INTRODUCTION

The growing demand for facial aesthetic enhancement without extended recovery time has fueled technologic advances that have made non-invasive facial rejuvenation a reality. Improvement of facial skin texture, pigmentation, tone, wrinkling and facial contour can now be accomplished using a combination of non-surgical therapeutic modalities, including botulinum toxins (Botox®, Dysport® and Myoblock®), injectable fillers and volumizers (Restylane®, Perlane®, Juvederm®, Juvederm Plus®, Cosmoderm®, Cosmoplast®, Sculptra® and Radiesse®), chemical peeling agents (glycolic and trichloracetic acids), intense pulsed light, photodynamic therapy, light-emitting diode devices, non-ablative and fractionated lasers, and skin tightening technologies (radiofrequency and infrared). These techniques usually require several treatment sessions, which are scheduled at intervals that allow the body to recover and respond appropriately. In most cases, these non-invasive procedures are not stand-alone therapies. They complement each other and have a cumulative effect. This multidimensional approach offers an acceptable trade-off for patients who want to avoid the lengthy healing time or potential risks required by many surgical approaches to aesthetic enhancement.

The purpose of this book is to inform physicians of the variety of non-surgical approaches to facial rejuvenation that are currently available, to provide information on how each of these individual components is applied and to demonstrate how each modality compliments the other. Used in combination, these non-invasive aesthetic enhancement techniques can often achieve results that exceed expectations. The wide range of currently available technology for facial rejuvenation is directed toward achieving improvements in three general categories:

• ⧫
  

  skin texture and pigmentation

  
  
• ⧫
  

  wrinkle removal

  
  
• ⧫
  

  skin tightening

A new approach to facial aging takes into consideration a three-dimensional level for rejuvenation, considering not only the epidermal photodamage or the dermal changes, what could be considered as a bi-dimensional concept, but also facial contour modifications and volume changes in facial structure.

Epidermal changes include textural modifications, dischromias, mottled hyperpigmentation, loss of shine and hydration level. Dermal changes represent loss of elasticity in combination with continuous muscle action, creating wrinkles related to muscular activity or dynamic wrinkles. The dermis becomes thinner and its functions as a connective and supportive tissue are reduced.

The facial fat compartments undergo a migration in the caudal direction, leading to fat atrophy in the orbital, frontal, buccal, temporal and perioral regions, while the submental, lateral malar regions of nasolabial fold will present an excess of redundant and ptotic tissue (festoons). The superficial musculoaponeurotic system (SMAS) becomes thinner and longer. The zygomatic bones have horizontal insertions in SMAS attachments; for this reason the superior and inferomedial aspects of face do not suffer all the gravity action. Atrophy of the malar and maxilla bones, reduction of mandibular angle, and reduction of the inferior orbit and chin projections are also associated with facial contour alterations.

The first step in evaluating patients who are seeking facial aesthetic enhancement is to discuss what bothers them about their appearance. Good rapport and open and uninhibited communication between physician and patients are essential. Patients have their own opinions about what they like and dislike about their appearance, so before making treatment recommendations it is a good idea to sit down and look in the mirror with them, and listen to their comments about their appearance. Encourage patients to specify which flaws or deformities they want to correct and then conduct a physical examination to identify the source of the patient’s complaint. They usually notice that their eyes are not the same and they notice bags, wrinkles, skin laxity and eyebrow changes but they do not see behind the symptoms the cardinal signs of the aging process: volume displacement, loss of skin elasticity and muscle hyperactivity. Some patients request the surgeon to pull sinking brows and lids up and out, unaware that this can exacerbate the effects of volume loss, or worse leave them with an artificial tailored look. Any patient who does not have gross dropping of the eyelids is a good candidate for minimally invasive techniques.

Clinical evaluation begins by examining the position and arching of the eyebrows, the muscle activity of the forehead, the heaviness of the upper eyelids and the upper eyelid skin texture, checking for drooping of the upper eyelid muscles and narrowing of the palpebral apertures (ptosis), excessive skin and prolapsing fat or prominent lacrimal glands. The lower lids should be examined for position of the lower lid margin-lower lid retraction or inferior scleral show. They should also be checked for skin texture as well as changes in pigmentation and vascular pooling, creating dark circles, prolapsing fat, creating shadows and contour irregularities, and laxity of the lateral canthal tendons and lower eyelid margin. The presence of extra folds of skin, muscle or fat on the cheek is known as a ‘bag on a bag’ (a malar festoon ).

Aging changes of the mid-face are manifest by skin laxity, loss of bony contours, less prominent cheek bones, soft tissue loss and deepening of nasolabial folds. The lower face shows the presence of more prominent jowls, deepening ‘marionette lines’ (melo-mental folds), submental skin redundancy and fatty deposition, creating a double chin. The lips lose volume and disappear, and the corners of the mouth may droop ( Figs 1.1 and 1.2 , Table 1.1 ).

Facial contour changes with age.

Aging facial changes by decades of life.

Once the source of the patient’s complaints has been identified, the patient and physician must decide what procedures are most appropriate for the patient and what alterations are most compatible with his or her face. They must agree on how much downtime is acceptable and balance that with how much improvement they will be satisfied with. The objective is to achieve a natural look. Reviewing old photographs can be helpful in tailoring the procedure to individual patients.

Patients should be informed of the available non-surgical options for correcting or improving their appearance, and presented with the pros and cons of each approach. It is important that patients have realistic expectations about the limitations of the recommended procedures and what the outcomes can be. They need to be made aware of the variability in healing and the important differences in the tone and texture of each person’s skin. Patientsalso need to understand that, although cosmetic enhancement can make them look better and feel better about themselves, it is unrealistic to expect their lives to change dramatically.

OVERVIEW OF NON-INVASIVE THERAPIES

As mentioned previously, the available non-surgical aesthetic enhancement procedures are not stand-alone therapies. The sum of their effects yields a result that exceeds their individual effects. Currently available therapies include intense pulsed light (and enhanced effect with amino-levulinic acid and photodynamic therapy), botulinum toxins, injectable soft tissue fillers, chemical peeling agents, volumetric radio frequency tissue heating instrumentation, and non-ablative and fractionated lasers.

Intense pulsed light , first introduced in the mid-1990s, is a well-recognized treatment modality for improving the appearance of the photoaged face. Photoaging refers to the clinical changes to facial and other sun-exposed skin caused by chronic exposure to ultraviolet light, including the appearance of telangectasias (red lesions in the skin caused by permanent dilation of preexisting small blood vessels), rough texture, fine and coarse wrinkles, yellow and mottled pigmentation, brown age spots or ‘liver spots’.

Injections of botulinum toxin type A are the most commonly used cosmetic enhancement procedures in the USA, and are used to relax facial muscles and diminish their secondary wrinkle-producing effects. Understanding the anatomy and balance of facial muscles will allow botulinum toxin, in addition to relaxing the dynamic rhytides, to be used to achieve facial symmetry by elevating brows, compensating for blepharoptosis and subtly adjusting a downturned mouth. It works by binding to the nerve endplate and blocking the release of acetylcholine. The bond is permanent until the nerve develops a new endplate that begins releasing acetylcholine again.

Injectable fillers and volumizers are used to add volume to the facial structure, filling in wrinkles and furrows, replacing lost facial volume and accentuating bony contours. Purified bovine collegen and autogenous fat are two FDA-approved fillers that have been successfully used in the USA for more than 20 years. The ease of use and the lack of adverse reactions and longer-lasting effect have made hyaluronic acids the most widely used fillers. They are available in an increasingly wide variety of viscosities and differing characteristics.

Chemical peels are an effective therapeutic option for reversing photoaging. They are recommended for treating a variety of superficial conditions involving the epidermis and superficial dermis, including mild sun damage, superficial wrinkling and pigmentary disorders, actinic keratoses (growths caused by excessive exposure to the sun) and active acne. They are available in a wide variety of strengths. Some strengths can be used without any downtime. More potent varieties require several days of healing.

Radiofrequency volumetric heating technology , or thermage , uses high-frequency electrical current to heat the deeper layers of the skin while cooling the surface; this minimizes downtime and enhances the effectiveness of the treatment. It is primarily a lifting, tightening and contouring procedure.

Infrared volumetric heating technology (i.e. Titan lasers and ALMA Lasers™) uses infrared properties to heat the deep dermis and promote a lifting effect.

Laser resurfacing is performed using a beam of laser energy. Three types of lasers – ablative, non-ablative and fractionated – are used for skin resurfacing. Ablative lasers stimulate collagen regeneration by removing the epidermis and heating the papillary dermis. Non-ablative lasers are less intense and require little or no healing time. They work by treating the papillary dermis, causing the skin to respond by regenerating as if repairing a wound. Lasers that use chromophores (tissues that have a color that attracts laser light of a specific wavelength) are used for treating telangiectasias, hemangiomas, vascular lesions, hair removal and abnormal skin pigmentation. Fractionated lasers , which are adaptations of ablative lasers, are designed to improve skin texture with a minimum of downtime and without anesthesia. They have the unique ability to create microthermal zones of tissue treatment between untouched areas of skin. They are used to improve skin texture, erase unwanted brown spots and improve wrinkles around the eyes and mouth.

Mesotherapy and carbon dioxide insufflation are helpful tools for minimally invasive face and body rejuvenation.

CONCLUSION

This textbook will summarize and address what is available in the technologies of minimally invasive facial and oculoplastic rejuvenation and how these technologies have enriched and revolutionized the field of plastic surgery.