The demand for facial skin rejuvenation is driving a wide range of technological advances in traditional and modern facial lifting and other related rejuvenation procedures, soft tissue fillers (Fillers) and Botulinum Toxin Injection (Botulinum Toxin Injection), Laser skin resurfacing, Radio frequency skitightening ), Laser skin resurfacing, Radio frequency skitightening, Chemical peel, Dermabrasion, etc. All the old and new technologies are developing rapidly, but none of them has all the All the new and old techniques are developing rapidly, but none of them have all the required characteristics. Understanding and appreciating the advantages, disadvantages and advances of each rejuvenation technique is important to properly guide the candidate in their choice.
The history of facial rejuvenation treatments begins with the history of surgical wrinkle removal, which dates back 2,500 years to Egypt and India. 1901 saw the first modern face lift performed by German doctors who simply removed excess skin without tissue separation. In 1974, Skoog proposed the landmark method of wrinkle reduction by separating the superficial fascial layer of the face and neck, followed by Mitz and Peyronie, who named this layer of fascia continuous with the latissimus dorsi muscle the superficial musculo-tendinous system ( superficial musculo-aponeurotic system, SMAS) [1]. Over the past 30 years, there have been many new inventions and improvements based on the scope, incision and separation levels of the traditional SMAS face lift, and many controversies have arisen as a result, with a general history of development and classification as follows.
Traditional superficial myotendinous system SMAS lift
The typical traditional SMAS lift involves freeing, tightening and repositioning the cervicofacial skin, and repositioning the SMAS/extensor carpi radialis as a unit. The extent of skin incision and release varies from person to person. Regarding the incision, Kridel recommends the shortest possible incision along the anterior ear screen margin, turning to a horizontal orientation to the temporal area, and a posterior ear incision along the auricular nail; regarding the extent of subcutaneous release, Thomas Baker recommends dissecting the lateral 2/3 of the zygomatic process, reaching a few centimeters forward to the lateral nasolabial fold to facilitate the lifting of the medial zygomatic skin by rotation of the SMAS; the dissection under the SMAS anteriorly reaching the anterior margin of the parotid gland, the flap is tightened posteriorly and superiorly, and the excess SMAS posteriorly and inferiorly is fixed to the temporal bone mastoid [1].
Deep and composite facelift
In response to the above-mentioned shortcomings of the traditional face lift, which did not emphasize the correction of zygomatic fat pad sagging, Hamra (1986) proposed a deep face lift including zygomatic fat pad, broad cervical muscle, and skin, which was refined in 1992 and named composite face lift: a composite tissue flap with blood supply from the facial artery, medial canthal artery, and infraorbital artery, including the orbicularis oculi, is lifted from the deep side of the SMAS to form Kamer [3] conducted a prospective study of 100 patients who underwent a deep face lift and 97% were satisfied with the results of the procedure.Hamra [2] reported 167 patients who underwent a composite face lift with one case of hematoma that needed to be aspirated and no complications of facial nerve injury.
Endoscopic wrinkle reduction
As more and younger people seek facial rejuvenation procedures, the advent of endoscopic wrinkle reduction has catered to the demand for less invasiveness, reduced perioperative and postoperative complications, natural appearance, and longer maintenance periods. A survey by the American Society of Plastic Surgeons (ASPS) has shown that about half of the surgeons choose to perform brow lifts through a coronal incision, which is considered more desirable than the endoscopic procedure for lifting the brow and reducing forehead lines and frown lines, and the older the surgeon, the more they prefer the coronal incision. However, with the improvement of fixation techniques, Dayan (2004) designed a rigorous retrospective study and concluded that a one-year follow-up comparison between coronal and endoscopic brow lifts suggested no significant difference in the degree of brow lift, with the same brow shape and position drooping after the fifth year of coronal incision debridement.
Small Incision Face Lift
In parallel with the development of endoscopic wrinkle reduction, there is a search for less invasive, faster recovery and less complications of small-incision facelifts that do not require complex instruments. These procedures are attractive because they reduce or avoid a retroauricular incision, narrow the flap anatomy, and can be performed under local anesthesia or local anesthesia + sedation.
Serrated (anchored) suture suspensions
The use of barbed or anchored suspension sutures with a guide needle through the soft tissues to achieve facial lift has recently received a great deal of attention Sulamanidze [9] in 2002 first introduced this type of polypropylene suspension suture with multiple barbs. The stitches are inserted from under the skin and traveled in the subcutaneous fat layer about 1-2 cm deep. The upper end is lifted tightly to the desired position, the ends of the sutures are cut and buried in the skin. The longest follow-up time was up to 2.5 years with good results. Overcorrection and localized depressions of the skin may disappear on their own. It can be combined with an open approach. Other similar sutures, such as the FDA-approved facial contouring suture in 2005; also, Eremia
[10] (2006) reported nodular anchor-shaped body absorbable suspension sutures (PDS or Maxon), most of which showed laxity at 6-12 months follow-up; as an initial study, the risks of suture exposure, suspension dislodgement and asymmetry are prone to complications, in addition, there are more concerns about their long-term efficacy.
From the above-mentioned evolution of facial rejuvenation surgery, the procedure seems to move towards the pursuit of complete results, but it also means more complex and more invasive, and in recent years, multiple, less invasive and minimally invasive treatments have challenged the trend of this surgical modality. 21 prospective hemifacial controlled studies by Ivy (1996) were randomized studies comparing conventional SMAS wrinkle reduction and extensive SMAS composite debridement with separation of the zygomatic fat pad, nasolabial folds, and tightening of the orbicularis oculi. Prado [12], a retrospective study of 82 patients aged 42 to 55 years, showed no difference between the 1-month and 2-year follow-up results of half of the traditional SMAS procedure and the other half of the MACS lifters. Skin laxity of the neck and jawline was reproduced in half of both at 2 years postoperatively. Similar findings were found in additional half-face controlled studies of suspension and conventional wrinkle reduction, suggesting the inevitability of more research focusing on minimally invasive procedures.
Non-surgical wrinkle reduction techniques
Facial rejuvenation has become an increasingly important topic in the field of cosmetic surgery, and traditional wrinkle reduction is no longer a soloist, but has added a number of preludes and accompaniments. The lackluster rise in the number of traditional wrinkle removal procedures and endoscopic wrinkle removal literature is more related to the development of non-surgical wrinkle removal techniques. It is because facial skin aging includes not only tissue relaxation and displacement and skin wrinkle formation, but also a combination of volume loss, skin texture, color change, and vascular dilation. Therefore, in addition to the use of surgery to achieve skin tightening and tissue (fat) filling and resetting, facial rejuvenation also includes non-surgical treatments such as chemical peels, physical grinding, soft tissue filler materials, botulinum toxin injections, and laser radiofrequency, which target photoaging, volume loss and skin sagging, and dynamic and static wrinkles on the skin surface, respectively, with the areas of laser, radiofrequency, and plasma being one of the fastest advancing areas [ 13]. In the case of radiofrequency, for example, from the past monobipolar radiofrequency to tripolar radiofrequency, from the early non-invasive electrodes to the latest invasive minimally invasive electrodes, there is a continuous attempt to find a better balance between efficacy and risk [14]. In terms of the direction of development, radiofrequency treatment for deep wrinkles and skin laxity, fractional laser and fractional radiofrequency for skin texture and static fine lines, and plasma skin rejuvenation for skin aging are a new starting point in the development process of non-surgical rejuvenation. Although certain treatments are not yet as effective as injectable wrinkle reduction, much less a substitute for surgical wrinkle reduction, rapid technological developments are bound to give such treatments an ever-expanding range of indications. How to dynamically recognize and evaluate, scientifically approach the indications for various treatments, and more correctly and objectively serve the patient, has forced plastic and cosmetic surgeons to slow down and become more involved and concerned with the skills and advances in the full range of non-surgical rejuvenation treatments.
In addition to our need for continuous study and practice and a comprehensive understanding of dynamic technological developments, a variety of factors need to be considered when deciding exactly which treatment is appropriate for a particular candidate, taking a detailed medical history, analyzing the main reasons for concerns about appearance, examining and considering the anatomical factors associated with facial aging, assessing the degree and location of laxity, skin and soft tissue conditions, the level of tissue involved in sagging, facial soft tissue volume, the deep bone tissue contour, previous scar growth, gender, and personality. On this basis, the choice of treatment plan can be started and the details of the treatment should be discussed with the candidate himself, informing about the experienced results of the improvement in each area after the procedure [15].
The concept of facial rejuvenation treatment is also evolving, for example, in addition to the repositioning of sagging tissues, a certain degree of rejuvenation can be obtained by subjective and objective evaluation after improving the contour of facial soft tissues by fat injection and improving overly enlarged cheekbones by osteotomy. Therefore, people will continue to enrich the connotation of the treatment into the broad category of facial rejuvenation treatment.
The organic combination and balance of concept and indications, technique and equipment, function and aesthetics, maintenance time and recovery time will continue to evolve and achieve results that were unattainable in the past. A complete understanding of facial rejuvenation treatments needs to be based not only on a comprehensive understanding of surgical and non-surgical techniques, but also incorporates a deep understanding of the scientific, artistic and social factors of the operator. Ultimately, however, an analysis of the results of well-designed prospective studies based on evidence-based medical principles will lead us to a clear consensus in the end.