Non-Surgical Rejuvenation Techniques
There are three main signs of aging in the face: the development of lines and wrinkles, sagging and relaxation of the tissues of the face, and changes in the quality of the skin (increased pore size, increased thickness, pigmentary changes, flaking, etc.).
In addressing wrinkles and relaxation of facial tissues, traditional corrective techniques have involved pulling the skin toward the ear, similar to stretching a sheet over a bed. However, this method does not result in complete correction of the problems. Similar to bed sheets that are wrinkled, any relaxation occurring in the skin that is pulled will be manifested by reappearance of wrinkles. Pulling tighter did not yield long-lasting results, but simply a “pulled” appearance.
Second to evolve in the solution for the wrinkle problem is pulling on structures deep to the skin with the hope of prolonging the surgical results, i.e. the SMAS technique with all its variants (SMAS is a musculo-fascial structure present just underneath the skin of the face). There is an improvement in the result, but the face does not always look youthful and this approach does not address all areas of the face.
The next step in the evolution of our understanding of proper correction of facial laxity and wrinkles was the observation that a youthful appearance is not equated with skin tightness, but rather with fullness of the soft tissues underneath the skin. Accordingly, efforts at correction should vertically reposition the fat and soft tissues that have migrated downward with gravity along with adding bulk where deficiencies exist.
With this advanced understanding of facial aging and its correction came new adjunctive techniques that can be used in conjunction with a surgical procedure. Many times such techniques alone can address the problems.
THE THOUGHT PROCESS
With this additional knowledge we had to rethink our approach to the wrinkle problem: We can pull on the skin as mentioned earlier; we can correct the muscles causing the wrinkle if it is a dynamic wrinkle or we can fill up the groove, thereby making the wrinkle disappear.
If the forces causing the wrinkles are due to underlying muscle contraction, then paralysis or weakening of that muscle results in fading or lessening of the wrinkle. This can be accomplished by Botox injections. If the wrinkle is not entirely due to muscle contraction, or if complete paralysis of the underlying muscle(s) is contraindicated, a variety of substances can be used to fill the wrinkle. The materials used for filling wrinkles can include human collagen (injection or sheets) or synthetic substances. Some are manufactured substances similar to tissues normally present in the body (Restylane, Radiance) Some are substances that are completely foreign to the human body (Silicone, Acrylic beads).
The traditional correction for the forehead is the forehead lift. This surgical procedure tightens the skin and allows
transection of the muscles responsible for the wrinkles. Botox, which paralyzes the muscles with a simple office injection, is also a good option in many cases. The wrinkle lines going from one side of the forehead to the other can be significantly reduced. To complete the correction, adjunct filler material can be used at the same time or at a subsequent visit.
Glabellar wrinkles (lines between the eyebrows) can be corrected in a fashion similar to that of the forehead, and this is where Botox is most frequently used. Filler substances that can be used in this area include Collagen, Restylane, and Radiance. The skin or fascial tissue from human cadavers is the source of human Collagen. Re-hydration of this material is needed before it can be injected.
Restylane (hyaluronic acid) is a substance that is normally present in the skin. Because pure hyaluronic acid injected into the skin will rapidly disappear, the molecule must be structurally modified. The hyaluronic acid molecules are attached together, thereby slowing the rate of absorption, and maintaining the correction for a longer period of time. Hyaluronic acid is obtained from bacterial or chicken sources. Restylane is exclusively used as an injectable material.
The third option is Radiance, made of calcium hydroxyapatite, a molecule found in bone and coral, the particles are small enough to be injected.
These are the lines at the corner of the eyes, sometimes also called “smile lines”. Although chemical peel can be used for these lines, I favor treatment with Botox. Results are apparent within three to five days and there is no downtime for the patient.
This is the line that runs obliquely from the inner corner of the eye. It delineates the junction between the eyelid skin proper and the cheek skin. A deep line here results in a tired looking appearance. During blepharoplasty, some of the fat can be pulled to correct this groove. Fat injection or Restylane is a more widely accepted option.
This is the line or groove that starts at the base of the nose and goes downward and outward toward the corner of the mouth. To correct this fold, the cheek contents need to be vertically raised and a mid-face lift may be indicated for optimal results. The other choice for correction is use of filler material. Fascian, Restylane or Radiance can be injected. A third option involves a small surgical procedure that allows us to place Alloderm (sheet of human skin) in the area to raise it and level out the groove.
The decision on how to proceed will depend on the severity of the problem, the patient’s preference and the potential outcome.
LIP LINES: (Lipstick bleed)
There is no perfect solution to this distressing problem. My recommended treatment is dermabrasion with chemical peel. The other choice is filling the vermillion border (the line between the skin and pink part of the lip itself) with either Fascian or Restylane.
To create lip fullness (if the lip is felt to have elongated), a lip-lift procedure can be done where the skin at the top of the upper lip at the base of the nostrils is removed and the lip is then pulled upward, thereby exposing more upper teeth and making the lip look fuller and younger.
The other choice, which has been very successful in my hands, is threading Alloderm, (human cadaver skin), through a tunnel created in the lips from one corner of the mouth to the other. The incisions for insertion remain invisible inside the mouth.
These are the lines that start at the corner of the mouth and go downward encircling the chin. Treatment can include a mid-face lift or fillers (fat or Restylane).
The advantage of using fat in the face to correct deficiencies is that the correction achieved is more permanent when it occurs, the disadvantage is that it needs to be done more than once to achieve the full result.
M. Vincent Makhlouf, M.D.