Jaw and Neck Contouring Combining Procedures for Ultimate Beauty Effect with Threads and Calcium Hydroxyapatite

Research Article in the International Journal of Clinical & Experimental Dermatology

Christeen Youssef, Everlast Wellness Medical Center, UAE, 

E-Mail: christeen.youssef@everlastwellness.com

Abstract

The most obvious signs of aging result from chronological remodeling of underlying soft tissue structures. Various modifications of the technique have been introduced to simplify the procedure for both patient and the practitioner. Early signs of aging in facial skin results from elastic tissue and collagen degradation, causing fine-to-deep wrinkles. In addition to decreased laxity, generalized thinning of subcutaneous fat tissue leads to volume depletion and a sagging appearance, especially on the jowls and neck. Always correct lax skin in the neck, one to two weeks using Calcium Hydroxylapatite (CaHA) to increase the body’s natural ability to produce collagen and elastin before a lifting procedure using threads with Poly L-Lactide-Caprolactone P(LA/ CL) to provide a complex solution for neck and offers good results. Using non-invasive light lift threads, which was created on the basis of the bio-absorbable materials and its structure with microscopic barbs, it is reliably fixed in soft tissues and forms a strong supporting skeleton. It is possible to reach a visible lifting effect on various areas of the face as well as on the neck. Threads could be combined with calcium hydroxylapatite to stimulate of collagen and elastin to improve quality of skin two weeks prior to threads insertion. This technique is effective to create contour and reposition of the volume of different areas of the face and neckResearch Article in International Journal of Clinical & Experimental

Introduction

Aging is an inevitable process and societal ideals of youthful appearance and beauty have become the driving force on the growing interest on understanding the underlying mechanisms related to aging as well as the advancement of the facial rejuvenation procedures.

Aging of the lower face and neck is multifactorial and ages more remarkably. Gradual increasing of skin laxity, weakening of malar and perioral fat deposit and resorption of the alveolar bone results to loss of definition of the jawline while loss of lateral and inferior volume and ptosis of the lateral chin can create a relative protrusion of the central chin and chin widening. Development of facial jowls, on the other hand, was due to the loss of masseteric ligament support which then allows formation of facial fat to the mandibular border. Moreover, fibrous band on the neck and horizontal rhytides was the result of contraction of the platysma muscle and laxity in the overlying skin. With progressive aging, continuous descending of the hyoid bone leads to loss of definition of the cervico mental angle.

Features of aesthetically youthful lower face and neck includes distinct jawline, absence of jowl, proper chin projection as well as smooth transition from the cheek to chin, a well- defined cervico mental angle and absence of horizontal and vertical rhytides. Additionally, distinct sternocleidomastoid muscle, sub hyoid depression and thyroid bulge is also appreciated.

Compared to the upper and middle zone of the face, these areas are often neglected and undertreated when it comes to rejuvenation and contouring that leads to most disturbing appearance and became the present challenge to most aesthetic practitioner.

Combined minimally invasive aesthetic techniques as an alternative of surgical interventions have widespread application in clinical practice for the correction of the aging lower face and neck. This involves Thread lifting for the improvement and repositioning of the saggy areas and dermal fillers for adding volume to the depressed areas in supplementation to threads.

Materials and Methods

Calcium Hydroxyapatite (CaHA) based dermal filler was administered in the saggy areas of the lower face and neck. CaHA is a biodegradable and naturally reabsorbed by the host’s metabolic processes and provides both replacement and collagen bio-stimulation as primary mechanism of action.

On the other hand, bio-absorbable thread made from Polylactic Acid in combination of Polycaprolactone + Hyaluronic Acid USP 2/0 with multi directional barbs of 170 mm through the use of rounded tip cannula with the hole aside 19 gauge x 150 mm were used for threading the jowls, mandibular lifting and neck according to the degree of skin sagging and texture. P (LA/CL) + HA threads work by improving elastin and texture of the skin together with the collagen synthesis.

Patient Evaluation

The study was conducted at Everlast Wellness Medical Center, Abu Dhabi, United Arab Emirates. Six patients with age ranging from 37-55 years old, having a concern on the lower face and neck appearance due to aging, were treated consecutively using the combination treatment of Threads and Fillers.

Participants included in this study should be 35-55 years oldpresenting age related concerns of the lower face and neck with no allergic history and underlying disease. Patient who requires immediate result, excessive lifting, hypertensive, pregnant and lactating women and allergy to the product composition were excluded. Furthermore, patient with severe sagginess on these areas were not included.

Evaluation Protocol

Patient evaluations were measured through three-zone approach to the face which consist of upper face, mid and lower face. This procedure was done since any changes of the midface also influences the lower part of the face, however, the treatment on this study only focuses on the lower face that comprises the perioral, chin and jawline, including the neck. Moreover, 3-dimensional images of before, immediately after, 2 weeks after, 1 month, after 3 months and 6 months after the procedure with 2 different angles of the same position using VECTRA H1 3D Imaging System (Canne field Scientific, New Jersey, USA) were performed for the assessment and comparison of results.

Assessment through blinded evaluation of the 2 physicians using Global Aesthetic Improvement Scale as the reference parameter (Table 1) and Patient Report Outcome through self-reporting options from 1- 5, 1 being very satisfied and 5 being not satisfied were also performed (Table 2).

Table 1: Global Aesthetic Improvement Scale

Table 2: Internal Patient Satisfaction Scale 

Treatment procedures

A 37 years old patient presented on Figure 1A concerns on the appearance of platysma band on the neckand skin laxity due to loss of volume and elasticity that is visible on the jawline. Patient received a total of 5 mL of local anesthesia comprising 9:1 ratio of 2% lidocaine with epinephrine (1:200,000) and 8.4% sodium bicarbonate was infiltrated on the entry and exit point parallel to the jawline. A total of 10 threads using a 19 G cannula were implanted into the subdermal layer through 2 adjacent inlet holes. A 1.5 mL of CaHA was diluted with 1.5 mL of 2% lidocaine in a 1:1 ratio was sub dermally injected using a fanning technique after the thread implantation. 0.05 cc of filler per injection point were injected into the neck to add volume on the saggy areas and reduce the appearance of the platysma bands. At 1 month follow-up, the patients demonstrate reduction of platysma bands and the improvement of the jawline. Additional 1 mL of CaHA was injected on the on areas where threads were implanted to supplement the volume loss.

Figure 1: Treatment of the neck and jawline in a 37 year old woman before A and after B combination treatment with Threads and CaHA Filler. Photographed B was taken 6 months after the treatment program

A 55 years old female (Figure 2A) also demonstrate appearance of platysma bands. The volume changes in the lower face lead to jawline shadow appearing an irregular “W-shape”.Prior to assessment of the photos, proposed area of implantation were marked on the sternocleidomastoid muscle being the entry and exit point on the midline connecting the chin midline to the sternum and in parallel to the cartilage of the thyroid. 10 pieces of threads were implanted using 19 G cannula into the subdermal layer neck after the infiltration of 8 mL of local anesthesia containing 2% lidocaine and epinephrine buffered with 8.4% sodium bicarbonate, wherein 4 mL each was infiltrated on the right and left lateral side of the neck. CaHA filler was administered right after the threads procedure being diluted with 2% lidocaine in 1:1 ratio.A total of 2 mL diluted CaHA was injected using 27G cannula to the areas needed for volume restoration using a fanning technique. 50 injection points on the labiomandibular border fold, prejowl, lateral jawline and platysma bandsto fill the volume loss with up to 0.05 cc per point of injection was administered. After 1 month post treatment, another 5 pieces of threads was inserted on the jawline to provide lifting on the remaining saggy areas and another 1 mL of CaHA was injected after 3 months to supplement the result of the threads.

Figure 2: Treatment of the neck and jawline in a 55 year old woman before A and after B combination treatment with Threads and CaHA Filler. Photographed B was taken 6 months after the treatment program

A 50 years old presented with moderate laxity of the mandibular septum that leads into fat mass across the mandibular border giving the a blurring contour of the jawline as well as horizontal lines (Fig 3). 10 pieces of threads were inserted on the mandibular region parallel to the jaw angle being the entry point. Thread lifting procedure was administered right after the infiltration of 7.3 mL of local anesthesia with a combination of 9:1 ration of 2% lidocaine and epinephrine (1:200000) with 8.4 % sodium bicarbonate. A total of 2.5 mL of diluted CaHA filler (1:1 ratio with 2% lidocaine) was administered on the horizontal lines and volume on the jawline. 3 months after, further skin improvement was seen especially on the skin tone and texture and another 1 mL of diluted CaHA was injected to increase the definition achieved by the threads procedure.

Figure 3: Treatment of the neck and jawline in a 50 year old woman before A and after B combination treatment with Threads and CaHA Filler. Photographed B was taken 6 months after the treatment program

A 51 years old (Figure 4A), shows loss of volume that reveals underlying jowls and skin drooping. Thread lifting was performed an hour after the infiltration of 7. 3 mL of local anesthesia comprising 9:1 ration of 2% lidocaine and epinephrine (1:200000) with 8.4 % sodium bicarbonate having infiltrated 4 mL on the right lateral side of the neck and 3.3 mL on the left. 10 pcs of threads were implanted sub dermally on the middle part of the chin to the Adams apple and exit point on the sternocleidomastoid muscle. CaHA diluted with 2% lidocaine was sub dermally injected using 27 G cannula on the horizontal lines of the neck and jowls with a total of 2.5 mL of filler in multiple injection points with 0.05 cc per injection point. 1 month after, additional 5 pieces of threads were implanted on the chin. Immediately after injection, visible improvement was seen. Additional 1 mL of CaHA was also administered after 3 months to supplement the volume deficit after thread lift.

Figure 4: Treatment of the neck and jawline in a 51 year old woman before A and after B combination treatment with Threads and CaHA Filler. Photographed B was taken 6 months after the treatment program

A 45 years old demonstrate a thin skin and volume loss through atrophy reveals underlying jowls (Figure 5A). On the initial visit, 10 pieces of threads were inserted sub dermally to the middle part of the chin as the main entry point to lift the saggy areas of the jaw to the neck and exits on the sternocleidomastoid muscle. 19G cannula containing the thread was inserted on the proposed area of insertion an hour after the administration of local anesthesia containing 9:1 ratio of 2% lidocaine with 1: 200000 epinephrine combined with 8.4% sodium bicarbonate. A total of6 mL of anesthesia were infiltrated, 3 mL on the left lateral side and 3 mL on the right lateral side of the neck. Immediately after the threads, a diluted CaHA (mixture of CaHA with 2% lidocaine with 1:1 ratio) was injected sub-dermally using 27G cannula on the horizontal lines and for the supplementation of the volume deficit after the threads procedure. A total of 1.5 mL with 0.05 cc per injection pointwas administered. 3 months after, further addition of 1 mL CaHA was injected on the remaining areas demonstrating laxity and father volume enhancement of the saggy areas.

Figure 5. Treatment of the neck and jawline in a 45 year old woman before A and after B combination treatment with Threads and CaHA Filler. Photographed B was taken 6 months after the treatment program

A 40 year old patient (Figure 6.A) with lower jowl formation due to fat mass accumulation and irregular jawline also received 10 pieces of threads using 19G cannula on the proposed entry point right after the assessment. Threads were inserted on the dermis deeper than the subcutaneous plane right after the infiltration of 6 mL of local anesthesia containing 9:1 ratio of 2% lidocaine with 1: 200000 epinephrine combined with 8.4% sodium bicarbonate on the left and right lateral side of the neck. Mixture of CaHA and 2% lidocaine was injected on the multiple injection points from the subdermal fat layer to the depressor labiiinferioris to minimize the palpable mass formation on the submental area and reduction of horizontal lines.

0.05 cc per injection points was administered consuming a total 2 mL of CaHA filler.of horizontal lines. 0.05 cc per injection points was administered consuming a total 2 mL of CaHA filler.

Figure 6: Treatment of the neck and jawline in a 40 year old woman before A and after B combination treatment with Threads and CaHA Filler. Photographed B was taken 6 months after the treatment program

Results

A total of 6 female patients with mean age 46± 6.9 who met the criteria were treated consecutively with combined Threads and 1:1 diluted CaHA filler. Majority of the patient are experiencing mild to moderate sagginess of the skin, volume loss, and for horizontal rhytides. 50 % of the patients concern was because of the visibility of platysma bands and jowl formation. Images of the patients being compared to its baseline photos showed improvement on the necklines, jawlines and jowls after 6 months post treatment.

Table 3 illustrates the satisfaction rate from the blinded physicians at different timelines. 66.7% of the patient demonstrated improvement (GAIS 3) for evaluator 1 and 50% for Evaluator 2 respectively, regardless of each patient’s condition immediately after treatment and 33% were considered very improved patients for evaluator 1 and 83 % for evaluator 2. 6 months after the treatment was the highest peak of satisfaction reported. Evaluator 1 rated 50% of the patients as very exceptional improvement (GAIS 1) and 67% for evaluator

2. On the other hand, evaluator 1 rated 50% of the cases as very improved patients and 33 % for evaluator 2.

Table 3: Global Aesthetic Improvement Score from Physicians

Patient’s satisfaction score is illustrated in Table 4 using questionnaires were based from the 6 months post treatment of the lower face and the neck.66.7% scored themselves as very satisfied and 33.3% respectively, indicate that patients were satisfied from the results of the treatment.

Table 4: Patient Reported Outcome Score

Results obtained from the before and after 3D photos revealed that after the 6 month treatment program, patients presented with reduced jaw height and chin projection and volume loss in the lower face down to the neck (Figure 2B, 3B, 4B, 5B) who undergone threads and CaHA have restored the curve of the jawline and the projection of the chin have also improved. In addition to that, the skin became tighter and plumper with evident decrease of the saggy areas.

Patient having concern with the appearance jowls and horizontal rhytides have improved after the 6 month. Figure (3B, 4B, 6B) showed the decrease of the appearance of jowls and horizontal lines and visible tightness of the skin which result to a well-defined jawline and firmer skin and more rejuvenated appearance.

A decrease of the appearance of platysma bands (Figure 1B, 2B) were also evident after the treatment program of the patients presented with prominent appearance of platysma band. This indicates that filler and threads have improved the appearance and contour of the neck.

Redness, swelling and bruising immediately after the treatment were experienced by most of the subjects. This is due to the slight injury occurred during the implantation of threads and the administration of fillers that usually resolves after 3- 5 days with the proper post treatment care.

Discussion

Majority of the people were anxious about the excess fullness under chin and jawline and on the appearance of horizontal and vertical line of the neck and the only intervention to address these concerns was primarily surgical however, the growing minimally invasive procedures that is used as an alternative to surgical procedures to improve the result of the lower face and neck became the demand of most of the patients who pursue a treatment with minimal risk of complication and less recovery time. The implantation of threads with the use of absorbable threads showed excellent result on the lower face and neck due to the immediate lifting of the tissue because of the mechanical action produced by the thread. Administrations of filler with the use of Calcium Hydroxylapatite to enhance the volume of the depressed areas as it stimulates neocollagenesis and improve skin quality.

In this study, the effect of the combination treatment of absorbable threads and CaHA filler was performed to evaluate the efficacy for the lower face and neck rejuvenation. A form of assessment was performed using the comparison of the pre-operative and post- operative treatment photos, blinded evaluation of physicians were assess on the immediately after and after 6 months post procedure and patient satisfaction score after 6 months.

Patient Satisfaction Scale are also relevant because of the patients perception of the treatment result is subjective. Overall, high level of satisfaction was obtained after 6 months period. Most of the patients noticed an immediate improvement of the jowls, depressed areas, skin laxity, necklines and chin projection right after the treatment.

The level of satisfaction of patients progressed with time. The exceptional level of extreme satisfaction increased from 0% (0 case) in the immediately after to 66.7% (4 cases) in the sixth month after treatment. 33% of patients were scored as very satisfied on the same timeline.

Results from the photos were also transparent as it demonstrates the visible improvement of the lower face and the neck of the patients in comparison of the pre-operative photos Furthermore, no potential complications were recorded and treatment was well tolerated. Patients who undergone the treatment were able to perform their daily normal routine due to rapid recovery.

The result of this study for the lower face and neck rejuvenation using the combination of threads and CaHA filler showed a significant outcome and has been a very good alternative for the surgical intervention based from the assessment gathered. The condition after treatment program demonstrate a well contoured neck and jawline with better skin tone and texture due to the collagen stimulation. Individually, thread lifting and filler injection have both demonstrated the efficacy on giving definition on the saggy and depressed areas and the duration of its efficacy were last for a year or more.

Conclusion

Ideal perception of beauty and youthful appearance has become the reason of the growing trend on facial rejuvenation procedures. However, familiarity on the aging process and anatomy of the face is a paramount to achieve optimal natural and aesthetic result including a thorough evaluation and counseling before proceeding to any intervention.Three dimensional procedures involving relaxation, volume restoration and resuspension for the process of rejuvenation in addressing to the aging lower face and neck, which has been always neglected, works best with in-depth knowledge of properties and techniques specific to each product in the on the treatment.

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