How to treat sagging skin

How to treat sagging skin

Lift me up

Text: Rachel Ho

Dr Rachel Ho of La Clinic tells us all about the surgical and non-surgical options when it comes to treating saggy skin

When it comes to signs of ageing, saggy skin has always been the bane of patients and doctors alike. Sagging of the face and neck finds its ways to us in many forms — droopy foreheads and droopy eyelids; sunken cheeks, nasolabial folds, marionette lines, jowls, loss of jawline definition and turkey necks. Despite our best efforts to age-proof ourselves, gravity and aging find us all eventually. Even in our 20s, sagging in the face and neck gradually creeps up on us with early signs such as of our once sculptured and defined jawline getting lost. As we move into our 30s and beyond, as the face continues to descend with nasolabial folds, marionette lines and jowls becoming more prominent. Sagging in the neck is also another bugbear for patients — loose skin, crepe-y skin and turkey neck — also starts making its debut in our 30s.

Unlike the other signs of ageing like wrinkles and pigmentation that can be easily treated with in clinic treatments like Botox, lasers and chemical peels; traditionally, the only medical treatment that really worked in getting rid of saggy skin in the face and neck was a surgical facelift and/or necklift, which are not without its risks. Up until the last decade, the non-surgical alternatives to treat sagging skin had less than ideal results and the myriad of anti-ageing creams offered nothing more than hope in a jar.  

Enter the Non-Surgical Facelift: a group of non-surgical and minimally medical treatments that have revolutionised the treatment of sagging skin by going right down to where it mattered: the superficial muscular aponeurotic system (SMAS); the same layer that is pulled, lifted and tucked in a surgical facelift. With the advent of the Non-Surgical Facelift, saggy faces and neck can be pulled and lifted with almost immediate results in the clinic without the downtime, hospitalisation stay, pain, cost and incisions associated with a surgical facelift. Finally, for patients who do not wish to go undergo surgery, the days of dealing with less than satisfactory results from non-surgical alternatives are now over. The Non-Surgical Facelift is steadily growing in popularity and this has also seen a growing number of non-medical establishments and treatments wanting to ride on the rising popularity of the Non-Surgical Facelift. Ultimately, the various forms of Non-Surgical Facelifts have been shown to work are medical treatments and in Singapore, these procedures can only be performed by registered medical doctors in clinics.

What exactly is the Non-Surgical Facelift?
The Non-Surgical Facelift is a group of different medical treatments that aim to address sagging and ageing in the face and neck. These treatments consist of injection based treatments (the Liquid Facelift) and non-injection, energy based treatments such as radiofrequency energy and high intensity focused ultrasound (HIFU). One of the most exciting trends in the last few years is the rise of face threadlift which is the closest to a surgical facelift without having to go under the knife. Allow me to break down the types of Non-Surgical Facelift treatments commonly done in Singapore; starting with the one that's on everyone's lips right now: face threadlifts.

What is a face threadlift?
Face threadlifts are the closest non-surgical alternative to a facelift. As the name suggests, very fine threads are placed under the skin to physically lift the saggy skin and saggy face tissues. The face threadlift was first introduced in the 1990s but were unpopular because the threads used in threadlifts then were nonabsorbable and permanently anchored to the scalp, temple and other parts of the face. In recent years, face threadlifts have undergone a complete makeover and seen their popularity soar. Some of these threads such as the Silhouette Soft threadlifts have received US FDA and European CE approval for their use in threadlifts. These newer threads used in face threadlifts are also dissolvable and compromise of materials such as poly-L-lactic acid (PLLA) and polydioxanone (PDO), which have been used as dissolvable sutures in various types of surgery for many years now. The appeal of the newer forms of face threadlifts lies in their immediate lifting with a lunch time appeal with minimal downtime.

How does the face threadlift work?
Threadlifts lift the skin and tissues of the face and neck via a unique two pronged mechanism which allows the face threadlift or necklift to have a continuous lift over time.

Firstly, the threads mechanically lift the skin and tissues where they have been placed during the face or neck threadlift. These threads may also contain additional barbs and cones for additional stability and pull. Once the face or neck has been pulled, the skin and tissues that have been lifted and pulled remain in place.

Secondly, the threads used in a the face or neck threadlift stimulate natural collagen formation by the skin and tissues in the face and neck. This additional collagen formation gives a continued improvement in the lift and pull over time and sustain the results of threadlift.

There are many brands of thread used for threadlifts in the face and neck and some of the more popular ones in Singapore are the Silhouette Soft threadlift from the USA, Ultra V Face threadlift from South Korea and Happy Lift from Italy.  There are some differences between each brand and technique, so speak to your doctor before deciding on your choice!

Am I a suitable candidate for a face threadlift?
Face threadlifts can be done to correct signs of ageing and sagging in the face and neck, especially for older patients who find that more conservative forms of non-surgical facelifts do not give an adequate pull. Younger patients in their 20 to 30s who desire a longer lasting form of a sharper jawline (aka the 'V face') compared to the use of Botulinum toxin are also suitable for a face threadlift.

When placed in the cheeks, the face threadlift can lift saggy cheeks and prominent nasolabial folds. A threadlift along the jawline can improve the jawline definition and improve marionette lines and jowling. When placed in the neck, loose skin and turkey necks can be pulled up to redefine the neck.

Woman going for a facelift

Face threadlift versus a surgical facelift
When it comes to pulling and lifting sagging faces and turkey necks, a surgical facelift remains as the gold standard. Compared to a face threadlift, a surgical facelift provides much longer lasting results and affords a greater magnitude of pull and lift of the sagging face and neck (unless multiple pairs of threads are inserted during the face and/or neck threadlift). For older patients or patients with a higher degree of loose and sagging skin and who desire  longer lasting results, a surgical facelift may be a better option.

However, the hospitalisation, recovery time, cost and larger scar of a surgical facelift are also reasons why face threadlifts remain popular. For an in-clinic procedure that takes 30 minutes, the face threadlift is the closest non-surgical alternative to a surgical facelift. Depending on the material and brand of threads used, the longevity of the face threadlift varies between one to three years.  There is also minimal recovery time required and so the face threadlift is sometimes known as 'Lunch Time Facelift'.

What is the liquid facelift?
The liquid facelift is another non-surgical facelift technique where dermal fillers and Botulinum toxin (Botox)are injected in specific areas of the face to create a gentle lift of sagging in the face. The liquid facelift is still one of the most popular non-surgical facelift treatments in Singapore.

How does the liquid facelift work?
Dermal fillers are injected into various parts of the face to restore facial volume that has been lost and redefine facial contours. This helps to stretch the skin and lift the skin for the facelift effect. Additionally, when injected into the nasolabial folds and marionette lines, these saggy folds and lines are softened for a younger and more refreshed look.

Wrinkles are associated with an older and tired appearance. Botulinum toxin injections help to relax wrinkles in the face and smooth out frowns for a younger and rejuvenated appearance. A newer skin tightening technique called Dermolift or Mesobotox  employs the use of Botulinum toxin to lift and tighten lax skin.

Am I a suitable candidate for the liquid facelift?
The liquid facelift is suitable for patients who want a gentle and natural lift and tightening of sagging faces. The lift from these injections of dermal fillers and/or Botulinum toxin are best suited for patients under 50 years of age. When performed by an experienced doctor, the results of the liquid facelift can be impressive and natural.

What is High Intensity Focused Ultrasound (HIFU)?
For patients looking for a non-invasive treatment of saggy faces that does not require any injections or threadlifts, the next option would be the use of energy-based devices to deliver ultrasound energy or radiofrequency energy to tighten saggy skin.

HIFU is the use of ultrasound energy to remodel collagen in the skin and deeper layers of the face and neck.  Examples of HIFU machines are Lifthera, Ulthera and Sygmalift.

How does HIFU work?
Ultrasound waves heat up the skin and deeper tissues. This causes the collagen fibres in to shorten and tighten, causing a tightening and lifting effect on sagging skin. The heat energy also stimulates production of new collagen fibres for lifting and support of sagging skin in the face and neck.

HIFU targets sagging at three different depths-1.5mm (dermis), 3.0mm (deeper dermis and connective tissue) and 4.5mm (SMAS layer).  The SMAS is the layer that is treated in a surgical facelift. Over the next 1-3 months, a gradual lifting of the skin and tightening is observed. This is because the collagen remodelling happens gradually.

Compared to long pulse lasers and 'lifting lasers', HIFU targets the skin and tissues at a greater depth i.e. the SMAS for more effective lift and tightening of the face and neck.

Is HIFU right for me?
HIFU is suitable for patients who have a mild to moderate degree of face sagging or for patients who want a totally non-invasive approach.

What is radiofrequency tightening?
Radiofrequency skin tightening is another non-invasive, energy based dermatological treatment that tightens saggy skin in the face and neck. One of the most common radiofrequency skin tightening devices in Singapore is Thermage, which is also US FDA approved. Radiofrequency tightening has also been used to tighten other organs such as the vagina

How does radiofrequency tightening work?
Radiofrequency transmitted to the skin and subcutaneous tissues gets converted to heat energy at a specific temperature. Similar to HIFU, the heat energy stimulates the existing collagen fibres to remodel for tightening of the skin and subcutaneous tissues. New collagen fibre formation is also stimulated for additional tightening and lifting effects. Radiofrequency also penetrates the tissues at a depth greater than lasers for a greater lifting effect.

Is radiofrequency tightening right for me?
Radiofrequency tightening is suitable for patients with mild to moderate sagging of the face or for patients who want a non-invasive approach.

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