why do it?
Age brings a person wisdom, life experience, and knowledge, but it can also bring unpleasant physical changes, such as wrinkles, age lines, and visible folds or fat deposits.
Facial aging is a complex interaction between degradation in skin texture and loss of facial volume. It reflects the dynamic, cumulative effects of time on the skin, soft tissues, and deep structural components of the face. Many of the facial manifestations of aging reflect the combined effects of major contributory forces including:
- hormonal imbalance
- chronic sun exposure
- other environmental factors: mental stress, diet, work habits, drug abuse, medications, alcohol use, body mass index, and endocrinologic status and disease
While face lifting procedures will not turn back the clock or permanently stop the aging process, they will help lessen the visible signs of aging by removing unwanted, excess fat, and tightening loose skin and the underlying muscles for a more flattering, youthful look.
Today, face lifting is sought after by patients wishing to
- Refresh their appearance: They want to look as young as they feel on the inside but their appearance doesn’t accurately reflect their youthful energy and verve. Some patients want to appear more amiable because as they grow older their wrinkles make them appear angry and guarded. This is important for patients seeking a partner and especially those working in a client facing job.
- Get ahead in their career: This is especially pertinent if they are interacting with clients face to face on a daily basis. They want their clientele to have confidence that they are up to the minute with the newest innovations and developments. There may be pressure to be trendy and not to look like the “boring old person” in the office so that they can keep pace with their younger colleagues and attract younger clients. Ageism in the business world affects the way the clients and bosses view people. Sagging, wrinkles and other signs of facial aging can affect social and career objectives.
to sculpt facial features safely and effectively
Fractional Energy Devices
Fractional Energy Devices stimulate skin remodeling and collagen deposition, resulting in skin tightening and improvement in skin wrinkles. The choice of which device to use would depend on the depth of wrinkling present and patient factors such as skin thickness and color.
Fractional Infrared Lasers
Fractional laser resurfacing involves the deposition of a pixelated pattern of microscopic laser wounds surrounded by healthy tissue resulting in both greater efficacy and shorter downtime compared to non-fractionated treatments. It can be further subdivided into ablative and non-ablative. Ablative fractional lasers have longer wavelengths (e.g. CO2 10600nm) and lead to full thickness destruction of skin, whereas non-ablative fractional lasers have shorter wavelengths (e.g. Erbium Glass 1550nm) and leave an intact skin surface. CO2 has greater efficacy compared with Erbium Glass but longer recovery time and a higher risk of complications.
Fractional Infrared Lasers have a good body of research evidence demonstrating safety and efficacy.
Fractional Picosecond Laser - Discovery Pico Plus
Discovery Pico Plus is a second-generation triple wavelength picosecond laser that generates the highest peak power in the world. A special microlens array further focusses the energy into numerous micro-beams 2mm under the skin. The highly concentrated energy produces laser-induced optical breakdown (LIOB) stimulating collagen production with almost no downtime.
Fractional Bipolar Radiofrequency
Fractional Radiofrequency creates a pyramidal thermal injury zone (a relatively large coagulation zone deep in the skin with minimal surface damage) as opposed to the columnar shape of ablative lasers. Hence Fractional Radiofrequency has a favourable side-effect profile (such as downtime, post-inflammatory hyperpigmentation) in comparison to fractional lasers.
Fractional Microneedle Radiofrequency
Skin remodeling requires heat delivery to the deep part of the skin. However, in most machine-based treatments for scarring such as lasers, much of the energy is dissipated at the skin surface and little reaches the deep layers. Fractional microneedle radiofrequency overcomes this using insulated microneedles to spare the upper part of the skin and deliver radiofrequency energy precisely up to 4mm deep in the skin, resulting in faster recovery, higher efficacy and increased safety.
High Intensity Focused Ultrasound
High-intensity ultrasound energy is focused precisely on the targeted fat layer, creating a rapid rise in local temperature at the targeted area without harming surrounding skin, tissue or organs. HIFU relies on the fact that, above a threshold of 56 degree C (for > 1 second), irreversible cell death occurs. The heat produces a dual tissue response within the treatment area - permanent destruction of targeted fat cells and contraction of surrounding collagen that helps improve tissue laxity. The body naturally removes the destroyed fat from the treatment area, reducing the size of a fat deposit.
Unlikely lasers or radiofrequency that have to be transmitted through the skin surface, HIFU is able to bypass the skin surface and focus only at specific depth to cause a very targeted heating. This makes it ideal for lifting the SMAS layer and targeting any bulging, malpositioned fat compartments.
Subdermal laser or radiofrequency
A tiny probe inserted under the skin is used to conduct laser energy or radiofrequency energy that is absorbed by the skin and surrounding tissues, stimulating collagen contraction and production to tighten loose skin, reshaping bulging or loose tissue.
A threadlift is a type of minimally invasive procedure suitable for people who want a facelift, but prefer not to go under the knife. With this procedure, threads made from biodegradable polymers are inserted into your skin with a special cannula or blunt needle.
Threads placed within or underneath the skin form a scaffolding that provides mechanical support for the skin. Such threads lend tensile strength to the skin while stimulating the production of more elastin and collagen. Longer barbed threads anchor to a relatively immobile tissues such as the temporal fascia and literally lift up the saggy skin and tissue, reposition the prolapsed facial fat pads and hold them in place.
Besides that, threads kickstart the skin cells to produce more collagen and elastin around the threads, to form a stronger, firmer collagen network, plumping up the skin, restoring hydration, reducing wrinkles and rejuvenating the skin.
These threads are bio-resorbable – meaning that they will be dissolved naturally by the body in 6-12 months (polydioxanone or PDO), 12-18 months (poly-L-lactic acid or PLLA) or 16-24 months (polycaprolactone or PCL). These materials are completely broken down by our cells into water and carbon dioxide and will not have any long-term residue.
Dermalift is an innovative intradermal neurotoxin injection technique that uses specific concentrations of neurotoxin injected at a specific depth at strategic points to produce a rapid skin tightening and face-lifting effect. Fibroblasts in the skin layer are stimulated, causing collagen fibre tightening, while depressor muscles of the face are relaxed leaving the elevator muscles unopposed to lift saggy skin. Dr Lee Young Seob (Seoul, South Korea) developed this technique for celebrities, to avoid the stiff, expressionless faces that could result from traditional intramuscular neurotoxin techniques.
Injectable dermal fillers are hydrogels that can be implanted to enhance the shape and contour of the nose. They can be classified into temporary, semi-permanent and permanent fillers. Temporary fillers are most popular and can be classified into 2 broad groups:
- mainly volume replacement - most commonly composed of hyaluronic acid, a naturally occurring glycosaminoglycan polysaccharide which draws and binds water to itself and the surrounding skin. Other examples include agarose or collagen
- collagen stimulating - contain materials such as calcium hydroxyapatite, polycaprolactone that cause the body to produce collagen
Fillers have different structural properties such as cross-linking that manifest in their rheological properties such as viscosity, cohesivity, hardness and resistance to deformity. Hard, cohesive and viscous fillers are preferable for facial lifting as they keep their shape well and have high lifting capacity. Softer, medium viscosity fillers can also be used for certain softer areas such as the temples.
dr wan's perspective
In Dr Wan’s view, every face is different. The face does not age as one homogeneous object, but as many dynamic components that are best analysed, restored, and replaced individually. Structural deficiencies in the skin, subcutaneous fat and skeletal support are present in each patient in different proportions. All four structural tissue layers—skin, muscle, fat, and bone—should be considered in ageing and it is necessary to address each layer in turn in order to produce a well rounded, holistic face lifting effect.
For example, if we only addressed tightening of the skin and SMAS layer (as in a surgical facelift) in a patient who mainly lacks facial volume, then the result would look like a shrunken head with very tight skin. Conversely, if we try to treat a patient who has prominent jowls and sagging skin with only fillers, the result may be a bloated, overfilled face.
There’s no one size fits all treatment and it is crucial to identify the relative contribution of each layer and specifically address the deficiency effectively, while being very careful to respect facial balance and proportions. Thus, it is paramount to understand the multifaceted effects of ageing on facial structures in order to address and correct each component correctly.
Ageing of the human face reflects both textural wrinkling of the skin surface and changes in the 3D topography of the underlying facial anatomy. The skin, soft tissues (subcutaneous and deep fat compartments, superficial musculoaponeurotic system or SMAS, and fascia), and structural support (bone and teeth) are individually affected by the ageing process and together determine the appearance of the face throughout life.
Skin wrinkling appears around the eyes, mouth and forehead due to repeated underlying muscle action resulting in permanent changes to skin and underlying tissues, progressing from fine dynamic wrinkles initially to deep static wrinkles over time. Sagging occurs due to a relative skin excess, lack of elastic recoil as well as fat accumulation.
Fractional Energy Devices tighten skin, improving wrinkles. The choice of which device would depend on the relatively thickness of the skin and wrinkles. The availability of multiple fractional devices allows Dr Wan to choose the most suitable and effective one for the clinical scenario.
HIFU with shallow depth cartridges such as 1.5mm or 2mm tighten skin, but Fractional Energy Devices may be more cost-effective especially for fine wrinkles in small areas of thin skin, like the eyelids and area around the lips where it can be difficulty to position the HIFU applicator and even 1.5mm may be too deep.
Fat Compartments and the Superficial MusculoAponeurotic System (SMAS)
The youthful face, characterized by diffuse, balanced distribution of superficial and deep fat, has a well-rounded 3D shape delineated by a series of arcs and convexities:
- primary arc of the jawline
- convexities of the temples
- multiple smaller secondary arcs of the lips
3 primary curves in the profile view are the most definitive features of youth:
- the lateral cheek projection (the “ogee” curve), an unbroken convex line from the lower eyelid to the cheek
- the arc of the jawline
- the arc of the forehead
Facial ageing is associated with
- loss of soft tissue fullness in certain areas: forehead, temples, around the eyes and cheeks, etc.
- persistence or accumulation of fat in others: eyebags, nasolabial folds, jowls and double chin, etc.
- fat pockets become more discernible as separate entities
- malar fat compartment gradually slides forward and down to bulge against the nasolabial fold
- the redistribution and demarcation of facial fat compartments gives rise to an unbalanced bottom heaviness
The SMAS is a continuous three-dimensional architecture connecting the periosteum, the facial muscles, and other supporting structures with the skin, consisting of an organized fibrous network of collagen fibres, elastic fibres, fat cells, and muscle fibres. The SMAS is an important support structure in the face and plastic surgeons specifically tighten and reposition the entire SMAS layer during a surgical facelift. As we age, loss of underlying skeletal support together with laxity and loss of elasticity in the SMAS result in weakened support to the fat compartments and overlying skin.
The fat compartments are divided into superficial or deep compartments by the SMAS
- superficial fat compartments between the skin and the plane of the SMAS - these are mobile and tend to sag with age
- deep fat compartments are beneath the facial muscles of expression, between the SMAS plane and the bone - these tend to lose volume with age
SMAS Laxity and Sagging of Fat Compartments
HIFU tightens the SMAS and cartridges with deeper focal depth such as 4.5mm or 6mm can be used to reduce the excess fat in ptotic fat compartments such as the jowls or nasolabial folds. Subdermal Laser can also be used to tighten the walls of the fat compartment.
Threadlifts directly lift and reposition the sagging mobile superficial fat compartments and stimulate the formation of new collagen, producing a rapid dramatic improvement.
Dermalift produces a fast, natural lifting effect with no downtime that is suitable for patients looking for a subtle party ready lift.
Combination treatment usually yields better results with threadlifts provide immediate lifting and repositioning while gradual tightening and fat resorption is produced by the stimulation of the energy devices
Ageing of the facial skeleton results from changes in the relative dynamics of bone production and bone atrophy:
- reduction in facial height, mainly due to changes in the midface and jaw bone
- increase in facial width and depth
- eye sockets increase in size
- midfacial skeleton decreases in size, worsening the sagging of the malar fat pad, accentuating the nasolabial fold
- loss of support in the upper lip contributes to wrinkles around the mouth
- jawbone resorption affects the shape and projection of the chin
Loss of Volume in Deep Fat Compartments or Lack of Skeletal Support
Volume should be replaced using highly cohesive, high G prime fillers with high viscosity and elasticity. This will help to support the overlying true facial ligaments and SMAS, lifting the sagging tissues lower down in the face.