Devising "lockdown face" treatment plans
According to a recent survey by cosmetic treatments company Uvence in January, almost 4 million women felt that stress and anxiety brought about by the pandemic has caused them to age by at least five years. This has resulted in more people considering aesthetic treatments for the first time.
It is well documented that the cortisol released during a long-term stress response accelerates ageing even at a DNA level.1,2 Below, I highlight some common lockdownrelated aesthetic presentations I’ve seen throughout the pandemic and share my personal approach to treating them once our doors have re-opened.
In both covid and non-covid times, I find the best results are achieved by combining at-home skincare with in-clinic interventions such as peels, injectables and energy devices. A holistic, whole-face approach should include skin health and a good skincare regime at home. I often use the analogy with my patients that seeing me for in-clinic treatments but not looking after their skin at home is like seeing the dentist but not brushing your teeth daily in between visits.
It is also important to recognise that not all conditions are treatable in our clinic or at home and in some cases other specialists should be consulted, such as experts in plastic surgery, dermatology, dietetics and psychology.
IN-CLINIC TREATMENT PLANNING
When it comes to approaching treatment planning for in-clinic treatments, I favour a systematic, multi-layered approach. After taking a thorough history, I take a top-tobottom approach when examining the face, studying each facial third separately and taking into consideration all anatomical layers in doing so. Most areas of the face can be split into layers one to five (superficial to deep) and each layer will age in different ways over different timeframes. Not appreciating all these layers in treatment planning will result in at best, underwhelming and at worst, unnatural, “over done” results as the anatomy of ageing hasn’t been fully understood or respected.
UPPER THIRD
Forehead rhytids
The most commonly requested treatment in my clinic is still three-area botulinum toxin injections, and in the right patient it can be extremely effective at smoothing fine lines. However, repeated use of the toxin can limit its effectiveness in some patients over time, so while frontalis (as part of the three areas) anti-wrinkle injections remain a large proportion of the treatments I perform, I favour alternative treatments for forehead lines in older patients, patients with low-set brows, heavier upper eyelids or hyperactive frontalis (among other factors).
A combination of microneedling and skin boosters works well either synergistically with toxin treatment or as an alternative in those with contraindications. A course of three treatments spaced one month apart in which I inject 1ml of Teoxane Redensity 1 in the forehead alternated with needling treatments, is currently a common treatment plan. If forehead volume changes are present from fat pad depletion and bony redistribution, then forehead filler can also help support the skin, allowing for a more youthful light reflex and softening of forehead lines.
Temples
The effects of temporal hollowing on the appearance of the ageing face are often under-estimated and certainly underrecognised by patients. It’s something I’m noticing more frequently in my patients after recent lockdowns. Having less time to eat well between work and homeschooling, alongside some new intensive exercise regimes (thank you, Peloton), the effects of fat and muscle loss are often seen prominently in the temples. My chosen technique for treating temples is using superficial placement of a low G-prime filler such as Teosyal RHA 2 with a cannula between layers 2 and 3/ 8.
When comparing this technique with the popular periosteal “gunshot” technique, I find superficial injection distributes more easily (and more safely) in both the superior and inferior temporal fossa and uses less product due to a greater surface volume coefficient. This not only supports the skin immediately over the temple but can also help support a drooping brow and lead to a more positive vector at the lateral canthus.
MIDDLE THIRD
Periocular
Eyes are probably the most common concern people develop during lockdown. The stress of the pandemic and squinting at a laptop for back-to-back zoom meetings has caused people’s periocular ageing to accelerate faster than other facial areas. Periocular rhytids and “looking tired when I’m not” are common patient concerns and are exacerbated by only being able to convey emotion via the eyes when wearing a mask. The periocular area is one that requires close attention in history taking and examination so that the treatment offered is appropriate for an individual, as the aetiology of these complaints are often multi-factorial.
A combination of non-injectable treatments like needling or ablative devices such as Tixel alongside injectable skin boosters is great for treating fine lines and milder skin laxity. I’m careful about who I select for toxin injections around the eyes,particularly in the older patient. The unwanted effects of toxin weakening the orbicularis oculi, such as herniation of underlying fat and slowing of lymphatic drainage around the eye, are hard to treat once they’ve occurred.
In carefully selected patients, volume replacement of the medial and lateral SOOF as well as tear trough and palpebromalar groove with filler can make a marked difference to the under eye. It helps those who have both skin laxity from orbital bony resorption and superficial fat loss and it softens the loss of confluence at the lid cheek junction. I often find that while it’s not the primary cause for treatment, periocular rhytids improve well following periocular filler with little to no need for toxin treatment as an adjunct.
LOWER THIRD
The term “tech neck” is not a new one but it has certainly become more relevant since lockdown began. Since becoming increasingly isolated during the pandemic, we are more reliant on our devices for day-to-day living (both work and play). Craning over multiple devices for most of the day leads to a constant bending of the neck which plays havoc with the appearance of the skin. “Necklace lines”, ‘turkey neck” and a heavier under-chin will become increasingly common presentations in all of our clinics. Again, combination treatments are key here.
Treatment of the platysma muscle to help define the jawline and minimise pull on the lower face that contributes to heaviness is a common starting point when treating the neck. I like to combine this with Profhilo for collagen stimulation to help tighten lax neck skin. Skin boosters such as Profhilo and Teoxane Redensity 1 also help soften “necklace lines”, and using these in combination with energy devices such as radiofrequency or ablation with Tixel can help smooth the skin as well as prevent further line formation. These neck rhytids can be stubborn however, and so I advocate for finishing this multi-layer approach with a low G-prime filler such as Teosyal RHA 1 injected superficially into the lines with a cannula to help smooth them out directly.
HANDS
An unexpected victim of lockdown for many is the hands. With more handwashing and the stress of the past year, patients are noticing their tendons and veins have become more prominent in the dorsal aspect of the hands. Skin thinning and fat atrophy is a normal part of the ageing process of the hands, but this seems to have accelerated during the past year. A great way to combat this is by using a combination treatment of subcutaneous Teosyal RHA 1 and Profhilo in each dorsum, giving an instant and satisfying result to mask the underlying structures but also to help with skin hydration (alongside advice on daily skincare).
Lockdown has taken its toll on every member of our society and more people are seeking advice on cosmetic treatments to overcome the aesthetic implications of the pandemic. The key to achieving noticeable results that satisfy both patient and clinician is in patient assessment, planning of the treatment journey and product selection. A multi-modal and multi-layer strategy has always been my approach and I find my patients tend to agree.
REFERENCES
1. J Pedro de Magalhães, J Passos. Stress, cell senescence and organismal ageing. Mech Ageing Dev.2018 Mar;170:2-9. doi: 10.1016/j. mad.2017.07.001. Epub 2017 Jul 5.
2. A Vitlic, J Lord, APhillips, Stress, ageing and their influence on functional, cellular and molecular aspects of the immune system, Age (Dordr),2014 Jun;36(3):9631. doi: 10.1007/s11357-014-9631-6. Epub 2014 Feb 25
Dr Catharine Denning is an advanced and technique-led cosmetic injector and medical director at Clinic One Point Six in London. With a focus on restorative treatment, her detailed knowledge of anatomy and understanding of Da Vinci’s golden proportions of the face have inspired her signature whole-face approach. Follow her on Instagram: @drdenning_cosmetic_doctor