Effects of hypoestrogenism
Beginning during the pre-menopause period, and continuing during menopause and post-menopause with declining levels of oestrogen, some degenerative changes take place with regard to the epithelium and connective tissues (especially hyperkeratinisation). This is accompanied by a decrease in function of the salivary glands (hyposalivation).
These considerations are especially important with regard to the lips. The lips are divided into the mucous membrane (internal) and skin (external). The vermilion is the transition zone between the skin and mucous membrane. The submucous layer at the vermilion border is absent. A large number of tiny salivary glands are located on the border between muscular layer and mucous membrane. The vermilion border is covered with multiplayer squamous keratinised epithelium, while the buccal vestibule is covered with squamous non-keratinised epithelium. The vermilion mucous border and mouth changes are the first clinical signs of menopause.
These considerations resulted in the authors starting the IMPACT© (Integral Menopausal Patient Anti-aging Cosmetic Treatment) Concept investigation.
Materials and methods
Every woman will experience three stages of hormonal reorganisation known as pre-menopause, menopause, and post-menopause. All bodily tissues undergo changes during these periods, as previously described, including bone, muscle and fat. Treatment options to correct such aesthetic changes will generally include hyaluronic acid fillers, fat grafting, skeletal implants, and fat transposition. Tear trough procedures usually require the addition of volume to the underlying depression, for which dermal fillers will often be recommended. The reason for undertaking this investigation was that this treatment methodology works well for smaller wrinkles, but the influence on the skin does not always sufficiently increase lost volume and has no impact on the bony contour.
However, complaints such as dryness, flaking and even skin fissures increase, and the patient will begin to consider the fallacy of high expectations. This is because no treatment to the mucous membrane is carried out when it becomes sensitive to hormonal imbalance and change.
The authors understand that complex treatments must be carried out in this patients cohort, as not only visible changes to volume occurred, but also invisible changes to hormonal levels caused by prolonged changes to the bone, and soft tissue quantity (fat) and quality (mucosa and skin). This is well known to endocrinologists, but is often not taken into account by the majority of cosmetic dermatologists and surgeons.
Figure 2 Non-surgical tear trough correction, (left) before and (right) after treatment
It is for these reasons that the authors have developed the IMPACT© Concept algorithm for diagnoses and treatment, to ensure that hormonal changes are taken into account when treating age-related changes to facial appearance (Figure 1). Once this algorithm is complete, then the decision with regard to treatment of the tear trough in the menopausal patient can be made. The authors believe that the degree of ptosis intensity determines the choice of either an invasive or non-invasive approach for correction. As a result, an optimum treatment outcome is achieved, which does not compromise the method with incorrect and short-term results.
