The Problem

The aging process of the skin is quite natural and the soft full features of youth are eventually replaced by wrinkles, splotches of discoloration and leathery texture. While aging affects all the areas of body, it is mainly the face which attracts most attention. Wrinkles and skin sagging and other aging related skin changes not only happen because of loss of soft tissues and fat but also there is appreciable loss of bone volume with age. Various external factors do play their role and most important being the photo aging effect.

For a treating physician it is important to understand pathology of these changes before deciding a plan of treatment. Various facial changes which occur with aging can be grouped in three main categories.

1. Gravitational descent or Ptosis of facial structures

2. Loss of volume or deflation

3. Surface Skin changes.

Changes because of gravity lead to ptosis of the facial structures particularly the malar pad of fat which moves down from its original position on the cheek bones. Appearance of jowls and loss of bony definition of mandible is also the effect of the gravity. As the skin is firmly attached down to deeper structures in certain areas of face like nasolabial folds, these lines appear deeper because of gravitational descent of facial structures above them making them look more prominent. Gravity also has profound effect in the eyebrow which becomes droopy with age.

Loss of volume or deflation is also a peculiar phenomenon which happens with aging. Loss of facial fat leads to shrunken look on the face and the skin which is taught in younger age because of facial fat becomes loose. Lower lid - cheek junction appears more defined because of appearance of nasojugal grooves and the smooth transition of lid into cheek which is hallmark of youth is lost. Loss of fat in temple and mid cheek is responsible for their hollow appearance.

Skin changes with aging are mainly because of loss of collagen content in the skin with age. Skin appears thin and wrinkles develop because of loss of collagen layers. Because of constant UV exposure skin gets various pigmentation problems and other signs of solar damages like keratosis.

The solution

Traditional face lifts was the only treatment available in the past to address this multifactor problem of facial aging. Face lift is limited in its approach as it only addresses the problem of loose skin which is pulled in one direction with removal of extra skin. This procedure leaves much to be desired in term of improvement of skin quality loss of volume and correction of the deeper facial structures like malar pad of fat. This led to rethinking over whole tissue of treatment of facial aging. With advent of multiple techniques this problem is targeted using multiple modalities.

Our Approach

In our practice every face has its own treatment protocol. Our treatment protocol is an amalgamation of various nonsurgical and surgical methods which leads to satisfactory outcome.

When approaching a patient for facial rejuvenation, a detailed physical and psychological evaluation is needed. In the initial macro analysis, which should include patient’s perspective of what is wrong with his/her face, the patient's face should be assessed as a single unit and the dominant cosmetic problems that contribute to the effective impression of age, fatigue, or anger should be assessed. In further second or microanalysis the dominant areas should be evaluated for their constituent parts. A detailed treatment plan is designed to address individual problems.

The various modalities which are used by us for facial rejuvenation are:

• Miniface lift
• Thread lift
• Diamond scalpel
• Fat Injections
• Fillers
• Botox
• IPL/ Laser Resurfacing
• Radiofrequency
• Mesotherapy
• Chemical peels

Thread lift or feather lift is a procedure for correcting problem of gravitational ptosis of facial structures. Thread lift is suture suspension face lift which can be used alone or in combination with miniface lift.

The problem of deflation or loss of volume in the face is very well addressed by using filler injections for various folds and depressions and fat transfer for larger areas of generalized volume loss. Base ingredient of various filler is cross linked Hyaluronic acid. Various other addition to Hyaluronic acid have been used for making these fillers permanent or semi permanent but because of associated problems they have not been very popular .

Various skin changes associated with aging are addressed by using various peels and mesotherapy. There are non ablative peels like vit c, Kojic, and phytic acid. There are medium depth peels like TCA and Glycolic acid and deep peels like phenol and Bakers. In Fitzpatrick type IV and V skin, medium and deep peels should be used very carefully since they can lead to problem of hypo pigmentation or post inflammatory hyper pigmentation.

Mesotherapy: was discovered in 1952 by Dr. Pistor in France but the big boom came with successful treatment of cellulites with mesotherapy in 1987. Currently the therapy is used for general facial rejuvenation, facial pigmentation and small area of fat deposits over cheeks, jowls and double chins. Various medications which are used in mesotherapy are noncross linked Hyaluronic acid, Multivitamins, Kojic acid, phosphedylcholine etc.

Botulinum Toxin: is mainly indicated for forehead and frown lines and for treating crow’s feet. Advanced indications include massetric hypertrophy, bunny lines etc.

Diamond Scalped: is a tool used for subcesion of deep wrinkles which can be simultaneously filled with fillers.

IPL and other facial rejuvenation lasers are now available for various indications like general facial tightening, pigmented lesions, rosacea etc and make an important tool in the armamentarium of Facial Aesthetic surgeon.

The obvious advantages of these procedures are, they are less invasive with significantly lower down time. They are quick procedures which can be performed under local anesthesia on day care basis.

After Care

Good skin care can delay many signs of aging. To reverse the signs of aging skin our approach is to stimulate skin repair by accomplishing the following very specific, yet critical criteria:

• Encouraging collagen production
• Increasing the skin's moisture content
• Improving the skin's ability to protect itself
• Neutralizing skin damaging free radicals
• Encouraging new skin cell growth

Teaching basic skin care, protection from sunlight, need of regular physical activities, good balanced diet with adequate hydration, leading a stress free life go a long way in treating age related problems and any skin treatment plan is incomplete without them.

In nutshell facial rejuvenation should have a multimodality approach, which should include skin care and skin pampering, repositioning of tissues or bringing out structural changes as planned after careful physical and psychological evaluation of the patient.