5R Principles of Facial Rejuvenation

There is a wide range of treatments available for facial rejuvenation. We understand it may be confusing for you to know which treatment is right for you. Many of the patients who come to see Dr Bernard Leung have done an enormous amount of research online, and have come to him with a specific treatment in mind, which may or may not suit them.

This is why during your personal consultation with Dr Bernard Leung, he will assess your facial structure and discuss your concerns. He will take note of the signs of ageing that are present and their relative severity. Based on these findings, he will then apply the principles of the 5Rs of facial rejuvenation to determine the most appropriate treatment for you.

Before choosing the right treatment you, it is first important to understand what is happening to your face.

Whilst most people think of wrinkles as the primary manifestation of facial ageing, the reality is far more complex. The ageing process affects the entire facial structure, including skin, subcutaneous fat, muscles and facial bones.

What are the signs of Aging?

To summarise the signs of aging, there are essentially 4 things that happen to our face as you age:

1. Volume loss due to shrinkage of subcutaneous fat: The subcutaneous fat layer in the face is arranged into compartments called ‘fat pads’. Most of these fat pads decrease in size with age. The process of shrinkage probably starts soon after teenage years and is unrelenting. How much effect this fat pad shrinkage has on an individual depends in part on how much subcutaneous fat there was in the first place. If someone has a full, round face at the age of 18, their face may well become well-proportioned when they reach their mid thirties. Conversely someone with a perfectly balanced teenage face is likely to have hollowing and sagging even in their thirties.

Site Images / Brunette (medium)Research presented in the Journal of Plastic and Reconstructive Surgery in 2011 concluded that substantial facial bone volume loss occurs with age. Since the skin also loses elasticity with time, it is not able to tighten around the spaces left by the bone loss. As a result, Dr Howard Langstein, chief of Plastic and Reconstructive Surgery at the University of Rochester Medical Center concluded that volume replacement is the optimal solution to achieving a more youthful-looking face.

2. Remodelling of facial bones: In addition to soft tissue changes, the facial skeleton also undergoes remodelling with age, albeit at a much slower pace. They shrink and they change shape. The maxilla (upper jaw) and the mandible (lower jaw) decrease in height and recedes backwards. The brow ridge becomes less prominent. The eye sockets and the nasal cavity, being the ‘negative space’ in artistic parlance, enlarge.

3. Sagging: The combined effect of the fat pad and skeletal shrinkages results in decreased support for the skin. In many ways, this is akin to someone wearing the same sized clothes after weight loss, the clothes will not drape properly and will hang loose. The loss of the brow ridge and the brow fat pad leads to sagging of the eyebrows and eyelids. The loss of mid face volume leads to sagging of the cheek, and causes deepening of the nasolabial fold. The sagging of the temple, the outer part of the face and the shrinkage of the mandible lead to poor jawline definition, jowl formation and sagging of the upper part of the neck.

4. Skin changes: All the major constituents of the skin deteriorate with age. Collagen is the main protein that is responsible for the structural integrity of the skin. It provides tensile strength amongst many other functions. The amount of collagen decreases with age. Elastin, as the name suggests, is responsible for elasticity of the skin. It is no longer capable of being produced after puberty. In fact, there is no current technology or technique that will allow us to generate more elastin. Once we have lost it, it is gone. It is important to bear in mind that sunlight stimulates the production of a group of enzymes called the metalloproteinases, some of which are particularly good at digesting elastin. Hence one of the major manifestations of sun damaged skin is the loss of elasticity.

Fibroblasts are the cells that produce collagen and repair wounds. They also exert a pulling effect on the collagen fibrils, effectively tightening them. It is a bit like tensioning a guitar or violin string. As fibroblasts age, not only do they produce less collagen, their pull on the collagen fibre network also becomes weakened. This decrease in tractile force on the collagen network contributes to sagging. The loss of collagen is most marked post-menopausally in women. It has been established, through skin biopsy studies, that women lose a staggering 30% of their skin collagen thickness within five years of the onset of menopause.

Muscles in general attach from one bone to another, spanning a joint so that the joint can be moved. The face is peculiar in that the facial mimetic muscles attach directly to the deep surface of the skin. The contraction of these muscles in a coordinated manner result in facial expressions. As skin ages and becomes thinner, less resilient and less elastic, less force is required to make facial expressions. As the facial muscles continue to contract with the same force as before, effectively we have a situation where the mimetic muscles are now overpowering the skin, causing wrinkles to form around key areas, such as the frown lines, forehead and crow’s feet. Initially these wrinkles only appear with facial expressions (dynamic wrinkles). Over time, they become progressively more deeply ingrained until they are permanent (static wrinkles).

The sun protection factor (SPF) factor of the skin diminishes with age and we get accelerated sun damage (photoaging) as we get older. This manifests as textural and colour changes. The skin becomes rougher, often with scaly patches. There is a loss of tissue rebound. Irregular brown patches are often present. Dilated capillaries or diffuse redness are often seen.

Although facial aging is progressive and cannot be completely halted, a number of facial rejuvenation treatments can slow down or even reverse many of these signs.

What are the 5Rs?

In order to target these changes in a logical manner, Dr Bernard Leung thinks of facial rejuvenation in terms of the 5 Rs:

1. Relax:

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This refers to the use of anti-wrinkle injections (TGA regulations forbids us from mentioning product names) which soften wrinkles by weakening the muscles that cause them to appear. As discussed previously, the facial muscles gradually become relatively more powerful compared to the aging skin, and by selectively weakening the muscles responsible, the development or progression of wrinkles can effectively be stopped.

Patients are justifiably concerned about looking frozen. Rest assured, the art of botulinum toxin is about achieving a balance and Dr Leung strives to obtain a natural look. The best result is obtained when the muscles are weakened by just the right amount, so that they can still move and allow facial expressions without causing excessive wrinkling. Dr Leung also prefers to treat inter-related groups of muscles together, in order to avoid an artificial look associated with demarcations between treated and untreated areas

2. Revolumise/Reflate:

Correcting facial volume loss (facial reflation/revolumisation) has become the mainstay of modern facial rejuvenation. Reflation can be achieved by either using one’s own fat (autologous fat transfer) or dermal fillers (which are made up of a naturally occurring substance in our bodies called hyaluronic acid). Dr Leung is able to perform both types of procedures. Facial reflation has been known as ‘Liquid Facelift’ in the past.

Autologous fat transfer involves harvesting fat through liposuction or ‘mini liposuction’. The fat is then injected into the appropriate areas in the face. The transplanted fat cells will have to re-establish its own new blood supply in the recipient site in order to survive. The main advantage to this technique is that it is permanent; it is also completely natural as it is taken from the same person. The main disadvantage is that the down time is usually significantly longer than dermal fillers and that several sessions 3-6 months apart are required to achieve a final outcome.

The development of long lasting ‘natural’ fillers have revolutionised facial reflation. By placing dermal fillers in the right places, it can simulate both fat pad and skeletal volume loss. Dermal fillers of different thicknesses can be tailored to the anatomical location, for example, the tear trough area is usually treated with a thinner filler to minimize any potential for swelling. Dr Leung is also able to lift facial structures by precisely administering boluses of dermal fillers under certain ligaments to provide structural support and lifting capacity.

The placement of dermal fillers not only requires technical expertise, but it also involves a very high degree of artistic judgment. Dr Leung recalled being taught at art school to visualize the underlying anatomical structure when doing life drawing or portraiture, the same applies to dermal fillers. Moreover, using his detailed anatomical knowledge and experience to ‘imagine’ what changes would have taken place over the years, Dr Leung tries to recreate the previous facial appearance.

Facial reflation can help reduce bags and dark circles under the eyes, give you higher cheek bones, help diminish the appearance of nasolabial folds and improve jaw line definition.

3. Remove:

There are a number of things that develop with the aging process where the only treatment would be their removal.

The jowl and under-chin fat pads, have a tendency to increase in size over time, particularly in association with weight gain. A more youthful facial and neck contour can be achieved by removing some of the fat from these areas. By treating this area with Vaser liposculpture, not only can the excess fat be removed, Vaser allows an unsurpassed amount of skin retraction, which minimizes the chance of any loose skin. The tumescent anaesthesia used for the Vaser liposculpture will allow a minimally invasive neck lift to be performed concurrently. When these procedures are combined with revolumisation higher up in the face, they give the most incredible, natural looking results.

Site Images / Eye (medium)The concept of loss of volume of the brow bone and the brow fat pad has previously been touched upon. The other phenomenon that develops in susceptible people is sagging upper eyelids. Removal of the loose hanging skin (known as blepharoplasty or upper eyelid surgery) and revolumising the brow will instantly take away that tired, aged appearance. In Dr Leungs hands, this procedure yields a very natural looking result, with the added benefit for minimal down time.

It is also not uncommon to develop aging spots, unwanted moles, broken blood vessels, brown spots or tags on the skin, especially on the face and neck. All of these can be easily and safely treated by simple removal techniques, such as cryotherapy, radio frequency ablation, surgical excision or intense pulse light.

4. Reposition:

Sagging tissue can be lifted and repositioned to where it used to be, and the lax skin can be redistributed over the facial tissues. This formed the basis of face lift surgery, which was once the ‘gold standard’ treatment for people wanting a more youthful appearance. Whilst a surgical face lift does reposition the skin, it can leave patients with a tight, pulled back look. In addition, there is a considerable degree of downtime associated.

With recent advances in the understanding of the mechanics of facial ageing and minimally invasive procedures, it is now possible to reposition the sagging tissue and redrape the skin with minimal downtime, usually no more than a few days. Patients can also expect long-lasting, natural-looking results.

Site Images / Neck (small)Dr Leung specialises in combining minimally invasive face lift and neck lift techniques with Total Face dermal filler treatment and other modalities to give his patients the best possible overall rejuvenation, which in his opinion gives far superior results than just an open surgical face lift alone.

5. Resurface:

Resurfacing of the skin refers to methods that remove the outer layers of the skin resulting in a smoother, more even-coloured appearance. Microdermabrasionchemical peelslaser resurfacing (confluent and fractional) all fall under this category. These techniques are used to treat sun-damaged, weathered, or aged skin.

We also include newer technologies such as radiofrequency skin rejuvenation into this category. Although it is usually labeled as radiofrequency skin tightening, it is something of a misnomer, as there is little skin tightening going on. The main benefit of radiofrequency skin rejuvenation is that it switches on the fibroblasts which enables new collagen formation.

Whilst these treatments are divided into 5 categories, this does not mean that you cannot combine them. On the contrary, all the ageing changes described above occur simultaneously, and patients ideally should address all the different aspects which are present to obtain the most natural looking result. It is for this reason that Dr Leung prefers to combine different treatment modalities.

With such a wide range of potential options, choosing the wrong treatment can be harmful, costly and the result can appear strange and unnatural. Choosing the right treatment is just as important as the treatment itself.

Facial Artistry is unique when it comes to the 5Rs approach. Whilst many clinics can only offer one or two treatments for facial rejuvenation, typically targeting only the skin changes, Dr Bernard Leung and his team firmly believe in, and have the capability to apply the principle of 5Rs in achieving a naturally looking and long lasting result. This means that you are not getting a ‘one treatment fits all’ approach, instead you are getting a tailored  and fully tailored approach that suit your needs.
Dr Bernard Leung cannot emphasise enough the importance of following a carefully structured, logical and artistic approach in order to achieve the best possible natural and attractive looking outcome.

This is why Dr Leung personally assesses each of his patients before determining which treatment is right for them. He listens to his patients concerns so he can tailor a treatment plan to give them tangible and natural looking results. Integrity and honesty are not just hollow words; every advice Dr Leung gives to his patients is truthful.

Through Dr Leung’s years of experience, he has come to the conclusion that in addition to performing treatments with technical excellence it is important to:

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  • perform a thorough assessment based on a detailed understanding of facial anatomy and the pathophysiology of aging
  • have an exceptional artistic eye to achieve an aesthetic outcome
  • understand the science and mathematics of beauty
  • have sound application of the principles of 5Rs
  • formulate a treatment plan based on these principles
  • apply expert technical skills to carry out procedures and treatments