1 The Consultation
Initial Evaluation
A combination of factors can lead a patient to visit a provider for injectable treatment or evaluation. Often it is a result of the patient looking or feeling tired, or being told that they give that impression to others. Sometimes it is the drive for youthful appearance or for simply a different look (whether that is fewer wrinkles, fuller lips, or higher cheek bones). The motivation for change may be preparation for an event that is fast approaching, like a wedding or reunion, or a longer-term goal, such as maintaining a competitive edge in the job market. All of these factors must be determined in the first discussions prior to developing the plan. The time frame for treatment and recovery, longevity of results, and patient expectations must be part of the planning.
Anatomic Considerations
The injector must have a thorough and comprehensive understanding of facial bone structure, muscle location and function, skin structure and thicknesses, as well as the location of nerve and vascular supplies to the face and neck. Greater familiarity will lead to increased comfort, sophistication, and talent with both diagnosing and treating the changes seen in facial aging. Most aging changes are a result of facial fat loss and redistribution away from key areas of the face, which leads to sagging, undesirable folds, and skeletonization. Loss of fat in the forehead and temples leads to dropping brows and hollowing of the temples. Loss of fat on the cheeks and around the eyes causes dark circles under the eyes and drooping of the malar skin, creating deeper nasolabial folds as well as hollowing, melolabial folding, and jowling. Buccal fat loss contributes to a gaunt look in the lower cheek and can create the effect of a “pouch” lateral to the mouth (which is really just a prominent modiolus due to hollowing anteriorly and posteriorly). Intrinsic changes of the skin due to solar exposure and collagen and elastin loss can accentuate these changes. Recognizing, understanding, and explaining to patients the global effects of these anatomic changes will greatly facilitate the consultation.
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