In performing minimally invasive facial rejuvenation, the tools of the trade are numerous: dermal fillers, neurotoxins, collagen stimulating lifting threads; platelet-rich plasma (PRP) delivered transdermally via needle, microneedle or cannula; fat transfer and more. Simply stated, one does not need surgery or energy-based devices to achieve the best facial rejuvenation treatment outcomes.
Non-surgical face-lifts, pan-facial rejuvenation and other modern aesthetic techniques are being employed routinely around the world, and are often referred to collectively as the “liquid face-lift.” This is a euphemism for rejuvenating and volumizing the face utilizing fillers, neurotoxins and / or fat. While surgical face-lifts can involve serious downtime and complications, minimally invasive approaches often yield immediate and even long-term results with fewer complications and virtually no patient downtime.
“Although plenty of practitioners work on facial skin with energy-based devices, we’re almost at the point in the industry where we can keep up with aging and even reverse aging using just non- or minimally invasive modalities,” expressed Steven F. Weiner, M.D., a facial plastic surgeon in Santa Rosa Beach, Fla. “I have patients that have been with my practice for 10 to 14 years that look younger now than they did when they first started; even better. If people maintain a treatment regimen and apply great skincare, they can keep up with the aging process pretty well.”
According to William Philip Werschler, M.D., F.A.A.D., F.A.A.C.S., a dermatologist and clinical researcher in Spokane, Wash., “From a non-surgical perspective, we break it down into putting something on top of the skin or under the skin, with consideration on whether we apply energy or material. The core of minimally invasive rejuvenation is going to be the use of neurotoxins and dermal fillers, predominantly.”
In terms of the latest clinical approaches, the state-of-the-art in minimally invasive facial rejuvenation is combination therapies, expressed Vic A. Narurkar, M.D., F.A.A.D., a San Francisco, Calif.-based dermatologist and dermatologic surgeon, and past president of the American Society of Cosmetic Dermatology and Aesthetic Surgery.
“It’s not any single treatment that will achieve optimal results. There are so many advances in skincare and less invasive drug-delivery, such as needle-less methods of delivering active agents. We are in a non-invasive renaissance in aesthetics, in which we are globallyrejuvenating multiple anatomic areas from both the inside and outside of the body,” he stated.
As such, treatment approaches have shifted away from cosmetic surgery, noted Antonella Quaranta, M.D., P.C., an aesthetic surgeon in Florence, Italy. “We want to achieve a higher level in aesthetic medicine, which includes procedures that provide appreciable and lasting results without the use of a scalpel, in a quick, effective manner without downtime,” she said.
The patient population for non-surgical facial rejuvenation has grown, as well, noted Dr. Narurkar. “While older people can certainly benefit from minimally invasive skin rejuvenation, Millennials have really embraced these approaches,” he said.
“Many are just not quite ready for surgery, and if they start earlier in life then we potentially prevent the need for more aggressive procedures later,” he continued. “I’ve been following these patients and we have been able to maintain their youthful looks without having to undergo surgery.”
The number and quality of injectable products has also improved, noted Dr. Quaranta. “In the beginning, I used collagen and had to subject my patients to allergy tests. Then hyaluronic acid (HA) came along, but in formulations that were, I dare say, too broad and not specific enough. Today, we have products that are more refined and resilient, with low BDDE. These provide natural, long-lasting results,” she said.
As Peter J. Damico, M.D., an aesthetic specialist in Fort Worth, Texas pointed out, the type and quality of injection tools are very important, as well. “I use a microcannula whenever I can, but sometimes I achieve a better result using a needle,” he expressed.
“The microcannula is much safer and not as traumatic, with less bruising and swelling,” he elaborated. “I don’t inject into people’s temples with needles anymore. I will use a microcannula on the lateral cheeks to obtain a good result, but in other areas like the anterior cheek there are times when you have to use a needle.”
Beyond fillers and neurotoxins lie new clinical methods that involve platelet-rich plasma (PRP) treatments, as well as the use of lifting threads, collagen stimulators, stem cell / fat grafting procedures and Micro Botox.
First popularized in the 1990s, thread-based lifting procedures have recently made a comeback. With this treatment, absorbable sutures derived from biodegradable polymers help lift and re-contour the lower and mid-face. The procedure fell out of favor around 2000, but in 2015 the FDA approved a new variation called the thread lift that takes less time and is less invasive than earlier versions.
Two approved products have emerged, one featuring PDO (Polydioxonone) threads and the other utilizing suspension threads with absorbable, dissolving suture material. These require minimally invasive applications to lift and tighten sagging skin tissues by inducing collagen production.
“I would actually venture to say that most practitioners put threads in and then flood the area with dermal fillers,” said Dr. Werschler. “I use a lot of Sculptra, and sometimes use Bellafill or the occasional HA. So, you not only get the lifting via suspension of the skin, but you also volumize.
“Aging is a loss of volume and lift. With fillers you really only address volume,” he pointed out. “For the most part, with sutures, face-lifts, or even with energy-based devices, all you’re doing is addressing gravity, none of which are really addressing volume. With PDO threads, for instance, there’s not as much lifting as there is the fact that the threads dissolve and encourage the growth of collagen so you get volume.”
Threads do have their issues, added Dr. Werschler. “They can break. Occasionally, the little cones can extrude or they make hard little bumps. People will play with them like they would play with a zit,” he noted. “Anytime you have a suture, even with really good technique and surgery, you can have extrusion of the ends of the suture. It just happens. Even though you do a good job placing them, it doesn’t mean they will stay the same forever.”
Another recently reintroduced technique, Micro Botox (also known as meso or intradermal Botox) has been in the marketplace for years, but has seen a recent surge in popularity. Physicians mix a diluted solution of Botox with hydrating substances and deliver small doses of this compound formula into the dermis of the face and neck. It is used mainly to treat fine lines and wrinkles.
“I’ve been using Micro Botox and Micro Dysport for around five years,” said Dr. Weiner. “It improves skin pores and texture, but the home run is with acne. Some have reported that Micro Botox also helps treat rosacea.”
Like Micro Botox, PRP has been around for years but has recently grown in popularity for a variety of indications, including facial rejuvenation. “PRP use is still in its infancy,” stated Dr. Weiner. “It is often hyped on the Internet as a miracle cure. However, the scientific value of PRP is based in the improvement in hair growth. I think that it also improves scarred or lasered skin. In normal skin that is not injured or aged, I haven’t seen solid scientific evidence that there are any benefits.”
Despite a lack of solid clinical studies surrounding PRP use, though, practitioners are including it and other regenerative medicine-type approaches in their liquid face-lifts, including fat transfer and stem cell-based therapies.
“Autologous fat grafts and bio-fillers are becoming more popular and even ideal for facial rejuvenation,” stated Dr. Quaranta. “For instance, take an autologous fat graft combined with a cross-linked HA-based formulation and you can get a product with regenerative qualities. Fat transfer alone can be used to redefine contours, eliminate shadows, increase volume, improve texture, soften folds, decrease wrinkles and achieve an overall rejuvenated appearance.”
Mixing fat grafting procedures with other modalities, such as dermal filler and / or neurotoxin treatments, is becoming a popular combination therapy for both filling and tissue regeneration.
For instance, Rejuvn8 (Liverpool, N.Y.) offers the Rejuvn8 LipoFilling Kit, in which autologous fat grafts containing macro, micro and nano fats are combined with a proprietary HA-based formulation that helps redefine contours, reduce shadows, volumize and improve texture, folds and wrinkles for an overall enhanced appearance. The procedure is best combined with both mono and bidirectional PDO threads.
The Rejuvn8 kit includes autoclavable cannulas and steel connectors that allow these procedures to be performed in a clinic setting. This simple, safe treatment gives natural looking results that improve with time and can last up to 12 months. In part, products like Rejuvn8 employ regenerative medicine-style means that hint at the next frontier in aesthetics.
Despite the promise of new techniques, most aesthetic practitioners stick with their tried and true products and methods, while always applying best modern practices. “Back in the day, we saw a fine line or a hollow space and filled it,” stated Dr. Damico. “Today, you can achieve strategic placement of fillers and that makes a big difference. It often allows you to use a lot less product, which is good for patients.”
Adding volume is often central to rejuvenation treatments and involves the full artistry of the physician, noted Alexander Rivkin, M.D., a cosmetic surgeon in Los Angeles, Calif. “When we replace the volume in the mid-face, what we are doing more than anything else is reframing the eyes in a way that the observer expects to see a youthful face. The focus of the face comes up to the eyes and so the person looks younger. Otherwise, the focus shifts down to the lower third of the face, and the person looks older.”
Lifting the face is to a small degree a physical lifting of the skin, Dr. Rivkin added. “This is because we’re expanding the mid-face. However, I think that is just a minor effect, while the major effect of the lifting is that your perception of the face changes when you bring up the focal point of the face to the eyes.”
In continuing to focus on reframing the face, the treatment of sagging jowls can be problematic, Dr. Rivkin added. “Injectors should avoid placing too much filler into the zygomatic arch and the malar area.
“If someone comes to you with jowls and you decide that the solution is to fill out that mid-face as much as possible and make those cheekbones as big as possible, the result of that is going to be a person with jowls that now look alien. At first, they just looked old but now they look weird and old,” he explained.
Moving further down the face, one of the most challenging areas to treat is the jawline, expressed Dr. Weiner. “You always have to take the jawline in conjunction with the chin and enhance them simultaneously,” he said. “In those cases, you’re placing the filler at the level of the jaw, making it a little broader and more distinct. If the patient has a lot of fatty tissue there then you have to dissolve that fat somehow.”
Starting in their 30s, people lose some of the height and angle of the jaw, Dr. Weiner indicated.
“When you improve the jawline and the chin area, you’re lifting skin that originally was in the face, chin area and jawline that is now in the neck. You bring it back to where it should have been, and you improve the appearance of the upper neck significantly in the submental area,” he said.
Next to the jawline, the submental area has routinely posed challenges for physicians, too. “A combination treatment often works best here,” noted Dr. Narurkar.
“We can treat unwanted fat and the double chin with deoxycholic acid or cryolipolysis. Using the latter, we will often debulk with CoolSculpting, use Kybella to contour and then apply Botox to the platysmal bands,” he expounded. “If there is any skin laxity, then you would address that with an RF-based skin tightening device. This is a staged approach with far less risk to the patient because none of the treatments are invasive. It doesn’t mean that surgical options go away. It just means that today we have alternatives.”
The further down one goes on the face, the more complex it becomes, agreed Dr. Damico. “A lot of the neck work starts on the face. You fill the chin if the chin has shrunk back, as that is the cause of laxity in their jawline and their mandible angle. You have to rebuild some of the structures that have allowed the neck to sag.
“You can address the platysmal bands with Botox in necklace lines, and Nefertiti lifts, which is an alternative approach that addresses neck and jawline concerns via a series of Botox injections,” Dr. Damico added.
For all physician-injectors, incorporating such artistry into these and other advanced methods requires intensive hands-on training and education. The American Academy of Facial Esthetics (AAFE), the American Association of Aesthetic Medicine and Surgery (AAAMS), The Aesthetic Show and The Aesthetic Academy are among top organizations that provide injectors with expert instruction in patient safety and the latest advancements.
While current advances are impressive, taking a look at the future of minimally invasive facial rejuvenation techniques, radical new approaches will likely combine traditional methods, such as fillers and toxins, with regenerative medicine. “We are just starting to unfold the potential of our own body tissues and blood, such as stem cells, within rejuvenation therapies,” said Dr. Narurkar.
Longer lasting products and a next generation of clinical techniques are also in order, noted Dr. Werschler. “The industry has been sort of slow to go after longer lasting products because of the business model, which will show diminishing return on investment when, for example, patients that overcome a skin condition using a particular product don’t need to buy it again after a while.”
In addition, future fillers will sit just below the skin’s surface, controlled via external light or energy. “For instance, you could place a filler and then outwardly manipulate the results,” Dr. Werschler highlighted. “Say I put some filler in your cheeks and you like it, but you want a little bit more. I would then put you under a light or energy source that affects the filler, such as expanding it or locking in a long-lasting result.”
In time, facial aesthetics will merge closer to beauty and health on a larger global scale. “We are still figuring out the compartmentalization of the face and how to improve the look and feel,” said Dr. Rivkin.
“We’re still riding the wave and it hasn’t crested yet. It has been an amazing transformation of the field. We went from nothing to an embarrassment of riches even now, and we’re nowhere near capacity or done. An entire field and specialty has been created over a short 15 years.”