only does symmetry matter, but so does the balance and proportion of these features,” said Dr Sherman. “Is bigger always better? I would say to you not necessarily, because if we just think about size, it’s not all about the lips, and we don’t want lipstick on a pig. That’s your job as an aesthetic expert to provide harmony and proportion.”
Read more insights from CBC 2020 at our Cosmetic Bootcamp Insights page.
Sherman D. Multi-dimensional facial analysis. Presented at: Cosmetic Bootcamp Virtual Meeting; July 11, 2020.