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Facial laxity rating scale offers a scientific, objective assessment of rejuvenation procedures

Article-Facial laxity rating scale offers a scientific, objective assessment of rejuvenation procedures

Key iconKey Points

  • Facial rating scales can be used to document measurement changes after cosmetic surgery
  • Clinicians established a facial laxity rating scale to facilitate quick and accurate reproducible assessments of laxity in all facial regions

A validated facial laxity rating scale proves to accurately document the changes and improvements achieved following facial cosmetic surgery procedures, introducing a more scientific approach and objective evaluation of aesthetic outcomes, according to Craig Jonov, M.D., D.M.D.

Various facial rating scales can be used to document facial measurement changes achieved following cosmetic surgery, and their implementation can offer much more objectivity in the assessment of outcomes, Dr. Jonov says.

"Today, we really do not have any objective data to say if a patient looks better or improved after cosmetic surgery. Commenting on improvements or even the absence of them is very subjective, underscoring the need for such rating scales," says Dr. Jonov, the Gallery of Cosmetic Surgery, Seattle.

FLRS IN ACTION Recently, Dr. Jonov and colleagues developed a facial laxity rating scale (FLRS) in order to facilitate quick and accurate reproducible assessments of laxity in all the facial regions. According to Dr. Jonov, the FLRS is based on the evaluation of four main signs, each located in one of the four facial compartmental regions that divide the face and the neck for laxity assessment proposes.

The four regions include the upper face (frontal), middle face (malar), lower face (mandibular), and the upper neck. The representative signs for each region to be evaluated are the eyelid fold, nasojugal fold, jowls and profile of the neck angle, respectively.

Based on standard patient photographs and line drawings, the designated FLRS signs are analyzed, compared or measured to establish its position in relation to neighboring facial structures. So that the scale could be applied to the widest range of patients, Dr. Jonov says the gold standard chosen for the FLRS is the ideal facial aesthetic positioning of youth and not a treatment effect such as surgical facelift.

For the assessment of facial laxity, evaluations are classified on a 10-point scale, namely, stage 0 (or no facial laxity), stages 1 to 3 (mild laxity), stages 4 to 6 (moderate laxity) and stages 7 to 9 (severe laxity).

After a given cosmetic procedure is performed, photographs and measurements taken at baseline can then be compared to those taken after the procedure to measure and assess the improvements made, Dr. Jonov says. The FLRS system can be implemented for any facial rejuvenation procedure that addresses skin laxity, including surgical procedures such as facelifts, blepharoplasties and necklifts, as well as less invasive procedures such as volume enhancements using filler techniques, botulinum toxin treatments and energy-based treatments including radiofrequency, and laser and light modalities, he says.

"Gauging the effectiveness of cosmetic treatments to reduce the sagging of facial skin and deep tissue can be challenging for both physicians and their patients. There are multiple characteristics of different facial types that combine to determine varying degrees or stages of deep facial flaccidity. These characteristics are difficult to group, as objective data for the purpose of determining the degrees of sagging and even degrees of improvement or worsening of deep facial laxity," Dr. Jonov says.

A 36-year-old female patient before (top images) and two-and-a-half months after upper and lower blepharoplasties, necklift and fat transfer to the midface region. From baseline, the eyes, midface, lower face and neck region showed improvement in the facial laxity scale by 3 points, 1 point, 2 points and 2 points, respectively, Dr. Jonov says. (Photos credit: Craig Jonov, M.D., D.M.D.)
OBJECTIVITY COUNTS According to Dr. Jonov, the FLRS offers both physicians and patients an objective way to assess the efficacy of the rejuvenation treatments chosen for a defined goal, rather than a subjective assessment, which differs from observer to observer.

"Sometimes you may have a cosmetic patient where technically, you did an outstanding job and by all standards the cosmetic surgery was a success, however the patient may not really be happy with the outcome. In the search of objective criteria, one can use the rating scale to evaluate improvements," Dr. Jonov says.

Dr. Jonov says he often will incorporate the facial rating scale data into the overall evaluation of the patient, offering an "identification of baseline" from which potential improvements can be planned and realistic goals set. The FLRS not only serves to document the improvements made; it can also point out the potential improvements that could still be achieved with other adjunctive cosmetic interventions, he says.

"The FLRS combines all of the methodology that we have to provide facial rejuvenation surgery today. With the proper training, cosmetic physicians can apply the FLRS in a consistent and reproducible manner in the grading of facial laxity," Dr. Jonov says.


The facial laxity study was sponsored by Solta Medical.

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