Syringe Vs. Scalpel
The evolving role of cosmetic injectables in facial rejuvenation and restoration
I recently had a patient tell me that a plastic surgeon advised them, “You can do so many things with filler these days that surgery isn’t necessary anymore.” While I agree that injectables have been an integral addition to the facial plastic surgeon’s armamentarium, I disagree that surgery no longer has a role in facial rejuvenation. To say so would be to wrongly assume that all people are alike. For this reason, it is important that patients be matched with a provider who will listen to their specific concerns and help them choose the most appropriate and effective solution.
What are the main classes of injectables and what can they do?
There are currently 3 main types of injectables on the market.
1. Neurotoxins: Neurotoxins are chemicals that prevent muscles from contracting and, in turn, soften the appearance of fine lines and wrinkles. Common brands include Botox, Dysport and Xeomin. These products are strategically injected with a very small needle, take about a week to take effect, and last about 3 months. Longer-lasting and topical formulations may become FDA-approved in the near future.
Beyond treating wrinkles, Neurotoxins can be utilized to prevent the face from forming deep lines in the forehead, crow’s feet and eyebrow region (glabella). Other off-label uses include softening a dimpled chin or clenching jaw, relaxing strained neckbands, reducing a ‘gummy smile’, and creating artful lift to desired areas.
Neurotoxins are best used as a means to prevent aging starting in one’s 30s, but we commonly see patients in their 20s seeking the preventative nature of the treatment.
2. Dermal Filler: Fillers are products that, as the name suggests, restore lost volume to the face or other parts of the body, such as the hands. The most common type of dermal filler used today is called HA, or Hyaluronic Acid. Naturally occurring in the skin and joints, hyaluronic acid is a molecule that attracts and retains water. As a result of this behavior, it causes surrounding tissue to hydrate and appear more full, smooth, and in some cases, lifted.
Common hyaluronic acid brands include Juvederm, Voluma, Restylane and Belotero. The manipulation of the molecular structure of the HA is what differentiates these products. For example, Belotero was made to be very soft and fluid, but in my experience its longevity was lacking. Voluma, on the other hand, is comprised of a larger and interlinked molecular structure. This makes Voluma firmer, longer lasting and perfect for revolumizing the midface area (cheeks).
Like Neurotoxins, Dermal Fillers can be beneficial to preventative aging as well. They can biologically trick your skin into thinking it is younger than it is! Laboratory studies have shown that if your skin feels more full, it makes more collagen (the component of skin that gives volume), which in turn slows the aging process.
This patient was very thin and had severe facial volume loss. This made her look older than her age. After Dr. Garrett Griffin injected several syringes of Juvederm and Voluma into the temples and cheeks, she looks younger, more rested and more attractive.
Fillers can be used in almost any part of the face, but my preferred application is to keep the upper 1/3 of the face (temples, brows, cheeks, and tear trough region) really youth-full (pun intended). When the upper 1/3 of the face has good volume, it draws attention to the eyes. In addition, it literally holds the skin of the face up where it should be, preventing the saggy loose skin and jowling in the lower face that patients often complain about. This restorative effect may be why some plastic surgeons have turned away from surgical options in the mid- and upper face.
But, even fillers have their limits. At some point, one would need unnatural and excessive amounts of filler in the upper face to prevent lower facial aging and sagging. Part of why you see “plastic surgery disasters” or middle-aged celebrities with ridiculously overdone faces, is that they depend too much on fillers and don’t turn to surgery soon enough. In other words, if you use so much filler in an attempt to treat aging, it defeats the purpose and makes you look OLDER!
3. Kybella: Kybella is the newest addition to the injectable market. It is deoxycholic acid, which is a naturally occurring compound made in our gut to digest fat. Kybella is injected with a very small needle into the upper neck to treat excess sub mental fullness, or the dreaded “double-chin”. Most people will require at least 2 injection sessions spaced about 3 months apart, but will see improvement after the first injection. Both my patients and I have been very impressed with Kybella, not only for its fat reducing nature, but also for its ability to redefine the jawline. Kybella can often achieve equivalent results to liposuction and can even rival a formal necklift surgery in some patients.
However, as people reach their 50s and 60s, Kybella may not be the most effective choice. As we age, our skin becomes less elastic, meaning that it does not “tighten back down” to the underlying bone structure as well as it did in our youth. Because Kybella is indicated to reduce fat and bulk, it will do very little to tighten this excess skin. Therefore, necklift surgery may be more appropriate in these individuals.
So why do we still need surgery?
As we now see, injectables can be optimized to prevent and treat facial aging in most individuals with incredible results. But, as pointed out above, at some point, they can no longer achieve the desired effect. This is primarily because later in life, the skin becomes too lax and wrinkled to respond appropriately to the injectables. There are many non-invasive devices on the market to “tighten skin” but in my experience, none of these can achieve even half the results capable with surgery.
Once excess and loose skin is removed with a browlift, eyelid lift (blepharoplasty), facelift or necklift, then injectables – particularly filler – are able to work their magic again and even enhance and maintain the results of your surgical procedure. We simply can’t escape the fact that volume looks best when it is combined with tight skin.
At Midwest Facial Plastic Surgery, we are proud to offer a full and comprehensive range of both surgical and non-surgical facial rejuvenation options including Juvederm, Voluma, Botox, and Kybella. This versatility allows us to determine and customize the best type of treatment for each patient.
You are unlike anyone else, and deserve the individualized care you will receive at Midwest Facial Plastic Surgery.