A Review of Minimally Invasive Cosmetic Procedures
In today's society the desire to maintain a youthful appearance has driven the development of minimally invasive dermatological procedures that are designed to rejuvenate the ageing face. The aim of this review is to present evidence for the use of techniques which can easily be incorporated into outpatient dermatology practice with low overhead expenditure. For this reason, laser and light-based treatments have been omitted. This review will instead focus on chemical peels, intradermal fillers and botulinum toxin. These techniques address the main aspects of facial ageing, namely photodamage, volume loss and dynamic lines, which correlate anatomically to skin, subcutaneous fat and muscle. A combination of such techniques will provide the practitioner with a reasonable portfolio of treatments for a balanced, holistic result.
Ageing of the face results from complex interactions at multiple anatomical levels including skin, subcutaneous fat, muscle and bone. The summation of these changes indicates advancing chronological age, and successful rejuvenation requires careful consideration of these interactions for an optimal, natural result.
A youthful face is full and balanced; the skin is smooth and unlined. One can make an analogy with an inflated balloon covered with tight, elastic Lycra® (Invista, Wichita, KS, U.S.A.). With age, there is atrophy of subcutaneous fat pads and the overlying skin droops due to loss of this underlying support, which may be exacerbated by cutaneous photodamage. The 'balloon' deflates and the overlying Lycra® simultaneously becomes less elastic, resulting in sagging. Although perhaps an oversimplification, this analogy is helpful in communicating to patients that facial ageing is not simply due to cutaneous wrinkles. Furthermore, dynamic lines associated with facial expression become exaggerated due to the combined diminution of overlying subcutaneous fat and reduction in skin tightness; this has been referred to as 'relative' muscle hypertrophy.
Numerous minimally invasive dermatological procedures have been developed which address changes associated with facial ageing to recreate a youthful appearance. The unrestrained demand for such procedures may reflect an intrinsic reverence of youth and beauty, which according to the evolutionary theory reflect health and increased reproductive potential. Psychological studies suggest that hyperkinetic facial lines can profoundly impair social function. Furthermore, facial rejuvenation procedures appear to have a significant positive impact on quality of life.
This paper reviews studies (not limited to randomized placebo-controlled trials) identified by searching PubMed, Ovid MEDLINE and The Cochrane Library databases for the following terms: 'botulinum toxin', 'fillers cosmetic', 'hyaluronic acid', 'liquid injectable silicone', 'calcium hydroxylapatite', 'Radiesse', 'collagen filler', 'autologous fat', 'phenol peel', 'pyruvic acid peel', 'alpha-hydroxy-acid peel', 'trichloroacetic acid peel', 'glycolic acid peel', 'salicylic acid peel' and 'chemical peel'. References of retrieved articles were also searched to identify further publications. The paucity of information in some areas, particularly chemical peels, highlights the absence of publication in the peer-reviewed literature, although extensive anecdotal evidence may exist. The minimally invasive techniques discussed [i.e. botulinum toxin (BTX), intradermal fillers and chemical peels] were chosen on the basis that together they address the main aspects of facial ageing and can conveniently be incorporated into general dermatology practice with minimal initial expenditure.
Abstract and Introduction
Abstract
In today's society the desire to maintain a youthful appearance has driven the development of minimally invasive dermatological procedures that are designed to rejuvenate the ageing face. The aim of this review is to present evidence for the use of techniques which can easily be incorporated into outpatient dermatology practice with low overhead expenditure. For this reason, laser and light-based treatments have been omitted. This review will instead focus on chemical peels, intradermal fillers and botulinum toxin. These techniques address the main aspects of facial ageing, namely photodamage, volume loss and dynamic lines, which correlate anatomically to skin, subcutaneous fat and muscle. A combination of such techniques will provide the practitioner with a reasonable portfolio of treatments for a balanced, holistic result.
Introduction
Ageing of the face results from complex interactions at multiple anatomical levels including skin, subcutaneous fat, muscle and bone. The summation of these changes indicates advancing chronological age, and successful rejuvenation requires careful consideration of these interactions for an optimal, natural result.
A youthful face is full and balanced; the skin is smooth and unlined. One can make an analogy with an inflated balloon covered with tight, elastic Lycra® (Invista, Wichita, KS, U.S.A.). With age, there is atrophy of subcutaneous fat pads and the overlying skin droops due to loss of this underlying support, which may be exacerbated by cutaneous photodamage. The 'balloon' deflates and the overlying Lycra® simultaneously becomes less elastic, resulting in sagging. Although perhaps an oversimplification, this analogy is helpful in communicating to patients that facial ageing is not simply due to cutaneous wrinkles. Furthermore, dynamic lines associated with facial expression become exaggerated due to the combined diminution of overlying subcutaneous fat and reduction in skin tightness; this has been referred to as 'relative' muscle hypertrophy.
Numerous minimally invasive dermatological procedures have been developed which address changes associated with facial ageing to recreate a youthful appearance. The unrestrained demand for such procedures may reflect an intrinsic reverence of youth and beauty, which according to the evolutionary theory reflect health and increased reproductive potential. Psychological studies suggest that hyperkinetic facial lines can profoundly impair social function. Furthermore, facial rejuvenation procedures appear to have a significant positive impact on quality of life.
This paper reviews studies (not limited to randomized placebo-controlled trials) identified by searching PubMed, Ovid MEDLINE and The Cochrane Library databases for the following terms: 'botulinum toxin', 'fillers cosmetic', 'hyaluronic acid', 'liquid injectable silicone', 'calcium hydroxylapatite', 'Radiesse', 'collagen filler', 'autologous fat', 'phenol peel', 'pyruvic acid peel', 'alpha-hydroxy-acid peel', 'trichloroacetic acid peel', 'glycolic acid peel', 'salicylic acid peel' and 'chemical peel'. References of retrieved articles were also searched to identify further publications. The paucity of information in some areas, particularly chemical peels, highlights the absence of publication in the peer-reviewed literature, although extensive anecdotal evidence may exist. The minimally invasive techniques discussed [i.e. botulinum toxin (BTX), intradermal fillers and chemical peels] were chosen on the basis that together they address the main aspects of facial ageing and can conveniently be incorporated into general dermatology practice with minimal initial expenditure.