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Embracing the natural look with facial injectables

How to Freshen-up an Aging Face with BonTA and Fillers: Respecting Facial Dynamics Whilst Retaining a Natural Look

According to the latest web-based Survata service, almost 70 percent of consumers are considering cosmetic treatments because they “want to look better for their age or as young as they feel.” One of the most popular procedures according to this data is combination injectables -neuromodulator and fillers.

The aging face tends to develop a characteristically negative expression thereby making the patient appear sad, tired and sometimes angry which often does not correspond to their true emotions. For this reason, aging patients are turning to cosmetic procedures to liven up their faces but are also wanting to maintain a natural look.

However, over the last 15 years during a learning curve in facial aesthetics, changing trends in  BonTA injections and dermal fillers being perfected, we have unfortunately seen many “frozen” and artificial looking faces, where a person’s essential facial characteristics have been changed. This has discouraged a number of potential consumers from all aesthetic treatments.

How do we ensure that while the face regains a refreshed and softer look, the essential facial expression and dynamics do not change?

The aesthetic doctor’s expertise is the single most important factor in ensuring a desirable outcome. The same survey data has shown that out of “11 factors influencing the selection of a practitioner, choices aligning to physicians expertise continues to receive top ratings.” Sometimes patients will show you a picture of a friend with a tight face, overinflated cheeks or duck-looking lips to ensure that you know what they never want to look like!

But who are these consumers who are walking around with frozen faces and distressingly big lips? Is this look their choice or they a representation of the practitioner who perhaps did not respect the facial dynamics?

Why a detailed consultation with patients is vital to understanding facial aging and how it is linked to negative expressions

When it comes to facial aging, patients often see frown lines that make them look angry, marionette lines and jowls that gives their face a tired expression, as well as sagging eyes and low-set eyebrows that create a sad look. They often don’t understand that these negative expressions are as a result of the complex aging process that involves collagen loss, descending of the fat compartments, HA loss, hyperactivity of certain muscles, photoaging consequences and bone reabsorption, among other things.

A detailed consultation is necessary to explain to patients what is and what is not achievable with injectables and to suggest additional procedures which can minimize the sad and tired appearance (RF, ultrasound, threading, etc.). Working with a negative point system for each facial expression often gives a patient a good understanding of what should be prioritized and addressed initially. If frown lines (which give an angry look) are rated at 4/10 and marionette lines (which give a tired look) are rated at 10/10, this means that we will prioritize using a filler (even RF) for the marionette lines to begin, and then will focus on BonTA  for the frown lines secondarily.

Sadly, in practice we often see older patients walking in with large amounts of BonTA done on the upper face without any treatments on the lower face, giving them an unnatural appearance. All their face is asking for is a little attention and a lift on the lower half! One has to wonder if some of these disproportionate treatments are done in practices that are not entirely dedicated to aesthetics.

How to apply Fillers to attain a natural look

Injection techniques have become extremely sophisticated in the past 10 years and many practitioners now have considerable experience in applying these different techniques. Irrespective of whether they follow any of the teaching “schools” (MD Codes®, The French Touch, Facesculpture®) or have decided to learn through master classes or hands-on classes, each practitioner has to strive to obtain the best possible education in respecting facial dynamics using injectables. This is even more important because of the lack of an official council stipulating the minimum level of education that a practitioner should have.

What makes these techniques really advanced is not just the extent of the experience needed, but the complex features of new generation fillers. Dermal fillers contain different concentrations of hyaluronic acid with varying amounts of crosslinking and various elastic, viscous and lifting properties that significantly vary from brand to brand.

Our face is a complex structure that is subject to various forces such as stretching and compression during the countless movements of associated with expressing emotions. Because of this, each area of the face must be matched with the type of filler that has the appropriate rheological properties. This means that the filler responds to the plastic flow instead of deforming in response to an applied force. Lips that look hard, have nodules or have an anterior protrusion (“duck lips”) have definitely had the wrong filler injected with inappropriate rheological properties that do not allow for a soft, naturally plumped and smooth look. Injection of the wrong product in a tear trough (i.e. the wrong place) can also give distressing symptoms such ongoing swelling or blue discoloration.

But the biggest errors in facial makeovers with injectables have come with the introduction of so-called 3D facial rejuvenation. The intention is to treat facial shadows, volume loss or simulate a skin lift, rather than just working on the visible wrinkles. Often a volumizing filler is used in the area which needs a lift, but not so much volume and that leads to that over-inflated look with a swollen and artificial appearance which can be noticed from a mile away. When a person ends up looking like this, the three things that have definitely gone wrong are usually the amount of filler, the type of filler or the place of application.

Understanding the performing and physical properties of the filler is an essential prerequisite for an effective facial rejuvenation. Knowing the tissue integration, durability, tolerance and water absorption properties of a filler is necessary for successful execution along with understanding the facial anatomy and facial dynamics. 3 things remain crucial in applying fillers: who is injecting, where it is injected and what is injected!
It is highly sensible for a practitioner to advise patients which filler is used in which area, as well as to explain about the brand being used and the reason for it being chosen. By now I am sure all our patients know that one 1ml of one brand is not the same as another brand, and each 1ml has “extra value” attached to it because of the expertise of the doctor performing the procedure!

Neuromodulator -BonTA – Why is it still scaring consumers?

These days as BonTA is available around almost every corner, professional aesthetic doctors have an even bigger responsibility to stop its negative reputation. BonTA is a serious medical procedure that can provide astonishing results. After 20 years of injecting billions of vials of BonTA  there is one thing we know for sure: Keep the amount injected very small, keep it natural, and keep the facial dynamic intact!

What we see nowadays are practitioners who are not updated, as well as patients who still insist on the old fashion way of getting  BonTA.  Both of these perpetuate the artificial look which is aesthetically unappealing. This means that many potential consumers are scared of changing their face and ending up with this unnatural look.

These are a few of the unpleasant effects of BonTA  that can change our facial dynamics, which with more education should begin to disappear:

  1. If a large amount of neuromodulators is used between the eyebrows it can eventually increase the space between them so the eyebrows look too far apart and the skin becomes saggy. Using a smaller amount and allowing some frowning will retain the natural look.
  2. If a person’s crow’s feet wrinkles don’t appear while smiling, it gives a “plastic” look to the face (their cheeks somehow start pulling up) and the face looks unnatural. So it is expected to keep some crow’s feet noticeable.
  3. When a patient’s forehead lines have been completely smoothed, this can create a huge contrast to any sagging and wrinkling on the lower half of the face, making it so obvious that they have BonTA done.
  4. Completely smooth forehead lines also cause the brows to become too heavy, giving the effect of an even more tired and sad look.
  5. A frozen facial look because of overdoing  BonTA in the forehead area and around the eyes causes a compensatory overexpression of the surrounding muscles (e.g. bunny lines). This gives an artificial look, particularly during smiling.
  6. Artificially raised eyebrows – described as a ”Mr. Spock” (Star Trek) look on one or both sides, is another possible side effect. However, it is easily solvable and only needs diligent practitioners to ensure they follow up their patients after 2 weeks and correct it if necessary. Even more strange is that some patients like this unusual “eyebrow lift” which has contributed to the negative publicity. And it is important for patients to not focus on these patients but rather the majority that leaves looking very natural and rejuvenated. Some practitioners also try to raise the eyebrow too much, resulting in stretching of the eyelid exposing its crepey appearance. This emphasizes the importance of selecting the correct practitioner with the most expertise.

I am convinced, however, that there is an amazing movement in South Africa working to elevate the level of Aesthetics to the highest degree. The first step is ensuring that practices are purely dedicated to Aesthetics and that these are continuously being updated with new advancements and techniques.

The next stage is educating patients and keeping them informed about the procedures and products used and that social media is promoting the natural look rather than the overdone “frozen” look. In the near future, we will see more sophisticated facial makeovers that leave patients feeling beautified and rejuvenated but with no obvious evidence of work having been done.



Disclaimer: Treatment results will vary on a patient to patient basis. No guarantees can be made.