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can be reversed in some cases with subsequent IPL treatments. Patients
should follow postprocedural instructions to avoid burns, which may result
from sun exposure and improper skincare. The use of occlusive dressings
can lead to infection in rare cases, requiring antiviral, antifungal, or
antibacterial treatment [79].
3.5 Microdermabrasion and Dermabrasion
Microdermabrasion combines skin abrasion, usually achieved with a solid
crystalline material-covered device, and vacuum suction. It has been shown
to increase the transdermal delivery of topical skincare products (when
applied at the time of treatment). It can additionally provide modest
improvements to the appearance of rhytids, superficial scarring, and
irregular pigmentation. The primary advantage of microdermabrasion is that
it can be safely performed in most patients, regardless of increased
susceptibility to hyperpigmentation and/or scarring. Rapid recovery and
minimal social downtime (if any) are additional advantages [83].
No anesthetics are required prior to treatment, as microdermabrasion is
not considered a painful procedure. The skin is prepared with a cleanser to
remove any makeup or oil and then treated with a microdermabrasion tool,
which is passed over the surface three times in various directions.
Aestheticians control the intensity by altering the speed of movement or
vacuum suction strength. Common side effects include redness, irritation,
and petechiae, which typically resolve on their own [83].
Dermabrasion penetrates the skin to the mid-dermis with an abrasive
motorized wheel. While it is well utilized in reducing the appearance of
deeper acne scarring, there is limited support for its role in facial
rejuvenation. Due to the increased risk of scarring, dyspigmentation, and
viral transmission, it has been used less frequently in recent years [76].
4 Skin Lifting
Nonsurgical facial rejuvenation is well utilized to lift and tighten the skin,
in addition to more traditional volume restoration and resurfacing
techniques. These treatments use devices to transmit ultrasound or
radiofrequency (RF) heat energy to the dermal skin layer. When heated to
115 degrees F for at least 3min, heat-shock proteins are released in the
skin, triggering collagen formation [84] (Fig. 11).
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Fig. 11 The left pane shows the formation of static rhytids in the forehead, periorbital, and mid- to
lower facial region, in comparison to youthful skin in the right pane [86]
Radiofrequency (RF) or ultrasound therapy delivers energy to the
dermal skin layer, which triggers collagen formation and subsequently
tightens the skin. Static rhytids (stable wrinkles) are targeted with this
treatment, in addition to dynamic rhytids (wrinkles with movement). The
most common treatments include Ultherapy (ultrasound heat energy) and
radiofrequency microneedling (penetrative needles used to apply RF heat
energy) [85].
4.1 Microfocused Ultrasound Therapy
High frequency ultrasound has become more popular in recent years as a
nonsurgical skin-lifting procedure. Ultherapy and Sofwave are the leading
treatments, both of which are indicated for wrinkle reduction, skin lifting,
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and beneficial in reduction of wrinkles. Efficacy decreases as age increases,
likely due to decreased tissue hydration and healing capacity or increased
severity of skin laxity/facial wrinkles [87–89].
Ultherapy uses the Ulthera System as a primary treatment modality in
combination with the Ulthera DeepSEE tranducer. The additional
transducer can give surgeons ultrasonic visualization below the skin
surface, allowing the appropriate depth of treatment while avoiding
superficial bony tissues [90]. Energy penetrates to the level of deeper
dermal tissue, with a maximal treatment depth of 4.5 mm. Microfocused
ultrasound therapy with visualization is considered the gold standard of
nonsurgical lifting [91] (Fig. 12).
Fig. 12 The thermal injury zone indicated by the triangular shading in the figure highlights the
mechanism by which high-intensity focused ultrasound targets the SMAS, allowing for deep tissue
tightening [86]
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Sofwave uses Synchronous UltraSound Parallel Beam SUPERB™
technology to transmit high-frequency ultrasound energy through the
epidermis to the mid-dermal tissues, with a maximal treatment depth of 1.5
mm. The device incorporates a cooling mechanism (Sofcool ™) to reduce
patient discomfort and epidermal damage [92].
Individuals with healing disorders or implanted medical devices are
contraindicated for ultrasound and RF rejuvenation [85]. The provider will
determine whether one high-intensity treatment or multiple low-intensity
treatments are indicated, based on the patient’s goals and existing
deformity. It should be noted that multiple low-intensity ultrasound
treatments may be more effective regarding collagen remodeling [93].
4.2 Radiofrequency Therapy
Variations to electrode configuration in radiofrequency treatment include
monopolar, bipolar, and unipolar. All of these variations transmit heat
energy to various layers of the skin, allowing for induction of thermal
damage and subsequent collagen remodeling.
Monopolar radiofrequency rejuvenation uses only one electrode to
transmit thermal energy while the body remains grounded. Deeper tissue
injury is generated with this technique, and intra-procedural discomfort can
be managed using topical anesthetics [85]. However, the upper epidermal
layers are damaged with monopolar therapy, as shown in Fig. 13.
Fig. 13 The right image shows a monopolar RF device and the layers of skin targeted by thermal
heat energy, which allows for collagen remodeling and subsequent reduction of rhytids [86]
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Subcutaneous electrodes may also be placed into the superficial
cutaneous tissues to target different areas of the face, usually perpendicular
to the direction of rhytids. Bipolar radiofrequency rejuvenation is a result of
current flow between two electrodes, which are placed subcutaneously and
percutaneously. This method allows for localized, superficial treatment and
is less painful for most than monopolar radiofrequency [93].
Unipolar devices use a single subcutaneous electrode to transmit energy
throughout the surrounding tissues. Both unipolar and bipolar
radiofrequency rejuvenation tend to require tumescent (injected) or general
anesthesia to manage intra-procedural pain [85, 93, 94].
Radiofrequency microneedling is another variation, which uses
microneedle electrodes to directly transmit energy to the reticular dermis.
Insulated needle electrodes only transmit thermal energy through the tip of
the needle, while noninsulated needles induce heat damage through the
entire shaft. This technique shows promising results in reduction of
wrinkles and can be used with transdermal drug delivery (TDD) while
reducing unintentional thermal damage to more superficial skin [94, 95]
(Fig. 14).
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Fig. 14 Insulated RF microneedle placement is compared with monopolar and bipolar RF therapy in
the left image, with the red areas representing the targeted areas for maximal thermal damage [96]
Numbness, swelling, and bruising can occur after therapy, although
these tend to resolve within 2months. Stable results are not expected for 6–
12months, and patients should be informed of this prior to treatment [93].
In multiple studies, radiofrequency microneedling is shown to be
successful in reduction of periocular wrinkles and can be safely combined
with transdermal delivery of Botox or pulsed signal delivery. Patients
should be informed of the longer recovery period due to the ablative nature
of this procedure [95, 97–99]. While the skin lifting results are not as
dramatic compared with surgical facelift, radiofrequency rejuvenation is
shown to be both safe and effective [100]. Additional benefits of RF
treatment include wrinkle reduction and facial slimming, although these
improvements have been documented with repeated treatment (at least three
sessions) [101, 102].
4.3 Threadlift
Threadlifting has gained popularity in recent years as a nonsurgical
alternative to rhytidectomy (facelift surgery) [103]. Temporary barbed
sutures are inserted into the skin, which act to simultaneously lift the tissues
while promoting collagen production. The major benefits of this procedure
include lower risk of complications, reduced recovery period, and relatively
long-term aesthetic improvements. Common areas targeted for
improvement with threadlift include the jowls and jawline, cheeks,
periorbital area, browline, and forehead [104, 105].
4.3.1 Patient Assessment
The improvements with threadlifting are more subtle, and this treatment is
not indicated for permanent repair of severe, deep rhytids. As such, the
patients who would benefit most from threadlifting are usually younger
(between the ages of 30 and 50). After rhytidectomy, patients may be
advised to stabilize the skin with threadlift to preserve the aesthetic effect of
surgery. If patients are contraindicated for more invasive facelift surgery,
this procedure can produce similar but muted effects of tissue lifting [106].
Deep rhytids or severe skin laxity cannot be adequately reduced with
threadlifting, and these individuals are likely to benefit from more invasive
procedures. There will be little to no visible improvement for patients who
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are obese and/or have thicker, heavier facial skin. Similar contraindications
for implant surgery are applied with thread lifting, including active allergic
reaction or infection of the face, systemic diseases (diabetes, tuberculosis),
and certain autoimmune diseases such as HIV/AIDS or cancer [107]. Blood
thinning medications or supplements should be discontinued 1week prior
to the procedure, and patients are instructed to avoid alcohol the day prior
to reduce the risk of ecchymosis. Threadlifting can be performed using
local anesthesia, with or without the use of IV sedation. Tumescent
solutions are injected along the areas of tissue lifting, containing lidocaine
and epinephrine for vasoconstriction and pain relief [108].
Various barbed thread types are available, and they are generally
categorized as either bidirectional, unidirectional, or cogged (barbs in
various directions). Bidirectional threads, such as the Silhouette Instalift®,
do not require an anchoring point, as the thread will remain in place due to
the variation in barb orientation. Unidirectional barbed threads must be
anchored superiorly to sufficiently lift the skin, and common brands include
Contour® and Silhouette® threads [109]. Nonbarbed mono threads can be
inserted and anchored, which have less of a direct lifting effect and instead
stimulate collagen production.
The different patterns of thread placement are shown in Fig. 15, which
vary depending on the areas targeted for wrinkle reduction and tightening.
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Fig. 15 The insertion points are highlighted in the left image, and different techniques are designed
to target the forehead, nasolabial and/or marionette lines, improve jawline contour, or tighten the
jowls [86]
4.3.2 Bidirectional Thread Placement
Surgeons begin with subdermal injection of a spinal needle into the upper
area of desired augmentation. Keeping between the fat and dermal tissue,
the needle will be advanced inferiorly along the track of predicted tissue
lifting. A zig-zag technique is used upon insertion of the cannula, which is
believed to produce improved results by maximizing barb and tissue
engagement. Caution should be taken to maintain this depth and avoid
damage to adjacent skin layers [106, 108].
The cheek is a common area of the face in which bidirectional threads
are well utilized. For malar lifting, the needle is inserted pretragally and
advanced inferomedially, following natural cheek curvature. In any facial
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region, it is recommended that another needle is inserted about 1.5 cm
superior and parallel to provide additional stability [106].
The bidirectional barbed threads are placed in the center of the
preinserted needle to avoid skin contact before placement. Once the thread
is loaded equally in the cannula, the surgeon will slowly retract the spinal
needle, allowing for tissue collection and fastening over the barbs in an
upward direction. Manipulation of the tissues after retraction may help to
further secure the lifted skin onto the thread. Superior fastening is not
required, and any remaining thread is cut as close to the skin as possible
[106].
4.3.3 Unidirectional Thread Placement
Unidirectional threads are well utilized in contour correction of the
midfacial region and neck. The surgeon begins by making small incisions
along the hairline and/or posterior to the sternocleidomastoid m. if neck
lifting is indicated. These threads are inserted in a similar manner as their
bidirectional counterpart and arranged in pairs fanning outwards from the
face for even lifting. An attached needle is used to pull the threads into their
position, allowing the barbs to adhere to the surrounding fascia and tissues.
Once placement is secured, the needle is pushed out of the skin inferiorly.
Excess thread is cut as close to the skin as possible distal to the insertion
site, and the sutures are fastened to the temporalis fascia superiorly [110].
4.3.4 Complications and Outcomes
Minor complications with threadlifting are quite common and include
bruising, localized facial edema, and bleeding or pain at the injection site.
Surgeons should instruct the patient to monitor for severe complications,
such as allergic reactions or infection. Symptoms of infection include fever,
discolored drainage, prolonged swelling (2days or more), and chronic
headaches. The threads should be removed if infection is suspected, and the
site is cultured to guide antibiotics therapy [111].
Careful placement of the barbed sutures can help to reduce aesthetic
complications and provide patients with more natural results. Even with
careful placement, there is a possibility of skin dimpling or contour
irregularities at the injection site. Subcutaneous lumps or bulges may result
from unintended migration of the threads [111].
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Absorbable threads incur a lower risk of paresthesia and thread
extrusion when compared to nonabsorbable materials [112]. Difficult
removal of polydioxanone (PDO)-composed threads with severe infection
has been documented in the literature, and bacterial infections are more
frequently documented with PDO sutures [113] (Fig. 16).
Fig. 16 (a, b) The image shows an irregular contour above the patient’s right eyelid resultant from
the migration of injected threads [114]
Generally, patients will notice subtle aesthetic changes for 2years with
threadlifting. Primary rejuvenation related to the physical lifting of tissues,
such as improved skin contour and reduced skin laxity, tend to last for about
1year. The reversal of these effects can be attributed to the temporary
nature of dissolving sutures [108]. Stimulation of collagen growth is
thought to produce secondary rejuvenation effects, which are retained in
some patients for up to 3years [112].
5 Injectable Neuromodulators
As discussed above in the relevant anatomy, chronic use of facial muscles
results in dermal atrophy and formation of rhytids (wrinkles) [247].
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