Body Language

The lipstick effect

The trend for minimally invasive procedures is continuing its exponential rise, according to recent US statistics. Dr Timothy Flynn reviews the data and discusses how, in combination, toxins and fillers can provide an ‘injectable face-lift’

The American Society for Plastic and Reconstructive Surgery (ASPRS) recently released its 2012 survey data on cosmetic procedures performed in the United States. Amazingly, in a down economy, minimally invasive procedures—such as the use of fillers and neuromodulators—were up by six percent. At the same time, the society reported that surgical procedures were down by three percent. Americans are spending more on smaller procedures while holding off on larger, more expensive surgery such as a face-lift or tummy tuck.

Much of this was explained by the press as the “lipstick effect”, a term coined by consumer psychologists. It is well documented that during hard times, a woman is more likely to buy a new tube of lipstick than she is to spend money on an expensive pair of designer shoes.

Following the devastation of Hurricane Katrina, dermatologists in New Orleans reported that they were very busy with injectables, with their patients commenting that toxin treatments boosted their self esteem. Other researchers have discovered that people will spend money on beauty items which make them feel good when facing hard times, either personal or economic.

There is an emotional component to beauty purchases, substantiated by data showing that during this same period of the depressed American economy, record numbers of dollars were spent on “beauty services”, such as spa treatments or hair care. Money spent on nails during 2012 also achieved a record high. When we are feeling a bit down and stressed, we like to do small things that feel good while we conserve our large expenditures.

When reporting on the ASPRS statistics, the press failed to recognise that using injectables in combination could produce what some have termed “the injectable face-lift.” Increased use of toxins and fillers has also been documented by the American Society of Dermatologic Surgery (ASDS), who noted that the use of neuromodulators increased by 24% and the use of injectable fillers increased by 10% by their members.

ASDS members have also noticed that the increasing use or the combination use of both fillers and neuromodulators have begun to restore the face to its youthful volume in correct proportion and return the ageing face and restore youthful beauty. Members have noted those patients who have chosen to continue injectable treatments to a point where they have a sufficient amount of volume restoring material placed correctly, have begun to hold time at bay or even look younger. Some physicians’ marketing have used the neologism “re-flation” for this youthful restoration of volume.

Anthropology

The reason why these injectable techniques are working so well can be linked back to two discoveries in two specialities—plastic surgery and anthropology. Doctors Rohrich and Pessa, while working with ageing cadavers, documented significant facial fat loss and detailed the fat compartments of the face. Using injectable dyes, they demonstrated that these fat compartments are isolated one from another and, when injected with visible dyes, they inflated and retained the dye within each individual anatomic fat pad.

Advanced injectors from core aesthetic specialties, working with newer injectable agents, have understood the power that placing volume in and around the fat pads can have. The deeper injectable fillers that have been used include hyaluronic acids, calcium hydroxyapatite and poly-L-lactic acid. These agents are often used in a diluted fashion to evenly distribute these filler materials.

Each deeper filling agent has its own particular technique, with properties specific to that agent. For example, Sculptra is exclusively a deep filling agent, where the poly-L-lactic acid particles cause a tissue response over time, building up volume by stimulating the body to produce its own collagen.

Multiple treatments are to be expected, and certain patients respond better than others. More robust hyaluronic acids can often achieve correction in one or two treatment sessions, and hyaluronic acids can be used more superficially as well as deeply. Some practitioners favour the use of a blunt cannula, while others use a sharp needle—there are advantages and disadvantages to each delivery system.

Anthropologists made another advance. Scientists working on the effect of age on the human skull documented that the skull changes predictably as we get older. They showed that there are specific structural changes that occur within the skull, which assist them in documenting the age of the deceased individual.

Radiologic techniques were used in living people to confirm these bony changes, showing that as we age, our eye sockets widen, there is dental and bone resorption, and malar collapse. These age-related bony changes in the skull are an additional cause of volume loss—the underlying hard structure supporting the facial fat pads and overlying skin shrinks. The eyes sink into the skull producing sags under the eyes and nasolabial folds develop. Lines around the mouth develop because of soft and hard tissue loss.

By using the correct fillers deeply, the areas of bone resorption can be “built up”, pushing the soft tissues outward and stretching the skin to correct concavities to convexities. Hyaluronic acids are used subdermally to build up areas of soft tissue loss and to correct individual wrinkles and depressions. Fine lines can now be treated with the injectable filler Belotero—a hyaluronic acid whose technology enables it to intercalate itself in and amongst collagen bundles within the dermis.

This filler can be used, diluted with lidocaine to reduce pain, with a 32 gauge needle to treat fine lines, particularly around the mouth. We love combination treatment when neuromodulators are used with fillers to stop excessive muscle movement and correct lines caused by overactive facial muscles. The combination can truly restore individuals’ appearance to that of a younger age, with beauty restored.

Americans will be seeing more “re-flation” or the “liquid face-lift” with the expected approval of Voluma from Allergan. This hyaluronic acid should provide us an even better ability to restore volume in the ageing face. It is possible that the surgical face-lift may be put off by several years as people gently correct the slow loss of soft and hard tissues.

Whatever terms are used, it is after all not a true face-lift. There are individuals who do need surgical procedures and these procedures are often the best money spent on their face.

However, many rhytidectomy patients will still benefit from proper volume restoration and further aesthetic treatment particularly in the central face. The complete aesthetic practitioner can also never forget the value of attention to proper skin care and the use of lasers and light-based technologies to restore age-related colour change and dyschromia.

Dr Timothy Corcoran Flynn is a consultant dermatologist, medical director at the Cary Skin Center, USA and current president of the American Society for Dermatologic Surgery