Dr Maryam Zamani details the facial ageing process and shares her new technique for rejuvenation
Ageing is a multifactorial process caused by the accumulation of both intrinsic and extrinsic factors. Gravity, skeletal remodelling, subcutaneous fat distribution changes and loss, and skin changes, all contribute to the ageing face.1 Extrinsic factors include environmental insult such as photodamage caused by UV exposure, and lifestyle factors including; smoking, stress, diet, and drug abuse.2,3,4 Loss of collagen, leading to the atrophy of the dermis, degeneration of elastin fibers and loss of hydration account for intrinsic skin ageing.4 Clinical signs of ageing skin include rhytides, lentigines, telangiectasia, loss of elasticity, uneven skin tone and volume loss.5 The sequence of ageing starts with loss of skin elasticity resulting in rhytides, volume loss, and downward descent of the skin and fat pads.6 The resorption of the infraorbital fat pads distorts the ogee curve, making the under eye appear aged.1,7,8 In the upper face, this progresses to create a longer eyelid to cheek junction, lengthening the lower eyelid and influencing the formation of a tear trough with a V-shaped deformity along the maxilla and zygoma.6 This cumulative process creates a more tired appearance of the face and eyes.
The primary goal of periorbital rejuvenation is to restore a balanced distribution of facial fullness while addressing the overlying skin.1 Repair of ageing skin epidermis and dermis can be pharmacologically enhanced by topical application agents such as mesotherapy.9 Hyaluronic acid can also be used to help restore facial harmony by replacing the volume depletion that occurs with ageing.
Hyaluronic acid dermal fillers help augment soft tissue imbalances. The importance and value of injections of hyaluronic acid into the periorbital and midface areas is well documented.6 Dermal fillers have evolved to help not only restore volume and enhance facial contouring, but also to hydrate the skin. Hyaluronic acid placed into the periorbital area should be placed on the periosteum to create a more aesthetically pleasing result, because it helps elevate overlying soft tissue.6 Obtaining a smooth aesthetic outcome is a challenge and is most feared for its complications.1 Knowing the facial anatomy, selecting the proper product and good delivery technique of hyaluronic acid fillers is essential in preventing visual and palpable lumps or nodules.
Mesotherapy is a minimally invasive technique used to rejuvenate the skin using a series of transdermal microinjections of a cocktail of various pharmaceuticals, vitamins and other bioactive substances.10 Originating in Europe with a strong following, mesotherapy is thought to increase the synthesis of fibroblasts and enhance the synthesis of collagen, elastin and hyaluronic acid to firm, brighten, and hydrate the skin.11 The injury created by the microneedling also helps stimulate the body’s own healing response, aiding the stimulation of collagen and elastin formation.
Platelet-rich plasma, known as PRP in medical aesthetics, is a relatively new modality. PRP is a highly concentrated autologous solution of plasma prepared from the patients own centrifuged blood.12 PRP is a minimally invasive treatment used to improve moderate lines, wrinkles and improve skin texture, volume and tone. It has been well documented for its use in wound healing and now for cosmetic uses.12,13 Platelets contain multiple growth factors in the form of alpha granules and dense granules.12 Alpha granules contain multiple growth factors including platelet-derived growth factors, transforming growth factors, epithelial growth factors, and vascular endothelial growth factors.14,15 Together these growth factors help cell proliferation, differentiation, angiogenesis and chemotaxis.12 Mehryan et al illustrated significant improvement in colour homogeneity in the infraorbital dark circles,16 while other similar studies showed improvement in infraorbital wrinkles and skin tone.17 PRP can help improve skin tone, texture and colour.
Short-term effects of mesotherapy, PRP and hyaluronic acid fillers include discomfort, redness, swelling, and ecchymosis. With hyaluronic acid fillers, excess injection of the filler can lead to increased swelling, the tyndall effect or visible irregularities.18 It is important to note that a slight under correction is always recommended to achieve the best aesthetic result. Periorbital rejuvenation with hyaluronic acid has the potential for significant complication of intravascular injection causing visual compromise, blindness or skin necrosis.19 Periorbital rejuvenation requires a deep understanding of facial anatomy. With an injection, there is always the risk of intra-vascular injection, nerve trauma, and skin infections. This treatment is contraindicated in any patient with a dermatological disease affecting the face, platelet dysfunction, pregnancy or lactation or who someone is currently undergoing anticoagulation therapy, chemotherapy or steroid therapy.20
Facial ageing is the interplay of multiple concomitant factors and therefore requires multiple different treatment modalities to help improve this common aesthetic concern. I have created a new Triple Boost HydraBright eye rejuvenation treatment that uses a combination of hyaluronic acid, PRP and mesotherapy to create a brighter, voluminous and rejuvenated lower eyelid.
Careful patient evaluation and selection is critical to any aesthetic treatments used, but particularly invaluable when treating the periorbital area. Upward gaze helps accentuate periorbital volume loss, allowing improved visualisation of tear trough deformity. A complete medical history is required to make sure that the snapshot of the patient is consistent and unchanging. Patients should not be susceptible to cheek oedema with waxing and waning of the lower eyelid swelling. The patients I have treated have all presented with tired eyes, hollowing of the eyes and sagging of the overlying skin. Pre-treatment photos are taken and informed consent is signed.
Hyaluronic acid: The patient’s face is anaesthetised for 15 minutes with 4% lidocaine. I begin this treatment by taking the 20ml of the patient’s own blood and centrifuging it at 2,500rpm for eight minutes. While the blood is prepared, I cleanse the face thoroughly with chlorhexidine and begin by injecting with hyaluronic acid. I prefer using Volift in the Juvéderm range of products as the hyaluronic acid to inject the lower eyelid and cheek in this treatment. Juvéderm Volift uses the Vycross technology allowing more effective crosslinking, so a lower concentration of hyaluronic acid can be used to create a smoother overall appearance with improved duration. The first injection is placed lateral to the infraorbital nerve, entering perpendicular as a bolus of 0.05ml to 0.15ml of Volift placed just superficial to the periosteum. The second injection of hyaluronic acid is placed in the lateral orbital rim just below the lateral canthus, again as a bolus of 0.05ml to 0.1ml just anterior to the periosteum. The third injection is placed medial, again perpendicular to the skin, and a bolus of 0.05ml of hyaluronic acid is injected superficial to the periosteum. The hyaluronic acid is then moulded gently with digital massage to create a smooth lid-cheek junction. Prior to any placement of hyaluronic acid, aspiration is done to help avoid vascular embolisation. All bleeding points are treated with immediate pressure to help prevent ecchymosis.
PRP: Once the filler process is complete, the centrifuged blood is prepared. The platelet poor plasma is separated from the platelet rich plasma. The PRP is then activated with calcium citrate. This is then injected as microinjections both deeply and superficially into the skin and some of the remaining PRP is used to gently massage the periorbital area. If there is excess PRP, this may be used on the remainder of the face.
Mesotherapy: Following the application of PRP, a series of microinjections (1-2ml) are administered as intradermal nappage into the periorbital area, and papules containing active ingredients including hyaluronic acid, vitamin C, Dimethylaminoethanol (DMAE) and silicone are injected to help boost collagen synthesis, hydrate the skin, restore skin firmness and improve skin tone.21
Patient selection, comprehensive knowledge of the facial anatomy and an aesthetic understanding of a refreshed periorbital area are critical in creating a rejuvenated result. Successful treatment of the periorbital area with this combination treatment provides a repeatable and aesthetically refreshed look for the patients. There are currently no clinical studies showing the synergist combination of these combined treatments, and such an undertaking would be beneficial for medical aesthetics. However, this combination treatment illustrated diminished appearance of tear trough defects while brightening and tightening the periorbital skin in treated patients. I found that this non-surgical correction of the periorbital area is effective to treat volume deletion and to strengthen the periorbital skin with high patient satisfaction.
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