Dr Frances Pitsilis - Non-surgical face lift treatments

We are all getting more out of life these days, and as the population ages, we are demanding more and more from our appearance as well. The goal is to get more without going under the knife.

There are a raft of new technologies sweeping New Zealand. So what are the causes of the skin thinning and sagging that clients seek to reverse? We often see this as inevitable as people age, without thinking about what is going on. In addition to too much sun exposure and bad living (eg smoking), these aging changes are related to poor diet and digestion, and diminishing hormones.

As a person ages the combination of facial bone changes, fat compartments in the skin moving downwards, skin thinning and gravity all contribute to the appearance of facial sag. This is not to mention the hormonal and nutritional changes that contribute with age.

Healthy Diet and Lifestyle
Diet and digestion are important. You know the old saying, ‘you are what you eat’? This is not correct. In fact, you are what you eat and absorb. As a person heads past 40, they don’t make as much stomach acid and/or digestive enzymes, so nutrients from food are not as easily absorbed into the body. If you are concerned about digestion, you could advise a broad-spectrum digestive enzyme preparation with main meals.

Diet needs to consist of good quality proteins throughout the day because our skin is made of collagen – that’s protein. The typical Western diet, containing a lot of sugar, starch and white flour, will not help the skin but will make it worse, because these substances cause inflammation in the body. The skin will show this because it is our largest organ. Acne in teenagers is a good example of this.

Good quality protein, lots of fruit and vegetables, and avoiding sugar and starch is the way to go. The way to fill up the rest of your diet will be with nuts and seeds, which are also good-quality proteins.

Supplements for Skin
These days everybody seems to be taking supplements; one survey found that 75% of us take them. The important ones for your skin are omega 3 fish oil, an antioxidant and anti-inflammatory, and the main antioxidant vitamins – A, C, E, B vitamins and selenium. In addition, in my clinical work I have noticed that virtually everyone I test has low zinc and low vitamin D. Zinc and vitamins C and D are important for collagen production, and D is also important for the skin and general health.

Hormones
Hormone losses cause a few tell-tale signs. Loss of hair from the outer part of the eyebrow and bags under eyelids can mean an underactive thyroid. Lines around the mouth, especially of the upper lip, can mean low oestrogen. The dropping of the lateral eye brow, the sagging of the cheek and the loss of volume in the cheek are related to a reduction in growth hormone levels.

It is possible to improve bags under the eyelids and sometimes prevent surgery by improving the clients’ hormone balance. However, some of the bags can be from fat, which cannot be cured with hormone balance.

So, if at all possible, prevention, or slowing down of ageing that involves loss of good biochemistry and hormones, is one of the first principles.

In the 40s and beyond is the time when many of these changes start. I have met many 50-year-old women who say, “When I hit 50 my face dropped.” Referring them to someone who can sort out their hormones can be useful, especially if they have other problems like heavy painful periods, severe PMT or menopausal symptoms that are causing a disruption in their lives.

Beauty Sleep
It goes without saying that sleep is important. We all know that if you get a good night’s sleep you feel and look better. This is because if you are in bed and asleep before 10:30pm the pineal gland, in the centre of the brain, releases melatonin, the body’s natural antioxidant and anti-aging substance. Melatonin is an anti-cancer compound and is responsible for preserving eyesight, the brain and the heart. It is also a natural anti-aging compound that is easily enhanced with a good night’s sleep.

Smoking
Smoking is a big “no-no” because twin studies have shown that smoking thins the skin. (I suspect it is because the body is starved of oxygen.) Any plastic surgeon will tell you that he will not perform a facelift on a smoker because of the poor wound healing. Similarly, any good cosmetic clinic would avoid performing light and laser-based therapies on smokers because of the expected poor response. In addition, smokers are exposed to chemicals like cadmium and arsenic – these will cause further damage to the skin and the body.

Sun Exposure
Sun exposure is an important cause of skin ageing because UV damage from the sun causes solar elastosis, meaning the collagen fibres are stretched out and less coherent – this is an important cause of skin thinning and sagging.

Manage stress, because it causes inflammation which is damaging to the skin. I’ve never seen a tired, stressed person look good.

Skin Care Specifics
Of course, skin care is the next step on top of healthy lifestyle and prevention; the most important aspects are protective and skin-tightening skin care.

Protective skin care consists of sunblock and antioxidants. A good broad-spectrum sunblock capable of stopping UV rays is very important, especially in New Zealand. I prefer a zinc-based morning moisturiser with sunblock combination, because zinc is a physical blocker that will block the whole spectrum of UV, as well as helping the skin.

Other blockers containing titanium dioxide or oxybenzone will not quite block the whole UV spectrum. A recent innovation marketed as Helioplex® is oxybenzone with an added compound to give it the extra spectrum – in my opinion, a zinc-based sunblock will work just as well.

Antioxidants on the skin, as well as in the body, are a good idea. The antioxidants need to be A, C and E, and often other antioxidants are added to skin care, including alpha lipoic acid, and coenzyme Q10. Natural antioxidants can include green tea, but there are many others in a variety of cosmetics, such as flavinoids, carotenoids and polyphenols, which can include soy, curcumin, silymarin, and pycnogenol. Anti-inflammatory botanicals include gingko biloba and green tea.

Among the most important skin-care ingredients are the Retinoids, the strongest of which is Retinoic. These are all vitamin A-derived and work powerfully on the DNA in the skin cells, stimulating them to normalise the skin. This results in older skin becoming plumper, less wrinkled, and less pigmented. Retinoids also protect the skin from UV radiation and reduce skin cancer. Now there are many natural products that can work well.

Microdermabrasion
Microdermabrasion is the process of resurfacing the top layer of the skin to a precise depth by the concurrent combination of exfoliation and vacuuming. Removing the dead skin cells and stimulating blood flow causes the deeper dermal level to be stimulated to produce collagen and fibroblasts.

The results are a fresher improved skin with an enhanced surface quality. This is a comfortable treatment with no downtime. Clinical studies have shown this treatment to be effective for acne, hyperpigmentation, sun damage, fine lines and superficial skin disorders. The normal recommendation is for six to 12 treatments, seven to 14 days apart, according to the severity of the client’s problem.

Because the suction component of microdermabrasion stimulates the deep dermal collagen, there is potential for this treatment to provide subtle skin tightening and thus a subtle lift. The treatment requires less than an hour and the patient’s skin can be pink or slightly red afterwards, but this can be easily covered by makeup and will resolve in a few hours. Maintenance needs to continue with a good skin-care programme and monthly treatments.

Skin Needling or Collagen Induction Therapy
Skin needling is something that has increased now, with many options available. It has been known about and used since the mid-1990s. It can improve collagen, slightly tighten as well as reduce pores and scars.

You have noticed by now that I have covered the least invasive and least costly types of treatments that to date have had a mild effect on any sort of tightening or lifting.

Muscle Relaxers
Now we start to move towards treatments that have more obvious effects, the first of which are muscle relaxers. We all know them as botulinum toxin injections which are used mostly in the upper half of the face on dynamic wrinkles (those caused by muscle movement) situated in the frown, brow and crow’s-feet areas. Carefully placed, botulinum toxin injections can lift the lateral eyebrow and open up the eye.

In addition, botulinum toxin injections can be used in the lateral chin area, where we have the depressor angularoris (DAO) muscle. This muscle is triangular, with its broad base along the jaw just lateral to the centre point of the chin. The tip of the triangle of this muscle inserts near the corner of the mouth. The action of the DAO muscle is to pull down the corners of the mouth. Relaxing this muscle, causes release the corner of the mouth and therefore lift it slightly.

In addition to lifting the corner of the mouth, it may help to release and therefore lift the cheek subtly. This is a common technique used before proceeding to a mid-face liquid facelift (using dermal fillers) which we will discuss later.

Dermal Fillers
The most popular dermal fillers on the market are those containing hyaluronic acid, which is generally found in the skin of animals. It is manufactured and placed into syringes for injection into the face. It is typically injected under lines and wrinkles to lift them up, and lasts six to 12 months depending on the product. Brand names include Restylane® and Juvederm®.

Their most popular use is in the lips, to define the lip borders, improve the ines around the mouth and to plump the lips. However, it they have also been used in the mid face to add volume to the cheek areas and cheek bone areas, giving a more youthful line to the cheeks and lifting the front of the face.

In addition, all fillers can be used in the lateral brow to raise it, as well as in hollow areas around the side of the eye – as you age you lose muscle mass around the temple area.

At the last international cosmetic surgery conference I attended, we had several international speakers exhibiting a definite trend away from surgical facelifting and towards using several syringes of filler to give volume and shape to the face. One international speaker used 12 syringes of filler in one patient!

The advantage of using fillers compared to a facelift is the low invasiveness of the procedure, as well as lowered risk and downtime. In addition, the contours of the face are being improved to youthful contours rather than just stretched back by a facelift. We have all seen the unfortunate results of too many facelifts – the ‘Catwoman appearance’.

Autologous Fat Grafting
This has been around for many years – this is a technique where the patient’s own fat is harvested from a position such as the buttocks and then injected into the cheek or other areas. It is a more invasive procedure and in some cases the graft does not last. In addition, the risks of adverse effects are higher. If you want to have this procedure done, you must see a doctor who has much experience in this procedure.

Laser and Light Treatments
Of these treatments, the two gold-standard treatments for skin tightening are Thermage® (monopolar radiofrequency) and Titan® (far infrared light procedure). Both have been scientifically validated and clinically proven to treat the deep dermis and permanently tighten the skin. Although the skin is permanently tightened, the skin continues to age and loosen.

I understand that Thermage is somewhat uncomfortable, and requires pain management. Clinics get around this by apply face-numbing cream, and using sedation and / or inhaled anaesthetic.

With Titan®, the ideal candidate is a non-smoker with thin lax skin. Often people over 50 respond the best. After an initial course of two to four treatments of the face, jowl and/or neck, one top-up treatment can be performed at one to two years to maintain the effect as the patient ages.

Other laser and light therapies can subtly tighten the skin.

Ultrasound has become a treatment for facial skin tightening in recent times.

Many clinics have intense pulse-light machines (IPL) and in some patients, after a series of treatments, a very subtle tightening might be observed. However, you wouldn’t have this treatment for tightening because it works very superficially in the skin – this is not where tightening occurs – it occurs deeper.

A particular treatment that does tighten the skin a little more than these IPL treatments, is the Laser Genesis treatment, a specific 1064 ND Yag laser which is used to heat the deep dermis. It is a comfortable, walk-in/walk-out procedure with no downtime. It can be uses for texture and rejuvenation as well as deep redness, including rosacea. Because it works on the mid dermis it will tighten the skin.

Titan and Laser Genesis are used a lot in Japan because the darker Japanese skin precludes the use of IPL for rejuvenation. After an initial course of treatment, to maintain the tightening and the other effects it needs to be topped up around six-monthly. There are only a few of these in New Zealand.

Hybrid devices are those that consist of intense pulse-light combined with bipolar radio-frequency. The combination of electrical and optical energy as seen in these devices is theoretically there to enhance the effect. I have only seen two studies about this technology – one which said that they did not see any evidence of tightening, and another that showed some benefits similar to Laser Genesis. Top-up treatments after a course will be six-monthly.

More invasive laser and light-based treatments exist primarily to improve pigmentation, collagen production and texture. They are not specifically designed to tighten as far as I can ascertain, but some tightening can occur as a side effect of the treatments.

Carbon dioxide laser is the oldest. It resurfaces the skin like a burn, and there is usually a recovery time of about three weeks. Modern innovations of this technology are the fractionated lasers which reduce the downtime to five to seven days and give fewer side effects – however, you need four to six treatments with some of them - Fraxel®, for instance.

All these treatments require pain management. Even newer innovations with, in some cases, different wavelengths to the CO2 Laser, are fractionated treatments that only require one treatment.

Suspension Threads
More invasive treatments start to use treatments like suspension threads. These are plain nylon threads or threads with barbs along them that are inserted behind the hairline, for example, brought down to the cheek or jaw area, and then pulled up and tied under the hairline. The procedure of inserting suspension threads requires sedation and a skilled experienced doctor to insert them. The results can be reasonable. Newer dissolvable threads also exist that are placed without as much drama. There can be side effects like infection or breakage of the threads. This procedure could possibly put off the need for a facelift. The dissolvable threads can be used alongside dermal fillers because they dissolve after a time.

Chin Implant
The chin implant is a bit more invasive and requires a general anaesthetic. It can be used in a weak chin to help pull up a sagging neck.

In summary, there are many comfortable treatments available to improve the skin and thicken as well as lift it, with no downtime. Combinations of these treatments can be used to enhance the effects.