• #6-3. Aging and Skin Sagging


    Based on the above mentioned characteristics of aging, we can devise the following treatment strategy. It can be described simply by plus and minus and lifting. The upper and mid face can benefit from plus procedure that supplements deficient volume or lifting procedure. The lower face can be best addressed with minus procedure where excess tissues are removed and lifting procedure.

    1. Upper face:Volume can be enhanced using dermal filler or fat graft(plus procedure, Image5).Forehead lift can correct droopy eyebrows (up procedure).Patients with ptosis can benefit from upper blepharoplasty with partial resection of the upper eyelid.

    2. Mid face: The upper cheeks should have sufficient volume. Accumulated fat in the lower cheeks (above nasolabial lines) creates a sagging look. Lacking volume can be corrected with fat graft or dermal filler (plus procedure, the lower eyelid may appear to protrude due to weakened fat pads).Liposuction or mid face lift can be carried out to address fat accumulation in the midface (up procedure).

    3. Lower face: Face lift can be beneficial in cases with the lower face volume increase and wrinkles from overall sagging (up procedure). However, patients without severe sagging may benefit more from a facial contouring procedure that reduces undesired volume or liposuction (minus procedure, Image6).



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    Image 5. Desirable Volume Change; It is better to head up


    Dermal filler injection in the forehead


    The facial skin consists of five layers(1. Skin, 2. Subcutaneous, 3. Musculo-aponeurotic, 4. Retaining ligament or Loose areolar tissue, 5. Periosteum and Deep fascia). As for injecting dermal filler into the forehead and temple area, I target Number 4. loose areolar tissue. This layer has a lower risk of lumps and allows easy molding after injection.

    This layer becomes the subgaleal fascia at the upper forehead and lies between deep galeal layers 2-2.5cmabove the eyebrows (Generally, dermal filler is injected into the subgaleal fat pad gliding plan). In the temple area, filler should be injected between the superficial temporal fascia and deep temporal fascia.

    To minimize complications, I vertically insert blunt cannula in the Number 3 layer and induce hydrodissection by injecting a local anesthetic before injecting the filler. I believe it is very important to carry out nerve block as well. This prevents pain during the procedure and also helps prevent bleeding by causing blood vessels to contract.

    In the next article, we will take a look at upper and lower blepharoplasty, forehead lift, face lift, thread lift, and additional botulinum toxin and dermal filler injection techniques.


    -To be continued-

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