Well, that was a long hiccup from my last entry. My apologies to my fellow readers. Sometimes it is hard to find that quiet time to let the words flow and produce good quality writing. Well, anyway, as I promised before. Let's continue our discussions on the sagging face.
So now we know that there are many factors causing the face to appear to sag, from anatomical differences i.e. weight loss or gain or alternating of the two, skin texture loss or just the very process of ageing which leads to bone resorption especially around the orbits and the maxilla. Let's discuss the options of treatment. Bear in mind, the options are not sequenced according to the most effective method. Based on the patient, sometimes 1 or more modalities are required or multiple sessions.
1. Botulinum Toxin A facelift injections.
I remembered when I first started to join the Medical Aesthetics field, my seniors were in the hype of the 'Botox-lift' which uses diluted BTA intradermal meso-injection techniques at certain areas of the face and neck to produce a slimmer tighter look and feel. The jawline tightening was dubbed the Nefertiti lift and was published in one of the medical journals. It was a quick and simple way of getting a tighter look by only spending 15 minutes in the office. Although the results were quite good, unfortunately, it only lasts between 1-3 months post injection and it does not tackle volume loss issues. Complications may include asymmetry of the face especially if there is a marked power difference from one side of the face to the other, or if the injections were too deep and inoculated into the underlying muscle. Per procedure will cost around RM 1000 - 2500, depending on the units used and the patient would have to come back to the clinic every 2-3 months to sustain the results. Some doctors are still doing this technique. Personally, I only do this upon patient's request.
2. Dermal Fillers - Hyaluronic Acids (HA)
Besides volume filling, dermal fillers can also be used for tightening. Nowadays with the newer HA fillers that gives better volume than the previous ones, we can do point injections to lift up the overlying tissues (muscle,skin, etc) to give a more tighter look. The injection sites usually involves the temples and the cheeks, with additional fillers used to fill up volume deficiency. However, you will need at least 2 syringes of a good volume filler (3-4 of the less dense fillers) to get the best effect. The good news is that it will last at least 12 months, and some of these HA fillers last up to 24 months or more. For non-HA fillers, Radiesse also has a tightening protocol using similar point techniques with an additional vector technique aimed to sharpen the jawline and bring up jowls. It requires at least 2 syringes on the first sitting, with possibly a follow-up syringe after 3 months for it to last 6-15 months. However, for both these types of fillers would require a fairly good texture of the skin in order to get the result. Other things consider is how good is your doctor at doing the procedure and the risks of bruising and lumpiness is always there. Cost wise, you will be spending around RM 5,000 (since its definitely going to be more than 1 filler) but if done well, you an have a good satisfactory result lasting 9-18 months on average.
3. Poly-L-Lactic Acid Fillers
These are a different type of filler that stimulates your own collagen formation by means of injecting PLLA into the face. There are 2 common ones in Malaysia which is Sculptura and Aesthefill. The procedure requires 3 sittings, once every 1-2 months. Per sitting 1-2 vials of the product is injected into the face. The effects of the procedure can be seen as early as 2 weeks but usually 4 weeks you can start appreciating difference. The only problem is the downtime. It requires multiple injections to the skin which may lead to bruising. Usually the bruising subsides in a few days to a week, but some patients can bruise up to 2 weeks. Another problem is that it may cause some fibrosis under the skin thus making future filler injections pretty difficult especially if the injector is less experienced. Despite the downtime and the bruising, I must say, I am pretty impressed with the results. I had a good friend who decided to go on an extreme diet and exercise regime which caused him to have very severe sagging and a turkey neck. However, after 2 months of the first session, he improved so much that he looked younger than when I first met him a couple years back. Its been almost 2 years, and he still looked great. He just redid his face recently. For this procedure, patients are required to take a whole course since you need to come back at least 2-3 times. The solution requires preparation, so you will really need to schedule the appointment beforehand. The price of 1 vial is RM 2500. Usually 3 sessions (4-5vials) would be charged at RM 10,000 for the package.
3. Radiofrequency Devices. (RF Devices)
This is perhaps one of the oldest techniques used for skin tightening but is still considered the best solution for skin tightening. However, bear in mid that there are different spectrums of machines used. The ones used in beauty salons are beautician grade, thus the power and intensity of the machine is much less. Some doctors buy these machines because they are cheaper (perhaps 10x cheaper) than the medical grade ones. Medical grade machines have to undergo series of clinical testing and approvals before sold to the market. It also requires proper training to avoid complications and deliver the best results. The medical grade machines in the market are like Thermage, Accent and Pelleve. Actually, there are so many RF devices in the market. Depending on which machine you are using treatment can be as low as RM 300 per session on the lower end of the spectrum to a whooping RM 12K per treatment with Thermage. Most RF machines except Thermage require repetitive treatments. The medical grade devices uses recommend 4x minimum. The beautician grade ones, usually 8-10x. The difference between medical grade and beautician grade device is that the medical grade devices are guaranteed to deliver the 40mJ of energy required to heat up the dermal tissue between 42-60 degrees. Thus, the results can be reproducible and repeat with more accuracy. However, the other factor in the delivery of treatment is the skill of the person handling the machine. A well trained user will deliver a better result, despite the machine being the same.
4. Intense Pulse Light (IPL)
IPL is one of the oldest light based devices used in aesthetics. Using filters to control wavelengths of light enables the user to target specific needs to the patients face. Similar to the RF devices, there are medial grade and beautician grade IPLs, which differs in terms of intensity and function. The usual wavelength filter used for skin tightening is between 500-1200nm and has shown great results in reducing skin laxity, wrinkles and also telangiectasia. Treatment price ranges from RM 800 - RM 1500 , depending on the type of IPL and area used. However, being a much older technology requires more skill on the doctors side to handle the device and the treatment. Complications are more common in darker skin types and are not limited to blistering, burns and peeling. Usually skin tightening procedures are not very painful compared to hair removal and is tolerable without anaesthesia. This treatment requires repetition to reach the best results, usually 4-10x depending on the type of IPL used.
5. Ultrasound Devices
The latest hype on skin tightening devices would be the ultrasound devices or also known as HIFU devices (High Intensity Focused Ultrasound). The most famous perhaps is the Ultherapy device that has been competing with Thermage since it first came into the market in 2009. Nowadays, other companies have also started to produce their own HIFU devices for skin tightening. My experience on Ultherapy was during the initial phase of its launch. The treatments were painful, but according to the latest protocols, the intensities have been reduced and still produced similar results. Tightening results were good, but may need annual repetition to maintain. What I love is that they have new FDA clearance for other things like neck tightening etc. What I don't love is the cost per treatment ranges between RM 12-18K and that the device costs a bomb.
6. LED Devices.
Some believe that LED devices give tightening effects to the skin. Although it is more for skin rejuvenation as a whole, it does to a certain extent help to tighten the skin. The wavelength used is the 633nm red light that helps with rejuvenation. The only problem is that the tightening effect is overall and not targeted, so although it may work, it will take a longer time. Treatment prices range between RM 300 - RM 800 per session depending on the type of LED device.
7. LASER Devices
Most LASER devices are designed for rejuvenation or ablation and as a side result, some skin tightening are observed. However, there are LASERs that can use for skin tightening. ND YAG long pulse LASERs have been seen to give a good lift for sagging skin. It can be pretty uncomfortable and repetitive treatments are required. Treatment costs between RM 800 - RM 1800 depending on area and machine used.
8. Platelet Rich Plasma Procedures (PRP)
PRP treatments made a huge hype when Kim Kardashian posted on her social media about getting it done. Obviously she had more than PRP done on herself, but her stunt put PRP as one of the medical aesthetic treatments available in the market. Although PRP does help with rejuvenation, it only gives minimal tightening effect immediately. In the long run, maybe with volume increase and skin thickness increase, it will appear tighter but it would not be working specifically for the jowls. Treatment costs anywhere between RM 1600 - RM 5000 depending on which system they use and which method they inject it with. If its too cheap, be wary, it could be under treatment or done by an unexperienced doctor and you may not get the results you want.
9. Threads
Threads use to be only the plastic surgeons territory for lifts, but now less invasive threads are available giving you an in-office procedure. There are 2 types of threads used in clinics which are the suspension threads and the PDO threads. Suspension threads like Silhoutte Soft suspends in the fat layer of the face giving a temporary lift immediately lasting anywhere from 6 months to up to 2 years. The main determinant will be the amount of threads used and the technique. Plus whether any anchoring to the SMAS was done. It works on lax skin making it tighter. However, usually 20% of the tightening effect will reduce after 2 months when the swelling from the initial procedure completely subsides hence why sometimes, the doctor tends to pull a lot tighter in the beginning. It would be a good solution to jowls except the cost of the treatment is around RM 4000 - RM 8000 per sitting depending on number of threads used. Some threads requiring anchoring can cost up to RM 20,000 per sitting, which makes you want to consider visiting the plastic surgeon instead. The other threads available are the PDO threads. Now the Koreans have modified them to allow longer lasting effects compared to the first generation of PDOs. Although we can use PDOs for tightening via collagen stimulation, it takes a few sessions (3-5 sessions) over a period of a couple months to get a really good result. The cost is cheaper than suspension threads, roughly around RM 2500- RM 5000 per sitting depending of amount and types of PDO used. Sometimes, doctors would used a combination of both suspension and PDO threads for a better result and this can cost a whopping RM 7000 - RM 12000 per sitting. The only problem with threads is the downtime. If you are lucky you may not bruise, but most of the time it takes between 5-14 days for the bruising and swelling to subside.
10. Mesotherapy
Mesotherapy is the practice of giving micro injections to the face. For face tightening, certain mesotherapy cocktails can be used to improve skin tightening. However, it may be temporary lasting only 2-4 weeks and they maybe risk of pain and bruising. You also require to do multiple sessions (5-10 sessions on average) to get a good result. Some clinic use mesorollers, mesostamps or mesoguns to aid the process. The cost can vary between RM 250-RM 1200 per session depending on the cocktail and the method used.
11. Tightening Creams
I included this in as now a lot of clinics sell products that promises instant tightening of the skin. There are a few scientifically proven substances that can help with skin tightening. One of the most mentioned are the DMAEs (di-methyl-amino-ethanol) which has clinically proven to tighten up the skin. Another common component would be the non-cross link hyaluronic acids which claim to help with hydration and skin tightening too. Personally, i think the molecules maybe too big to be absorbed well. Plus it is aquaphilic, and our skin is water proof. Another amino compound that has made highlights is the 8-hexapeptide complex that helps to reduce wrinkles for 8-12 hours dubbed as the alternative to botulinum toxin. (Honestly, BTA works faster and better). Other active ingredients include retinoids (Vitamin A derivatives), salycilic acid, ATP, Coenzyme Q-10, and other peptides and cytokines. Epidermal Growth Factors (EGF) also plays a role although it is more of rejuvenation of the skin compared to just tightening.
Regardless of whatever treatment modality that appeals to you, a good consultation with your aesthetic doctor is always important to get a better idea of which treatment or treatment combinations suit you best. It is always good to preplan the procedure so that you can afford the social downtime if required.
For more question or to book an appointment, do contact us at drmmclinic@gmail.com or call / text /whatsapp to 0129660852 .
