Why choose a liquid facelift?

Dermal fillers are both alternatives and complements to plastic surgery. Some patients are reluctant to undergo surgery, have contraindications for surgery, or wish to avoid the postoperative recovery period. Fillers can temporarily achieve many of the same results as plastic surgery and may, in some cases, prepare a patient for surgery. Dermal fillers can also be important allies after surgery. For example, in the treatment of nose sequelae after aesthetic rhinoplasty, they can help to relieve patient anxiety without the need for repeat surgery.

It is important that all patients have realistic expectations for these procedures and understand that fillers can restore balance, enhance appearance, and minimise the signs of ageing. Facial features may be refined, but they will not be changed completely or permanently (Figure 1).

Facial reshaping with dermal fillers requires regular maintenance. Results will usually last for 3–12 months once the desired result has been achieved. However, patients may return two to three times per year for regular maintenance to prevent defects from getting as bad as they were originally. Maintenance of these results would require two or three treatments during the first year, followed by treatment twice per year, and possibly once per year thereafter.

The restoration of volume using dermal fillers can rebalance facial proportions, increase symmetry, and by reducing wrinkles, produce a younger appearance. Plastic surgery can also achieve these effects, but with considerably greater financial and patient costs, including lost work time and the painful recovery process. Many patients who do not have weeks for recovery are seeking faster alternatives for aesthetic improvement that do not involve significant surgical procedures. Dermal fillers also provide a non-aggressive treatment that can be used preventively in younger patients, or as a means to ‘test drive’ some of the changes that can be made more permanent with surgery8.

There are four commonly reported techniques for filler injection—serial puncture, threading, fanning, and cross-hatching—but there is currently no algorithm for choosing an injection technique. While certain situations may lend themselves to a particular technique, this decision is typically surgeon-dependent and related to experience, defect size and location, as well as the particular filler being used. In the serial puncture technique, the skin is held taut and the needle inserted up to the appropriate depth. The product is then delivered in a small bolus to fill the defect, following which the needle is removed. The needle can then be reinserted along a particular defect and a new bolus injected. This technique is often used for lip augmentation or superficial placement of fillers along a particular wrinkle. In the threading technique, the needle is inserted into the defect and tunnelled through at the appropriate depth. As the needle is being withdrawn, the product is delivered in a slow, continuous stream. This technique is commonly used for lip augmentation and nasolabial fold injection. The fanning technique is similar to the threading technique, but the direction of the needle is continually changed in a radial fashion, and new lines are injected without withdrawing the needle tip. Cross-hatching involves a series of threads injected in a perpendicular fashion to each other. The fanning and cross-hatching techniques are generally used to fill larger defect areas6.

Surgical facelift

The composite facelift is a well-described technique for comprehensive facial rejuvenation that includes tissue repositioning of every part of the ageing face. The most distinct characteristic separating this from all other facelifts is the movement of the cheek and malar tissues in a superior–medial vector instead of a superior–lateral vector and arcus marginalis release and septal reset, in which the orbital septum is sutured over the orbital rim.

The aim of the composite facelift is to reverse the normal course of ageing, which includes the skeletonisation of the periorbital area as the soft tissue changes lead to the appearance of the underlying bony anatomy. The soft tissue contour of the lower eyelid becomes concave, and an ‘eye socket’ slowly develops. The vertical height of the lower eyelid elongates, and the eyelid–cheek junction becomes clearly defined. The composite facelift, with its arcus marginalis release and septal reset, attempts to re-establish the youthful appearance of the lower eyelid–cheek junction, creating a convex lower eyelid contour.

The composite facelift technique has evolved in a well-documented fashion over 25 years of performing the Skoog facelift. This was followed by a modification in 1978, ‘The Tri-Plane Facelift’, which added a preplatysmal cervical dissection separating the preplatysmal fat from the lower face.

Postoperative care is much the same as that for any facelift operation, except that more care is needed for the eyes owing to the fibrosis and healing of the periorbital area, which results from the surgical attachment of the orbicularis to the periosteum of the lateral orbit. This causes tightness and thickening of the eyelids that prevent adequate closure for a number of weeks.

The composite facelift includes periorbital rejuvenation requiring a superior–medial facelift vector that uses a zygo-orbicular flap for orbicularis repositioning coupled with a septal reset. It creates a harmonious rejuvenation in primary facelift, rhytidectomy, and can return harmony to faces distorted by previous facelifts9.