Minimally Invasive Facial Rejuvenation

Current Concepts and Future Expectations

Moetaz El-Domyati; Walid Medhat


Expert Rev Dermatol. 2013;8(5):565-580. 

In This Article

Abstract and Introduction


Aging of the skin is a multifactorial phenomenon in which ongoing intrinsic changes combine the cumulative effects of chronic exposure to the elements, primarily UV radiation, in a synergistic fashion, causing the skin to lose its thickness and elasticity and develop wrinkles. There is now an increased interest in a wide range of non-ablative treatments for skin aging, which are used to rejuvenate skin with minimal downtime and complications. As the demand for minimally invasive rejuvenation is increasing, different modalities have been designed to produce favorable alterations in the dermis with no epidermal damage via photomodulation, selective photothermolysis, fractional photothermolysis, radio waves, electro-optical synergy, injectable fillers, neurotoxins, skin needling and biorejuvenation to stimulate collagen synthesis and rejuvenate the aged skin while preserving the integrity of the epidermis.


Aside from being the largest organ of the human body, skin is also the only organ continually exposed to the surrounding world, interacting with the environment and reflecting the general health condition and age changes.[1]

Understanding the mechanisms by which the skin ages has been increasing significantly, along with considerable progress on the way to prevent and reverse the visible signs of aging. However, there are still several mysterious factors concerning aging process and why we all appear to age differently.[2] Aging of the skin is likely caused by both intrinsic (biologic) 'intrinsic aging', and extrinsic (environmental) factors 'extrinsic or photoaging'; these factors are interconnected and may share a final common pathway.[3] The quality of skin features is greatly affected by aging, as skin ages, it tends to become roughened, lax and wrinkled with some telangiectasia and pigmentary changes.[1,4,5]

The main histological feature of photodamaged skin is solar elastosis; with accumulation of elastotic material in the papillary and middle dermis. Meanwhile, photoaged skin shows gradual decrease in collagen content.[6] Additionally, collagen network becomes disordered with decreased synthesis and enhanced breakdown.[7] These changes contribute to the skin laxity and wrinkling formation.[8]

Besides being an art, facial rejuvenation is a developing science. Patients now routinely present to their physician requesting information on improving the signs of facial aging; it is the physician's responsibility to select the most appropriate intervention(s) based on the patient's age, physical needs and concerns, extent and location of volume loss and cosmetic goals.[9,10] Different therapeutic approaches were used throughout the years to give the face a youthful appearance. However, because each person is unique, there is no one modality that is best for everyone.[11] Therefore, to choose the most appropriate therapy, distinctions must be done between rhytides caused by loss of collagen within the dermis, wrinkles due to volumetric loss of fat, redundant folds created by gravitational pull and those caused by hyperfunctional facial muscles.[12]

For ease of patient education, the treatment options for addressing these changes may be simplified into five categories, often referred to as the '5 Rs (Redraping, Resurfacing, Retaining, Relaxing and Refilling) of skin rejuvenation': surgically Redraping and lifting redundant tissue; Resurfacing photoaged skin with ablative or non-ablative technologies whether physical, chemical or mechanical; Retaining with skin care; Relaxing dynamic rhytides that are due to hyperfunctional muscles with neurotoxins and Refilling of diminished subcutaneous tissue by restoring 3D volume.[13,14]

Although ablative modalities remain the gold principle for photodamaged skin rejuvenation, its use is associated with significant risk of side effects as well as a prolonged and an unpleasant post-treatment 'downtime' and recovery period.[15] Thus, interest in ablative treatment has waned considerably while non-ablative modalities as well as fractional skin rejuvenation have become appealing alternative treatments.[16]

New perspectives in non-ablative skin rejuvenation treatments have been established with the development of new technologies and techniques, which are used to rejuvenate skin with minimal downtime and complications.[3,17] Many different terms have been used to describe these procedures including: subsurface resurfacing, laser toning and minimally invasive skin rejuvenation. These modalities are designed to produce many cosmetic benefits, including improvement of wrinkles, skin laxity and texture.[18]

Beside lasers and various in-office procedures, many topical skin care agents were used for prophylaxis as sun screens and for rejuvenation such as retinoic acid and different anti-oxidants including vitamins C and E, co-enzyme Q10 and green tea.[19]