The Low Down. Rejuvenating the Lower Face

01 Feb 2014

Practitioners discuss the importance of a cocktail approach to lower face ageing, sharing their tips and techniques

Studies have shown that while younger women are mostly concerned about the look of their bodies, older women tend to be more dissatisfied with changes related to facial ageing, particularly in the lower face.1 As discussed in the previous feature, multiple, interacting changes to the soft tissues and skeleton cause the visible signs of ageing in the lower face.

Before Ulthera
After Ulthera

Dr Nick Lowe says contributing factors including smoking, acne and genetic factors. “Smokers have been found to appear five to ten years older than non-smokers of the same age, with increased sagging and more lower facial lines. Previous inflamed acne on the lower face increases collagen and elastin damage and contributes to sagging around the chin and mouth. Orbicularis oris movements such as lip puckering and pursing create wrinkles. Familial thin lips create a higher risk of barcode lines as they have less resistance to the folding of skin around the lips, and an inherited small or posterior chin (micrognathia) will also add to sagging of the jawline. Cosmetic dentistry, if done well, can considerably improve perioral ageing.”

As the causes of visible ageing in the lower face are complex, reversing age-related changes using non-surgical methods may require a ‘cocktail’ approach, involving topical treatments, toxins, dermal fillers and skin tightening.
For patients whose primary problem is superficial damage, such as wrinkling from smoking or UV exposure, Dr Lowe suggests encouraging use of a cream with both UVA and UVB protection plus a minimally inflammatory retinol. “My favourite is Isotrex gel,” he says. “If there is relatively superficial sun damage I may also use the Fraxel laser at 1550 nanometres. This penetrates into the mid-dermis, producing tightening and stimulating of collagen. For deeper folds and wrinkles I may suggest Intracel. The insulated needles deliver radio frequency and resultant tightening to the collagen and elastin tissues. Both Fraxel and Intracel produce minimal inflammation which is very important.”

Intra RF - Mono & Bipolar X 4 - Before
Intra RF - Mono & Bipolar X 4 - After

For ageing around the mouth due to loss of volume, fillers are the treatment of choice. Says Dr Lowe, “In my opinion, only hyaluronic acid fillers are safe to use in the lips and perioral area. I prefer to use a product which includes a local anaesthetic. This means choosing from the Juvederm, Restylane or Emervel families. I use a very fine, 30G cannula for the vermillion border then use the needle to deposit a small amount of dermal filler into the body of the lip and massage it smooth. I like Volbella as it is soft and produces little swelling at the injection site. However it may not last as long as other fillers. “I use approximately 1cc in the lower lip and a third of this in the upper to maintain good proportions. For patients with thinner lips, I’ll consider refining the effect with a maximum of one further syringe four to six weeks later. A slower improvement is more discreet for the patient, is less likely to cause bruising and increases the persistence of the filler, probably due to less inflammation, swelling and oedema in the area.”

If a patient presents with significant ‘barcode’ lines above the lip, look at the patient’s dynamic movements to see how the lines change with muscle activity.
Says Dr Lowe, “If this is significant I may consider botulinum toxin as an additional treatment. I use a total of about four units of Botox, or 12 units of Dysport or five units of Xeomin, deposited in two to four tiny amounts spaced out along the upper lip, depending where the maximum muscle activity is.” Dr Rita Rakus, who also likes to use Volbella for lip enhancement, says that many patients are concerned about the risk of a ‘trout-pout’. “For these patients discussion of the role of Hyalase in dissolving hyaluronic acid fillers can allay their fears.“ she says. “It is part of sensible counselling that includes warning of possible bruising and swelling that may occur. It is important to remember that lip enhancement is never totally predictable. As they age, some patients develop a thin, compressed look to the lateral border of the lips, and ask for volumisation in that area. However, on injecting I sometimes discover that only the central portion of the lip will become fuller, with the edges remaining flat. In these cases I add more product to the centre of the lip at the top and bottom, and add a very small amount, around 0.5mls, to the area around the mouth, halfway between the centre of the border and the lateral edge, with more emphasis on the bottom lip, to lift the lip line. For patients with thin, ‘letterbox’ lips it can be difficult to get volume while the mouth is closed. For those patients it can be helpful to show them in a mirror how their lips look fuller when they are in motion.” For barcode lines, Dr Rakus says, “Fillers still achieve good results, but lasers such as Fraxel and Total FX can be highly effective in minimising fine lines and are often used in a combination treatment plan.”

EndyMed 3DEEP

Ageing is often associated with a downturned, ‘sad’ mouth, which develops due to descent
of surrounding tissue, habitual expressions and loss of volume. The use of botulinum toxin in
the lower face, in particular to relax the depressor anguli oris muscles to create lift at the oral commissures is increasingly popular. However, Dr Mervyn Patterson warns that special care must be taken when treating the lower face. “If treatment of the depressor anguli oris is unequal on both sides the smile will be asymmetrical and difficult to correct. Slight diffusion laterally of toxin in the mentalis will affect the depressor labia inferioris which leads to a very unusual looking movement of the lower lip.”
Aesthetic nurse Sharon Bennett says, “To avoid asymmetry, when targetting the perioral area and the depressor anguli oris it is important to avoid the orbicularis oris, which would affect the sphincter and closure of the mouth with reduction in ability to pucker, while injections given too medially will affect the depressor labii inferioris between the DAO and the mentalis. This will cause a flattening of the contour of the lower lip, an asymmetric smile and reduction in the ability to purse the lips. You can normally palpate the DAO by getting the patient to contract the muscle for example asking them to pronounce the letter ‘e’.” Dr Mervyn Patterson warns that, “Over zealous orbicularis oris injections impair the ability to pronounce ‘p’s and ’b’s. The correct procedure only lasts about 6 weeks.”

I use the tower technique when injecting in the zygomatic arch, placing little towers of one of the thicker fillers, Dr Nick Lowe 

Surgeon Adrian Richards adds that excessive relaxation of the depressor anguli oris muscle (DAO) may lead to the elevation of the corners of the mouth. This occurs because of the action of their antagonist levator anguli oris muscles, which elevate the corners of the lip. With less resistance to the levator muscle, the lips can curl up in an unnatural ‘joker smile’. This may be a particular risk with older patients because the philtrum area tends to lengthen with age, which lowers the central part of the upper lip. Says Richards, “The key is to be very conservative and very superficial. I would use 2 to 2.5 units of Botox, and inject just into the skin, allowing the toxin to diffuse into the muscle.”

Dr Ariel Haus using the Sublime skin tightening system

If a patient has a strong platysmal muscle pulling down the angle of the mouth giving jowls and marionette lines, Dr Lowe says, “I inject a maximum of ten units of Botox
or equivalent into the muscle, divided equally between the right and left sides of
the platysmal bands.” Lower facial ageing may also be caused by volume loss in the mid-face, so don’t ignore the use of lifting fillers injected into the lateral cheek and over the zygomatic bone to lift the lower face and mouth area.

Dr Lowe says, “I use the tower technique when injecting in the zygomatic arch, placing little towers of one of the thicker fillers, injected vertically right on the periapical of the zygomatic arch with either SubQ or Voluma. Sculptra treatments can lift the mid-face but it is important to avoid the area around the mouth as it appears that the action of the muscles in this area concentrate Sculptra into small areas, which may result in nodules.”

However, Dr Patterson says, “There is only so much lift one can be achieved with fillers, and lifting becomes more difficult with more aged faces without creating an over-inflated look to the cheek. Early intervention is best and patients should be informed when surgery is the best answer to their concerns.”

For early signs of jowling, Dr Lowe says a more youthful jawline appearance can be achieved using a hyaluronic dermal filler injected into the indentation just below the chin and before the jowl. “Used in combination with a thicker filler to lift the cheek skin this can be extremely effective, In addition, Nefertiti injections of Botox along the jawline can be effective in cases where the platysmal bands are pulling downwards and Thermage can be used above the jawline and to the lateral and mid cheeks to tighten.” The growing desire of patients for non-surgical skin lifting has led to the development of more skin tightening treatments. One of the newest to the market is 3D-skintech used by Dr Martyn King, which uses tri-polar radio frequency for painless skin tightening. Dr Lowe says, “I would consider radio frequency lifting and tightening lateral to the marionette and nasolabial lines. I use Thermage or Intracel using both monopolar and bipolar frequencies.” Dr Rakus advises, “Combining volumising with radio frequency treatments such as Thermage or Pelleve, or ultrasound therapy such as Ulthera can be very effective in helping to rejuvenate the lower face and oral commissures.” Dr Lowe also recommends the Venus Freeze (a combined radio frequency magnetic resonance system) to tighten skin sagging in this area. “Studies conducted by US dermatologist Dr Neil Sadik and presented at the 5-continent Congress of Dermatology in Cannes in 2013 are very compelling. The treatment is painless but patients need at least five or six sessions a week or so apart to see long lasting results, plus a top up treatment three to six months later.”

Dermatologist Dr Ariel Haus uses the Sublime skin tightening system on lower face folds, sagging jowls, neck and crepey skin. Sublime uses bipolar radio frequency and infrared light and requires three to five sessions spaced three to four weeks apart for best results. He says, “It is a comfortable treatment with zero downtime, making it a good choice for those who prefer a non-surgical option. It also gives a temporary instant lift, and I normally show patients half the face done before completing the treatment and they are very positive about the change.” Endymed 3DEEP is another pain-free option for skin tightening, with the energy delivered via multiple phase – controlled skin electrodes. Surgeon Chris Inglefield describes it as “safe and effective.” For ‘pebbly’ or puckered chins, Adrian Richards recommends injecting either the central area or both lateral sides of the mentalis muscle with 2-2.5 units of Botox or equivalent. 

Dr Lowe adds, “Injections of Voluma or SubQ can do a lot to improve the appearance of a receding chin. When injected under the mentalis muscle, these fillers can last two years or more, as the anterior mandible does not move much.”
For submental fat and fat around the jawline, the best treatment in future may be injectable fat dissolving injections. Ones currently in use include the deoxycholate-based treatments Lipodissolve or Aqualyx, while Kythera’s ATX-101 drug, after successful phase 3 trials, is expected to receive approval for use in the US this year.
Dr Lowe says, “The lower face usually changes because the whole face is changing. It is extremely important to examine the patient carefully to assess the causes of ageing before treating the area, and a combination approach normally works best for global rejuvenation.” 

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