Full title: IMPACT© Concept for the full-facial correction of post-menopausal female patients: new horizons, new possibilities, a new scoring scale

Many patients who have undergone cosmetic procedures over the last 20 years will now have entered the menopause and post-menopause periods, and it is often the case that many aesthetic practitioners will not know the best ways in which to treat this patient cohort. With regard to this patient group, the authors wish to propose an algorithm for treatment, especially as some areas of the face become much more sensitive to hormonal ageing during this period of life.

In order to achieve the most natural and harmonious rejuvenation of the face, all changes that occur as a result of the ageing process should be corrected. Traditionally, soft tissue lifting and reshaping have constituted the cornerstone of the majority of facial rejuvenation procedures. However, in the authors’ experience, changes to the facial skeleton that occur with ageing, and their impact on facial appearance, have not been well appreciated. Accordingly, the failure to address changes to the skeletal foundations of the face may limit the potential benefit of any rejuvenation procedure.

These areas resorb in a specific and predictable manner with ageing. In patients with a congenitally weak skeletal structure, the skeleton may be the primary cause for the manifestations of premature ageing. These areas should be specifically examined in patients undergoing facial rejuvenation and addressed to obtain superior aesthetic results. Every woman experiences three stages of hormonal reorganisation, which are known as pre-menopause, menopause, and post-menopause. The levels of oestrogen play an important role in the correct functioning of the female organism in general, and in such details as bone structure, where changes to this level can cause resorption of soft tissues, which can become dry as a result of low levels of oestrogen.

With this in mind, it is essential to consider how low levels of oestrogen can influence facial contours, and particularly the perioral skin and lips during menopause and post-menopause, and to consider how aesthetic practitioners can adapt their techniques for the correction of tear trough deformities.

Anatomical considerations

Correction of the skeletal framework is one of the most important goals in facial rejuvenation. Areas with a strong predisposition to resorption include the temporal area and the mid-facial skeleton, particularly the maxilla and the pre-jowl sulcus of the mandible.

Depending on the age of the patient and her individual features, the facial contour will inevitably change due to:

Figure 1 Different types of tear trough

• Ptosis
• Loss of elasticity, firmness, and radiance
• The migration of localised fat (double chin)
• Wrinkling
• Deepening of temporal areas
• Bone resorption
• Deepening of the temporal fossa
• Depression of eyebrow line.

Without doubt, ageing of the lower eyelid and tear trough area is very much influenced by the changes that take place in facial fat tissue. In younger patients, the cheek fat pad tends to be dense and abundant. With age, fat and bone atrophy cause a loss of prominence in the mid-facial area. These are the vectors of facial ageing and soft tissue ptosis, and in the post-menopausal period these changes become more visible owing to hormonal changes, and creating a greater appearance of age as a result.

The lower eyelid and tear trough area can be challenging to treat in facial rejuvenation. While lower eyelid bags are one of the most common reasons that patients present for treatment, a separate entity known as a tear trough deformity may occur in conjunction with lower eyelid bags (or alone).

The osteocutaneous ligament, also known as the tear trough ligament, is placed between the palpebral and orbital parts of the orbicularis oculi muscles. With ageing, there is a gradual tissue migration as a result of gravitational ptosis, changing the quality and location of the facial fat pads, as well as muscle spasm and a weakening of the ligaments that create the tear trough. It is the authors’ opinion that the degree and intensity of this ptosis should determine the choice of invasive or non-invasive approaches to correction.

Therefore, the choice of patient treatment algorithm (i.e. surgical or non-invasive correction) will help the aesthetic practitioner to achieve an optimum result and not compromise the method with incorrect and short-term results.