Artistry in Augmentation

Experts discuss how advanced treatments like PDO threads, dermal fillers, PDRN injections, and HIFU offer natural, harmonious results with minimal downtime.

he principles of facial augmentation have changed over the years with today’s work being more of a T blend of art and science where the aesthetics of the face is enhanced with lesser invasions. The term facial augmentation embraces all the operations aimed to bring changes in face volume, shape, and balance.

As more developments are made in the field of cosmetic surgery, people have different ways to alter the appearance of their face. Like all forms of augmentation, the purpose of facial augmentation is not just to place filler or implants but to create a balance and harmonised appearance based on facial structures and the client’s preferences.

Although the surgery has been a common practice for implant and fat grafting, new functional approaches like dermal fillers, neurotoxin (botulinum toxin), threads, and HIFU give similar results with minimal downtime and risk factors.

Laugh Lines

Facial aesthetics have come a long way, and today’s advanced non-surgical techniques allow for personalised treatments to address common concerns such as laugh lines, also known as nasolabial folds. These are the lines that form from the nose to the corners of the mouth and become more prominent due to factors like skin laxity, volume loss, and repetitive facial expressions.

Dr Ashish Davalbhakta, Chief Aesthetic Plastic Surgeon and Managing Director, Aesthetic Medispa, notes that the formation of laugh lines is a result of “Volume loss and skin laxity, particularly from the cheek area.” He emphasises the importance of evaluating the skin’s condition by manually lifting the skin to determine whether volume augmentation or lifting procedures are more suitable.

Thread lifts

For cases where skin laxity is the predominant cause, a thread lift is often the first line of treatment. Dr Chiranjiv Chhabra, Chief Dermatologist and Director, Alive Wellness Clinics, recommends using “PDO threads” (polydioxanone), which are absorbable sutures designed to lift sagging skin. She highlights the importance of placing multiple threads for a noticeable result. “I would start with six PDO threads on each side of the face, which ensures adequate lifting of the sagging tissue,” explains Dr Chhabbra. “Following the thread lift, after about three weeks, I would often introduce fractional lasers and fillers to further enhance the results.” The fillers help smooth remaining folds and restore lost volume, ensuring a more youthful appearance. She proposes using a filler with high viscoelastic properties to fill the laugh lines, while using more hygroscopic fillers for areas like the pyriform fossa (the depression near the nose), where volume restoration is needed.

Fillers and combination treatments

Dr Soma Sarkar, Dermatologist and Aesthetic Physician, Dr Soma’s Aesthetic Clinic and Academy, says that while threads and fillers are effective, a comprehensive approach often yields the best results. She suggests using different types of threads, including “PDO, PLA, and Aptos threads,” based on the patient’s budget and specific needs. “For midface lifting, I might place additional threads in the lower face and jawline to provide better traction,” she adds.

Dr Soma suggests introducing fillers in specific areas, such as the pyriform fossa, a small depression adjacent to the nose. “I like using a filler with high viscoelastic properties here to give some volume and correct the remaining folds. Combining both techniques gives a natural, lifted appearance,” she notes.

1. Neurotoxins for wrinkle management

Beyond threads and fillers, neurotoxins like botulinum toxin play an important role in managing wrinkles, including frown lines and glabellar lines.

Dr Chiranjiv typically starts with around 24 units of Botox for glabellar lines, while Dr Ashish might administer up to 30 units in certain cases, particularly in patients with stronger muscle mass.

However, they both cautioned that lower-face treatments, particularly around the mouth, require greater precision due to the risk of complications. Injecting Botox into the DAO (depressor anguli oris) muscle, which pulls the corners of the mouth downward, can sometimes lead to undesirable effects like asymmetry or difficulty smiling. Dr Chiranjiv recounts a case where the toxin diffused incorrectly, causing an upward pull of the lip.

2. Bio-stimulation with PDRN

Dr Soma mentions the concept of bio-stimulators and PDRN (polydeoxyribonucleotide) injections, which are designed to stimulate collagen production and promote skin regeneration. “We can introduce bio stimulators, boosters or PDRN.” She also emphasises how PDRN can complement thread lifts and filler treatments for patients over 50, especially when addressing volume loss and fine lines.

Dr Sonia Tekchandani, Cofounder &Medical Director Tender Skin International Mumbai and The Wedding Clinic Pune, shares her experience using PDRN for periorbital melasma and under-eye concerns. “There are a lot of clients who come, who don’t want to go for a filler, and they just come with a little bit of following, more pigmentation and a lot of wrinkling. These are the candidates we chose for PDRN.”

Dr Chiranjiv suggests that while surgery might yield the most dramatic results, most patients shy away from it, opting noninvasive alternatives like fillers and threads. She proposes a treatment plan starting with “fillers to address volume loss and improve the jawline, cheeks, and lips, while threads could follow for added lifting.”

3. Integrating HIFU into treatment plans

For patients who do not want to undergo surgery, Dr Ashish states, “If patients refuse surgery – fillers, threads, and HIFU are the next best alternatives.”

HIFU (High-Intensity Focused Ultrasound) is a first-line treatment for lifting and tightening according to Dr Apratim Goel, CEO and Medical Director, Cutis Skin Solution. “It is usually the first step in our approach.” She highlights that buccal fat and under-chin fat contribute to the appearance of a heavier lower face. “When we see a heavy face, there are two things which make a face heavy. One is the buccal fat, the lower face fat, and the second is the under-chin fat.”

Dr Ashish says, “I would look at the three-quarters view to see where her malar region is, and whether that is giving her a nice orgy curve or not. Otherwise putting a high Gprime filler there and along the zygoma would be one way of lifting and also giving her the triangle.”

For cases where surgery is not an option, Dr Chiranjiv highlights the importance of addressing masseter hypertrophy with botulinum toxin and using fillers strategically to lift the lower face without broadening it. “If I do Botox, if it is there, I would do fillers in the preauricular region and at the gonial angle, just to lift this area without making it broader.”

One of the most challenging areas to treat is the neck, particularly horizontal lines. Dr Ashish acknowledges that these lines are difficult to manage but suggested nano fat injections or fine fillers as effective solutions. “While we use nano fat injection in there, fillers are another alternative. You can inject intradermally, and it has to be a fine filler, very soft filler.”

Dr Chiranjiv adds that using profile fillers can provide lateral support to the skin, stretching it and minimising the appearance of lines. “What happens is that it spreads under the skin and stretches the skin, it gives some kind of lateral support. And then if I have to go into the horizontal line, I will use a softer filler.”

Evolving facial aesthetics

Facial augmentation is advancing as cosmetic procedures continue to unfold. Individuals can now choose surgical and non-surgical options to enhance their facial features. Nonsurgical treatments such as dermal fillers, neurotoxins, threads, and energy-based devices like HIFU have transformed facial aesthetics, offering effective solutions with reduced downtime and fewer risks compared to traditional surgical methods. Innovative treatments like PDO threads, fillers with high viscoelastic properties, and PDRN injections provide versatile options for enhancing facial contours and rejuvenating the skin. The future of facial augmentation lies in the continuous refinement of these non-surgical methods, driven by innovation and collaboration among aesthetic practitioners.

The above article has been extracted with excerpts from the panel discussion on ‘Facial augmentation mastery: Discussing aesthetic outcomes through successful case studies’ that was held at the Aesthetic Medicine India Conference 2024.