Non-surgical lifting of the lower third of the face

Elena Lukyanchenko , dermatovenerologist, cosmetologist, chief physician of the Global Medical Group medical cosmetology center, assistant at the department of dermatovenereology and cosmetology of FIPO DonNMU, certified trainer in Aptos thread technologies (Ukraine)

Before talking about the new possibilities of cosmetology, let's remember the morphology of the anatomical layers of the face, which today are quite well studied.

Deformation type of aging

Of the five known morphotypes of aging, the most difficult to correct is the deformation type of aging (according to I. I. Kolgunenko). “Heavy” faces with excess subcutaneous fat and oily, porous skin are susceptible to this type of involutional changes. It is characterized by impaired skin elasticity, changes in the tone of facial muscles, thinning of the ligamentous apparatus, downward displacement of fat compartments under the influence of gravity, impaired lymphatic outflow and venous congestion.

Changes in facial muscle tone include hypertonicity of the main muscles of the upper and lower third of the face and hypotonicity of the muscles mainly of the middle third of the face. As a result, the configuration of the face and neck changes: the oval line of the face is disrupted, the area of the skin of the upper and lower eyelids increases, a double chin appears, the depth of the nasolacrimal and nasolabial folds increases, and deep wrinkles appear from the corners of the mouth to the chin. Against the background of impaired muscle tone and increased extensibility of ligaments, gravitational displacement of subcutaneous fat occurs in the mental and submental areas. This leads to deformation of the facial contour, which especially clearly demonstrates age-related changes.

It is known that the ligamentous apparatus provides a supporting framework for the fatty compartments of the face. All ligaments are concentrated in the lateral sector, and therefore the first signs of gravitational aging begin in the central part of the face (nasolacrimal groove, nasolabial fold, deformation of the oval of the face, double chin).

In the places of attachment of the ligaments of the facial muscles, signs of gravitational ptosis are indicated - nasolacrimal groove, nasolabial fold, deformation of the oval of the face, double chin, as shown in the figure.

It is important to know the anatomical location of the main facial ligaments and their zones of maximum branching. Visually, each ligament resembles a tree in its shape and has the maximum number of branches at the level of the reticular dermis. It has been scientifically proven that the ligamentous apparatus of the face also undergoes age-related changes - thinning, rapidly developing atrophic processes, a decrease in the content of proteoglycan complexes in them, disorganization of fibers, are the main pathogenetic link of deformation changes. It has been studied that with genetic aging, atrophic processes intensify in all skin structures, the basis of which is a slowdown in metabolic processes and cellular regeneration. The functional activity of cells decreases, the balance between the rate of cell division and differentiation and their death is disrupted.

In the epidermis, the morphology of cells is disturbed in the form of nuclear atypia, the number of mitochondria in the cells decreases, as a result of which the energy processes and proliferative activity of epithelial cells are weakened. The stratum corneum, on the contrary, thickens, and the horny scales themselves become thinner and slough off more slowly. The desquamation of epidermocytes slows down against the background of a decrease in lipid synthesis in Odland bodies and a decrease in the amount of filaggrin, which leads to increased transepidermal water loss. Due to the smoothing of epidermal processes and a decrease in the cytoplasmic microprocesses of basal cells, the dermoepidermal connection is weakened, which leads to a disruption of the barrier function of the skin and its regenerative abilities.

In the dermis, the number and functional activity of fibroblasts, mast cells and macrophages decreases. The number and disorganization of the structure of collagen and elastin fibers occurs. Collagen fibers thicken and weave into bundles with random orientation, become denser, coarser, the number of cross-links in their fibrils increases, which leads to a slowdown in the rate of collagen turnover. Elastin fibers become thinner, lose their branches and stick together. In the reticular layer of the dermis, characteristic cysts and lacunae are formed, and within the papillary layer of the dermis, a network of thin elastic fibers is formed. The mechanical strength, mobility and elasticity of the skin are impaired, and its turgor decreases. There is a gradual decrease in the amount of glycosaminoglycans, RNA synthesis is inhibited and the amount of glycoproteins increases, as a result of which the processes of metabolism and synthesis of biologically active substances in skin cells slow down.

An important substance in the dermal layer of the skin is the extracellular matrix, which consists of fibers and ground substance. The intercellular substance is formed as a result of the synthetic function of the most important representative of the cellular structures of connective tissue - fibroblasts. The main substance of the intercellular space consists of water, proteins (glycoproteins, proteoglycans), fats and carbohydrates (glycosaminoglycans, GAGs). The main representative of GAGs is hyaluronic acid (HA), which has a large molecular length, is hydrophilic, is quickly synthesized and quickly destroyed, forms special compounds with protein, being a constituent substance of proteoglycans.

It has been shown that the concentration and composition of GAGs in the skin changes at different ages and that both the core protein and GAGs have a unique set of functions that play a crucial role in the aging process. Proteoglycan complexes of the matrix are responsible for hydration, compressive strength, the ability to deform and overcome deformation, restore its hydrated state and elasticity. Cell mitosis, receptor protection, regulation of cell growth and differentiation, fibrillogenesis and connective tissue regeneration depend on the quantitative and qualitative ratio of proteoglycans in the intercellular matrix. With involutive changes in the skin and other soft structures of the face, the number of proteoglycans is significantly reduced, which affects the trophism and mechanical properties of the connective tissue, including in the ligamentous space.

Regarding the morphology of the extracellular matrix, I would also like to pay attention to the structure and functions of fibrous structures. Fibers are divided into collagen, elastic and reticular. The collagen protein family makes up only 25–30% of all proteins in the intercellular substance of connective tissue. Collagen molecules are capable of forming filaments, fibrils, or forming flat networks that interact with other proteins of the extracellular matrix. Currently, 19 types of collagen have been described. Collagen molecules are formed by three threads twisted in a spiral. The amino acid composition of the chains is specific and is represented by a number of amino acids, such as glycine, lysine, proline and hydroxyproline, which is important to consider when choosing drugs for biorestructuring.

Elastic fibers form an extensive and very fine network in the dermis; they look like thin, straight, often branching and anastomosing threads that form a three-dimensional network. Due to their high-molecular organization, elastic fibers are capable of contraction - returning the skin to its original state after stretching. Elastin, like collagen, contains a lot of glycine and proline, as well as two unique amino acids: desmosine and isodesmosine, consisting of four lysine molecules.

Biorevitalization

A large assortment of injectable preparations with different compositions and different characteristics of hyaluronic acid and peptides allows for much more precise individual work with the patient (Doublyx, Hyalax, Pluryal, Twac, Revofil). In addition, it should be understood that the techniques for introducing biorevitalizants are important depending on the “target” to which we want to direct our influence. When affecting the main substance of the matrix, it is advisable to carry out injections shallowly, at the level of the papillary layer of the dermis, using the linear technique and the papules technique. This is due to the fact that, as stated earlier, in the upper layer of the dermis, the ground substance, proteoglycan complexes predominate. For this purpose, you can use, for example, the drug Doublyx, which contains HA at a concentration of 2% and chondroitin sulfate, which is such an important component of the matrix. This drug belongs to the group of biostimulants, so it is recommended to use it from 30–35 years of age in any area of the face, neck, décolleté and on the skin of the body.

Fine wrinkled type of aging

When targeting the fibrous component of the matrix, injections are performed at the level of the middle layer of the dermis, where precursors of collagen and elastin fibers are needed. In this case, the linear technique is preferable. Since the periorbital, perioral zone and neck are primarily susceptible to aging processes due to their anatomical characteristics, the task of a dermatocosmetologist is to make the skin denser and reduce expression wrinkles. Therefore, for the fine-wrinkled type of aging, it is recommended to use preparations containing hyaluronic acid and precursors of collagen and elastin fibers (amino acids glycine, lysine, proline and hydroxyproline), which belong to the group of biorestructuring agents (Peptidyal 115, Meso-Wharton P199™, Viscoderm, Ideal). Using Peptidyal 115 containing 1% HA with these four amino acids, in a clinical study we obtained a significant improvement in all biophysical properties of the skin and obvious clinical results in improving its tone and reducing the depth of wrinkles. In addition, the effectiveness of the combined use of these two drugs has been studied and proven, alternating one after another: the first session is a drug with chondroitin sulfate, the second session, two weeks later, is a biorestructuring agent with amino acids.

Biorestructuring

Having an understanding of modern aging mechanisms and knowledge of facial anatomy, we have developed a new technique for performing a biorestructuring procedure using a combined injection drug containing peptide components that are structurally identical to proteoglycan complexes. The peptides included in the drug have short chains and have regulatory properties, which will have the maximum physiological effect on the skin and ligaments without side effects, preventing accelerated aging processes or providing a therapeutic effect of existing changes. In addition, calcium hydroxyapatite (CaHA) molecules at a concentration of 0.01%, which are part of the drug, have an optimal size to stimulate fibroblasts to produce not only collagen, but also elastin, hyaluronic acid and glycosaminoglycans. When performing this biorestructuring technique, the “target” is the middle layer of the dermis and ligaments. Accordingly, to obtain a pronounced lifting effect in the mental and submental areas, it is recommended to perform injections using a linear technique in the projection of the location of the ligamentous apparatus according to the diagram shown in the figure.

Rice. 3. Projection of the ligamentous apparatus of the mental and submental areas

Read the full version of the article in the magazine Les Nouvelles Esthetiques Ukraine 6 (112)/2018