Minimally Invasive Anti-aging Procedures

Minimally Invasive Anti-aging Procedures

 

 

Serion Dermatologic & Asthetic Surgery Center, Whang Kyu Kwang, MD, PhD, Seoul

 Rejuvenation of aging skin can be summarized in 4 Rs; Relax (relaxing the muscles to reduce wrinkles), Refill (using fillers to prop up sunken cheeks or deep nasolabial folds), Reposition (pulling the sagging skin with threads or through surgery to restore youthful position of the tissues), and Resurface (using resurfacing methods including laser to remove wrinkles, age spots or blemishes caused by sunlight and natural aging process).

 

1. Minimally invasive anti-aging procedures

 

Autologous fat grafting
 Autologous fat grafting was innovated by Dr. Donofrio, a professor of dermatology at Yale School of Medicine. Dr. Donofrio proposed a theory where the anatomical changes in the aging skin are modified to resemble the anatomical structure of a younger skin. In this technique. Autologous fat is injected into the depressed and wrinkled areas around the eyes, forehead, cheeks, etc. to bring back the tighter skin with restored volume. This technique is a more fundamental approach of anti-aging procedure.
 This procedure kills two birds with one stone. As fat is harvested from areas of excessive fat deposition such as the lower abdomen, lateral thigh, and hips, it also achieves local removal of unnecessary fat. The primary purpose is the restoration of 5-10 years young looking appearance in areas of volume loss, skin atrophy and aging in the forehead, cheek, deep wrinkles and hand, etc.  Autologous fat grafting is also effective in scleroderma or skin atrophy due to sequelae of graft, breast enhancement and correction of deep nasolabial folds, etc.
 Once harvested, the fat can be cryopreserved for several subsequent injections with an interval of 2-3 months. Fat can be reabsorbed into the body, however, more refined techniques such as FAMI technique (where fat droplets are injected in muscle for better survival), harvest and transplantation of stem cell adipocytes, and combination with PRP, etc. can improve the survival of transplanted fat for potentially permanent correction. The filler injection I have discussed in the previous article may also be used as a simpler substitute of autologous fat transplantation.

 

Thread lift
 In a thread lift procedure, a thread with cogs is used to pull up the sagging skin tissues. This procedure has many fetching names including ‘magic lift’, ‘happy lift’ or ‘miracle lift.’ Surgical threads should be safe enough to be used in the heart surgery. By pulling the normal soft tissues together, this lift can reposition the soft tissues and provide a volumed facial contour for youthful appearance without using synthetic materials. Especially, the nasojugal grooves are pulled upward to smooth the cheeks. The neck wrinkles, nasolabial folds, and sagging eyebrows can also be effectively corrected. As a minor plastic surgery procedure, thread can be used to refine the shape of the nose tip. Major drawbacks of this procedure are that the thread can be undone over time and that the thread permanently remains in the skin. Side effects may include granuloma formation, bruising, edema, pain, and muscle or skin stiffness.
Lately, cogged  or screwing PDO (polydioxanone), an absorbable suture material, is available but the lifting effect may be short-lived. Indications of thread lift are jaw-line tightening, sagging cheeks, and neck lines, etc. It is also used in square jaw reduction and contouring of the calf muscle, sagging breast and buttocks.

ePTFE lift
A thin Gore-Tex strip is inserted through a 1.5cm post-auricular incision into the cheek. At least a month after the initial insertion when adhesion of Gore-Tex strip and skin occur, an incision at the same site is made to elevate the tissues to the desired location and fix them firmly onto the post-auricular fascia. The advantage of this procedure is that it can be repeated years later when the skin is loosened again and can be performed to correct the sagging jowls. Caution should be taken to avoid nerve damage during dissection for insertion.

 

Accu-lift, Micro fat transfer
 This lift procedure is performed using 1444nm wavelength Accusculpt lipolytic laser. Based on the principle of selective photothermal damage from laser generated by less than 1mm thick optic fibers, this procedure delivers heat to the dermis in the desired direction to induce tightening and lifting effect. Especially, if used on fatty, aged tissues such as sagging cheeks, nasolabial folds and chin, combined effects of fat reduction and lifting can be achieved. Parameters should be set carefully not to deliver excessive heat and tumescent local anesthesia is carried out.
 In the lower eyelid fat bulging as a aging process, Accu-lift can be used to dissolve, micronize and transfer fatty tissues to correct the depressed area under the fat bulging. A small puncture is created using a needle at junction of the medial canthus and under-eye wrinkle. The Accusculpt laser fibers are inserted through the puncture to emulsify the fat under the eyes, then the arcuate ligament (orbitomalar ligament) is separated. The micronized fat is pressed and moved  with a finger to the sunken area and the dermis is tightened by heat. This procedure can be applied to the nasolabial folds and wrinkles around the mouth (Figure 1, before and after micro fat transfer of lower eyelid fat bulging).

 

 

 

Figure 1. before and after micro fat transfer of lower eyelid fat bulging.

 

 

Chemical peeling
 Chemical peeling entails a long downtime following the procedure but is considered as a comprehensive solution to various signs of aging due to its excellent effect. Phenol is mainly used as the deep peeling agent, however, problems related to authorization and side effects limit its application and require caution. When used in high concentrations, local or partial peeling is advised.  Light chemical peeling with salicylic acid or Jessner solution can be used without serious complication.

 

Surgical facelift, MACS lift
 This procedure can be applied to the most severe form of facial skin aging; drooping cheeks without elasticity, and fatty tissues collecting around the nasolabial folds or mouth. Surgical facelift, mini or MACS (Minimal Access Cranial Suspension) face lift are suitable in elderly patients in their 60s to 70s who do not expect improvement from the above mentioned procedures.
 The drooping skin of the upper face area can be lifted through cranial incision or endoscopic surgery. Patients often complain of mid to lower face sagging. Various ligaments that work between the skin and bone are distended causing deepening of the marionette lines and a dent under the zygomatic arch. The incision is made along the hairline and periauricular areas of the temporal head. The excess skin is resected and the fascia is elevated. 
 MACS lift uses purse string sutures, and may lead to nerve damage and masking face if performed aggressively, and therefore should be cautious. In case of sagging jawlines, the platysma muscle is also elevated with the procedure. To remove the nasojugal fat, Acculift lipolysis is combined with this procedure. If MACS lift alone is insufficient to achieve an overall rejuvenation effect, fractional laser is combined to enhance the effect.