Transcription
This week, we're talking about chins. In particular, the one injection that you might consider, or maybe two, on the base of the chin. I would say chins are like the cherry on the bottom, though. One of the most important parts of overall facial shape, particularly in females, in terms of the heart shape, but also in males, in terms of a masculine structure. They're very different to inject in men and women, and there are some commonalities and some differences. And this week, we're going to be discussing how small variables make big differences when you inject the chin.
So, chins are a really important part of overall beauty in the feminine face. The way I've come to understand it is, I often think of the face as a presentation box for the eyes. So, if you imagine a presentation box that's kind of holding the eyes up to the world, there's a base to that, and then all the other structures frame. So, the jawline, the cheeks, the highlights around the eyes are essentially presenting the eyes to the world, and the chin is like a base of those structures. In a male face, it's much more around strength and a sense of power, essentially of having a strong chin. So, we associate that with masculinity, but it's also part of that structure that presents basically a more masculine structure to the world.
So, chins are very important. And as you get older, they tend to become a softer part of the face. So, your chin starts to rotate up, the jowls compete with the chin, and you end up with a rounder structure where the chin is less dominant. And that presentation box is simply less of a gift to the world and more of a, somewhere lost in there is this idea of presentation. But you do lose it, unfortunately, as you get older, or if you just don't have those proportions. And that's where injectors come in to help restore and maintain, and hopefully improve, the overall beauty of the face through augmenting chins appropriately.
So, what are the differences between the male and the female chin? The main difference is that the male chin is wider. Typically, it is as wide as the mouth, and it is also typically squarer. So, a female chin often comes down to a single point, whereas a male chin often has two points. And knowing this is one of the simplest ways that you can masculize or feminize a face.
So, what is difficult about injecting a chin? I think it's actually one of the harder places to inject. And it's not because the individual injections are difficult, or because it's particularly risky, but it's because you are actually changing multiple planes and dimensions at once. So, if you think about a lot of areas of the face, you can get away with a slightly two-dimensional approach in many simple cases. But the chin is the meeting point of multiple surfaces of the face. So, as you augment in one direction, sometimes the new injector will forget that they're also changing the other dimension in a bad way. I call this the Rubik's Cube problem, because you correct one thing, but it throws something off somewhere else. This is particularly the case where you have multiple planes all meeting in one point. So, if you think about the female face, you've got planes from all directions converging on one point. So, if you have a female, for example, with a small chin from a frontal view, and you augment them down but out at the same time, you could make their chin too strong from the side. This happens quite often. It's one of the more common mistakes you see when people are augmenting, and they particularly get it right from this angle. So, when you turn your face, it looks great, but then it doesn't look right from the frontal angle because you suddenly see the chin is too long, or even worse, occasionally you see a little bump at the bottom which doesn't fit with the rest of the face. So, this all comes from the complexity of trying to augment it congruently with all the planes of the face simultaneously, which is one of the hardest things.
So, a simple tip you can use is just to look at your patient. You'll see good injectors do this. They rotate around as they're injecting. They're getting a three-dimensional view, not just a two-dimensional view, as they are making decisions about where to inject. So, you can think about the planes that we're correcting as in, you can cause projection of the chin, you can cause elongation, and then there's somewhere in between where you're doing both. And quite often, that's what you're trying to achieve, but it's different with different cases. So, whenever you're injecting, ask yourself, what is the aesthetic area that you're trying to augment, and where is it good already? So, are you trying to project or elongate, or somewhere in between? And quite often, it's somewhere in between, but just be clear before you start.
What are the vascular risks involved with treating the chin? So, you've got two arteries to think about. You've got the submental, which, as the name suggests, curves underneath the mental and curves up and supplies the anterior part of the chin. You've also got the mental artery, which supplies the same, a similar area. But in terms of injecting the chin, I think quite often it's the submental that ends up at risk because this is a rather large vessel that curves up, and you can cause blockages affecting the chin, but also part of the neck, if you're not careful, or perhaps even if you are. If you are careful, but you're unlucky.
First of all, you've got to think about where those arteries are likely to be. So, they tend to be on the lateral side rather than the middle, but they can be in the middle. In fact, one of my Mastery students, we were injecting a chin, we got a positive aspect. I ultrasounded afterwards, and lo and behold, right in the middle of her chin was an artery. So, although the textbooks suggest they tend to be lateral, they are not always in this position. They tend also to not be on the bone. They tend to be just a little bit more superficial in a more fatty area, as are most arteries. But this is also something that is not a hundred percent true. So, if you ultrasound, you'll find mostly arteries are where they're supposed to be, but unfortunately, not always. And because we use rather large volumes in chins, this is one, what I think makes chins a slightly more risky area than many people would suspect. And I've seen many chin revascularizations. Thankfully, I've never seen anyone suffer with a significant injury because they're diagnosed and treated early. But it's the size of the blockage that becomes the bigger issue rather than the fact that there's a blockage at all. We tend to use larger volumes in chin augmentation.
And what about needle versus cannula? Which do I prefer? Both are acceptable to use. I do like using cannulas for reducing the total risk of vascular occlusion in most parts of the face. The downside is that you're nearly always more superficial. And the way I imagine filler working is that if it's deeper, it's more stable. This, I call the effect of being under the water. If you're in the sea, for example, the waves on the top, lots of movement, whereas the deeper you go, the stiller it tends to be. And it's a lot like that, I think, on the face. So, if the superficial areas of the face are much more mobile, and they're more likely for filler over time to be moved around than if you place it more deeply. That's just my current understanding. And why I prefer injecting when I'm trying to emulate bone, I will inject on the bone rather than use a cannula, which nearly always puts you in a more superficial, basically a fatty plane where the resistance is lower. You can dig harder to get to a deeper plane, but it kind of nullifies the benefit of using a cannula if you're pushing very hard to get to a plane that the cannula naturally wants to drift away from. So, I imagine most of the cannula injections people do to be in the fatty layer, which I think is a bit less good at emulating bone in the chin.
So, is there anything about a particular patient that would make me want to use a needle or a cannula? It really goes back down to whether I'm blending in two superficial fat pads, for example. So, quite often I lean towards a cannula if I think it's an almost like a kink in the fat pad, like a nasolabial fold where there's an actual ripple. I might use a cannula more similarly with a chin or some of the structures around the chin. If I'm filling rather than so filling a space between two projecting points, it's volume replacement rather than bone augmentation, I might lean towards a cannula. So, you'll often see me use cannula in what we call a bow tie area because it looks like a bow tie on your chin. But when it's augmenting the bone, I tend to lean more towards using needle on bone, mostly in terms of understanding the depths of the artery. I just imagine most of them being off the bone by at least a couple of millimeters. As you'll always find this out as you scan more patients, or if you just pay attention on social media, that there are exceptions to all of these rules. But as a general rule, arteries float more in the fatty layer than they do on the bone, unless they've just emerged from a foramen. But always exceptions. So, you've always got to inject as if the anatomy is atypical, because every now and then it will be.
This leads me on to one of the new trends that's happened in recent years, which is this idea that moving the needle is safer. Safer than what? I'm not exactly sure, because people are not comparing apples and oranges in this scenario. But I think what I see on social media of moving a needle in and out is actually increasing the total risk of vascular occlusion, because you're traveling from a position where arteries are less likely to be on the bone, pulling the needle out while you're injecting, presumably not aspirating, because many of these are advocates of not aspirating. So, you're essentially increasing the risk of blocking the vessels that tend to be not on the bone, but just above the bone. So, you're going from a high risk, from a low risk area, to a high risk area, in and out. And it doesn't take much to block a vessel. If you work out the overall size of many of these vessels, you can block most of the vessels in your face with 0.05 mils. So, it doesn't take much. So, I'm not a big fan of this idea that by moving, you're reducing the total risk. I actually think you're likely to be causing more vascular occlusions and still injecting enough to completely block a vessel than if you are in a place where there are statistically fewer vessels and injecting more product in that area. There's nothing to stop you doing it in small components, maybe moving the needle a millimeter left, a millimeter right. But the in-out movement, I think, is full of logical flaws. But interesting to hear what you think in the comments down below.
So, what am I thinking? Just before I do an injection, I always say the last thing that goes through my mind as I'm injecting is the anatomy. So, I want to think, how am I injecting in such a way to decrease the probability of injury? Now, nothing we can do can get it down to zero, but I like that to be the final thought before the needle goes in. And then my brain switches to the aesthetic. Now, how am I seeing a change that's consistent with increasing the beauty of my patient? And I'm constantly thinking, is this projecting in the right way, or is it flowing slightly incorrectly? In which case, I stop and make a correction with my supporting hand, or change the position of the needle. But you go from anatomical concerns until you think you're in the right place, you validate the safety of your position, you may aspirate, and then you can do an injection and monitor the change. So, it goes from anatomy to the aesthetic. And then I might stop, reevaluate, and decide to inject differently or make an adjustment. So, this is something that might also help a lot of people. If you think you have to have your entire plan in your mind perfect and then just execute, that's not how I go through a treatment normally. I'm making many small decisions along the way with the feedback that I get from seeing the patient respond to the injections. So, sometimes that means I need less volume than I thought, or I change the injection position. But it's a continuous sculpting process. Feedback, revision, improvement, adjustment is normal for me.
The next thing that might happen, if you're injecting particularly on the bone, is I'm a big fan of really having a good understanding of where your needle is on that bone. Are you on the anterior surface, the inferior surface, or often aiming for the apex, the greatest curvature of that surface? Because if you think about filler sitting on the bone, as you're injecting, it can only push away from that structure. And the overall structure and position and direction of that surface will dictate the augmentation direction very well. I think you can very clearly tell if filler is on the apex and pushing the chin out and down, versus just on the anterior surface where it just pushes it out, projection only, or just on the inferior surface where you get the elongation only. So, often we're trying for multiple planes to be augmented, but just know where you are. This is also where I like to do gentle taps with the needle, because I think with practice, you can tell very accurately which surface you're on. Are you skidding upwards, downwards, or really right plum in the middle of it where it feels much more stable? And that just gives you a bit more confidence of injecting that area for the aesthetic result that you want.
So, in terms of evaluating that aesthetic difference, I think because it's quite difficult with chins, because you have so many planes, sometimes I like to think about what's a good way of describing that plane. And if you imagine being an ant on the surface of the jawline and you're walking down, what's the view that you would get? Because often what you're trying to do is just prolong that path and allow it to peter out slowly, rather than to have a step in it or to have a sudden end. And that's kind of what I imagine when I'm injecting. Is this chin coming down and meeting at an apex? I'm usually changing subtly the endpoint, the apex of all those curves, but I want them to be confluent with each other. I don't want them to suddenly step. And so, what I sort of imagine happening is, what would it look like if I was really small, walking along the jawline? Would it gradually fade away, or would I feel a step or a bump or an uncomfortable turn? That's how I make decisions. Is this a gentle end, confluent with the rest of the structures, or is it causing some disruption from one of the many angles you can look at the face?
So, how does the average clinician end up injecting a chin? Because I think it's one of the areas that's more led by a good consultation than by the patient. But of course, people are much more aware of chin augmentation as a thing, and so they will often come and ask for a chin augmentation or a jawline defining procedure. Now, the tricky bit here is you've got to relate that to what the limiting factors are of this treatment. The most common reason I see people attempting this is because the patient has lost their jawline, often due to basically a fat pad that covers the definition, and they are asking for definition back. Now, you can sometimes give them this, but if you go for definition and you ignore the fact that there's excess volume there already, you end up masculizing a woman. And this is probably the most common mistake, even some of the best injectors that I know, I've seen them make this mistake, which is you over-try with the chin and you end up with a masculinized face, or somewhat of an alien-like chin, or a pointy chin, because you're compensating too heavily with creating definition at the expense of upsetting the proportion.
So, one of the things you might find useful is firstly attempting to do this with Photoshop first. It's very easy on. And if you don't want to pay for Photoshop, there's a free software tool, it's actually called GIMP software, but it's just like Photoshop. And you can augment and drag the pixels across and see, is this really something you're likely to do with filler, or is it something that's beyond the scope of filler? Show your patients and let them see with you why you're basically going to say no to many of them. It's very hard to compete with a heavy jaw by augmenting the chin without upsetting the ratio. And typically, this is a feminine chin is relatively small. And you can make it straight from the side, but as soon as you look at the front on, they have this elongated chin. It's not pretty. And it's for most people, it's better to basically just look like they haven't got a great defined jawline than it is to look odd or alien-like. So, have that discussion, let them see on the screen, and make a decision with them. And it'll make sense with them. Otherwise, I think badly consulted patients who get a no, go somewhere else and have it done anyway. So, you've got to win them over about why it's the wrong thing to do.
I hope that helped you think a little bit more clearly through chins. Let me know what you've learned in the comments down below, and also what you'd maybe like me to cover next. Thanks for watching.