The Sagging Face .......... Part 2 (Treatment Options)

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.

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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.

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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. 

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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.

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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.

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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 .

Dermaqueen - a solution for hydration.....

Finally, a quiet Sunday I can sit and write my blog. I know I owe my readers a lot of entries, hopefully before month end, I will be able to write up all of them. Today, I'm going to write on Dermaqueen. It took me awhile to write this entry because I was trying to decide how I felt about this treatment. 

Nowadays, a lot of people are looking for more solutions for their skin besides lasers and IPLs although there are some die hard fans of these procedures. The reason is because now we realize that there are a lot of complications with energy based procedures especially for Asian skin type IV or V i.e. burns, scarring, post-inflammatory pigmentation and also the fast recurrence of pigmentation post procedure. The other issue that most doctors worry about is trying to get the patient to abstain from sunlight for 3 months to avoid complications which in a country of 12 hours hot blazing sun is pretty difficult. Yes, we do advise sunblock but most people only use sunblock when they plan to leave the house only, and apply it once in the morning. (Seriously, you need to reapply every 2-4 hours for sunblock and 6-8 hours for sunscreen). Another issue post-laser/IPL is dryness of the skin and loss of hydration due to high heat procedure which can be tackled with religious application of a good lipophilic moisturizer but there is always a group with severe dryness that requires more intervention.There are also a group of patients on retinoid acid creams or Obagi which have persistent dryness until you can see cracking and fine wrinkles appearing. And not to forget the peri and postmenopausal women who have generalized dryness due to hormonal issues, despite using vitamin E oils and taking evening primrose still have problems.

That is why they came up with the Dermaqueen system. So what is Dermaqueen? Dermaqueen is a procedure that you can do to improve hydration of your skin as it delivers hydrating solutions/brightening solution and even non-cross link HA intradermally and this helps to give you instant hydration. It uses fine needles and a vacuum assisted device and plants the desired solution into the mid dermis. The good thing about this system is that it is preprogrammed to deliver an accurate dose at the accurate site. The only thing that makes people worry is the needles part. But nowadays with better lignocaine creams to numb the the face, the procedure is almost painless. Added with the vacuum suction allows doses to be delivered accurately into the skin with just a slight pricking sensation.

Its a pretty short procedure and takes about 20-30 minutes to do. In terms of downtime, although it claims to have no downtime, I would still say that it will depend on your skin and what solution you are using, so normally I'd advise patients to have 1 day off for the first time and see how long it takes to recover. As for myself, There was only  minimal needle prick marks on my face, and not much pain. It disappeared after 1-2 days. For those who have tendency for bruising or rosacea issues, yes, you may bruise but it can be covered with concealer and it will depend on your own system how long you would bruise.

So what is is good for? Mainly hydration and brightening. We use peptides solution from Dermaheal which is an established product from Korea and has been in the market for the past 3 years. I love Dermaheal as the results are fascinating and almost instant. The only thing about this system is that you will need more than 1 session. They recommend 3-6 sessions done weekly for best results and then maintenance every 3-6 months afterwards.The major complaint will be the cost of the treatment. At the moment 1 session is between RM 900-RM 2000 depending on solutions used. Some even argue say, why not I do laser instead. But the function of this treatment is different i.e. it is more for hydration of the skin and overall rejuvenation.

Other functions of Dermaqueen are as follows:

Other functions not included in the table is also Breast rejuvenation which helps sagging breasts that has loss the upper volume and also hand rejuvenation to make your hands look as young as your face. So what can you expect from this treatment?

Reduction in melasma - I think this was after 6 sessions

This one used non-cross-link HA mixed with peptides after 8 sessions

Rejuvenation of hands - 1 session with non-cross link HA

Pore reduction and skin tone improvement - this was after 1 session.

 I've met this guy. This was after 6 sessions of using Dermaqueen with hair restoration peptides. Although still a bit bald, but there is improvement in hair texture and volume.

So my take on Dermaqueen? I think this is a good alternative to doing Laser treatment for texture issues and for pigmentation improvement. It also helps those who have very dry skin to improve the hydration. The only setback is the cost as 6 treatments can set you back to around 10K but it does solve certain issues with more comfort and less complications.

Interested? Please contact the clinic at 03-21440080 or email us at info@faceworksclinic.com for appointment.

Medical Aesthetics for age groups......

I went to Penang two weeks ago and enjoyed beautiful sun rises and sunsets on the beach, despite some haze but the ambiance was wonderful. The only thing was the lack of internet access in my room which made it less convenient to update my blog. Still, I did get nice writing ideas which I would like to share.

Today's entry is about medical aesthetic procedures for age based groups. It is just a simple suggestion of things you can get done based on your age to improve how you look. As I always tell my patients, it is always better to do something than nothing because by doing something, there will be some change in your end result. I would also include a rough budget of how much the procedures will pinch you just as a guide.

Early 20s (18-25)

Usually at this age group, you will not have much aging issues. However, acne control and skin tone problems are very common because in this age group, you will still have some hormonal imbalance and is more active outside. Acne treatments would include chemical peeling, extractions, hormone pills or even retinoid A to clean up the skin and control sebum production. The usual skincare would range from acidic wash to exfoliators and gel based products to cope with the active sebum productions. You need to treat acne, because if you don't, you may end up with scars. Medically, we do have oral medications to help control sebum and a change of habits is usually advised. Smoking, late nights, low personal hygiene, stress and food selection does influence worsening of acne. Treatment for acne will depend on severity. Usually doctors would charge between RM 200-RM 1000 per treatment depending on what is involved in the treatment. Skin care can range between RM 300-RM 1000 for a full range depending on brand. Some doctors will use IPL or long pulse lasers to reduce sebum production and reduce P. agnes bacteria that is abundant in acne prone skin. To even out skin tone, I normally would recommend regular skin peeling and religious use of sunblock. Laser peels are also an option but if you have acne issues, there is a high chance of acne breakouts post procedure due to heat stress.

Besides acne and skin tone, this would be a good age to fix asymmetry of the face or to augment. The skin is young, hence fillers will sit in better. But because of the young age, I normally would only recommend doing hyaluronic acid fillers (Juvederm, Teosyal, Restylane) which are non permanent because it is easier to change the look when you've decided and because as you age, a lot of your face fat pads disappear so putting a permanent structure there may look awkward after a couple of years. For face shaping, you can slim down your face with a simple injection of botulinum toxin A (Botox/Dysport). You can read more about this in my previous entry on face shaping. (http://faceworksclinic.blogspot.com/2012/03/face-shaping-it-only-takes-5-minutes.html) Filler prices would range between RM 1400 - RM 2000 per syringe depending on type and how long the filler lasts. 

Late 20s- 30s (26-35)

This is usually when a person is most prime in their life. Biologically for most people, the hormones have settled and you start losing the baby face and your face becomes more defined. The early signs of aging start appearing such as wrinkles on your forehead, frown lines, crows feet and some loss of volume especially at the malar area. (cheeks) Pigmentation problems start occurring and the skin texture becomes drier. Botulinum toxin A can help with dynamic wrinkles. Fillers can help with the slight loss of volume and also to define the face to make it more attractive. Regular peeling can help with the skin texture but a definite skin care range change need to be considered. For pigmentation, using hydroquinone will help to reduce the pigmentation substantially but requires constant use. Lasers can help to reduce pigmentation and improve the skin texture but if proper sunblock used religiously is not applied, there is a high recurrence rate and may even worsen the pigmentation. This is also the point where I would normally suggest to add serum vitamin C into the skin regime as a maintenance and preventive program to help with texture and pigments. Supplements and vitamins are also important at this point to keep the skin glowing healthy. 

Another issue would be the body contour change, where most people find that certain areas are not as attractive as before. For this, I would recommend body contouring programs using medical grade radiofrequency machines (http://faceworksclinic.blogspot.com/2012/02/radiofrequency-tightening-rf.html) , or other medical grade body contouring machines to help. For some people, they prefer mesotherapy injections to reduce fats n certain parts but this requires recurrent treatment of specific area and so may add up to be costly. Regular exercise helps, and target specific exercises are more warranted.

Late 30s to 40s (36- 45 years old)

Most people are more stable at this age but due to the aging process, coupled with stress of work and family and other responsibilities can cause you to look older than you really are. For the face, At this age, most people would start complaining of more pronounced wrinkles on the forehead, frown lines and crows feet. There would be a more marked loss of volume in the malar and lower face, especially around the mouth and the folds by the side of the nose looks more prominent. The skin texture is still good, but pigmentation is more seen if nothing has been done before. Sagging of the cheeks is felt, although not extremely obvious and causes a lot of concerns in some people. Fillers and botulinum toxin A are a good investment for non-invasive treatment to treat lines, wrinkles and volume loss. Some would consider lip fillers because the upper lip has started to thin out more and you lose that youthful look. (Check out http://faceworksclinic.blogspot.com/2012/05/sexy-lips-in-15-minutes.html) Regular chemical peeling and face tightening with radiofrequency devices or lasers would help improve overall skin texture and turgor. At this point, you should also consider having a retin-A or derivatives cream supplement to the face to help with fine wrinkles. 

For the body, you can still opt for body contouring and tightening programs but the expectations should be more realistic. There will be improvement although subtle, and you may need to consider options of skin lifts and fat grafts to get a more marked improvement. Weight control can be achieved by modifying the diet and exercise and I do suggest most everybody above 36 with BMI more than 25 to go on HCG diet (http://faceworksclinic.blogspot.com/2012/03/hcg-diet-my-experience.html) to not only lose the excess weight and reduce body fat percentage but also to retrain yourself to a much more healthy diet and lifestyle. If done properly, you will be able to maintain your weight and enjoy a better life. It also helps increase personal health consciousness as only organic and non-processed meats are allowed during the diet.

After 46 (46 to 65 or more)

At this age, the skin texture is more wrinkled and you will need more moisturizers to help maintain suppleness. Laser resurfacing treatments are a good investment as it helps to improve your skin texture and tightens it as well. Radiofrequency device tightening of the face is another method to help improve sagginess. At this point, fillers are used for volumnization, and a lot of fillers would be needed to have a good effect. (At least 3 syringes per sitting usually). Semi permanent fillers (Aquamid) can be considered for structures like lips and cheek. Mesotherapy treatment with PRPs (http://faceworksclinic.blogspot.com/2011_02_01_archive.html) or non-cross link hyaluronic acid fillers (Dermaqueen, Restylane Vital, Juverderm Hydrate, Teosyal Redensity) is also an option to increase hydration of the dermis layer. Skin peeling is still a good way to maintain the skin. Surgical options would be fat graft to the face and face lifts. Vitamin E  and hyaluronic acid topical creams can help maintain hydration as dryness is always a problem. 

After 46, a lot of our natural hormones start to decline. Because of this, we will have vague tired symptoms that we cannot explain. Another thing that you should consider is to undergo anti-aging consultation and the use of bioidentical hormones to help supplement the decline of hormones. The blood test are expensive (a complete test would cost around +/- RM 1000). The hormone supplements are in cream form. Please be sure to go to a proper anti-aging doctor (trained) because not all doctors are trained properly.

This is just a rough guide of procedures you can do at the certain age. However, the current environment pollution, poor diet and nutrition, work stress and health problems can always make you look aged more than you really are. A proper consultation can help give you a good idea of the possible intervention to help make you maintain a healthy and youthful you. But one thing for sure, you need to start taking care of yourself early, to stay younger longer.

Any enquiries please email to info@faceworksclinic.com or call 03-21440080 and book an appointment to see me.