Botulinum toxin is the technique that has revolutionized nonsurgical rejuvenation methods. It is a safe and effective technique that provides natural results when used carefully. The use of botulinum toxin alone without other treatments is not an ideal approach because it only improve wrinkles; in most patients the best results are obtained when it is used in combination with other techniques to obtain more harmonious results.31Table 1 lists the 10 commandments for optimum use of botulinum toxin in facial rejuvenation.

Several non-invasive procedures used to treat body fat can also be used to treat a double chin by reducing submental fat. The appearance of a double chin is an age-related change that worries a large number of patients and is sometimes neglected by aesthetic dermatologists. Treating submental fullness produces a strong emotional impact and improves the patient's self-image.32 In a study of 600 men recently published by an American team, the double chin was the third most likely motive for treatment cited by the respondents.33 In our experience, it could be the leading reason for consultation among men and a very common motive among women if the possibility of nonsurgical treatment were more generally known. Until relatively recently, surgical liposuction was the only effective way to eliminate submental fat. Today, there are 2 other safe and effective methods for eliminating submental fat: cryolipolysis with the Coolsculpting® device and injection with deoxycholic acid (marketed in Europe for this indication as Belkyra®.

Selective cryolysis of subcutaneous fat (or cryolipolysis) involves the application on an area of the skin of a device that pulls the skin in by suction and cools it to induce inflammation (initially leading to lobular panniculitis) and the specific destruction of adipocytes. Given the greater sensitivity to cold of fat cells, the treatment does not damage the epidermis or other structures.34 For the treatment of localized fat, the Coolsculpting® device is the technology that has been most validated. It was the first cryolipolysis system to be developed and approved by the regulatory agencies and its effectiveness has been demonstrated. Although other treatments, such as other cryolipolysis systems and devices based on radiofrequencies or focused ultrasound, can be considered, Coolsculpting® is the only device that has been shown to be safe and effective for this indication; it achieves predictable results and a high degree of patient satisfaction. Coolsculpting® is a simple technique: no anesthesia is required and there is no downtime after treatment. The Coolsculpting® device can also be used to treat other areas of the body, including the abdomen, flanks, back, as well as the inner aspect of the thighs and arms. Many authors have reported on the use of Coolsculpting® to eliminate submental fat. The mean reduction achieved was 2 mm of subcutaneous fat per session, as measured by ultrasound,35 or 33% of the fatty fold, as measured by a pleximeter after 2 sessions.36 A new method requiring shorter sessions of about 35 minutes in duration has been developed based on a redesigned applicator.37 In our experience, an approximate improvement of 20% can be observed in 1 session. Ideal candidates for this technique are patients whose weight is within the normal range and who have modestly pronounced fat deposits that are difficult to eliminate through diet or exercise. There is no limit to the number of sessions a patient can undergo, but in general we recommend 2 sessions separated by an interval of at least 1 month.

The other nonsurgical technique that should be considered when treating submental fat is deoxycholic acid.38 This is available in 2-mL vials of a 10-mg/mL solution (marketed as Belkyra® in Spain and Kybella® in the United States). The product was launched in Spain in 2017 and 2 years earlier in the United States.38 Before administration, the injection sites (1cm apart) are marked on the area to be treated using a template. Then the treatment is administered in subcutaneous injections of 0.2mL up to a maximum infiltration volume of 15 mL per session. The injections can be somewhat painful, making it advisable to use local anesthesia, cold, and analgesia. After infiltration, pain, swelling and bruising in the treated area is not uncommon. The most feared complication of this technique (rare when the injection sites are properly marked) is the accidental injection of the product into the marginal mandibular branch of the facial nerve, causing paralysis on 1 side of the mouth lasting for some months. Patients can undergo a maximum of 6 separate sessions separated by intervals of at least 1 month.39 The usefulness of this technique has been demonstrated in men, in whom it is recommended that a larger surface area be treated at the first session to obtain the best outcome.40

In the 1980s, the rise of cosmetic surgery led to a growing trend in surgical facelifts, a technique that was very effective in reducing visible wrinkles but tended to produce unnatural results. The use of dermal fillers first started to become generalized at the end of the 1990s. This was the first technique to address the problem of creating facial volume to compensate for the loss of volume secondary to changes in facial fat and bones.41 While some aesthetic protocols continue to include permanent fillers such as silicone,42 the most widely used fillers today are non-permanent products based on hyaluronic acid, calcium hydroxyapatite, and polylactic acid. The results obtained are constantly improving as a result our of greater understanding and knowledge of age-related anatomical changes and the way the products available should be applied.43

To properly apply a dermal filler, the first thing we must address is the diagnosis of the area to be treated. Over time, some of the facial convexities characteristic of childhood are lost, giving rise to areas of shadow around the eyes and mouth, which can give rise to an appearance of tiredness. The best way to correct these changes is with the prudent use of fillers. Another aspect that should be taken into account in any rejuvenation protocol is the so-called “triangle of youth”: the face of a young person is shaped like a triangle with the base across the forehead and the apex pointing downwards. With age, the triangle is inverted and the base moves to the lower part of the face: the face becomes wider and less oval. Consequently, adding volume to the lower third of the face should be avoided. Hyaluronic acid is our dermal filler of choice. It has the added advantage that an “antidote” exists in hyaluronidase, although the effect of the antidote may vary depending on the hyaluronic acid filler used.44 In Spain, hyaluronidase can only be obtained as a customized compound for off-label use; our protocol for its use can be found in Table 2. The other dermal filler we use is calcium hydroxyapatite, although the effect in this case is more collagen-inducing than filling. Currently we do not use any other fillers in our practice.

In our opinion, the replacement of facial volume is secondary compared to other goals, such as improved skin quality, in the aesthetic patient. Even when the fillers used are temporary in nature, they should be used with caution because it has been observed that, in the long-term, excessive treatment or “filler fatigue” can give rise to an inharmonious appearance. Filler fatigue is caused by a decrease in skin elasticity, fibrosis, and the creation of an unnaturally wide face. All of these changes can occur not only because of excessive use of collagen-inducing fillers such as calcium hydroxyapatite (which induces fibrosis and may persist in the treated area for years45) but also owing to overuse of hyaluronic acid (which triggers an increase in profibrotic growth factors and collagen fibers types I and III).46 It has also been observed that fillers that have a greater degree of cross-linkage and the use of techniques such as superperiosteal injections can lead to more long-term effects47 and increase the likelihood of adverse events.48,49 Fillers are, therefore, a useful tool provide they are used in moderation and applied by someone who has a great deal of knowledge about facial anatomy and in combination with other, complementary, techniques.

The 2 nonsurgical techniques we currently use to treat skin flaccidity without increasing volume are ultrasound (using either high-intensity focused ultrasound [HIFU] or microfocused ultrasound) and thread lifting.

There are several devices on the market designed to reduce skin laxity.50 While non-ablative techniques based on external radiofrequency may have some tightening effect,51 in our clinical experience the actual clinical effect is minimal. In recent years, therefore, we have opted to use HIFU devices, which apply focused ultrasound waves at various depths. A device with the broadest range can focus the power at 1.5, 3, and 4.5 mm, modulating the frequency to 10, 7 and 4.5 MHz). This device can produce small thermal coagulation points in fat and fibromuscular tissue that have a tightening effect; tolerance is good and the procedure has very few side effects (infrequent bruising, tingling, or temporary muscle weakness), which resolve within a few days or weeks.52 While rare, more serious adverse effects may occur53; these could be related to poor technique or inappropriate use, underscoring the importance of proper training in the technique and an extensive knowledge of facial anatomy. This technique is ideal for patients with mild to moderate laxity or sagging along the jawline, on the neck, and around the eyes. It is particularly appropriate for correcting infraorbital laxity and for closing up the infrapalpebral space, where the edema that gives rise to “bags” accumulates).54 It achieves unobtrusive results within a month of treatment. The results are cumulative and can have a preventive effect, which is why some plastic surgeons have called HIFU a “facelift by installments”. For best results the procedure can be repeated every 6 to 12 months. HIFU can be combined with other noninvasive treatments.55,56

Thread lifting is an interesting resource in any global approach to facial rejuvenation. The threads are easy to apply and do not add volume (making them ideal for use in the lower third of the face). Their tightening and firming effect can be used to reposition loose or sagging tissue.57 There are many types of lifting threads on the market (monothreads, barbed threads, cone threads, etc.). They can be grouped into 2 basic types.

On the one hand, we have simple, monofilament strands of polydioxanone (PDO) (monothreads), which are used to increase skin density. These threads are inserted with a needle into the deep dermis, where they trigger the formation of collagen and produce a revitalizing effect that can last between 3 and 9 months. The areas most often treated are the jawline, cheeks (to reduce the nasolabial folds), neck, and the neckline or décolletage. Other areas that can be treated using this technique include the eyebrows, arms, legs, and buttocks.30

On the other hand, we have PDO or poly-L-lactic acid (PLLA) threads with barbs, cones, and other kinds of hooks. These have a greater tightening effect because they facilitate anchoring, traction, and repositioning of the tissue as well as having collagen inducing properties. These threads are inserted into the hypodermis. They produce visible effects that last up to 1 year. The areas most often treated include the jawline and neck, although they can also be used to treat the cheeks and eyebrows.30,58 A mild and transient side effect of the insertion of both types of threads is bruising and edema at injection sites.

The doctor-patient relationship established in the initial consultation is the key to the clinician's empathy or “connection” with the patient. In Table 3, we list a series of suggestions we consider should be taken into account by any physician treating aesthetic patients with a view to attaining the optimum results for each patient. Following this advice can have a remarkably positive effect on patient satisfaction and loyalty as well as on adherence to the treatment. If we, as doctors, give greater importance to the art of the aesthetic consultation, we will feel more comfortable with ourselves and provide a reason why we can never be replaced by machines or robots.

In the field of dermatology and aesthetic medicine, we believe that there has been an absence of major innovations in recent years. In other words, there has been no revolution comparable to those that have transformed other areas, such as on-line shopping, urban mobility, the consumption of audiovisual content, information search, and interpersonal communication. In the field of aesthetics:

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  Retinoic acid, which is still the most effective anti-aging ingredient in creams, has been on the market for over 40 years.

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  Research on the effects of nutricosmetics59 has not, as yet, provided evidence of extraordinary benefits that would justify their routine use.

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  Technology has not yet led to any disruptive innovations. The laser devices we use today for vein treatment, hair removal, photorejuvenation, and spot removal are similar, despite progressive optimization, to those we were using 15 years ago. While the new radiofrequency devices, intense pulsed light, and focused ultrasound have not offered exponential advances, we believe that cryolipolysis and the use of microwaves for the treatment of hyperhidrosis represent qualitative leaps in the technology in recent years.

Having had occasion to try most of the technologies currently used, many dermatologists involved in the treatment of aesthetic patients have come to the conclusion that the last truly disruptive innovation in this field was introduced over 15 years old: the liquid facelift, that is, the use of a combination of injectables (essentially botulinum toxin, dermal fillers, collagen inducers, and lifting threads) in a prudent and intelligent way. The term liquid facelift was coined by Mauricio de Maio, a Brazilian plastic surgeon who has been one of the promoters of the use of a combination of injectables to relax expression lines, compensate for loss of volume, and induce collagen productio.60

In our clinic, we classify liquid lifting techniques into 5 types depending on the complexity of the technique (from lower to higher complexity) (Fig. 2). In patients who can benefit from this approach, after a meticulous physical examination and after assessing and discussing the patients expectations, we decide on what level of liquid facelift is appropriate and will achieve the most natural results and satisfy the patient.

Figure 2.

Description of the treatments in each level of the liquid facelift (nonsurgical facial rejuvenation).

NCHA indicates non-crosslinked hyaluronic acid.

The collagen inducer we use is calcium hydroxyapatite (Radiesse®).

(0.3MB).

Generally, when patients are informed about what can be achieved with rejuvenation techniques, the information they are given is usually framed in terms of objective outcomes (the reduced visibility of the wrinkle, the removal of a mark or discoloration, and so on). It is vital, however, for the clinician not only to clinically assess the individual patient but also to gain a better understanding of their emotions, values and expectations in order to achieve the highest possible degree of satisfaction. The patient will understand the message better if rather than saying that the procedure will improve a wrinkle, the physician explains that the aim of the technique is to eliminate a facial expression associated with annoyance, fatigue, or sadness.

Using these minimally invasive techniques, dermatologists can achieve an improvement in the patient's mood and quality of life.61 Messages like those exemplified in the previous paragraph reinforce the positive feedback loop between the result obtained, what the patient perceives, and what was discussed in the initial consultation. For example, it has been reported that patients who cannot look sad may experience an improvement in mood.62