Cosmetic News - Nov 2010

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Treatment Spotlight - Rennova

Aesthetic nurse practitioner Lucy Banks and Dr Elisabeth Dancey present their clinical findings as part of an in-clinic study into the use of the dermal fillerRennova for upper cheek augmentation and facial rejuvenation.

ELISABETH DANCEY - Elisabeth Dancey was one of the early Practitioners of cosmetic medicine and trained and practiced in the UK and Belgium. She continues to be at the forefront of cosmetic medicine having introduced mesotherapy to the UK in 1992 and electroridopuncture in 1995. She has worked on several commercial projects associated with her early work on cellulite and oversaw the consumer trial of Roc's anti-cellulite cream and later assisted Vibrant Medical with their pilot study and launch of the Vibrotone cellulite reductions system. Elisabeth Dancey has also written a book Cellulite Solutions and later the video, Beautiful Legs, she also featured in the original series of Tea Years Younger and continues to regularly feature in the media and on television.

Bioabsorbable fillers have been the mainstay of facial rejuvenation since the 1980s. Hyaluronic acid fillers were first described in 1998 and have been used successfully since then, with increasing popularity.

LUCY BANKS RGN - Lucy Banks RGN has been working with Dr ElisabethDancey for close to 10 years and qualified in nursing two years ago, joining her team at the Belgravia Practice, Bijoux Medi-Spa. Trained by Elisabeth in non-surgical medicine Lucy is able to implement advanced techniques of fillers and botulinum toxin and enjoys the artistry and independence that aesthetic medicine brings. Prior to her role at Bijoux: Lucy also has a BA in English and worked in communication and public relations.
 
Until recently, facial rejuvenation techniques were directed specifically at the line itself. As our understanding of facial ageing has increased, so has the sophistication of filling techniques and the availability of products to satisfy this new thinking. A landmark study published in 2002 (Sasaki, Gordon H. M.D.; Cohen, Andrew T. M.D) proved that facial fat is not one homogenous mass but rather a series of well-defined and anatomically demarcated fat pads. Furthermore the authors delineated the decline of the respective facial fat pads and put these into context with the chronological features of the ageing face. This changed our appreciation of how we view the ageing face and introduced the concept of volume replacement.

It is not only the fat pads that change with age; the facial bones, muscles, soft tissues as well as the skin itself alter with each passing year. Many physiological and catabolic processes reduce the soft tissues and the mandible and, contrarily, increase other aspects of the skull such as the orbital margins. The most visible summation of these effects is a softening of the roundness of the face, an increased scatter of light reflected from the surface of the skin, and an altered balance between the width of the upper face compared to the lower face. This is frequently compared to the inversion of a triangle.

In 2005 Le Louarn, Buthiau and Buis identified the ageing marker fascicles (AMF) illuminating how, with repeated muscle movement over a lifetime, muscles change from being flexible to being rigid, increasing their resting tone and pressing on the deep-lying fat tissues. The deep lying fat is expelled outwardly to the surface level, where it remains on either side of the muscle, causing hollows and masses to be created. This suggests that the deep supraperiosteal fat stores are key to the maintenance of a young face. This gave the authors reason to introduce a toxin early into the management of the ageing face, but also made us appreciate that filling lines and adding to the superficial fat stores was not a rational solution. The deep fat stores needed to be replenished in order to regain the roundness of the face.

One of the most common complaints in aesthetic medicine is the development of nasolabial lines or folds. Historically these were filled to some degree of success. Lines respond well to filling but gravitational folds do not respond; indeed an unwelcome exacerbation of the fold frequently occurs as products slips superolaterolly.

Many trials of filler products centre on the nasolabial folds; understandable in view of their reproducibility, measurability and ease of administration.

"As our understanding of facial ageing has increased, so has the sophistication of filling techniques and the availability of products to satisfy this new thinking''

OUR STUDY - We decided to challenge the rationale of injecting locally and to inject in a more rational manner, given the understanding of the underlying processes. We also decided to investigate the psychological effects of rejuvenating the face, based on anecdotal observations.
One of the early areas of the face to disappear is the lateral fat pads, together with the lateral cheek pad, lying directly under the highest point of the zygomatic arch. The loss of this fatty area is directly responsible for the appearance of nasolabial lines and folds, allowing the tissues of the upper face to fall unsupported downwards and medically. Only by remedying this area and resupporting the face do we achieve resolution of the nose to mouth area. We used a monophasic HA filler new to the UK market, Rennova, to illustrate our point and to begin to unravel the psychological effects of a filler.

PATIENT PRODUCT AND SITE SELECTION - We selected 14 healthy volunteers aged between 40-77, who had not had a filler substance in the last six months. We used Rennova Fill, a monophasic cross-linked, hyularonic acid gel. Whilst Rennova Lift is the product within the range indicated for cheek, augmentation (with a greater viscosity) we decided to use Rennova Fill in view of its short duration of action, should the clients not like the result. Two of the study group were treated with an analogous HA filler from a major brand. The upper cheek was the selected site. The upper cheeks were divided into three zones, working inferior to the infraorbital rim, from the mid-pupillory line laterally to the malar mound.

1 ml of the product was administered to each cheek by deep, bolus injection to the supra- periosteal plane. Volunteers were injected across the three sites of each upper cheek, the amounts tailored to the volumetric requirement at each site. A 26g (brown) needle was used and, once injected, the product was first flattened and then massaged laterally, to encompass the medial and lateral infraorbital groove and hollow, the sub-malar hollow and malar mound.

OUTCOMES - Results were measured by photographs taken directly before and after the treatment. In each volunteer the technique showed an immediately enhancing effect, working in particular to reframe their eyes and create a more refreshed and youthful appearance, to a greater or lesser extent. Also apparent was a lift, albeit subtle, to both the mid face and nose-to-mouth lines, with the effect of overall rejuvenation.

Participants were again photographed at three months where, for the majority of Rennova Fill patients, the results were still 80-100% effective. Whilst many of the study group were unable to appreciate this, having become accustomed to the filler, they were pleasantly surprised when shown the pre treatment photographs. In addition to the physical results, volunteers were asked to complete a questionnaire with simple psychological markers set to measure any changes in their perception of themselves following treatment. It is understood that looks play an enormous role in our society, for better or worse. The relationship between one's appearance and emotional response to it is a complex one. It is understood that enhancing and refreshing one's looks is a positive and energising experience for most.

The initial responses of the study group were upbeat. Each volunteer appreciated the lifting effect of the filler to the upper cheeks and the more youthful appearance that this created. In a follow-up questionnaire at three months, participants reported other positive findings such as unprompted compliments from friends, an increased desire to take effort with other elements of their appearance and a higher level of self-confidence overall.

REFERENCES
Buis, Jaques. Buthiau, Didler, Le Louran, Claude.
Treatment of Depressor Anguli Oris Weakening With the Face Recurve Concept Aesthetic Surgery - JournalSeptember 2006 26

Sasaki, Gordon H. M.D.; Cohen, Andrew T. M.D.
"Meloplication of the Malar Fat Pads by Percutaneous
Cable-Suture Technique for Midface Rejuvenation:
Outcome Study 392 Cases, Six Years, Experience".
Plastic & Reconstructive Surgery, August 2002 - Volume 110 - Issue 2

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