Friday, May 11, 2018

Filler Fatigue

New York facial plastic surgeon, Dr. Andrew Jacono: “As we get older, our facial tissues becomes more lax and loose. So the only action is to fill it more – it’s like having a pair of pants that are too big. If you were 50 – 70 pounds overweight and you lost 70 lbs, the fabric becomes looser. So you have two options: you can take in the pants or you can get fat again. As we get older, our face becomes like a big pair of pants. Surgery takes in the pants or you can try to blow it up with more filler.”
by Delia von Neuschatz

“Show me a woman that wants to look like she’s in her 40s,”
challenges Dr. Andrew Jacono. “I haven’t met one yet because they don’t exist.”  In describing a good portion of his practice – high profile women in their mid to late forties “who need to look great all the time” – the New York City facial plastic surgeon explained what brings well-heeled patients to his Park Avenue office after years of assiduously visiting their dermatologists. A circumstance that leads a path to his door, according to Dr. Jacono, is the diminishing returns women (and men) are seeing from non-invasive cosmetic procedures, especially when it comes to injectable fillers. They book a consultation, in other words, because they have Filler Fatigue.

“People assume that because you’re young, you shouldn’t have a face lifting surgery. The problem is fillers are great and you should use filler until they don’t achieve your goals,” says Dr. Jacono.  “What happens is that a lot of people eventually hit a brick wall. They’ve been using fillers [like Restylane and Juvéderm] since their mid to late thirties, even in their early forties,” discloses Dr. Jacono, “and it gets them kind of far.” But by the time women reach their mid-forties, fillers aren’t as effective anymore because the facial tissues become too loose. Tighter skin is better able to retain fillers and thus experience a bit of a lift. However, as Dr. Jacono explains, filler has weight and as your skin gets looser, filler actually weighs the face down more.  In short, fillers don’t pick up the slack.

Dermatologist, Dr. Anne Chapas:  “We have patients from their 20s to their 90s getting filler. We have many different kinds of filler and we’re seeing a younger population adopting these fillers for things that aren’t age-related like lip augmentation or hollowness under the eyes. I also have patients in their upper 80s and 90s who come to see us for filler. They’re looking for something different. They are coming to have their individual wrinkles filled in – which is a great instant gratification for someone who’s very senior and can’t go through a resurfacing laser procedure and they just want their lines to look better.

”I think when you’re talking about fatigue, it’s the patients who are trying to get a lifting result and what they really need is maybe a surgical or semi-surgical procedure. I recommend surgery to approximately 10 – 15 percent of my patients. A lot of that initial treatment is my advising patients to get all those things back where they should go. Let’s make sure your neck is in the right position, your jowls are in the right position, brows are in the right position’ and then even those patients we will then touch up with filler and lasers down the road.”
The volume of the face changes around menopause concurs New York City dermatologist, Dr. Anne Chapas. “That’s when women start to say they age very quickly and you see that the upper face kind of starts to fall inward and downward and that’s when a lot of times people come for filler to try to replace that volume,” continues the dermatologist. By then, other factors like sun damage have also started taking their toll.

“So, fillers just to kind of pick up and change the volume isn’t always the answer and people think it is and so they keep wanting more and more and more filler.” A dose of filler, explains Dr. Chapas, is only one ml. - a fifth of a teaspoon. “So, you really have to put a lot of volume in a patient who’s in his 60s to create that lift. That’s when you get into that distortion.”

So, the same amount of filler just doesn’t achieve the same results women had when they were younger. “People think the solution is to add more filler. And as they continue to add more filler, they start looking like all the people who look overfilled,” explains Dr. Jacono. “They don’t look younger, they look distorted. They lose their facial identity. So the solution isn’t more filler.”

What is the solution, then? A facelift is Dr. Jacono’s emphatic answer. Advances in the old-school, skin-pulling procedures are yielding much more natural-looking results rendering surgery more appealing to a younger audience.  If you’re not ready for the scalpel, some minimally invasive skin lifting options will bridge the gap between surgical and non-surgical alternatives. Ultimately, a combination approach may be ideal.

SMAS Facelift

The most commonly performed type of facelift in the United States today is the SMAS (superficial muscular aponeurotic system) lift which elevates the muscles of the lower face and the platysma muscles in the neck. In this procedure, though, the skin is separated from the underlying muscles and soft tissue, creating a tight look. The surgery, which treats only the lower third of the face and jawline, does not address drooping cheeks. As a result, surgeons will simultaneously perform fat grafting to the cheeks which “often makes the cheeks look overfilled because they are not lifted, but are simply inflated,” says Dr. Jacono.

Deep Plane Facelift

A deep plane facelift, on the other hand, repositions the skin and muscle layer together. The skin is never separated from the saggy muscles and fat of the face. Leaving the skin intact in this manner not only results in a more natural look, but in less bruising too.
The above diagram shows how the cheeks are re-volumized by releasing the zygomatic ligaments and repositioning the malar fat pads in a deep plane facelift. Illustration: New York Center for Facial and Plastic Surgery
This diagram shows the tethering points of the face that are released during a deep plane facelift procedure. Illustration: New York Center for Facial and Plastic Surgery
MADE Facelift

The Minimal Access Deep Plane Extended facelift is the gold standard of facelifts according to Dr. Jacono. It is a hybrid technique developed by Dr. Jacono, which combines short incisions with a vertical (as opposed to horizontal) lift while extending the deep plane into the neck, thereby lifting the neck area. “That was never done before,” says Dr. Jacono.

Draping is a key component to a good facelift.  The traditional horizontally directed tightening of facelifts results in a flattening of the face and cheeks. Pulling the skin up in a more vertical direction or vector restores the cheeks, creating a smoother more natural appearance. Another bonus is that vertically lifting the cheeks brings volume up to the under-eye area reducing the hollows in that region.  “The MADE lift is a combination of an extended deep plane lift with a vertical vector. It makes a huge difference in the way people look,” says Dr. Jacono.
The proper vertical vector or angle of the lift is crucial to achieving natural results in a facelift. Dr. Jacono has determined that the ideal vertical facelift “Angle for Maximal Rejuvenation” to be 60 degrees for patients with a mean age of 60 years old.  By lifting the face more vertically, the cheeks are lifted creating the heart shaped face of youth and higher cheek bones without the need for cheek implants or additional fat transfers. It also elevates the corners of the mouth that sag with age, and gets rid of the jowls and turkey neck. As the age of the patient increases, the angle decreases. Conversely, patients younger than 60 years old will require a greater more vertical facelift angle. The Golden Proportion, the ratio used first by artists and then by plastic surgeons when attempting to create symmetrical beauty, is still observed with the “Angle of Maximal Rejuvenation.”  Reference and illustration: New York Center for Facial and Plastic Surgery
Before and After photos of MADE facelifts. 
Photos: Dr. Andrew Jacono
You’re tired of going back for top-ups of cheek filler, but are not yet ready to commit to a facelift? There are some less invasive options.

Customized Cheek Implants

A permanent alternative to filler is facial implants. Off-the-shelf cheek implants, however, are often too big, frequently resulting in an unnatural look. The solution for Dr. Jacono is designing bespoke implants. Using CT scans of the patient’s skull and muscle structure, the doctor works with an engineer to create a 3-D model of the face enabling him to design customized molds. The implants, ready two to three weeks later, are made from FDA-approved silicone. During a one-hour outpatient procedure performed under twilight anesthesia, the implants are inserted in the cheek via a small incision inside the mouth and attached to the cheekbones with titanium screws. “Your face can’t just have a piece of plastic that was fabricated to be used as a generic thing,” says Dr. Jacono. “It’s not an evolved way to do cosmetic surgery. There’s no one else in New York who is doing custom implants.”  Bespoke implants, like haute couture, however, don’t come cheap. Be prepared to pay upwards of $30,000 for this level of individualization.
Before and After customized cheek implants. Photos: Dr. Andrew Jacono
Thread Lift

A more affordable and minimally invasive, but impermanent option, is a thread lift like the Silhouette InstaLift. This procedure uses absorbable sutures gently inserted under the skin to lift sagging jowls, cheeks, nasolabial folds and neck.  It is an in-office procedure performed in under an hour with local anesthesia. Once fixed, the threads encourage collagen production. The results, which can be seen quickly, last up to 18 months. “This procedure is a bridge. We’re using these thread lifts as a bridge between filler and surgery. Not everybody is ready to undergo a surgical procedure and these are giving people a one to two year benefit,” explains Dr. Chapas. Cost start at $3,500 per area.

There are several options – from the minimally invasive to the surgical - available to lift and tighten facial skin beyond the use of injectable fillers. But, it’s not a one or nothing approach. Ultimately, a combination methodology may provide optimal results. “All these things come together,” says Dr. Chapas. “What we’ve learned in aesthetics with plastic surgeons and dermatologists is that there’s no one special magic treatment for the age-related process. Patients are doing surgery with filler or fat transfer. Patients are doing filler with laser. It’s not really one thing that’s going to make someone look better or less aged. It’s usually that combination approach.”
Before and After photos of an InstaLift procedure combined with subtle filler. Photo: Dr. Shereene Idriss of Union Square Laser Dermatology
Expert Beauty Tip: Beware of doing too much Ulthera warns Dr. Jacono:  The ultrasound face-tightening treatment “creates scars in the deeper parts of your skin. It thins the skin and the fatty tissues of your face, making it more difficult to do a facelift on somebody who’s had too many Ultherapy treatments. That’s because as the skin gets thinner, it loses some of its strengthening structure and it droops more. When you have a steak that has fat on it and you put too much heat on it, what happens to it? It melts away. And Ultherapy uses a form of ultrasonic heat energy that’s delivered to the subcutaneous fat in your face. You deliver hot heat to fat it’s just like a steak on a grill.”

As for the ideal number of Ulthera treatments, Dr. Jacono says that “generally speaking, you should never do more than two. And honestly, most people will tell you that they get a big effect from their first Ultherapy treatment, but they don’t see that much in their second or third or their fourth, but they’re doing it because they’re fearful of aging.”

Beware also of the filler Sculptra cautions Dr. Jacono, because of its scarring potential: “Hyaluronic acids don’t cause scarring. Sculptra, however, is a suture material that causes an inflammatory reaction. That inflammatory reaction causes scar tissue under the tissues. So when people get procedures done, they say they create collagen, people don’t realize that collagen is scar tissue. Scar tissue is collagen. So, when you get Sculptra in your face, you don’t get a filler effect like with hyaluronic acid. The body builds up scars which makes your tissues thicker. The problem with that is when you operate on somebody like that, it’s extremely hard to tame all the scar tissue. It makes the operation much more difficult or the person when they’re getting a facelift. It will limit healing and cause other complications. So, if you’re going to do filler in your face, it makes more sense to do something like hyaluronic acid and not Sculptra. That’s a big piece of advice that I give patients who see me who are getting filler injections done.”

On the other hand, it’s difficult to go overboard with Botox injections, according to Dr. Jacono:  “Botox, when done in a metered fashion, can be part of a person’s aging regimen for the rest of their lives because when you’re not crinkling certain parts of your face, you’re not developing wrinkles over time. So there are people who start to do Botox at a very young age to try to prevent the formation. And there are people who have surgery and Botox is part of the regimen to help not re-create the folds and lines and wrinkles we were able to erase with surgery. Starting somewhere in your early 30s is probably ideal.”

For more beauty tips and information, follow Delia on Instagram: @chasingbeautywithdvn