The role of anatomy in energy-based facial aesthetics

In recent years, aesthetic treatments have predominantly focused on the use of soft tissue fillers or neuromodulators to increase midface volume or address forehead rhytids. The short recovery time, immediate results and relatively low price point have been key factors driving patient demand for these minimally invasive procedures.

However, soft tissue filler injections carry a risk of vascular adverse events, which can be devastating, particularly when filler material gains access to the ophthalmic artery circulation.

Neuromodulators have a relatively low adverse event profile, with eyelid or eyebrow ptosis being among the most significant concerns. Although temporary and limited to the duration of the drug’s effect, upper eyelid ptosis can be distressing for patients.

The rise of energy-based technologies in facial aesthetics

The emergence of new technologies employing various forms of energy for facial aesthetic treatments has accelerated in recent years, driven by technological advancements and a deeper understanding of facial anatomy. Increasing interest has been directed towards facial muscles, as recent research has shown that, similar to skeletal muscles, facial muscles experience age- and hormone-related reductions in muscle mass, termed sarcopenia, a condition previously thought to affect only skeletal muscles.

Electromyographic studies have demonstrated that the current produced by facial muscles, known as the motor unit action potential, is reduced in older individuals.

This reduction reflects a decline in muscle mass actively contributing to contraction and can be used as a surrogate marker for muscle health.

Studies suggest that facial muscles undergo sarcopenia comparable to osteoporosis in bones, affecting both sexes but predominantly postmenopausal women.

The potential to target and improve muscle function has become an area of high interest, potentially explaining the popularity of practices like facial yoga (despite the current lack of scientific evidence supporting its efficacy). More recently, novel energy-based technologies such as synchronised radiofrequency (RF) and high-intensity facial electrical stimulation have emerged.

Facial anatomy & the mechanisms behind facial electrical stimulation

Recent clinical studies using synchronised RF and facial electrical stimulation technology have reported increases in midface volume and reductions in forehead and lateral canthal rhytids, with outcomes maintained over six months.

At first glance, claims of increasing midface volume or reducing upper facial lines through energy treatments might sound like marketing gimmicks. But when looking into the intricacies of facial anatomy, suddenly the results of these studies sound scientifically plausible.

Some fundamental anatomical concepts help explain these effects:

1. Facial muscles lack a traditional fascia covering like skeletal muscles; instead, they are embedded in a three-dimensional connective tissue framework, known in the midface as the superficial musculo-aponeurotic system (SMAS).
2. This connective tissue framework is attached to the skin, enabling facial muscles to move the skin during contractions.
3. The skin, connective tissue and muscle together form a biomechanical unit, which drives all facial expressions.
4. Targeting any part of this unit with appropriate energy can improve its function (with each tissue type requiring specific energy modalities).

Midfacial volume increase

The zygomaticus major muscle connects to the underlying maxilla through the transverse facial septum, a structure that allows deep and superficial fat compartments to shift during muscle contraction; similar to how a hammock tightens when weight is applied.

Each contraction of the zygomaticus major pushes the midfacial fat compartments cranially, hence the colloquial term of ‘apple cheeks’, especially visible in children when they smile.

Targeting the transverse facial septum, the zygomaticus major and the midface SMAS has been shown to enhance midface volume and can be explained by the presence and function of the transverse facial septum.

Reduction of upper facial lines

The frontalis muscle is encased within a fascial system, with the suprafrontalis fascia on its surface and the subfrontalis fascia beneath. This fascia connects the muscle directly to the skin, explaining why every frontalis contraction results in forehead lines. As the sole elevator of the eyebrows, the frontalis muscle increases in tension when the eyebrows need to be suspended or elevated during various facial expressions; this can be observed clinically as wrinkle formation.

Applying energy to this fascial system induces tension, allowing the frontalis to relax. Additionally, tensing the fascial system helps elevate the brow and stretch the lateral orbicularis oculi muscle, thereby reducing lateral canthal lines.

These effects can be best understood within the context of three-dimensional facial anatomy, rather than viewing muscles as isolated structures. Many emerging technologies utilise this deeper anatomical knowledge – and synchronised RF and high-intensity facial electrical stimulation will not be the only strategy shaping the future of aesthetic medicine.

Nonetheless, this example demonstrates how an ‘old’ and seemingly static field like anatomy can drive clinical innovation and enhance patient outcomes. AMP