Introduction The philosophy behind an invasive or a noninvasive facial retightening treatment is to rejuvenate the and/or reverse the aging clock. This backward shift must be accomplished in such a way that when the clock runs thereafter, the aging process remains uniform for the entire face.

There is a lot of confusion when using the word “facelift”. A facelift or face-lifting is and has always been a surgically invasive procedure. However, as used today, the word “facelift” does not only refer to a surgical invasive technique, but also to some non- surgical, minimally-invasive or non- invasive procedures, depending on the epidermis penetration. Nevertheless, the goal is always the same i.e. the repositioning of the facial tissues and the rejuvenation of the face, an attempt to make the person look fresher, younger and more harmonious. Therefore, it seems necessary to define very precisely what a facelift is, what an invasive technique is, and what we refer to when talking about “minimally-invasive or non-invasive facial lifts”.1

Minimally-invasive and Non-invasive Facial Rejuvenation Techniques (Lifts) by Dr Michel E. Pfulg

56 AJAM 2015 Official Journal of the American Academy of Definition among our patients. In the years 1970-2000, multiple Aging is a global process that affects all layers of the techniques were described.3 Nowadays, a facelift can skin. It is a normal process that might be different in each be cervico-facial, addressing the lower two-thirds of the patient, is genetically determined (chronoaging), and face. It can also be total when a brow lift is included has to be accepted by everyone as something natural. in the dissection. A mid-face lift addresses mainly the With aging, the skin suffers dermal disorganization, middle third of the face and can be sub-periosteal atrophy of its components, and loss of the dermo- or sub-cutaneous. A mini-lift refers to a short epidermal papillae making the tissue weaker and less technique; it can be a Soft-lift, an S-lift, or a MACS-lift. firm. A facelift addresses the ptosis and sagginess of the An endoscopic facelift addresses the upper and/or facial tissues. It has no effect on the quality of the facial mid-face. All these techniques are surgical and each one skin itself.2 Therefore, a facelift is not a treatment for has its own indications and drawbacks. We will let the wrinkles, age spots or creases which are better treated reader search for details of each technique in with rejuvenation procedures and/or skincare products. the literature. Non-invasive or minimally-invasive treatments have little influence on the ptosis of the tissues, but their mild Minimally-invasive Facial Rejuvenation retightening effects are probably the reason why the Procedures term “facial lift” is now also used for such non-invasive A rejuvenation procedure is minimally-invasive when it techniques. Marketing issues are another reason why penetrates the epidermis, whether with a scalpel or such a word – facelift – is now used for such non- a needle. aggressive procedures. Depending on the penetration or non-penetration of the epidermis, we use the term An optimal rejuvenation program should try to correct “minimally-invasive” or “non-invasive”. all the signs of aging to “bring the patients back to their real age…or even five to ten years back” but without Before delving into the different minimally-invasive and changing their personal and differential “characteristics”. non-invasive techniques used today to address the aging A non-surgical, minimally-invasive technique is much less skin of the face, we will try to define exactly which term traumatic than a , and tends to have a mild should be used for each one of the techniques applied. lifting effect of the facial tissues. However, the long-term results cannot be compared with those of a surgical lift. Facelifts Those techniques address young patients with discreet The term “facelift”, in my opinion, should be reserved for laxity, borderline patients who do not want or cannot be the invasive surgical facial lifting treatments, which are submitted to an invasive surgical facelift. always aggressive and address the ptosis of the face. Face-lifting, or rhytidectomy, was first performed in the Rejuvenation treatments with fillers early 1900s and today involves skin undermining with or Fillers are used in the face to address atrophy, dryness, without smas undermining, with or without sub-periosteal loss of volume, wrinkles and depressions. Their filling undermining, plus skin excision. A revolution occurred effect gives the face a fresher and more harmonious in the 1970s when Skoog described the dissection of appearance. the face in continuity with the platysma in the neck. Since then, the procedure has become very popular Absorbable materials (temporary) : Collagen is a natural protein that gives the tissue elasticity. The effects of collagen fillers generally last for three to four months. Collagen can be extracted from human, porcine or bovine material.4

Hyaluronic acid: Hyaluronic acid is a polysaccharide present in skin and cartilage, a natural substance that absorbs water and thus, helps maintain the “hydration” level of the skin. This further helps maintain the structure of the skin. This acid is sourced from bacteria or rooster combs (avian), and can be modified with cross linking technique to give the molecule a longer lasting effect. Before After The effects of this material last approximately six to Results at one year after surgical soft-lifting 12 months.4

Official Journal of the American Academy of Aesthetic Medicine 2015 AJAM 57 Calcium hydroxyapatite: Calcium hydroxyapatite is a mineral that is found in human teeth and . The calcium hydroxyapatite particles are suspended in a gel which can be injected to restore lost volume, correct deep lines or wrinkles, and retighten the skin. The effects of this material last approximately 18 months.4

Poly-L-lactic acid (PLLA): PLLA is a biodegradable, biocompatible “fibrosing agent”. That means that once injected, it acts by stimulating the production of collagen by fibroblasts. The effects may last up to two years.4 Before After Partially absorbable materials Before and after (brow and glabella) Lipofilling, also referred to as free fat transfer or fat grafting, is a procedure to fill up facial features with your own body fat instead of using a chemical filler or an implant. This is a highly efficient procedure as it is minimally-invasive and produces natural results. About 70% of the fat stays forever.5

Non-absorbable materials (permanent) Such materials are no longer in use because of their high rates of complications.

Rejuvenation treatments with threads Thread lifts are procedures that use resorbable, partially Before After resorbable or non-resorbable threads to lift facial tissues Before and after botulinum toxin upper-face + fillers (lips and through a puncture with a needle, or a small incision. cheekbones) These threads can be free floating, cogged or barbed threads, each one with different devices to stabilize the tissues.6 Manufacturers have invented various names to Facial rejuvenation with botulinum toxin market their products (e.g. Silhouette Lift, Aptos Lift, etc.). Botulinum toxin A is produced by Clostridium botulinum, a gram-positive anaerobic bacterium that reduces or even blocks the activity of the muscles. When used in the face, it decreases dynamic wrinkles as well as static ones. Too aggressive treatments might cause excessive muscle relaxation or palsy that turns the face inexpressive. Thus, a very low dose of this toxin will be selectively injected into target muscles (around the eyes for crow’s feet, on the forehead for forehead wrinkles and on the glabella for glabellar lines). It lasts for about four to six months.7 When rejuvenating the face, a combination of botulinum toxin with fillers is referred to by some as a “softlift”, Before After leading to confusion with the surgical Soft-Lifting Results at four years after a mini-invasive thread-lift invasive technique.

PRP (platelet-rich plasma) is created when blood from a vein is placed in a special centrifuge to concentrate the platelets (usually three to five times their normal concentration). The platelets are isolated together with growth factors from the patient’s blood. When these growth factors enter the face (injected by the physician), multi-potent stem cells become activated to grow new tissue.

58 AJAM 2015 Official Journal of the American Academy of Aesthetic Medicine A non-surgical, minimally-invasive technique is much less traumatic than a rhytidectomy, and tends to have a mild lifting effect of the facial tissues. However, the long-term results cannot be compared with those of a surgical lift. Those techniques address young patients with discreet laxity, borderline patients who do not want or cannot be submitted to an invasive surgical facelift.

Skin rejuvenation with microneedling Chemical peels Skin microneedling is a procedure that uses dozens or There are three types of peels: superficial, medium as many as 200 needles with a limit of penetration up to and deep. These have varying percentages of active 1.5mm, creating a channel or micro-wounds. These micro- ingredients and different pH levels. Superficial/light peels injuries stimulate collagen and elastin production in the are usually made from alpha hydroxy or beta hydroxy papillary dermis, and the neovascularization improves the acids, known as AHAs and BHAs, and include glycolic quality of the skin.8,9,10 acid, lactic acid and salicylic acid. Nowadays, it is also common to use fruit enzymes and acids from natural Vampire lift sources such as pumpkins, cranberries and pineapples. This term has been chosen for commercial interests. Medium depth peels derived from TCA (trichloroacetic However, it should be named “platelet self-transfusion acid) penetrate deeper into the skin and can be used to rejuvenation”. PRP (platelet-rich plasma) is created when treat sun damage, pigmentation and wrinkles. Deep peels blood from a vein is placed in a special centrifuge to usually use carbolic acid (phenol peels) or high strength concentrate the platelets (usually three to five times their TCA to penetrate the deeper layers, or dermal layers, of normal concentration). The platelets are isolated together the skin. with growth factors from the patient’s blood. When these growth factors enter the face (injected by the physician), Mechanical abrasion multi-potent stem cells become activated to grow new Dermabrasion is a type of surgical skin planing performed tissue. This new tissue includes new collagen, new fatty in a professional medical setting. Mechanical abrasion tissue (for smoothness), and new blood vessels (for a involves the controlled deeper abrasion of the upper healthy glow). to mid layers of the skin with any variety of strong abrasive devices including a wire brush, diamond wheel Non-invasive Facial Rejuvenation or fraise, sterilized sandpaper, salt crystals, or other Procedures mechanical means. A rejuvenation procedure is non-invasive when it does not penetrate the epidermis. Non-invasive facial procedures Lasers are tension inducers that fight against the laxity of the The use of ablative lasers for facial resurfacing began tissues of the face. Different options are available. The in the early 2000s. The lasers provide dermal heating non-invasive procedures can be ablative and non-ablative causing collagen denaturation and then remodeling.13 and are sometimes referred to as “scarless facelifts”. It heats the water of the skin up to a point where it is vaporized. It induces a controlled but superficial burn of Ablative procedures the entire skin surface. Ablative resurfacing is a skin procedure that causes injury and consequently, stimulates healing and the growth Non-fractionated lasers, less used nowadays, are more of new skin. These methods include chemical peeling, aggressive and act in the whole area, increasing the risk dermabrasion, and laser resurfacing.11,12 of infection and causing a longer recovery period.

Official Journal of the American Academy of Aesthetic Medicine 2015 AJAM 59 division of transient amplifying cells into the treatment column. After two to three days, the tops of the wounded areas are shed as microscopic epidermal and dermal necrotic debris (MENDs).19,23

Radiofrequency technology (RF) RF devices rely on the production of heat within the treated tissue.24,25 The energy delivered is directly proportional to the product of the square of the current, the impedance, and the time of application (Ohm’s law).26,27 These devices establish an electromagnetic field within the treated tissue, resulting in the movement of charged particles directed from one pole or electrode to the other. The tissue tightening elicited by RF devices has two phases, immediate (collagen contraction response to thermal injury) and delayed (collagen Fractionated lasers create pulses that are deeper than they remodeling – gradual skin tightening occurring over several are wide, creating “micro thermal zones” of heated tissue weeks to four to six months).28 Over the last ten years, several surrounded by intact epidermis and dermis to provide devices have been developed: monopolar RF and bipolar structure and nutritional support during the recovery phase. RF.29 The devices vary in intensity, shape and area treated.14 Electro-optical synergy (ELOS) Non-ablative procedures ELOS is a new concept that combines light energy in the Non-ablative resurfacing is a procedure that provides form of a laser, such as the diode laser, intense pulsed light, collagen modulation by breaking upon heating the weak or a broadband infrared light, together with radiofrequency hydrogen bonds, leading to a random coil configuration energy, to impart changes in dermal collagen and effect of the alpha-chains and subsequent shortening and skin tightening. These devices act by increasing the levels of thickening.15,16,17 There are different types of non-ablative tropoelastin and synthesizing collagen.30 procedures: Microfocused ultrasound Intense pulsed light sources (IPL) Microfocused ultrasound devices work by causing a discreet IPL devices are able to activate the production of new focal heating of the dermis and stimulate neocollagenesis and collagen and subsequent dermal remodeling for up to six elastin remodeling. They reduce wrinkles and skin sagginess months following the treatment, achieving overall photo with minimal downtime, discomfort, and risk of adverse rejuvenation with a significant clinical improvement in rhytides, events.31,32 Unfortunately the manufacturer markets his device skin texture, and pore size.15,16,18 In addition, IPL increases as “The non-surgical way to lift your facial skin”! epidermal thickness, and induces an improvement in pore size and skin tone. Conclusion An optimal rejuvenation program should correct all the signs Mid-infrared lasers of aging. Our patients should look better, and one should not These devices act by shortening and thickening the collagen be able to identify what treatment our patients underwent. fibrils, followed by fibroblast proliferation and deposition To achieve such results, we might perform aggressive or of new collagen types I and III. They improve all aspects of minimally- or non-invasive procedures, depending on the photo-aged skin. However, full clinical impact may not always stage of the aging process. With regards to non-invasive be apparent for up to four to six months following a series of facial treatments, we believe that the word rejuvenation treatments.19,20,21 and not the word “lifting” should be used to describe non- aggressive techniques. In no way can a minimally- or a non- Fractional non-ablative infrared lasers invasive technique replace a surgical lift when the indication The concept of using fractional non-ablative photothermolysis is given for an aggressive intervention. Therefore terms like was developed by Manstein et al in 2004, to attempt to get softlifting, scarless lifting, vampire lifting, mini-lifting, silhouette good results without the associated risks and lengthy recovery lifting, etc. should be avoided when talking about non- period seen with their ablative counterparts.22 The stratum invasive techniques. Nevertheless, all these techniques are corneum remains intact during and after laser firing. The re- complementary, the final goal being the satisfaction of our epithelialization is performed by keratinocyte migration and patients and aesthetically pleasing natural results.

60 AJAM 2015 Official Journal of the American Academy of Aesthetic Medicine References 18 1 Jones BM, Lo SJ. How long does a face lift last? Objective and Bitter PH. Noninvasive rejuvenation of photodamaged skin using serial, subjective measurements over a 5-year period. Plast Reconstr Surg. full-face intense pulsed light treatments. Dermatol Surg. 2000;26:835- 2012 Dec;130(6):1317-27. 42. 19 2 Bernstein EF, Andersen D, Zelickson BD, et al. Laser resurfacing for Berlin AL, Goldberg DJ. Non Ablative Resurfacing. Facial Resurfacing dermal photoaging. Clin Plast Surg. 2000; 27:221-38. 1st Ed. (2010). Chapter 2 pg. 23-34. 20 3 Charles H. Thorne. Facelift. Grabb & Smith’s Plastic 6th Ed. Trelles MA. Short and long-term follow-up of nonablative 1320 nm Chapter 49 pg. 498. Nd:YAG laser facial rejuvenation. Dermatol Surg. 2001;27:781-2. 21 4 http://www.fda.gov/medicaldevices/productsandmedicalprocedures/ Dang Y, Ren Q, Liu H, Ma J, Zhang J. Effects of the 1320-nm Nd:YAG cosmeticdevices/wrinklefillers/default.htm. Accessed 20th July 2014. laser on transepidermal water loss, histological changes, and collagen remodeling in skin. Lasers Med Sci. 2006;21:147-52. 5 http://www.isaps.org/procedures/fat-transfer-facial. Accessed 20th 22 July 2014. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: a new concept for cutaneous remodeling using 6 http://www.isaps.org/procedures/barbed-suture-lift. Accessed 20th microscopic patterns of thermal injury. Lasers Surg Med. 2004;34:426- July 2014. 38. 7 Simpson LL. The origin, structure, and pharmacological activity of 23 Tannous Z, Laubach HJ, Anderson RR, Manstein D. Changes of botulinum toxin. Pharmacol Rev. 1981 Sep;33(3):155-88. epidermal pigment distribution after fractional resurfacing: a clinicopathologic correlation. Lasers Surg Med. 2005;36(Suppl 17):32. 8 Fabbrocini G, De Vita V, Fardella N, et al. Skin needling to enhance depigmenting serum penetration in the treatment of melasma. Plast 24 Dierickx CC. The role of deep heating for noninvasive skin rejuvenation. Surg Int. 2011;2011:158241. Lasers Surg Med. 2006;38:799-807. 9 Aust MC, Fernandes D, Kolokythas P, et al. Percutaneous collagen 25 Abraham MT, Vic Ross E. Current concepts in nonablative induction therapy: an alternative treatment for , wrinkles and skin radiofrequency rejuvenation of the lower face and neck. Facial Plast laxity. Plast Reconstr Surg. 2008;121:1421-9. Surg. 2005;21:65-73. 10 Liebl H, Kloth LC. Skin cell proliferation stimulated by microneedles. J 26 Alexiades-Armenakas M, Dover JS, Arndt KA. Unipolar versus bipolar Am Coll Clin Wound Spec. 2012 Dec 25;4(1):2-6. doi: 10.1016/j. radiofrequency treatment of rhytides and laxity using a mobile painless jccw.2012.11.001. eCollection 2012. delivery method. Lasers Surg Med. 2008;40:446-53. 11 Stegman SJ. A comparative histologic study of the effects of three 27 Zelickson B, Kist D, Bernstein E, et al. Histological and ultrastructural peeling agents and dermabrasion on normal and sundamaged skin. evaluation of the effects of a radiofrequency based nonablative dermal Aesthetic Plast Surg. 1982; 6: 123-35. remodeling device: a pilot study. Arch Dermatol. 2004;140:204-9. 12 Monheit GD. Presentations at the American Academy of Dermatology 28 Alster TS, Lupton JR. Nonablative cutaneous remodeling using in New Orleans, March 25, 1999. radiofrequency devices. Clin Dermatol. 2007;25:487-91. 13 Tournas JA, Zachary CB. Fractional Ablative Resurfacing. Facial 29 Dudelzak J, Goldberg DJ. Non-surgical Facial Skin Tightening. Facial Resurfacing 1st Ed. (2010). Chapter 3 pg. 38. Resurfacing 1st Ed. (2010). Chapter 4 pg. 64. 14 Tournas JA, Zachary CB. Fractional Ablative Resurfacing. Facial 30 El-Domvati M, El-Ammawi TS, Medhat W, Moawad O, Mahoney Resurfacing 1st Ed. (2010). Chapter 3 pg. 41-44. MG, Uitto J. Electro-optical synergy technique: a new and effective nonablative approach to skin aging. J Clin Aesthet Dermatol. 2010 15 Krane SM. The importance of proline residues in the structure, stability Dec;3(12):22-30. and susceptibility to proteolytic degradation of . Amino Acids 2008; 35: 703-10. 31 Alam M, White LE, Martin N, Witherspoon J, Yoo S, West DP. Ultrasound tightening of facial and neck skin: a rater-blinded 16 Verzar F, Nagy IZ. Electronmicroscopic analysis of thermal collagen prospective cohort study. J Am Acad Dermatol. 2010 Feb;62(2):262-9. denaturation in rat tail tendons. Gerontologia 1970;16:77-82. doi: 10.1016/j.jaad.2009.06.039. 17 Nagy IZ, Toth VN, Verzar F. High-resolution electron microscopy of 32 Oni G, Hoxworth R, Teotia S, Brown S, Kenkel JM. Evaluation of a thermal collagen denaturation in tail tendons of young, adult and old microfocused ultrasound system for improving skin laxity and tightening rats. Connect Tissue Res. 1974;2:265-72. in the lower face. Aestht Surg J. 2014 Jul 2. pii: 1090820X14541956.

Dr. Michel Pfulg is the founder and medical director of Laclinic-Montreux, Switzerland. Dr. Pfulg was appointed Consultant Plastic Surgeon at the Cantonal Hospital of Fribourg (Switzerland) in 1984. In 1988 he became Head of the Department of Aesthetic Surgery at Clinique Valmont, located above Montreux, Switzerland. From 1992 to 1999, he practiced his art as Consultant Plastic Surgeon at Clinique La Prairie, in Clarens-Montreux. In 1999 he turned his attention to creating his own clinic, entirely devoted to beauty, in Montreux-Territet on the shores of Lake Geneva. Inaugurated in May 2002, Laclinic-Montreux rapidly became a renowned medical establishment, among the most exclusive and successful in the world. In May 2014 the exclusive clinic “The Beauty Suite by Laclinic-Montreux” was opened in Lausanne, Switzerland. Dr. Pfulg has published many scientific papers and is a member of the scientific board of Helena Rubinstein (L’Oréal) with whom he developed a cosmeceutical line called “Re-Plasty” in 2008. He is a member of the Swiss Medical Society, the Swiss Society of Plastic, Reconstructive and Aesthetic Surgery, the Swiss Society of Aesthetic Medicine (President in 2004), the International Society for Aesthetic and the International Confederation of Plastic and Reconstructive Surgeons.

Images of patients are courtesy of Dr Michel Pfulg, Dr Serge Le Huu, Dr Marco Cerrano and Dr Antonio Campo of Laclinic-Montreux, Switzerland.

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