Minimally Invasive Facial Rejuvenation
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Larry Weinstein MD FACS
Chester, New Jersey
In assessing an aging face, the first thing I do is assessing the quality of the skin. Everyone hates wrinkles. Assessing the nature of the wrinkles is critical to the treatment. The single most important factor for treatment of hyperdynamic muscle wrinkle lines is the use of temporary or permanent paralysis. Botox has revolutionized the noninvasive armamentarium of facial rejuvenation. Forehead wrinkles, glabellar frown lines, crows feet, vertical lip lines and facial asymmetry are areas I have successfully treated with botox.
I have found that the 100 units of Botox can be diluted with 10 cc of normal saline. I use one to two milliliters per patient. Five units of Botox placed under the skin of wrinkled crows feet is effective in softening and or eliminating crows feet lines for three to four months or more. It is not necessary to actually inject the muscle, as attempts to inject actual muscle may cause deep penetration, which may result in paralysis of unwanted muscle. One of the reported complications of Botox is an extraocular motion problem, which has been completely avoided in my practice by this simple superficial injection.
Prior to my injection, I prefer the patients to apply EMLA cream one to two hours before the procedure. If this is not done, I’ll use ELAMAX 15 minutes before the procedure. I also like all patients to have ice applications one to two minutes before the injection and I apply pressure to the injection site for two minutes immediately afterwards. In eighty-three Botox injections in the past year, I have had two patients with minimal bruising and no other complications. One of my patients on Coumadin stated, “after Botox injections in LA, I had bruises for ten days around my eyes. With Dr Weinstein’s preinjection ice and postinjection pressure, I have none.” Ice and pressure are the simple keys to atraumatic Botox injection technique.
Vertical lines of the upper lip are one of the most difficult aging problems of the face. I was surprised to read an article in the Aesthetic Journal describing the use of Botox for these vertical lines. Subsequently, I followed the advice of our colleague and found four injections of 1 to 1.5 unites of Botox to the superior aspect of the upper lip beneficial in the temporary elimination of deep hyperfunctioning vertical muscle lines of the lip. Although in the past I used a CO2 or ERBIUM LASER for many of the lines, I now find they usually respond to Botox. Prolonged pain, rawness and red skin color with LASER treatment in contrast to Botox no down time is clearly attractive to patient and surgeon. The fact that patients have no down time is particularly attractive to this atraumatic Botox injection technique. Unfortunately, the temporary nature of its effect may cause undue distress in a neurotic patient. The risk of a droopy lip may err a physician from the benefits that can be seen with Botox superficial injection technique.
After identifying the hyperfunctioning muscle lines that can be treated easily with Botox, I then concentrate on the areas that can be fixed with our minimally invasive plastic surgery armamentarium. When I check brow position, I also look carefully at the anterior hairline. I find in the aging patient, both male and female, that a receding hairline is common. So, although my preference is the endoscopic technique for brow elevation, I will offer an anterior hairline incision for brow elevation in those patients with a receding hairline. This anterior hairline technique allows the hairline to be brought forward, while elevating the brow and correcting glabella furrows. As in Figure 2 and 4 the anterior hairline was used to elevate the brow and bring the hairline slightly forward. Respecting the widow’s peak is important in obtaining a natural result. Endoscopic brow lifts are ideal for patients with normal or low anterior hairline. In Figure 1 an endoscopic brow lift raised the brows to a natural level. I don’t attempt to elevate the brows beyond the upper bevel of the superior orbital boney ridge. The surprised unnatural look can be avoided by palpating the superior orbital ridge and setting the lift not to exceed this easily palpable parameter.
I correct lateral lid hooding by upper Blepharoplasty. I excise excess skin and muscle in an ellipse. If the Corrugator muscle is hyperactive I consider a palpebral incision for corrugator muscle resection. Corrugator muscle resection can be a more permanent method of correcting glabella furrows. I close the upper lid with a running 4-0 Nylon suture on a P-3 needle. I assess lower lids for excess skin, muscle, and fat. I perform lower Blepharoplasty through external subciliary incision. I remove excess skin as necessary, tighten the muscle and do limited fat removal. In figures 1,2 and 4 lower Blepharoplasty was performed as described. I close the lower eyelid skin with a running 6-0 Nylon on a P-1 needle. Through this incision I occasionally elevate nasolabial folds. However, I perform a facelift for heavy nasolabial folds, jowls and excess neck skin.
Minimally invasive procedures have been described as early as 1912, temporal skin excisions in 1926 and expounded by Gilles in his textbook of Plastic Surgery principles. The principal that stands out most resolute in my mind is to listen to the patient. Sometimes a minimal incision facelift focusing on one area of patient need, can be effected easily with minimal recovery. I use anterior auricular incisions, posterior auricular incisions, or both depending on the patient’s needs. I am not a purist, or firm advocate of either. I always avoid hairline displacement by using a high flap to eliminate transverse retroauricular scars. Regardless of where the incision is, I do a 2-layer closure with 3-0 or 4-0 Vicryl deep dermal sutures and 4-0 or 3-0 Monocryl subcuticular closure. In figures 2,3 and 4 both preauricular and posterior auricular incisions were performed to correct excess laxity of facial skin, nasolabial folds, jowls and slight excess in neck skin. If treating a fatty neck, I use liposuction and or direct excision of neck fat with a lighted retractor. I imbricate the platysma to tighten the neck through an inferior chin crease incision. A lighted small polyurethane-coated retractor is used to visualize the edges of the muscle. I close this incision in two layers. The only time I use staples is for endoscopic forehead lift, when using the technique of screw fixation to the periosteum and securing lift with the staple. I have used staples if the patient needs a quick wound closure to urinate. The latter has only happened once. I do most of my facelift and brow lifts under general anesthesia. On a rare occasion a patient with a weak bladder gets on my ambulatory facility local standby table.
When doing the facelift closure, I want the wounds to be barely visible. Women are concerned that if the wind blows their hair up, that there be no visible scars. Some women like to wear their hair back in a scrunchie or ponytail. My posterior auricular incision is the posterior sulcus and I run back from this as necessary above the superior aspect of the posterior concha. In an anterior approach, my incision for a facelift is posterior to the tragus of the ear. I also place two stay sutures one just above the superior anterior aspects of the ear and the second to the mastoid periosteum to hold the skin in place. After which I trim the skin with a curved Iris scissors. I prep the hair on the facelifts with Betadine and prior to my suturing I move the hair away from the sterile area with Bacitracin ointment.
I use collagen injection for thin lips, static lines, and as a filler. A patient requesting fat augmentation of the lip may better be served by collagen injection first for thin lines, static lines, and as filler. A patient requesting fat augmentation of the lip may better be served by Collagen injection first to allow the patient a gradual or temporary increase in size, which is more easily accepted than a large increase in size. It is better to use collagen to augment a lip temporarily and gradually. This helps to avoid the psychological stress associated with massive lip augmentation with autologous fat injection. No amount of Prozac will calm a patient who feels the have lips at they can us to stick their body to a wall. Albeit, one could do gradual increase of lip with 1-cc increments of autologous fat injections, however, this would incur greater expenses for the patient. My experience is that 25 to 30% of the fat remains as a permanent increase in size of the lip.
Attractive alternatives are available for minimally invasive facial rejuvenation. Tailoring the procedure for the right circumstances, physical findings, patient concerns health of the patient and physician abilities can be balanced to achieve consistent improvements. Definitive improvement in one area can help a patient realize trust and confidence to have a procedure to improve another. Carefully delineating all the areas of an aging face prior to embarking on the treatment of one area is helpful for patient understanding of what can be achieved. Utilization of minimally invasive techniques with minimally visible incisions is critical to patient satisfaction. Rapid recovery and return to normal activities is accelerated with these widely accepted techniques.