Anti-Aging Procedures

With the plethora of collagen-building, minimal down time anti-aging treatments at our disposal, the onus is on the cosmetic facial surgeon to learn, master, and offer these exciting modalities to his or her patients. With such treatments, our goal as surgeons is to triangulate, sculpt, and tone the aging face which tends to get square, bottom-heavy, and lax with loss of collagen and youthful volume. To replenish lost volume and attain a natural look, I am of the opinion that only modest amounts of filler ought to be used—to avoid the “stuffed and puffed” look of “killer filler.” Unfortunately, too many patients have succumbed to aggressive filler injections with devastating aesthetic outcomes—not realizing that filler builds up with time and fat grafts can lead to chronic swelling issues.

Here are some mistakes I commonly see and revise:

1. Overzealous and serial injections of hyaluronic acid (HA) fillers like Voluma, Juvederm, Restylane and autologous fat grafts

in the under eye and cheek area: possible result is a poofy look with festoons months or years later
in the central third of the face (lips, nasolabial folds, marionette lines): possible result is a chipmunk look with duck lips
in the jawline: possible result is a square, bottom-heavy look that aids gravity

2. Overdosing Botox or Dysport treatments

to the forehead: possible result is a frozen look with dropped eyebrows and hooded lids
to the crow’s feet: possible result is increased fluid in patients with excessive HA fillers/fat grafts or frank festoons. Botox/Dysport debilitate the orbicularis oculi muscle that pumps fluid out of the eyelid/cheeks.

Sculptra or Silicone nodules

possible result is nodules that surface after “hot” treatments like laser resurfacing

My experience dictates these guidelines for my patients:

Do not use HA fillers in the under eyes, cheeks, or jawline
Use modest amounts of HA fillers in the lips, nasolabial folds, and marionette lines AFTER the cheeks have pulled up and the jawline is pulled back
Use a calcium-based filler in the cheeks to avoid festoon formation—because it is not water-loving, or hydrophilic like HA fillers
Use threads or skin rejuvenation treatments wherever possible to lift and tone the skin to minimize the use of fillers

PDO Thread Lifts

Polydioxanone, or PDO, thread lifts have become the mainstay of anti-aging treatments in my practice. Following face lift principles, I utilize the largest (18 gauge) barbed, cannulated (no needle) threads to pull up and pull back the skin of the midface, jowls/jawline, and neck. I also place smaller threads in the tear troughs to improve skin texture and tone in the under eye area. I have developed a special technique for pain-less and precise placement of threads at the right skin depth (see diagram below). Thread lifts are ideal for skin rejuvenation at any age because they stimulate immense amounts of collagen (see photograph below). The threads dissolve over 6-9 months, but the improvement in the skin tone, quality, and facial sculpture lasts 3-4 years on average in most patients. It is important to remember that thread lifts are not a substitute for surgery for those with advanced skin and muscle laxity but may serve as helpful adjuncts before or after surgery. In some, preventative thread lifts may ward off surgery altogether. The threads yield a very natural look and you will not look pulled—you will still look yourself. As I always say, “Threads are our undercover agents working 24/7 for us!”

The procedure takes about 30 minutes to perform. There is no pain, down time, or swelling for most patients. There may be some tenderness to touch for the first few days. Bruising is minimal to none. Makeup and work may be resumed the next day.

The above drawing shows proper placement of the cannulated thread in the dermis while he bottom shows removal of the cannula once the thread is inserted.

This histology photograph demonstrates the robust collagen response stimulated by the PDO threads.

Radiesse® (Calcium Hydroxyapatite) Cheek Lift

One of my favorite “instant gratification” treatments is the Radiesse® cheek lift. Radiesse® was FDA approved in 2006 and is comprised of calcium hydroxyapatite, the same substance that is found in our bones and teeth. As such, it is a natural filler that restores lost volume in our cheeks and midface. This filler must be injected supraperiosteally (deeply) by a skilled surgeon for optimal, aesthetically pleasing results.

Radiesse® FAQ’s:

How long does it last?

The body disintegrates the Radiesse^® over 6-9 months, but the collagen response (see histology photo below) and the result may last 12-18 months.

Does the treatment hurt?

We apply a numbing cream over the cheeks which is followed by a few quick injections of lidocaine to further numb the area. This way, there is minimal to no discomfort as I painlessly and artfully inject the filler over the entire cheekbone and sculpt it smooth to create your own customized cheek implant!

Will I have puffy cheeks?

No!! Unfortunately, we see too many people sporting puffy cheeks these days, most likely due to fat grafts and/or hyaluronic acid (HA) fillers like Voluma®, Juvederm®, or Restylane®. Radiesse® is not hydrophilic and does not draw in water like the other fillers, enabling the surgeon to create a “customized” cheek implant that enhances the patient’s own anatomy.

What is the down time?

Most patients have minimal to no bruising and some swelling that will dissipate over the ensuing 24-48 hours. Women may resume makeup the next morning.

Will I get any lumps and bumps?

Absolutely not! The Radiesse^® will look smooth and natural and unless you tell someone, nobody will notice anything other than gorgeous, high cheekbones!

This histology photograph depicts the collagen response (pink) surrounding the calcium hydroxyapatite crystals (gray). The filler will disintegrate in 6-9 months but the collagen remains for up to 18 months.

Neuromodulators: Botox ® , Dysport ® , Dermafirm

Botox ® and Dysport ® are FDA-approved neuromodulators (NMs) that are a staple in my anti-aging campaign.

View Gallery

Neuromodulators FAQ’s:

How do they work?

They are called neuromodulators because they modulate (block) the release of a neurotransmitter, called Acetylcholine (Ach), from the presynaptic nerve terminal at the neuromuscular junction. Ach binds to the muscle and transmits the signal from the nerve to the muscle. Without Ach, the muscle cannot contract and the effect of that muscle is weakened.

Ach is also the messenger to produce sweat in our sweat glands in the armpits, palms, and soles. Those who have excess sweating have a condition called hyperhidrosis which can be problematic, especially for athletes. NMs are a game changer for such patients.

We have tiny muscles in the sweat glands of the skin, which when relaxed with a special dilution of Botox, called Dermafirm, enables firming of the skin and reduction of pore size through reduced sebum output. Moreover, Dermafirm also decreases vascular dilation and local inflammation which improves the redness and flushing in patients with Rosacea.

Are they safe?

Absolutely! With the microdose we use for cosmetic purposes, Botox/Dysport are safe, effective, and useful anti-aging tools, given proper knowledge and training on the part of the practitioner. One would have to inject about 400 times the cosmetic dose to exceed the safety
profile!

How long does the effect last?

Botox: 3-4 months
Dysport: 6-8 months
Dermafirm: 6-12 months

What is the down time?

For 2 hours after the treatment, the head should be kept upright to optimize treatment effect. Heavy exercise should be avoided for 48 hours. Rarely, a small bruise may occur at an injection site but it clears within a few days. With my meticulous and gentle technique, most patients do not experience any bruising.

How long does the treatment take?

15-20 minutes (including numbing time and injections)

What is the difference between Botox ® and Dysport ® ?

They both block Ach release and reduce muscle contraction but Botox tends to “stay put” whereas Dysport tends to spread more. I capitalize on this property and use Botox ® where I want minimal spread, such as crow’s feet and neck bands and Dysport ® for broader, thicker muscles where I want more spread, such as the forehead or between the brows.

Why is knowledge of anatomy so important?

Muscles work in pairs, called agonist/antagonist. While some lift the brow up, others pull it down. While some close the eyes, other open them. While some lift the corners of the mouth up, others lower them. By understanding and then carefully manipulating these muscles with the judicious use of NMs, I am able to attain the optimal "pick me up" for each patient without compromising necessary muscle function and without looking frozen.

Which areas/conditions can I have treated?

Areas:

Horizontal forehead lines
Lip lines around mouth
Crow’s feet (eyes)
Glabellar “11” lines b/w brows
Dimpled chin Bunny lines (nose)
Down-turned mouth corners
Platysmal neck bands
Gummy smile

Conditions:

Hyperhidrosis (Armpits/Palms/Soles)
Rosacea
Large pores
Migraines
TMJ/Jaw grinding (Tooth pain/Headaches)
Blepharospasm (Eyelid spasm)

Platelet Rich Plasma Treatments

Dark Circles, Skin Health, Hair Growth

Platelet Rich Plasma, or PRP, is a very popular treatment in my practice. I love this modality for its organic nature—it is you helping you!

Platelet Rich Plasma Treatment FAQ’s:

How does PRP work?

PRP contains a high concentration of platelets which are rich in growth factors that promote wound healing. When PRP is injected into the desired area, the platelets spew out these growth factors over the ensuing 2-3 weeks, nourishing the local milieu with improved circulation. They also stimulate stem cells and fibroblasts to lay down new collagen and elastin, which, in turn, serve to tighten and brighten the skin.

What are the benefits of PRP?

Skin: Improved color, tone, fine lines, scarring—resulting in a more radiant complexion
Hair: Decreased hair fallout with improved quality, thickness, and luster of hair. May also stimulate new hair growth (terminal hairs).

What are possible treatment areas?

Under eyes, skin of face, scalp, scars on body and face.

How many sessions do I need?

To jumpstart the process and obtain an optimal response, I recommend 3 sessions spaced 4-6 weeks apart with a maintenance session 1-2 times per year.

How is the treatment done?

Blood is drawn from the arm and centrifuged to separate out your “liquid gold” –the clear yellow portion (plasma and platelets) from the red and white blood cells (see photo). The plasma is then activated with calcium chloride prior to delivery of PRP via a cannula, microneedling pen, or tiny needle into the desired area.

How long is the treatment session?

About 45 minutes, including numbing time.

Does it hurt?

After numbing cream, there is minimal to no discomfort with the treatment. For those who prefer no discomfort whatsoever, I administer a small amount of local anesthetic.

Is there any down time?

For the face and scalp, there is no down time. For the thin skin of the under eye area, the injected PRP may need a few days to settle down. Most patients do not experience any significant bruising.

How long do the results last?

The effects on the skin or hair may last up to a year after the initial sessions, but to stay ahead of the aging game, it is ideal to maintain with at least one treatment per year.

Photograph of “liquid gold”, or PRP, the platelet rich plasma rich in growth factors and an important anti-aging tool to improve hair and skin health.

Skin Rejuvenation

Lasers, Light, Microneedling

As the largest organ in our body, the skin performs vital biologic functions such as protection from sun, germs, toxins; temperature and moisture control; and sensory perception. Equally important is the skin’s role in aesthetic rejuvenation and maintenance. By building collagen, reversing sun damage, and hydrating the skin, we fortify our skin envelope. Toned skin with a healthy glow not only looks radiant and youthful but it also translates to fewer injectables and surgical procedures! I encourage each patient to be their own advocate by using science-based skin care at home daily, including a retinoid, vitamin C, hyaluronic acid serum, specialty eye cream, and sunscreen. My favorite skin rejuvenation treatments include laser resurfacing (Fraxel, Erbium:YAG). Intense Pulse Light (IPL) photofacials, and Microneedling/ Radiofrequency (RF) Microneedling. All are FDA-approved, safe, effective, and backed by science.

Laser Resurfacing
The energy from carbon dioxide (CO₂) and Erbium:YAG lasers is absorbed by water in our skin cells causing lysis and destruction of the surface layers of the skin. This induces formation of a new layer of skin with more youthful collagen. Laser resurfacing improves pigmentation (sun-induced, hereditary, hormonal), pores, fine lines, and scars. Erbium:YAG laser (2940 nm wavelength) energy is readily absorbed by water and does not penetrate deeply into the skin, making it gentler with modest collagen deposition. CO₂laser (10,600 nanometer wavelength) energy penetrates deeper into the skin with creation of more collagen but also more redness and down time. The advent of fractionated CO₂ (Fraxel) leaves areas of normal skin that helps heal treated skin, minimizing down time but maintaining a good collagen response. The result can be enhanced with topical application of PRP after the treatment.
Intense Pulse Light (IPL) Photofacial
Unlike lasers which are monochromatic (single wavelength), light devices emit different wavelengths (from 500-1200 nm) that can be absorbed by multiple target tissues called chromophores. IPL can target melanin to improve pigmentation as well as hemoglobin to improve broken capillaries as in Rosacea.
Microneedling, Radiofrequency Microneedling
Microneedling, or collagen induction therapy, involves creating tiny channels in the skin with the use of a pen that contains microneedles. Studies show that there is actual deposition of collagen in the microscopic channels (see photograph). The regenerative effect can be enhanced with PRP, which is rich in growth factors. Though it sounds painful, the microneedling is actually quite tolerable as the pen glides across the skin which is coated with a peptide gel or PRP. Radiofrequency employs gold-plated micro pins to create tiny punctures in the skin to a depth of 3.5 mm and 3 megahertz high frequency radio waves to stimulate collagen deposition to a depth of 5-6 mm.

Skin Rejuvenation FAQ’s:

Do the treatments hurt?

After topical numbing cream, the treatments are tolerable with minimal discomfort.

What is the down time?

IPL: None
Resurfacing: 4-5 days
Microneedling: Few hours

What skin types are safe for treatment?

All skin types can be safely treated–as long as the proper settings are used!

How many sessions do I need?

IPL: 4 treatments, spaced 4-6 weeks apart then maintenance 1-2 times/year

Microneedling: 3 sessions, spaced 4-6 weeks apart, then maintenance 1-2 times/year

Resurfacing: once yearly

When will I see the result?

With safe skin care, patience is a virtue! As your body needs time to mount the collagen response, results begin 2-3 months after the initial treatment and continue to improve over a year.

Are there any complications?

Although rare, they include infection, reactivation of cold sores, and hypo or hyperpigmentation. Avoidance of sun and makeup by the patient and conservative treatments help to prevent any adverse effects. Patients with a prior history of cold sores are given prophylactic acyclovir to prevent reactivation.

The after photograph shows a robust collagen response in the dermis (arrows) after microneedling.

View Gallery