Gravitational ptosis: a synergy of views between a surgeon and a cosmetologist

Alexander Borodko , surgeon at the Visit Cosmetic clinic, full member of the Russian and Ukrainian Associations of Plastic Reconstructive and Aesthetic Surgery (Ukraine, Kiev)

Polina Laiter , medical cosmetologist PME, specialist in the field of natural restoration and rejuvenation of the face, author of the method of restorative layer-by-layer therapy Reface Laitlift System, member of the medical society of acupuncture of the Israeli Medical Association (Israel)

Gravitational ptosis of the soft tissues of the face and neck combines the following visual signs: ptosis of the eyebrows and upper eyelids, nasolacrimal grooves and nasolabial folds, drooping corners of the mouth, unclear oval of the face, “jowls,” the presence of a double chin. These signs begin to appear at the age of 35–40 years, at 40–55 years they are more clearly visible, and after 55–60 years they are clearly noticeable and even striking.

Conventionally, gravitational ptosis of the soft tissues of the face and neck (skin, subcutaneous fat, muscles, fascia and ligaments) can be divided into three degrees, each of which corresponds to certain external changes.

I degree of gravitational ptosis

• The outer sections of the eyebrows acquire a more horizontal position than at a young age.
• Minor blepharochalasis of the upper eyelids (with open eyes, folds form on the upper eyelids, not reaching the ciliary edge, which disappear when the eyelids close). This sign is a relative indication for blepharoplasty and can be partially eliminated by volumetric contouring with fillers based on hyaluronic acid.
• Congenital or acquired ptosis of the upper eyelids of varying severity. Microsurgical intervention is often necessary here, and the apparent simplicity of correction for aesthetic surgeons can end extremely unsuccessfully.
• Exposure (skeletonization) of the lower edge of the orbit, which often causes the appearance of so-called dark circles under the eyes due to the venous vessels coming close to the skin. This occurs due to weakening, expansion and, as a result, lowering of the lower portion of the orbicularis oculi muscle. During this period, weakened by the absence of a natural muscle band, the septal septum, which starts from the lower edge of the orbit and reaches the edge of the lower eyelid, allows the fatty “cushion” of the eyeball to slightly “bulge” forward. Many patients perceive this phenomenon as a hernia of the lower eyelids, but if you ask the person to smile, the pseudohernia disappears. Removing such “excess” fat in the classical way is a gross mistake for a novice surgeon, since as a result of the operation, the edge of the lower eyelid will necessarily be rounded due to the lack of muscle support, and the skin after removing the “hernia” will further emphasize the bony edge of the orbit. In this situation, in my opinion, volumetric contour plastic surgery of the infraorbital zones in combination with peeling is more acceptable.
• Minor signs of the presence of a nasolacrimal groove, which can also be successfully corrected with volumetric contouring.
• A slight depression of the nasolabial fold at the outer wing of the nose is a safe indication for light correction with hyaluronic acid.
• A barely noticeable drooping of the outer corners of the mouth is successfully eliminated by the combined use of botulinum toxin A and subsequent correction with hyaluronic acid fillers.
• Violation of the clarity, smoothness and continuity of the contour of the lower jaw, especially when the chin is tilted towards the chest: in this situation, good results are achieved by using botulinum toxin A along the contour of the lower jaw, followed by modeling with hyaluronic acid.

II degree of gravitational ptosis

(may include all of the above symptoms)

• Overhang of soft tissues over the bridge of the nose (especially pronounced in people with inelastic, dense skin and sedentary facial expressions). At this stage of ptosis, the biggest mistake is the use of botulinum toxin A to correct forehead wrinkles.
• Marked drooping of the outer eyebrows, causing overhanging skin folds in the area of crow's feet (external periorbital wrinkles). In this situation, dabbling in injections is extremely inappropriate.
• Severe blepharochalasis of the upper eyelids (the skin fold of the upper eyelids practically lies on the eyelashes when the eyes are open; it does not disappear even after the eyelids close; this condition is often accompanied by a protrusion of the “hernia” of the inner corner of the upper eyelid) can be considered an absolute indication for upper blepharoplasty.
• The outer corner of the eye (the so-called external canthus) decreases to the level of the inner one, whereas normally it should be 3-4 or even 5 mm higher, depending on the shape of the palpebral fissure. Due to the weakening of the ligamentous apparatus of the outer canthus, a rounding (sagging) of the edge of the lower eyelid occurs, which in itself is not able to support the array of soft tissues of the infraorbital zone.
• Zygomatic fat, which creates a smooth S-shaped curve at a young age, starting from the outer corner of the eye, in mature years “slides” along the surface of the cheekbone down and towards the middle, creating in “enlightened” patients a firm belief that this is nothing more like a fatty hernia. Moreover, without stopping its “sliding”, the fatty tissue of the zygomatic zone significantly emphasizes the previously formed barely noticeable nasolacrimal groove and, even worse, shifts the underlying soft tissues with its weight towards the nasolabial fold, which form a decent overhang over it. An attempt to lift such a “block” only by directly introducing fillers into the nasolabial fold is doomed to failure in advance, since all overlying tissues remain, at best, in an unchanged position, and therefore, no rejuvenation occurs. In such a situation, contour volumetric lifting modeling of the entire midface zone with monophasic, highly concentrated, tightly bound fillers based on hyaluronic acid is indicated. Botulinum toxin A at this stage of gravitational ptosis should be used with extreme caution; especially, one should not rush to eliminate “crow’s feet” with it, so as not to provoke an even greater “sliding” of the zygomatic “cushion”, thereby increasing the depth of the nasolacrimal groove and further relaxing the lower one. a portion of the orbicularis oculi muscle, which, in turn, will lead to the movement of horizontal wrinkles of the lower eyelid towards the nose and their location in an oblique direction. Also, under no circumstances should you block the “overhanging bridge of the nose” with Dysport or Botox. Otherwise, we risk, in addition to weighting the area between the eyebrows, getting as a result of our manipulations an expanded bridge of the nose with obliquely overhanging folds of skin on the inside of the upper eyelids. To achieve the visual effect of straightening and lifting the bridge of the nose, contouring with the same hyaluronic acid can be used much more successfully. The most predictable result, of course, can only be achieved by surgical frontotemporal lifting.
• Significant drooping of the outer corners of the mouth with a noticeable deepening of the labiomental folds, which undoubtedly gives the face a rather dull appearance.
• A visible violation of the continuity of the line and smoothness of the contour of the lower jaw (the so-called “bulldog cheeks”) often becomes a logical continuation of pronounced labiomental folds and is often accompanied by vertical strands of skin located on the neck. If the skin tone is sufficiently good and the PMJ (superficial muscular-fascial system) is not completely weakened, the above-mentioned folds and cords can be successfully corrected by combining botulinum toxin A and contouring with hyaluronic fillers, but in more advanced cases, surgical correction cannot be avoided. The main thing is not to make mistakes when analyzing all the details of the face during the first consultation.
• A decrease in the tone of the soft tissues of the cervical-mental area due to the divergence of the platysma along the sagittal line is very often mistakenly assessed by patients as excess mental “fat”. In this case, only platysmoplasty is indicated, but not liposuction. And woe to those surgeons who followed the lead of very competent clients.

All of the above “disgrace” in the middle, lower zone of the face and neck does not appear until it is held by the superficial muscular-fascial system (PMFS, or in overseas SMAS), which originates at the level of the arches of the zygomatic bones and extends to décolleté area. In the process of aging, it does not immediately and not everywhere give way, but you shouldn’t even try to predict in advance where this will happen and when, since this process, firstly, is controlled by the individual genetic program of aging for everyone, and secondly secondly, it is greatly influenced by the above-mentioned internal and external causes of infirmities. The logical conclusion follows: each face is like fingerprints; if you missed a small detail, you made a grave mistake.

III degree of gravitational ptosis

(age category from 50 years and older)

In this case, in addition to increasing the signs of gravitational ptosis of soft tissues, visible involutive changes occur, which are manifested by noticeable thinning of the skin, a decrease in the red border of the lips, the formation of deep furrows, creases and wrinkles, and a smooth change in the proportions of the facial skull. Unfortunately or fortunately, in this situation there is no room for small-scale “salon design”. With mutual understanding between the doctor and the patient, Her Majesty's surgery comes into force. But in the postoperative period, with a successful operation, and even more so with an unsuccessful one, there is no end of work to perform all kinds of corrections and additions.

Surgeon and/or cosmetologist?
Probably, every specialist in the aesthetic industry should know very simple but important things: surgical intervention can tighten what has sagged; remove what is abundant and replenish what is missing. Injection techniques and contouring can temporarily imitate face lifting and rejuvenation, smooth out fine wrinkles and restore volumes if gravitational ptosis of soft tissues has not reached the third degree and there are no gross changes in skin texture. The skin itself, in the presence of deep involution of the dermis (furrows, creases, large wrinkles), can only be corrected by grinding (peeling), mainly medium or deep, performed under anesthesia. No lift without peeling can eliminate wrinkles. Attempting to fill furrows and large creases with fillers is not the best choice for a doctor, as it can further emphasize the unsightliness of the altered skin texture, lifting it from the depths to the top.

What can restorative cosmetology do?

Having come for a consultation with a plastic surgeon about the correction of gravitational ptosis of the soft tissues of the face and neck, the patient, of course, hopes that the surgeon will be able to predict the result of surgical correction. He also expects the surgeon to know how to avoid the individual pitfalls that may arise during or after surgical correction. Is it really possible to predict or guarantee the result of aesthetic plastic surgery?

Typically, a good clinical result after surgery lasts for 7–10 years. Then why do many “age-related” details eliminated on the operating table and clearly visible positive results in the early postoperative period worsen after 3-6 months? We are talking about such things as sagging of the cervical-mental angle, “jowls” along the contour of the lower jaw, and zygomatic “bags.” At least, the most frequent complaints from patients to surgeons six months after operations appear precisely in this regard. Why is this happening?

Having successfully completed the operation, surgeons, at best, send the patient to “their” cosmetologist, and at worst, they limit all conceivable violations of a calm lifestyle and prescribe ointments for bruises and swelling and creams for scars, that is, they are released into nowhere and answer with a sinking heart to this patient's calls several months later. What, they say, did they come with: to execute or have mercy, to scold or to praise? Fortunately, if the results of the operation after bruises and swelling are excellent, then plastic surgeons are again on horseback, again the elite of the aesthetic industry. But scar (read: connective) tissue is a capricious thing, and no one is immune from unpleasant consequences.

The author's method Reface Laitlift System belongs to a new direction of restorative cosmetology - restorative layer-by-layer therapy and is characterized by the fact that in it each type of therapeutic effect is consistently aimed at restoring certain layers of connective tissue (both superficial and deeper). The result of this approach will be the restoration and improvement of muscle tone, microcirculation, lymphatic and venous drainage.

Why is this method effective and important in anti-aging programs for invasive correction of gravitational ptosis of soft tissues of the face and neck?

Rehabilitation therapy and physiology

According to the currently generally accepted connective tissue concept of age-related changes in the face and neck, it is the connective tissue structures that are the target of damaging factors during age-related changes in the face and neck. Such factors include any changes in the body, as a result of which specific standard tissue damage occurs along the vector “edema - fibrosis - sclerosis”.

The modern structural theory of facial aging states that over time, the muscles of the face and neck generally do not stretch, but spasm and shorten, which causes muscle imbalance, imbalance of the tissue field, changes in the position of the bones of the facial skull, migration of fatty packets, impaired blood circulation, venous and lymphatic drainage. All this leads to a deterioration in the barrier functions of the skin, disruption of microcirculation and, as a consequence, disruption of nutrition, hydration and regeneration of the skin. But the main thing is that it forms the so-called age shadows: folds, furrows, wrinkles, swelling, puffiness, unclear oval of the face - in other words, all the visual signs of gravitational ptosis.

You can, of course, immediately try to apply such lifting methods as various kinds of threads, contour plastic surgery, hardware or surgical effects, that is, methods when the intended lifting should occur either through mechanical lifting (moving) of heavy and sagging tissues, or through by creating artificial volumes or “framework” caused by fibrosis. But the problem is that from a physiological point of view, the process of formation of gravitational ptosis of the soft tissues of the face and neck is not affected by mechanical movement, and the process of creating additional volume/framework in some cases can aggravate the ptosis, and the tissues will continue to sag. Of course, this conclusion applies to a greater extent to patients who are prone to edema and are overweight, belonging to such subtypes of the deformation type of aging of the face and neck as edematous and fatty.
The deformation type of aging, as recent studies show, in a fairly large number of cases (40%) has a congenital pathology of connective tissue, caused by a relative excess of immature type III collagen, which leads to a decrease in the ratio of mature type I to type III collagen and a decrease in the strength of connective tissue.

It is in this group of patients that unfavorable results of invasive and, in particular, surgical interventions in the face and neck can be predicted.
In such cases, in my opinion, the mandatory elements of the gravitational ptosis correction program should be not only the preparatory and rehabilitation stages, but also an equally important stage to improve the result of surgical correction. That is, along with eliminating swelling and bruising, the task of strengthening the muscular, ligamentous and fascial framework should always be urgent.

The homogeneous origin of the skin, muscles, ligaments, fascia, bones, blood, lymph, joint fluid from a single mesenchymal sheet of the human embryo and the relationship of all these elements to the category of connective tissue suggest the establishment of a healthy physiology of each of the listed elements, subject to competent influence on at least one of them, since they are closely related from birth to each other by mesenchymal origin.

It is this approach that will significantly reduce existing gravitational ptosis and improve the result of surgical correction for certain types of aging of the face and neck. I would like to note that considering tense muscles to be “strong” and relaxed muscles to be “weak” is a big mistake. In fact, strong muscles are muscles of ideal length.

Why hope for chance, if you can calmly transfer the patient into the hands of a clinically minded cosmetologist-rehabilitation specialist, who will not only restore the skin, but also improve the aesthetic effect of the correction.

Case Study

The patient (52 years old) came to the clinic for correction of gravitational ptosis of the soft tissues of the face and neck. After collecting an anamnesis and triple diagnosis, the cosmetologist compiled and carried out a program consisting of six procedures of systemic restorative layer-by-layer therapy Reface Laitlift System. The procedures were carried out once a week.

Photo 1. Before and after six procedures of the Reface Laitlift System systemic restorative layer therapy

Depending on the purpose, this program item can be considered as:

• stage of non-invasive correction of gravitational ptosis of soft tissues of the face and neck;
• the first (preparatory) stage for invasive correction of gravitational ptosis;
• rehabilitation stage;
• stage that improves the result of surgical correction.

Conclusion

As long as the cause-and-effect relationships between the various mechanisms of the formation of aesthetic dysfunction, leading to gravitational ptosis of the soft tissues of the face and neck, remain outside the field of view of specialists, the result of any correction of age-related changes in the face and neck will be incomplete, unstable, or leading to premature aging of the face and neck.

First published : KOSMETIK international journal No. 3 (57) / 2014, pp. 18-22