Summary

Facial and neck aging results from the complex interplay between the body skeleton, facial retaining ligaments, soft tissue envelope, face and neck fat compartments, and the overlying skin elasticity due to genetic and extrinsic factors. Gravity is responsible for a lifetime of downward pull upon the face and neck tissues. Coupled with a loss of ligamentous support and localized fat collection, it results in skin redundancy and loss of smooth skin contours. The First step for successful treatment is to diagnose skin problems; dark spots, red spots, scars, wrinkles, or skin folds. Improving the skin’s condition is mainly done with resurfacing procedures, laser and light therapy, daily skincare, and ultraviolet (UV) protection. Type two rejuvenation is more profound, targets decreased collagen, disorganized glycosaminoglycans, and elastin, manifested by superficial rhytides and is best treated with non-ablative mid-infrared lasers and intense, intense lasers pulsed light (IPL). Rejuvenation type three is the most in-depth and targets deep dermal collagen disorders and skin laxity; here comes the role of fractional lasers, radiofrequency, infra-red light, and ultrasound are the most effective). Loss and redistribution of sub-¬dermal fat in aging is handled with liposuction and Liquid facelift (Botox, fillers, and fat). Correction of soft tissue ptosis is usually surgically treated with a brow lift, mid-facelift, and lower face rhytidectomy or non-surgically by energy-based technologies such as radiofrequency or ultrasound. Clinical experience shows that combining multiple aesthetic therapies targeting numerous aspects of the aging process provides optimal results, with greater overall efficacy and higher patient satisfaction. The goal of facial cosmetic surgery is to improve and refresh the appearance of the face and neck without any signs of apparent surgical intervention.

The world places a high value on looking young and fit, that is why cosmetic surgery is up, and men are a big part of the increase. More men today are having cosmetic surgery to help them look younger and attractive. Like their female counterparts, they have discovered the benefits of cosmetic surgery not only personally but also professionally. Men seem to be changing their attitude about several issues that were previously reserved for women. Feeling the need to look youthful and dynamic, well into your 40s, 50s, and 60s has led to men rethinking their attitudes to pills, diet, exercise, face-care products, and cosmetic surgery. In a society that values youth, 50-year-old executives are competing with younger, fitter, and more competitive 30-year-olds, who are often willing to work harder, and for less money. On the home front, men are also finding they want to keep pace with younger-looking wives.

The elements that characterize a youthful neck include a distinct inferior mandibular border, visible sub-hyoid depression, noticeable thyroid cartilage bulge, visible anterior sternocleidomastoid line, and 90_ angle with the submental line and cervical mental angle of 105 to 120. These criteria are seen in glamour models. In evaluating the neck properly,  the neck aging changes may be due to skin excess, fat accumulation, platysma laxity, digastric hypertrophy, submandibular gland abnormalities, or anatomic variants such as a low hyoid bone. Surgical approaches to neck rejuvenation include liposuction, anterior or submental incision, direct skin excision, and Z-plasty. Straightforward neck procedures include the following: defatting superficial to the platysma, subplatysmal and interplatysmal defatting, medial platysmaplasty/platysma tightening, platysma plication over the submandibular gland resection, and alloplastic anatomic chin implant placement when indicated.

The elements that characterize a youthful neck include a distinct inferior mandibular border, visible sub-hyoid depression, noticeable thyroid cartilage bulge, visible anterior sternocleidomastoid line, and 90_ angle with the submental line and cervical mental angle of 105 to 120. These criteria are seen in the glamour model. Unfortunately, as we collect birthdays, we also tend to gain a bit of weight, and sometimes fat begins to accumulate in the under the chin region.  Storing fat in the neck region can also be genetic (thanks, Mom and Dad).  When treating the neck, the goals are often the restoration of a slender neckline, a well-defined neck to chin angle, treatment of the vertical bands that can form, reduction of neck fullness due to fatty tissue, and wrinkle control. Neck liposuction creates a firmer, smoother, and more refined appearance to the neck and chin and helps restore balance to facial features by providing a better-defined jawline that frames the rest of the face.

Recognition of this volume loss in the upper face and its effects has changed our understanding and treatment of facial aging. A brow lift, also commonly called a forehead lift, rejuvenates the face above the eyes to restore a more refreshed appearance that better reflects a patient’s natural vibrancy. By removing excess sagging skin on the forehead and repositioning the underlying muscles and tissues, a brow lift can correct a heavy, sagging brow, eliminate deep furrows, and restore a smoother, more youthful contour to the upper one-third of the face. dThrough fat augmentation, the brow is directed outward and can support the overlying skin without raising the brow to an unnaturally high position.  The superior orbital rim is approached through a lateral forehead entry site. A midline entry site is then utilized to blend the fat into the medial rim and glabellar region, totaling 1 to 2 mL per side. Upper eyelid sulcus grafting may take place at this time utilizing an entry site in the brow.

Blepharoplasty surgery is showed when the eyelids require recontouring. Specifically, blepharoplasty is most useful when excess skin needs to be removed, the muscles are enlarged or require tightening, or eye fat needs to be removed or redistributed. Upper eyelid lift surgery typically involves an incision made in the natural crease above the eye, through which your cosmetic surgeon will remove a precise amount of excess skin and fat and adjust the surrounding muscles to make the desired improvements. There are a variety of surgical techniques that cosmetic surgeons can use to improve the lower eyelids; incisions are located on the outer edge of the lower eyelid, just beneath the eyelashes, or inside the eyelid. Depending on the case, excess, sagging skin may be removed, or the lower eyelid muscle may be tightened to supply the most natural, effective results.

Rhinoplasty is still one of the most performed aesthetic surgical procedures. Over the past 20 years, the trend has shifted from ablative techniques involving reduction or division of the osseo-cartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support. The foundation for a successful experience for both patient and surgeon involves accurate preoperative analysis and clinical diagnosis, identification of both the patient’s expectations and the surgeon’s goals, and a thorough review of the plan of care and expected postoperative recovery. Rhinoplasty remains one of the most challenging procedures in cosmetic surgery. I can achieve excellent surgical outcomes only through a thorough understanding of the multiple nasal anatomical variants and a comprehensive knowledge of the ultimate long-term effects of various surgical techniques on the overall appearance and function of the nose. I should practice a philosophy of balance, preservation, and restoration of tissues (rather than a purely deductive approach, which can introduce tissue spaces and uncontrolled scarring of tissues).

The social implications of ear deformities for the developing child are well documented. Protruding ears are a frequent source of ridicule by peers and may contribute to various developmental abnormalities, including social phobias and outright behavioral disturbances. Correction of even minor deformities can have profound benefits to appearance and self-esteem.  The ear development is virtually completed by the age of five when I can undertake adequate measures.  Correction ear surgery, also known as otoplasty, can improve the ear’s shape, position, or proportion. Otoplasty creates a more natural form while bringing balance and dimension to the ears and face.

The First step for successful treatment is to diagnose skin problems; dark spots, red spots, scars, wrinkles, or skin folds. Improving the skin’s condition is done chiefly with resurfacing procedures, laser and light therapy, daily skincare, and ultraviolet (UV) protection. Type two rejuvenation is more profound and targets decreased collagen, disorganized glycosaminoglycans, and elastin, manifested by superficial rhytides and is best treated with non-ablative mid-infrared lasers and intense pulsed light (IPL). Rejuvenation type three is most in-depth and targets deep dermal collagen disorders and skin laxity; here comes the role of fractional lasers, radiofrequency, infra-red light, and ultrasound. Loss and redistribution of sub-¬dermal fat in aging is with Liquid facelift (Botox, fillers, and fat). Correction of soft tissue ptosis is usually surgically treated with a brow lift or non-surgically by energy-based technologies such as radiofrequency. Clinical experience shows that combining multiple aesthetic therapies targeting numerous aspects of the aging process provides optimal results, with greater overall efficacy and a higher level of patient satisfaction.

The periorbital region is one of the first facial regions to show signs of aging. It is critically important to understand precisely what feature of the periocular area is of the most concern to the patient before making therapeutic recommendations. Aging skin is characterized by the appearance of fine and coarse rhytides (wrinkles), rough and uneven texture, dryness, and changes in pigmentation. Fat atrophy occurs in the upper and lower periorbital region leading to progressive skeletonization of the orbit. Fat atrophy in the lower periorbital complex leads to a more prominent infraorbital rim, increasing the height of the lower eyelid and the overall soft tissue vertical dimension of the orbit. Typically, the nasojugal crease is more evident with aging, the malar fat pad has atrophied, the temples have hollowed, and the brow and upper lid have lost volume. In general, changes in skin texture, tone, laxity, or pigmentation are treated with physician skincare cosmeceuticals, chemical peels, lasers, or energy-based solutions. I can augment volume loss with the use of fillers, Autologous fat injection, and BOTOX A. Hyaluronic acid (HA) is the workhorse for the periorbital area because of its good efficacy and predictability and an excellent choice for correcting static rhytides that cannot be treated with BoNT alone and to recontour. Millifat, microfat, and nanofat with the addition of SVF and PRP for more massive volume deficits around the eyes may also be beneficial.

Today’s facial surgeons have more options than ever before to rejuvenate the perioral area. It is essential to have a thorough understanding of both perioral anatomy and perceived signs of aging to put the correct treatment plane. The patient and physician need to understand the types of defects that can be improved using noninvasive techniques and those that require a surgical approach. Many products and devices are available to physicians to address these issues and obtain favorable results from dark lips to perioral wrinkles. In general, changes in skin texture, tone, laxity, or pigmentation are treated with chemical peels, lasers, or energy-based solutions. Dermal fillers, Autologous fat, surgical lip implants, botulinum toxin A, and micro-pigmentation are all adjunctive therapies that may be used to augment or rejuvenate the lips. It can modify Orbicularis oculi muscle function via botulinum toxin (BTX) injections or surgery.

Botox is the most effective tool in cosmetic medicine and should be used first and most often. BOTOX dosing and injection points should be based on an assessment of the patient’s anatomy, goals, preferences, and the physician’s own professional experience with prior treatments. Gender, cultural, and ethnic standards of attractiveness may significantly influence the patient’s preference. Each patient’s treatment should be individualized for the best results. The use of cosmetic BOTOX in the mid and lower face and neck has increased drastically over the past few years. Indeed, there is now a greater appreciation that BOTOX-A is one part of overall facial rejuvenation therapy, in which all aspects of aging are addressed in the same individual. Finally, new esthetic indications are starting to emerge, including the treatment for scars, the horizontal upper lip line, musculus risorius excessive gingival display (‘‘gummy smile’’), and masseter reduction to improve facial shape. BOTOX is also beneficial with other aesthetic modalities, such as dermal fillers, laser, skin resurfacing, and surgery. Several more general applications push BTX-A toward an ‘‘art,’’ rather than a clinical procedure.

What’s Up In Facial Filler Injections?

The two principal categories of temporary fillers approved by the U.S. Food and Drug Administration for facial rejuvenation are hyaluronic acid and calcium hydroxylapatite. The selection of HA implant is based on the indication and site of placement. For lifting and restoring volume, improving the structural foundations and facial contour, a high-density HA implant is injected deeply into the supraperiosteum. To treat medium-deep depression, we used a mid-density hyaluronic acid filler injected subdermally. For treating the periorbital area and the area around the lip, giving finished facial refinements, a low-density hyaluronic acid filler is selected with a water-like consistency filler. The most significant limitation of a filler compared with fat transfer is the potential cost compared with the latter as each syringe can be pretty expensive. The greatest benefit of a filler is accuracy. The other benefit is that a filler is bioinert and does not increase with patient’s weight gain but obviously may not look good when a patient does gain or lose weight as the filler has been injected to match a person’s current weight status.

Macrofat, Microfat, and Nanofat Injections

The clinical applications of adipose tissue have undergone a remarkable expansion in recent years. The loss of subcutaneous fullness results in pan-facial deflation, the results of which were previously attributed solely to skin redundancy and descent. Recognition of this volume loss and its effects has changed our understanding and treatment of facial aging. Surgeons can no longer excise or reposition tissue in a singular vector and claim to have achieved a correct restoration. Aging is a three-dimensional process and must be treated as such. To ignore either the gravitational descent of the soft tissue and fat pads or the loss of facial volume will lead to consistent sub-optimal results. The minimally invasive technique using Fat autologous transfer has become a standard procedure in facial rejuvenation. I can use autologous fat to augment facial structures, rejuvenate rhytids, or fill depressed scars or defects of the face. The areas of the face that I can enhance include the cheeks (malar, sub-malar), lips, and chin (mentum). I may lift the brows with fat transfer to the forehead, and I can improve indentations in almost any facial area. Rhytides in the glabella, nasolabial fold, and marionette lines can be improved. Any area of the face can have a depressed scar elevated by subcision and fat transfer.  At the current time, structural autologous lipo-augmentation is the most effective way to change the framework of the aging face. Prof. Moawad adopts a pan facial technique that allows for even and complete volume replacement with minimal downtime and superior results. Although many surgeons have approached fat injection as the only correct method to rejuvenate the face, Prof Moawad contends that fat injection can serve more effectively to complement other rejuvenation techniques. In the midface, aging is treated with a combination of soft-tissue fillers to bolster structural support and replace lost volume; skin tightening devices to improve laxity; and lasers and light-based therapies, along with topical cosmeceutical products, to reduce fine rhytides, improve surface texture, and hyperpigmentation, and brighten the skin. Because of fat grafting, facelift techniques have evolved significantly and can now avoid the signs associated with classical approaches. They now involve moderate dissection of tissues to allow fat transfer in the central areas of the face. There is also a growing tendency toward combining techniques, making it possible to meet more natural and complete results.

The platelet-rich plasma (PRP) has been applied in androgenic alopecia in both males and females successfully. Although platelets rich plasma (PRP) microinjection is new in aesthetics, PRP has been recognized as an effective treatment in sports injury, diabetic ulcer treatment, and orthopedics, to name a few. Platelets have essential growth factors that, when secreted, handles tissue regeneration and rejuvenation, increases collagen production, recruit other cells to the site of injury, induces cell differentiation and extracellular matrix formation. It has an anti-inflammatory effect that will speed up healing time and ease recovery time after resurfacing procedure. With PRP therapy, we stimulate long-term collagen growth, eliminating skin wrinkles, rejuvenating the skin, improving the appearance of acne scarring, and hastening the healing process after a facial peel. PRP is injected subcutaneously into the area of alopecia with many growth factors and stem cells. Hair transplantation is no exception, and MSI is at the forefront in developing these applications.

People want to look better with as little as possible downtime. Although a quick fix is not possible for severe wrinkles, newer treatment options such as fractional lasers and fractional radiofrequency are available to slow down the aging aspects that affect the face, neck, décolleté, and the back of the hands. Vampire Facelift is a name for a non-surgical cosmetic procedure involving the injection of platelet-rich plasma (PRP) derived from a patient’s blood back into multiple areas of the skin of their face to treat wrinkles and “rejuvenate” the face. Platelets have essential growth factors that, when secreted, handle tissue regeneration and rejuvenation, increase collagen production, recruit other cells to the injury site, induce cell differentiation and extracellular matrix formation. It has an anti-inflammatory effect that will speed up healing time and ease recovery time after resurfacing procedure. In a new approach, Prof uses fractional ablative lasers to overcome the epidermal barrier and increase topical agents’ penetration as laser-assisted drug delivery (LADD). Prof Moawad offers his patients a full-face fractional CO2 laser or fractional radiofrequency (FRF) to make tiny holes into the skin to overcome the stratum corneum to enhance PRP and /or nanofat. The results are doubles. You will enjoy both the rejuvenating effect of fractional skin resurfacing systems and the regenerative effect of growth factors and stems cells present in PRP and/or nanofat.

Mesotherapy (mesohair and mesolift) Injections

In today’s active, outdoor lifestyle, it is not just time that is aging us anymore. Sun exposure damages the skin, breaking down cells, hardening lines, and leaving freckles and blemishes every day. Coupled with dehydration, stress anxiety, and exposure to smoke and pollution, it is no surprise that people are looking for ways to make their skin look younger and more revitalized. The Mesolift is a Mesotherapy approach to treat aging, sun-damaged, and wrinkling of the skin involving the face and neck. This minimally invasive treatment delivers vitamins, minerals, and amino acids directly into the skin to nourish and rejuvenate, promote the production of collagen and elastin, and stimulate your metabolism. Mesohair is used for hair loss both in men and women. A tiny amount of active ingredients of minoxidil, finasteride together with all vitamins and trace elements are injected via microinjection needles into the mesoderm of bald areas—platelet-rich plasma or (PRP) or nanofat (mesofat) microinjection is performed subcutaneously above the galea and in proximity to the hair bulb, which is the region where stem cells exist.

basis of microneedling (MN) relies on physical injury. It has been proposed that the trauma generated by needle penetration in the skin induces dermis regeneration. This results in the deposition of collagen by fibroblasts. The technique of microneedling has been well-exploited to increase the penetration of drugs across the skin barrier, including macromolecular biopharmaceuticals and drugs such as minoxidil, tretinoin, and L-ascorbic acid, vitamins and hyaluronic acid (Mesolift), platelets rich plasma (PRP), and nanofat (vampire facelift) and even botulinum toxin microinjection (mesobotox) into the deep layer of skin and subcutaneous tissue. Microinjections and microneedling are successful in skin rejuvenation, hair loss, and scars therapy.

Looking great in public is demanding. Whether you are trying to look your best for job interviews or get attention, Skin Rejuvenation, resurfacing or a skin peel is a way to go.  MSI Skin peel (thigh-tech) is a comprehensive antiaging, anti-acne, scar treatment program that uses state of the art in aesthetic medicine. It is tailored precisely to your skin condition, needs, and expectation. It includes steam, masks, exfoliation, comedones extraction, cosmeceuticals, PRP, chemical peels, LED, IPL, laser, ultrasound, and radiofrequency. In addition, we apply new techniques to enhance skin penetration of cosmeceutical ingredients, such as whitening, vitamins, and anti-acne, antiaging dermal roller, dermapen, no needles mesotherapy (electroporation), microdermabrasion, fractional laser, and radiofrequency. Skin Rejuvenation (high-tech skin peel) can be performed anywhere on the body, but most generally are shown on the face, neck, hands, arms, and legs.

Many ablative skin resurfacing techniques are available at MSI, broadly grouped as mechanical, chemical, and laser abrasion. All ablative techniques result in upper to the mid-dermal wound. Dermabrasion relies on mechanical ‘cold steel’ injury, acid peels result in a ‘caustic’ injury, and lasers result in a thermal injury. All ablative resurfacing treatments work the same way. First, the outer layers of damaged skin are stripped away. Then, as new cells form during the healing process, a smoother, tighter, younger-looking skin surface appears. Superficial or medium resurfacing is limited to the epidermis and papillary dermis. For deeper resurfacing, it can also remove the upper levels of the reticular dermis. Unlike chemical peels and dermabrasion, laser skin resurfacing (LSR)  with the CO2 laser generates heat, which results in immediate tightening because of shrinkage of collagen, which forcefully shortens the collagen fibers by 30%. This translates clinically into the smoothing out of superficial irregularities, including wrinkles, acne scars, nevi, epidermal growths, and even tumors, as well as a tightening effect that improves the skin’s overall appearance. The laser continuously stimulates healthy new collagen and elastic fibers in the skin for six months after resurfacing. Therefore, any wrinkles or scars will continue to improve for up to one year. Nonablative or minimal ablative fractional CO2 holds great promise in both treatments of skin textural abnormalities (acne scarring, wrinkles, and skin mottling associated with photoaging) as well as pigmentary variation (melasma, hyperpigmented scars, lentigines, and dyschromia).

Minimally invasive procedures to tighten and lift skin give natural results with minimal risk and recovery time. Monopolar radiofrequency deliver a high-frequency electric current—tissue resistance to electrical current, results in volumetric heating to the deep dermis and underlying tissue. The resulting heat leads to immediate collagen contraction and a delayed wound healing response, with new collagen formation up to 4 to 6-month post-treatment.  The FDA initially approved monopolar radiofrequency (RF) devices to treat periorbital wrinkles. Since then, they have been used to treat laxity of the forehead, cheeks, nasolabial folds, marionette, lines, jawline, and neck. Although the results of RF are not as dramatic as a facelift, over 90% of patients obtain noticeable tightening of the treated areas, and it never looks “pulled.” Another benefit of radiofrequency is its ability to reduce fat and tighten the skin by directing energy to target collagen. For example, a patient with flabby upper arms may have more loose skin than fat in this area. In this instance, Prof Moawad might use radiofrequency to tighten the skin first and then remove excess fat. However, if he determines that there is fat primarily in an area, he will remove the fat first and then tighten the skin afterward. “Radiofrequency is a very versatile procedure that can be used on any area of the body – from large areas like the abdomen to minimal areas such as the chin – with the same degree of success.

Fractional radiofrequency (FRF) deliver energy creates zones of affected skin adjacent to unaffected areas. The treated areas result in thermal damage in the deep dermal collagen, stimulating wound healing, dermal remodeling, and new collagen, elastin, and hyaluronic acid formation. The unaffected areas serve as a reservoir of cells that promote and accelerate wound healing. FRF improves acne scars and large facial pores, wrinkles, and facial laxity reduction. The most common sequence effects are erythema and edema, which are transient (few days). You may use a topical anesthetic cream before the treatment to minimize pain. In a new approach, Prof Moawad offers his patients a full-face FRF to make tiny holes into the skin to overcome the stratum corneum to enhance PRP and /or nanofat. The results are doubles, and you will enjoy both the rejuvenating effect of the FRF resurfacing system and the regenerative effect of growth factors and stems cells present in PRP and/or nanofat. Recently, we applied FRF before botox treatment of excessive sweating or hyperhidrosis of the axilla.

Photo-rejuvenation encompasses many procedures using light or laser-based technology to reverse the effects of photoaging. Non-ablative photo-rejuvenation refers to the controlled use of thermal energy to carry out skin rejuvenation without disturbing the overlying epidermis and with minimal to no downtime. Currently employed non-ablative modalities include primarily intense pulsed light (IPL), visible wavelengths including 585nm pulsed dye laser (PDL), and 532 nm green light (KTP laser). Different infrared wavelengths with water as the target are used for remodeling dermal collagen. The primary mechanism of action is thermal injury either by heating the dermis to stimulate fibroblast proliferation or by heating blood vessels for photocoagulation. The newest way to deliver these wavelengths is by fractionating the dose. The non-thermal mechanism, which represents a fundamental change in thinking, is the theory of photo-modulation. This novel approach to photoaging uses non-thermal light treatments to regulate the activity of cells and not to invoke thermal wound healing mechanisms. The two types of Photo-facial (foto-facial) or Photo-rejuvenation are available are the Intense-Pulsed Light (IPL) and the Light-Emitting Diode (LED) treatments; however, to get the results you hope to do, it’s essential to understand the difference between these facial rejuvenation technologies before you book an appointment. Your best bet for minor skin problems is to schedule an LED (often called a Non-IPL) treatment, and for more severe conditions, you’ll book to IPL.

There is a demand for compounded pharmaceuticals in dermatology because they can offer medications for patients that are not commercially available. Cosmeceuticals can be cleansers, toners, moisturizers, serums, and masques that hold active ingredients such as retinoids, alpha-hydroxy acids, polyhydroxy acids, skin lightening, antiacne, growth factors, peptides, and vitamins. Medically based skincare products target three cellular components that contribute to aged skin: keratinocytes, melanocytes, and fibroblasts. Instituting the correct routine will slow the progression of aging and work towards reversing the extrinsic and intrinsic aging changes. In aesthetic practice, using cosmeceuticals in combination with cosmetic procedures is a new treatment ideal for skin rejuvenation. Pre-treatment with cosmeceuticals can prime the skin for procedures, and post-treatment can reduce complications. Patients with conditions such as rosacea, eczema, seborrhea, and acne require specially selected products that will enhance skin appearance without irritating their underlying conditions.