The Importance of Anatomy

Measure twice, inject once.

The importance of a detailed understanding of facial anatomy, especially the vascular framework, when delivering non-surgical aesthetic procedures will likely not come as a surprise. The assessment, diagnosis and appropriate treatment selection all rely on deep anatomical understanding to ensure the efficacy, success and safety of procedures. However, recent surveys in both the UK and North America have revealed that clinicians perceive modern anatomical education to be inadequate (Kumar et al. 2018). With more than 6.7 million botulinum toxin injections and more than 2.4 million soft-tissue augmentation procedures performed each year, this issue is of growing concern (Beer et al. 2016). Academics and practitioners are researching the best ways to tackle it.

In most medical programs, core anatomical knowledge is developed during preclinical years at the beginning of study and is only applied and contextualized clinically in the final, predominantly clinical, years (Kumar et al. 2018). As such, studies have shown that residents fail to recall a considerable portion of anatomical knowledge in the transition between the preclinical time and time of practice (Kumar & Rahman, 2017). Medical educators and physicians have expressed concern over limited recall even in a spiral curriculum where anatomical structure is repeated several times during the course. This calls into question the efficacy of different teaching styles as well. Measuring knowledge retention also has its own challenges. There is no single agreed upon measure but rather several different methods; “open-ended (recall) and true-false (recognition) questions are most commonly used in educational contexts to measure retention. However, multiple choice questions (MCQs) enable the testing of both recall and recognition” (Kumar & Rahman, 2017). So what can be done?

Where do we study?

According to one study conducted by Narendra Kumar, MSc, Arthur Swift, MD, and Eqram Rahman, MBBS, MS, PhD, there is “an urgent need to integrate all the available anatomical nomenclature into a mandatory list of critical structural knowledge that is common to all nonsurgical facial aesthetics procedures” (Kumar et al. 2018). A single database would ensure that course directors can uniformly cover the same critical knowledge, as well as allowing practitioners to refer back to a central source of information if needed. The above researchers therefore attempted to assess the effectiveness of such a database by conducting a survey questionnaire comprised of 154 anatomical structures of the face and neck – including topographical landmarks, neurovascular structures, mimetic muscles of facial expression, functional muscles of mastication, superficial and deep fat compartments, true osteocutaneous and false ligaments, fascial planes, and defined anatomical spaces – compiled from multiple sources including in-depth review of published literature and textbooks, detailed cadaver dissections, and the author’s extensive experience with surgical anatomy (Kumar et al. 2018). This survey was then distributed to a group of international professionals from the Americas, Asia, Australia and Europe, selected for their experience as global thought leaders in the field of nonsurgical facial aesthetics. In conclusion, consensus was reached on the essential knowledge of 137 of the 154 facial anatomical structures presented for safer injection therapy. The overall response rate of 97.22% would indicate agreement of the usefulness of such a database. 

How do we study?

There is also a question about the type of study that is best optimized for anatomical knowledge retention. Superficial memorization through textbooks often proves insufficient (Kumar et al. 2018). Another study conducted by Narendra Kumar and Eqram Rahman explored the “Effectiveness of teaching facial anatomy through cadaver dissection on aesthetic physicians’ knowledge.” Cadaver dissection has been a principle teaching method of anatomy for the last 400 years, and allows for appreciation of the three-dimensional perspectives of structures, identification of anatomical variations, and exposure to more realistic tactile features in comparison to  technologically supported synthetic training models (Kumar & Rahman, 2017). 

In the study, a total of 168 aesthetic physicians underwent two days of applied anatomy training covering the detailed facial anatomy of neurovasculature, fat compartments, ligaments and muscles, followed by simulated practice of safer injection techniques. On comparison of pre-course and post-course test results, the knowledge of all participant groups improved significantly. However, in recent times, the use of cadaver dissection based teaching has declined significantly due to the expense, required time, and religious restrictions as integrated medical curricula have been adopted worldwide (Kumar & Rahman, 2017). 

With the meteoric popularity of cosmetic aesthetic procedures globally, f proper training from an accredited institution such the Medical Aesthetics & Injections Academy (MAIA) is essential. We teach delegates evidence-based practice coupled with anatomy-focused education, leading to the highest standard of client care. Intravascular complications associated with injectables most often occur from a lack of facial anatomy knowledge of the practitioner. A review article published in 2012 cited 32 cases of blindness as a result of inadvertent cosmetic filler or autologous fat vascular occlusion (Kumar et al. 2018). At  MAIA, we not only ensure core competency skills, but allow practitioners to elevate their basic skills to expert levels. As patients age and changes occur deep below the skin’s surface, rigid bony structures and soft tissues recede and atrophy in all three dimensions, making a detailed knowledge of facial fat compartments essential for precise injection (Beer et al. 2016). Study with cadaver dissection deepens three dimensional knowledge and better equips the practitioner. A strong case is also made for creating a universal database of anatomical knowledge and a standardized curriculum as facial aesthetic courses rise globally. For more information on the offerings at MAIA, feel free to browse Our Courses that offer both theoretical and practical training.

References

Kumar N, Swift A, Rahman E. Development of “Core Syllabus” for Facial Anatomy Teaching to Aesthetic Physicians: A Delphi Consensus. Plast Reconstr Surg Glob Open. 2018;6(3):e1687. Published 2018 Mar 6. doi:10.1097/GOX.0000000000001687

Kumar N, Rahman E. Effectiveness of teaching facial anatomy through cadaver dissection on aesthetic physicians’ knowledge. Adv Med Educ Pract. 2017;8:475-480. Published 2017 Jul 17. doi:10.2147/AMEP.S139893

Beer, Jacob I.; Sieber, David A. MD; Scheuer, Jack F. III MD; Greco, Timothy M. MD, FACS. Three-dimensional Facial Anatomy: Structure and Function as It Relates to Injectable Neuromodulators and Soft Tissue Fillers. Plastic and Reconstructive Surgery – Global Open: December 2016 – Volume 4 – Issue 12S – p e1175 doi: 10.1097/GOX.0000000000001175