Most practitioners are taught how to use dermal fillers when they embark on their journey into aesthetics. It looks simple, but it is not easy. To help with this, I have devised the 5P (patient, practitioner, product characteristics, plane and precision) framework, which should always be used no matter which area of the face is being treating.
The 5P framework
Patient
Every patient should be asked a series of questions. These will include:
What are you hoping to achieve?
Is it reasonable and can we deliver the results they want? With nasolabial folds, we do not want to eliminate them completely, as this will make the cheeks look flat and age them.
What are your expectations? Are they realistic regarding the results they want?
Specifically, in relation to treating the nasolabial folds, we want to assess whether these are the cause of ageing or rather, its consequence. Patients will see lines or folds that they are unhappy with and assume we can place filler directly in the fold to eliminate the crease. The job as a professional is to educate them about where and what we should be treating.
The use of dermal fillers in patients with mild to moderate nasolabial folds (NLFs) is usually quite successful. However, using dermal fillers to treat patients with deep NLFs is usually modestly successful at best. In these patients, with significant cheek ptosis, filling the fold actually pushes the redundant skin upward, creating a more pronounced ridge at the superior aspect of the NLF (Rubin, 2004).
Discussions about alternate options will also take place, which always starts with ‘do nothing’; other treatment options may include: toxin (Kane, 2003), surgery, threads, chemical peels or laser resurfacing.
What is your timescale?
When do they want the results by? Like other treatments, dermal fillers will require some downtime, with anticipated side effects such as swelling, redness, bruising and lumps that can take 2 weeks to settle down.
Any reason why you have chosen to address your concerns now?
Do they have a major function, wedding anniversary or a birthday party coming up soon? Treatment should not occur too close to a major event as the results may not be optimal and they could have potential side effects (as noted above).
Do you have a budget in mind?
If so, can the results be delivered within it? The patient may be unaware that, to get the optimal results, restoring loss volume mid-face may need to come first, after which the nasolabial folds can be tackled.
If they have previously had treatment from another practitioner, why have they changed?
Two reasons to ask this question. First, we want to know who they have seen. If it is someone respected locally that delivers outstanding results, then alarm bells will start ringing—if they are not happy with them, then they will have the same problem with their next clinician. Second, repeating the same mistakes the previous practitioner made need to be avoided; for example, they were rushed, it hurt, costs were not explained, no review appointment was offered.
Patients suffering from body dysmorphic disorder (BDD) must also be considered. Mind (2022), the mental health charity, defines BDD as ‘an anxiety disorder related to body image’. Reputable facial aesthetic practitioners understand that BDD is a contraindication to cosmetic procedures, not least because it makes obtaining true consent impossible and any treatment can make the patient's mental health issues worse.
Screening for BDD is essential and every clinician should be doing it. I use the Cosmetic Procedure Screening (COPS) score devised by the Body Dysmorphic Foundation. A series of 10 questions are answered by the patient and the scores totalled. A score of less than 30 indicates it is fine to treat. A score between 30–40 indicates further assessment and a score of above 40 indicates specialist referral.
Practitioner
Do we have the experience to assess and treat the patient and can we achieve their desired expectations?
I have devised my own internal competency score that allows you to see if you have reached the desired level.
There is a points score for each of the below:
- Observing your mentor delivering the treatment—1 point
- Mentor observing you delivering the treatment—3 points
- You have delivered the treatment independently—5 points
I have found with over 20 year's experience, once you have reached a total of 50 points you will have the experience to be able to assess and deliver the treatment competently.
As mentioned above, we want to evaluate whether these are the cause of ageing or its consequence. In the case of NLFs, the first thing that should be assessed is loss of volume in the mid-face. If this is observed, planning the treatment in stages is essential, addressing the mid-face loss of volume (cause of ageing) and if needed, in the next stage, addressing the nasolabials directly (consequence of ageing).
Product characteristics
Is the right product, with the properties required to deliver the result in a safe manner, being used?
Where practitioners go wrong is that they either hone on techniques without due care of the final result or stick to a narrow range of products.
My checklist for product choice falls into 2 categories.
The first checklist is what the final result you want to achieve are. Generally speaking, it will be one of the following: definition, volume or projection.
Once we determine this, then we can move on to our second checklist of product choice, which looks at the characteristic of the filler properties. Broadly speaking, we are looking at three product characteristics: particle size, degree of cross-linking and G Prime.
Particle size
Particle size will determine the amount of volume enhancement—the bigger the particle size, the larger the volume restoration will occur.
Degree of cross-linking
Degree of cross-linking will determine the amount of lifting and projection achieved. Similarly, the higher the degree of cross-linking, the more lifting and projection will be achieved.
G Prime
The G Prime determines the level of resistance to force. The higher the G Prime, the more resistant it is to the face, allowing more definition and projection. For example, in the treatment of NLFs, if the mid-face area needs to be treated first, then we would look to see if we need cheek volume and/or cheek projection. For cheek volume, normally a large particle filler is used (due to volume restoration required), whilst for cheek projection, a high cross-linking filler is used and high G Prime product (for maximum lifting and rigidness).
If the NLFs need to be addressed directly, either immediately or after mid-face treatment, look at where we need to place the filler. Starting with the pyriform fossa, see if there are any defects in this region, and address it with a large particle size filler, deep into the periosteum.
Then depending on the severity of the NLF, a medium sized particle, either retrograde or cross hatching technique is preferred.
Understanding these characteristics will enable you to choose the appropriate product for each patient.
Plane
Injecting in the right plane is critical, whether this be superficial, medium or deep.
This is directly linked to the particle size of the dermal filler used. For a large particle sized filler, inject deep, normally just above the bone. For medium particle size, inject mid dermis. For small particle size, inject superficially.
Check the product you are using is correct for the desired result. When injecting, check the depth before depositing any filler. For deep injections, we do not want to be able to see the needle or cannula at all. For medium plane injections, seeing the shape of the needle is critical. For superficial injections, the skin should be blanching.
Inject deep for cheek volume and projection. Inject deep again for the pyriform fossa, and inject medium to deep for directly addressing the NLF.
Always check the depth before every injection.
Precision
Where to inject and how much to give are a common concern amongst those starting in facial aesthetics. When I first started offering facial aesthetics back in 2002, we saw a line and either eliminated it with botulinum toxin or plumped it up with dermal filler. We were basically ‘line chasers’! Now as a competent practitioner, you need to understand the ageing process and how if affects different structures and layers in the skin.
Facial ageing reflects the dynamic, cumulative effects of time on the skin, soft tissues, and deep structural components of the face, and is a complex synergy of skin textural changes and loss of facial volume. Many of the facial manifestations of ageing reflect the combined effects of gravity, progressive bone resorption, decreased tissue elasticity and redistribution of subcutaneous fullness (Coleman and Grover, 2006).
The competent practitioner will look at the ‘cause’ of ageing and address that concern, and not be swayed by the patient who will pinpoint its ‘consequence’.
The amount of volume to inject will come with experience and I refer back to my ‘internal competency score’.
The second most common question asked by my delegates is whether to use needle or cannula. There is no one answer that satisfies all criteria. For cheek volume, preference is given to a cannula, for cheek projection, needle is preferred, for the pyriform fossa, a needle is indicated and for the NLF, cannula works best.
Summary
Follow the 5P framework to get the best results for your patients when treating with dermal fillers.