Dr Pradnya Apte shares her protocol for facial rejuvenation combining filler, toxin and threads
As our patients age, most will visit our clinics describing their main concerns as ‘looking old and tired’, having lacklustre skin and no longer having the ‘glow of youth’. This is because, as we age, the dermis thins and morphological changes, along with genetic and lifestyle choices, contribute to a diminished appearance.
Facial ageing is a multifactorial process. There have been many theories on how the face ages, but these have developed with our increased understanding on how the bones, fat, muscles, soft tissue, skin and facial volume depletion changes.1-8
Epidermal thinning and variations in collagen cause the skin to age and lose elasticity. Gravity is also a factor, as the pull of the facial muscles causes the formation of wrinkles and lines that move with animation.9
As the skeleton is the foundation for all overlying structures it is important that we address the support it gives. Remodelling of the skeleton adds to morphological changes of ageing. If the changes presented are not addressed, then the resulting aesthetic outcome can be unfavourable.10 To add to this, there is evidence that the skeleton expands throughout life.11-14 Hellman identified that the facial shape changes as one ages.7 Computed tomography (CT) scanning shows radiological evidence that the facial bones remodel, which is a result of bony resorption of the maxilla, mandible, orbits and piriform areas.15-17 It has been noted that patients with a weak congenital skeletal structure may be prone to premature ageing.15-17
These changes cause overlying soft tissue structures to move and increased laxity in the retaining ligaments of the face which, combined with volume loss, contribute to facial ageing.15-17
Rochrich and Pessa15 described the presence of superficial and deep fat pads, later confirmed by Gierloff et al.,18 which showed not only soft tissue compartments but also that there was volume deflation in the compartments over time. These compartments are clearly defined. The increased laxity of the zygomatic, orbitomalar and mandibular retaining ligaments cause descent of the facial soft tissues. These retaining ligaments act like ‘hammocks’ to give support to fat compartments that are starting to atrophy, which lead to the appearance of tear troughs, malar bags and jowling around the mandible.18-25 How the fat pads change over time suggest that the deep fat compartments tend to atrophy with age, while the superficial compartments may be more prone to hypertrophy. Redistributing this fat can rebalance the facial fat compartments which mimic the facial structure in youth.26
With all of the above in mind, I decided to create my trademarked protocol, the ‘rejuvalift’. I wanted to do this so that all the underlying principles of facial ageing were addressed and that it had a more descriptive term.
The principles of the rejuvalift are aimed at addressing the multi-factorial components that lead to facial ageing. It comprises:
As the principles of my protocol are founded on the rejuvenation of the face, it is important to start with providing the bony support that has been lost through bone resorption of the maxilla, mandible and temporal area. Collagen-stimulating filler is injected deep onto bone using a needle in the temples, pogonion, as well as the angle of the mandible. I prefer to use a needle for these injection areas as the collagen-stimulating filler injected to the bone gives support and lift. It is also placed onto the bony aspect of the zygomatic arches to create a more uplifted look. Addressing the temporal area gives the illusion of a more open eye, in my experience. The pre-jowl sulcus is also addressed by injected onto the bone, as there is more bone resorption in the mandible at this point.
The product is also placed into the soft tissues under the lower lip and marionette areas to give lower lip support, as well as correction of the labiomental crease. The nasolabial folds are also injected at this time, and I tend to correct the area using a cannula due to it being a higher risk area. I find that injecting into the piriformis region of the nose, deep onto the bone using a needle, is a good way to soften this particular area. Neocollagenesis takes approximately 12 weeks once the collagen-stimulating filler has been injected. This is a crucial time as type I collagen is being produced by the patient. It is not until this point that I assess where the threads should be placed.
The sutures are placed in a straight-line pattern to mimic lifting forces in straight line vectors. It is recommended by the manufacturer to place five sutures on either side of the face with the fifth suture under the mandible and extending posteriorly. The threads have cones that are bi-directional and it is the breakdown of these cones that give a gentle volumisation and stimulate type I collagen.31 The threads address the nasolabial folds and jowls, as well as tightening the skin under the mandible to give a fresh, rejuvenated look.
Placement of HA filler in the lip is the next step in the rejuvalift protocol. There is evidence that there is bony resorption in the maxilla, especially the piriform area, and I find that lip augmentation is necessary to achieve a natural profile and overall balance to the face.28-30 There are a variety of ways to deliver the HA filler and there is no specific technique to carry this out. However, I find that as we are trying to achieve a fuller lip, I use a cannula method (preferably 25 gauge) whereby the filler is injected into the lip above the muscle. Amounts that are injected vary for each individual but I find that, on the whole, 1ml is more commonly used.
The placement of botulinum toxin is the final treatment in my phased and multi-layered approach. Not only is it important to treat the upper face for dynamic rhytides, it is also important to consider the lower face to treat the mentalis (this reduces the hyperactivity of this muscle to reduce the labiomental crease) and the DAO muscle which, in turn, helps improve marionette lines and oral commissure shape.
Difficulties that may arise from the rejuvalift protocol primarily result from poor patient selection, especially when assessing them for the thread-lifting criteria. Skin that is too thin or too thick is not appropriate as we cannot achieve a pleasing aesthetic result. There is also a risk with particularly thin skin that the aesthetic outcomes are unfavourable with skin puckering, especially after the sutures have been tightened. Thicker skin, on the other hand may not allow the threads to ‘lift’ the soft tissues. Ideal patients for this treatment are those with mild jowling, good skin texture, preferably non-smokers and those whose skin has not suffered from visible ageing from the sun. I have not had any experience with other types of thread systems, so I am not able to comment on whether they would be better for patients with thick skin.
Understanding the principles behind how the face ages is important to achieve an optimal aesthetic result. The understanding of the facial structures that lead to this process are what I believe makes one aesthetic practitioner stand apart from another. Managing patient expectations, careful patient selection, understanding facial anatomy, where best to place product, at which level and at which phase of the treatment process, is vitally important. The rejuvalift involves treating the ageing face as a complete entity and taking into account static and dynamic movements of the face. The key elements of the treatment, as mentioned above, can work well synergistically and, in my personal practice, I have seen incredible results, while retaining a natural appearance.