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Trends come and go, but one that seems to be here to stay is the desire for noninvasive alternatives to cosmetic surgery. As a result, the nonsurgical facelift is making headlines in newspapers and women's magazines.
Certainly, botulinum toxin, fillers, chemical peels, lasers and topicals can rejuvenate the face. Although these techniques are effective when used appropriately, each only addresses specific, individual signs of facial aging.
Because the mechanism of facial aging is multifaceted, any plan for a nonsurgical facelift must include several factors. These are the appearance and quality of the skin, the tone and activity of the underlying muscles and the volume of fat in critical areas of the face. Only by addressing all three components can we achieve a complete nonsurgical facelift.
History of Surgical Facelifting
As plastic surgeons better understand the process of aging, our surgical approach to facelifting has evolved. Early surgical techniques focused on removing loose skin to "tighten" it to produce a younger appearance.
But surgeons soon recognized the importance of a fibrous layer, called the superficial muscular aponeurotic system (SMAS), that supports the muscles and fat of the face. With laxity of the SMAS, the facial muscles and fat pads descend, contributing to an aged appearance. Surgical techniques over the past 15 years, therefore, have focused on tightening and lifting the SMAS layer, rather than tightening only the skin.
Modern three-dimensional imaging has shown us that tissue laxity is only one part of facial aging. The cheek's fat pads descend and the facial bones lose density, resulting in an overall loss in volume. This volume loss causes the face to "deflate," worsening the appearance of laxity.
In fact, if we examine photographs over one's lifetime, paying particular attention to fixed marks on the skin, such as moles, the fixed points descend only minimally. Therefore, the most current techniques also restore facial volume, which helps lift the face.
Noninvasive Trends
Although plastic surgeons continue to refine and improve surgical techniques, we recognize the desire for noninvasive and nonsurgical alternatives. However, any nonsurgical technique must closely approximate the predictable, reproducible and long-lasting results that can be achieved through surgery.
When evaluating the face, we naturally tend to focus on the most obvious-the skin. Although the skin is a critical component, I prefer to begin with evaluating the deeper layers. Experience has taught me that the greatest improvement will be seen after addressing the deep layers that serve as the foundation of the face.
A youthful face is characterized by prominent cheekbones, a well-defined jawline and a gentle curvature to the side of the face. Four critical fat pads are contained beneath the SMAS that contribute to the overall shape of the face: malar and -buccal fat pads on each side. As part of our approach, we need to evaluate the position and volume of these fat pads.
The malar fat pad overlies the cheekbone and is responsible for the prominence of the cheek. Loss of volume here flattens the cheekbones. Descent of this fat contributes to circles and an aged appearance under the eyes.
The buccal fat pad is located in the soft portion of the cheek. Loss of volume will produce a "sunken in" appearance to the cheeks. Furthermore, when the buccal fat pads descend, the jawline will lose its definition and jowling will occur.
While surgical suspension of the SMAS is the only way to correct true descent of these fat pads, we can address loss of volume with injectable materials. By augmenting the fat, we can redistribute the facial volume to a more youthful pattern. This volumizing of the deep foundation also serves to lift the overlying tissues, restoring a youthful shape and reducing the appearance of lines and wrinkles.
Volumizing the Face
When augmenting critical areas of the face, I prefer the term volumizing. While others may use the term filling, I believe this is overly simplistic and is best reserved to describe placing injectable material in facial lines or folds. Volumizing the face, on the other hand, targets a broader area and requires knowledge of the deep structures and how they contribute to facial balance and shape.
Commonly used materials for volumizing include calcium hydroxylapatite (Radiesse,® Bioform Medical, San Mateo, CA) and poly-L-lactic acid (Sculptra;® Dermik Laboratories, Berwyn, PA).
Radiesse contains small calcium particles that when injected into the tissue, increase volume with results lasting upwards of one year. Sculptra uses material that's easily broken down by the body. After we inject this product, a normal inflammatory response to the material stimulates collagen production over the course of several weeks. This causes an increased thickness of the skin and underlying tissue. The results are long-lasting (up to two years). And because the product stimulates the body's own collagen production, there is no "foreign" material that remains.
Significant improvement can be seen after "volumizing" the deep foundation of the face, regardless of the material chosen.
Some prefer to use their own fat cells for tissue volumization. This technique requires obtaining fat from another part of the body through liposuction and injecting it into the face. Approximately 30 percent to 60 percent of the transplanted fat cells survive, but this depends on harvest and injection technique.1 The need to harvest these fat cells precludes this from being considered noninvasive. And because of the variability in fat cell survival rate, I prefer to use more predictable, reproducible and commercially available materials.
Popular hyaluronic acids, such as JuvedermT (Allergan; Irvine, CA) and Restylane® (Medicis; Scottsdale, AZ), may be used for volumization. However, I've found that the viscosity of the material makes it better suited for line filling rather than tissue volumization. Moreover, HAs tend to have shorter duration of correction than Sculptra and Radiesse.
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