In this blog post, our clinical mentor and faculty ambassador, Dr Amanda Penny, teaches us how to conduct a facial assessment thoroughly and the importance of doing so.
A complete facial assessment of your patient is essential before developing any aesthetic management plan. A systematic, three-dimensional evaluation of the structures of the face aids in choosing the most appropriate methods for facial rejuvenation or enhancement.
It is useful to establish a rapport by having an initial chat about the patient’s concerns and wishes and a thorough medical history must be established before the assessment stage. Remember that the examination can be particularly daunting for the patient. Rather than listing all their ‘defects’, perhaps start by paying them a genuine and specific compliment.
You should assess the patient globally and up close. Good lighting is essential for examining skin quality and many practitioners find a magnifying lamp useful. More advanced tools, such as a dermatoscope, Wood’s lamp, photographic imaging and skin physiology analysis may be useful, but are not considered here.
The examination should include an assessment of the following:
- facial shape, symmetry, proportions
- layers of the face from skin, through fat pads and muscles to bone
- static vs dynamic features of facial expression
- areas beyond the face
Facial shape, symmetry, proportions
Overall impression, face shape, sexual dimorphism, how attractive they may seem to others (also whether this is in keeping with the patient’s own views). The patient should ideally be viewed standing and resting at 30-45º, face on, on the diagonal and from the sides. Views from above and below may be useful in certain cases (e.g. in assessing symmetry of cheek volumes, tear troughs)
Horizontally, the face can be divided into upper, mid and lower thirds, their proportions and specific features evaluated systematically. In addition, the lower third of the face my be sub-divided into thirds to assess lip volumes and relation to chin position.
Regional assessment in vertical fifths is useful in evaluating proportions (each fifth ideally equal to roughly intercanthal distance), shadows, volume defects, left-to-right symmetry and effects of facial expression on symmetry.
Of note, facial asymmetry should be documented with photos and explained to the patient prior to treatment. Remember – “before is an explanation, after is an excuse”.
The practitioner may also choose to use other analysis methods, e.g. Hinderer’s lines, Ogee curve, Ricketts analysis, but these are beyond the scope of this article.
Layers of the face from skin, through fat pads and muscles to bone
Skin quality, tone, texture, skin type in terms of its tendency to burn (e.g. Fitzpatrick scale), redness, uneven pigmentation, including assessing for signs of photoageing or specific conditions including acne, rosacea and melasma.
Volume and contour. In youth, the contours of the face are gently curved, with good anterior projection of the mid-face, defined jawline and smooth transitions between fuller fall pads. With increasing age, bony resorption and changes in fat pad volumes, the contours become less smooth and the triangle of youth tends to invert, with loss of mid-face volume, a heavier, less defined jawline and specific features associated with increasing age (e.g. deepening of nasolabial folds).
Static vs dynamic features of facial expression
Patients will frequently present with a complaint about specific lines and wrinkles and furrows. These must be assessed in relation to the changes in bone, fat and muscle tone with age as this will determine the best single or combination treatments (e.g. neuromodulation, soft tissue fillers, cosmeceuticals, invasive skin treatments, energy-based devices or surgery).
It is useful to objectively measure the severity of wrinkles and photoageing (e.g. using the Glogau scale) at rest (static) and during facial expression (dynamic). Photographic records of these are essential before any treatment is considered. Photos are useful in explaining treatment options to patients as well as being an excellent point of reference to assess the effects of treatments.
Areas beyond the face
Remember that the face is not the only area exposed to the effects of UV. The neck, décolletage and hands are important areas to assess and treat.
This describes a basic approach to aesthetic facial analysis that will identify the most appropriate treatment modalities to address the patients aesthetic needs globally, rather than simply “chasing the lines”. By discussing these findings, not only is the patient empowered to make educated, informed decisions, in partnership with the treating clinician but both parties are more likely to be satisfied with the outcome of the agreed treatment.
About the Author
An experienced anaesthetist and entrepreneur, Dr Penny is a member of both the British College of Aesthetic Medicine and Joint Council of Cosmetic Practitioners. Her teaching combines high standards of cosmetic care with an entrepreneurial approach.