A.S.S.E.S.S. for Facial Fillers

Abstract

Background: An in-depth and detailed facial assessment is critical in treating and achieving desirable dermal filler and neurotoxin results.

Methods: An acronym called A.S.S.E.S.S. simplifies an often complex and overwhelming amount of data needed to assimilate when performing facial filler and neurotoxin injections. Applying this method to patients in six simple steps provides a starting point and offers a guideline to capture key details for a more comprehensive facial assessment. The A.S.S.E.S.S. acronym stands for animate, shape, side, external, symmetry, and shadows and is helpful in following a methodical approach in analyzing facial shape, profile, and natural facial curves in both static and dynamic states.

Results: Following a regimented A.S.S.E.S.S. approach prior to treating filler and neurotoxin patients allows providers a straightforward guide to achieve a desirable facial shape and profile.

Conclusion: This stepwise facial assessment establishes a logical and detailed approach to ensure the important aspects of facial details are appreciated in creating reliable and pleasing filler and neurotoxin results.

Keywords: aging face; dermal filler; facial assessment; facial profile; facial shape; filler; neuromodulation.

FIGURE 1

The six basic facial shapes are heart, diamond, oval, oblong, round, and square/rectangle. The heart shape is the most desirable female shape, while the square/rectangle is the most desirable for a male face.

FIGURE 2

Basic geometric shapes can be modified with filler to transform one shape into a more pleasing one. For example, if a patient has an oval face, then filler can be added to the cheeks and point of the chin to create a more heart shape. Likewise, if a person's face is squarer, then filler can be added to the lateral cheek and central chin, while also slimming the face by reducing lower facial width with injections of neurotoxin to the masseter muscles.

FIGURE 3

(a) A clinical example of a patient with a round facial shape. A rounder facial shape is often associated with chin deficiency, especially regarding length. (b) Same patient converted from a round to a more heart shape with 8 mL of HA filler. A high G' filler was injected with a cannula in the lateral cheeks and central chin to lengthen her face. A total of 6 mL was used to improve facial shape in addition to 1 mL of HA filler in her tear trough and lips. It is fascinating that adding filler can have the overall effect of facial slimming when placed appropriately (photograph courtesy of Dr. Drew Taylor, Aspen CO).

FIGURE 4

(a) Patient with a square facial shape and strong masseters from teeth grinding. (b) Same patient after 2 mL pf high G' HA filler to lateral cheeks and 1 mL to her chin point with a cannula in subcutaneous plane. Her masseters were injected with 50 units of neurotoxin to slim her lower face. The result is a transformation of a square facial shape into a more heart‐shaped face (photograph courtesy of Dr. John Fezza, Sarasota, FL).

FIGURE 5

(a) This athletic patient had low body fat and a more rectangular facial shape. (b) She received 3 mL of High G' HA filler to her cheeks with deep, periosteal needle injections, in addition to 1 mL of HA filler with cannula to her tear trough deep to her orbicularis oculi muscle and 1 mL of HA filler with needle to her lips. She also had 40 units of neurotoxin to her masseter muscles to create a tapered lower face and more heart shape (photograph courtesy of Dr. John Fezza, Sarasota, FL).

FIGURE 6

(a) This patient desired upper face rejuvenation and displayed temple hollowing, mid face deflation and hollow tear troughs. (b) Same patient after 2 mL high G' HA deep temple filler delivered with needle on bone, 2 mL of HA mid face filler, and 1 mL of low hydrophilic HA filler with cannula to her tear troughs (photograph courtesy of Dr. Julie Woodward, Durham, NC).

FIGURE 7

Transillumination of the skull reveals thin bone that transmits light and thick bone that does not. The thicker bones are buttress areas of the skull and are used for stability points when fixating broken facial bones. These same thick buttress areas of the skeleton are convexities and are also the regions filler is best placed to create lift in the face. The lateral brow, cheek, pyriform, chin, and gonial areas contain thicker bone that do not transilluminate and are typically the regions that produce the most projection when filler is injected.

FIGURE 8

This oblique view demonstrates the pathologic signs of aging with fatty deposition in the superficial nasolabial and jowl fat compartments creating a medial fullness and facial sagging. The loss of fat and facial deflation is evident laterally. Restoring a youthful appearance was achieved by injecting 3 mL of high G' HA filler with cannula primarily in the subcutaneous plane lateral to the line of ligaments in the cheek, which resulted in a filling and lifting effect. 1 mL of filler was also placed in the tear troughs, marionette lines (1 mL) and nasolabial fold (1 mL). A total of 6 mL of filler was injected (photograph courtesy of Dr. John Fezza, Sarasota, FL).

FIGURE 9

There are three basic facial profiles, convex, straight, and concave. The lower face profile can be assessed with Reidel's Plane, which is a line that connects the most prominent portion of the upper and lower lips and touches the soft tissue menton. If the chin falls behind this line, it means that there is microgenia and a convex profile. The convex lower face is heralded by chin recession and often type 2 dental malocclusion and benefits from adding filler to the chin to create a straighter profile.

FIGURE 10

(a) Sagittal view of patient with microgenia and poor chin projection. (b) Same patient after 4 mL of high G' HA filler delivered in the subcutaneous plane to lateral cheeks and central chin. An additional 2 mL of the same filler was injected in the chin deep on bone with needle in the area for ideal female chin width, which respects the vertical lines dropped down from her inner canthus and ala. The after unfortunately shows a chin up position in comparison to her pre injection photograph, but it is still evident her profile was transformed from a convex to a straight profile.

FIGURE 11

Gonial Angle: 127° is typically considered a desirable gonial angle. Men typically have sharper, more right‐angle contour than women. A larger, open angle over 130° is associated with a longer face and chin recession.

FIGURE 12

(a) When asked to draw a square and then a circle in the square, most people will try to fill the square with a circle that touched the square. (b) In fact, when asked to draw a circle in a box, very few people will draw a small, off‐center circle in the square. This is due to our innate belief that symmetry is beauty.

FIGURE 13

Monet's painting of the Rouen Cathedral painted in different lightening demonstrates the power of light and shadows on the appearance of an object or face.