MedSpa Frequently Asked Question by M. Vincent Makhlouf M.D. F.A.C.S.


Minimally Invasive Facial Rejuvenation

Skin Aging

There are three main areas of skin aging in the face:

  • development of lines and wrinkles,
  • sagging and relaxation of the tissues of the face,
  • changes in the quality of the skin – increased pore size, increased thickness, pigmentary changes, flaking, etc.

To treat wrinkles in the face, surgical techniques are used to stretch the skin back towards the ears and upward.  This can be compared to a bed sheet being stretched over a mattress. However, this method doesn’t address all of the skin aging issues:

  • skin quality (flaking and pigmentation)
  • and the deflation of the face

Our results significantly improved when we realized that a youthful appearance does not necessarily come from having tight skin. But, rather when the skin was properly supported by the underlying structures: the fat, the muscles and the bones.

Wrinkle Treatment

With this new understanding, a new approach to the treatment of wrinkles emerged. We started asking what is the source of the wrinkles?

Tissue Deflation

If the source of wrinkles is tissue deflation, we correct it with fillers.  Fillers come in different forms:

  • hayaluronic acid (*Restylane and Juvederm),
  • calcium hydroxyappatite, (Radiesse) and
  • poly-L-lactic acid (Sculptra).
*Restylane (hyaluronic acid) is a substance naturally present in the skin. Pure hyaluronic acid, when injected into the skin, tends to dissipate rapidly.  The reason being due to the naturally recycling processes in the body.  Its original structure must be modified to slow down its absorption rate and maintain results for a longer period of time. Restylane is used exclusively as an injectable material.


Overactive Muscles

If the source of the wrinkle is from overactive muscles, we weaken and paralyze the offending muscles.  Botulinum toxin is used for the muscle over-activity and there are three brands approved by the FDA: Botox, Dysport and Xeomin.

Skin Quality

If the skin quality is predominantly responsible for the lack of vibrancy and freshness, we use creams (i.e. – Obagi, Retin-A), chemical peels, dermabrasion etc.

Forehead and Eyebrows

The traditional way to correct the lines in the forehead is with a forehead lift. This surgical procedure stretches the skin and also allows for correction of the muscles that cause wrinkles.

A non-invasive option is Botulinum toxin.  When injected, it paralyzes the same muscles.  It’s a very common option because of its speed, simplicity and lack of downtime.

The lines that are formed between the eyebrows (the “glabellar area”) can be corrected in a similar fashion to those on the forehead. It is here where Botulinum toxin is most often used. Fillers can also be used to erase the lines.

Crow’s Feet

The lines around the outer corner of the eyes are called crow’s feet. These lines, also called smile lines, can be treated with a chemical peel.

Dr. Makhlouf recommends using a botulinum toxin such as Botox, Dysport or Xeomin. The results will be visible between 2-5 days.  Again, here, patients can continue with their normal activities the same day.

Nasojugal Fold

Otherwise known as the “tear trough”, this is an oblique line that goes from the inner corner of the eye to the cheek bone. It delineates the junction between the skin of the eyelid and the skin of the cheek.  With migration of the facial fat downward, this line becomes more noticeable.  When this fold is very deep, it gives a tired look to the face.

Non-invasive options include fat injections or fillers, such as Restylane.

Nasolabial Fold

This is the crease that begins at the bottom of the nose and extends to the corner of the lips. To correct it, the cheek must be lifted, a mid face lift may be required to obtain optimal results.

Another option that can be used for the correction of this fold is the use of fillers. Fat, hyaluronic acid or calcium hydroxyapatite can be injected.

At times, patients have asked for a definitive and simple procedure.  Direct excision of the fold, particularly in men, has been most satisfying in this instance.

The right option will depend on the depth of the fold, the patient’s preference, and the results that can be achieved.

Lines Around the Lips

There is no perfect solution to this problem. The treatment Dr. Makhlouf recommends is dermabrasion in conjunction with a chemical peel. A non-invasive option is to fill the lip border with hyaluronic acid, such as Belotero or Restylane.

For patients with the corner of the mouth turned down, a lip lift done at the corner can be an extremely satisfying procedure. This procedure is done in the office and under local anesthesia.

Thin Lips

Lips may become thin either from deflation or from sagging. If it is a case of simple deflation then hyaluronic acid is the product of choice.

Unfortunately, it needs to be repeated more frequently than in other places of the face. In the lips hyaluronic acid gets recycled faster due to the rich circulation and the constant movement.

There is a small surgical option that is quite rewarding, for sagging lips. The lip can be shortened and lifted through an invisible scar in the lip to nose junction. Again, this procedure is done in the office and under local anesthesia.

Marionette Lines

These are the lines that begin at the corners of the lips and extend downward on the sides of the chin. Traditional surgical treatment may include a mid face or face-lift.

For a non-invasive option, fillers are very frequently used for this correction.

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