Chicago — Patients seeking full facial rejuvenation can now choose from an unprecedented array of nonsurgical options, according to William P. Werschler, M.D.
"There are finally enough tools available that one can discuss nonsurgical facial rejuvenation comprehensively," says Dr. Werschler, assistant clinical professor of medicine and dermatology, University of Washington School of Medicine. "It used to be that we essentially broke the face up into parts. We said, 'We can treat forehead lines and frown lines with botulinum toxin A (Botox Cosmetic, Allergan). Or we can inject collagen into the lips to make the lips fuller and smooth out the lines around the mouth."
However, he says, "We really didn't have a recipe that was nonsurgical all the way around. In the last few years, though, we've had Sculptra (poly-L-lactic acid, Dermik), Restylane (hyaluronic acid, Q-Med Laboratories) and ThermaCool™ (Thermage Inc.) approved. Combining those with other treatments we have, we now possess a package that allows one to approach total facial restoration nonsurgically." According to Dr. Werschler, today's nonsurgical approach to total facial restoration or rejuvenation encompasses the following elements:
- Botulinum toxin for the upper face.
- Poly-L-lactic acid for the midface. "Though it's not a dermal filler like Restylane or collagen," Dr. Werschler says, "Sculptra adds volume back and helps to restore the youthful convexity of the face. Restoring volume can also be done with surgical implants, fat transfers and some types of lifting that basically reposition the cheek. But, essentially, today, in the concept of nonsurgical facial restoration for the midface, one is going to be using Sculptra."
- Hyaluronic acids for the perioral region and lower face. "Principally," he says, "Restylane is used around the mouth, for augmenting the lips, treating smokers' lines, lifting the nasolabial folds and addressing marionette lines that emanate downward from the corner of the mouth."
- Resurfacing the skin. Dr. Werschler says, "This procedure helps alleviate photodamage, as well as pigmentary and textural changes. In a patient whose skin has been relatively well-protected from the sun, one might use something as simple as retin-A (tretinoin, Ortho Dermatological) or one of the other anti-aging creams. Most people, however, probably require chemical peels, intense pulsed light (IPL) or photodynamic (PDL) treatments. For people with extensively damaged skin, one must perhaps use laser resurfacing. Also, tucked into the concept of tightening and smoothing the skin is Thermage®."
- Maintenance. "At minimum," he says, "this phase includes a sunscreen every morning. And for most people, it will include some kind of exfoliating agent at night. That may be retin-A, Renova (OrthoNeutrogena), Tazorac (tazarotene, Allergan) or glycolic acid. The list goes on. It's going to be somewhat unique to the needs, desires and tolerances of the individual."
Assessing patient needs
Assessing and consulting with patients, Dr. Werschler adds, begins with looking at what's gone wrong over time.
"In the upper face," he says, "with botulinum toxin, one is mainly treating muscle movement and associated pleating of the skin with muscle folding. But around the mouth, lines can form because the skin is attached directly to the muscle. It's one of the few areas on the body where that's the case. So one tends to see unique spokes in a wheel formation around the mouth. And with age, we tend to lose volume in our lips. And as the upper lip loses volume, it tends to elongate somewhat and roll inward. Therefore, we lose the sharp Cupid's bow and red hue of the lip."