Facial rejuvenation

Facial rejuvenation is any cosmetic or medical procedure such as facelift, brow-lift, neck lift and/or blepharoplasty that are used to increase or restore a youthful appearance, they may improve societal perceptions of attractiveness, success, and health, conferring an even larger social benefit than just restoring a youthful appearance to the face ¹. The specific term, however, refers to a set of surgical procedures which try to restore facial geometry and skin appearance which are typical of youth, by using a combination of brow lift, elimination of eye bags, eyelids lift, elimination of senile spots, skin aging, facial sagging and wrinkles by face lift and rhytidectomy and physical or chemical peeling, chin lift (reduction of double chin), restoration of facial hairline, etc. These procedures are usually successful and in some cases achieve striking results.

When considering facial rejuvenation treatments, it is important to have a partnership with a real board-certified plastic surgeon who is an expert in facelift surgery and understands the science of facial aging.

You need a professional who not only understands the aging process but can determine whether a noninvasive or invasive procedure will be required to achieve your desired results. You might think you need a facelift or neck lift when you actually may just need filler and Botox or vice versa. What are your options for facial rejuvenation? The most commonly sought-after procedures include eyelid rejuvenation, facelifts after age 50 and the use of facial fillers and Botox when there is no facial skin sagging or jowling.

Is eyelid rejuvenation right for me?

Eyelid rejuvenation, also known as blepharoplasty, is a common area of the face that patients request to refresh first. Eyelid rejuvenation usually precedes a face and neck lift or can be done at the same time. The eyes are the windows to the soul, and as you age, that window will start to show severe signs of aging. Loss of volume in the face leads to sunken eyes and sagging skin that was never there before. Since your eyes are the most prominent feature of your facial structure, it is vital, when considering eyelid rejuvenation, that you do not change the appearance of your eyes too dramatically. We cannot overemphasize this concept enough because excessively slanting or making your eyes smaller with surgery will forever change how you look to yourself and to others. The goal is to look like yourself only better.

Is a facelift what I need?

Facelifts, also known as rhytidectomy, is sometimes required to correct sagging facial skin. There are many different techniques used to accomplish a facelift. We cannot stress enough the importance of choosing a real board-certified plastic surgeon who is a true expert and who specializes in facial rejuvenation when considering a facelift. Facial rejuvenation is so much more than just a facelift, and when done correctly, facial rejuvenation focuses on facial harmony. To maintain facial harmony, often facelifts are accompanied with eyelid surgery and filler to restore the eyes, bring back the natural jawline and reestablish fullness in your cheeks.

Do I need Botox?

Neuromodulators such as Botox and Dysport and Xenomin are agents that block muscular nerve signals, which in turn weakens the target muscle limiting or nullifying muscle contraction. The action of Botox, in turn, results in diminished unwanted wrinkles in the target area. Botox has multiple uses and can be used to treat crow’s feet, forehead furrows, frown lines, skin bands on the neck, etc. When considering plastic surgery procedures to address the effects of aging, you should always work in close partnership with a board-certified plastic surgeon who understands the aging process. You need an expert that can help you determine if neuromodulators are appropriate to correct lines and wrinkles or if a more invasive procedure is necessary.

Do I need fillers?

As you age, your body naturally loses fat. This is especially evident in the face. Fat loss is especially apparent in the hollowing of the eyes and cheeks. Soft tissue fillers help to reduce fine lines and wrinkles by adding volume and fullness back to the face. Most fillers such as Restylane, Voluma or Juvéderm work by replenishing the hyaluronic acid levels in your skin and pulling in moisture from the body to add to its plumping and smoothing effect. These safe, degradable hyaluronic acid fillers are helpful at reducing early signs of aging such as plumping thin lips and softening facial creases and wrinkles.

When should you have facial rejuvenation?

As with any elective medical procedure, you should only undergo facial rejuvenation when you are in good health physically, psychologically and mentally. When deciding to have plastic surgery, you want to make sure your body and your immune system are in good shape to minimize the risk of complications. Facial rejuvenation is not advisable if you have any significant underlying medical issues, and especially if you smoke.

For your safety, we cannot stress enough the importance of discussing your goals with a board-certified plastic surgeon who understands the natural aging process and can therefore perform the correct anti-aging surgical procedure that will restore your youthful face. An expert plastic surgeon can also determine whether a noninvasive or an invasive procedure will be required to achieve your desired results.

Plasma facial rejuvenation

Most studies evaluating plasma facial rejuvenation or platelet-rich plasma (PRP) injection for facial rejuvenation and other cosmetic procedures have reported positive results ². In this randomized clinical trial with 27 adults aged 18 to 70 years with bilateral cheek rhytids of Glogau class II or greater. The duration of the study was August 21, 2012, to February 16, 2016. Each participant received 3 mL intradermal injections of platelet-rich plasma to one cheek and sterile normal saline to the opposite cheek. The photoaged facial skin of those treated with platelet-rich plasma was found to be significantly less rough and wrinkled at 6 months after a single treatment ². But the research evidence supporting platelet-rich plasma for facial aesthetic procedures has important limitations, especially a lack of standardized platelet-rich plasma preparation and injection techniques, concludes the report by American Society of Plastic Surgeon Member Surgeon Alexes Hazen, MD, and colleagues of the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Health, New York. More studies are needed to optimize platelet-rich plasma (PRP) treatment techniques.

In another study investigating the effect of hyaluronic acid on facial rejuvenation, Reuther et al ³ reported that micropuncture injections of hyaluronic acid increased the net elasticity parameter, showing improvement in skin elasticity. Moreover, a recent study showed that 3 sessions of platelet-rich plasma injection at 1-month intervals resulted in significant improvement of skin elasticity and skin smoothness parameters ⁴. Of note, the platelet number of platelet-rich plasma may vary depending on the individual from which the blood is drawn. Thus, treatment with platelet-rich plasma might show variable efficacy depending on the source of the platelet-rich plasma.

Stem cell facelift

A stem cell is an unspecialized cell that is capable of replicating or self renewing itself and developing into specialized cells of a variety of cell types. There are essentially 2 categories of stem cells: the embryonic stem cell (cells from the preimplantation-stage embryo) and the postnatal stem cell (ie, adult stem cell) ⁵. Embryonic stem cells are stem cells derived from the undifferentiated inner mass cells of a human embryo ⁶. Embryonic stem cells are pluripotent, meaning they are able to grow (i.e. differentiate) into all derivatives of the three primary germ layers: ectoderm, endoderm and mesoderm. Embryonic stem cells hold enormous therapeutic potential, yet are subject to significant ethical, legal, and political concerns ⁷. On the other hand, the few restrictions placed on adult stem cells facilitate their use in clinical applications and experiments. Unlike embryonic stem cells, which are defined by their origin (cells from the preimplantation-stage embryo), the origin of adult stem cells in some mature tissues is still under investigation ⁸. An adult stem cell is thought to be an undifferentiated cell, found among differentiated cells in a tissue or organ. The adult stem cell can renew itself and can differentiate to yield some or all of the major specialized cell types of the tissue or organ. The primary roles of adult stem cells in a living organism are to maintain and repair the tissue in which they are found. Scientists also use the term somatic stem cell instead of adult stem cell, where somatic refers to cells of the body (not the germ cells, sperm or eggs). Adult stem cells are rare ⁹. Adult stem cells primary functions are to maintain the steady state functioning of a cell—called homeostasis—and, with limitations, to replace cells that die because of injury or disease ¹⁰. For example, only an estimated 1 in 10,000 to 15,000 cells in the bone marrow is a hematopoietic (bloodforming) stem cell ¹¹. Furthermore, adult stem cells are dispersed in tissues throughout the mature animal and behave very differently, depending on their local environment.

Multipotent stem cells can be isolated from various mesenchymal sources, most commonly bone marrow, and have been identified in virtually every tissue in which they have been sought.16–18 The Ontario Cancer Institute initiated stem cell research by describing self-renewing cells within the bone marrow of mice in 1963 ⁵. In 2002, researchers at the University of California, Los Angeles described a novel adult stem cell population isolated from adipose tissue (adipose tissue-derived stem cell) ⁷. Stem cells self-renew by asymmetric cell division, whereby 1 daughter cell differentiates while the other remains a stem cell ¹²; it is this characteristic that allows stem cells to replenish differentiated cells lost due to the normal functioning of the organism, as well as to participate in regenerative processes in response to acute injury without diminishing the original stem cell population ¹³. Adipose tissue-derived stem cell have been shown to possess the potential to equally differentiate along multiple lineage pathways into cells and organs of mesodermal as well as nonmesodermal origin ¹⁴. They are pluripotent and capable of forming multiple cell types within all 3 germ layers ¹⁵. At present, adipose tissue-derived stem cell remain one of the most frequently used populations in the stem cell field ¹⁵. The popularity of adipose tissue-derived stem cell stems from ease of access, isolation, and utilization as well as their ready availability in the human body—namely, in the significantly expendable adipose tissue ¹⁴.

Despite some controversy about the magnitude of stem cell differentiation potential, several functional characteristics have been identified that make these cells attractive for regenerative medicine applications. Stem cells have been found to migrate to the site of injured tissues, release different growth factors, and support the processes of wound healing by promoting cell proliferation, differentiation, angiogenesis, and matrix remodeling ¹⁶. To date, just one stem cell procedure for cosmetic purpose has received U.S. Food and Drug Administration (FDA) approval, after extensive evaluation. That product, designed to treat fine facial wrinkles, is undergoing extensive post-approval surveillance. In June of 2011, after almost 10 years of review, the US Food and Drug Administration (FDA) approved laViv (azficel-T), a first-in-class personalized cell therapy for eliminating fine wrinkles or nasolabial folds around the nose and mouth ¹⁷. Each laViv treatment involves harvesting a patient’s own fibroblasts from behind the ear, culturing them for 90 days, and then reinjecting expanded cells into the dermis during a series of treatments ¹⁷. The company’s safety data were sufficient to warrant approval, but because laViv is so novel, approval was contingent on extensive post-market surveillance for immune effects and skin cancer ¹⁷.

Of more than 100 clinical trials being performed to evaluate fat-derived stem cells, only a handful are focusing on cosmetic treatments. Stem cells offer tremendous potential, but the marketplace is saturated with unsubstantiated and sometimes fraudulent claims that may place patients at risk ¹⁸. Stem cell therapy remains in its infancy, but there are a growing number of cosmetic practitioners that are advertising minimally invasive, stem cell-based rejuvenation procedures. With unsubstantiated claims that these procedures are safer, have equivalent or better outcomes, and faster recovery periods than conventional procedures, many of these practitioners are emphasizing profit over quality and safety ¹⁸. Furthermore, without advanced cell-sorting procedures, these products used in these procedures likely contain many other types of cells besides fat-derived stem cells. Many clinics also offered plasma-rich platelet protein treatments, which they inaccurately marketed as stem cell therapy ¹⁹.

Inherent risks of cell processing

When considering clinical use of stem cells, one must be cognizant of the fact that cell and tissue processing pose a risk of contamination and/or damage to cells. Regulation of stem cell therapy is thus paramount to ensure patient safety. For this reason, the growing number of “stem-cell based” cosmetic procedures is worrisome, due to the lack of oversight and dearth of scientific studies or trials to evaluate their efficacy and safety in vivo.

Potential contamination of and damage to cells becomes an issue when cell-based products involve more than minimal manipulation, including cell expansion in culture and differentiation ²⁰. In theory, cells removed from a patient and replaced during the same surgical procedure pose no greater risk of disease transmission than the surgery itself ²⁰. However, cell culture typically involves the use of nonhuman serum, usually obtained from fetal calves, and therefore introduces a potential risk for prion infection ²¹. In light of this, current FDA guidelines specify that fetal-calf serum must come from a country certified to be free of this disease. Additionally, cell expansion in vitro may also involve the use of xenogenic feeder cells, particularly in the case of human embryonic stem cells. This also poses a potential risk of infectious disease transmission.

Another safety concern revolves around malignant stem cell transformation. Stem cells have clear similarities to cancer stem cells, and it has been demonstrated that mesenchymal stromal cells can undergo spontaneous malignant transformation following long-term in vitro culture ²². Despite the enormous potential for stem cells demonstrated in preclinical testing, it is thus essential to recognize and appreciate both the promise and limitations for use of stem cells in clinical therapeutics ²³.

Summary

Currently, the marketplace is characterized by direct-to-consumer, corporate medicine strategies that are characterized by unsubstantiated, and sometimes fraudulent claims, that put patients at risk. With plastic surgeons at the forefront of stem cell-based regenerative medicine, it is critically important that they provide an example of a rigorous approach to research, data collection, and advertising of stem cell therapies. Stem cells offer tremendous potential for cosmetic applications, but consumers must be vigilant to avoid unsubstantiated and sometimes fraudulent claims which may threaten the field of stem cell therapy for facial rejuvenation.

References

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2. Alam M, Hughart R, Champlain A, et al. Effect of Platelet-Rich Plasma Injection for Rejuvenation of Photoaged Facial Skin: A Randomized Clinical Trial. JAMA Dermatol. 2018;154(12):1447–1452. doi:10.1001/jamadermatol.2018.3977 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583756
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