Facial Rejuvenation – the multitude of options

October 23, 2016

The quest for youth has spurned a multi-billion dollar industry. The multitude of rejuvenation options is bewildering. The choice of rejuvenation technique is generally determined by the patient’s physical state, patient acceptance, tolerance for pain and downtime, and financial constraints.
The clinical problems to be addressed usually include : pigmentation, superficial textural imperfection, wrinkles (dynamic or static), deep folds or contour deformities and skin laxity.
Rejuvenation options are divided broadly into non-invasive (non-surgical) and invasive (surgical) procedures with a few options in the borderline zone. Patient must understand that all these rejuvenation techniques have a common goal to cause controlled damage to the various layers of the skin to stimulate repair and regeneration. Sun avoidance and strict usage of sunscreen is the key to maintenance of result and prevention of hyperpigmentation.

NON-INVASIVE (NON-SURGICAL) PROCEDURES

Chemical peel using glycolic acid of varying concentrations used to be popular. This has been largely taken over by phototherapy.
The commonest phototherapy used is intense pulsed light (IPL) or Broadband Light (BBL). It is able to improve the general complexion, lighten pigmentation, improve fine wrinkle and mildly tighten the skin. It is also effective for permanent hair removal. IPL or BBL are suitable options for regular maintenance without downtime.
To achieve further textural improvement to the superficial layer of the skin, laser resurfacing is more effective. Erbium Yag or carbon dioxide lasers are commonly used to ablate a thin epidermal layer. Erbium Yag laser is more suited for Asian skin type due to its high water affinity, shallow depth of ablation per pass with lower collateral heat damage. The treated area is raw and require regular application of antibiotics. The downtime for microlaser peel is about 3-5 days after which patient can resume putting on make-up.
Various treatment modalities are available to further tighten the dermal layer to for lifting and improvement of static wrinkles. Profractional Erbium Yag (or carbon dioxide) laser, radiofrequency, focused ultrasound and infrared wave can be used to cause thermal injury to the dermal collagen and elastin in a controlled manner. This induces regeneration of new collagen with skin firming effect. The clinic results are best assessed 3-4 month after the procedure although most patient would notice clinic improvement after about a month.

Profractional laser ablate narrow channels into the skin unlike conventional laser resurfacing which ablates the entire treated area. This allows for faster epithelialisation from the surrounding intact skin. Profractional laser is commonly used to treat atrophic acne scars. The raw treated area require regular topical antibiotics. Epithelialisation takes place after about ve days. Most patients are able to return to work 4-5 days after the procedure.
Radiofrequency, focused ultrasound and infrared wave therapy for skin tightening does not result in open wound and incur less downtime than laser resurfacing. Post procedure oedema and erythema commonly resolve within a few days. However, clinical result may not be as dramatic as ablative laser procedure.
Botulinum toxin injection is the standard treatment for dynamic wrinkles i.e. wrinkle that are worsened by facial animation. It can improve crow feet, frown lines and forehead wrinkles. Its effects usually last for 3-4 months. Mild bruising may be present at the needle entry sites. Clinical judgement needs to be exercised to deliver the optimal amount of toxin to alleviate wrinkles without causing unnatural mask-like appearance.
Filler replaces volume and is used correct static deep facial folds (e.g. tear trough and nasolabial fold) and contour deficits (e.g. sunken temporal areas). It is also used to volumise the cheeks for more youthful appearance. It provides an alternative for those patient who wants augmentation of nasal dorsum without undergoing rhinoplasty. However very rarely, the injection of filler into the nose can result in blindness or tissue necrosis. The chemical composition of fillers can be biological (e.g. hyaluronic acid or collagen) and synthetic (e.g. polytetrafluoroethylene). Hyaluronic acid has largely replaced collagen as the most common filler material and resorption occurs within about 6 months. Synthetic fillers may last for more than a year but there is risk of infection and granuloma formation. In the interest of safety shorter-acting filler material is preferable.
Botox and filler complement each other and some patient require both for optimal outcome.

INVASIVE (SURGICAL) PROCEDURES

Fat transfer (grafting) has gain much popularity over the recent years for volume replacement. Fat is a good filler option because it is autologous and contains a small amount of stem cells with rejuvenating properties. Fat grafting has been shown to improve the healing of post-irradiated chronic wounds. Fat is usually harvested from the patient’s abdomen or thighs. Post procedure swelling and bruising last for a few weeks. The final result is firmer skin with increased volume and improvement in wrinkles. This procedure may be repeated for better cumulative result.
Thread lift provides added level of skin lifting to the cheeks and temporal area. Several barbed threads made of absorbable material are inserted skin deep and best stabilised by suturing to the temporal area. Swelling and bruising can last for a few weeks. The initial appearance may appear over corrected and this normally improve over a few weeks to months. The clinic effects may last for 1-2 years.
The common surgeries for facial rejuvenation include: blepharoplasty, browlift, temporal lift, facelift, and neck lift. These procedures can be done singly or as a combination depending on the clinical state.
The management of aged droopy eyelids may involve upper blepharoplasty with levator mechanism correction (levator plication or advancement), and brow or temporal lift.
Lower blepharoplasty for eyebag may include judicious removal of excessive fat and redundant skin, followed by fat redistribution, tightening of the lower lid mechanism and fat injection to improve contour and skin texture. This may be combined with a mini-face lift to achieve more harmonious appearance.
Sagging chin and jowl may need a face and neck lift with division of platysmal band for turkey neck deformity.
When we performing surgery to rejuvenate an isolated site may result in it appearing out of sync with the surrounding area. Combined procedures aim to achieve a harmonious look.