UNDERSTANDING FACIAL ATTRACTIVENESS AND FACIAL AGING
The face is the primary esthetic unit of the body. Its combination of distinctive characteristics and features serve as the physical reminder that we are all unique (even “identical” twins exhibit subtle differences in facial features.) These features also play a role in identity, self esteem, and self confidence. Psychologists have shown in a multitude of studies over more than 25 years that we, as a society, associate facial beauty with an entire variety of positive qualities. They have demonstrated that persons with attractive faces are frequently interpreted to be more intelligent, nicer, healthier, superior in skills, and generally more likely to experience positive outcomes. Attractive individuals are more likely to be hired, promoted, and more compensated. In interpersonal relations, the human face has been shown to be a key factor in mate choice during all stages of courtship.
Facial attractiveness is usually processed by our brain unconsciously as a result of five key elements: 1) proportional balance of facial elements, 2) uniformity of skin pigmentation and texture, 3) degree of symmetry, 4) averageness, and 5) sexual dimorphism. The appearance of hair and teeth are additional features that are considered highly relevant to attractiveness.
It is through this unconscious processing that each of us sees an attractive face and automatically perceives it to be attractive without necessarily thinking about what factors or combination of factors actually makes the face attractive. Furthermore, these elements of attractiveness appear to cross over to all ethnic cultures.
Youthfulness is very often, but not always stated, the 6th element of attractiveness. Controversially, some would argue that this element is more relevant and thereby more important in determining attractiveness in women than in men. Youthfulness is typically determined by uniformly pigmented, smoothly textured skin that reflects light in a particular pattern. There is usually more volume in the upper two-thirds of the face and smooth three dimensional transitions from one facial zone to the next. This surface contour causes ambient light to be reflected broadly especially in the central cheeks, forehead, and chin with gentle shadows accentuating these highlighted regions. Zones of light transition softly into zones of shadow, but importantly in the right locations of the face. By looking at photographs of our younger selves, this concept is plainly evident.
I have been going to Dr Andrews for several years. I would not go to anyone else. He is skilled, doesn’t try to talk you into anything you dont need or want. He tries for noninvasive solutions. He performed botox, sculptra and perlane on me. He fixed my droopy lower lid with a simple filler shot. Other doctors recommended expensive surgeries or told me there was nothing they could do. Dr Andrews in one visit fixed the problem. The staff are awesome. Pain and bruising is minimal. I recommend Dr Andrews with complete confidence. I would not see anyone else.
Patient Review, Ratemds.com
It is the structural organization of the anatomic elements of the attractive, youthful face (skin, muscle, fascia, fat, and bone) that determine this ultimate appearance. Three dimensionally, these elements are appreciated as youthful “arcs of convexity.” The woman below is an excellent demonstration of how proper recreation of these convex arcs can create the illusion of youth. Though she is 63 years old in these photos, most observers believe her to be much younger.
Dating back to ancient Greek sculptors and later Renaissance artists, the concepts of proportional balance have been a focus of interest to those who work with the human form. Since that time, we continue to recognize that facial attractiveness is determined partially by the dimensional balance of facial components.
Leonardo DaVinci presented Vitruvian Man (above) and Male Head in Profile with Proportions to outline his observations of this phenomenon. Among this work and others, the observation is similar: when the dimensions of one facial element are mathematically harmonious (based on measured length,width, etc.) with the dimensions of other features, we usually find that face attractive. This ratio is referred to as the Golden Ratio, the Divine Proportion, or Phi. It actually measures out to be 1.618 : 1. Interestingly, this same ratio appeals to the human eye in all forms. For this reason, automobiles (Aston Martin, Ferrari, etc.), corporate logos ( Apple, etc.) are actually designed following this same ratio.
These faces are absolutely identical with the exception of the dimension and shape of the jaw.
For example, a nose with a specific shape and dimension, when placed on a face with a weak chin (above left) can often look too large. Thereby, the face on the left is perceived as unattractive. By contrast, the exact same nose balanced against a strong jaw can look appropriate and prove the entire face to be attractive.
Another example to illustrate proportional balance and youthfulness can be found in the relative size of the nose and eyes. Relatively large eyes with a relatively small nose is considered “infantile” in nature as this proportional feature is typically found in youth. Studies have shown that both sexes perceive this proportional feature to be more attractive than a relatively larger nose and smaller eyes. A similar phenomenon is found in the perioral region (area around the mouth). Here, we typically measure the vertical height of the upper lip complex in a young person to be approximately one-half or smaller than that of the lower lip complex. This can be appreciated both at rest and with facial animation. As a youthful person speaks, the upper teeth are visible and are showcased with movement of the lips. Similarly, with smiling, the entire upper teeth and upper gumline are also typically visible in a younger face. With aging, however, the upper lip lengthens and we find with measurement, that the the vertical height of the upper lip complex becomes comparable in height to the lower lip complex. In this process, the upper lip begins to obscure the upper teeth. As an older person speaks, the lower teeth are now visible, rather than the upper teeth. Likewise, when the aging face smiles, the upper segment of the upper teeth and the gumline are typically hidden, as well. This relatively subtle change in proportion of the perioral components can yield the unconscious perception of an aging face.
This concept of proportional balance of features is very important in approaching the treatment of the face. By addressing an imbalance and bringing the facial elements more into harmony, Dr. Andrews renders the face more attractive and/or more youthful. This may be accomplished by reducing the size of a structure that is too large or too long, by enlarging the surrounding elements that may be too small, or sometimes by doing both.
UNIFORMITY OF SKIN PIGMENTATION AND TEXTURE
To the naked eye, what differentiates youthful, attractive skin from older appearing skin is a long list of changes to the skin. The three primary factors are : a) changes in skin texture, b) loss of uniform skin pigmentation, and c) the presence or absence of a whole variety of skin “blemishes” (bumps, tags, “broken blood vessels”, moles, etc.)
With aging, principally because of harmful sun exposure and other harmful exposures (poor diet, smoking, etc. ), the skin breaks down at the microscopic level. The structural proteins (collagen, reticular fibers, elastic fibers) and sugars (hyaluronic acid) that give the skin much of its structural support and strength are damaged and/or lost following such exposures and the skin effectively “caves in” on itself. To the naked eye, this manifests visually as wrinkles or “rhytids” and the loss of a smooth appearance. In severe cases, the skin can actually look like leather. To the touch, this manifests as a loss of a “soft and smooth” sensation.
The millions of surface skin cells that manufacture pigment do so during youth with remarkable consistency. With ongoing harmful exposure, however, the consistency of pigment synthesis is lost. Patches of increased pigment appear throughout the face. Skin color is no longer even; rather, it is splotchy. This is referred to as dyschromia and naturally confers an “older” appearance to the skin. In patients with naturally darker skin, especially persons of Latin or Mediterranean descent, a more significant condition known as Melasma may develop. Here, a mask-like pattern of even darker skin may develop, especially in the cheeks and forehead.
With aging, a wide variety of new skin growths can also occur. Most are of a benign nature and represent primarily an esthetic detraction for the face. These include skin tags, fibromas, moles, etc. Other growths, particularly those that recurrently crust or bleed, actually represent skin cancer and should not be ignored.
As the structural support of the skin breaks down, blood vessels dilate and take on the appearance of “spider veins” or “broken” blood vessels. This most commonly occurs around the base of the nose and in the cheeks and gives the skin here a ruddy appearance.
Psychologists argue that symmetric facial features (a feature on the left of similar shape and dimension as a feature on the right) are processed by the brain unconsciously and suggest better genetic quality. For this reason, they argue that we are attracted to facial symmetry as part of the primal drive to reproduce with more genetically desirable and healthy mates. This is supported by studies that show in both men and women an increased number of sexual partners and infidelities for those with low facial asymmetry (better symmetry).
The concept of symmetry is also important when approaching treatment of the face. By addressing an asymmetry and bringing the facial elements more into symmetry, Dr. Andrews can render the face more attractive. This is usually accomplished by enhancing the 3 dimensional projection of a deficient zone on one side of the face to approach symmetry with the opposite side.
Averageness refers to the tendency for one’s physical appearance to look like the mean (average) of the population. For example, individuals from cultures where noses are typically small are usually attracted to individuals with small noses. Repeated studies have shown that we are usually attracted most to features that reflect averageness within our population (whether single culture or multicultural). Interestingly, in multicultural populations like the United States, we are frequently attracted to individuals whose facial features represent a mixture of ethnic backgrounds. Many theorize that we are drawn to averageness because we unconsciously associate it with good genetic makeup, thus indicating health and fertility. Studies show that this preference for averageness appears to be universal.
To test this theory, composite photography was used so that many different faces from contestants in the Miss Universe pageant in 2005 were “blended together ” by a computer to form an “average sum of the parts”. When individuals were asked to compare these composite images to actual individual contestants, they usually chose the composite images to be more attractive.
The six composite images above are from a) contestants from a particular continent (Africa, Europe, Asia, the Americas) b) the 15 finalists in the contest and c) all 81 contestants from the Miss Universe competition in 2005. These images nicely demonstrate how physiognomy (facial features indicative of ethnic origin) varies from continent to continent. Within this context , each face is highly attractive while retaining traits characteristic of ethnic origin.
Throughout the animal kingdom, species exhibit varying external characteristics that serve to visually differentiate males vs females and assist in mating rituals. This is dramatically depicted in peacocks where males display impressive colorful feathers to attract females.
At birth, human males and females differ only slightly in appearance. With aging, primarily due to the exposure to estrogen and testosterone, certain physical traits in the face become more distinct to differentiate males from females. These include eyebrow size, jaw shape, nose size, cheek shape, lip fullness, and eye size.
General facial shape additionally plays a similar role in this separation of the sexes. Masculine faces are customarily rectangular where feminine faces are more oval with a heart-shaped taper.
As a demonstration, the four faces here depict masculinized versions on the right, and feminized versions on the left, of a woman on top, and of a man on the bottom.
In the figures on the left (feminine version), subtle differences include: thinner brows, rounder eyes, thinner noses, and fuller lips. The shape of the masculine version (face on the right) is more rectangular where the feminine facial shape on the left is more oval.
When facial features fulfill these ideal sex-related proportions, the individual is usually seen to be more desirable to the opposite sex (sexy). Sociologists argue that our brains are essentially hardwired to see these traits as desirable and play a role in physical attraction for mating ( part of the “spark” that initially brings two people together).
For females in particular, ample volume in cheeks and lips (not exceeding a reasonable limit) plays an important role as demonstrated in the images of two women commonly appreciated as sexy, Sophia Loren and Racquel Welch. Similar fulfillment of these criteria with an emphasis on rectangular facial shape and a wide jaw are seen in popular male figures like Brad Pitt and David Beckham.
In summary, without consciously thinking about it, if we see smooth skin with uniform pigmentation draped over a symmetric, proportionally balanced, oval to heart-shaped face where facial elements tend to reflect the average of the population, and include high round cheekbones, large eyes, and full lips in a female or a strong jaw in a male, our human brain is drawn hedonistically toward staring at this and we automatically think, “ This looks good.”
THE PROCESS OF FACIAL AGING
What is fascinating to most people is that the face is in a constant state of change from the moment we are born until the day we die. It is interesting that this physical form that plays such a major role in our identity, never in fact maintains a constant form over time. What is particularly interesting is that we all tend to prefer and identify with a particular form of the face that exists at a particular moment in time. It is not at all the face of our childhood and rarely the face in our teens or 20s. Most patients older than 50 tell us that they prefer the face at some point in the mid 30’s to early 40’s. The process of early facial aging can actually cause changes that bring the face into better proportional balance and make the face more attractive. Unfortunately, this process continues and the face starts to look worse and worse.
At this point, most of us look in the mirror and see an image that doesn’t quite resemble the face we know as our face. The eyes take on a “tired” look, and the face loses its fresh appearance. Even to the untrained eye, some changes of aging are obvious: The skin develops lines and wrinkles and new dark and light patches appear. Extra folds of skin appear in the upper eyelid and pockets of fullness ( bags) form in the lower eyelids. The lips become thinner and the tissues under the chin sag.
The softly accentuating shadows throughout the youthful face that gently separate facial zones are replaced by sharply demarcated narrow shadows so that well-defined specific facial zones become more clearly their own isolated entities.
Of great importance, the location of facial zone demarcation shifts to alter the relative dimension of each facial zone. In the upper cheek region for example, the seamless transition from lower eyelid to cheek is replaced by a clear line of demarcation between these two zones. The vertical height of the lower eyelid zone becomes taller (shown in green below) and the vertical height of the cheek becomes shorter. The forehead narrows and elongates; the lower face widens and shortens.
The photo of younger Angelina on the left demonstrates a shorter vertical height of the lower eyelid zone (shown in green). With aging, the cheeks change in shape and dimension consistent with the normal changes seen in facial bony remodeling. To the trained eye, there are actually multiple changes that are occurring at three primary levels within the face ( the skin, the soft tissues, and the bone). These ultimately manifest as the “older-appearing” and “less attractive” face. The skin surface takes on irregularities in both texture and pigment. Fat and bone undergo atrophy (shrinking) and remodeling in specific targeted locations throughout the face.
Typical younger (left) and older (right) skull are shown below. With remodeling of bone due to the aging process, there is a change in shape of the orbits (eye sockets) and a notable drop and reshaping of the cheekbones. Compare the shape of the area around the eyes (especially below the eyes) in the photos of younger and older Angelina above and in the skeletons below. If one focuses on the region around the eyes, these changes in volume are readily apparent and correspond to the changes in the orbits.
Yes, the facial bones actually remodel and change shape, becoming most readily apparent after age 50. The result is a loss of a strong platform of physical support for overlying muscle, fat, and skin. In women, this is most likely a result of demineralization after menopause.
In addition to bony changes, there are significant changes in the fat and skin as well. The skin loses elasticity and therefore cannot support this deflation of underlying bone and soft tissue. Fatty deposits undergo atrophy (shrinking) with a particular emphasis for specific locations and specific depths throughout the face.
The result is a loss of 3 dimensional roundness especially in the upper two-thirds of the face. This leads to sagging and shifting of facial tissues and alteration in the entire facial shape and contour, so that the lower one-third of the face appears as full or fuller than the upper one-third. This alteration in fundamental shape is processed by the brain as “older.”
With further aging into the 50‘s and 60‘s, youthful arcs of convexity in facial shape are lost one after another.
Narrow depressions or 3 dimensional valleys interrupt the convex arcs previously seen in youth and the boundary lines between facial zones become precise. The dimensional balance of the facial zones, which is typical of youth, is lost. In normal ambient light, distinct narrow shadows appear in unwanted locations, especially under the eyes, between the cheeks and mouth, in the temples, and around the chin.
Professionals who work with the face know this phenomenon well. In order to make a client look his or her best, professional photographers strategically position multiple light sources specifically for the purpose of minimizing or hopefully eliminating the boundary lines between facial zones. Makeup artists work with this understanding to add concealer to these darker regions of the face. When drawing a face, portrait artists pay particular attention to light, shadow, and shape in order to convey a specific age.
TREATMENT OF THE AGING FACE
Treatments (whether surgical or non-surgical) that are designed for facial rejuvenation fundamentally involve addressing one or more of the underlying phenomenon as described above that account for the aging process. Importantly, interventions can be performed while considering the elements of both “attractiveness” and “youthfulness” to render the face not only more youthful in appearance but also simultaneously more attractive. Some aspects of facial aging (bone loss for example) cannot be reversed at present. However, volume can be replaced in a manner that creates the illusion of bone restoration when targeted in areas of importance, thereby restoring a more youthful dimension and shape to the face.
Copyright J. Todd Andrews, M.D
ULTIMATE REJUVENATION Patient of J. Todd Andrews, M.D. This patient underwent surgical facelift, followed by finishing touches with facial injections.
PRINCIPLES OF REMARKABLE REJUVENATION
Historically, most surgeons have focused on surgical solutions to the problem of the aging face and most dermatologists and nurse injectors have concentrated on non-surgical solutions (Botox and Fillers). Though each may serve a potential role in rejuvenating the face, too much of either can lead to the strange and distorted appearances associated with bad or overdone plastic surgery (as shown below.)
We have all seen the patient, who with the goal of eliminating facial lines, has received from her overzealous surgeon a stretched look that looks like the skin has been pulled tight over a drum. These patients have the “deer in the headlights” look. Similarly, in the same goal of eliminating lines or folds, some patients are subjected to more volume than is warranted and the end result is an unusual facial fullness that makes the face appear too inflated and/or resemble that of a monkey or a lion (as above). From a slightly different error in judgment, overenlarged lips or cheeks can lead to a visual result that is by definition a caricature : An image that exaggerates or distorts the essence of a person….often insulting… often drawn for entertainment. In short, there can be too much of a good thing!
In reality, each treatment modality (surgical or nonsurgical) is capable of achieving a defined amount of improvement to achieve a younger or more attractive looking face that simultaneously looks natural. With each modality, however, there is a point, beyond which, additional similar therapy can lead to odd, unnatural, distorted results. This principle applies to both surgery and volumizers. Many physicians and nurses understand this principle. Unfortunately, many also do not.
In Dr. Andrews’ opinion, for most patients pursuing facial rejuvenation, the ideal esthetic result occurs when non-surgical revolumizing , neuromodulator therapy, and skin treatment is combined with surgical procedures. He finds that this fusion of therapeutic options achieves a synergistic effect with maximal refreshing changes while preserving a natural quality. He refers to this approach as Remarkable Rejuvenation and believes that it is this approach that leads to the “Wow” effect seen in popular actresses who seem to defy Father Time.
Copyright J. Todd Andrews, M.D
ULTIMATE REJUVENATION Patient of J. Todd Andrews, M.D – Combination Surgical & Non-Surgical Treatment. This patient had surgical brow lift and laser resurfacing followed by finishing touches with facial injections.
As a facial plastic surgeon with expertise in BOTH non-surgical treatments and surgical procedures, Dr. Andrews can offer either or even both options with a discerning eye, a talent for technique, and a healthy respect for the limitations of each treatment modality. His trademarked method of Remarkable Rejuvenation maximizes the benefit of each modality, allowing a cooperative interaction of both surgery and/or non-surgical methods while emphasizing a natural, attractive result that his patients appreciate. Based on the specific way that YOUR face is aging, he will make recommendations to 1) achieve the best esthetic result and 2) do so while achieving the best value for your investment.
Thus, for the ULTIMATE REJUVENATION, patients undergo a strategically-planned COMBINATION of surgical and non-surgical procedures — SEE BELOW. The surgical plan varies according to each person’s unique anatomy and may include cheek lift, browlift, necklift, eyelid lift, rhinoplasty, or laser skin resurfacing. The non-surgical component maximizes the results from a variety of in-office treatments to further enhance results with some performed before surgery and some treatments performed after surgery.
IF YOU KNOW THAT SURGERY IS NOT RIGHT FOR YOU at this time, you are not alone! Non-surgical treatment options have been the fastest growing trend in facial rejuvenation, especially over the last 5 years as treatment options have grown in number and quality.
Dr. Andrews’ non-surgical REMARKABLE REJUVENATION is designed to your unique anatomy and to address the specific components of aging that are occurring in your face. This may include single or combination treatment with Revolumizers, Neuromodulators and Skin Tighteners. This treatment program offers truly exceptional results without the need for actual surgery.
Copyright J. Todd Andrews, M.D
Remarkable Rejuvenation Patients of J. Todd Andrews, M.D. All results above are through non-surgical intervention.
Dr. Andrews first performs a careful assessment, and then formulates a customized treatment plan to maximize esthetic results exclusively through a variety of non-surgical method including:
1) Revolumizers: The workhorse of revolumizing is hyaluronic acid. (Voluma, Restylane, Juvederm, Restylane Lyft, Restylane Silk, Vollure, Volbella, Belotero, Restylane Refyne, and Restylane Defyne — see below for more detailed explanation). Revolumizing through biostimulation can also be achieved through treatment with SculptraAesthetic.
2) Neuromodulator Treatment with BotoxCosmetic, Dysport, or Xeomin,
3) Skin Tightening and/or Smoothing Treatments involving in-office laser resurfacing, focused ultrasound treatment (Ultherapy), Chemical Peels, and/or Daily Skin Care Regimens.
All treatments are performed in the office utilizing a unique comfort program to minimize, if not eliminate the sensation of pain.
Of all facial zones, the periorbital zone (region around the eyes) is one of the most meaningful zones to undergo rejuvenation. It is commonly the first region to undergo signs of aging and, in doing so, impart a “tired” look to the face. For many patients, it is a region that is very amenable to non-surgical rejuvenation. Because the technical demands in this region are significant and less forgiving than other facial zones, it is an area often ignored by novice injectors.
Following treatment by Dr. Andrews, patients are often pleasantly surprised by the degree of improvement after a brief 10 minute in-office procedure. To the surprise of most, there is minimal discomfort (usually a few very tolerable stings). Roughly 2/3 of patients have either no bruising or minimal bruising that is easily covered with camouflage makeup. 1/3 of patients experience bruising that is not completely camouflaged with makeup.
Results commonly last 18 months and longer, making treatment of this facial zone one of the greatest values of non-surgical treatment.
Copyright J. Todd Andrews, M.D
Non-Surgical Remarkable Rejuvenation Patient of J. Todd Andrews, M.D.
Copyright J. Todd Andrews, M.D
Non-surgical treatment options exist to address almost any region of the face.
b) the ability to perform the procedure(s) in office with no need for general anesthesia,
c) minimal (sometimes no) downtime, (Downtime is primarily due to temporary bruising.)
d) increasing duration of effects from available products with effects lasting up to 2 years and more,
NON-SURGICAL treatment is especially appealing to patients who have already had a surgical facelift in years past, as shown in these diagrams:
Copyright J. Todd Andrews, M.D
Remarkable Rejuvenation Patient of J. Todd Andrews, M.D. – Non-Surgical Treatment Only
The above patient had already undergone a facelift procedure in the “before” photograph and certainly did not look her age of 62 years old. However, the volume distribution of youth was lost and her face appeared too thin and somewhat skeletal in nature. She didn’t have “sagging” per se, but the face still didn’t look healthy and vibrant. With restoration of proper volume distribution through the Remarkable Rejuvenation method, even more youthful characteristics are imparted to her face. At 63 years of age in the “after” photo, she appears 15 – 20 years younger. This approach serves to counteract the ongoing loss of facial volume and skin changes caused by Father Time to achieve and preserve a more youthful and attractive appearance.
For a patient who is considering surgery …….but not quite ready for the actual surgical procedure, this option can also allow her or him to look better now, and delay surgical intervention until months to years down the road.
“It’s not the injectable, it’s the injector!”
Most patients are beginning to appreciate that results achieved with these types of products are often less dependent on the particular product and HIGHLY dependent on the technique of the injector. Serving in a variety of roles as International Lecturer, Master Trainer, Consultant, and Advisory Board member for the major manufacturers within the U.S. (Allergan, Galderma, Merz,Valeant, and Kythera), Dr. Andrews is sought after to share his expertise in this field. In this role, Dr. Andrews educates other plastic surgeons, dermatologists, facial plastic surgeons, and nurse injectors across the nation on the most advanced techniques in nonsurgical facial rejuvenation.
Based on these important principles mentioned above, the Remarkable Rejuvenation program is employed to maximize a patient’s outcome based on his or her interests while simultaneously prioritizing value. That is, as Dr. Andrews discusses the variety of options available to each patient, he educates her or him on what procedural options are likely to achieve the maximum improvement and therefore greatest value for a particular investment. This obviously takes into consideration not only the visual result achieved but the anticipated duration of effect.
Patients are usually pleasantly surprised when they experience a minimal amount of discomfort associated with these Remarkable Rejuvenation techniques. Most commonly, patients describe the procedures as “ a few stings here and there”, “definitely tolerable”, and “not nearly as bad as I was anticipating.”
Copyright J. Todd Andrews, M.D
Remarkable Rejuvenation Patient of J. Todd Andrews, M.D. – Non-Surgical Treatment Only
The above patient had already undergone a facelift procedure in the “before” photograph. Because of age-related volume loss, the face appeared drawn and tired. The region around the mouth in particular appeared old with an exaggerated distance between the nose and upper lip, thinning of the lips and a downturn of the corners of the mouth. Following treatment, the face appears lifted and youthful balance, proportion, and gentle convexity has been restored. Importantly, she appears refreshed and not overdone.
REMARKABLE REJUVENATION TREATMENT PLAN APPROACH
During your evaluation, should you choose the non-surgical Remarkable Rejuvenation option, Dr. Andrews will recommend a treatment program for full facial rejuvenation that will include:
Prior to treatment, his assistant will explain the fees associated with this full program. If you are in agreement with this plan, the procedure can even be performed on the same day as your evaluation. If the cost exceeds the budget you had in mind, no problem. Simply let the nurse know the budget you have established, and Dr. Andrews will adjust the treatment to prioritize among treatment options in order to give you the best esthetic result for your investment.
For the ULTIMATE REJUVENATION, patients undergo a strategically-planned COMBINATION of surgical and non-surgical procedures. The surgical plan varies according to each person’s unique anatomy and may include cheek lift, browlift, necklift, eyelid lift, rhinoplasty, or laser skin resurfacing. The non-surgical component maximizes the results from a variety of in-office treatments to further enhance results with some performed before surgery and some treatments performed after surgery.
Copyright J. Todd Andrews, M.D
ULTIMATE REJUVENATION Patient of J. Todd Andrews, M.D -Combination Surgical & Non-Surgical Treatment. This patient had a Surgical Facelift with Ear Lobe Reduction and Laser Resurfacing, followed by finishing touches with facial injections.
When a patient chooses the ULTIMATE REJUVENATION for maximal rejuvenation effects, the scheduled program is organized by Dr. Andrews’ patient care coordinator:
Step One- the patient first undergoes in-office volume correction through injections in specifically targeted facial locations. This provides immediate improvement in facial appearance pending the surgical procedure.
Step Two – The surgical procedure is then performed according to a scheduled date.
Step Three – Approximately 6 weeks later, the patient undergoes supplementary volume restoration to achieve the polished look (finalized look).
(For those patients interested in traditional surgical procedures without supplementary volume, Dr. Andrews recommends the appropriate combination of techniques, again considering value so that patients receive the best result for their investment.)
Copyright J. Todd Andrews, M.D
ULTIMATE REJUVENATION Patient of J. Todd Andrews, M.D. This patient had both Surgical Facelift and Revolumization with facial injections.
HYALURONIC ACID PRODUCTS : Restylane, Restylane Lyft, Restylane Refyne, Restylane Defyne, Juvederm, Voluma, Restylane Silk, Volbella, Vollure, and Belotero
Hyaluronic acid (HA) products are the workhorse of facial revolumizing. HA is a complex sugar naturally found in the body, especially in the skin and soft tissues. It is an important supportive molecule that helps keep your skin looking young. HA attracts and holds water like a sponge (holding almost 1000 times its weight in water) to function like a supportive glue that reinforces skin proteins like collagen and elastin. This nicely hydrated (filled with water) sugar thus serves to “plump up” the skin, making it appear softer and more youthful. All humans and animals constantly manufacture and constantly breakdown this material to maintain a steady quantity within the body. With aging, production of HA decreases and breakdown of HA increases, yielding a decreased content of HA in the skin and soft tissues. This type of loss is accelerated further with sun exposure and smoking.
Now, with advances in science and medicine, this complex sugar can actually be manufactured in a lab (using the same basic method used for manufacturing insulin and other important organic molecules), and then stabilized to make it last longer. This gives us the option to instantly replace in a simple 10 – 15 minute office procedure what Father Time has taken (or supplement what Mother Nature never provided, as with thin lips, weak chins, or lack of cheek fullness).
All brands of hyaluronic acid are composed of the same fundamental, organically bound double sugar molecule that repeats to form a very long chain. When that long chain is coiled onto itself and cross-linked in a particular manner, the resulting gel is soft, smooth, and silky. When the same chain is cross-linked and processed in a different manner, it is strong, supportive, and lifting. In yet another cross-linking and preparation, the gel can have rheologic properties somewhere in the middle with elements of both. In fact, numerous (10 currently) brands of Hyaluronic acid exist and are approved in the US by the FDA. In Europe and Canada, there are many more!
What we find is that different zones of the face respond better to HAs with different physical properties. Understanding these physical properties, and therefore, based on these properties, where in the face the specific gel may function best, Dr. Andrews is able to often combine various brands of HA within a single facial treatment. In doing so, he utilizes each particular HA within the facial zone where it performs best to take advantage of each product’s strength and achieve the best results.
With all HA products, the visible results from treatment are instant, allowing immediate gratification. The treatment is also REVERSIBLE, allowing removal of the product with a simple injection for the very rare situation of dissatisfaction.
Restylane Lyft, Restylane, and Restylane Silk are hyaluronic acid products manufactured by Galderma as a solid gel that is then passed through a filter to micro fractionate the product into very small particles (like breaking a sheet of ice into crushed ice).
When broken into very fine (50 – 220 um ) particles, the product is called Restylane Silk. When microfractionated into very small (330 – 430 um) particles, the product is called Restylane. When broken into larger particles (750 – 1000 mm), the product is called Restylane Lyft. Thus, the fundamental organic molecule in both products is identical; the particle size however differs. This variation in particle size effects the physical properties of the product. The larger particle size product (Lyft) provides greater physical support and lift for effects on facial shape and contour. The very fine particle product, Restylane Silk provides a very silky smooth texture for smoothing the superficial skin and naturally enhancing the lips. Restylane, in between, has properties of both. These products are particularly versatile in revolumization of various facial zones and excellent at simultaneously providing superior esthetic results and good value (based on prolonged duration of effect.) Using innovative cross-linking technology, the newest Restylane family products, Restylane Defyne and Restylane Defyne are hyaluronic acid dermal fillers that are able to help restore a more youthful, natural-looking appearance, while helping you maintain your natural expression. In contrast to other HA’s, these products are more FLEXIBLE, making them particularly suited for treatment of facial regions that are highly mobile (like the region around the mouth.)
Juvederm, Voluma, Vollure, and Volbella are manufactured by Allergan (makers of BotoxCosmetic and Latisse), as monophasic gels. Voluma, Vollure, and Volbella are cross-linked through a proprietary process called Vycross technology designed to slow the body’s ability to break down these gels. As such, they are designed for longer duration with FDA studies reporting effects lasting up to 1 year for Volbella, 18 months for Vollure, and 2 years for Voluma. The physical properties imparted by this engineering afford excellent lifting effects that are particularly effective in revolumization of the midface (Voluma), lip augmentation and treatment of lines around the mouth (Volbella), and other regions of the face (Vollure).
Belotero is manufactured by Merz (makers of Radiesse and Xeomin) using proprietary technology called Cohesive Polydensified Matrix. This process gives the final injection solution a very high degree of elasticity and resistance to the Tyndall effect. ( John Tyndall was a 19th century physical chemist who described the phenomenon of light dispersion in colloidal suspensions to cause blue color).
Prior to the availability of Boletero, superficial injections of hyaluronic acid fillers ( for defined superficial lines) would result in a bluish hue on the skin. This is called the Tyndall effect, a phenomenon that occurs when light passes through a clear gel with small particles. Belotero’s manufacturing process makes this phenomenon much less likely. Among all HAs, it is therefore the preferred choice for superficial injections in the fine lines around the mouth and around the eyes.
Observed duration of effect for HA products is reported by the three product manufacturers to range from 6 – 24 mths, depending on the product and method of application.
HA products manufactured by Galderma, Allergan, and Merz have been used in the United States and internationally for more than 12 years, with over 30 million syringes used worldwide.
Based on Dr. Andrews’ experience over the last 13 years with all HA products, there is no single product that works ideally for all facial zones. He finds that varying facial zones respond better to varying products. That is, by following a customized approach where a combination of these materials is used to treat a combination of facial zones, Dr. Andrews is able to take advantage of the strengths of each product to maximize patient results and maximize value.
In the United States, the FDA indication for HA products is for implantation into tissue levels ranging from the superficial dermis (skin) to superficial subcutis (just underneath the skin) for the correction of moderate to severe facial folds and wrinkles, such as nasolabial folds. Use in other locations and for other purposes is considered off-label and has been performed in patients worldwide.
How are HA’s administered?
Prior to treatment, local anesthesia is provided by cream applied to the skin. When HA’s are injected directly into the skin by an ultra fine needle where the support structures have been weakened, depressions can be raised to the level of surrounding skin. This smoothes and minimizes facial lines and most types of scars. In addition, skin texture is improved and has a softer tone. The procedure is simple and quick, and results are practically instantaneous. For most patients, treatment results in minimal discomfort. Before treatment to the lips or around the mouth, a local block similar to that at a dentist’s visit may be used in order to optimize your comfort during the short procedure.
What patients are appreciating more and more is that technique, experience, and expertise matters greatly with the use of hyaluronic acids products. When HAs are placed in the correct facial zone at the proper depth in the appropriate pattern, results can be remarkable and natural. When placed in the wrong locations or at the wrong depth, results can be distorting. As a consultant, speaker, and trainer for Galderma, Allergan, and Merz, the major distributors of all HAs available in the US, Dr. Andrews actually trains other physicians and nurses in the most contemporary techniques in the use of these products.
IMPORTANT PRE-TREATMENT CONSIDERATION: With all non-surgical treatments that involve the delivery of products through injections, Dr. Andrews utilizes techniques designed to minimize the risk for bruising. A bruise is simply the presence of blood cells underneath the skin that have leaked out of a blood vessel. If, during treatment, the very small needle touches even a tiny blood vessel, blood cells may be released. The techniques utilized by Dr. Andrews are designed to minimize this type of event and keep bruising to a minimum. To further render these methods to be most effective, you should avoid taking the medications, vitamins, and herbal compounds that are known to “thin” the blood, Medications To Avoid,unless recommended by your doctor. If in doubt, please check with your primary physician before discontinuing any medication.
After Treatment Considerations
Patients usually have minimal swelling and discomfort in the areas of treatment. For over 95% of patients, Tylenol (acetaminophen) is more than sufficient to treat any soreness. Swelling is usually minimal, allowing most patients to return to full activities the next day unless there is bruising. Approximately 1/3 of patients have no bruising whatsoever; 1/3 have minimal pinpoint bruises easily covered with makeup; 1/3 have bruising that is not completely covered with makeup. In order to minimize the possibility of bruising, we first instruct patients to abstain from all medications that are known to thin the blood (Medications To Avoid). In addition, we recommend a) Sinnech (a preparation of Arnica Montana that has been prepared by a licensed pharmacist and tested to demonstrate both efficacy and safety) and b) Auriderm ( topical Vitamin K oxide cream shown to speed up the resolution of bruising). In addition, we recommend eating fresh pineapple as this fruit contains Bromelein enzyme that is believed by many to speed up the resolution of bruising). When bruising does occur, we recommend the use of Laura Mercier or Dermablend products.
Dr. Andrews recommends three important precautions following treatment:
1) Avoid sleeping face down (prone position) for the first week after treatment. This might lead to additional facial swelling and therefore should be avoided if possible.
2) Avoid massaging, firmly pressing, etc. the areas of treatment for the first 10 days. The product is malleable in this early period and can be displaced if pressure is applied. After 10 to 14 days, the product has integrated into the tissues and will not move despite manipulation. Light cleansing of the skin or removal of makeup is perfectly acceptable.
3) Avoid extreme exercise where core body temperature may be elevated (Hot Yoga, Spinning Classes, etc) for 24- 48 hours. Abstain from full body massages with the face in the prone position for at least 2 weeks ( the face-down maneuver is the problem; face-up body massages are not a problem.)
Does Dr. Andrews ever use HA’s with Botox or other fillers?
Yes, Dr. Andrews often combines treatment options as part of the Remarkable Rejuvenation Program.
How long will the results of a HA treatment last? Duration of effect varies with choice of the specific HA, technique, and location of treatment. The FDA has established indications for use with duration ranging 6 mths to 24 mths depending upon the specific product.
Daily Skin Care Regimen
There are a myriad of professional skin care products available to improve the appearance of the skin surface. Many contain ingredients that actually lead to significant improvements in texture, elasticity, and uniformity of pigment expression. Others, particularly those that invest significant funds in marketing and advertisement are often unfortunately more hype than substance. As most patients find, there is no single brand that works well for all skin types. For specific types of skin and specific signs of aging, however, there are a variety of products from different brands that produce consistently good results. During your visit with us, Dr. Andrews will examine your skin carefully, identify the components of aging that most negatively affect your skin and make recommendations for a care regimen to improve your skin’s health and appearance.
Neuromodulators like BOTOX® Cosmetic, Xeomin, and Dysport produce targeted relaxation of facial muscles to soften or eliminate skin wrinkles. BOTOX® Cosmetic, Xeomin, and Dysport are indicated in the United States by the FDA for temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity in adult patients less than or equal to 65 years of age. BOTOX® Cosmetic is also indicated for temporary improvement in the appearance of moderate to severe lateral canthal lines associated with orbicularis oculi activity in adult patients. Treatment to other areas of the face is off-label and has been performed in millions of patients worldwide.
In both the early and later stages of facial aging, treatment with either of these neuromodulators alone can produce truly remarkable results when administered properly. Facial expressions can be softened to yield a serene facial appearance.
This is an important distinction, as many who treat patients with these
products aim for complete elimination of muscular function–leading to a “mask-like” appearance. Dr. Andrews doesn’t believe this endpoint to be attractive. Rather, his focus is on the art of using neuromodulators to aim for a more rested, refreshed, and serene appearance—not the “mask” or “mannequin” look. When considering the “bang for your buck” concept, treatment with any of these three products offers some of the most significant improvements for the investment. Results are temporary, lasting from 3 to 6 months.
This is an important distinction, as many who treat patients with these products aim for complete elimination of muscular function–leading to a “mask-like” appearance. Dr. Andrews doesn’t believe this endpoint to be attractive. Rather, his focus is on the art of using neuromodulators to aim for a more rested, refreshed, and serene appearance—not the “mask” or “mannequin” look. When considering the “bang for your buck” concept, treatment with any of these three products offers some of the most significant improvements for the investment. Results are temporary, lasting from 3 to 6 months.
I went to see Dr. Andrews for a nose job and to treat the bags under my eyes. I am VERY pleased! Excellent results. The doctor and his staff were EXTREMELY caring. People have stopped telling me ” You look tired .” That was getting really bothersome… Thank you Dr. Andrews!
Patient Review, Ratemds.com
Dr. Andrews’ signature approach with neuromodulators is to achieve the best visual result while using no more product than necessary. This has been developed over 19 years of experience with these products in order to give each patient the optimum result without wasting excessive product. Experience has shown that the visual result from treatment improves more and more with increasing dose UP TO A POINT. Beyond this point, the visual result is no better with increasing dose, but the duration of the effect actually does improve, again UP TO A POINT. Beyond this ideal dose, patients notice neither increased duration nor improvement in visual result. Essentially, additional dosage here is wasted. For this reason, Dr. Andrews follows a unique approach to identify this ideal dose in order to give his patients the best value for their investment.
What is SculptraAesthetic™ made of?
Sculptra Aesthetic is made of poly L lactic acid (PLLA), a chain of lactic acid molecules. The body makes this molecule naturally during exercise and is routinely broken down into carbon dioxide and water. These same lactic acid molecules are made synthetically in the laboratory utilizing simple sugars derived from organic wheat and corn.
How does SculptraAesthetic™ work?
SculptraAesthetic™ is placed under the skin with a specific pattern of application into targeted regions of the face in a manner similar to that of planting seeds. As these particles break down into carbon dioxide and water, the body responds with the formation of type I collagen to plump up the skin. This has been confirmed with microscopic tissue examination. For this reason, Sculptra Aesthetic is seen not as a wrinkle filler but as a volumizer through biostimulation. The initial visible effects begin subtly at 2 months as seen in the middle photograph. Over the subsequent 3 – 6 months, the ongoing metamorphosis occurs as seen in these photographs. PLLA has been widely used for over 35 years in the United States as dissolvable sutures so its safety and compatibility with the human body is well established. When placed at appropriate strategic locations, significant youthful changes can be achieved. A google review of this product reveals that results with this product can be exceptional but are also highly technique dependent. As a master trainer for sanofi-aventis, the makers of SculptraAesthetic™, Dr. Andrews serves three important roles in the education of other physicians in the use of this product. He instructs novice physician users on the proper techniques in the use of this product. He provides additional onsite training to more experienced physician users on advanced techniques. Finally, he also evaluates and trains experienced physicians on how to actually train other additional physicians on the use of the product.
Where can SculptraAesthetic™be used?
SculptraAesthetic is indicated for use in immune-competent patients as a single regimen for correction of shallow to deep nasolabial fold contour deficiencies and other facial wrinkles in which a deep dermal grid pattern (cross hatch) injection technique is appropriate. When used in both an on-label and off-label method, this product can be used to restore volume to hollow areas of the temples, cheeks, chin and under the eyes, as well as to define the jaw line. It can also be used to reshape the face, improving both symmetry and proportional balance. The goals of treatment with this product are very similar to those of fat transfer. While fat transfer routinely involves significant and prolonged facial swelling lasting weeks, treatment with SculptraAesthetic™typically involves minimal swelling that usually lasts for only 1 – 2 days. SculptraAesthetic is not recommended for the lips. Lip augmentation is best accomplished with other products such as Perlane, Restylane, Juvederm, or Collagen.
Are the results of SculptraAesthetic™ immediate?
Sculptra does not give results immediately. In contrast to hyaluronic acid (HA) products or calcium hydroxyapetite products, the results achieved with SculptraAesthetic™ are gradual in onset. There is a time factor involved since the true volume effect is created by your own collagen, not the product itself. This collagen replenishment takes place over a period of several months. Observing the process is similar in many respects to watching hair grow. Most individuals don’t really notice their hair growing until a certain visual threshold has passed and suddenly, it becomes apparent that it is time for a hair cut. Two or three days earlier, however, the hair seemed fine. In a similar fashion, following treatment with SculptraAesthetic™, most patients (and their friends, coworkers, and family) don’t notice abrupt changes in the beginning and then slowly start to notice that the face appears fresher and more rested. See below. Some patients have characterized the process as “growing young” in appearance. Many patients highly appreciate the nature of this metamorphosis as it affords them the option of “not telling” about their procedure. Sudden changes in appearance with surgical procedures or some other products usually prompt questions that some patients prefer not to answer. Patients usually receive more than one injection session (typically three to four in total) to accomplish optimal re-volumization.
Copyright J. Todd Andrews, M.D
SculptraAesthetic Patient of J. Todd Andrews, M.D. Treatment with SculptraAesthetic lead over approximately 6 mths to the metamorphosis demonstrated above.
Copyright J. Todd Andrews, M.D
SculptraAesthetic Patient of J. Todd Andrews, M.D. From the oblique perspective, you can appreciate the transformation that occurs in the shape of the entire face in this 65 year old woman. Following the technique employed by Dr. Andrews, SculptraAesthetic treatment stimulates the body to form collagen and revolumize targeted zones of age-related atrophy.
Copyright J. Todd Andrews, M.D
SculptraAesthetic Patient of J. Todd Andrews, M.D. The top left photo reveals the patient’s face prior to treatment. She had undergone a facelift by another surgeon years earlier. The top right photograph is the result one month after the first SculptraAesthetic treatment session. The bottom left is the result 6 weeks after the second ScuptraAesthic session. The bottom right is the result 8 weeks after the third SculptraAesthetic session. These photographs demonstrate the slow metamorphosis in the facial appearance (especially appreciated as a change in the facial SHAPE.)
What are the side effects of SculptraAesthetic™?
As with all injectables the most common side effects are temporary swelling and bruising. We observe that approximately 1/3 of patients will have no bruising whatsoever, 1/3 will have minor pinpoint bruising that is easily camouflaged with makeup, and 1/3 will have significant bruising that cannot be completely concealed. Otherwise, there is no ‘downtime’ per se. Other risks include the transient appearance of palpable, but usually not visible, nodules(collagen pearls) under the skin which usually resolve spontaneously over a period of weeks to months.
How long does SculptraAesthetic™ last?
The lasting effects of SculptraAesthetic™ vary from patient to patient; however, studies have shown results lasting up to 25 months or greater with 80% of patients still “very satisfied” with their results at 2 years. Periodic touch up treatments are recommended to continue the defense against Father Time and the ongoing natural facial atrophy associated with aging.
How is SculptraAesthetic™ administered?
Each treatment consists of a few injections to the areas to be volumized i.e; temple/cheeks/chin/jaw line. The product is administered with local anesthesia and the discomfort is most commonly described by patients of Dr. Andrews as “a few stings”, “ minimal,” or “definitely tolerable.”
After Treatment Considerations
The most important task following treatment with SculptraAesthetic™ is a regimen of facial massaging important to maximize the appearance and minimize the risk of formation of nodules (pearls of collagen under the surface of the skin). A review of the current worldwide literature has shown that patients who massage the treated areas experience on average a less than 4 % chance of forming nodules. By contrast, in patients who do not massage, the risk is much greater and may approach 36%. For this reason, Dr. Andrews or his staff actually demonstrate the massage technique (not difficult or complex) following each treatment session.
For over 95% of patients, Tylenol (acetaminophen) is more than sufficient to treat any soreness. Approximately 1/3 of patients have no bruising whatsoever; 1/3 have minimal pinpoint bruises easily covered with makeup; 1/3 have bruising that is not completely covered with makeup. In order to minimize the possibility of bruising, we first instruct patients to abstain from all medications that are known to thin the blood (Medications To Avoid). In addition, we recommend a) Sinnech (a preparation of Arnica Montana that has been prepared by a licensed pharmacist and tested to demonstrate both efficacy and safety) and b) Auriderm ( topical Vitamin K oxide cream shown to speed up the resolution of bruising). In addition, we recommend eating fresh pineapple as this fruit contains Bromelein enzyme that is believed by many to speed up the resolution of bruising. When bruising does occur, we recommend the use of Laura Mercier camouflage makeup.
Swelling and discomfort is usually minimal, allowing most patients to return to full activities the next day unless there is significant bruising. Dr. Andrews recommends that you avoid sleeping face down (prone position) for the first week after treatment. This might otherwise lead to additional facial swelling and therefore should be avoided if possible.
Radiesse is a calcium hydroxyapatite volumizer indicated in the United States by the FDA for subdermal implantation for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds.
In Dr. Andrews’ experience, this product is an excellent instant volumizer for multiple locations in the face and the preferred treatment option for revolumizing and revitalizing the hands. As a Calcium based product, it is a biologic material already found in the human body that serves as a robust, supportive filler. It provides both immediate results by volumization and also serves to stimulate collage synthesis. As such, it has both the benefits of HA products and Sculptra. In contrast to HA, this treatment is not reversible. It is particularly suited to lift and volumize the mid face and to address aging of the lower face and jawline. To date, there have been more than 5 million syringes administered worldwide. It is well established as a safe and effective treatment method.