Wrinkle correction

What is a wrinkle?

It is important to differentiate between:

• SAGGING (jowls, neck, eyelids) that require surgical tightening by means of a face-lift or de blepharoplasty.
• SINKING (cheekbones, chin, lips, temples) justifying the surgical addition of volume (lipostructure) or by injecting a dermal filler.
• CREASING (NASO-LABIAL FOLD, between the nose and the corner of the mouth, MARIONETTE FOLDS below the corner of the mouth, LABIO-CHIN creases parallel to the lower lip), may often appear very early in life but they are aggravated by the stretching of the skin. A surgical procedure will correct recent exacerbation due to skin sagging but injections with dermal filler will be necessary to complete the result.
• Actual WRINKLES and crows’ feet, RIDULES (forehead, FROWN LINES, between the eyebrows, crow’s feet in the corner of the eye, lips, cheeks) are not greatly improved by surgery but require an additional procedure. Certain wrinkles, due to folding of the skin by means of too highly toned skin muscles, could benefit from botulinum toxin injections, others that are due to “breakage” of the surface of the skin require dermal filler or skin peeling.

BOTULINUM TOXIN (BOTOX°)

Type A botulinum toxin has been used in medicine since 1975, to treat strabismus (squint) in the child, facial tics and uncontrolled blinking of the eyelids (blepharospasm). Since 2003, cosmetic indications have been used for the temporary correction of:

• Vertical wrinkles between the eyebrows seen when frowning
• Crow’s feet wrinkles
• Forehead wrinkles

Botulinum toxin only last for a few months so the injections need to be repeated to extend the result. Several forms of botulinum toxin are used in cosmetic treatments – VISTABEL™ (BOTOX™), AZZALURE™ (DYSPORT™) , BOCOUTURE™. Their effects are equivalent.

Precautions to be taken before botox injections

• Contra-indications: known hypersensitivity to the botulinum toxin and myasthenia gravis and not advisable for pregnant women.
• Infection or inflammation of the botulinum toxin injection site, the existence of peripheral neuro-muscular disorders or amyotrophic lateral sclerosis impose restrictions of usage.
• The use of botulinum toxin during treatment with aminosides is inadvisable since there is the risk of increase in the effects of the toxin.
• There is also a need to be vigilant if there are haemostasis difficulties linked to a medical condition or the use of certain medicines (risk of sub-cutaneous bleeding). Avoid taking aspirin or anticoagulants during the 15 days prior to injection with botulinum toxin.
• Finally, it is a good idea to be cautious in the case of patients who are psychologically unstable.

Botox injections

• Botulinum toxin injections are performed at the doctor’s office after an information consultation. They are virtually painless since they are performed with very fine needles and need no anaesthesia.
• The results of botox become visible after four days. An attenuation of the wrinkles can be seen while small movements are preserved.
• In certain cases, an asymmetry in the correction or the persistence of a few small lines can be observed. In general, this requires an additional injection of botox.
• After four to six months, the effect diminishes and a new session is needed. With time and regular injections, the effect often becomes more long-lasting and the injections need to be less frequent.
• Any consequences and complications from botox injections will be explained to you by Dr COURBIER during the consultation and in the literature provided to you.

DERMAL FILLERS

This term covers all of the substances available to fill superficial or deep wrinkles, as well as increasing facial volume.

The basic principle is the injection of a liquid into the thickness of the skin or the sub-cutaneous space designed to create a filled or increased volume.
There are very many dermal fillers on the market that benefit from the EC (European Community) marking.

Biodegradable products : these are gradually reabsorbed by the body.

Hyaluronic acid (Juvederm™, Voluma™, Emervel™, Restilane™, Perlane™ etc.) is the most frequently used product (– it is of synthetic origin and cannot be pre-tested – the results last for between eight and 18 months). It is the product of choice and generally contain a local anaesthetic to make the injection more comfortable.
Collagen (Zyderm™, Zyplast™, Resoplast™ etc.) is of animal origin. There are risks of allergy, justifying two successive skin tests prior to the injections. The effect is of synthetic origin – no test is administered – it is partially reabsorbable – hardly ever used now.
Polylactic acid (New-Fill™) is of synthetic origin – no test is administered – it is partially reabsorbable – hardly ever used now.

Non-biodegradable products: these last in situ for several years or even indefinitely (but they have been abandoned by most surgeons).

• Silicone: banned in injectable form since 1997 due to the side effects, some of which were disastrous.
• Acrylic hydrogel (Dermalive™) and Methyl Polymethacrylate (Artecoll™): non-biodegradable synthetic particles “transported” either by hyaluronic acid, or by collagen. There is an allegedly high risk of granuloma.
• Polyacrylamide: (Aquamid™, Bioalcamid™, Outline™).

Hyaluronic acid injections

• Hyaluronic acid injections are performed in the doctor’s office after an information consultation. Contact anaesthesia using an anesthetising ointment is possible. Sometimes full local anaesthesia is administered beforehand by injection of an anaesthetising (Xylocaine™). The injection is performed using a very fine needle. The session lasts for about 30 minutes. An additional session may be necessary after 2 to 3 weeks.
• The average time a hyaluronic acid injection lasts is 8 to 18 months.
• How well it works depends on several factors such as age, skin quality, healthy lifestyle (smoking, exposure to the sun or to UV rays can reduce the efficacy), choice of product and the area injected.
• Dr COURBIER will explain the sequels and possible complications from hyaluronic acid injections during the consultation and explanations are also to be found in the literature supplied to you.

LIPOSTRUCTURE^®

“LipoStructure^®” or “lipofilling” or “reinjection of autologous fat” is a surgical technique described by DR S. COLEMAN for injecting under a patient’s skin purified fat removed from this same patient (self-transplant). It is used to fill a large number of natural or post-traumatic depressions (hollows) and enables some people to make an ageing face more youthful by giving it back the volumes it has lost. Microinjections sometimes make it possible to replace hyaluronic acid in the treatment of wrinkles.
The LipoStructure® technique, is a definitive technique since the adipose cells grafted will live as long as the tissues surrounding them. On the other hand, this is a true “graft” of the fat cells (adipocytes) and only part of these cells (about half) will be accepted by the organism (the rest will be destroyed and eliminated).

The operation

• Usually general (sometimes local) anaesthetic.
• Removal of the fatty tissue is performed without trauma through a micro-incision hidden in the natural folds of the skin by means of a very fine aspiration cannula.
• The fat is then centrifuged so that only the living fat cells are retained.
• The re-injection of the fatty tissue is performed through micro-incisions using micro-cannulas.
• The amount of time that the intervention takes depends on the amount of fat to be re-injected and the number of sites to be treated (30 minutes to 2 hours).

After the operation

• Day surgery.
• After the operation, there is generally little pain.
• Swelling of the tissues (œdema) and ecchymosis (bruising) generally last about a fortnight (no exposure to sunlight).
• There is a variable difference between the amount of fat re-injected and the amount that the graft accepts. An additional correction may therefore be necessary in order to achieve the desired result.
• The sequels and possible complications from LipoStructure® will be explained to you by Dr COURBIER during the consultation and in the literature provided to you.

SKIN PEELING

Skin peeling uses plant or chemical substances which, depending on the strength of their active ingredient, their concentration or the length of time for which they are applied destroy the top layer of the skin, i.e. all or part of the epidermis and they may even penetrate the superficial dermis, depending on the result sought.

There are various types of skin peeling

• Fruit acid peeling (glycolic, lactic or mandelic acid, etc.) to improve skin tone is too mild a treatment to have a decisive action on the components of skin ageing. It has a “refreshing” aspect, however, that improves the complexion though it needs repeated treatments.
• Light and superficial peeling peels the skin, performs exfoliation, affect the complexion and produce a “refreshed” look. This is a scrub that more or less scrubs out certain superficial imperfections of the skin; they have a moderate action on the components of skin ageing such as fine wrinkles.
• Average or deep peeling (PHÉNOL ), on the other hand, involves deep abrasion that can destroy the epidermis and the top layer of the dermis. It consists of a controlled chemical burn. The control depends on the choice of peeling type, its concentration or the amount of time on which it lies on the skin. It is used to treat signs of ageing especially sun damage (spots and marks, elastosis, superficial or medium wrinkles).

How the procedure works

• Superficial peeling is performed at the doctor’s office and does not require anaesthesia.
• Deep peeling is performed in the clinic under general anaesthesia or neuro-leptanalgesia with day surgery hospitalisation (sometimes there is local anaesthetic in the case of a restricted area such as the lips).
• After cleaning and disinfecting the skin, the product is applied according to a protocol (concentration, length of time of the application) that is specific to each type of peeling and depending on the size of the defect to be corrected, the area to be treated skin quality and the purpose.
• Local skincare, which is careful and very precautionary, based on oils or dressings will be performed until complete healing, achieved in 10 to 15 days in the case of peeling using phenol. Subsequently, emollient creams for sensitive skin, suitable make-up and protection against the sun are recommended to conceal the redness or pinkness of the treated skin for two to six months.
• Sequels and possible complications will be explained to you by Dr COURBIER during the consultation and in the literature that will be provided to you.