The largest area of growth in the cosmetic industry is in the minimally invasive world. Appropriately applied, the field offers diverse choices to treat early facial aging effects. Applied incorrectly, dissatisfied consumers and significant complications can occur. The fact that a procedure doesn’t involve a knife or anesthesia doesn’t inherently make it safe or appropriate.
Treatments that can be effective at a certain age can be ineffective or produce a poor result at a later age since the face has aged past the point where the treatment can be useful. Certain face types respond better than others, regardless of age.
Just because a modality or treatment is new doesn’t make it better. Since the most sophisticated procedures are often accomplished expertly only by a few, and obvious outcomes are visible and scare the consumer, the demand for newer minimally invasive procedures is powerful. Unfortunately, none of them can truly reverse gravity’s effects and are being developed not because they are better but as shortcuts to allow a wide variety of health care providers to offer anti-aging treatments.
Ironically, many are called minimally invasive as they either burn the soft tissue of the face or introduce toxins and foreign substances into our bodies. There is no long-term data on the issues or complications in this whole field.
Understanding facial aging and how these treatments work will allow the correct applications of these procedures.
By understanding facial aging, treatment choices, and their positive or negative, effects can be predicted.
The goal for the majority of people seeking facial rejuvenation is to restore or maintain their past appearance without evidence of a procedure or intervention. Most people like their past appearance and would agree with the statement, “If it looks like I had it done, then I don’t want it.” Looking better without looking different.
Research has shown that when we look at past pictures of ourselves, our appearance not only has a “look” but it has anatomy, or structure, that creates that look. A group of 35 years old’s may have their individual “looks,” but they all have the same structure. (The research in the causes and patterns of facial aging was published by Neil A. Gordon, MD, FACS)
Understanding Facial Aging
The anatomy of youth can be understood using some basic analogies. Your ‘look” is created by your “frame,” the same way the frame of a couch creates the “look” of a couch. The research I have conducted and published shows that your “frame” doesn’t change (until extremes of aging) and explains why using the proper techniques, at the right time, can duplicate your past appearance the same way reupholstering an older couch can restore the couch as new since the frame did not change.
Our frame is fitted with a “garment.” Imagine a quilted comforter that fits our frame like a glove when we are a mature yet youthful adult at our best. So, our 35-year-old appearance is essentially our frame that creates our look, our attractiveness, our uniqueness, and our individuality and is fitted perfectly by a thick garment, allowing everyone to see our unique frame.
While our frame stays similar most of the time, the garment that originally fits it like a glove does not. If we look at the garment separately, it has the same biomechanical behavior as pizza dough. If pizza dough is held in the air, over time, it will predictably stretch and descend toward the ground. Stretched out pizza dough and an aged face have similar principles.
So youth is like wearing a perfectly fitted pair of pants, the garment, on our lower body, our frame. Aging is essentially the pants getting bigger and bigger as time progresses.
WHY DO PEOPLE AGE DIFFERENTLY
The reason people age differently, with most having similar aging changes at similar ages, can be understood with the pizza dough analogy. If we hold different types of pizza dough in the air, white flour in one hand and multi-grain in the other, each will stretch out at different rates. The same concept is occurring, gravity is pulling on something elastic, but the rates are dependent on the consistency of the pizza dough.
We all have a genetic profile that makes our soft tissue, the “garment,” either resistant or susceptible to gravity’s effects. This is independent of our attractiveness, which is based on our frame. This is why certain attractive people from our youth may not age well, while certain average appearing people can make good looking 50 year-olds. Interestingly, genetics play a much more significant role than behavior and explains why people with compliant, stretchy faces may see aging changes at younger ages despite taking great care of themselves.
This is why we don’t define treatments based solely on your age. If a person has early changes because they genetically have a stretchy, compliant face, then they should be treated based on their face, not just their age. Whereas the opposite can also be true. By defining treatment options by the stage of aging, we will predictably reproduce someone’s past appearance. If we ignore these facts, even the most simple, innocuous treatment can create an unnatural or unacceptable result because it is not matched to the person’s face and stage of aging.
THE ILLUSION OF VOLUME LOSS
The most promoted cause of facial aging in the last decade has been the concept of volume loss. By defining the appearance of facial aging as due to volume or fat loss, it had legitimized the treatment modalities of facial filler injections and fat injections as the most important treatment. But is this correct? What scientific evidence supports this concept?
Certain faces do appear to be deflated with age, and areas of the face can appear to have hollows. Whereas we also see that the use of facial filler alone can create some of the most unnatural results in all of aesthetic medicine.
How can we make sense of this?
Based on scientific research I have done on the causes of facial aging, I published a treatise called “The Illusion of Volume Loss.”
This paper became so well recognized that I have been invited to present these concepts on five different continents.
The reason volume loss, specifically facial fat loss, is an illusion can be explained and supported by my research. As stated above, youth is not just a look but an anatomy. Our frame creates our look and unique identity, and it is covered by a garment that has a thickness of a quilted comforter. In youth, the garment fits our frame like a glove or like a perfectly fitted pair of pants fits our lower body (our frame). As we age, the frame stays relatively the same, but the garment behaves like pizza dough and is affected by gravity’s force, stretching out in an inferior direction.
Viewed a different way, imagine the face is a one-liter container of water. If we pour the water into a two-liter container, the water will fill the larger container only halfway. If we don’t have the original one-liter container to compare, it appears that the container is missing volume, but what occurred is the container became twice as large, creating an illusion of volume loss.
How Do Facelifts Differ: Understanding The Deep-Plane Facelift
Further proof of this can be accomplished by just feeling your face. If we feel an older face, there is a lot of redundancy, or extra soft tissue, especially in our neck. If volume loss were the cause of facial aging, there would be no extra soft tissue. We can validate this further as volume loss does exist in one group of unfortunate people, AIDS patients; they don’t look old; they look sick.
Finally, there has never been a scientific study that shows facial fat is lost with aging, but there have been recent studies that not only show that facial fat is not lost but gained in the lower aspects of the face, consistent with the appearance of soft tissue redundancy. These studies were accomplished and published by Neil A Gordon, MD, FACS.
The use of facial fillers to treat facial aging has become one of the most popular treatments. When used appropriately, facial fillers can camouflage certain aspects of early aging. When used inappropriately, an overt, unnatural appearance is common. In addition to understanding which filler types are reversible and which are not, it is also important to understand the risks associated with these procedures.
By referring back to the causes of aging, we can predict when facial fillers are appropriate options and when they are not. Since we have shown youth is analogous to wearing a pair of pants that fit our frame, and aging is the pants keep on getting larger every year, then adding material to our pants make it fit is the way facial fillers try to work. But if the pants are too large, this will only create the same look as a heavier person.
The best way to understand is to compare buying shoes. Although it is best to have shoes that fit our size; if a shoe is ½ size too large we can make them fit by using a cushion, or filler, to camouflage the size difference. But if the shoe was only available in a size that was 4 sizes too large, this approach would never work.
This is how we can predict. When we look at ourselves in the mirror, if we see lower midface widening, jowls, and neck laxity, then using filler would be the same as filling up a large, baggy pair of pants, instead of using a tailor. This is why filler used inappropriately creates a heavy appearance; you are creating the anatomy of a fat person.
An important potential complication is an intravascular injection, where material enters an artery; this can be devastating with tissue loss and possible blindness. This is why an experienced injector should only be utilized.
Since facial fillers are relatively new, we do not have long-term studies to define potential issues. One of the issues being seen from facial filler injections is the creation of festoons, bags under the eyes, which are not treatable by surgery or other means. Lastly, filler-made hyaluronic acid are reversible fillers.
Fat injections are unpredictable in process, recovery and result with poor solutions when dissatisfied with the outcome.
There is much myth in creating the appeal of fat injections. Although there are stem cells in fat, they are at a minimum in the fat harvest, and they do not behave as a stem cell treatment. Most importantly, since aging is a stretched-out face, fat injections are no different than adding filler and should be treated under the same circumstances. Again, it is just creating the anatomy of a heavy person.
This is why stem cell treatments could never reverse significant aging effects. Stem cells treat disease or injuries. Facial aging is physical, just stretched out face and only treatment of the actual cause can create the most natural outcome.
Fat has a highly unpredictable survival and recovery process. Fat can feel unnatural in the face and change over time. Fat can be difficult to adjust if uneven survival occurs.
Since one of the most important issues for prospective patients is a predictable recovery process, the lack of these features is important to consider.
RELAXANTS – BOTOX
As the first neuromodulator, Botox, the brand, is one of many different neurotoxins available on the cosmetic market. As a toxin from bacteria, it causes temporary muscle paralysis wherever injected.
Similar to facial filler injections, when used appropriately, neurotoxins can camouflage certain aspects of early aging. When used inappropriately, an overt, unnatural, and stereotypical appearance is common.
If we refer to science, the soft tissue of the face is elastic and stretches out over time. It will appear different in different regions of the face due to the function of that region. In the upper face, the important function is our vision. Our brain will not let a stretched-out forehead fall over our eyes, so there is extensive musculature that supports the entire region and allows unique emotional expression.
This is why we often don’t notice gravity or sagging, changes in our foreheads, unlike our neck, because the muscles will work and support our forehead without our conscious input. The loose forehead is camouflaged but at the expense of forehead wrinkles and furrows.
So, by paralyzing the specific muscles in the forehead region the furrows or wrinkles will flatten out, the result will depend upon how stretched out the forehead is. Since the muscles hold the forehead and eyebrows in place, in early-stage aging 45-50 year-olds, paralysis will usually not harm the appearance of the eyes or produce the “Botox look.”
When used inappropriately, the neurotoxin is paralyzing forehead muscles needed to support a loose, stretched-out forehead. Since the furrows are often in the glabella region, between your eyebrows, the glabella area droops over the nose and eyes while the side muscles need to overcompensate, causing an unnatural, high arch to the side of the eyebrows. The combination is the stereotypical “Botox look;” in which the people look like “Spock from Star Trek,” not their former selves. Ironically, when used on people with greater aging changes, regardless of age, neurotoxins will make the eyes look worse by causing the formally supported forehead to fall over the eyes and produce a masculine, angry appearance.
This is why neurotoxin forehead treatment cannot replace forehead procedures in the post-55-year-old segment. The furrows are there for a reason, and paralyzing the necessary support muscles will sacrifice the appearance of our best feature, our eyes, to flatten out the forehead.
One area of concern is toxins used in young people. Neurotoxins do not make you better looking; they temporarily reverse one specific aspect of early facial aging if you have it. When used in young patients, it can often make them appear older.
MACHINES/ ENERGY DEVICES
One of the newest modalities and areas of change is in energy devices. Ulthera, Profound, and Exillis are some examples. The cause of the appearance of the aged face is due to gravity’s effects in stretching out the soft tissue of the face. Whether it is a drooping neck, nasolabial folds, or a furrowed forehead, the aged appearance is due to excess facial soft tissue. Energy devices use different forms of energy, such as ultrasound or thermal, to heat up and create burn-like injuries to shrink soft tissue.
At best, these machines can produce a slight, temporary shrinkage to the superficial aspects of the face. The problem is that all the layers of the face are affected by gravity, so superficial tightening cannot treat the majority of the tissue creating the aged appearance. Additionally, much of the result is due to temporary injury and is short-lived, automatically requiring repeated treatments.
The best way to envision how these treatments work and when to use them is to recall that youth is wearing a garment, a pair of pants that fit our frame. Aging is the frame stays similar, but the pants are elastic and stretch out like pizza dough. On people who respond, and not all patients do, it will affect similar to placing your pants in the dryer. A small amount of shrinkage for a small amount of time.
The problem occurs when a significantly stretched out face or a thicker face, regardless of age, utilizes these treatments. No different from placing a pair of jeans four sizes too big in the dryer, a small improvement doesn’t make the jeans wearable. By using these machines at this stage, if you have neck and/or lower face changes, the minimal temporary change rarely has any real effect and is associated with a high level of dissatisfaction.
Most important, although these procedures may not use knives, they are not necessarily minimally invasive. Essentially burning tissue below the superficial skin, energy treatments are not benign and can have a similar recovery to surgery. Fat loss, loss of nutrient blood vessels, and scarring are known side effects and can make the face look worse over longer periods, as the tissue treated behaves like a smoker’s face. This is especially true when repeated energy treatments are performed.
As I have recently published complications in plastic surgery, the largest change in complication type has been from energy-based machines.