Nonsurgical facial rejuvenation Complete review
As the demand for noninvasive facial rejuvenation continues to grow, it’s imperative that plastic surgeons maintain a mastery of nonsurgical techniques for restoring a youthful facial appearance. during this article, noninvasive interventions for skin resurfacing, tissue tightening, rhytid reduction and volume restoration are discussed with a stress on technical outcomes and potential complications. Overall, this review should function a primer for the aesthetic cosmetic surgeon who aims to supply safe, effective facial rejuvenation to patients who desire maximal results with minimal downtime.
Keywords: Nonsurgical, noninvasive, facial rejuvenation, laser, injectable, radiofrequency skin tightening, ultrasonic skin tightening, skin care
Over the past decade, plastic surgeons have seen a dramatic increase within the demand for noninvasive rejuvenation procedures. consistent with American Society of Plastic Surgeons statistics, there have been 15.9 million minimally invasive cosmetic procedures performed in 2018 – a 2% increase from 2017 and a 228% increase from 2000. In contrast, there have been 1.8 million cosmetic surgical procedures performed in 2018 – a 5% decrease from 2000. These numbers highlight the very fact that the expansion of noninvasive procedures outpaces that of surgical procedures. For that reason, it’s critical that plastic surgeons are prepared to supply safe and effective nonsurgical rejuvenation to reply to the present growing demand.
Part of the increase in noninvasive procedures are often attributed to the rise in new injectables and technologies offered to patients. Many of the soft tissue fillers, laser treatments, and radiofrequency- or ultrasound-based skin tightening methodologies used today were introduced within the last decade. With the growing availability of novel techniques, plastic surgeons are charged with maintaining a masterful knowledge of the way to deliver these interventions to optimize outcomes and minimize complications.
This article focuses on the four key age-related facial changes – diminished skin quality, increased soft tissue laxity, formation of rhytids and volume deflation or redistribution – and the way each of those are often countered using noninvasive technology – skin resurfacing, soft tissue tightening, rhytid reduction, and volume restoration, respectively. The aim of this review is to arm the aesthetic cosmetic surgeon with the knowledge and techniques to get the simplest leads to the safest, nonsurgical fashion.
Sun exposure accelerates intrinsic skin aging by damaging dermal collagen and elastin and interfering with normal skin metabolism. Together, these derangements promote irregular pigmentation, telangiectasias, elastosis, and rhytids. However, multiple studies have demonstrated that sunscreen effectively combats further progression of photoaging, while not reversing existing effects. Inorganic sunscreens, specifically flowers of zinc and titanium oxide , provide superior, broad-spectrum ultraviolet protection, increased photostability, and reduced allergenic potential compared to organic sunscreens like aminobenzoates, cinnamates, and salicylates. the perfect sunscreen to supply to cosmetic surgery patients contains the very best percentage of nano- or micro-sized titanium oxide and flowers of zinc to permit for a cosmetically elegant application without the white appearance characteristic of traditional inorganic sunscreens. Patients should be instructed to use sun protection thirty minutes before sun exposure, reapply frequently, and use in conjunction with other sun avoidance habits.
Antioxidants are intended to guard skin from oxidative stress and to revive skin subjected to environmental damage. vitamin C enhances collagen production and epidermal turnover to enhance skin surface appearance, while vitamin E synergistically neutralizes reactive oxygen species. The addition of ferulic acid stabilizes these two antioxidants and increases their efficacy in retarding and reversing cutaneous signs of aging. the perfect antioxidant should contain a mix of those ingredients et al. , like polyphenols, flavonoids, and carotenoids, during a stable formulation and during a high enough concentration to be effective without causing irritation. Patients should be encouraged to use these antioxidants as a part of their daily skincare routines.
Retinoids increase dermal collagen content, epidermal thickness, and glycosaminoglycan deposition. These histologic effects cause increased skin smoothness and wrinkle reduction. The prescription formulation, tretinoin, is restricted by compliance issues thanks to problematic side effects like redness, irritation, and desquamation which will cause patients to prevent treatment if they’re not fully educated on the way to manage these issues like with reduction in frequency of application or concentration of medication. However, while these side effects are shown to be dose dependent, the skin rejuvenating effects aren’t . Therefore, patients are often prescribed rock bottom concentration (0.025%) of tretinoin and still expect maximal benefit. Retinol, a tretinoin precursor, must be converted to its active counterpart within the skin and is, therefore, 20-fold less effective and has 1000-fold lower dermal concentration than tretinoin. Retinaldehyde, another tretinoin precursor, has similar efficacy to tretinoin with fewer side effects. However, its long-term benefits haven’t yet been compared to tretinoin. For these reasons, tretinoin
Figure 1. Skincare regimen. 53-year-old Hispanic female treated with a skincare regimen which incorporates topical retinoid, vitamin C, and hydroquinone. Before (top) and following 5 weeks (bottom) of daily skincare treatment
remains the gold standard retinoid for skin rejuvenation and will be recommended as an adjunct to other aesthetic treatments.
An example of a patient treated with a mixture regimen of a retinoid, vitamin C, and hydroquinone is included in Figure 1.
Alpha hydroxy acids, like glycolic, lactic, and citric acids, work to exfoliate the skin and interfere with epidermal cohesion, creating a younger skin appearance. One study demonstrated a rise in skin thickness with improved elastin quality and collagen density in patients employing a combined alpha acid formulation. Another study showed a dose-dependent improvement in skin smoothness and reduction in rhytids with use of topical lactic acid. Patient should be encouraged to use the topical alpha acid with the very best effective concentration that they will tolerate without significant redness or desquamation. they ought to be instructed that acids shouldn’t be used with antioxidants because the combination can destabilize vitamin C and reduce its efficacy.
Dermal infusion facials (such as those offered by HydraFacialÔ, Diamond GlowÔ, and SilkPeelÒ) include a mixture of mechanical exfoliation, suction-based extraction, and active ingredient infusion. The exfoliation technique related to dermal infusion facials is termed hydradermabrasion and combines microdermabrasion with pressurized application of an ingredient-containing serum. In one study comparing combined hydradermabrasion and antioxidant serum infusion with topical application of an equivalent antioxidant serum, the treatment group was found to possess increased epidermal and dermal thickness, increased antioxidant levels, decreased fine lines, decreased pore size, and decreased hyperpigmentation.
Though further study is required to support these conclusions, dermal infusion facials are a low-risk, appealing adjunct to other nonsurgical rejuvenation techniques.
Chemical peels are an economical means of skin resurfacing which will be tailored to varied patients. before treatment, a Fitzpatrick analysis is critical as patients with a Fitzpatrick sort of IV through VI are at highest risk of pigmentary abnormalities. These patients should be treated with extreme caution or not in the least .
Pretreatment increases the effectiveness of chemical peels and will be initiated four to 6 weeks before treatment. Tretinoin pretreatment leads to more uniform frosting and more rapid reepithelialization. Hydroquinone should be recommended to patients with Fitzpatrick type III or greater to scale back the danger of post-inflammatory hyperpigmentation. glycollic acid at a degree of 10% or less is additionally administered daily before treatment so as to accelerate exfoliation. These are all stopped one week before treatment to avoid irritation before the peel. Antiviral therapy should even be given to patients with a history of herpes simplex starting two days before and continuing for ten days after.
Immediately before treatment, the skin should be de-greased with acetone or lotion . Following this, the peeling agent are often applied by facial subunit with gauze or a cotton-tipped applicator and feathered at the sides to blend with untreated areas. Application to the eyes, mouth, and alar facial groove should be avoided thanks to the danger of abrasion .
Superficial chemical peels are indicated for mild skin texture abnormalities and dyschromias. they need the advantage of minimal to no downtime and are usually used serially to maximise effect. the acceptable superficial peel depth through epidermis only is achieved when a cloudy white frost on a pink background is noted. When this frosting is achieved, the peel should be neutralized if needed. glycollic acid at a degree of 30%-50% is superficial peeling agent that has got to be neutralized with water or a weak base. Jessner solution is another superficial peeling agent that doesn’t require neutralization.
Medium depth peels are indicated for fine wrinkles and dyschromias. Depth of peel is acceptable when a white frost with erythematous strikethrough is observed, indicating penetration to or through the papillary dermis. At this point , glycollic acid 70% is neutralized as above and TCA 30%-50% doesn’t require neutralization. These peels require between three to seven days of downtime during which patients should expect swelling and erythema.
Deep chemical peels are indicated for coarse wrinkles and deeper acne scars. thanks to their depth of penetration, these peels should be administered with intravenous sedation or regional blocks. Phenol based peels, including Baker-Gordon formula must be performed with cardiac monitoring and intravenous fluids. Depth of peel through the papillary dermis into the reticular dermis is achieved when solid white frosting without background erythema is noted. a gray hue should be avoided as this means excessive depth of peeling. Deep chemical peels require ten to 14 days of downtime and are related to a more painful recovery.
Hetter’s solution – the mixture of phenol and oil to extend penetration – are often performed as a superficial, intermediate or deep peel. The depth is varied by adjusting the amount of swipes, amount of solution applying, or concentration of the phenol and oil .
Peel depth are going to be evident within the nature of the frost, with pink frost indicating an epidermal injury, pink- white a papillary dermal injury, and white a reticular dermal injury.
Following medium and deep peels, patients are advised to moisturize frequently with petroleum-based cream. Sun avoidance should begin immediately, but application of sunscreen can resume starting from immediately after a superficial peel to 2 weeks after a deep peel when re-epithelialization has occurred. Hydroquinone should be initiated by the treating physician immediately at the primary sign of hyperpigmentation. Milia typically answer treatment with topical tretinoin.
In addition to oral acyclovir in patients with a known history of herpes simplex, patients with prolonged, painful erythema should be treated with two doses of fluconazole out of concern for a yeast infection.
Laser resurfacing induces an epidermal or dermal injury and regeneration, leading to improved skin tone, effaced wrinkles, and reduced dyspigmentation. Resurfacing should be performed with caution in patients with history of scarring and Fitzpatrick sort of V or greater. The pretreatment regimen is analogous to the regimen outlined for chemical peels above, including tretinoin and hydroquinone, also as acyclovir which can be used selectively for patients with a history of herpes infection or could also be used for all patients. Superficial resurfacing are often performed with local anesthetic , while deeper treatments should be performed under nerve blocks, intravenous sedation, or general anaesthesia . Resurfacing lasers are often categorized as ablative or non-ablative and fractionated or non-fractionated.
Non-ablative lasers have reduced downtime and lower risk, while ablative lasers have a more dramatic rejuvenating effect. Ablative lasers, like the CO2 (CO2) laser and erbium:YAG (Er:YAG) laser, use water as a chromophore and vaporize treated zones, inducing collagen remodeling. CO2 lasers are limited by their prolonged recovery time – occasionally up to 6 months – and their risk of hypopigmentation. The Er:YAG laser is more specifically absorbed by water-containing tissue and leads to less fatal accident . However, due to these characteristics, its skin rejuvenating effect could also be less pronounced. Non-ablative lasers and non-ablative non-coherent light sources, like intense pulsed light (IPL), pulsed-dye, and neodymium:YAG (Nd:YAG), generate heat to induce dermal injury and improve rhytids without creating open wounds. The thermal energy is hypothesized to stimulate dermal fibroblasts while keeping the epidermis cool and protecting it from injury.
Lasers also can be fractionated or non-fractionated. While fractionated lasers create small columns of injury with unaffected areas between, non-fractionated lasers injure the whole treated area. Fractionated lasers can reach a deeper level of injury while still having reduced downtime thanks to the uninjured skin between injured columns. However, for an equivalent reason, multiple treatments between 2-4 weeks apart could also be required to realize the specified result.
Of the combinations of laser resurfacing treatments, ablative non-fractionated lasers like 10,600 nm CO2 and a couple of ,940 nm Er:YAG have the foremost dramatic effect with the best downtime. On the opposite end of the spectrum, non-ablative fractionated lasers like 1,440 nm Nd:YAG are rock bottom risk with the smallest amount downtime, but even have the foremost modest effect.
Non-ablative non-fractionated lasers like 1,319 nm pulsed dye, 1,320 nm Nd:YAG and 1,450 nm diode, also as ablative fractionated lasers like 10,600 nm fractionated CO2 and a couple of ,940 nm fractionated Er:YAG, function a middle ground in terms of effectiveness, safety, and downtime. samples of patients
Figure 2. Skincare regimen together with pulsed-laser phototherapy [intense pulsed light (IPL)]. 46-year-old Fitzpatrick II Italian- portuguese female seeking perioral rejuvenation before (left) and after (right) a mixture of daily skincare regimen (topical retinoid, vitamin C, and hydroquinone), mucopolysaccharide filler to treat the upper lip rhytids, IPL for 3 sessions, microneedling to a 2 mm depth
who underwent pulsed-dye laser resurfacing using IPL, along side a mixture of other noninvasive treatments, are shown in Figures 2 and three . When choosing the right laser for a private patient, it’s important to think about the patients expectations in terms of desired effect, social downtime, and willingness to undergo multiple procedures.
Posttreatment skincare consists of petrolatum or occlusive dressings until epithelialization is complete, which is between 24-48 h for fractional treatments or a couple of weeks for full field treatments, at which point a nonocclusive moisturizer are often initiated. Sunblock should even be started as soon as re-epithelialization is complete. Other skin care should be initiated judiciously to stop irritation.
The most common untoward effect of laser resurfacing is erythema, which is an expected a part of the healing process. Skin eruptions, like milia or acne, can occur and typically answer discontinuation of occlusive agents. Hypopigmentation can’t be treated but can sometimes be camouflaged by treating and reducing pigmentation in other areas. For hyperpigmentation, it are often an expected sequalae of laser treatments in patients with higher Fitzpatrick types or who have early sun exposure, as in Figure 4 In these cases, it’s self-limiting. If hyperpigmentation persists, it are often treated with IPL treatments. In rarer situations, burns can occur thanks to noncompliance with preoperative skincare and sun avoidance, as seen in Figure 5. Other infections rarely occur without the utilization of prolonged occlusive dressings. If these do occur, they ought to be treated with the acceptable antiviral, antibacterial or antifungal agents.
Other laser indications
In addition to resurfacing, lasers also can be used to specifically treat pigmentary and vascular lesions, which are quite common sequelae of skin aging. Flat pigmented lesions are often treated employing a diode laser at 805 nm or IPL at 515 nm with melanin as a chromophore. Lesions with any concern for malignancy shouldn’t be treated with laser as this interferes with or prevents pathologic diagnosis. Vascular lesions like telangiectasias or cutaneous angiomas are often treated with a diode at 805 nm or IPL at 560 nm using oxyhemoglobin as a chromophore. These lesions often require multiple treatments.
Microdermabrasion may be a technique that employs an abrasive component, usually a solid crystalline material, and a vacuum component. Though it’s touted as an efficient treatment for rhytids, dyspigmentation, and superficial scarring, its effects are shown to be modest. However, it’s been proven to effectively
Figure 3. Skincare regimen, pulsed-dye laser resurfacing [intense pulsed light (IPL)], high-intensity focused ultrasound (Ultherapy), and recurrent Botox injections to the glabella, forehead, and crow’s feet. 43 yo Caucasian Fitzpatrick II presented with effects of long-term sun damage including dyschromia, rhytids, and mild skin laxity. The patient was initiated on a skincare regimen consisting of topical retinoid, vitamin C, and hydroquinone for four weeks before undergoing two sessions of full-face and neck high-intensity focused ultrasound followed by three treatments of pulsed-laser phototherapy (IPL), and recurrent neuromodulator injections to the glabella, forehead, and crow’s feet at 3-4 month intervals. Total treatment time was approximately 19 months
increase transdermal delivery of active skincare ingredients when these modalities are combined. the most advantage of microdermabrasion is that, unlike lasers and chemical peels, it’s safe in most patients including patients with higher Fitzpatrick types or who are otherwise at higher risk of pigmentary changes or scarring.
The procedure begins with facial cleansing and degreasing, followed by three passes in several directions over the treated skin. The degree of dermabrasion depends on the speed of handpiece movement and strength of flow. No anesthetic is required. Following treatment, sunscreen is applied, and there’s typically no social downtime. Patients are advised that they’re going to likely undergo multiple treatments. Complications are mostly self-limiting and include erythema, irritation, and petechiae.
Figure 4. Phototherapy-induced inflammatory hyperpigmentation (PIH). 46-year-old Fitzpatrick II Female pre-treated with our skincare regimen (Tretinoin, Vitamin C, and Hydroquinone 4%) 1 month before intense pulsed light (IPL) phototherapy (left) with a traditional physiological hyperpigmentation response to phototherapy (right). PIH normally occurs within 6 h of IPL treatment and typically resolves at 5-7 days
Figure 5. Pulsed-laser phototherapy [intense pulsed light (IPL)] complication. Patient presented for IPL therapy without compliance to preoperative skincare regimen and with extended sunlight exposure over a period of 72 h before IPL therapy. Prior sunlight exposure resulted during a cumulative more than UV light which resulted during a superficial burn. The burn fully resolved with a brief course of topical hydrocortisone cream
Dermabrasion uses an abrasive motorized wheel to make a mid-dermal wound. it’s less frequently used since the arrival of laser resurfacing given its increased risk of aerosolized viral particles, dyspigmentation and scarring. it’s still an efficient option within the treatment of deeper acne scars, but its indications in facial rejuvenation are limited
SOFT TISSUE TIGHTENING
Radiofrequency skin tightening works by transmission of thermal energy to the reticular dermis, triggering a transforming cascade with subsequent collagen, elastin, and vascular formation. it’s a non-ablative technology that specifically treats the dermis and spares the epidermis, thereby reducing scarring or pigmentary complications and speeding recovery
Indications and contraindications
Radiofrequency treatments been shown to be beneficial for the treatment of facial wrinkles, brow lifting, periorbital wrinkles, nasolabial folds, jowls, marionette lines, jawline contouring, and neck laxityRadiofrequency skin tightening is contraindicated in patients with implantable medical devices and people with underlying healing disorders. Multiple studies have shown it to be less effective in older patients, either thanks to decreased capacity for dermal healing, decreased tissue hydration, or increased severity of preoperative deformity
The administering practitioner must determine whether to treat in one session with higher energy or in multiple sessions with lower energy. One study showed that using lower energy over more sessions was simpler for reworking of collagen and improvement in skin elasticity
These modalities are often administered through monopolar devices (one electrode with body grounded for unidirectional current flow through the skin like ThermageÒ), bipolar devices (two electrodes
– one subcutaneous and one percutaneous -with current flowing between like Body-TiteÔ), and unipolar devices (one electrode without a grounding pad for omnidirectional field of effect administered subcutaneously like ExilisÒ) While monopolar radiofrequency penetrates through all tissue layers and creates deeper tissue injury, bipolar radiofrequency is more localized and offers more superficial treatment, while also being less painful]. Furthermore, monopolar radiofrequency are often administered under local anesthetic , while unipolar and bipolar usually require tumescent or general anaesthesia
Fractional radiofrequency treatment or radiofrequency microneedling (such as Profound RFÒ and MorpheusÒ) uses microneedle electrodes to deliver fractional radiofrequency energy on to the reticular dermis, while protecting adnexal structuresThe ablative effect of the microneedling allows for both a resurfacing and tightening effect and may be beneficial in patients who require treatment of both these signs of aging and are willing to simply accept a extended recovery than traditional, non-ablative radiofrequency treatments.
Outcomes and complications
Patients should be instructed that full results of treatment are often expected within six months to at least one year. the foremost common adverse events are swelling, numbness, and bruising which generally resolve within 1-2 months and may be treated expectantly
Figure 6. Ultherapy treatment areas. Markings demonstrating the areas and individual yellow ultrasound energy points treated to induce lifting and tightening for the neck, submental region, and cheeks
Ultrasound-based skin tightening (such as UltherapyÒ) uses a lower energy, microfocused ultrasound to heat tissue through vibration and friction. This heating produces small coagulation points within the reticular dermis to induce remodeling, while sparing the overlying papillary dermis and epidermis. Like radiofrequency skin tightening, this epidermal sparing reduces the danger and recovery time related to this procedure. Unlike radiofrequency skin tightening, however, microfocused ultrasound energy can heat deeper tissues without heating the skin, allowing transmission of upper energies and penetration to the superficial muscular aponeurotic system and platysmaIt also allows for direct visualization of treated tissues during treatment, adding a further level of safety
Indications and contraindications
Ultrasound skin tightening is approved for the eyebrows, chin, neck and chest. the perfect patient has mild to moderate skin laxity and doesn’t have any underlying condition that might inhibit wound healingBecause treatment in higher Fitzpatrick types has not been thoroughly studied and since two cases of hypopigmentation are reported, ultrasound based skin tightening should be used with caution in patients with Fitzpatrick type V or VILike radiofrequency skin tightening, microfocused ultrasound has been shown to be less effective in older patients with more severe age-related deformities
The procedure is performed following application of local anesthetic . Given the moderate to severe pain related to this treatment, some options for extra anesthetic include nerve blocks, laughing gas gas, and oral anxiolytics. Focal depth is visualized on the monitor and calibrated to correspond to the layer intended to be treated before delivering a linear array of ultrasound pulses. Most therapy platforms have pre-programmed protocols for specific treatment areas, as shown in Figure 6, and treatment times vary from 30-60 min per region
Figure 7. High-intensity focused ultrasound (Ultherapy). 64-year-old African American female before (left) and a couple of months following (right) High-intensity focused ultrasound therapy to the neck, cheeks
Outcomes and complications
Following treatment, patients should expect swelling, erythema, and transient bruising, all of which are self-limiting. Complete results can usually be expected within six monthsStudies report that greater than 80% of patients and providers note an improvement following treatmentAn example of a patient treated with high-intensity focused ultrasound is included in Figure 7. Other samples of patients who underwent a mixture of ultrasonic skin tightening and skin resurfacing is shown in Figures 8 and 9.
Rarely, patients can develop linear patterns of skin discoloration that resolve within a couple of weeks. There are reports of nerve paresis, specifically within the temporal and marginal mandibular branches of the facial , but these have all resolved within six weeks
Figure 8. Fractionated bipolar radiofrequency sublative skin resurfacing (eMatrix) and high-intensity focused ultrasound (Ultherapy). 56 yo Caucasian Fitzpatrick III with a history of lower lid blepharoplasty and full-face TCA peel presented with fine facial rhytids and mild facial ptosis. Before (top) and after (bottom) full face fractionated bipolar radiofrequency skin resurfacing (eMatrix) and high-intensity focused ultrasound (Ultherapy) to the neck, face, and brow
Infrared light energy
Of the noninvasive skin tightening modalities, infrared technology (such as SkinTyteÔ) is the least well studied. The procedure works by delivering infrared energy via broadband light to create heat in the dermis and initiate collagen remodeling.
Unlike ultrasound-based skin tightening, infrared energy does not penetrate to the deeper subcutaneous tissues. Therefore, it is indicated only in mild forms of skin laxity that do not involve the underlying tissue. Similar to other modalities, it should be used with caution in patients with higher Fitzpatrick types.
Typically, infrared skin tightening is not painful enough to require any form of anesthetic. It is performed by heating individual treatment zones to a particular temperature by performing a series of treatment cycles and skin temperature measurements. The skin is then allowed to cool or cool compresses are applied
Figure 9. Skincare regimen, fractionated bipolar radiofrequency sublative skin resurfacing (eMatrix) and high-intensity focused ultrasound (Ultherapy). 48 yo caucasian Fitzpartrick II, before (upper top, lower top) and after (upper bottom, lower bottom), a series of three full-face fractionated bipolar radiofrequency sublative skin resurfacing treatments, a single full-face high-intensity focused ultrasound treatment, 1 mL Hyaluronic acid filler to the nasolabial folds, and recurrent injections of neuromodulator to the glabella, forehead, and crow’s feet. Marked improvement in skin texture, dyschromia, and fine rhytids are seen. Treatments occurred for a period of 12-months
Outcomes and complications
Usually patients experience mild discomfort post-treatment. Full results should be expected after three to six treatments performed at two- to four-week intervals. Results are variable and outcome and complication data is not well published
Microneedling is performed by breaching the epidermis with micron-sized needles to create an injury to the outermost layer of the skin. These micro-punctures are touted as a means of injuring the skin and causing elastin and collagen production and deposition
Figure 10. Skincare regimen and microneedling (x3). 61 yo Caucasian female Fitzpatrick I skin before (left) and after (second from left) skincare regimen (topical retinoid, vitamin C, hydroquinone) with 1 mL hyaluronic acid filler to the lips, followed by microneedling procedures. Shown at one-week post-needling (middle), two-week post-needling (second from right), and three-week post-needling (right). Total course of treatment was approximately 12 months
Because the treatment is so superficial, it has only been shown to treat very superficial rhytids. A newer application of microneedling is for drug delivery, which will be discussed in a later section.
The procedure is performed by cleansing and applying a topical anesthetic. The microneedling device is applied to the skin in a perpendicular fashion and the device is moved in multiple directions to evenly distribute passes. Uniform, pinpoint bleeding is the endpoint of the procedure, at which point in time a moisturizing sunblock is applied routinely for at least forty-eight hours or indefinitely
Outcomes and complications
Treatments can be repeated every two to four weeks until desired effect is achievedAs seen in Figure 10, effects are modest secondary to the superficial level of injury. However, this superficial penetration also reduces the downtime and risk profile associated with this treatment, with the primary adverse effects being bruising, erythema, and irritation that are self-limiting
RHYTID RELAXATION OR REDUCTION
Botulinum toxin is the most commonly used nonsurgical facial rejuvenation modality in the United States.The toxin works to temporarily paralyze facial muscles, thereby eliminating dynamic rhytids and reducing static ones. Multiple formulations of the toxin are commercially available currently (e.g., BotoxÒ, DysportÒ, XeominÒ, JeaveauÒ), with additional preparations set to be released (e.g., Daxi). The principle difference in these products is their content of proteins that may cause sensitivity or resistance over time. A meta-analysis of studies comparing three formulations of botulinum toxin failed to find any significant difference in treatment response but concluded that further comparison study is needed
Botulinum toxin treatment is generally safe, but is contraindicated in patients who have allergies to eggs or albumin, who have an infection at the injection site, and who are pregnant or breastfeeding. Relative contraindications include use of anticoagulation given the presumed elevated bleeding risk, underlying neuromuscular disorder given the possibility of increasing severity, or blepharoptosis given the risk of worsening with frontalis paralysis
A general schematic of botulinum toxin injection sites is included in Figure 11 with additional detail
Forehead and periorbital botulinum toxin injections should be performed with careful attention to brow morphology, as each injection will have a resulting impact on brow position. An illustration of how each muscle impacts brow position is show in Figure 12.
|Muscle/muscle group||Muscle action||Static/dynamic rhytids|
|Frontalis (A)||Elevation brows||Horizontal forehead lines|
|Glabellar muscles: Corrugator supercilii (B) Procerus (C)||Medial Elevation of brows Depressor of brows||Frown lines, glabellar creases|
|Orbicularis Oculi (D)||Elevation of eyelids, concentric tightening of periorbital tissue||Crow’s feet|
|Nasalis (E)||Medial elevation of nasal skin||Bunny lines|
|Levator labii superioris alaeque nasi (F)||Elevation of the central lip||Gummy smile, nasolabial Folds|
|Orbicularis oris (G)||Lip pursing, lower lip and corner of mouth depressor||Radial lip lines, smoker’s lines|
|Depressor anguli oris (H)||Corner of mouth depressor||Down turned smile, marionette lines|
|Mentalis (I)||Elevation of chin and lower lip||Dimpled chin, Chin lines|
|Common Neuromodulator Injection Sites|
Muscles of facial expression, their actions, corresponding wrinkles, and points of neuromodulator injection
The frontalis, which creates transverse forehead rhytids, as seen in Figure 13, should be injected in 1.25-2 unit aliquots, depending on the injector’s preferred dilution. Injections should be deep given the anatomy of the frontalis muscle and should be planned based on the individual patient’s forehead rhytid pattern. To maintain an aesthetic brow shape, injections should not extend too inferiorly or laterally to preserve brow height and arch.
The glabellar muscles, which create mid-brow rhytids, as seen in Figure 14, include the corrugator and procerus. These can be injected in a V pattern with 4-5 units of botulinum toxin per injection. The plane of injection should be deep in order to preserve frontalis in this area. The specific injection pattern should be titrated to the individual patient’s rhytid morphology when animating.
Upper face muscle pull on eyebrow. An illustration of the direction that each upper facial muscle pulls on the eyebrow, showing the medial glabellar muscles exerting a downward force, the frontalis exerting an upward force, and the orbicularis oculi exerting a downward force
Frontalis muscle anatomy. Facial muscle anatomy (top) and morphology, as seen with animation (bottom)
Glabellar muscle anatomy. The corrugator and procerus are seen anatomically (top) with their bony attachments illustrated (middle) and their functional rhytid pattern (bottom)
Orbicularis oculis anatomy. Anatomic drawing of the orbicularis oculi muscle (top) and functional anatomy showing dynamic rhytids (bottom)
The orbicularis oculi, Figure 15, should be injected very superficially to target the muscle and avoid spread to the levator palpebrae superioris. These injections serve to obliterate lateral orbital rhytides and to raise the lateral brow. Injections should be performed in 1-2 unit aliquots in three to five sites. Patients with very active muscles may require a second row of injections
Complications of upper facial botulinum toxin injections are undesirable but reversible based on the temporary effect of treatment. Brow asymmetries or overly peaked brows can be managed with additional, judicious injections. Blepharoptosis, however, is not reversible for the duration of treatment effect and can only be mitigated with alpha-adrenergic activation of Muller’s muscle to temporarily elevate the eyelid (e.g., with apraclonidine drops). Other adverse effects such as swelling, bruising, or redness are self-limiting
Lower face and neck
Botulinum toxin injection in the lower face and neck is more difficult and less reliable than in the upper face. Therefore, knowledge of anatomy is critical for using this treatment safely and effectively.
Treatment of the orbicularis oris softens fine vertical perioral rhytids that occur with animation. It is performed by injecting very superficially in two points on the superior and inferior lip at the vermilion
border. Ideally, a small amount and volume of product should be injected to minimize diffusion (e.g., less than 0.1 mL of concentrated toxin). It will not treat the static rhytids that occur due to chronological aging or smoking as these are better managed with resurfacing treatments.
Injection into the depressor anguli oris raises the oral commissures. Injections should be performed a few millimeters above the mandibular border just anterior to the jowl at two sites per side, each with 2-2.5 units.
The mentalis muscle can be addressed to reduce its cobblestoning effect on the chin. It is injected at one point per side, five millimeters lateral to midline and one centimeter above the tip of the chin using 2-2.5 units per injection.
Injection of the platysma muscle softens platymsal bands. Usually several (up to ten) superficial injections of 2-2.5 units are required in a vertical line on each side at the anterior border of the muscle with one to two centimeters between injection sites. This technique is facilitated by pinching the muscle between the injector’s fingers. Treatment of this area can also help to elevate the oral commissures.
Adverse effects of botulinum toxin in the lower face can be debilitating and are difficult to treat. These can include smile asymmetries, speaking difficulties, drooling, and dysphagia. Safe injection technique and mastery of the relevant anatomy will help to reduce the risk of complications
VOLUME RESTORATION OR REDISTRIBUTION
Injectable soft tissue fillers can be either resorbable (hyaluronic acid and poly-L-lactic acid) or non- resorbable (calcium hydroxyapatite and polymethylmethacrylate). Due to its enzymatic reversibility in the face of adverse outcomes, hyaluronic acid is the most commonly used filler. Its degree of cross-linking determines its viscosity and indications. Specifically, the more highly cross-linked formulations are more viscous and are indicated for deeper injections, whereas the less cross-linked formulations are thinner and indicated for more superficial injectionsA schematic of the layer of injection for higher and lower degrees of cross-linking is shown in.
In the upper face, filler can be used to elevate the lateral brow by injecting into the deep tissue of the lateral eyebrow at the inferior aspect of the supraorbital rim using 0.25-0.5 mL of product .It can also be injected into the upper lid sulcus deep to the orbicularis to correct an A-frame deformityThe tear trough is more difficult to correct due to the thin skin and high risk of discoloration or contour irregularities. The safest method to treat this area is to place a 0.25 mL aliquot of a low cross-linked filler along the preperiosteal infraorbital rim rather than injecting directly into the tear trough. Various injection strategies for correction of the tear trough deformity are shown in Figure 18. All areas are massaged following injection to create a smooth, even contour
In the midface, cheek augmentation can be achieved by performing small volume injections along the zygoma at the level of the periosteum beginning lateral to the midpupillary line with subsequent massage to smooth the filler. In this area, a more highly-crosslinked filler should be used given the depth of injection. Nasolabial folds are treated by injecting the mid to deep dermis with a medium cross-linked filler [Figure 19].
In the lower face, the lips can be injected to create a more full, everted youthful appearance. Many patients require small aliquots of local anesthesia or nerve blocks for this procedure. Lip augmentation can be performed using many techniques, and the best is one that is tailored to the patient’s unique anatomy and asymmetries. A lower viscosity filler should be used and aesthetic lip proportions should be respected,
Filler injection depths. Blue areas illustrate depths of filler injection from intradermal (top), to various levels of intramuscular (middle three), and preperiosteal (bottom)
Filler for lateral brow elevation. Location and direction of lateral brow filler injections for brow elevation
injecting along the white roll, within the vermilion and below the commissure. Some patients also benefit from philtral injections. Marionette lines and the pre-jowl sulcus can be treated by a superficial subcutaneous injection of a medium cross-linked filler material. Finally, a recessed chin can be augmented using a supraperiosteal bolus of a highly cross-linked filler material at three sites across the lower chin
Tear trough filler injection strategies. Various strategies for using filler to correct the tear trough deformity are shown including injection along the tear trough and along the infraorbital rim (top) and within the volume defect in the midcheek (bottom)
Nasolabial fold filler injection. The directions and pattern of injection for correcting nasolabial fold
Mild adverse events following filler injection include bruising, edema, and erythema that are self-limiting. A herpes flare is a more concerning reaction, which highlights the importance of thorough preoperative history taking to determine the need for pre- and postprocedural prophylaxis. Nodules may form if too much filler is injected in one area or if highly cross-linked fillers are placed too superficially. A trial of massage can be initiated followed by dissolution of the nodule with hyaluronidase (20 units of enzyme for every 0.1 mL of filler). Most of the dissolution should occur within a few minutes of injection. Vascular
Mechanism of filler-induced blindness. An example of how retrograde arterial flow after injection into an ophthalmic artery branch can cause blindness. This phenomenon can also occur with injection of other periorbital vessels
occlusion resulting in either soft tissue loss or blindness is a rare but known complication of filler injection. This devastating outcome is minimized by safe injection techniques (aspiration prior to injection, avoidance of anatomic areas that risk vascular compromise via compression or embolization, and avoidance of injecting large volumes). However, if this complication does occur, early detection is key with immediate hyaluronidase injection if a hyaluronic acid filler was used at the first sign of color or sensory change or onset of pain. The treatment algorithm involves 500 units per anatomic unit every hour until resolution of soft tissue changes are noted. Blindness is the most feared complication of fillers and occurs due to retrograde arterial flow after injection into an ophthalmic artery branch [Figure 20]. If this should occur, there is no known consistent means of reversing filler induced visual changes. Retrobulbar hyaluronidase has been suggested, but it is a controversial means of treatment, and its use in unpracticed hands is ill- advised. Yet, immediate ophthalmologic evaluation to reduce intraocular pressure and encourage return of blood flow is recommended.A photo of the senior author’s in-office filler emergency kit is included [Figure 21]. Because the success of hyaluronidase injection for clearing an intravascular occlusion is not certain, prevention of embolism is critical. The careful injector should aspirate prior to injection to ensure the needle is not intraarterial, move the needle during injection to avoid injecting a large volume in one area, and apply only gentle pressure to avoid forcing filler into a false, undesired plane.
Fat grafting is another tool for facial rejuvenation and volume restoration. It has the advantages of availability and cost effectiveness, but is limited by unpredictable ultimate retention. Many of the injection techniques are similar to those used for fillers. However, special consideration must be given to the harvesting and processing techniques that optimize fat graft retention and to the methods of minimizing complications specific to fat grafting.
When harvesting fat for grafting, a careful technique should be used to minimize adipocyte trauma and maximize viability. Although harvest location has not been shown to impact viability, ultrasound- or power-assisted liposuction should be avoided due to the trauma inflicted upon adipocytes. Fat is then prepared by gravity separation, centrifugation or Telfa rolling – none of which have been shown to more or less effective for increasing ultimate graft retention as long as centrifugation is limited to less than 3000 rpm and less than three minutes. Fat should be injected using 18-20 gauge blunt-tipped cannulas and in small
0.1 mL aliquots to reduce the risk of fat necrosis or nodule formationIn the periorbital region, injection should be performed deep to the orbicularis and overcorrection should be avoided. Suborbicularis injections are critical as injection just deep to the skin will result in visible contour abnormalities and nodule formation.
The most common complication of fat grafting, particularly periorbital fat grafting, is contour abnormality that is visible or palpable. Liposuction is rarely a successful management strategy. Triamcinolone injections
can be attempted but direct excision may be necessary. Vascular compromise can occur, similar to synthetic fillers, but is more difficult to treat as no enzymatic digestion is available .Importantly, patients should be counseled that multiple treatments may be needed to achieve the desired effect.
When performing facial rejuvenation, volume reduction is most commonly indicated in the submental region. Deoxycholic acid (KybellaÒ) is an injectable agent that disrupts adipocyte cell membranes and is used for noninvasive fat reduction.
Deoxycholic acid injections are indicated for the pre-platysmal fat, but should not be injected deep to the platysma. They can be performed in men or women and do not require anesthesia. The ideal patient has good skin elasticity in order to expect skin retraction following the procedure
When injected into the submental fat, an average of three to four rounds of injections are needed with decreasing amounts of product and a reduction of 92.8% of submental fat volume is achievedInjections are performed in a pre-marked grid with approximately two milligrams of product per square centimeter, amounting to up to fifty injection sites.
Risks of the procedure include swelling, which occurs within 48 h of the procedure, lasts an average of 2 weeks, and results in an average 8.68% volume increase. In spite of this post-procedure swelling, patient satisfaction was significantly improved with deoxycholic acid injections. Other reported risks include nerve paralysis, dysphagia, dysphonia, and wound formation, but these are rare and reversible
Submental fat reduction can also be achieved through cryolipolysis. Cryolipolysis (CoolSculptingÒ) works by controlled cooling to selectively damage adipocytes while sparing surrounding tissue.
Prior to treatment, the area is cleaned and a gel is applied. The procedure is then performed using a small applicator intended for the submental region and lasts approximately forty-five minutes. Massage is required following treatment to rewarm and reshape the tissue which will be significantly swollen immediately upon probe removal
Studies of submental cryolipolysis demonstrated a volume reduction of 20.3% that was stable by 6 weeks following treatment. Seventy-six percent of patients were satisfied with the results of their treatment.Patient selection is critical in this regard as patients with significant overlying skin laxity will have worsened laxity following fat dissolution.
Adverse events following cryolipolysis most commonly include erythema, edema, and paresthesias. All of these are self-limiting. There have been cases of paradoxical fat hypertrophy following treatment, but these cases are rare, affecting approximately 1% of patients. Risk factors for this complication include male gender, history of cryolipolysis, and Hispanic origin. Other risk factors, such as abdominal region and large handpiece, do not apply to the submental region
Platelet rich plasma
Platelet rich plasma (PRP) is an autogenous solution derived from a sample of a patient’s own blood. It is theorized to work to promote wound healing by releasing secretory granules that contain growth factors to induce tissue regeneration and collagen formation that, altogether, increase skin thickness
PRP has been used in facial rejuvenation to reverse skin aging and to supplement fat grafting for increased retentionThere have been seven studies of PRP for rejuvenation of aging facial skin. These studies varied in their number of treatments (one treatment or three treatments every two to four weeks) and in their sites of intradermal injection. Findings included improved skin texture and elasticity, decreased rhytids, improved skin color, improved fullness, and normalization of pigmentation. Given the heterogeneity of these studies, variable samples sizes, and short follow up duration, additional studies are needed.
There have also been seven studies of PRP supplementation of fat grafting. The ratio of fat to PRP in these studies varied widely from 2:1 to 10:1. Injection sites included nasolabial folds, malar region and temporal region. Most of these studies evaluated results after only one treatment. Results were variable with some reporting aesthetic improvement and others reporting increased resorption. Of note, these studies did not have a control group so results should be interpreted with caution
If planning to offer PRP for either of these indications in one’s practice, it is important to realize that standardized, evidence-based protocols have yet to be developed. Of the available articles on PRP in aesthetic surgery, the volume of blood drawn, PRP isolation procedure, and PRP yield varied widely. Therefore, each surgeon is encouraged to determine the protocol that is most efficient and effective in his or her practice
In terms of complications, patients may experience self-limiting redness, swelling, or bruising, but there were no reported serious complications secondary to PRP harvest or injection
Microinjection (e.g., AquagoldÒ) is the combination of microneedling, which was discussed previously, and the delivery of active ingredients such as hyaluronic acid, peptides, and other active ingredients. By injuring the stratum corneum, this technique is theorized to allow for more efficient drug delivery into the deeper layers of the dermis where they can exert their intended effect.
Hyaluronic acid microinjection is intended to increase dermal thickness and skin quality. Peptide microinjection is beneficial as peptides cannot naturally permeate the skin barrier. These peptides have various applications including stimulation of collagen production. However, both these indications are theoretical and have yet to be fully studied.Other skincare ingredients, such as antioxidants and retinols, have also been hypothesized to benefit from microinjection. Early studies have confirmed their effective delivery. However, the benefit of this system is yet to be confirmed
While this technique requires further study, the use of microneedling with drug delivery or with subsequent application of active skincare ingredients has been shown to increase the penetration of these agents and is a relatively safe procedure with risks including irritation, erythema, swelling and bruising that are self-limiting.
With the growing demand for noninvasive rejuvenation procedures, it is imperative that plastic surgeons remain experts in the safest and most effective ways in which to use these emerging technologies. This review article provides an overview of the modalities available for skin resurfacing, skin tightening, rhytid
reduction, and volume restoration, as well as novel modalities to combat facial aging. For most patients, a combination of these interventions will deliver optimal outcomes. Our goal is to prepare plastic surgeons to continue to offer the best and safest results to patients who desire appreciable results with minimal downtime.
- American Society of Plastic Surgeons Release. 2018 Plastic surgery statistics report. Available from: https://www.plasticsurorg/ documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf. [Last accessed on 2 Dec 2020]
- Sambandan DR, Ratner Sunscreens: an overview and update. J Am Acad Dermatol 2011;64:748-58.
- Hughe MCB, Williams GM, Baker P, Green Sunscreen and prevention of skin aging: a randomized trial. Ann Intern Med
- Wang SQ, Balaqula Y, Osterwalder Photoprotection: a review of the current and future technologies. Dermatol Ther 2010;23:31-47.
- Xu S, Kwa M, Agarwal Sunscreen product performance and other determinants of consumer preferences. JAMA Dermatol
- Mancuso JB, Maruthi R, Wang SQ, Lim Sunscreens: an update. Am J Clin Dermatol 2017;18:643-50.
- Verschoore M, Nielson The rationale of anti-aging cosmetic ingredients. J Drugs Dermatol 2017;16:94-7.
- Nusgens BV, Humbert P, Rougier A, et al. Topically applied vitamin C enhances the mRNA level of collagens I and II, their processing enzymes and tissue inhibitor matrix metalloproteinase 1 in the human J Invest Dermatol 2001;116:853-9.
Murray JC, Burch JA, Steilen RD, et al. A topical antioxidant solution containing vitamins C and E stabilized by ferulic acid provides protection for human skin against damage