Wrinkles

The Generation of Forehead Wrinkles

The position of the eyebrow depends on the state of muscle balance between elevators and depressors of the eyebrow. The skin wrinkles as a consequence of different muscle groups contracting.
Here the depressors of the eyebrow located on the eye socket rim are overactive. This pulls the eyebrow downwards. Forehead muscles try to elevate the eyebrow upwards to its normal position. This muscle pull causes the skin to wrinkle as illustrated.
A circular shaped muscle which screws up the eyes is overactive. This lowers the whole brow, and produces a fold (F) on the outer side of the eyelid and “crow’s feet” wrinkles.
Contraction of muscle in the midline further depresses the eyebrow and causes a fold on the inner side of the eyelid.
Forehead wrinkling is treated by the removal of depressor muscles through five incisions set 1cm behind the hairline. Dots are placed on top of the eyebrow and the difference between the actual and ideal brow height is determined.



The key to treatment is the position of the eyebrow.

If the eyebrow is in a normal position treatment options are:-

  • Botox (therapeutic muscle paralysis)
  • Skin resurfacing
  • Fillers
  • Autologous Cellular Regeneration (Isolagen)

If the eyebrow is depressed / flattened, with hooding of the upper eyelid, a forehead lift is required for optimum aesthetics. Following this treatment a limited upper blepharolplasty is often required.

Forehead Lift Options

  • coronal flap technique
  • endoscopic forehead lift
  • pretrichial forehead lift
  • featherlift


Patient satisfaction with this technique is generally high (95%).

Complications include:

  • Bleeding (especially in smokers)
  • Numbness of the forehead (sensory nerve injury)
  • Paralysis of the forehead (motor nerve injury)
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    Wrinkles Facial Areas

    Wrinkles in the facial area occur secondary to ageing and :-

    • redistribution of body fat
    • loss of collagen
    • u.v damage to skin surface
    • laxity of facial ligaments

    Treatment

    • skin resurfacing techniques - laser / IPL / ELOS / chemical peel / microdermabrasion
    • fillers - temporary fillers / permanent fillers e.g. Bio-Alcamid
    • autologous cellular regenration - Isolagen
    • facial surgery - facelift


    Collagen Injections

    • A cosmetic adjunct to dentures, and facelift
    • Treatment of deep wrinkles
    • Maintenance injections (3-6 monthly)
    • Lip enhancement (Paris Lip Technique)

    Nerve Blockade - Botox

    Some wrinkles are produced by muscle contraction.
    They are commonly seen around the eyes (crow’s feet) lips, (lipstick lines) and forehead (frown lines). Muscles can be selectively paralysed by the injection of Botox into the wrinkle. Botox prevents the release of chemical transmitters from nerve endings which make the muscles contract. Muscle paralysis is variable; it may take around 3 days to occur and lasts about 6 months. Injections may be associated with some bruising.

    Patients should not fly for 72 hours following injection as low cabin pressure may cause spread of the Botox to other muscle groups, producing unwanted paralysis. Complications include temporary paralysis of un-intended paralysis of adjacent muscle groups and a subtle loss of facial expression. With repeated injections some permanent muscle weakness has been reported.

    BIO-ALCAMID™



    BIO-ALCAMID™ i
    s an injectable product that is an absolute innovation in the medical sector. For the first time, medical science can employ a product comprising 97% water and 3% synthetic reticulate polymer. This association guarantees softness to the touch; the implant has almost the same consistency as the surrounding tissues without causing unsightly visible or palpable effects of artificiality.



    WHERE IS BIO-ALCAMID™ USED?

    BIO-ALCAMID™ i
    s used in medicine and surgery to correct all types of secondary imperfections caused by substance deficit, including naso-labial fissures, post-traumatic and post-operatory scars, serious congenital facial microgenia and severe post-traumatic deficit. It is also an excellent implant for defining the lip outline and correcting volumetric deficits of the cheekbones, chin, etc. The filler can also be used to correct severe and vast substance deficit without significant risk of unexpected side effects. This Tissue Lifting Effect is a useful adjunct or even an alternative to facelift in some patients with an immediate effect.

    HOW LONG DOES BIO-ALCAMID™ LAST ?

    In physiological conditions BIO-ALCAMID™ is a definitive implant like any other artificial prosthesis (unless it is intentionally removed). The visible effect created by BIO-ALCAMID™ clearly cannot last forever, since, with the passage of time, the skin ages and the tissues (especially muscle tissue) change position and shape creating new imperfections and anomalies in spite of the “mechanical support” provided by the injected substance. However, the defect can be corrected even after a period of time.

    IS THE IMPLANT PAINFUL?

    Like any injected substance, BIO-ALCAMID also causes some pain, but only during the injection. Any type of anaesthetic (even local) can be used to reduce the pain, depending on the doctor’s opinion.

    SUNLIGHT AND SKIN PIGMENTATION

    It is advisable to avoid exposure to direct sunlight for at least a month following the implant; this is to prevent possible alteration of the secondary pigmentation in the temporarily inflamed area caused by the implant.

    CAN ANYONE USE BIO-ALCAMID™?

    Studies conducted so far have shown that BIO-ALCAMID™ is a safe product; it does not require any sensitization test as no allergic reaction has ever been reported. However, it is advisable to inform the doctor regarding any tendency to allergic reactions (“polyallergic” subjects).

    WHAT HAPPENS AFTER THE IMPLANT?

    I mmediately after the introduction of BIO-ALCAMID™, a thin, natural, physiological capsule is formed. This encloses the Substance, forming an actual endoprosthesis that can be easily identified and removed (easy and painless) at any moment. The oedema that develops immediately after the implant is minimum in normal conditions and does not last more than a few hours.

    Immediately following the injection, there is a slight reddening in the area, but this disappears after a few minutes. Any type of cosmetic product can be used after the implant without any risk of interaction with the implanted substance.

    A few days later, there will be no sign in the area concerned (not even to the touch, since BIOALCAMID™ is 97% water). This produces a good aesthetic effect.

    IS BIO-ALCAMID™ A SAFE SUBSTANCE?

    Years of strict and scrupulous clinical experimentation have allowed the manufacturers to provide the maximum guarantees as to safety, so much so that it has been granted the CE mark by official European authorities for product quality control systems.

    Clinical and laboratory analyses show that BIO-ALCAMID™ is non-toxic, non-sensitizing, nonmutagenic, biocompatible, permanent, removable, and physically and chemically stable.

    In addition to this, BIO-ALCAMID™ is also radio-transparent and hypoechogenous, thus allowing differential diagnosis when there are other structures present in the implant area.



    Autologous Cell Therapy

    Click for movie



    WHAT IS ISOLAGEN ?

    Isolagen is an autologous cell therapy that uses the patient’s own (autologous) fibroblasts in sufficient quantity to correct defects, including wrinkles and scarring. It is the first and only natural process to use the patient’s own cells to repair and rejuvenate the skin.



    HOW DOES THE PROCESS WORK ?

    1. Skin Biopsy

    Under local anaesthesia a 4mm skin sample is taken from behind the ear by Isolagen trained clinicians. Skin edges of biopsy site may be glued together.





    2. Cell Culture

    The sample is taken to the Isolagen laboratories where myofibroblasts (the precursors of collagen producing cells) are grown to a large quantity. These cella have the ability to contract like muscle, and this property enables the cells to take part in a facelifting like effect, following injection.





    3. Autologous Cell Injection - New Protocol 2005





     

    After 8-10 weeks period, you receive the first treatment of newly grown myofibroblast cells. These times depend on how the cells are growing as not all patients’ cells grow at the same rate. Following the inital injection treatment this is followed by one more treatment at around a thirty (30) day interval, which takes into account the length of time it takes for your dormant tissue fibroblasts to be activated by the Isolagen process. Following this activation your tissue fibroblasts continue the Isolagen process.







    Is Isolagen Cell Therapy a Safe Procedure?

    Early evidence to date indicates that Isolagen is a long-lasting, safe and effective procedure in clinical trials involving approximately 3,500 injections and 1,200 people. At the National Centre for Aesthetic Facial and Oral Surgery we have treated over 100 patients (February 2005). Our cases are audited in great detail, in line with Health Commission regulations.

    The use of the patient’s own (autologous) cells, substantially reduces the risk of an allergic reaction compared to commonly used antiwrinkle treatments. The body recognises the new cells as its own and does not reabsorb or reject them as it does with foreign materials.

    Stimulation of Natural Collagen Production

    Isolagen should not be regarded as a dermal filler -but a completely new concept - that stimulates collagen production and significantly increases the number of active skin cells below creases and wrinkles.

    It does so through a natural process that uses the patient’s own cells not only to regenerate collagen but also to repair and rejuvenate the skin.

    Skin rejuvenation occurs in relation to specific chemical messengers produced by the implanted fibroblasts, resulting in safe, effective and apparently long-lasting results.

    Fillers involve the introduction of materials or cells that are not the patient's own into the skin that have an often temporary bulking effect and little or no effect on skin rejuvenation.

    How long does Isolagen take to work ?

    Clinical studies show that some patients see results in as little as weeks, whereas other individuals may experience a gradual improvement over several months. However, from that point on, patients see a continued cell growth for up to 18-24 months.




    Images courtesy Isolagen



    In 2004 Isolagen reported that many patients continue to see the improvement for up to 7 years following treatment.




    Images courtesy Isolagen



    Why does it take time to see improvement ?

    Isolagen is a process that assists the body in its own natural healing. It therefore takes the body’s own timescale to regenerate collagen with new collagen producing cells and to rejuvenate the skin. No significant adverse effects have been reported.

    Facelift Prevention ?

    The timing of Isolagen cell therapy in the third and fourth decades of life raises the intriguing possibility elimination rather than the reversal of some of the cellular processes associated with ageing. In 2004 Isolagen treatment stability has been documented at 7 years. If these results can be replicated, many major cosmetic surgery procedures such as facelift (which are not associated with skin rejuvenation) may become obsolete. This possibility has profound implications for cosmetic facial surgery.

    Facial Rejuvenation


    Images courtesy Isolagen



    Isolagen cellular therapy may be used to rejuvenate the whole facial area and not just the grooves and lines around the mouth lips eyes and forehead. The amount of required rejuvenation depends on :-

  • the age of the patient
  • the intrinsic quality of the fibroblasts
  • the area of skin to be treated
  • the size and depth of facial lines


  • As a general rule a minimum of 2 injection sessions are required.

    Fibroblast Storage




    On request, Isolagen laboratories offer a storage service in which cells from the patient’s original biopsy can be stored and kept for future use - years after the original biopsy. This incurs an annual fee, beginning six months after the first biopsy.

    Contraindications:

  • Autoimmune disease - Rheumatoid, SLE, Psoriasis Scleroderma etc. No clinical studies to show efficacy
  • Patients on cortisone, chemotherapy for cancers
  • Organ Transplant Patients
  • Depressed Immune Status
  • Bowens Disease / multifocal cutaneous cancers, history of melanoma
  • Viral and skin infections
  • Areas of previous herpetic lesions or other active viral / bacterial conditions
  • Smoking - may prevent the development of new fibroblasts within the body. This may result in treatment failure.
  • DO NOT take aspirin nor non steroidal anti-inflammatory drugs NSAID during treatment
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    Isolagen Research

    On Februray 18th 2005 Isoalgen announced the 12 month follow-up data from a Phase III Exploratory (double blind placebo control) trial, which was conducted at multiple centres accross 10 sites in the United States. Data from 146 / 158 patients was evaluated, and the therapeutic effect of Isolagen over the Placebo group is shown in the graph below aty 6 months. This therapeutic effect was maintained at 12 months.


     

    We can therefore state that on the evidence of this small sample that the therapeutic effect of isolagen is more than double the effect of placebo.

    More detailed studies will be forthcoming and this technology looks very promising.

     

    Cell Regeneration Therapy - Future Applications?

  • Periodontal (Gum) Disease (promising studies in progress)
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    Images courtesy Isolagen

  • Stretch Marks - Striae Gravidrum (anecdotal evidence only available)
  • Cellulite (no documented evidence available)
  • Burns (early studies show remarkable results)
  • Hair loss ?
  • Nerve Regeneration ?
  • Paralysis / Stroke / Spinal Injury / Multiple Sclerosis / Alzheimer's Disease



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    Skin Resurfacing – Carbon Dioxide and Erbium: YAG Lasers

    Laser treatment is the high tech equivalent of dermabrasion and chemical peels, and is mainly performed with the carbon dioxide or Erbium YAG lasers. Although carbon dioxide lasers have been in medical use since the 60's as cutting tools it is only in the last few years that technological advances in laser design have allowed the laser beam to hit the skin surface for less than the “thermal relaxation time of skin” i.e. 695 microseconds allowing controlled vaporisation of skin with minimal unwanted "collateral" heat damage.

    Skin resurfacing is used principally for

  • Elimination of fine wrinkles
  • Improving scars (acne, chicken pox or trauma)
  • Improving the appearance of photo damaged skin.
  • Removal of some skin lesions (epidermal naevi /congenital pigmented naevi).


  • The results of these latter treatments depend on the depth of lesion. Generally deeper respond poorly.

    The advantage of laser skin resurfacing over dermabrasion and chemical peels, is in more accurate depth control with laser treatment. Distinct colour changes occur as the laser injury becomes deeper. This is a helpful indicator to monitor treatment during surgery and lets the surgeon know when the end point is reached - and treatment is finished.

    Carbon dioxide lasers vaporise skin in layers of about 65 microns with a zone of "collateral" damage of about 75 microns. Erbium YAG lasers vaporise about 25 microns with a zone of "collateral" damage of about 5 microns i.e. Erbium YAG laser produces less tissue damage and is potentially safer. These figures will vary with different power settings. Less tissue damage occurs with pulsed laser beams, which improves safety margins further.

    These newer pulsed carbon dioxide and Erbium YAG lasers tend to give shorter periods of skin redness although redness does vary with the depth of injury and also between different individuals. Although the redness can be distressing it is associated with the formation of new collagen, which is important to the long term result of laser resurfacing.

    New collagen formation seems to continue for about one year.


    Many resurfacing procedures require repeat treatments to get the best result and many patients are happy in order to have a shorter period of redness a more shallow treatment is required and accept that they may need an extra treatment to eliminate the cosmetic problem.

    There has been some adverse publicity related to laser treatment. Whilst this has been the result of inaccurate reporting in some cases suitable patient selection and counselling is vitally important.

    All patients will have a raw, weeping, uncomfortable superficial burn for about one week.


    Treatment in this initial period may either be open, with regular cleansing and the application of Vaseline to keep the wound moist, or alternately, closed with dressings. Infection of the superficial burn - bacterial, viral or fungal - could potentially cause scarring if not promptly treated, although this is rare.

    Skin erythema (redness) will last for 5 weeks to 6 months depending on:
    • which laser is used
    • the depth of injury
    • individual variation.



    Blushing may cause increased redness in the treated area even after this period.

    Complications of Laser Skin Resurfacing Treatment:

    Skin Colour

    Skin darkening (Hyperpigmentation) may be a problem particularly in darker skin types and is related to the post laser inflammation. It is important that patients with darker skin types are treated with a test patch in a hidden area to test for hyperpigmentation before treatment commences on the face.

    Skin Lightening (Hypopigmentation) may occur if the resurfacing has damaged the pigment cells melanocytes. This is more common with carbon dioxide lasers. If hypopigmentation persists in the long term cosmetic make-up may be required to maintain cosmesis.

    Skin Infection

    Acne may flare up in susceptible individuals and require treatment.

    Cold Sores

    Acyclovir should certainly be given to patients with a history of cold sores, as laser treatment may activate the cold sore virus. If this occurs infection may be severe involving the treated area of skin. For this reason some surgeons give acyclovir to all patients.

    Antibiotics given prophylactically can lead to infections with resistant bacteria and as in accidental burns antibiotics are not routinely given unless there is evidence of infection.

    Skin Care Products - Enhancing Results

    Pre and late postoperative skin care with Retin A or alpha hydroxy acids may enhance results and can be combined with hydroquinone in patients at risk of hyperpigmentation.

    Corticosteroids have been used particularly in the U.S.A. to limit erythema although as noted above the inflammation which causes erythema may in fact enhance the long term results.

    Postoperative Care – Laser Skin Resurfacing

    Skin Care

    Following a skin resurfacing procedure, using either a pulsed CO2 or Erbium YAG laser, your skin will appear red and weepy. It will take between five to seven days before your skin heals and, during this time, it is very important to remove any crusts that may build up on your skin. Most patients find Vaseline, applied two hourly during the day time, to be the most effective and soothing topical medication at this stage. For the first two or three nights after the skin resurfacing procedure, you may find that Vaseline gauze applied to the treated skin, after it has been first liberally covered with Vaseline, would be the most soothing dressing.

    Once the skin has healed, small crusts that have developed can then be removed gently, using water containing a little white vinegar. This can be prepared by adding five or six drops of vinegar to a cup of water at a comfortable temperature as far as the skin is concerned.

    Some pinpoint bleeding after an Erbium YAG resurfacing procedure is normal and usually doesn’t cause any great problems. It is important to remove dry blood from the face to minimise the risks of infection.


    General Anaesthetic

    If you have had a General Anaesthetic, it is important that you do not drive for 24 hours and that, when you go home, there is someone at home all the time for at least 24 hours to look after you.

    Swelling

    Please note that it is quite usual to get some swelling around the eyes, particularly if the resurfacing procedure has been carried out in this area. This may take three or four days to disappear.

    Infection

    Infection of the skin following a skin resurfacing procedure is rare and often antibiotics are not required. It is important to continue taking Acyclovir for the full five day course if you are prone to cold sores on the face. Otherwise, this treatment is not necessary, although a small proportion (about 6%) of treated patients without a history of cold sores may develop this complication. It is very important to let your doctor know if you develop any blisters or pustules in the treated area.

    Sleeping

    If you are not a good sleeper, you may find that you will need to take a sleeping tablet for two or three nights to help you sleep after an extensive facial resurfacing procedure.

    Family

    It is very important that you let your partner or your family know that you are having a resurfacing procedure carried out; otherwise your appearance may give your partner quite a shock!

    Make-Up

    It is best not to put on any make-up until at least ten days after your skin has healed. This is because the skin is readily sensitised following a resurfacing procedure to anything potentially sensitising such as cosmetics applied to it.

    Skin Redness

    Please note that the redness that follows a skin resurfacing procedure is entirely normal. This is always much more marked following the use of the CO2 laser than with the Erbium: YAG laser and persists much longer. The redness can be very marked, especially in fair skinned individuals and can persist for up to three or four months following the procedure. It is nothing to be alarmed about and, in exceptional circumstances, can be treated using another laser called the Pulsed Dye Laser if individual patients find it aesthetically displeasing.

    Retinoic Acid

    It is known that the beneficial effects on your skin of the resurfacing procedure can be augmented and perpetuated by the regular use of retinoic acid topically. Most patients can begin this treatment once daily each evening to the facial skin about three weeks after the skin has healed. Once more however, fair skinned individuals with delicate white skin may have to wait much longer before they can use retinoic acid.

    UV Blocking Creams

    It is important to use an Ultraviolet light blocker on the skin on a regular basis, beginning about ten days after the skin has healed. This is best applied each morning and should be used regularly thereafter. Your Consultant will advise you on which strength of ultraviolet light blocker is required in your individual case. The regular use of an ultraviolet light blocking cream on the skin minimises the risk of the development of pigmentary change in the treated area, but the risk of skin darkening after a resurfacing procedure carried out with the Erbium:YAG is much less than with the pulsed CO2 laser.

    Wrinkles - may take 6-10 months to disappear



    Please note that the best results after a resurfacing procedure are seen 6 - 10 months after treatment and are due to new collagen formation under the site of your wrinkles or acne scarring. Do not feel despondent because you can still see wrinkles or scarring immediately after your treatment. Your laser resurfaced skin will usually continue to improve with time up to ten months after the procedure.

     

    Skin Type

     

     

     

    Photorejuvenation

     

    Intense Pulsed Light (IPL)

    Intense Pulsed LightTM (IPL) skin treatments using the photorejuvenation process represent a breakthrough in skin care. This new technique treats sun damaged skin invasively — there is no disruption of the skin's epidermal surface. IPL treatments address the effects of photoageing and sun damage with low risk of complications and no recovery time.

    IPL produces dramatic results for a variety of benign conditions, including :-

    • age spots
    • sun-induced freckles
    • (acne) rosacea
    • birthmarks
    • unsightly veins
    • acne scarring and other blemishes
    • hair. removal
    • as an adjunct to Isolagen (Autologous Cellular Regeneration)

     

    Whilst comparatively aggressive Laser resurfacing and deep chemical peels produce excellent long term results, these treatments produce significant redness and swelling which take from 2-6 weeks to subside. Microdermabrasion addresses skin irregularities, but is not effective against all complexion problems including redness, flushing and broken capillaries. IPL is less aggressive in tackling some of these problems and is the fastest growing cosmetic procedure in the U.S. and now Europe.

    Practitioners determine an IPL treatment plan for each new patient, accounting for the number and severity of skin conditions being treated, as well as skin type. On average, four to six treatments are recommended, scheduled at three-week intervals. Each session usually lasts about 20 minutes, with patients returning to normal activity immediately afterwards. IPL treatments provide gradual, natural improvement with excellent long-term results.

    What to Expect

    Before treatment, a cold gel is usually applied to the areas to be treated and patients wear protective eyewear. During treatment, a physician or trained staff member gently applies the smooth, glass surface of the IPL handpiece to the skin. Light is delivered to the skin surface in precise pulses that are typically pain-free. Occasionally some signs of treatment, such as redness, can last for one or two hours. In most cases, the entire face is treated, but the therapy can also work well on the neck, chest and hands. Results from a full series of treatments usually last for a year or more.

     

     

     

     

    IPL Procedure

    Before treatment, a cold gel is usually applied to the area to be treated, and patients are given protective eyewear. During treatment, the smooth, glass surface of the IPL handpiece is gently applied to the skin, delivering precise pulses of light to the area being treated. IPL treatments are usually pain-free, but an anesthetic cream can be used if the light pulses are uncomfortable. Some patients compare the sensation to a light pinch or the snap of a rubber band. Treatment sessions usually last about 20 minutes, and a complete program usually includes four to six sessions.

    After treatment, patients can immediately return to normal routines and activities. Occasionally evidence of treatment such as redness or blotchiness may last for an hour or two.

     

    Why are multiple treatments necessary?

    Several IPL treatments are required to provide gradual, natural-looking improvement with very low risk. Results usually last a year or more.

     

    Complications of IPL

    The main problem is one of de-pigmentation which may have an adverse effect on patients with a pigmented complexion. This is the main limiting factor of the therapy, and test treatment patches help to identify those patients at risk from this treatment. A possible solution to this problem is ELOS therapy.

    Electro-Optical Synergy (ELOS)

    ELOS Technology

    Syneron's ELOS technology maximizes the synergy of conducted radiofrequency energy (RF) and optical energy.

    RF energy has limited effectiveness in hair removal and treatment of skin disorders. Combined with optical energy ELOS provides an exceptionally effective, safe and affordable method for a broad range of medical aesthetic treatment applications including

    • hair removal
    • skin resurfacing - wrinkles /acne
    • leg vein vascular
    • collagen regeneration
    • treatment of cellulite

     

    Syneron's Galaxy ELOS Machine

     

    How ELOS works:


    Optical Energy - Selectively absorbed by vascular and pigmented lesions

    Electrical Energy (Conducted RF) - Does not affect the melanin of the epidermis

    • Selectively heats hair follicles and bulge, blood vessels, and deep pigmented clusters
    • Effective for heating deep collagen and connective tissue

    ELOS Technology

    • Uniform temperature distribution across hair shaft and follicle (for hair removal)
    • Minimal effect on epidermis
    • Greater treatment depth than optical energy alone, without causing skin damage
    • Parallel selective heating of different lesions
    • Cooling protects epidermis from overheating
    • Fully controllable - maximum effectiveness with minimal side effects