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.
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“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.”
“I think that we are still on the track of maintaining patients’ aesthetic appearance, or returning the more youthful appearance people had when they were younger, but obviously we can also improve facial features, as well, all in order to obtain a naturally rejuvenated look,” said Sabine Zenker, M.D., a dermatologist and researcher in Munich, Germany.
“I have patients that are now 15 years older than when I first started treating them, but they look 20 years younger. In addition, people have started taking care and maintaining their faces and skin earlier in life,” she added.
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 the realm of purely non-invasive, non-energy-based rejuvenation treatments, the state-of-the-art is combining different modalities and therapies to achieve certain results, noted Dr. Zenker. “The smart combination of the ‘right’ treatments to replace volume, redefine contours, lift and stimulate the skin and relax the muscles is key. Amazingly enough, we are able to fix these concerns with non-invasive procedures,” she said.
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.”
According to Nantapat Supapannachart, M.D., a dermatologist and CEO of Apex Medical Center, which operates 20 aesthetic centers in Thailand, such treatments are fast becoming the first option for facial rejuvenation in Asian clinics.
“Offering a combination of existing non-surgical techniques and technologies to optimize individual results is the recent trend in facial rejuvenation,” she maintained. “The currently available options of injectables, neurotoxins, thread lifting and cell-assisted fat transfer actually target volume loss and expression lines, which are the main reasons for an aging appearance.”
Non-surgical or minimally invasive procedures are in high demand throughout the APAC region, reiterated Kwun Cheung Hau, M.B.Ch.B., M.R.C.P., F.H.K.A.M., F.H.K.C.P., D.C.H., a dermatologist in Hong Kong.
“People want a natural, subtle effect after procedures,” he indicated. “Most Asians want to receive compliments from their friends, who are unaware of the fact that they underwent surgery.”
“This approach is very popular in this region, representing a huge market that is growing at a fast rate, around 20% annually,” stated Peter Huang, M.D., a plastic surgeon at the Rebecca Cosmetic Center in Taipei, Taiwan. “Patients are really interested in the minimally invasive aspect of these treatments,” he said.
“With minimal or no downtime, physicians can now plan custom treatment regimens by catering to a patient’s individual timeline and budget. The results are manageable and can be dramatic or subtle depending on the emotional desires of the patient,” Dr. Supapannachart indicated.
“In addition, volume replacement is one advantage not seen in conventional surgical lifts,” she pointed out. “From my point of view, reversibility of non-surgical facial rejuvenation is a major advantage over surgery.”
With Asian skin particularly, minimally invasive facial rejuvenation is an ideal approach, stated Peter Hsien-Li Peng, M.D., a dermatologist, and founder and director of the P-Skin Professional Clinic & Hair Restoration Center in Kaohsiung, Taiwan.
“Because of the facial bone structure there are differences between Caucasian and Asian patients. The Asian patient has areas of bone deficiency, such as a low nasal bone and chin recession, infraorbital maxilla recession, etc.,” he elaborated. “These aspects make Asian people seek transformative treatments at a very young age, often in their 20s.”
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.
In addition, injection techniques have evolved. “While I continue to use the same products over the last several years, what has changed are the protocols,” said Ruth Moro Garcia, M.D., an aesthetic physician in Valencia, Spain.
“Also, we are lucky in Europe because there is an abundance of HA-based products on the market. They are very effective and deliver good results. Nevertheless, there is one area where we still experience issues with most fillers – when the person smiles, the filler doesn’t flow with the smile. It doesn’t look natural. However, there are new HAs that can provide better results in this area.”
Improved products and injection techniques enhance and better support the target tissue instead of just filling spaces, Dr. Huang pointed out.
“We call it building the wall. We are filling some areas to boost the tissue and also decrease its heaviness,” he explained. “We also call them plus and minus procedures. We try to balance the facial tissue using injectables. To be successful, it is critical for the physician to thoroughly understand the facial anatomy.”
“Dermal fillers of different G-primes help to create ‘architectural effects,’ such as bony prominences, volumization, structural support and skin hydration,” Dr. Supapannachart noted.
ART FILLER® from FILLMED Laboratoires by Filorga (Paris, France) is an example of a modern filler range that provides a balance of sculpting, volumizing and smoothing properties depending on the indication. This distinctive set of HA-based gel fillers feature proprietary Tri-Hyal® technology, which creates a flexible and moldable material for a naturally-sculpted look. ART FILLER products address superficial to severe facial wrinkles, volumization of the lips, skin moisturizing and revitalization, as well as volume creation and restoration, especially for the cheekbones and chin.
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.”
Dr. Zenker has been impressed with the increasingly small size of some needles. “They make a difference when injecting products because they do not produce that much pain, there is a lower risk for bruising, and we can better administer the product at the right levels. So, while we don’t really have a lot of new products, we have become better in administering the products that we use,” she explained.
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.
Representative of modern PDO thread lifting products, Princess® Threads from Croma-Pharma GmbH (Leobendorf, Austria), rejuvenate, reinforce and elevate skin. Absorbable PDO threads provide an immediate and long-lasting effect for the body and face. Along with the firm’s Barb II PDO suture, the new Barb II Anchor suture is an innovative variation of the barbed subtype for skin elevation. Bidirectional-oriented arrow-shaped cogs are produced by a special molding method to ensure the strength of the suture and maximize its fixation ability. The suture comes housed in an L-shape, ultra-thin wall cannula.
Thread-lifting technology has been improved in recent years, Dr. Zenker stated. “We now have different, more sophisticated protocols for administration of the threads. It all comes down to the fact that it is not only the product itself that creates a result, it is the administration of a physician’s technique and knowledge that makes the difference. Choosing the right threads and following the protocols carefully is critical. A lot of physicians are performing this kind of procedure without really knowing what they’re doing.”
Thread suspension procedures are an essential part of Dr. Hau’s aesthetic practice. “Thread lifting is unique and effective, requiring a strong aesthetic sense and surgical acumen, and patients are growing more aware of this treatment option,” he said.
“I prefer to use barb threads, particularly the bi-directional suspension thread for successful lifting and tissue repositioning strategies. As there are many options on the market, one has to be careful in choosing the appropriate product and evaluating the thread design, as well as the scientific materials and available clinical evidence.”
During initial contouring of the face and neck, Dr. Supapannachart uses skin tightening devices as a basic foundation, but complements that with thread lifts.
Dr. Peng utilizes thread lifting for repositioning of fat pads. “The goal is the lifting of saggy tissue, which is done in combination with filler and neurotoxin injections,” he described. “If the skin quality needs further improvement, I will place fine, simple PDO threads in the dermal or subdermal layer to enhance new collagen formation. We do a lot of thread lifting and are developing injectables that will replace the surgical lifting effect.”
“Aging is a loss of volume and lift,” Dr. Werschler noted. “With fillers you really only address volume, and for the most part, with sutures, facelifts, or even with energy-based devices, all you’re doing is addressing gravity. I would actually venture to say that most practitioners put threads in and then flood the area with dermal fillers so, you not only get the lifting via suspension of the skin, but you also volumize.
“What’s more,” he continued, “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, Dr. Werschler added. “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 pimple,” 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.”
Although there have been adverse events reported with thread-lifting products, Dr. Moro is circumspect. “Threads are very popular with patients, and I have not seen any complications from the threads I typically use, which are Poly L-lactic bidirectional absorbable thread cones,” she said.
“I think the problem of adverse events usually lies with the practitioner,” she continued. “In addition, a bigger problem with threads in Europe is that they are very expensive. Due to the cost of threads, patients expect an incredible result that may be unrealistic.”
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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.”
Micro Botox is popular in APAC, noted Dr. Peng. “It can be used for many clinical conditions, such as treatment of the jawline, or to perform a ‘mini lift’ of the face.”
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.”
“PRP and fat-derived stem cells have many applications, such as skin rejuvenation and hair restoration,” expressed Dr. Zenker. “But we run into limitations very quickly, as there is no consensus on many aspects, such as the best method of harvesting fat, preparation, ideal composition, etc. Furthermore, related legal aspects vary from country to country.”
While not all physicians are enthusiastic about PRP, stem cell treatments, or other emerging approaches, many practitioners are including these regenerative medicine-type therapies in their liquid facelifts.
“PRP has become more accepted as more studies have begun demonstrating its beneficial effects on a variety of conditions,” stated Dr. Peng. “The combination of PRP with other cosmetic procedures, such as injectables and devices have shown synergistic effects.”
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,” she said.
Newer fat transfer processes yield highly filtered microfat and nano-fat, which can be used for both filling and tissue regeneration. “Fat transfer is a wonderful tool to replace volume and rejuvenate the skin, but its use still involves some controversies,” noted Dr. Zenker. “For instance, which fat is the best one – microfat, nano-fat, etc.? Also, which method is best to harvest fat? We are currently lacking good, controlled trials to compare the different ways of transferring harvested fat.”
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.
However, autologous fat grafting and the use of biofillers, are less common in the APAC region. As reported by Dr. Supapannachart, “There is still a limitation of long-term viability of injected fat.”
Despite the promise of new techniques, most aesthetic practitioners stick with their tried and true products and methods, while always applying best modern practices. “In the past, 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.”
For instance, to address the specifics of the Asian face, Dr. Peng uses fillers for midface augmentation, area reshaping and lifting of lower face. “First, I usually do the injections for the foundation, which means on the lifting points and over some bone loss areas, followed by contouring or reshaping. In Asians, we address the forehead, eyebrows, glabella – the areas of the T-zone – including the nose, lips and chin. After that, we improve and beautify the nasolabial folds, the tear trough, etc.”
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, so the focus of the face comes up to the eyes and the person looks younger. Otherwise, the focus shifts down to the lower third of the face, and the person looks older.”
“Newer injection techniques have focused on lifting tissue in order to create more projection for a youthful and attractive looking face,” Dr. Peng commented.
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 up to the eyes.”
Moving further down 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 both weird and old,” he explained.
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.
Dr. Peng uses neurotoxin injections to the masseter muscle. This causes the muscle to lose mass and helps to improve the shape of the lower face, as well as create a more defined, youthful and sharp jawline.”
Under the jawline, the submental area has routinely posed challenges for physicians, too. “The neck is still a neglected area, and there are various reasons for that,” said Dr. Zenker. “Primarily, it is difficult to effectively rejuvenate with only a small number of treatments, and it will cost a lot of money to treat. In all honesty, you can try skin resurfacing, line filling or lifting with threads, but it still may not deliver a very good result even after a significant amount of effort.”
The submental area is usually addressed after facial treatments, Dr. Zenker added. “Patients prioritize very clearly and make it known that after the face, neck treatments might be too much of an effort or too expensive, although some may go for a neck lift. They will spend thousands of dollars on their face and then not have any money left to improve the neck or the hands. Money is one of the biggest factors among patients.”
“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,” Dr. Narurkar 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 neck is a unique body area to treat,” said Dr. Huang. “A combination of microneedling and HAs is still the best approach. Another option is to utilize PDO threads to enhance the skin. Also, you need to combine these with neurotoxin injections because you really need to relax the platysmal muscles in order to obtain a good result.”
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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.
Whether employing the latest facial injectables, collagen stimulating lifting threads or the newest autologous fillers and serums, the best protocol for using any product is to abide by standard foundations of safe medical practices.
When considering what protocols and best practices should be applied, Dr. Peng says it depends on the condition of the patient. “The four major things to evaluate are sagging of the skin, volume loss, areas of volume accumulation and skin quality,” he noted.
A combination approach is best, noted Dr. Hau. “I usually start with neurotoxin to stabilize the muscle movement and contour a nice expression profile. With toxin I can also erase the excessive dynamic wrinkles,” he began.
Following that, Dr. Hau will assess whether there is any significant volume loss that needs to be addressed. This involves injecting some mid-range HA-based fillers. “I prefer to use fillers that do not result in too much tissue swelling. I focus on areas that are sagging, which can be improved using vector pulling. Asian skin is thicker and has more fibrosis compared with Caucasians; therefore, they are more responsive to thread suspension surgery. Once I can build up the basic foundation of facial reshaping I will follow up with any other necessary modalities such as toxins and/or fillers.”
“Safe practices rely on observation of minute details and knowing how to prevent and correct unwanted results,” Dr. Supapannachart noted. “Mastering the basic anatomy and understanding the principles of the procedure are the best approaches to achieving effective, safe outcomes and minimizing adverse events.”
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.”
According to Dr. Zenker, improved diagnostic tools will be part of the future, as a person’s overall health and wellness need to be documented.
“I imagine that the aesthetic world will adopt diagnostic tools that can better predict what’s going to happen within the aging process of an individual, and then apply preventive measures,” she said.
“Look at all the self-diagnosis apps that can check moles and other things. What about apps that evaluate facial wrinkles or facial volume loss? That might change the demands, expectations and profile of the patient. People come into clinics these days and many of them already know what kind of treatment they want. They know about Botox and they know a bit about lasers.”
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.
“Patients and physicians seek treatments with less downtime that also provide a natural result. People want to age gracefully. In the future, these procedures will become even more popular with the introduction of regenerative treatments, such as stem cells and growth factors. These will be the rising stars in the future,” Dr. Peng stated.
Ultimately what will also change is the perception of human beauty, said Dr. Moro. “Increasingly, the pressure will grow for people to always look good or younger looking. The norms of beauty are changing, especially among younger generations. The consumer profile is on the verge of changing very dramatically in the aesthetic arena,” she predicted.
“We’re still riding the wave and it hasn’t crested yet,"Dr. Rivkin added. "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.”
