Correction of the face, neck and décolleté area in older patients requires a special approach, since the skin condition is influenced by factors such as photoaging, hormonal age-related changes. In addition, it is necessary to take into account the type of facial aging, as well as the psychological characteristics of the patient, who has certain expectations from the results of contouring and does not want to be disappointed.
Irina Krasnoslavovna Zhukova
doctor-cosmetologist candidate of medical sciences
Editor-in-chief of the journal "Aesthetic Medicine"
Types of Facial Aging
The main types of aging depending on the constitutional structure of the soft tissues of the face in patients over 45-55 years old (i.e. the older age group) are as follows.
Fine wrinkled - characterized by the presence of numerous small wrinkles on the skin of the face and neck, especially pronounced around the eyes and mouth. It occurs in women with poorly developed subcutaneous fat, medium-sized facial features, and thin skin. With age, such patients experience a significant decrease in the volume of soft tissues in the area of the temples, cheeks, in the infraorbital and perioral areas, as well as the volume of the lips. At the same time, ptosis of the soft tissues is slightly expressed.
Gravitational, or deformation - is distinguished by the absence of small wrinkles, which sometimes occur only in the upper and lower eyelids, pronounced ptosis of the soft tissues of the face with the formation of deep nasolabial folds and the so-called "puppet wrinkles", running from the corners of the mouth to the edge of the lower jaw. With this type of aging, the second chin is expressed and "flew" in the lower parts of the cheeks. It is typical for women with well-defined subcutaneous fat on the face, thick skin.
Mixed - is a combination of fine wrinkled and gravity types with a predominance of any of them.
Muscular - occurs predominantly in Asian women. This type is characterized by a rather late appearance of wrinkles, slight ptosis of the soft tissues of the face due to the developed muscular structure and structural features of the facial skeleton (flattened face with a wide lower jaw).
In addition, the overall process of facial aging is significantly affected by factors such as photoaging of the skin, hormonally determined age-related changes, especially the deficiency of female sex hormones - estrogen and, accordingly, the presence or absence of hormone therapy during menopause.
When planning a complex of anti-aging procedures, including contouring, it is necessary to take into account the individual characteristics of each patient, the full clinical picture of age-related changes, concomitant factors, as well as the psychological characteristics of the woman, since the main reasons for unsatisfactory results and complaints from patients are their overestimated expectations and misunderstanding of the real possibilities of the method.
The best results during contouring are observed in patients with a finely wrinkled type of aging, since in such women the main age-related manifestation is the loss of volume of the soft tissues of the face, which can be easily corrected with the introduction of fillers.
Correction of the upper third of the face
In the upper third of the face, contouring is performed with preparations based on hyaluronic acid. It is injected to a considerable depth in the area of the temples and the lateral part of the eyebrows. Correction of vertical and horizontal mimic wrinkles in the bridge of the nose is carried out with medium-density preparations in combination with botulinum toxin.
The area of the lateral corners of the eyes (crow's feet) in the absence of ptosis of the upper eyelid also lends itself well to correction with low-density hyaluronic acid preparations.
The area of the lower eyelid is a high risk area for contouring due to the tendency of periorbital fat to accumulate moisture. The introduction of hyaluronic acid can significantly enhance this process and cause the formation of bags under the eyes. In addition, all injection procedures in this area very often lead to vascular damage and the formation of quite pronounced and long-term hematomas, which is very negatively perceived by patients. A good aesthetic effect is obtained by filling the so-called "tear groove", which runs from the inner corner of the eye to the upper edge of the orbit. In this zone, it is very important to prevent excessive filler injection and the effect of hypercorrection, so it is better to treat it in two stages with an interval of 2-3 weeks between procedures.
Special attention should be paid to the problem of contouring patients after upper and (or) lower blepharoplasty. The location of the anatomical structures of the periorbital region changed during surgery can lead to unexpected results for the doctor in the introduction of fillers. Therefore, it is desirable in such a situation to carry out the procedure in 2-3 stages: first, inject a small amount of the drug (0.2-0.3 ml), and then add it to the area of insufficient correction.Correction of the middle zone of the face
This area in older patients with a finely wrinkled type of aging, as a rule, requires correction in the palpebromalar (infraorbital) area, since it is the retraction in this area that gives the face a tired and sad look. The formation of this aesthetic defect begins quite early, often already at the age of 30-35.
There are different methods for correcting this zone: subcutaneous injection of low-density fillers or deep injections using vertical injections to the level of the periosteum of denser ones (used most often). cheeks.
The nasopharyngeal sulcus is also filled with deep injection of sufficiently viscous fillers to the supraperiosteal level.
Small wrinkles in the cheek area are recommended to be corrected by linear injections, which are performed in the direction perpendicular to the course of wrinkles, with preparations of low and medium density (depending on the thickness of the skin and the depth of wrinkles). A good effect in this area can be obtained using the bio-reinforcement technique. In this case, the medium-density drug is injected over the entire surface of the cheek and zygomatic zone along conditional lines, which are a "lattice" or "honeycomb". The procedures are carried out 3 times with an interval of 3-4 weeks, for one procedure about 1 ml of the drug is injected on both sides. In addition to smoothing wrinkles, the bio-reinforcement procedure provides the effect of lifting the lateral parts of the face, which leads to the formation of a more distinct oval and a decrease in cheek sagging.
The young face is characterized by an expanded upper part and a narrowed lower part, but with age, on the contrary, the zygomatic region recedes and the face expands below. Therefore, many older patients are advised to increase the volume of the cheekbones by introducing high-viscosity preparations at the level of the periosteum. The volume of the drug varies depending on the individual characteristics of the face - from 1.0 to 2.5 ml on each side. It should be noted that not all patients achieve a positive aesthetic result as a result of such manipulation. This is due to the possible number of small wrinkles in the lower eyelid area as a result of the “lifting” of the zygomatic zone.
Correction of the lower third of the face
In women with a finely wrinkled type of aging, it is in this zone that age-related changes are most pronounced. The classic nasolabial fold correction procedure is well known to all specialists, does not require any additional explanation and almost always gives excellent results. It is much more difficult to cope with wrinkles in the corners of the mouth, especially pronounced ones. Sometimes a good effect is obtained by the use of a fan technique, when a medium-density drug is injected medially and below the wrinkle. With sufficient severity of subcutaneous fat, deep administration can be practiced using 2-3 injections of a sufficiently large (1.5-2.0 ml on each side) volume of dense hyaluronic acid preparations, followed by treatment of superficial wrinkles with a low viscosity preparation.
With age, the lips become thinner, somewhat sunk, so for rejuvenation it is desirable to slightly increase their volume. If the patient does not want to undergo such an intervention, only the contour line can be corrected, which will make the lips more defined and partially reduce vertical wrinkles on the upper and lower lip. For this purpose, both hyaluronic acid preparations and collagen-based fillers should be used, which will allow you to get a clearer contour. In addition, it is possible to recommend 2-3 sessions of mesotherapy using biorevitalizants based on hyaluronic acid. A good effect is given by the "Mona Lisa" technique, developed or described by E. Gubanova. In this case, the drug is injected linearly along the border of the red border in the corners of the mouth and additionally along the border of the mucous membrane of the upper lip (0.1-0, 15 ml). This allows you to slightly lift the corners and give the face a more youthful look.
The correction of "purse-string" wrinkles in the area of the upper lip is of particular difficulty. To obtain satisfactory results with significant mimic activity of the circular muscles of the mouth, a combination of fillers and botulinum toxin preparations is necessary. Preparations based on hyaluronic acid are not always able to correct vertical wrinkles of the upper lip due to their physical qualities - hydrophilicity, plasticity and the ability to be well distributed in surrounding tissues. Therefore, with a small volume of HA injection, effective correction of wrinkles does not occur, and with an increase in volume, the volume of the entire zone above the red border increases, which is not always desirable. For this purpose, preparations based on collagen are more suitable, which is located exactly at the injection site and does not increase the volume of the entire correction zone.
At the end of the procedure, if there are indications (micrognathia, a pronounced horizontal crease), the chin area can be corrected. Volume augmentation with high-viscosity preparations improves the aesthetic proportions of the face and slightly reduces skin ptosis under the chin, while horizontal wrinkle correction (in combination with botulinum toxin) makes this area smoother and more youthful.
Neck and décolleté correction
In the area of the neck and décolleté, it is recommended to carry out a biorevitalization procedure in combination with low-density contouring preparations. Injections are administered with a linear technique perpendicular to the direction of wrinkles or along them. The use of denser fillers on the neck is undesirable due to the danger of contouring under the thin skin of this area. In general, the effectiveness of fillers in the neck is worse than on the face.
Features of correction in gravitational type of aging
It is much more difficult for patients of this group to carry out contour plastic surgery, since with this type of age-related changes, the phenomena of soft tissue ptosis predominate, there are much fewer fine wrinkles and, therefore, there are fewer areas for the introduction of fillers. In the upper third of the face, good results are possible with the correction of mimic wrinkles in the bridge of the nose with medium-density preparations (in combination with botulinum toxin), as well as "crow's feet".
It is recommended to carry out the procedures in 2-3 stages to obtain a more stable and pronounced result. The area around the eyes, especially in the presence of ptosis of the upper eyelid and, moreover, orbital hernia of the upper eyelid, is unfavorable for the introduction of fillers.
Correction of the infraorbital and nasopharyngeal furrows in this type of aging is also difficult due to ptosis and thinning of the soft tissues. The introduction of fillers into this area often causes prolonged (for several weeks) lymphostasis with edema, which also cause overstretching of the skin, followed by increased wrinkles in this area.
In the middle zone, such patients are recommended to undergo correction of the nasolabial folds. However, it can be difficult, and sometimes even impossible due to the pronounced overhanging of the medial buccal ridge. In such a situation, the introduction of large volumes of the drug leads to an even greater "weighting" of this zone, the rejuvenating effect is not achieved.
The cheek area of patients with gravitational aging rarely needs contouring, and the bio-reinforcement procedure does not give pronounced results due to too "heavy" tissues in this zone.
In the lower third of the face, the best results are obtained with the correction of the shape of the lips, perioral wrinkles of the upper and lower lips, as well as the chin zone. "Marionette wrinkles" and corners of the mouth in patients with severe soft tissue ptosis are also difficult to correct. Preference should be given to the technique of deep injection of high-density preparations, while trying not to weigh down the lower part of the face. It is possible to improve the condition of the skin in this area with the introduction of drugs using the technique of "mesh" or "reinforcement" of the skin with drugs of medium density.
Peculiarities of facial correction of mixed and muscular types
For these types of aging, the listed techniques are used depending on the predominance of certain processes, the thickness of the skin and subcutaneous tissue, the structure of the facial skeleton and the individual characteristics of the patient. In addition, it is imperative to take into account the activity of mimic muscles in each specific case, since with active facial expressions in any zone it is impossible to achieve good results only with the help of contour plastics and save them for a certain period without additional use of botulinum toxin preparations. In those areas where their use is impossible or limited (lower third of the face), it is necessary to look for other methods of cosmetic correction.
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