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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 1  |  Page : 1-5

Nonsurgical facial rejuvenation: common methods in practice


1 Whiston Hospital, Liverpool, UK
2 Department of Plastic Surgery, Al-Azhar University Hospitals, Cairo, Egypt

Date of Submission13-Sep-2017
Date of Acceptance28-Mar-2018
Date of Web Publication20-Nov-2018

Correspondence Address:
Yasser Helmy
Department of Plastic Surgery, Al-Azhar University Hospitals, Cairo, 12655
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_49_17

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  Abstract 


Since the concept of surgical and nonsurgical facial rejuvenation has been introduced, scientists have developed a wide range of agents that can treat an aging face. With the high bill of surgical manoeuvres, most of the antiaging procedures are nonsurgical. A fair knowledge of nonsurgical facial rejuvenation is as important as the surgical tools to the practice of plastic surgeon or a dermatologist who offers cosmetic surgery. Nonsurgical facial rejuvenation has gained its popularity owing to the low-cost, quicker recovery and guaranteed results but with short-lasting effect. In this review article, the basics of different modalities of nonsurgical facial rejuvenation are reviewed regarding the concept behind them and their advantages and disadvantages. With the successful integration of each of these modalities, a complete facial regimen can be achieved, and patient satisfaction can be maximized.

Keywords: chemical, fillers, laser, nonsurgical, rejuvenation


How to cite this article:
Alfeky H, Helmy Y. Nonsurgical facial rejuvenation: common methods in practice. Al-Azhar Assiut Med J 2018;16:1-5

How to cite this URL:
Alfeky H, Helmy Y. Nonsurgical facial rejuvenation: common methods in practice. Al-Azhar Assiut Med J [serial online] 2018 [cited 2018 Dec 18];16:1-5. Available from: http://www.azmj.eg.net/text.asp?2018/16/1/1/244148




  Introduction Top


Aging of the human face is a continuous dynamic process that takes place when there is superficial textural wrinkling of the skin and changes in the three-dimensional topography of the underlying structures. It affects all the components of the face including skin, soft tissues (subcutaneous fat, muscle and fascia) and structural support (bone and teeth). The reasons behind facial aging are multifactorial and those include changes in dentition and bony architecture, facial fat loss and decreased dermal thickness from photo damage and genetic changes. The additional loss of the collagen and the glycosaminoglycans also causes aging by causing in folds and hollows that age the face. Gravity, subcutaneous fat redistribution, hormonal imbalance, chronic solar exposure, smoking and skeletal remodelling are the major forces that contribute to facial aging. Other environmental factors can include mental stress, diet, work habits, drug abuse and disease [1].

The skin has been classified according to the amount of melanin pigment in the skin into six types. This is determined by constitutional colour (white, brown or black skin) and the result of exposure to ultraviolet radiation (tanning). Pale or white skin burns easily and tans slowly and poorly: it needs more protection against sun exposure. Darker skin burns less and tans more easily [2].

Nonsurgical techniques for facial rejuvenation procedures have gained popularity over the past few decades owing to the low-cost, office-based practice. The methods available for facial resurfacing are mesotherapy, peeling, dermabrasion, fillers, botox, laser, topical agent, thread agent and in the future using stem cells and antioxidants [3].

Nonsurgical techniques have many advantages such as minimal pain and risk of infection, no use of anaesthesia and less time-consuming procedure and natural and healthy look. Skin rejuvenation improves the quality of the skin by increasing the production of elastin and collagen and restoring the moisture content of the skin [4].


  Fillers Top


Introduction

Injectable fillers were introduced to the aesthetic field when the bovine collagen injections were developed in the 1980s. Since then, there has been much work to improve the quality, enhance the longevity and minimize the allergy to those products [5]. Their use has increased worldwide by ∼253% from 2000 to 2014 and has become a popular adjunct for facial rejuvenation. Facial fillers are an important tool for facial rejuvenation to the practicing aesthetic surgeon. A thorough knowledge of their uses, risks and methods of delivery is imperative to provide patients with a wide spectrum of options that can be individualized to specific patient needs [6]. Filling concavities of the face with fillers restores a more youthful appearance without the need for a facelift [7].

Indication

Soft-tissue fillers are indicated for the treatment of cutaneous and subcutaneous defects and deficiencies, improvement in facial contouring, revision of depressed scars and reduction in facial rhytides and skin folds. Moreover, to soften signs of facial aging and restore the facial aesthetic ‘triangle of youth’, there are hundreds of different types of fillers in use. Physicians always select the filler for an individual based on the area to be treated, risk factors, budgetary constraints and their own historical preference [8].

Classification of filling agents

Fillers are either permanent, which have adverse effects ([Table 1]) and not approved to be used for facial enhancement in current practice [9], or temporary fillers. These are classified as bovine-based collagen like Resoplast, Zyderm and Zyplast; porcine-based collagen like Permacol or human tissue-derived collagen like Autologen and Dermalogen. Autologous fat, plasma gel and hyaluronic acid-based fillers like Juverderm and Restylane are common fillers in current practice as well [10].
Table 1 Characteristics of the ideal filler [8]

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Complications

Informed consent should be obtained from the patient after explaining all the possible risks and adverse reactions. Most of these are short term and disappear spontaneously within 7 days. These can include pain, swelling, erythema, pruritus, tenderness or bruises. Hyaluronidase should always be available to immediately reverse an unwanted aesthetic outcome or ischaemic event [11],[12].


  Chemical peel Top


Introduction

Skin peeling using natural products of milk and honey has been used for thousands of years. It has developed to include caustic methods through using materials like mustards, sulphur, limestone and even fire. Modern forms of chemical peels became a common method of facial rejuvenation in the early 20th century, with Hollywood stars undergoing the procedures by nonphysicians [13].

The chemical peel is a cosmetic procedure that gives the skin a smoother and fresher look by removing epidermis and superficial dermis with aim of reorganizing the collagen of the papillary dermis without causing any damage to the reticular dermis. Chemical peel resurfacing is a relatively safe option to treat some skin deformities. However, postoperatively, desquamation, oedema and erythema could be expected specifically in deep peels [14].

All patients should be pretreated for 1 month with tretinoin and other desquamating agents to enhance the even penetration of peeling agents before medium and deep peeling. To minimize risk of postpeel hyperpigmentation, hydroquinone can also be added [15].

Three to four days before the date of the peel, pretreatment should cease and may be resumed 1 week after the peel. Any history of herpes simplex should alarm for some prophylactic treatment with antivirals to reduce the chances of recurrence. Great care should be paid towards a patient with cardiac, hepatic or renal dysfunction [16].

Jessner solution is composed of resorcinol (14 g), salicylic acid (14 g) and 85% lactic acid (14 g) in 95% ethanol. It is commonly used to treat acne and hyperpigmentation through its exfoliative and keratolytic properties. Jessner solution is applied layer by layer with erythema as the endpoint. It can improve mild rhytids if the papillary dermis is reached through the use of additional layers of application secondary to stimulation of collagen production [17] ([Table 2] and [Table 3]).
Table 2 Indications and contraindications for dermabrasion [18]

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Table 3 Types of chemical peel

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  Thread Top


With aging, the tone of our skin and underlying structure become weaker and the fat support becomes less evident. The effect of this along with the loss the fat volume causes ptosis and sagging. The areas to suffer this sagging are the brows, around the eyes, the cheeks, the jowls and the neck. This creates a longer, older looking face. Thread lift provides a simple surgical method, with specially designed suture material, to relieve facial soft-tissue ptosis and decrease the duration and problems of the postoperative period. It is a quick, easy-to-learn bloodless procedure. It can be used when little to moderate rejuvenation is needed [19].

Threads, recently and commonly are made of a monofilament or multifilament material called‘polydioxanone’ Absorbable PDO, Barbed, wih unidirectional edges which lie in one direction and open up. So, when implanted into the subcutaneous fat and tugged into place, they allowing the gathering of the soft tissues and creating lift and volume contouring. They should be placed in certain vector carefully in each areas in the face and neck to support the tissue and lift it. This procedure is considered much less invasive than traditional facelift procedures and requires less downtime without the need for an operative theatre. Thread lifting effect is neither magic per say or alternative to surgery, but It might have superior esthetics’s for skin lifting, and rejuvenation, especially when combined with one or more of another methods of facial rejuvenation.

Safe areas for threads include the following:
  1. The outer brow for zygomatic arch ptosis.
  2. The cheeks for buccal and infraorbital ptosis.
  3. The jaw line for mental ptosis such as jowls.
  4. The neck for submental ptosis [20].


Complications

Despite being rare, they can include allergic reactions, haematoma, seroma, infection. Sometimes thread ends may poke through the skin and may possibly result in an infection. Dislodging of the thread may occur resulting in a lopsided or crooked result (asymmetry). Failure of threads can occur with overbending or snapping of the delicate barbs causing them to lose their grip on the tissues [19].


  Botox Top


Introduction

Botulinum toxin type A was first introduced to the market in the early 1990s by Jean and Alastair Carruthers. It was a novel concept. Over the years, the use of B toxin has largely increased and become more popular. It is used for facial rejuvenation, facial paralysis, dystopia and spasticity [21].

Discovery and development

The bacterium Clostridium botulinum was first identified as a causative agent in food poisoning more than 110 years ago. In the two decades that followed, it was discovered that there were different strains of C. botulinum and that they produced serologically distinct types of botulinum toxin identified as A, B C, D, E, F and G. A crude form of botulinum toxin type A was isolated in 1920s and begun to purifying in 1944, and pure botulinum toxin type A was isolated in crystalline form in 1946. Botox is available in two common types: botox A, which is available commercially in two distinct formulations, Botox Cosmetic and Dysport, and botox B, which is commercially known as Myoblock [22].

Aesthetic considerations

When planning to use botulinum toxin for facial rejuvenation, the mainstay of treatment will start by understanding the patient concerns as well as his desires, analyse the facial units and emphasize on facial shaping and enhancement. The muscles of facial expression do not act in isolation but have complex anatomic and physiologic interactions. For example, treatment of glabellar lines, ‘crow’s feet’ or forehead lines can alter eyebrow shape and position, which are considered central to aesthetic evaluations of the upper face. Therefore, potential effects on eyebrow shape and position should be considered in advance for all treatments in the upper face [21].


  Laser Top


Introduction

LASER is an acronym for light amplification by the stimulated emission of radiation. Many of the cosmetic procedures of skin lasers are extremely precise and noninvasive. They work by removing only unwanted skin components without altering the overall structure of the skin. Laser resurfacing alters the skin’s structure. It replaces aged, wrinkled facial skin with a new layer of regenerated skin. The real benefit of this treatment results from the skin’s ability to renew itself. Under the right conditions, the entire face can be resurfaced and will heal without scarring [23].

Lasers target specific tissues according to the depth of the lesion or tissue targeted in the treatment. This depends on the absorptive and scattering characteristics of these tissues primarily. Each targeted tissue has its own chromophore, and this could be water, haemoglobin or melanin. Because each of these has its own absorption profile, the laser wavelength will only affect that chromophore. Scattering is, however, inversely proportional to the laser wavelength. Selective photothermolysis is a technique that uses selective absorption of tiny radiation pulses that generate and keep heat within a selected pigmented target, so the targeted tissues can be destroyed without damaging surrounding structures [24].

Applications

Laser can be done either under general anaesthesia or nerve block or field block. Safety measures as per the institute guidelines should be applied in every single case to avoid any damage to the patient, staff or the facility, such as appropriate eye protection and covering shiny reflective objects and display signs. Deeply scarred or lined areas need more aggressive treatment, and they require three or four passes with the laser, cleansing the debris between passes. These aggressively treated areas should be feathered into the surrounding tissue by gradually reducing the energy per pulse or making fewer and less confluent pulses, as the margin of the treatment area is approached [25].

Nonablative, fractionated lasers are used generally for mild-to-moderate skin lesions and where moderate-to-mild changes are needed, but it also takes time and multiple sessions. These lasers are used to improve texture, mild-to-moderate wrinkles and hyperpigmentation secondary to aging or sun damage and for acne scarring. Topical pain control is usually needed to control the pain [1],[25] ([Table 4]).
Table 4 Common types of lasers: characteristics and indications

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Post-treatment care

After the debris resulting from the last pass is cleansed, the skin can be cooled with an ice pack, and then covered with Vaseline or Polymyxin/Bacitracin ointment. hydrocolloid dressing may be needed. The day following the treatment, the patient can shower and cleanse the face with a mild cleanser and cotton balls. Sunscreen for several months is a must, and the hydroquinone cream should be restarted in a pigmented patient. A good occlusive dressing for skin resurfacing is the use of silicone sheets, which facilitate rapid re-epithelialization of treated areas [26].

Complications

The most frequent complications are pigmentary disturbances, erythema, infection and scarring. These can be minimized with patient’s education and by using optimal laser settings, applying occlusive dressing and anticipating the possible risks and complication [27].


  Conclusion Top


Noninvasive facial rejuvenation has become increasingly popular over the past decade. Some methods have gained popularity and proven to have relatively long-term outcomes with minimal adverse effects. Others, however, failed to prove so. It is the sole responsibility of the physician to make the safest and most effective tool to meet the justifiable patient requirements. A combination of realistic patient and experienced surgeon only can offer the right treatment formulas.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Fitzpatrick RE. Resurfacing procedures; how do you choose? Arch Dermatol 2000; 136:783-784.  Back to cited text no. 3
    
4.
Wu WTL. Facial rejuvenation without facelifts − personal strategies. Hong Kong: Regional Conference in Dermotological Laser and Facial Cosmetic Surgery; 2002. pp. 13-15.  Back to cited text no. 4
    
5.
Kanchwala SK, Holloway L, Bucky LP. Reliable soft tissue augmentation: a clinical comparison of injectable soft-tissue fillers for facialvolume augmentation. Ann Plast Surg 2005; 55:30-35.  Back to cited text no. 5
    
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Costa CR, Kordestani R, Small KH, Rohrich RJ. Advances and refinement in hyaluronic acid facial fillers. Plast Reconstr Surg 2016; 138:233.  Back to cited text no. 6
    
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Eppley B, Dadvand B. Injectable soft-tissue fillers: clinical overview. Plast Reconstr Surg 2006; 118:98.  Back to cited text no. 7
    
8.
Werschler PW. Treating the aging face: a multidisciplinary approach with calcium hydroxylapatite and other fillers, part 1. J Cosmet Dermatol 2007; 20:739-742.  Back to cited text no. 8
    
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Rao J, Chi GC, Goldman MP. Clinical comparison between two hyaluronic acid-derived fillers in the treatment of nasolabial folds: hylaform versus restylane. Dermatol Surg 2005; 31:1587-1590.  Back to cited text no. 10
    
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Schütz P, Ibrahim HH, Hussain SS, Ali TS, El-Bassuoni K, Thomas J. Infected facial tissue fillers: case series and review of the literature. J Oral Maxillofac Surg 2012; 70:2403-2412.  Back to cited text no. 11
    
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Rohrich RJ, Herbig KS. Minimizing pain, maximizing comfort: a new technique for facial filler injections. Plast Reconstr Surg 2009; 124:1328-1329.  Back to cited text no. 12
    
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Johnson CL, Mark AD, Malcolm ZR. Mesotherapy, microneedling, and chemical peels. Clin Plast Surg 2016; 43:583-595.  Back to cited text no. 13
    
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Al-Waiz MM, Al-Sharqi AI. Medium-depth chemical peels in the treatment of acne scars in dark-skinned individuals. Dermatol Surg 2002; 28:383-387.  Back to cited text no. 15
    
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Jennifer L. Superficial chemical peeling: minimal effort, maximal results. In: Cosmetic dermatology. 9(4). Available at: https://www.the-dermatologist.com/content/superficial-chemical-peeling-minimal-effort-maximum-results-jennifer-linder-md. Accessed: 15 January 2018.  Back to cited text no. 17
    
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Berson DS, Cohen JL, Rendon MI et al. Clinical role and application of superficial chemical peels in today’s practice. J Drugs Dermatol 2009; 8:803-811.  Back to cited text no. 18
    
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Wu WTL. Facial rejuvenation using APTOS and WAPTOS (the WOFFLES LIFT): a novel approach. Sydney, NSW: 13th International Congress of the International Confederation of Plastic and Reconstructive Surgery(IPRAS); 2003. pp. 10-14.  Back to cited text no. 19
    
20.
Ali YH. Two years’ outcome of thread lifting with absorbable barbed PDO threads: Innovative score for objective and subjective assessment. J Cosmet Laser Therapy 2018; 20:41-49. DOI: 10.1080/14764172.2017.1368562  Back to cited text no. 20
    
21.
Carruthers JA, Lowe NJ, Menter MA et al. A multicentre, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines. J Am Acad Dermatol 2002; 46:840-849.  Back to cited text no. 21
    
22.
Schantz EJ, Johnson EA. Botulinum toxin: the story of its development for the treatment of human disease. Perspect Biol Med 1997; 40:317-327.  Back to cited text no. 22
    
23.
Greg JG. Facial rejuvenation lasers and lights. 1st ed. Heidelberg, Germany: Marion Philipp; 2007. pp. 1-44.  Back to cited text no. 23
    
24.
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25.
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26.
Meaike JD, Agrawal N, Chang D et al. Noninvasive facial rejuvenation. Part 3: physician-directed-lasers, chemical peels, and other noninvasive modalities. Semin Plast Surg 2016; 30:143-150.  Back to cited text no. 26
    
27.
Alster TS, Lupton JR. Prevention and treatment of side effects and complications of cutanous laser resurfacing. Plast Reconstr Surg 2002; 109:u.  Back to cited text no. 27
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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  In this article
   Abstract
  Introduction
  Fillers
  Chemical peel
  Thread
  Botox
  Laser
  Conclusion
   References
   Article Tables

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