Advertorial: Combination Lifting

09 Feb 2021

Dr Huw Jones shares his approach to facial ageing using dermal fillers, platelet-rich fibrin and PDO threads

Morphological changes to the facial skeletal structure, soft tissue, retaining ligaments, fat compartments, and skin interact to give the ageing facial appearance. For best results, the different elements should be considered together. Skin rejuvenation techniques promoted without consideration of volume loss or muscle/ligament laxity will not be optimal. Volumising perceived facial fat loss in the lower third of the face without addressing upper and middle facial loss will produce sub-optimal results.

We now have a greater appreciation of the multifactorial causes of the gravitational and centripetal movement of the facial tissues that result in the inverted ‘Triangle of Youth’. Fat pads get thinner and descend. We lose fullness. Hollows form at the temples and beneath the eyes, drooping skin can cause deeper lines around the nose and mouth, loose skin can result in a sagging jawline.

My combination lifting approach

I realised that for a great part of my career I had failed to address the ageing temples and lateral temporal fat (LTF) pads appropriately and the effect this had on my results. Volume loss from these two regions not only results in a hollowed/aged appearance but also removes vital lifting support for the lateral supraorbital and infraorbital regions. They also provide support for the mid-cheek and the jawline. I found that addressing these areas whilst applying tension with PDO Cog Threads provided a more harmonious result, which were both instantaneous and relatively long lasting (15-18 months).

Now I start by addressing the temples. Volume loss in this area is one of the earlier signs of ageing. Volume replacement will reverse this and help elevate the lateral brow and reduce periorbital rhytids. Intraline M4 Plus has a high concentration of HA (24mg/ml) with a high G-prime, resulting in an impressive lifting effect. I approach this region with respect due to the vascularity and the potential side effects that can result from injudicious filling. I inject deeply using a single injection with a 27 gauge needle placed vertically 1cm above the temporal fusion line and 1cm laterally. The needle tip is placed deeply onto periosteum. A bolus injection is made and digitally massaged inferiorly to spread the filler.

Next, I treat the superficial aspect of the temples and the inferior continuation of the lateral temporal fat pad. The skin in this region is thin and using a high G-prime filler may result in lumpiness and filler visibility. Numerous published papers reference HA filler ‘hydrated’ with normal saline +/- lidocaine to provide a greater volume and smoother injection. It has been my practice to ‘hydrate’ the Intraline M4 Plus with injectable platelet-rich fibrin (PRF).

The PRF is obtained using a one-step centrifugation process without the use of anticoagulants and is totally autologous. The M4 Plus HA filler is mixed with the PRF which is stable for 15-20 minutes. I prepare the skin and inject 0.1% lidocaine at the insertion point. Using a 25 gauge 70mm cannula I proceed to fill the temple and lower LTF with a fanning retrograde filling technique. The injected area is then gently massaged to achieve a smooth result. The multitude of growth factors in the PRF will also help to address some of the ageing skin issues including collagen and elastin content, lentigines etc.

The first two stages described above will address some of the volume issues and at the same time will start to lift sagging in the mid and lower third of the face. Using a cannula in the LTF will also help to reduce some of the tethering of the skin caused by free radical induced sub dermal fibrosis. The use of absorbable barbed PDO threads produces an initial mechanical tensile lift enhanced by a delayed fibrosis induced lift seen at three to six months after treatment.

This is supported by histopathological studies indicating dermal and subcutaneous foreign body reaction in the form of lymphocyte infiltration, collagen deposition, and fibrosis. I use the Intraline 19 gauge 100mm Dimension 360/720 Cogs, which produces great results. Using a single entry point high on the zygoma I insert three sub-dermal threads bilaterally down to the angle of the jaw and the jawline. Gentle traction and upward placing of the skin on the threads will then give the desired lifting effect. Another benefit of treating the LTF with the HA/PRF combination is that it makes insertion of the cogs easier and less painful.

A solution to facial ageing

I have found that addressing the issues of mid and lower facial ageing by managing temples and lateral temporal fat pads is very effective and also reduces the issue of hollowed temples. I address the lower face laxity issues simultaneously with PDO Cog Threads that give an immediate and a delayed lift. The procedure can be repeated as required to achieve optimal results, which are showing an acceptable longevity of 12-18 months.

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