There are a number of non-surgical rejuvenation products and devices globally available to support patients and help them address their skin and rejuvenation goals. While some products and devices provide more predictable and noticeable results and are less technician dependent, some products and devices, such as neurotoxins and dermal fillers, do require a particular skillset and are heavily technician dependent, which leads to increased variables in achieving ideal outcomes. This article will discuss an algorithm to provide facial rejuvenation and ideal facial ratio achievement by focusing on a more global and holistic approach, beginning with topical skin health promotion, full face muscle modulation, revolumisation and important safety and side effect considerations for optimal outcomes (Figure 1).
A basic topical skincare routine is an example of a non-surgical and at-home intervention that can assist with setting the stage for skin health through the use of daily and nightly topical products, such as cleansers, moisturisers, sun protection factor (SPF) and exfoliants. Skincare can assist with preparation and recovery for non-surgical and in-clinic interventions. Safety considerations include avoiding topical formulations with ingredients that are known to contribute to allergic atopic dermatitis, as well as other skin and systemic disturbances (Cohen et al, 2022).
Topically applied active products are characterised as non-surgical rejuvenation options that promote increased cell turnover frequency, such as vitamin A and retinol preparations, exfoliants (such as glycolic, salicylic and lactic acids), peptides (such as signal peptides, neurotransmitter peptides and enzyme inhibitor peptides) and growth factors to promote skin health on a cellular level to promote stimulation of various biochemical pathways to impact concerns, including hyperpigmentation, acne, loss of collagen, large pores and sagging skin (Derm Collective, 2022).
Energy-based rejuvenation options include photobiomodulation, ablative, unfractionated and fractionated laser resurfacing, radiofrequency, ultrasound, thermal and cryo technologies, microcurrent, microneedling and microneedling with radiofrequency continue to gain popularity for promoting collagen and elastin. They are also useful in repairing ageing skin and photodamage. With a surplus of options available, considerations include how long the technology has been used; realistic outcomes; predictable outcomes; technician skillset; pre- and post-recovery optimisation with topical skincare; the overall health of the patient; an ethical and transparent fee; and treatment plan of interventions provided for the patient. Lasers are known to carry the highest rates of litigation in the aesthetics sector, and attention to device quality, maintenance, treatment planning, application and oversight by regulated healthcare practitioners are essential (Halepas et al, 2020).
Injectable non-surgical intervention with neurotoxins can be used for softening dynamic wrinkles, lifting the brows and eyelids and off-label slimming of the jowls and masseters. Dermal fillers are used for revolumisation in areas such as the temples, cheeks, lips, jawline, necklace lines and other areas of the body. Biostimulatory agents promote neocollagenesis and elicit the body's own gene expression of collagen for revolumisation. Deoxycholic acid has gained popularity in recent years for its ability to dissolve adipose tissue in the submental area with the main concern being the close proximity of application superior to the delicate thyroid tissue and potential long-term implications with the increasing prevalence of autoimmune and thyroid diseases. Neuromodulators in the upper, mid and lower face can provide benefits but care must be taken with accuracy and dosing to reduce distortion of the smile, articulation with eating and speaking and possible asymmetric outcomes. Headaches, double vision and eyelid ptosis are other potential side effects of neuromodulators. Side effects from dermal fillers and biostimulatory agents can result in nodules, granulomas and blockage of facial blood supply. This may result in tissue necrosis and blindness, which requires urgent attention by a health practitioner with sufficient experience in the management of side effects and vascular occlusions (Varga, 2021).
Mesotherapy and mesococktails are gaining popularity and can be a customised concoction of the previously mentioned non-surgical cosmeceuticals and pharmaceuticals delivered into the dermis or subcutaneous layer through no-needle or microneedle techniques. Despite its popularity, there is a scarcity of large-scale safety studies on the safety, efficacy and pharmacokinetics of cosmeceuticals mixed with pharmaceuticals and their interactions with one another and the skin (Kandhari et al, 2020).
Aesthetic medicine is becoming increasingly commoditised, with an observable increase in various types of new rejuvenation technologies and devices being introduced without a long-term understanding of anticipated results, safety and efficacy profiles and optimised clinical treatment protocols. This not only raises potential questions regarding expected outcomes, but also long-term impacts and safety concerns around comorbidities and pharmacokinetics.
The rejuvenation process begins with the consultation
Before employing any rejuvenation intervention, an in-depth aesthetic consultation must occur to gain a patient's history, discuss goals and create a treatment plan in accordance with their rejuvenation goals, budget and lifestyle. It is becoming increasingly popular for aesthetic medical clinics to employ a consultant or support staff member to perform initial consultations with prospective patients. An ever-evolving aesthetic clinical model with an increased number of support staff and unregulated providers performing the initial consultation reduces access for patients to meet with regulated providers for an in-depth consultation, assessment and planning process. This may result in more ambiguous answers during the consultation process and less detailed treatment plans, which may later need to be adjusted, resulting in an increased likelihood of confusion for the patient and, thus, a lower consultation to treatment conversion rate.
» When one aspect of the face is enhanced, such as the lips, but the cheeks and marionette zone are not addressed, there is an increased risk of suboptimal outcomes and facial ratios becoming distorted «
With the rise in more conscious consumers seeking clinicians with similar values, trust can be better established through an initial consultation with the prospective patient and the practitioner who will perform the rejuvenation. This allows for a more detailed assessment and discussion of patient expectations, realistic outcomes and treatment planning. This also best supports the process of informed consent prior to moving forward with a rejuvenation treatment plan for best practice. It would be expected that, if a clinic's model is to first have the patient meet with an unregulated support staff member, more time will need to be spent with the regulated provider at the scheduled rejuvenation treatment appointment time to establish trust with a new team member, answer remaining questions and possibly provide clarification. When a patient transitions between an unregulated consultant to a regulated practitioner, there can be an increased opportunity for missing crucial health history insights, such as allergies and comorbidities (including underlying autoimmune conditions, such as thyroid disease in the case of deoxycholic acid injectables), that may deem a patient an unsuitable candidate for the scheduled rejuvenation procedure. If these health insights are missed, there may be an increased risk of unforeseen side effects with an underlying autoimmune condition, or if the general health of a patient is not considered, elevated levels of inflammation or environmental toxicity may contribute to an increased likelihood of adverse events and, thus, suboptimal outcomes (Varga, 2021).
Treatment planning
Providing the patient with a clear and concise treatment plan is both ethical and essential to allow for the patient and provider to discuss costs, pre- and post-care and manage rejuvenation interventions. It is postulated that key factors that result in a higher level of patient satisfaction include establishing and maintaining trust; communicating personal values and rejuvenation goals; providing an opportunity to ask questions; receiving a clear rejuvenation treatment plan, including take-home information; and organisation of interventions with an interval schedule, fees and pre- and post-recovery resources.
Prior to the implementation of rejuvenation procedures, to determine patient compliance to pre- and post-care, it is advisable to integrate an at-home cosmeceutical grade skincare routine and discuss lifestyle practices. This is to reduce overall systemic inflammation for optimal outcomes and slowing ageing and to establish a professional method of communication before and after rejuvenation for support and guidance. The importance of a patient's ability to manage inflammation, have balanced hormones, live a healthy lifestyle and lower an overall toxic burden are directly related to their ability to heal and receive optimal outcomes.
Preparation of the skin prior to interventions
Patients who exclusively seek or are solely directed towards only non-surgical neurotoxins, dermal fillers and biostimulatory injectables experience a missed opportunity for foundational skin health support benefits, including skin tone, texture, pigmentation and collagen promotion improvements. When multiple layers of non-surgical modalities are considered and employed in a comprehensive at-home and in-clinic non-surgical rejuvenation treatment plan, it is postulated that a higher likelihood of more optimal outcomes is achievable. A proposed algorithm for introducing a global approach to rejuvenation and, essentially, stacking interventions from less invasive to more invasive, includes guidance in lifestyle modification to reduce inflammation and improve cellular health, customised at-home skincare, in-clinic exfoliation, energy-based skin rejuvenation, neuromodulators, biostimulatory agents and, lastly, dermal fillers, has the potential to provide a better-tolerated rejuvenation journey and allows for more optimal outcomes through building upon the benefits of each intervention (Varga, 2019).
Safety considerations of non-surgical interventions
From an aesthetic liability standpoint, energy-based devices account for the highest number of litigation cases, which may be related to the delegation of rejuvenation to unregulated care providers or the wide range of energy and laser device options on the market. These widely range in their levels of product research and development, education training, experience with the technology and the ever-increasing opportunity of counterfeit products and devices when purchased from non-manufacturers and third-party sellers (Maksud et al, 1996).
Dermal fillers present the greatest risk for serious sequelae out of all rejuvenation interventions due to their potential to block blood flow to the tissue, resulting in an adverse event known as a vascular occlusion. This can result in tissue necrosis, scarring and, in rare cases, blindness. There is no area of the face or body with zero risk of side effects. The knowledge level, experience and ongoing level of training of an aesthetic practitioner are key elements in providing the highest standard of care and managing adverse events when and if they arise. Well-established vascular occlusion protocols should be followed, and clinicians should collaborate with various practitioners to ensure the optimal health, safety and monitoring of a patient, should a vascular ever need to be urgently addressed and blood flow restored to reduce long-term sequelae. It is critical that an aesthetic provider cultivates a network of colleagues who are highly skilled and experienced in the management of dermal filler adverse events (DeLorenzi, 2017). Furthermore, groups such as the Complications in Medical Aesthetic Collaborative exist to support clinicians.
Achieving balance and symmetry with a combination of non-surgical injectables
As the body ages, certain aspects of facial features change, such as the nose, ears and chin, due to anatomical changes in the loss of bone, soft tissue and fat. Other muscular structures of the face, including the masseters, depressor angularis oris, mentalis and platysma bands, can appear to enlarge over time and are accelerated by certain lifestyle factors. These include grinding teeth; clenching and jaw tension; overly active facial animations during communication (which can be noted in certain types of actors who are required to be overtly expressive); and eating overly chewy foods requiring prolonged mastication, and regular recruitment of these facial muscles can result in hypertrophy of the lower third facial muscles.
Neuromodulators can be employed before applying dermal fillers to provide a slimming effect on the lower third facial muscles, which often enlarge with age. It is well established that the ageing process creates descent of the global facial structures, resulting in the lower third of the face looking fuller than the upper and middle thirds of the face. Hypertrophy of the lower third facial muscles can be reduced through neurotoxins prior to mid and lower face dermal filler application, so as to not contribute to further enlargement of the lower third of the face, particularly in a female patient, as this may present a masculinisation of the jawline, which is not ideal for many. By first performing full-face neuromodulators, which are considered less invasive than dermal fillers, this allows for the patient to experience non-surgical injectable interventions prior to dermal fillers, which does include deeper placement of the product and more manipulation of tissues. Additionally, there is an expected higher degree of pain and swelling compared to neuromodulators, simply based on the principle that tissue is being displaced and prostaglandins will be released, resulting in the feeling of pain by the nociceptors. Careful attention to product placement and dosing is imperative with neuromodulators, so as to not interfere with speech and eating or contribute to smile asymmetries, which can have devastating impacts for months (Varga, 2021).
It is recommended that neuromodulators are employed globally to the upper, mid and lower thirds of the face, so as to relax the orbicularis oculi, nasalis and the lateral aspects of the zygomaticus major and minor muscles, which do impact the positioning of fat and soft tissue that lay overtop of the zygomatic bone, as seen in Figure 2. A 2-week interval between the application of neuromodulators is recommended for the toxin to take full effect and tissue redraping to occur, followed up by a dermal filler or biostimulator application to essentially take care of what is left over from a facial ratio and rejuvenation perspective. This allows for a more natural-looking outcome and gradual enhancement over time, which is appreciated by discreet and conservative patients.
Once the stage has been set through the delivery of topical skin cosmeceuticals, in-clinic energy-based treatments and neuromodulators, an opportunity can be taken to evaluate the efficacy of previously employed rejuvenation. This determines the next phase in the provision of dermal fillers and/or biostimulatory agents in order to achieve an optimal outcome for skin health, revolumisation, ideal ratio achievement and overall facial rejuvenation.
Selecting treatment areas for dermal fillers
The injectable industry is fast-paced and constantly evolving, with new and innovative applications of product placement continuing to gain popularity. Generally, there are three key regions of the face that respond well to dermal fillers in the long term: the midface, perioral and marionette/jawline. There are many other areas of the face that can be exciting to learn about and inject, such as glabellar lines, periocular regions, including the tear troughs, the bridge of the nose for a non-surgical rhinoplasty, nasolabial folds and the lateral aspects of the face in the preauricular area, which have all gained popularity. However, it must be noted that the nasal area and glabellar lines are high-risk areas to treat, and should only be done so by very experienced clinicians. The propensity of certain dermal filler formulations to have a higher or lower tissue integration or behave in a more hydrophilic manner must be taken into consideration during product selection. When placed correctly, dermal filler rarely migrates. However, through various product histology analyses, it has been noted in head computed tomography scans (CT) that some fillers have migrated from an area of initial placement near the anterior aspect of the periocular region to the posterior aspect. This may have no noticeable impact on ocular function or may have detrimental effects on the retina, causing vision loss, and should urgently be assessed by an ophthalmologist or other skilled provider in dermal filler occlusion management, who is trained in retrobulbar injections and, in rare cases, may need to apply a hyaluronic acid-dissolving agent to restore blood flow to the retina using this technique (Varga, 2019).
Maintaining ideal facial ratios
When one aspect of the face is enhanced, such as the lips, but the cheeks and marionette zone are not addressed, there is an increased risk of suboptimal outcomes and facial ratios becoming distorted. Taking a global approach to applying dermal fillers to the cheek, lip and jawline regions together will lend to more optimal and balanced outcomes in alignment with the patient's natural proportions, and the ideal ratios will be more likely to be respected. Within the medical aesthetics sector, it is imperative to improve the understanding of ideal facial ratios and take into account the naturally occurring proportions of the patient as an individual. It is not advisable to provide a ‘cookie cutter’ approach and idealise celebrity facial ratios and features. By taking the time to review the patient's goals, discuss how ideal facial ratios can be achieved and detect signs of body dysmorphia throughout the consultation and rejuvenation process, a higher degree of ideal outcomes will be achieved.
Risk reduction
It is advisable that novice injectors begin to develop their skillset around employing facial injectables, including control of the depth and angle of injections, through the application of neuromodulators. These are not without risks of side effects, but they do not carry the risk of vascular occlusion prior to providing dermal fillers and biostimulants. This allows for an opportunity to develop dexterity and control of fine motor skills, which is crucial in the safe and precise delivery of injectable products. When applying dermal fillers, it is also advisable to employ the practice of aspiration to aid in reducing the likelihood of a vascular occlusion. Aspiration times vary with dermal filler products, and it is advisable to pause after initiating aspiration for at least 10 seconds prior to injecting dermal fillers in any area of the face (Casabona, 2015).
By practising in a team environment, including regulated healthcare providers, when and if an emergent adverse event presents itself, a timely referral to a practitioner experienced in managing vascular occlusions is prudent in vascular occlusion management. Cultivating a local team with experience in the management of adverse events can enhance patient safety and optimal outcomes.
Conclusion
By taking a holistic and comprehensive approach to facial rejuvenation, fewer invasive interventions are necessary, which carry greater inherent risks. By listening to the patient's skin and rejuvenation goals through a consultation with a regulated healthcare practitioner who also performs the initial assessment and taking the time to create a thoughtful at-home and in-clinic rejuvenation journey, there is a greater likelihood of achieving higher conversion rates from consultation to treatment and optimal outcomes. This will also instil a greater sense of confidence from the patient in a practitioner who takes the time to outline the various aesthetic options in accordance with their goals. Achieving optimal non-surgical aesthetic rejuvenation encompasses tailored at-home cosmeceutical skincare with healthy lifestyle practices to reduce underlying systemic inflammation and oxidative stress, which is, in essence, the root cause of ageing. Taking a balanced approach in employing at-home skin health practices, energy-based skin rejuvenation and injectable interventions for the remaining balance and symmetry aspects will reduce the potential for more serious side effects and lead to more natural-looking outcomes.
Key points
- Practitioners can learn how to guide the modern aesthetic patient through a treatment algorithm to promote safe and optimal skin rejuvenation outcomes
- It should be understood which rejuvenation options carry the highest risk of litigation and severe adverse events and how to reduce the harm
- Practitioneres should standardise the consultation process to include opportunities for health assessments by a regulated health care professional with adequate opportunities for questions and answers to allow for informed consent in an effort to reduce harm and establish if a patient is a candidate for available options.