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Mar 2, 2021 1:39:57 PM

BY A THREAD: Combination Lifting



AUTHOR: Dr. Huw Jones, Intraline Medical Director

The appearances associated with aging relate to the morphological changes to the facial skeletal structure, soft tissue, retaining ligaments, fat compartments, and skin. The rate at which the process proceeds and the way that the various components interact to give the aging facial appearance varies greatly between individuals and will be influenced by both intrinsic and extrinsic factors. Having assessed each aspect, we can direct our surgical and non-surgical interventions most appropriately. Where surgical intervention is not indicated, or desired, consideration of numerous non-surgical options can be explored.

So that we may attain the best possible outcomes, the different elements should be considered together. Skin rejuvenation techniques for example, promoted without consideration of volume loss or muscle/ligament laxity will not be optimal. Volumizing perceived facial fat loss in the lower third of the face without addressing upper and middle facial loss will again produce sub-optimal results.

When I first started using dermal fillers (Zyderm/Zyplast) in the early 1990’s, we generally tried to fill lines and folds, especially the naso-labial region, without appreciating the underlying causes. We now have a greater appreciation of the multifactorial causes of the downward and centripetal movement of the facial tissues that result in the appearance of the inverted “Triangle of Youth”. Fat-pads get thinner and descend. As a result, our face may not look as round and firm as it did in our youth. Hollows can form beneath the eyes, drooping skin can cause deeper lines around the nose and mouth, loose skin can result in a sagging jawline. The loss and downward movement of fat-pads can also make the face appear deflated and sunken in the cheek area.

It became quite obvious to me that in order to achieve better results I needed to address more than one element of this process and to assess the face from the upper third down and the outside inwards. I also had to use more than one treatment/procedure to better address the overall appearance. I also realised that for a great part of my career I had failed to address the aging temples and lateral temporal fat (LTF) pads appropriately. Volume loss from these two regions not only results in a hollowed/aged appearance but also removes vital lifting support for the lateral supraorbital and infra-orbital regions. They also provide support for mid cheek and the jawline. I found that addressing these areas whilst applying tension with PDO Cog Threads provided a more harmonious result which were both instantaneous and relatively long lasting (15 – 18 months). The treatments can be staggered for optimal outcome and to meet the patient’s financial concerns.

Having agreed a treatment plan with the patient I start by addressing the temples. Younger women tend to have slightly concave or flat temples whilst the male tends to have a slight convexity. Volume loss in this area tends to be one of the earlier signs of aging. Replacement of volume loss will reverse this and help to elevate the lateral brow and reduce periorbital rhytides. The skin in this region also tends to be relatively thin affecting the choice of filler you select.
I now use Intraline M4 with Lidocaine. This filler has a high concentration of HA (25mg/ml) with a high G Prime resulting in an impressive lifting effect. I approach this region with respect due to the vascularity and the potential side effects that can result from injudicious filling. 

Firstly, if indicated I inject deeply. I have tended to follow a technique advocated by Dr Arthur Swift MD. This is a single injection using a 27G needle placed vertically 1 cm above the temporal fusion line and 1 cm laterally. The needle tip is placed deeply onto periosteum where it is maintained during bolus injection. Aspiration as always being performed firstly. In addition, a handheld vascular doppler probe can be used to highlight any arterial presence. The HA is then digitally massaged inferiorly to spread the filler.Aesthetics Journal Image
I then treat the superficial aspect of the temples and the inferior continuation of the lateral temporal fat pad. As previously mentioned, the skin in this region is relatively thin and using a high concentration/G prime filler may result in lumpiness and potential filler visibility. In addition, this is a large volume and would require many syringes to address. A large number of papers have been published using “hydrated fillers” where the chosen HA filler is “hydrated” with normal saline +/- lidocaine to provide a greater volume and smoother injection. It has been my practice to “hydrate” the Intraline M4 Plus with injectable PRF. Platelet‐rich fibrin (PRF), a second‐generation platelet concentrate is obtained using a one‐step centrifugation process without the use of anticoagulants and thereby totally autologous. The resulting product contains cell types (platelets, leukocytes, red cells), an extracellular fibrin matrix, and an array of bioactive molecules (predominately growth factors).

The M4 HA filler is mixed with the injectable PRF and the mixture will remain in an injectable form for 15-20 minutes. Having pre- selected my puncture side and injected 0.1 ml lidocaine HCL intradermally I then make a single puncture with a 21G needle. Using a 25G 70mm cannula I proceed to fill the temple and lower LTF with a fanning retrograde filling technique. The injected area is then gently massaged to achieve a smooth result. The multitude of growth factors released in the PRF will also help to address some of the aging skin issues including collagen and elastin content, lentigines etc.

The first two stages describe above will address some of the volume issues and at the same time will start to lift sagging in the lower third of the face and the jawline. Using a cannula in the LTF will also help to reduce some of the tethering of the skin caused by free radical induced sub dermal fibrosis.

To bring about an improved lifting effect I now turn to my PDO threads.

The recent introduction of absorbable barbed threads, producing a mechanical tensile effect (lifting effect) associated with the biological effect (neocollagenesis), is a good alternative.

Many histopathological studies have indicated dermal and subcutaneous foreign body reaction, after inserting the thread, in the form of lymphocyte infiltration, collagen deposition, and fibrosis.
The fibrosis process is followed by fibrous tissue contracture and traction on the skin and results in skin tightening. The barbs (cogs) on the thread get hooked and adhere to the tissue providing a firm grip (anchorage effect). After 6-9 months the implanted thread undergoes biodegradation consisting of hydrolysis, fragmentation, absorption, and excretion. During this time however, they will be replaced by collagen and firous tissue producing a longer effect (12-15) months.

I have been using the Intraline 19G 100mm 360/720 Cannula Cogs with great results. Using a single entry point high on the Zygoma insert 3 sub-dermal threads bilaterally down to the angle of the jaw and the jawline. Gentle traction and upward placing of the skin on the threads will then give the additional lifting effect desired. One additional benefit of treating the LTF with the HA/PRF combination is that it makes insertion of the cogs easier and less painful.

In summary, I have found that addressing the issues of mid and lower face aging by firstly managing temples and lateral temporal fat pads, very effective. It also provided a more global improvement by reducing the issue of hollowed temples. The procedure can be repeated as required to achieve optimal results and the results are showing an acceptable longevity (12-18 months). Just as importantly, the procedures described are extremely well tolerated and can be carried out with local anaesthetic injections with or without topical anaesthetic creams.