Neuromodulating the SMAS for Natural Dynamic Results

Treatment with synchronized radiofrequency and facial muscle stimulation: Histologic analysis of human skin for changes in collagen and elastin fibers

BACKGROUND

Skin's exposure to intrinsic and extrinsic factors causes age-related changes, leading to a lower amount of dermal collagen and elastin.

AIM

This study investigated the effects of a novel facial muscle stimulation technology combined with radiofrequency (RF) heating on dermal collagen and elastin content for the treatment of facial wrinkles and skin laxity.

METHODS

The active group subjects (N = 6) received four 20-min facial treatments with simultaneous RF and facial muscle stimulation, once weekly. The control subject (N = 1) was untreated. Skin biopsies obtained at baseline, 1-month and 3-month follow-up were evaluated histologically to determine collagen and elastin fibers content. A group of independent aestheticians evaluated facial skin appearance and wrinkle severity. Patient safety was followed.

RESULTS

In the active group, collagen-occupied area reached 11.91 ± 1.80 × 106 μm2 (+25.32%, p < 0.05) and 12.35 ± 1.44 × 105 μm2 (+30.00%, p < 0.05) at 1-month and 3-month follow-up visits. Elastin-occupied area at 1-month and 3-month follow-up was 1.64 ± 0.14 × 105 μm2 (+67.23%, p < 0.05), and 1.99 ± 0.21 × 105 μm2 (+102.80%, p < 0.05). In the control group, there was no significant difference (p > 0.05) in collagen and elastin fibers. Active group wrinkle scores decreased from 5 (moderate, class II) to 3 (mild, class I). All subjects, except the control, improved in appearance posttreatment. No adverse events or side effects occurred.

CONCLUSION

Decreased dermal collagen and elastin levels contributes to a gradual decline in skin elasticity, leading to facial wrinkles and unfirm skin. Study results showed noticeable improvement in facial appearance and increased dermal collagen and elastin content subsequent to simultaneous, noninvasive RF, and facial muscle stimulation treatments.

U-SMAS: ultrasound findings of the superficial musculoaponeurotic system

The superficial musculoaponeurotic system (SMAS) is a complex fibrous network connecting facial muscles to the dermis, with varying morphological characteristics across different facial regions. Recent studies have identified five distinct types of SMAS morphology, highlighting the need for region-specific interventions in facial rejuvenation. This pictorial essay explores ultrasound imaging of the SMAS using ultra-high frequency (24-33 MHz) probes, known as U-SMAS. Analysis of 186 full-face U-SMAS scans revealed consistent patterns in the facial and neck layers, with regional variations aligning with the Sandulescu classifications: type I (preparotideal); type II (chin and lip); type III (eyelid); type IV (temporal and parotideal); and type V (cervical). Understanding these morphological differences is crucial for accurate interpretation of ultrasound images and for optimizing pre-procedural assessments to ensure that aesthetic treatments are safe and effective. Knowledge of the SMAS architecture enhances the ability to visualize facial and neck anatomy accurately, particularly through U-SMAS imaging, ensuring comprehensive patient care in rejuvenation procedures.

Hi5 Protocol for the Use of Microfocused Ultrasound with Visualization

Background

Microfocused ultrasound with visualization (MFU-V) is used for lifting and tightening of facial tissues. Standard protocols are completed in a single session. Despite excellent outcomes, we identified several barriers of entry for a significant number of patients. Therefore, we devised an individualized pan-facial protocol that is delivered as a series of short, intense treatments to address these issues.

Methods

We enrolled 12 participants with mild-to-moderate skin and fibromuscular laxity to receive one superficial and one deep pass per visit (average 280 lines). Qualitative improvements were rated by both patients and physicians at 6 or 10 months due to COVID-19 delays. Changes in the submentum and eyebrow heights were quantified.

Results

Ten patients (age range: 31-61 years) underwent an average of four MFU-V treatments. Two patients were excluded after massive weight gain. Skin and fibromuscular ptosis and overall soft tissue laxity improved in all patients. Mean brow height increased by 1.7 mm, whereas the mean submental lift was 78.7 mm2. All patients and treating physicians rated an improvement in appearance, whereas independent physicians rated improvements in 87% of cases. Four patients self-rated as "markedly improved." Pain was rated at up to 6.2 (out of 10). Although mask-wearing was mandatory, loss of elasticity, wrinkles, and skin roughness all improved. Superficial welts (n = 5), erythema (n = 3), tenderness (n = 3), and mild bruising (n = 2) occurred, but all resolved within a few days and no severe or permanent adverse events occurred.

Conclusion

The Hi5 protocol was noninferior to standard single-session protocols and improved brow heights and submental lifting.

Creating Lift in the Lower Face With Botulinum Toxin A Treatment: An Anatomical Overview With Videos and Case Studies Illustrating Patient Evaluation and Treatment

Background

Relaxation of depressor muscles in the lower face with botulinum toxin A (BoNT-A) can create a lifting effect and dramatically improve jawline contour and resting facial expression. Even with the recent increase in interest in lower face rejuvenation, BoNT-A is a relatively under-recognized tool for treatment of this area. When treating the lower face, an understanding of anatomy and the relationship between the facial muscles is especially important, as injection patterns must be customized for consistently positive outcomes.

Objectives

This study was aimed to provide basic knowledge of the activities of the muscles in the lower face and neck and to describe the basis for injecting BoNT-A to create lift in this area. Expert guidance for injection is also provided.

Methods

As part of a continuing medical education course on differentiating botulinum toxin products, a panel of 4 expert physician injectors participated in a live webinar to discuss the implications of increasing toxin use.

Results

The practical guidance in this manuscript is based on the most frequently requested information by audience members and the information considered critical for success by the authors. The authors outline the functional anatomy of the lower face most relevant for BoNT-A treatment and case studies as well as methods for patient evaluation and injection technique are also provided. Videos showing treatment planning and injection technique for the lower face and neck are included.

Conclusions

BoNT-A is an important nonsurgical tool for creating lift in the lower face.

Level of Evidence 5