Ptosis of the lower third of the face: correction methods

Natalya Mikhailova , dermatologist, cosmetologist, member of the American Academy of Dermatology (AAD) and the American Society of Laser Medicine and Surgery (ASLMS), certified trainer of Bioscientific Trading LTD (France) and Cynosure (USA), scientific director of the Martinex Medical Center, chief doctor at the Reforma clinic, president of the All-Ukrainian public organization "Union of Mesotherapists", vice-president of the National Society of Mesotherapy (Moscow)

Deformation of the oval of the face and the appearance of a double chin may be one of the manifestations of age-related changes - gravitational ptosis of the middle and lower third of the face - or a consequence of the accumulation of fatty deposits in the submandibular zone.

Clinical manifestations of ptosis of the lower third of the face and submental area are expressed by a violation of the clarity of the oval of the face, an increase in the volume of subcutaneous fat, smoothing of the cervical-mental angle, and a decrease in skin tone and elasticity.

Excess subcutaneous fat aggravates the overall clinical picture of ptosis of the lower third of the face. They make the tissue heavier, causing deformation of the submental area to develop and the face to acquire a trapezoidal shape.

Anatomy of Aging

Ptosis of the lower third of the face and a double chin are signs that we primarily associate with age. Involutional changes in all facial tissues contribute to their formation.

A young face is characterized by a sufficient volume of subcutaneous fat and its uniform distribution. During the aging process, two processes occur in it: atrophy and fat redistribution. In some areas of the face, volume loss occurs (periorbital and perioral zones, temporal and zygomatic areas, subzygomatic space, chin area and angle of the lower jaw), in others, hypertrophy of adipose tissue develops (submental area, lower jaw area). Hypotrophy of adipose tissue is caused by a general decrease in estrogen levels. Hypertrophy is caused by the migration of fatty tissue from the overlying areas of the face under the influence of gravity.

In the dermis, atrophy and elastosis develop with age, the amount of hyaluronic acid decreases, and reticulation of collagen fibers occurs. The skin stretches, loses firmness and elasticity, and becomes flabby. Since collagen is actually the framework of the skin, along with the loss of collagen and the accumulation of its reticulated forms, the skin's ability to resist gravity and hold soft tissue in the desired position is also lost.

The muscular and skeletal systems are also subject to natural aging. Thus, osteopenia and osteoporosis of the lower jaw are observed in 37–50% of women over the age of 50 years. These symptoms are associated with hormonal changes and estrogen deficiency. Age-related resorption of the lower jaw begins in the area of its upper edge - the alveolar process, which is clinically manifested by a decrease in the height of the lower third of the face and a violation of the proportions of the face as a whole.

Another important age-related change is the appearance of the prebuccal groove. This groove occurs due to progressive tissue atrophy and resorption of the centrolateral areas of the mandible. As a result, there is a prolapse of soft tissues below the edge of the jaw. A decrease in the bone base entails compensatory wrinkling of soft tissues, which ultimately disrupts the proportions of the face and changes its contours.

With age, the balance between different groups of facial muscles changes. In the levator muscles (muscles that lift tissues), the phenomena of atrophy and atony develop, and in the depressor muscles (muscles that lower tissues down) - hypertonicity. Since the facial muscles are attached to the skin through connective tissue (superficial fascia), with age, a predominance of downward vectorial tissue movement is expected.

To summarize, there are two components to facial aging:

• relief (gravitational shift of soft tissues and loss of volume);
• skin (dystrophic changes in the skin, thinning and loss of elasticity).

Morphotypes of aging

Age-related changes in facial oval depend, among other things, on constitutional and architectural features. These features formed the basis for the classification of aging morphotypes developed by I. I. Kolgunenko.

Tired morphotype

People of this type have a normal build, an oval or diamond-shaped face, normal skin in youth and moderately dry in adulthood. Subcutaneous fatty tissue is moderately expressed. The shape of the face remains unchanged for quite a long time. Ptosis and deformation changes of the face mainly affect the middle third. The main reason for their occurrence should be considered a decrease in skin tone and elasticity, stretching of the periosteal-cutaneous ligaments of the face, an imbalance between various groups of facial muscles and a slight accumulation of fatty tissue in the submandibular zone. Therefore, therapy should be aimed primarily at restoring skin firmness and elasticity and resorption of minor fat deposits.

Finely wrinkled morphotype

This type includes people who are not inclined to be overweight, with an asthenic physique and a narrow oval face. They are distinguished by thin, dry skin prone to irritation and rosacea, multiple fine wrinkles and a special predisposition to hyperpigmentation and photoaging. Subcutaneous fatty tissue is poorly developed, and muscle tone is slightly reduced, therefore gravitational ptosis is not clearly expressed. Changes in the oval of the face with increasing cervical-mental angle occur due to atony, loss of elasticity and stretching of the skin. In the correction program, special attention should be paid to skin restoration and the fight against photoaging.

Deformation morphotype

This morphotype of aging usually manifests itself in people with a hypersthenic physique, prone to obesity, with normal or oily skin type. They have a well-developed layer of subcutaneous fatty tissue, there is a tendency to disrupt microcirculation and fluid retention, and rosacea may be expressed. Wrinkling and pigmentation disorders are not typical. The main manifestation of aging in this morphotype is gravitational ptosis. Aging of the lower third of the face is most unfavorable. The excess subcutaneous fat layer on the face, under the influence of gravity, moves over time to the lower third of the face and neck. Under the weight of excess fatty tissue, the skin loses elasticity and stretches. Clinically, this is manifested by deformation of the oval of the face and subchin area, and the formation of folds on the neck. The purpose of the correction is to reduce fat deposits in problem areas, tissue lifting, and restore the functional properties of the skin.

Combined morphotype

This is the most common type of aging. This morphotype includes in varying proportions the characteristics of the three previous ones. Changes in the submandibular region, associated mainly with excess fat deposits, are corrected in the same way as with the deformed morphotype. If ptosis occurs as a result of loss of skin elasticity, the main efforts should be directed at stimulating neocollagenogenesis in this area.

Methods for correcting fat deposits in the chin area

The causes of a double chin also dictate how to correct it. They should include three mechanisms:

• lipolysis of excess fat deposits;
• restoration of skin firmness and elasticity;
• tissue lifting.

For the purpose of lipolysis of excess fat deposits in the submental area, several effective techniques can be used, including the following:

• mesoperfusion is a method of therapeutic lipolysis using hypoosmolar cocktails;
• mesodestruction - lipolysis with the help of biodetergents (phosphatidylcholine and sodium deoxycholate);
• bioreparation using preparations based on hyaluronic acid.

Moreover, of the listed methods, only bioreparation can simultaneously reduce local fat deposits and increase the firmness and elasticity of the skin. Today, this is one of the most physiological and safe methods of injection lipolysis, which also allows you to achieve a pronounced aesthetic result within a short course of procedures.

Bioreparation

The basis, the carrier matrix in bioreparants is hyaluronic acid (HA) of bacterial origin. The amazing properties of this molecule are well known to all aesthetic medicine specialists. It has an anti-inflammatory, disinfectant, and wound-healing effect, but its main advantage is its ability to improve the condition of the intercellular matrix, on which the severity of age-related skin changes depends.

Technology: the main obstacle to the use of HA in injection cosmetology has always been the high rate of its degradation. Mesotherapy cocktails with HA can moisturize the skin, improve its appearance and condition, but due to the rapid destruction of HA by hyaluronidases, they do not have time to start self-healing processes in the skin. In order to preserve HA in the skin, it is necessary to modify it or change its spatial structure, thereby protecting HA from hyaluronidases. In the production of bioreparants, this problem is solved by using innovative technology - solid-phase modification of HA under the combined influence of ultra-high pressures and shear deformations. It is important to note that this technology avoids the use of bifunctional technological additives (chemical reagents) that are used in the production of biorevitalizants. It not only makes it possible to create a HA depot in the dermis, but also makes it possible to synthesize bioactive compositions based on it, using the features of the chemical structure of the HA molecule.

As a high-molecular polysaccharide, HA includes up to 25 thousand disaccharide units containing numerous free hydroxyl groups as functional groups. The presence of these groups allows for chemical immobilization, that is, attaching biologically active compounds necessary for skin restoration - vitamins, amino acids, peptides - to the HA macromolecule with a strong covalent bond.

Another unique property of HA, which allows for targeted delivery of the necessary active ingredients, is the presence of biorecognition sites that can interact with the cell surface of fibroblasts (HA on the surface of the cytoplasmic membrane binds to specific protein receptors CD 44 and RHAMM).

Action: when introduced into the dermis, the bioreparant drug forms a kind of macromolecular depot at the injection site. Since the modified HA has limited mobility of the polysaccharide chain, it is no longer so easy for hyaluronidase enzymes to “unfold” it and divide it into subunits. This ensures a long (up to three weeks) presence of the drug in the dermis. Of course, it is impossible to stop the hydrolysis processes, and the “strings” connecting the bioactive components with the HA molecule gradually break. At the same time, the necessary vitamins, amino acids, and oligopeptides are present in the injection zone for quite a long time in stationary concentrations. And only after all the “strings” are broken does the gradual destruction of the HA molecule itself occur. Thus, the long-term presence of HA and biologically active substances in the dermis creates an optimal physiological environment in which cells independently begin to produce a sufficient amount of HA.

Area of application: the main area of application of bioremedies is the correction of age-related skin changes. But since the effect of the drugs is associated both with the physical characteristics of HA and with the activity of additional ingredients in the formulation, their use can effectively solve a wide range of aesthetic problems, as well as prevent aging.

Double chin correction protocol

On the Ukrainian market, bioremediation drugs are represented by the injection line “Gialripayer”, created on the basis of the Martinex research center with the joint efforts of scientists working in various fields of chemistry, biology and medicine. This line includes ten different preparations based on HA salts with chemically immobilized vitamins (ascorbic and folic acids, riboflavin), amino acids (glycine, proline, lysine, valine, carnitine, cysteine, methionine) and oligopeptides (glutathione).

In the proposed protocol for the correction of involutive changes in the face in patients with gravitational ptosis and excess fat deposits in the submandibular region, we used the drug "Gialripayer-08 / Bioreparant", which includes:

• hyaluronic acid (sodium hyaluronate) at a concentration of 14 mg/ml – creates an optimal physiological environment for the normal functioning of fibroblasts;
• vitamin C – affects the formation of glycosaminoglycans (in particular, HA and chondroitin sulfate), stimulates the proliferation of fibroblasts, reduces the production of metalloproteinases (enzymes that destroy dermal collagen), and provides antioxidant protection;
• L-carnitine – participates in lipotropic processes of fatty acid oxidation as a carrier of their active forms through membranes, helps normalize the water-salt balance of the skin.

With intradermal administration of the drug, we get a good lifting effect due to neocollagenogenesis, with subdermal administration, the bioreparant acts as a lipolytic.

Administration techniques:

• diffuse intradermal in the area “face – neck – décolleté”;
• infiltration in the area of accumulation of excess fat deposits.

The drug remains in the skin and subcutaneous fat for about 3 weeks, and all this time the lipolytic effect and restoration of the intercellular matrix continues.

The double chin correction course consists of 3 procedures, which are carried out at an interval of 3 weeks.

Clinical trial results

As a result of a bioreparation course of 3 procedures according to the described protocol:

• in 33% of patients, skin elasticity indicators increased by an average of 10–12% compared to the initial level;
• in 100% of subjects, skin moisture increased by 17–20% (with a constant pH value);
• in 100% of the subjects, the thickness of the skin fold in the submental area and the size of the cervical-mental angle decreased (Table 1);
• 100% of the subjects noted a smoothing of superficial wrinkles, an improvement in the color and texture of the facial skin, an increase in its turgor, a pronounced lifting effect in the lower third of the face, and a reduction in excess fat deposits in the submental area.

Table 1. Indicators characterizing the condition of the lower third of the face in patients with deformational and combined morphotypes of aging before and a month after the end of a course of 3 bioreparation procedures

The course of bioreparation carried out according to the presented protocol goes well with lipolytic mesotherapy - mesoperfusion and mesodestruction, which can be supplemented with botulinum therapy of the lower third of the face and neck, vector lifting, and the use of fillers.

Conclusion

Innovative technologies, which served as the basis for the creation of a new class of injectable drugs, make it possible to influence a wide range of problems and quickly achieve the desired aesthetic result. In particular, the course of bioreparation allows not only to improve indicators such as moisture and elasticity of the skin, to create optimal conditions for its normal functioning, but also at the same time to influence complex aesthetic problems, in particular fat deposits in the facial area and gravitational ptosis.

The lipolytic bioreparation method gives excellent and long-term results, allowing our patients to look 10–15 years younger after one course of treatment.

First published : Les Nouvelles Esthetiques Ukraine, No. 3 (79), 2013