The Masterpiece of Aesthetic Medicine
Essential anatomy for combination modalities (toxins, fillers, threads)
Sound knowledge of the anatomy of the face and neck is the cornerstone to the safe use of aesthetic modalities to ensure optimal outcomes, Lucero said.
He said clinicians should be familiar with the various tissue layers of the skin on the face and neck, from superficial to deep (the skin, the subcutaneous tissue, the superficial muscular aponeurotic system (SMAS), the retaining ligaments and spaces, and the periosteum and deep fascia overlying the bones). He noted that the SMAS, a thin muscular sheath, overlies facial muscles and neurovascular structures and should be avoided during threading and filler procedures. Several dermatological procedures should instead pass through the subcutaneous layer and the supraperiosteal plane, which are considered safe areas void of neurovascular structures.
Shifting the discussion to the anatomy of the midface, Lucero explained that the upper branches of the facial nerve should be avoided during Happy LiftTM (Revitalizing) thread procedures. The facial nerve emerges from the parotid gland and runs superoanteriorly over the zygomatic arch and towards the frontalis.
He then proceeded to discuss several aspects of the anatomy of the nose, nasolabial area, and lower face, before defining the two most commonly used safety lines during thread lift procedures (Figure 1). The first safety line runs from the lateral canthus to the tragus and the second line runs from the medial canthus to the modiolus. The temporal branches of the facial nerve run cranially from the first line while the facial artery runs medially from the second line. Hence, these areas should be avoided, he concluded.
The science behind novel aesthetic modalities
Paz-Lao presented the integrated approach in aesthetic medicine characteristic to RELIFE. This approach combines multiple techniques to achieve the tailored needs and desires of each individual patient. Using the “three R’s” of Reshape (using threads), Restore (using fillers), and Resurface (using cosmeceuticals), RELIFE is able to achieve a noticeable and natural-looking effect.
RELIFE reshaping is achieved through Happy LiftTM (Revitalizing) threads. These are a wide selection of absorbable, monofilament, suspension-barbed threads of synthetic origin, which can be used for tissue support and noninvasive facial lifting.1 Paz-Lao explained that these threads exert dual action on tissues: (1) an immediate lifting mechanical effect for tissue support and repositioning; and (2) delayed revitalizing action by stimulating the synthesis of collagen, hyaluronic acid, and elastin.2 Happy LiftTM (Revitalizing) threads have twice the tensile strength compared to other threads tested. Importantly, clinical studies have shown that Happy LiftTM (Revitalizing) threads result in immediate facial reshaping and high patient satisfaction.2,3
RELIFE restoration, on the other hand, can be achieved with SkinfillTM plus, Paz-Lao explained. SkinfillTM plus is a range of cross-linked hyaluronic acid (HA) based fillers for the restoration of facial volume. SkinfillTM plus is based on COESIX technology, an innovative cross-linking technology employed in the last stage of production of HA.1 COESIX technology uses a micronization process to optimize the size of HA microparts. This process leads to unique benefits, such as high cohesivity and a stable, long-lasting effect. SkinfillTM plus is available in three formulations: (1) SkinfillTM Silver plus (light cross-linked HA); (2) SkinfillTM Gold plus (medium cross-linked HA); and (3) SkinfillTM Diamond plus (high cross-linked HA).
Paz-Lao concluded that both Happy LiftTM (Revitalizing) threads and SkinfillTM plus have been evaluated and approved by the Philippine Food and Drug Administration for safe and effective use in clinical practice.
Clinical expert sharing: Novel hyaluronic acid fillers
Somasundaram outlined the role of SkinfillTM plus in natural-looking facial restoration and shared his experience using SkinfillTM plus. He explained that SkinfillTM plus is a cross-linked HA-based filler that comes in three variants, which allows for its use in a wide variety of facial restoration procedures. For example, he uses SkinfillTM Silver plus, a light cross-linked HA filler, in the treatment of periocular wrinkles.4 For perioral wrinkles, he uses SkinfillTM Gold plus, a medium cross-linked HA filler. For mid-deep wrinkles and folds, he prefers to use SkinfillTM Diamond plus, the high cross-linked variant.
Somasundaram added that the variants of SkinfillTM plus can be used together on the same patient for a tailored treatment. He demonstrated this through a case of a female patient with a good jawline and beautiful lips but would like to improve her tired eyes and have sharper, more distinctive features (Figure 2).
Somasundaram explained that for this patient, the plan was to focus on the midface. Enhancement of the nasal bridge and chin was done using SkinfillTM Gold plus while the chin was enhanced with SkinfillTM Diamond plus. Finally, the eye area was softened using SkinfillTM Silver plus. These resulted in the rejuvenation of the eyes and enhancement of the projections of the nose, chin, and midcheeks.
• Eyes: 0.3–0.4 mL of low-viscosity hyaluronic acid (HA) filler (ie, SkinfillTM Silver plus)
• Nasal bridge: 0.1–0.2 mL of medium-viscosity HA (ie, SkinfillTM Gold plus)
• Cheek: 0.5 mL of medium-viscosity HA (ie, SkinfillTM Gold plus) per cheek
• Chin: 1 mL of high-viscosity HA (ie, SkinfillTM Diamond plus)
Clinical expert sharing: Novel bio-absorbable suspension threads
Due to the ageing process, skin loses some of its natural elasticity and support, which leads to tissue sagging and wrinkles. Happy Lift-TM (Revitalizing) threads are minimally invasive face-lifting threads that, according to Fundaro, can be used safely in most patients using a few, quick, fundamental techniques. He emphasized that the best results require knowledge of the facial anatomy and careful evaluation of the ageing-related modifications of a patient’s face. “The ideal candidate for Happy LiftTM (Revitalizing) threads is a patient between 30 to 60 years old with minimal or moderate signs of ageing—although even patients with severe ageing may demonstrate a slight improvement after treatment—and have normal or thick skin and trophic or moderately hypertrophic superficial fat compartments,” he explained.
Fundaro then described the five fundamental techniques that could be performed using Happy LiftTM (Revitalizing) threads. These are the Jawline Reshaping Technique (JR), the Malar Reshaping Technique (MR), the Lateral Reshaping Technique (LR), the Oval Reshaping-Vertical Technique (OR-V), and the Oval Reshaping-H Technique (OR-H). Most of these techniques use the J-stitch, wherein the thread forms a 15o to 20o angle at the “J point”. This stitch provides greater holding strength and is formed by having the suture exit and enter at the same point at an angle.
The JR Technique
The JR technique is the basic jaw-reshaping method. The entry point of this technique is at a point 1 cm above the mandibular angle. The thread then moves in two directions: (1) towards the medial margin of the jowl; and (2) from the same entry point until 4-5 cm cephalad towards the pretragal area, and then turns at a J point downward along a line towards the direction of the first exit point but exiting just 2 cm from the J point.
The MR Technique
This technique provides contouring of the malar region. The entry point of this technique is at the pretragal area. The thread then runs towards the two exit points, namely (1) a point near the modiolus just lateral to safety line 2 (SL2) (Figure 1) and (2) a point just lateral to the midline of SL2.
The LR technique
The LR stitch reshapes the lateral face by contouring both the jaw and the malar area. The LR technique shares the same entry point as the MR technique, which is also its J point. The first part of the thread then runs downwards towards the angle of the jaw, then bends to run along the medial margin of the jaw. The second part of the thread runs from the entry point along the malar area towards the modiolus and exiting just lateral to SL2.
The OR-V technique
This technique gives an oval contour to the lateral face. The entry point is also at the pretragal area. The thread is run towards the midline of the lateral margin of the jaw, just until before the thread’s section without cogs to reach the entry point. The remaining part of the thread is then threaded from the entry point forward just below safety line 1 (SL1, Figure 1), towards an intermediate point 2 cm away. The thread is then run downwards towards the modiolus, just lateral to SL2.
The OR-H technique
The OR-H technique uses two threads. The first thread’s entry point is at the pretragal area. The first part is threaded down and exits at the angle of the jaw, while the second part is threaded upwards and exits a few centimetres from the entry point. The second thread enters at the intermediate point indicated in OR-V. The first part of the second thread runs downwards towards the anterior margin of the jaw, while the second part also runs cephalad, parallel to the first thread, for a few centimetres. Care should be taken to ensure that the temporal vessels and branches of the facial nerve are not damaged.
Clinical experience sharing: Happy LiftTM (Revitalizing) threads among Filipino patients
Arzadon described the different steps when performing a Happy LiftTM (Revitalizing) thread procedure, using the basic JR technique as an example. He explained that the entry and exit points should be anaesthetized with 1:100,000 (epinephrine:lidocaine) local anaesthesia, while the thread paths should be anaesthetized with 1% lidocaine. The entry point is then stabbed with the G19 needle, and the needle is then carefully inserted at a 90-degree angle. The needle is then advanced towards the exit point.
Arzadon then presented several cases of Filipino patients he has treated using the Happy LiftTM (Revitalizing) threads. He noted that in most patients, favourable results can be achieved using only one technique. However, Arzadon also demonstrated that some techniques may be combined in a single patient to achieve specific results as desired by the patient. For example, he presented the case of a middle-aged woman who wanted lifting of lax tissue on the cheeks as well as improved facial definitions. Arzadon performed a JR technique to lift lax tissues on the cheek areas and add contour on the jowl, combined with an MR technique to add tone and contour on the malar area. The end results are shown above (Figure 3).
1. Rigano Laboratoires S.r.l.Prot 148/17. 2. Savoia A, et al. Dermatol Ther 2014;4:103-14. 3. Kalyan R, et al. Int J Clin Expl Dermatol 2017;1:1-3. 4. SkinfillTM plus instructions for use.
Happy LiftTM (Revitalizing) thread
INSTRUCTIONS FOR USE
Description: Happy Lift (Revitalizing) monofilament thread is a surgical medical device of absorbable synthetic origin. It is made from poly (L-lactide-co-ε-caprolactone) or poly (p-dioxanone). Happy Lift (Revitalizing) is available in both white natural colour or dyed violet (D&C Violet N°2 – C.I. 60725) and is available in various lengths and gauges (EP/USP) in a free thread version and pre-assembled with stainless steel needles of different sizes and shapes; it may present, over its entire length, superficial indentations. The device is also packed in pouches containing pledgets in TEFLON, “various accessories” (polypropylene beads, collars and buttons) or with a final button (of the same material of the thread) used to anchor the thread. Precautions: HAPPY LIFT (Revitalizing) is to be used in hospitals operating theatres and ambulatories or in any hospital environment by qualified personnel. Care should be taken when handling the thread material to avoid any bending or flattening to the thread due to the application of surgical instruments such as forceps or needleholders. Surgical threads are disposable medical device and must be disposed of as waste material.
INSTRUCTIONS FOR USE
DESCRIPTION: Skinfill Plus is a sterile, injectable, non-pyrogenic, reabsorbable medical product made out of reticulated hyaluronic acid of non-animal origin, produced via bacterial fermentation. Skinfill Plus is a colourless gel contained in a pre-filled, graduated, disposable, and sterile syringe with a Luer adapter CONTRAINDICATIONS Skinfill Plus must not be used: • for injections into eyelids and sockets; • for injections into blood vessels; • for breast augmentation, or for bone, tendon, ligament or muscular implantation. Skinfill Plus must not be administered to patients with: • ascertained tendency to develop hypertrophic or keloid scars or pigmentation disorders; • previous active autoimmune diseases or those under immunotherapy; • serious multiple allergies or active inflammations; • coagulation disorders; • acknowledged hypersensitivity to hyaluronic acid. Skinfill Plus must not be used on pregnant or breast feeding women nor on people below the age of eighteen.