Botox
22 June 2022
Sagging skin in the face and neck is one problem of aging that’s frequently blamed on skin laxity. The gradual descent of our faces and unfolding of laugh lines, marionette lines and jowls is more than skin deep; they are due to the scaffolding of our faces gradually losing their support. Age related changes to the soft tissues and bone structure of our faces play an important role in the sagging of our faces and necks.
This doctor’s guide will help you to understand why and how sagging occurs; and the skincare and treatments that can help you to put the snap back for more lifted and defined face and neck contours.
Although signs of aging in the face can be seen in our 20’s, aging is an ongoing and dynamic process. Besides collagen and elastin loss in the skin causing laxity, hyperpigmentation, wrinkles, loss of volume (fat loss) causes flattening and hollowing of the cheeks.
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Sagging in the face begins most notably in the midface. These are the signs of sagging in the face and neck:
• Deepening of nasolabial folds (laugh lines)
• Marionette lines
• Jowls
• Skin laxity and loose skin
• Cheek descent
• Loss of jawline definition
• Eyebrow ptosis and eyelid hooding
• Tear trough deformities and dark eye circles
• Neck: loose, crepe-y, saggy skin (aka turkey neck)
From the skin to the skull, the face is organised in 5 different layers. These 5 layers undergo changes as we age to cause sagging in the face and neck.
Skin
The skin is the largest organ in the body. As we age, the skin loses its fibres of support- collagen and elastin. Some studies estimate the rate of collagen loss in the skin is 1% every year. The skin also becomes more lax and wrinkled; and pores also enlarge due to the loss of collagen and elastin fibres that support the skin.
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Facial fats and connective tissues
Our faces contain pockets of fat called fat pads. These fat pads give our faces its youthful contours and full face shape. These facial fat pads also give support to their surrounding structures i.e. the adjacent fat pads, muscles and skin.
These fat pockets atrophy or shrink as we age and descend downwards. Coupled with age related skin laxity, the skin and soft tissues of the face move downwards to create tear trough deformities, worsening laugh lines (nasolabial folds), jowling, marionette lines and sagging along the jawline.
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Muscles
The facial muscles of the face atrophy i.e. become thinner with age.
Bones
Besides shaping our facial contours, the facial skeleton also supports the soft tissues and muscles overlying the bones. The bones of the face also undergo changes as we age- the bones undergo resorption, leading to loss of bone projections. This leads to loss of support and sagging of facial fats, soft tissues and skin and the appearance of jowls.
Although visible signs of aging and sagging can be seen in our faces and necks in our mid thirties, the aging process begins earlier; when we are in our mid twenties.
There are two parts to aging of the skin- intrinsic aging and extrinsic aging. Intrinsic aging occurs due to the normal and inevitable phenomenon of aging. Extrinsic aging is due to external factors such as sun exposure, smoking and gravity.
Although visible signs of aging and sagging can be seen in our faces and necks in our mid thirties, the aging process begins earlier; when we are in our mid twenties.
There are two parts to aging of the skin- intrinsic aging and extrinsic aging. Intrinsic aging occurs due to the normal and inevitable phenomenon of aging. Extrinsic aging is due to external factors such as sun exposure, smoking and gravity.
Skincare
UV rays from sun exposure are the biggest factor for extrinsic aging. Besides causing burns, UV rays from the sun also cause DNA and protein damage to the cells of the skin, causing premature aging. Some of these signs include loss of collagen and firmness in the skin; fine wrinkles and hyperpigmentation (e.g. solar lentigo).
Two simple ingredients to include in your daily skincare routine to mitigate sun damage is to use a sunscreen and antioxidant daily. Antioxidants neutralise free radical damage caused by UV rays and some antioxidants like vitamin C, can brighten dull skin. And here’s a protip, get started on retinoids early; your skin will thank you for this.
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Smoking cessation
Smoking causes premature skin aging and skin dullness. If you smoke, consider stopping to save your skin.
Diet
A few studies suggest that consuming vitamins C and E and omega-3-fatty acids reduced the deleterious effects of UV rays on the skin.
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Lifestyle and changes can help to delay signs of aging in the skin. However, aging is literally more than skin deep- it also affects the deeper layers of the face- the muscles, soft tissue and bone too.
Non-surgical treatments for sagging are directed at addressing sagging in the skin and soft tissues of the face. In a nutshell, the non-surgical treatments for sagging in the face and neck are:
• Energy based devices for skin tightening and lifting treatments e.g. High Intensity Focused Ultrasound (HIFU e.g. Ulthera) or Radiofrequency (e.g. Thermage)
• Injectables to lift the face e.g. Liquid facelift, Botox Dermalift, Profhilo
• Face and neck threadlifts
In energy based devices, a machine transmits energy to the skin to cause skin tightening and lifting. In Singapore, there are two main types of energy devices- High Intensity Focused Ultrasound (HIFU) and Radiofrequency.
High Intensity Focused Ultrasound (HIFU) e.g. Ultherapy
In HIFU, focused and high intensity ultrasound energy is delivered into the skin to stimulate the skin to build collagen. This causes skin tightening and lifting in the face and can be used to address jowls, laughlines and sagging skin.
HIFU vs Ultherapy: What are the differences?
There are different brands of HIFU devices available in Singapore such as Ultherapy and Sygmalift. In other words, Ultherapy is one of the several types of HIFU devices.
Radiofrequency e.g. Thermage
Radiofrequency treatments for skin tightening and lifting is the alternative to HIFU in Singapore. Radiofrequency heats up the deeper layers of the face and neck to stimulate collagen production (similar to HIFU) to lift and tighten the skin. HIFU and radiofrequency skin tightening and lifting are non-invasive treatments. For patients who have mild to moderate sagging, these treatments offer good results.
The Liquid Facelift is a non-surgical lift of the face using dermal fillers and/or botox. Dermal fillers are soft liquid gels used to sculpt and replenish volume loss due to age. In the Liquid Facelift, small amounts of dermal fillers are injected strategically to restore lost volume and contours and lift the face. For example, cheek fillers can lift the nasolabial folds and reduce dark eye circles and restore cheek volume at the same time. Dermal fillers used in the Liquid Facelift can address sagging in various regions of the face. One advantage of usings dermal fillers to lift the face (as opposed to modalities like HIFU and Thermage) is that the results are immediate and volume loss due to fat and muscle atrophy can be addressed.
Botox can also be used together to remove wrinkles and enhance the overall anti-aging results.
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Botox Dermalift is another minimally invasive skin tightening treatment using Botox (botulinum toxin). Small amounts of diluted Botulinum toxin are injected intradermally; as opposed to injections into the muscles for wrinkle removal. Intradermal botox causes the collagen fibres in the skin to tighten and lift the skin. Skin laxity and facial definition (especially along the jawline) are improved.
Although the results of Botox Dermalift are immediate, most optimum results are seen 2-4 weeks after the treatment.
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Profhilo is a new skin hydrating treatment in Singapore that has the unique ability to bioremodel the skin. It consists of a mixture of high and low molecular weight hyaluronic acid complexes which build collagen and elastin in the skin. Some of the benefits of Profhilo are healthier, firmer, lifted and tighter skin.
Compared to the rest of the injectables mentioned, the lift and tightening of the skin with Profhilo injections is milder. However, the skin remodelling benefits-improved skin hydration, rejuvenation and tightening are impressive. In Profhilo, the injections are administered at 5 points on each side of the face called Bio-Aesthetic Points. You can read about the details of Profhilo and see how it is done in my blogpost Is Profhilo the Injectable Skincare of the Future? Profhilo has received HSA approval in Singapore. It can be injected in the face and neck.
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Face and neck threadlifts are the closest alternatives to facelifts without going under the knife in Singapore. In a face or neck threadlift, very fine and dissolvable sutures are placed under the skin of the face and neck to lift and reposition loose and saggy skin and tissues. The threads in face threadlifts also stimulate collagen formation in the skin for a sustained lift of the face and neck.
Face threadlifts are especially useful addressing fat pad migration. This treatment can reduce sagging cheeks, nasolabial folds, marionette lines, jowls and restore definition in the jawline. Neck threadlifts can address turkey necks and double chins.
In Singapore, the major brands of threads for face and neck threadlifts are Silhouette Soft, MINT, Ultra V and Happy Lift.
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Aging affects the entire depth of the facial and neck architecture- skin, fat pads, muscles and bones. Taking this into consideration, there isn’t one size fits all for treatment for everyone when it comes to treating sagging in the face and neck- yet, at least.
Sagging of the face does not occur in isolation; it is often accompanied by other signs of aging such as deflation of fat pads, enlarged pores, wrinkles and hyperpigmentation. To find a treatment plan that addresses your issues and priorities- speak to your doctor to learn about the best options for you. Some treatments like HIFU have good skin tightening results, but do not restore lost volume. Dermal fillers can restore volume and contours, but do not address wrinkles.
For some patients, combination therapy is a better option as choosing a single treatment alone might result in less than ideal outcomes. For example, HIFU can melt facial fats while tightening the skin. This may make the face look more gaunt or hollow. Similarly, too much dermal fillers can cause a pillow face. The aim is to restore your appearance to a more youthful version of yourself; not to look overdone!
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