Dr Rinky Kapoor, Professor Dr Debraj Shome, and Dr Monika Surana, write about non-surgical facial contouring and how these can be approached.

A geing is an ongoing process. Early signs of ageing such as fine lines and wrinkles to advanced signs such as sagging skin and fat, skin pigmentation due to sun damage are some of the common features seen in the individuals. As we age, the facial fat starts redistributing downwards and medially causing deep nasolabial folds, under eye bags, under eye hollowness, increase in lip philtrum length, droopy corners of mouth, and loss of volume overall from different areas of the face. This means that ageing causes everything to be pulled on the face downwards and medially towards gravity. Hence, the anti-ageing should be anti-gravity, i.e., upwards and laterally. This is basically achieved through face lifts, be it surgical or non-surgical. Surgical face lifts are invasive, long down-time and can have sideeffects such as undesirable results.

With the advancement in the dermal fillers, botulinum toxin and facial threads, non-surgical face lifts have become the new accepted modality of face lifts among patients seeking facial contouring and facial rejuvenation. Earlier, rhinoplasty was mostly done surgically even for minor corrections such as nasal hump or droopy nasal tip. But with emerging usage of facial threads and dermal fillers, such corrections can also be done non-surgically, giving exactly the same results to patients. Even the face lifts can be done non-surgically by a combination of these modalities.

Botulinum toxin: Botulinum toxin is a neurotoxin protein released by bacteria Clostridium botulinum and related species. It causes chemo-denervation and prevents the muscle actions in the localised area of injection. This helps in reducing fine lines and wrinkles, which has formed due to continuous action of facial muscles over time. The effect lasts for up to three to four months.

Facial threads: Thread lift is a cosmetic procedure that offers a minimally invasive alternative to facelift surgery. Thread lifts tighten your skin by inserting medical-grade thread material into your face and then “pulling” your skin up by tightening the thread. Different types of threads such as COG and PDO threads, Monofilament, etc, are used. Threads dissolve in around three months producing neo-collagen beneath the skin causing tightening and lifting effect.

Dermal fillers are gel-like substances that are injected beneath the skin to restore the volume loss, smooth lines and wrinkles, and enhance facial contours. They also help

Dr Rinky Kapoor

Consultant Dermatologist, Cosmetic Dermatologist & Dermato-Surgeon, The Esthetic Clinics (located in Mumbai, new Delhi, Hyderabad, Bengaluru and kolkata) & Fortis Hospitals in Mumbai, India. A MBBS; DDV; MD (LTM General Hospital, Mumbai); Dr kapoor has a Fellowship in Dermatology, Dermato-Surgery & Lasers, national Skin Centre, Singapore; and is a visiting Fellow at the Stanford University School of Medicine, CA, USA.

lift the face non-surgically through myomodulation. Different materials are used as fillers such as hyaluronic acid, calcium hydroxyapatite, poly-L-lactic acid, polymethylmethacrylate and autologous fat. The most commonly used materials are hyaluronic acid and autologous fat for facial contouring and volume replacement. Dermal fillers can be temporary, semi-permanent or permanent in nature depending on their effects. In India, only temporary fillers are approved by FDA to be used, which lasts for around 12-18 months.

A new device called as Ultherapy is used for lifting the neck, chin and brow area. It is the only US FDA approved non-invasive procedure for non-surgical facelifts. As we age, collagen breaks down, resulting in loss of skin strength and elasticity. Through time-tested ultrasound technology, Ultherapy helps produce new collagen growth.

Ultherapy relies on ultrasound therapy to go deeper than other non-invasive treatments for collagen stimulation. As it leverages traditional ultrasound imaging, ultherapy providers can see the layers of tissue they are treating. This ensures the treatment energy is delivered to where it benefits you the most. It has zero downtime and results can be partially appreciated immediately. Final results take around three months to show, which lasts up to two years.

Let us look at this patient who had undergone non-surgically facial contouring with a combination of facial threads, dermal fillers and botulinum toxin.

Here, in this beautiful patient, we can observe the following signs of ageing:

• Static lines and wrinkles on forehead

• Crow’s feet

• Under eye hollowness

• Under eye bags

• Tear trough deformity

• Deep nasolabial folds

• Sagging of the midface

• Downturned corners of the mouth

• Loose skin

• Volume loss from malar region and temporal areas Now to address her issues, we can treat her using combination therapies like botulinum toxin, fillers and threads. The forehead area was treated with botutilum toxin for dynamic lines and wrinkles, crow’s feet and peri-orbital region. For addressing her under eye bags and hollowness, dermal fillers like Juvederm Voluma with high G-prime was used with lateral injection technique which corrected her under eye region.

For rejuvenation of the midface region, such as malar area, nasolabial folds, and sagging tissues, a combination of threads and fillers was done. COG threads were used which have barbs to engage and pull the tissues beneath the skin. Different directional threads lift the midface region, contour the malar or cheek sagging and contour the jaw

A new device called as Ultherapy is the only US FDA approved noninvasive procedure for non-surgical facelifts and is used for lifting the neck, chin and brow area.

Professor Dr Debraj Shome

Super Specialised in Facial Cosmetic Surgery. A MBBS, DO, DNB, FAACS, FACS, FRCS (Glasgow), FLVPEI, FICO (USA), Fellowship Facial Plastic Surgery (Utah, USA), mNAmS, mbA (USA), Fellowship Cranio-maxillo-Facial Surgery (morriston Hospital, Wales, UK), he is board Certified & Diplomate from the American board of Facial Cosmetic Surgery. He is a consultant surgeon at breach Candy Hospital; Apollo Spectra Hospital; SL raheja Fortis Hospital; mumbai, India, and is the Director of The esthetic Clinics, India.

line as well. The nasolabial area was also treated with fillers with cross hatch and fanning technique to replenish the volume loss. The corners of the mouth were also dropping downwards. So they were corrected and upturned with combination of botulinum toxin and fillers to restore the volume of the lips and corners.

With combination therapy of fillers, threads and botulinum toxin, this beautiful patient was rejuvenated non-surgically and she definitely looks a decade younger. For skin rejuvenation, carbon dioxide laser resurfacing was done to replenish the overall collagen beneath her skin. These kinds of results are now achievable which are as good as surgical facelifts and surgical facial contouring.

Coming on to another female patient aged 60 years who had come for enhancing her lower face and neck sagging. She was not happy with the way her skin laxity was affected. Along with other combination treatment, Kybella for her double chin and ultherapy for her lower face and neck was done. Kybella is a non-surgical injectable technique used to target the fat beneath the chin. Deoxycholic acid (DCA) is one of the secondary bile acid, which are metabolic byproducts of intestinal bacteria. It is injected for removing the pre-platysmal fat in submental area. For this, 0.1 ml per injection site, 1 cm apart is given in the submental area covering the entire region. A total of 5-10 ml per session may be required. Sessions are repeated one month apart.

Such results are achievable nonsurgically now. Patients can look a decade younger, replenish lost volume, rejuvenate and contour the face. In the era of “under the needle” rather than “under the scalpel”, more and more individuals are opting for non-invasive and non-surgical modalities to achieve these results. Surgery now only remains reserved for patients with severe deformity, or deviated nasal septum, and ptosis of eyelids, among others.

Apart from that, a combination of nonsurgical therapy for facial re-contouring is becoming the mainstay of treatment among youngsters.

Dr Monika Surana,

MDS, Maxillofacial Surgery, is Fellow, Facial Plastic Surgery & Facial Cosmetic Surgery. She is an Associate Consultant at The Esthetic Clinics, and is a Life Member at the Association of oral & Maxillofacial Surgery (AoMSI).