Imagine for a moment that you are the owner of an old, worn out car. The wheels are out of alignment, the paint is beginning to chip, and the front bumper barely hangs on by a bolt.
Sure, you could spring for a new paint job or a shiny set of rims. But if you choose to fix up just one area, you can still bet that almost anyone you pass by on the street will be able to size up the jalopy that lies beneath. The lesson: true restoration often requires a comprehensive approach.
Incidentally, it turns out that this same principle holds true for the aging face. While lasers, threads and fillers each do their part toward a rejuvenated look, it is only in combination that these treatments can deliver a comprehensively natural, younger look.
With this concept in mind, Singapore cosmetic surgeon Dr. Woffles Wu has distilled the art of facial rejuvenation into a short list of non-surgical treatments, termed the five pillars – or, alternatively, the five Rs – of non-surgical facial rejuvenation. He says that this system has helped his patients achieve a younger look while avoiding the complications and downtime associated with surgery.
“This is my own take on the whole concept of non-surgical facial rejuvenation,” Dr. Wu says. “It’s not just about finding one technique that will be good enough to replace the traditional facelift. Rather, there are many small non-surgical procedures that can be used together.”
Any way you slice it, surgery for aesthetic purposes necessarily entails a certain amount of downtime. For decades, cosmetic and plastic surgeons have sought ways to whittle down or eliminate this recovery period. The best way to do this, Dr. Wu notes, is to cut surgery out of the picture.
“The people who have been involved with techniques in aesthetic surgery have always tried to achieve a successful form of facial rejuvenation without surgery, and hence without downtime,” he says. “That would be the ideal treatment. Obviously, it doesn’t exist, so that’s like the Holy Grail for us as surgeons.”
However, the evolution and emergence of a number of technologies in recent years have allowed surgeons to inch ever closer to this goal. Advances in light-based treatment have fostered newer, gentler means of skin resurfacing, while BOTOX (botulinum toxin type-A) injections have bolstered doctors’ arsenals in the fight against wrinkles. Each treatment in this new generation of non-surgical procedures seems to hone in on a particular facet of the aging process, allowing doctors to turn back the clock more gently than ever before.
In his five-pillar philosophy, Dr. Wu opts to combine the effects of all of these treatments. Using this combination approach, he says, surgeons can deliver comprehensive rejuvenation to their patients – non-surgically and with a minimum of downtime.
“There are five pillars, which I also like to call the five Rs,” Dr. Wu explains. “You relax with Botox® ; restore volume with synthetic fillers; resurface skin with a host of treatments such as IPL, laser and chemical peels; rejuvenate the eyes using the non-surgical double eyelid technique; and re-drape with the Woffles Lift and/or the APTOS Feather Lift.
“Each one of these techniques on its own has a beneficial effect for rejuvenation,” he continues. “So when you put them together, you can have a really significant rejuvenation.”
Few treatments have hit the cosmetics scene with quite as much fanfare as BOTOX , and considering its notable wrinkle-busting properties, one can conclude that the buzz over its use is well deserved. However, Dr. Wu says the application of BOTOX can be taken a step further by using it to mitigate the subtle tug-of-war between the muscles of the face that result in an aged appearance.
“As we age and certain parts of the face begin to sag, other muscles become complementary,” he says. “For example, in the forehead as the eyebrows droop and the skin becomes more excessive, the frontalis muscle in the forehead has to work overtime to lift the brows so we can see. What you end up with is horizontal lines across the forehead, which are appropriately called compensatory lines.”
The forehead isn’t the only area of the face that adopts these lines. As we age, the muscles of the chin create their own sets of vertical and horizontal lines around the mouth.
“The chin begins to sag, and the muscles compensate by pulling upwards,” Dr. Wu explains. “This gives us tension, which is why you often see old people appearing to pucker. It’s no longer smooth and relaxed.”
A paralytic agent, BOTOX relaxes the muscles that exert this constant, aging pull. The result is a reduction in lines and tension across the face – from forehead and frown lines to crow’s feet and lines around the mouth.
“Botox® relaxes all of these muscles and gives the face a more relaxed and youthful expression,” Dr. Wu notes. “In this way, Botox® becomes a very important tool.”
In addition to its wrinkle-releasing properties, BOTOX has other uses – applications that Dr. Wu has helped to pioneer. One of these techniques, Botox® facial sculpting allows for restructuring of certain muscular components of the face to achieve a more youthful shape.
“When people are young, they have a sharp jaw line and an inverted triangle shape to their faces,” he says. “Once people get older, however, this can turn into an inverted triangle.”
To counteract this effect, Dr. Wu injects BOTOX into the masseter, or jaw, muscle. In so doing, he can slim down a broad, manly face, which generally looks older, into a thinner, triangular, more youthful face.
The other technique he has helped develop is a procedure called microBotox® , also known as mesoBotox® .
“This is essentially the injection of tiny microdroplets of Botox® into the skin of the face,” he explains. “The microBotox® technique improves the sheen of the skin, closes pores, reduces oiliness, and gives a subtle tightening and lifting to the entire face.”
Despite these recently developed applications, however, Dr. Wu says that BOTOX alone can only go so far when it comes to facial rejuvenation.
“Botox® only resculpts the face, releases muscle tension, and improves the sheen of the face,” he notes. “While this is a good start, it cannot restore volume or get rid of deep lines that have formed in the face.”
For this, Dr. Wu says that surgeons must enlist the help of the second pillar of non-surgical facial rejuvenation.
Though they are the archetypical features of an aging face, wrinkles and fine lines are only part of the problem. As people age, the fat deposits beneath the facial skin begin to dissipate and drift, resulting in the characteristically gaunt and hollow appearance of age. Surgeons have formulated a number of strategies to bring back this volume; however, not all of these are surgery-free.
“Of course you can use fat injections or the insertion of implants to restore volume, but in doing so you’re performing invasive surgery,” Dr. Wu says. “We’re now trying to restrict ourselves to the parameters of non-surgical procedures. So one option is to use synthetic fillers.”
Dr. Wu notes that when it comes to these fillers, today’s surgeon has a wealth of options at his or her fingertips.
“We have totally resolvable fillers, the effects of which disappear relatively quickly, and we have semi-permanent fillers, which last longer,” he says. “There are also permanent fillers, but I choose not to use these because of safety issues.”
What these fillers allow doctors to do is to restore a smooth contour to different areas of the face. Fillers are commonly used under the eye and near the temples, as this area is particularly prone to the hollowness that occurs with age. Dr. Wu adds that using them to augment the cheek and chin areas has additional dividends when it comes to rejuvenation.
“Consider that augmentation of the cheek and chin areas enhances the triangular look of the face, and it is plain to see how fillers have a very significant role to play in the restoration of a youthful face,” Dr. Wu says.
Just like the paint job on the aforementioned car, the surface of the skin reveals the ravages of age on the face. More often than not, these ravages manifest themselves in the forms of pigmentation and vascular lesions.
“Nobody is going to look good if their skin is speckled, dirty, blotchy and has a lot of broken veins,” Dr. Wu notes. “So with this in mind, we can resurface the skin in a non-surgical, no downtime way, either with IPL, laser, or with a chemical peel.”
He says IPL, or intense pulsed light, is the natural choice when it comes to removing age spots and the red, blotchy appearance that comes with years of sun damage. More localised pigmentation, on the other hand, can be dealt with effectively using various types of lasers.
“The NdYag laser is very good for melasmic pigmentation,” Dr. Wu says. “When you combine this together with an antioxidant skin care regimen, you can get a very nice result.”
Another option for resurfacing the skin is a chemical peel. Dr. Wu says he tends to use a trichloroacetic acid(TCA)/ Resorcinol combination peel when rejuvenating the skin. This treatment works by dissolving away the dead upper layers of the facial skin, allowing the skin to rejuvenate itself afterwards. Though the TCA/Resorcinol peel provides a considerable effect, the procedure generally only requires about ten minutes to perform and is effective in dealing with fine wrinkles, blemishes and pigmentation problems.
Finally, to improve wrinkles, saggy skin and facial laxity, Dr Wu employs the use of Thermage and INDIBA Radiofrequency treatments. Both of these new therapies have patented technologies which allow the monopolar RF frequencies to heat up the underlying skin thus causing collagen contraction and eventually remodeling which in turn causes the firming and tightening of the skin envelope.
Perhaps no other feature of the age-worn face is more revealing than a set of tired-looking eyes – a consideration that Dr. Wu says any surgeon attempting a comprehensive rejuvenation of the face must take into account.
“You can have everything else in place, but if you have old-looking eyes, there is no way that you can have a youthful look,” he notes. “This depends mostly upon the upper eyelid area. If you have a bit of sagging in the under-eye area, you can still look young, but even if you’re young and your upper eyelid is droopy, then you’ll look old.”
The surgical solution to this problem is open blepharoplasty – essentially cutting into the areas around the eye to reshape and restore the surrounding tissues. However, Dr. Wu says that this goal can be achieved sans scalpel, thanks to his non-surgical stitching technique that restores a youthful fold in the eyelid.
“What we’re doing through this method is recreating the crispness of the double eyelid without using a knife,” he explains. “The principle is attractive: pass a needle and thread through the skin of the eyelid, creating a loop through the skin, and continuing into the cartilage of the tarsal plate.”
The tarsal plate, a thin band of cartilage that lends rigidity to the eyelid, offers a convenient and reliable anchoring point for the tiny suture. By pulling this loop tightly, the surgeon creates a minute, imperceptible scar that holds the soft skin tissues of the eyelid to this plate of cartilage. The eye-opening result grants a wide, youthful look to the eye and the tissues that surround it.
The procedure is as quick as it is effective; an experienced surgeon can perform the entire procedure in only 20 minutes. It has virtually no recovery time, uses only a small dose of local anaesthetic, and utilises just three to four stitches for each eyelid.
And, unlike many other stitching techniques for the upper eyelid, this procedure is a permanent, scar-free fix.
“Because there is no cutting involved, when the patient closes their eyes, there is absolutely no scar on the eyelid,” Dr. Wu says.
The last of Dr. Wu’s pillars has traditionally been the most elusive as well – the non-surgical re-draping of the facial skin on the underlying structures of the face.
“There had always been one missing element, and that had been the re-draping of the skin,” Dr. Wu notes. “There had been no non-surgical technique for that until I developed the Woffles Lift. Prior to this it was always assumed that re-draping needed to be done surgically. But this technique allows us to really re-drape the skin of the face in a non-surgical way.”
In both the Woffles Lift and its sister procedure, the APTOS Feather Lift, the key to this re-draping is a very special thread. What makes the thread unique are hundreds of tiny barbs, etched by a laser, that fasten the thread to the tissues it penetrates.
“Essentially, it’s like the leg of a fly,” explains Dr. Wu. “If you look at a fly’s leg under a microscope, you will see hundreds of tiny barbs. Those barbs are like Velcro – they stick to surfaces. The thread used in the Woffles Lift is similar, as it sticks to the soft tissues of the face.”
Dr. Wu says the threads are normally injected near the sideburn and temple on each side of the patient’s face and pulled out near the scalp. Then, with all the skill and precision of a marionette puppeteer, Dr. Wu manipulates the strings to pull up sagging tissues and tighten loose jowls.
“Whereas some of the other treatments improve the firmness and the texture of the skin, the Woffles Lift and the APTOS Feather Lift lift everything upwards, essentially re-draping the skin tissues on the face,” he says.
The fine needles used in these procedures leave no permanent marks on the face, as the invasiveness of the technique is limited to a few pinhole-sized entry points. And Dr. Wu says general anaesthesia is not required for the procedure.
“It uses only a little local anaesthetic at the sides of the face, and you get a very dramatic pull,” he says. However, the true benefit of this technique is the remarkably brief recovery period.
“With a conventional facelift, you have four to six weeks of recovery time, during which you’ll experience significant bruising and swelling, and the result will not be nice for the first couple of months,” Dr. Wu says. “With the Woffles Lift, the patients are able to get back to work in only three days, which is really just fantastic.”
For most patients, the idea of a comprehensively rejuvenated face is, in itself, a good thing. Throw in the fact that these results can be achieved non-surgically, however, and this collection of procedures becomes a godsend for those concerned with facial aging.
“They love it,” Dr. Wu says. “They love the fact that they don’t have to come in for long periods of time. Most of these patients can go to work on the day after treatment, or at most a few days following treatment.”
He adds that more and more of his patients are opting for all five Rs. “They usually start off with Botox® and fillers, then they come for a course of resurfacing. That soon becomes an ongoing affair. Eventually, they choose to have me re-drape the facial skin with the Woffles Lift and rejuvenate the eyes with the stitching technique.”
Some patients even opt to have several – or even all – of the five Rs performed at one sitting. Dr. Wu says this strategy has definite advantages, particularly for those with hectic lifestyles. “First of all, there is no loss of income through not being able to go to work,” he says. “If you were a CEO or were in sales and you are out of work for one week, you could lose a number of deals in that one week. Using these methods, these patients have little or no downtime. They don’t lose any clients or deals, and they can get back to their social lives more quickly.”
Considering the fact that recovery time has traditionally been one of the chief deterrents to many who would otherwise seek cosmetic surgery, this combination of treatments could well bring a whole new genre of patients to surgeons’ offices in the years to come.
“I had hardly ever had a patient in the past who would have had a facelift and been so enthusiastic about it that they would have come back and brought five or six friends but with my new, combined Non surgical approach, they do!,” Dr. Wu says. “Everyone I treat using the 5R principle likes it so much because of the results. I think it has really changed the way we do facial rejuvenation.”
