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Talent & Techniques: A nonsurgical combination approach to achieve “4 Rs” of facial rejuvenation

Surgical face lift, thread lift, botox, lipolysis, skin rejuvenation

Medical aesthetic interventions to delay facial aging and improve the cosmetic features of a face require individual, sophisticated and safe solutions for the most natural and harmonious results. Facial imperfections and changes due to aging require treatment concepts that target various aspects, beyond the scope of what one single product or technology can achieve. Therefore, combination is key.

The most common indications associated with facial aging are poor skin quality with pigmentary changes and creases, wrinkles, volume loss and deflation, sagging skin and sagging, drooping structures beneath the skin.

My personal, indication-specific treatment concepts combine a variety of non- or minimally invasive procedures and techniques. And by applying the 4 Rs of facial rejuvenation – relaxing, resurfacing, revolumizing and repositioning of lax tissues – I can counteract these typical signs of aging and improve facial aesthetics.


To begin let’s explore aging in the mid- and lower face. At its surface, aging skin in this area typically shows creases and wrinkles, in addition to unwanted pigmentary changes.

There are various treatment options to resurface the skin, stimulate collagen production and treat unwanted hyperpigmentation caused by melanin overproduction or broken vessels.

My preferred method to increase the skin’s overall quality consists of customized combination peels using compounded formulations, as well as ready-to-use agents (not regulated as drugs) in combination with penetration enhancers, such as microneedling devices. I typically add energy-based devices, such as intense pulsed light (IPL) systems, to target any residual red pigment/hemoglobin, or age spots not previously treated with other methods.


Second, hyperactive muscles form crow’s feet that can reach to the cheeks; the corners of the mouth droop; overactive muscles, such as the mentalis muscle, form dimpling and an orange peel-like texture; and the platysma muscle can cause sagging and undefined contours to the jawline.

For these indications, I set up customized protocols by delivering exact doses of botulinum toxin type A. In addition to on-label treatments, I also use an off-label approach most commonly known as “micro Botox”.

With this multi-point, multi-level injection protocol I use dosing systems to accurately and reliably fractionate neurotoxin down to micro doses to smooth wrinkles and relax the relevant muscles in the most individualized way.


When it comes to volume, there are basically two ways that facial volume changes: volume loss and drooping.

Aging in the upper midface typically includes a deficiency in the frontal projection of the cheeks and loss of the well-defined contour of the cheek over the zygoma area, while volume loss in the lower face can mean formation of the prejowl sulcus or a recessed chin. Replacing lost volume is the best approach to counteracting such changes. I do this by using biodegradable volumizing fillers.

When it comes to drooping volume, this typically happens in the lower face and results in jowling and double chin formation. In this situation my preferred method is to adjust the unwanted volume by reducing it with injection lipolysis.


Finally, there is the issue of sagging. Looking at the mid- and lower face, it is not only about sagging of the skin, but also about sagging of the underlying structures resulting in a 3-dimensional (3D) deflation.

To combat these forces of gravity, my best approach is to reposition the tissues with resorbable suspension sutures (thread lifts) as they not only reliably lift the sagging skin, they also help to effectively and sustainably reposition all of these structures.

It is important to note that filling such wrinkles would either create lumps or result in a really short duration of effect. However, additional vectoring with resorbable filler to replace volume and stimulate collagen production using advanced cannula technology, really enhances the results of the suspension sutures.

Combine for best results

Considering all of the different aspects and indications related to the aging face, it absolutely makes sense to combine some or all of these technologies and products in an effective, custom-designed treatment protocol.

My process is to first determine the most bothersome problem to the patient, and then define which modalities need to be combined to achieve efficacious results, as well as the sequence and timing of treatments for the specific patient.

One major principle in this combined approach is to avoid treating the exact same anatomical area in the same session in order to reduce safety risks.

Another important aspect is that any technique or treatment needs time for its mechanism of action to work (e.g., after injecting a collagen stimulating filler, I don’t give any filler touch-ups for six to eight weeks post-treatment to allow time for the initiation of collagen formation).

In addition, all therapy-related side effects need time to stabilize. And of course, the patient needs time to get used to his or her new look, so they can appropriately judge whether they might need a touch-up.

At the end of the day, it all comes down to providing the natural, individualized results that our patients desire, and the key to this is the practical combination of the right non- and/or minimally invasive treatment concepts to achieve the 4 Rs of facial rejuvenation.

Meet the Expert
Sabine Zenker, M.D.

Dr. Zenker is a world-renowned, board certified German dermatologist who combines her dermatological expertise with a distinct sense for facial and body aesthetics. Since establishing her private practice, DrZenkerDermatology, in Munich, Germany, in 2003, Dr. Zenker has dedicated her daily work to diligent individual patient care, as well as clinical research for non- and micro invasive aesthetic procedures. For more than 15 years, Dr. Zenker has been a speaker, trainer and consultant. She is widely and regularly quoted in major publications, and frequently consulted by major media to offer expert scientific opinions on clinical and aesthetic dermatology.

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