Newest Facial Rejuvenation Techniques in the International Plastic Surgery Arena

I have just returned from an international plastic surgery conference in New York City where the world’s leaders in plastic surgery convened to discuss the latest and greatest facial rejuvenation techniques. I always enjoy this particular meeting, because the old guard and the new guard square off to discuss and debate the tried and true methods of rejuvenation and compare them to new and emerging technologies and techniques…sometimes in a fairly animated way! I am happy to be able to share some of what I took away from this meeting with you in this article.

Facial aging occurs in three ways:

1. The skin thins and the texture becomes dull, wrinkled and pigmented. This is surface aging.
2. Secondly, the tissues sag in response to gravity.
3. Finally, in some patients, the face deflates due to fat shrinkage, called atrophy, in the deeper layers of the face.

Each of these different types of aging is rejuvenated more effectively with different types of treatment. It is agreed by all in the plastic surgery community that skin rejuvenation is paramount to providing the best surgical results. How the skin is rejuvenated the best is rarely agreed upon.

Lasers vs Chemical Peels

Lasers have been in the limelight for at least the last ten years in the plastic surgery and dermatology worlds. They became popular because the public usually wants the least invasive, least downtime treatment that will provide them with a great result. Unfortunately, for many patients and physicians alike, the results from laser therapy have been less than overwhelming, and disappointment has been common. There have been several generations of lasers during my career. However, in my mind, there are two main groups. The early group such as ablative CO2 lasers got rid of all the wrinkles, but came with very prolonged healing times and loss of skin pigmentation. The newer generation of fractionated CO2 and erbium lasers have much reduced healing times, but the results are incomplete and very short lived. As you can probably tell, I am not a fan of lasers in facial rejuvenation and interestingly many of the speakers at the meeting have abandoned its use. Not all, but the majority.

So if not laser, what is the best way to rejuvenate the skin surface? Old-fashioned chemical peels are making a slow but sure resurgence, and I couldn’t be happier about it. There are many different types of acids used for peels and many different strengths. Each peel comes with different downtime, risks, and results. Many of today’s young plastic surgeons have never done a deep peel, because when lasers became popular, peeling was relegated to the dermatologists or aestheticians. In the US, chemical peels started in the hands of lay persons in Hollywood. Ultimately, a Florida plastic surgeon obtained the secret formula and began using it on patients. Primarily due to a lack of understanding of how the formula worked and why it worked, some complications occurred and it fell out of favor. Elegant research done in the 1990s by a plastic surgeon named Hetter led to a clear understanding of the formula’s active ingredient and how to vary the concentration to provide different results.

Deeper peels such as 35 percent trichloroacetic acid or phenol peels should not be done without adequate skin preparation. Topical skin care products have entered the era of being science based. The formulations now are made in such a way that anti-oxidants such as vitamin C and phloretin are actually absorbed and have a profound effect on stimulating collagen production, which is greatly diminished in aging skin. In summary, a comprehensive skin care program followed by a deep peel will have a tremendously beneficial effect on the appearance of the surface of the skin.

Gravity or Loss of Volume?

To correct sagging, there is currently a great deal of debate over whether gravity or deflation has the greatest impact on our appearance with aging. The deflation theory advocates recommend fat grafting at the time of all of their facial surgeries to assist in filling the face back up to a more youthful fullness. While it is ragingly popular, I am not a fan of this technique. First of all, in the land of plenty, I do not see a lot of deflated faces in my office. I see plenty of tissue; it’s just not in the right position. I think facial aging is primarily the result of gravity. In a well-executed facelift, the facial tissues are recruited back into more favorable positions where they existed at earlier stages of life. I feel this provides the more natural results and does not lead to the doughy or overly full appearance on those I see who have been aggressively fat grafted. Also, fat grafting is still a bit unpredictable. Sometimes the fat takes well and evenly, and sometimes it doesn’t, at which point revisions are required. If patients gain weight after fat grafting, the fat grafts that take get bigger, just like tummies. I prefer a more natural re-creation of a more youthful appearance. Too many fat grafted patients look like different people and not as natural in my opinion.

Many patients are interested in non-surgical skin tightening. There are many radio-frequency and ultrasound-based energy devices that are currently being used to attempt to re-tighten lax skin in the face and neck. In short, I am completely underwhelmed with the results. While there may be some minimal tightening that occurs in the short term, any tightening that is present at six months is rare and difficult to discern. While these types of therapies may help some people with very early signs of aging or very localized skin laxity, for the majority of patients, the results remain unimpressive, and I hear of their discontent frequently in the office.

In summary, plastic surgeons are people and their preferences vary like any other group of people. For me, lasers and energy-based devices provide inadequate results. Fat grafting creates some odd looking individuals and has a high revision rate. Neither meet with my desire to provide predictable and natural results. Peeling is a lost art and I am happy to be able to continue to broaden the variety of peels I offer to my patients as well as a scientifically based skin care program that provide stellar results. In selecting a plastic surgeon, meet with several until you find one who seems to share your philosophies and desired aesthetic outcome.

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