Nonsurgical Rejuvenation Research Articles

Three Key Submuscular Points for Nonsurgical Rejuvenation of the Midface in Caucasian Patients: A Methodological Approach Using Injectable Hyaluronic Acid Fillers.

Since aesthetic medical treatments providing natural results are becoming increasingly popular, we developed an innovative hyaluronic acid infiltration technique for midface rejuvenation. In this prospective study, only patients with a negative or neutral lower eyelid vector were included. Treatment consisted in injecting three hyaluronic acid boluses at the cutaneous projections of the levator labii superioris, zygomatic major and minor muscles insertions. All patients were administered before treatment the FACE-Q questionnaire, whereas after treatment, they were administered the FACE-Q questionnaire and the Global Aesthetic Improvement Scale (GAIS). All treatments were documented with standardized photographs. A plastic surgeon from another Institution reviewed the photos and scored the treatments according to the GAIS scale. We included 567 patients (101 males and 466 females) who met the inclusion criteria. The mean age was 41 years, and mean follow-up time was four months. The FACE-Q scores after treatment were significantly higher (p < 0.001) in every domain investigated. The GAIS scores demonstrated significant improvement posttreatment in 89.8% of patients. An average of 1.5 ml of hyaluronic acid (VYC-20) was used for each zygomatic region. No major complications were reported; only 27 patients reported bruising, which resolved spontaneously. In all patients, there was an inversion of the lower eyelid vector, which had transitioned from neutral or negative to positive. Lifting the insertions of three selected muscles with hyaluronic acid allows a midface upward repositioning. This technique provides a reproducible and safe approach for midface rejuvenation through tissue repositioning rather than augmenting facial volume. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A survey on the cosmetic use of injectable polynucleotide: The pattern of practice among Korean Dermatologists.

Skin boosters denote injectables that promote global improvement of the skin which includes skin texture, elasticity, hydration, and overall appearance. Polynucleotide (PN) products have become popular, but there is surprisingly little guidance on their use. We aimed to maximize the safety and efficacy of injectable PN by providing information on their pattern of practice among board-certified dermatologists. A total of 235 Korean board-certified dermatologists familiar with skin boosters participated in a survey which questioned the participant's years of practice, selection of skin boosters in one's clinic, and range of lasers and light sources as well as skin care devices that are available. For those who use PN, one was asked to check all its aesthetic indications, mode of delivery, injection depth, treatment interval as well as options for combined therapy. Seventy-one percent of the survey participants had at least 5 years of professional experience as a board-certified dermatologist, and among the different skin boosters, 88% replied that they practiced PN injection. The top six indications for PN were fine lines on the cheek followed by infraorbital fine lines, periorbital fine lines, uneven skin texture, dry skin, and fine lines on the forehead. Many opted for a 33G needle and the serial puncture technique targeting the dermis. A total of three sessions of PN injection spaced 4 weeks apart is most often recommended. 79 percent of PN users blended PN injection with lasers and light therapy with the most popular being radiofrequency (non-invasive, needle RF) and high-intensity focused ultrasound (HIFU). PN is a skin booster which is widely practiced among Korean dermatologists. According to our survey, the best indication of PN is facial fine lines, and as such PN injection is often repeated and combined with a variety of non-surgical rejuvenation procedures. We hope our data help dermatologists better understand and utilize PN injection.

Surgical Management of Polymethylmethacrylate-Collagen Gel Complications in the Lower Eyelid: A Case Series.

As nonsurgical rejuvenation with fillers continues to grow in popularity, patients are increasingly interested in more durable results. Polymethylmethacrylate (PMMA)-collagen gel is unique among fillers in that the PMMA microspheres are not completely absorbed and phagocytosed by the body. This durability coupled with the biophysical properties of PMMA makes it a poor choice for periorbital rejuvenation, an unforgiving and highly complex anatomic area. Between 2011 and 2018, 14 patients with PMMA granulomas in various facial areas self-referred to the senior author's practice. Of these patients, 11 were managed nonsurgically; however, all 3 patients who presented with granulomas in the infraorbital area required surgery to remove the filler and restore a natural aesthetic. The 3 patients with significant swelling and PMMA filler nodules in the infraorbital area with unacceptable cosmetic appearance were females between the ages of 50 and 55 years. Nonsurgical protocols were unsuccessful, and surgical removal was required. All subjects have been followed for a minimum of 2 years with no immediate- or long-term postoperative complications secondary to PMMA removal. Patients remain satisfied with the outcome of the surgery. Despite the evidence that the periorbital area is prone to adverse events when injected with particulate fillers, misguided enthusiasm for PMMA-collagen gel as a durable treatment continues to lead to unnecessary and severe complications in patients. The case studies presented here highlight that this product should not be introduced into the periorbital area. We also describe a surgical treatment approach for its removal if complications arise.

Current Use of Cosmetic Toxins to Improve Facial Aesthetics.

After studying this article, the participant should be able to: 1. Compare and contrast the various types of botulinum toxin on the market. 2. Appropriately select patients for treatment with cosmetic botulinum toxin. 3. Understand the common injection patterns for treating various regions of the face with cosmetic botulinum toxin. 4. List the complications associated with treating various regions of the face with cosmetic botulinum toxin. Nonsurgical rejuvenation of the face with botulinum toxin is one of the most commonly performed procedures in the United States. This article reviews the current evidence in treating different regions of the face: upper face, lower face, masseter, and platysma. Dosing and complications associated with different facial regions are reviewed.

Novel technique of non-surgical rejuvenation of infraorbital dark circles.

Infraorbital dark circles are a common esthetic concern which can be challenging to treat given their multifactorial nature. Under-eye darkcircles are seen in all skin types, with a strong familial component in darker skin types. Other major contributing factors include soft tissue and bony changes, skin changes, lifestyle contributions, and allergies. Involutional periorbital volumetric changes cause volume loss in the tear trough, naso-jugal and palpebro-malar grove, skin and subcutaneous tissues with tethering of the eyelid skin to the tear trough ligament, giving a sunken and hollow appearance to the lower lid. Associated prolapse of the orbital fat and thin skin can worsen the appearance of a dark circle. Hyaluronic acid fillers placed in the pre-periosteal plane in the tear trough, palpebro-malar and naso-jugal grooves, give good results in patients with thick eyelid skin and negligible fat prolapse. However, in patients with thin skin and moderate fat prolapse, authors have reported worsening outcomes with risk of Tyndall (blue-gray discoloration) and contour irregularities from visible lumps. To describe a novel technique to improve dark circles caused by a diffuse valley-type pre-septal tear trough deformity in patients with thin eyelid skin. Retrospective case note review of 330 eyelids treated with microdroplet subdermal placement of filler in the preseptal tear trough area by a single surgeon. This novel technique shows good esthetic outcomes in patients with dark circles, with good longevity and a low risk of complications.

Reshaping the Lower Face Using Injectable Fillers.

The lower third is very important for the pleasant appearance of the face. A well-contoured jawline is desirable in men and women, giving a perception of beauty and youth. It is also key to sexual dimorphism, defining masculine and feminine characteristics. The nonsurgical rejuvenation and beautification of the lower third of the face is becoming more frequent. Injectable fillers can reshape the jawline, lift soft tissues, and improve facial proportions, effectively improving the appearance of the area.It is paramount to understand the facial anatomy and perform a good facial assessment in order to propose a proper aesthetic treatment plan. The aesthetic goal of the rejuvenation approach is to redefine the mandibular angle and line. In young patients, beautification can be achieved through correction of constitutional deficit or enhancement of the contour of the face, improving the facial shape. It is very important to possess knowledge of facial anatomy and of the aging process in order to deliver effective and safe results.In this article, we discuss the anatomy of the lower third of the face, facial assessment, aging process, and treatments of the chin, prejowls and mandibular line and angle with injectable fillers. The authors’ experience in the approach of this area is discussed.

Botulinum Toxin Treatment for Mild to Moderate Platysma Bands: A Systematic Review of Efficacy, Safety, and Injection Technique.

Platysma bands are characteristic of an aging neck. Resection and plication of the platysma muscle is the basis of treatment. However, unfavorable surgical outcomes and improved understanding of platysma band etiology have shifted treatment towards nonsurgical rejuvenation. The aim of this paper was to assess the efficacy, injection techniques, and complications associated with botulinum toxin injection for the treatment of platysma bands. A systematic literature search was performed to identify articles reporting botulinum toxin injections for platysma bands in neck rejuvenation. The search included published articles in three electronic databases-Ovid MEDLINE, EMBASE, and the Cochrane Library-between January 1985 and December 2017. Three studies met the inclusion criteria, with a total of 78 patients undergoing botulinum toxin injection for platysma bands. Incobotulinumtoxin A was used in 62.3% (n = 45/78) of patients, with 38.4% (n = 30/78) receiving abobotulinumtoxin A. Efficacy was assessed using the Merz platysma score scale. A mean score improvement of 2.0 points, with a response rate of 93.7%, was observed after 14 ± 2 days. At 3 months, the mean score improvement was 1.2 points with a response rate of 86%. Patient-reported metrics demonstrated an improvement in 91% (n = 71/78) of subjects. The three studies used a standard injection technique, with a maximum 20 IU of incobotulinumtoxin A and 5 U abobotulinumtoxin A administered per band. Complications were reported in 15.4% (n = 12/78) of patients, with none requiring further intervention. Botulinum toxin is a highly effective treatment for isolated platysma bands. A safe injection technique is described and recommended for clinical practice.

Nonsurgical Rejuvenation of the Eyelids with Hyaluronic Acid Gel Injections.

There has been an increased recognition for the role volume deflation plays in the aging periorbital area, and as such, rejuvenation strategies to augment and restore volume have developed and evolved. Hyaluronic acid fillers provide an efficient option for volume augmentation with good efficacy, longevity, and safety. An understanding of the changes in the upper and lower periocular area due to aging, the meticulous identification of focal hollows, and the precise delivery of filler to these areas can smooth contours and restore a rejuvenated periorbital area.

Nonsurgical Facial Rejuvenation Procedures in Patients Under 50 Prior to Undergoing Facelift: Habits, Costs, and Results.

Facial rejuvenation in patients younger than 50 years of age has experienced an unprecedented growth with multimodality nonsurgical and less invasive rhytidectomy techniques. To analyze the nonsurgical treatment habits of patients prior to undergoing rhytidectomy at <50 years of age. Retrospective study to enlist patients who underwent primary rhytidectomy at age <50 years between January 1, 2003 and December 31, 2013 by the senior author (AAJ) to complete a survey. One hundred and fifty-seven patients were surveyed. Patients had nonsurgical rejuvenation starting at an average age of 37 years and rhytidectomy at an average age of 44 years. Thirty-two percent of responders had injectable treatments prior to their facelift, reporting a mean of 7 rounds of injectable treatments prior to pursuing rhytidectomy. Sixteen percent of responders had laser skin resurfacing undergoing 4 separate treatments prior to rhytidectomy, and 10% had energy-based facial tightening treatments one time prior to their rhytidectomy. Average expenditure on nonsurgical treatments prior to rhytidectomy was $7000 cumulatively. Fifty-nine percent of patients who went on to rhytidectomy did not report regret over this cost expenditure. Patients reported that they appeared 4 years younger after nonsurgical intervention, and 8 years younger after their facelift, a statistically significant difference (P = .048). Patients undergoing rhytidectomy <50 years old begin less invasive facial rejuvenation treatments at an even earlier age. The majority of these patients did not regret the costs associated with noninvasive treatments, even though they saw that rhytidectomy provided a greater rejuvenation effect. Rhytidectomy surgeons should incorporate nonsurgical techniques into their practice to best serve the needs of the modern aging face patient.

Filling the Midface: Injectables.

Volumizing the face has become commonplace on the facial aesthetic scene, with a rapid explosion of popularity in the field of nonsurgical rejuvenation. Three-dimensional enhancement of the midface with fillers provides the surgeon with a minimal downtime opportunity to treat early aging or reverse nonsurgical volume loss. With new products come advancements in techniques and the understanding of reversal of the effects of aging. While providing minimal downtime and risk, complications can occur and the physician must be able to recognize and treat these issues. It is crucial for the injector to understand and process these factors to ensure patient satisfaction and safety.

Pertinent anatomy and analysis for midface volumizing procedures.

The study was conducted to construct an anatomically inspired midfacial analysis facilitating safe, accurate, and dynamic nonsurgical rejuvenation. Emphasis is placed on determining injection target areas and adverse event zones. Twelve hemifacial fresh cadavers were dissected in a layered fashion. Dimensional measurements between the midfacial fat compartments, prezygomatic space, mimetic muscles, and neurovascular bundles were used to develop a topographic analysis for clinical injections. A longitudinal line from the base of the alar crease to the medial edge of the levator anguli oris muscle (1.9 cm), lateral edge of the levator anguli oris muscle (2.6 cm), and zygomaticus major muscle (4.6 cm) partitions the cheek into two aesthetic regions. A six-step facial analysis outlines three target zones and two adverse event zones and triangulates the point of maximum cheek projection. The lower adverse event zone yields an anatomical explanation to inadvertent jowling during anterior cheek injection. The upper adverse event zone localizes the palpebral branch of the infraorbital artery. The medial malar target area isolates quadrants for anterior cheek projection and tear trough effacement. The middle malar target area addresses lid-cheek blending and superficial compartment turgor. The lateral malar target area highlights lateral cheek projection and locates the prezygomatic space. This stepwise analysis illustrates target areas and adverse event zones to achieve midfacial support, contour, and profile in the repose position and simultaneous molding of a natural shape during animation. This reproducible method can be used both procedurally and in record-keeping for midface volumizing procedures.

Volumizing viaducts of the midface: defining the Beut techniques.

In nonsurgical facial rejuvenation, autologous fat and dermal fillers have become an effective method to achieve symmetry and balance of the midface. Nonsurgical techniques that target the dynamic anatomical relationships existing in the midface can improve rejuvenation outcomes in this commonly augmented region. The authors described techniques for fat compartment and potential space volumization of the midface via a standardized and reproducible technique. They placed emphasis on access to anatomical spaces and compartments within the midface. In 11 hemifacial cadavers, hyaluronic acid filler homogenized with red dye was injected via 3 midfacial ports that were anatomically designed to access the superficial fat compartments, deep fat compartments, or traverse the prezygomatic space. Specimens were dissected in a layered fashion to analyze relationships between the injected filler and midfacial anatomy. We have described 4 site-specific procedural techniques and created a video containing anatomical renderings of each targeted viaduct accompanied by technique demonstrations. We found that Beut techniques 1 through 4 can be performed through 3 midfacial viaducts. Port placement 1.5 cm inferolateral to the alar base in the nasolabial crease created a medial midface viaduct, suitable for access to the deep medial cheek fat, medial superficial fat compartment, premaxillary space, and adjacent superior nasolabial cheek compartment. Port placement within the nasojugal groove provided a middle midface viaduct to access the middle superficial fat compartment and medial suborbicularis oculi fat (SOOF). Port placement 1.5 cm inferolateral to the lateral canthus created a lateral midface viaduct to approach the pre-periosteal fat, prezygomatic space, lateral SOOF, and infraorbital fat compartment. Our findings indicate that anterior and lateral cheek projection, V-deformity correction, rhytid softening, and tear trough effacement can be achieved through the midfacial viaducts. Systematic assessment and site-specific nonsurgical rejuvenation of the midface may lead to increased safety, accuracy, and technique reproducibility in this commonly injected region.

Management of tear trough complications post lower eyelid rejuvenation

Non-surgical rejuvenation of the lower eyelid incorporating the correction of a tear trough deformity can be a treacherous procedure for the aesthetic practitioner. However, there are several benefits associated with injecting hyaluronic acid based dermal fillers in this area, such as immediate results and minimum downtime. Helena Collier discusses this treatment and its risks

Management of tear trough complications post lower eyelid rejuvenation

Non-surgical rejuvenation of the lower eyelid incorporating the correction of a tear trough deformity can be a treacherous procedure for the aesthetic practitioner. The anatomy of the nasojugal region is challenging and, combined with the fragility of the lower eyelid skin, this can create a suboptimal outcome that is not only problematic with iatrogenic complications, but can also lead to a patient experience fraught with dissatisfaction. However, the benefits of injecting a hyaluronic acid-based dermal filler to rejuvenate the lower eyelid include high satisfaction, immediate results, minimum recovery, reduced morbidity and the potential to reverse outcomes hyaluronidase medication.

Lior Heller, M.D.

I would like to thank my colleague, Dr. Lior Heller, for serving as guest editor of the current issue of Seminars in Plastic Surgery on “Abdominal Wall Reconstruction,” and the authors that he has invited to write on this topic. We are always grateful to our contributors for taking the time away from busy schedules to share their knowledge with peers. Dr. Lior Heller is an associate professor in the Division of Plastic Surgery in the DeBakey Department of Surgery at Baylor College of Medicine in Houston, Texas. He is a graduate of the Hebrew University Medical School in Jerusalem, Israel; he is board certified in plastic surgery by the Israeli Society of Plastic Surgery and in general surgery by the Israeli Society of General Surgery. Upon completion of his residency training, Dr. Heller completed three fellowships that included a 1-year fellowship in minimally invasive and endoscopic cosmetic surgery of the face with Dr. Oscar Ramirez in Baltimore, Maryland, a 2-year fellowship in reconstructive plastic surgery at Duke University Medical Center in Durham, North Carolina, and a 1-year fellowship in microsurgical oncologic reconstruction at M.D. Anderson Cancer Center in Houston. He then served for 3 years as a clinical instructor in the Department of Plastic Surgery at M.D. Anderson Cancer Center. Dr. Heller specializes in body contouring, reconstructive surgery after oncologic resection, and aesthetic surgery and nonsurgical rejuvenation of the face. He is actively involved in academics as a teacher of residents and students and has had numerous articles published in plastic surgery peer-reviewed journals and chapters as well. Dr. Heller enjoys presenting at professional meetings at the national and international level and is often invited to do so.

Treatment of Wrinkles and Acne Scars Using the TriFractional, a Novel Fractional Radiofrequency Technology—Clinical and Histological Results

Introduction: The need for cosmetic facial enhancement procedures with minimal down time and low risk has led to the development of methods for non-surgical skin rejuvenation. Various ablative lasers were developed, which remove the full skin surface in a controlled manner. However, the prolonged recovery and the significant risks prompted the development of fractional lasers which ablate the skin in a fractional manner, leaving untreated areas to improve healing process. In the past few years, fractional radiofrequency (RF) systems have been introduced that enable controlled skin resurfacing accompanied with dermal collagen remodeling. The new TriFractional technology from Pollogen? is designed to enable skin resurfacing and treatment of wrinkles using RF energy. The objective of the current research was to evaluate the safety and effectiveness of the novel TriFractional technology using the TriFractional applicator (A3F) for micro-ablative skin resurfacing and the treatment of wrinkles and acne scars. Methods: Healthy volunteers consented to undergo TriFractional treatments for various aesthetic indications. In addition, in-vivo and ex-vivo histologycal results showing immediate and long term effects of the TriFractional technology were obtained. A portion of the subjects underwent the complete TriLipo MedTM Procedure which includes 2 TriFractional treatments spaced one month apart, with 2 TriLipo RF + Dynamic Muscle Activation (DMA) face treatments two weeks after each TriFractional treatment. Results: Subjects experienced an improvement of wrinkles, skin texture and acne scars along with facial contouring. No significant adverse effects were detected post-treatment. Histology findings demonstrated immediate and long term TriFractional effects on both epidermal and dermal skin layers. Conclusions: TriFractional is a promising technology for skin resurfacing, treatment of wrinkles and improvement of additional aesthetic indications such as acne scars. The TriLipo MEDTM procedure is a unique combination approach for total facial rejuvenation and contouring.

Commentary on: Minimal-Scar Handlift: A New Surgical Approach

We enjoyed reading the article by Handle et al entitled “Minimal-Scar Handlift: A New Surgical Approach.” Their technique is certainly a worthwhile addition to the plastic surgery literature and a procedure that we may elect to utilize in select patients. The basic idea behind their approach—namely, excising skin and leaving the scar hidden—is an essential tenet of plastic surgery. It is what many of us aim for in our aesthetic surgery practices on a daily basis for many anatomical areas. However, as the authors note, excisional procedures solve only some of the problems of the aging body, leaving unaddressed losses of skin elasticity, bone, muscle, and fat, as well as changes in position of these structures. Plastic surgeons have made great strides in the last 10 years in terms of nonsurgical rejuvenation with lasers and other energy devices, as well as fillers and toxins. The ultimate goal of any rejuvenation procedure is to restore elasticity and multiple-level volume loss with no scars—we think of this as the “holy grail” of cosmetic surgery. However, we are currently unable to currently achieve complete rejuvenation with nonsurgical procedures alone, regardless of anatomical area. Studying the “state of the science” in terms of a nonsurgical approach to the aging hand is indicative of where technology is today in regard to aesthetic restoration, and it gives us a good idea of where we might go in the future. Features of the aging hand include color …

Book Review: Lasers and Non-Surgical Rejuvenation

Barry E. DiBernardo, Jason N. Pozner, eds. Lasers and Non-Surgical Rejuvenation. Techniques in Aesthetic Plastic Surgery Series. Philadelphia: Saunders/Elsevier, 2009. ISBN-10: 0702030902 Lasers and Non-Surgical Rejuvenation , published by Saunders-Elsevier, is a part of the Techniques in Aesthetic Plastic Surgery series edited by Dr. Mark A. Codner. The editors of this volume, Drs. DiBernardo and Pozner, are highly respected and recognized as experts in the laser field, as are many of the plastic surgeon and dermatologist contributors. The book is timely in that it discusses not only recent refinements and improvements in laser treatment but …

Lasers and Non-Surgical Rejuvenation

Lasers and Non-Surgical Rejuvenation

Nonsurgical Rejuvenation of the Aging Face With Injectable Poly-L-Lactic Acid for Restoration of Soft Tissue Volume

Characteristics of the aging face include soft tissue atrophy, loss of skin elasticity resulting in excess facial skin, and gravitational descent or ptosis of facial soft tissues. Poly-L-lactic acid (PLLA) is a synthetic biodegradable polymer that provides soft tissue augmentation through stimulation of an inflammatory tissue response with subsequent collagen deposition. The authors discuss the special considerations inherent in facial aging, describe the mechanism of action and indications for a new PLLA filler under consideration for Food and Drug Administration (FDA) approval (Sculptra Aesthetic, sanofi-aventis US, Bridgewater, New Jersey), and detail the results of a two-year off-label pilot study with the product. The senior author (LAC) treated 106 patients with PLLA in an off-label indication, as part of a pilot study while Sculptra Aesthetic was being evaluated for FDA approval for cosmetic indications. All patients were followed up for two years to help develop a protocol for injection technique. The age range of patients in this series was 40 to 78 years. Three patients were male and 103 were female. Patients received an average injection of 1.6 vials per session, over an average of 2.3 sessions, to achieve volume restoration in the tear trough, midface, malar region, nasolabial folds, prejowl area, mandibular border, and mandibular angle. The authors we achieved 100% follow-up with 99.1% patient satisfaction. The rate of nodule formation was 4.7% at a minimum follow-up of two years. Because of its unique mechanism of action, PLLA for nonsurgical facial rejuvenation requires meticulous injection technique with special considerations for optimizing outcomes and minimizing adverse events.