Defying Gravity: Tightening Sagging Jowls

Besides our wrinkles and crinkles, a sagging jaw line is one of the tell-tale signs of facial ageing. While Botox can help iron out our fine lines, how do we keep our chins from our chests? We asked Aesthetically trained Practitioner, Dr Alek Nikolic to report on combination techniques for tightening jowls…

There are a number of ways of improving the appearance of visible jowls – yet the choice of the treatment will entirely depend on the severity and the contributing causes.

The appearance of the jowl fat pad (the most inferior fat pad in the face) is found below the jaw line and has a number of contributing factors:

1. Occurs secondarily to volume loss (and therefore the loss of support). This includes fat compartments higher in the face (middle, & latero temporal cheek compartments).
2. Soft tissue egress resulting from gravitational pull.
3. Tissue laxity.
4. Elongation of elevator muscles in the face.
5. Laxity of the mandibular septum and Platysmal band ‘pull’.

Considering that multiple factors cause the appearance of the jowl below the jaw line, we need to use a combination of treatments in most patients. Taking into consideration the complexities of the causes and recommended surgical approaches, it becomes clear that using a single technology based treatment or injectable approach will not achieve the desired end results. It will also not meet the patient’s expectations.

Very simply:
Combination of Causative Factors = Combination Treatments = Best Results
There are several treatment approaches:

1. Dermal fillers (such as Juvederm® Voluma)
2. Botox™
3. Technology based treatments

Dermal Fillers:
There are a number of fixation points and retaining ligaments in the face that can be used - not only to anchor certain facial structures, but also to lift these structures (this is including the jowl fat pad).
Considering the fact that the cheek area consists of three separate fat pads (each with their own fixation points), they can be used to our advantage when lifting and supporting the facial structures.

Small boluses of dermal fillers injected at these points will act very similarly to a tent pole. Not only does it increase volume, but it also anchors and lifts the more inferior fat pads. Further volumisation (if necessary) of the cheek area will only add to the lifting effect that can be achieved.

This approach will tackle our first two points listed under the causes. If performed correctly, a total lift of between 0.5 and 1 cm can be achieved on the jowl area (see Figures 1 & 2 demonstrating lifting of the jowl and neck structures).

Botox™ is a great tool to relax muscle structures. It can be used along the jaw line, while the platysmal bands reduce the downward pull that is created by these muscle bands.

Further relaxation of the depressor angulioris muscle (responsible for pulling the corners of the mouth down) will only add to the lifting effect achieved. By reducing these downward vectors, further improvements in lifting the jowl can be achieved - and this approach tackles point number four and five in our list of causes.

Technology Based Treatments:
These treatments should be divided into direct fat removal, skin rejuvenation & skin tightening devices.

Excess Show Jowl Fat Removal:
If the jowl fat pad is still visible below the angle of the jaw line (even after following the above two approaches), then the next step would be to remove the noticeable part. There are a number of technology-based treatments that can be used to achieve this.

1. Invasive Devices: Laser Lipolysis
A laser fiber is inserted into the fatty pad to deliver its energy directly into the fatty pad. The resulting buildup of heat will burst the fat cells, resulting in the permanent destruction of these cells. The fatty liquid released will need to be aspirated with the use of a cannula, and some downtime can be experienced including swelling, tenderness and bruising.

2. Non-Invasive Devices:
Today, patients have the choice between three separate technologies to reduce the appearance of unwanted fat:

• Low level laser energy (such as i-Lipo)
• Freezing devices or Cryotechnology (such as Zerona)
• High Frequency Ultrasound Cavitation Technology (such as Coccon)

Cavitation Technology:
Cavitation technology can be used to reduce and eliminate unwanted pockets of fat including the jowl area. Cavitation is a method which uses low frequency ultrasound waves to penetrate into the subcutaneous layers. This produces alternating waves of compression and decompression on the localised fat cells - as well as oscillating fat cell membranes. This results in the fat cells breaking up permanently with a resultant circumferential reduction, fatty pad contouring and shaping.

The added benefits include a quick (10 minutes per side), painless and comfortable treatment with no downtime.

Typically, patients feel a mild heat of the treated area and on bony areas (such as the jaw line).
The oscillating ultrasound energy can be heard in the auditory canal. The above approach will achieve similar results of the surgical removal of the inferior jowl fat pad.

Skin Rejuvenation & Skin Tightening:
Syneron’s e2 device can be used to achieve skin tightening and an overall improvement in the quality and glow of the skin.

This novel new device pairs two technologies: the sublative fractional bi-polar radiofrequency, and the combined infrared and bipolar radiofrequency. The direct effect of these technologies is to stimulate new collagen and elastin (neo collagenases) and to tighten and shorten existing collagen. Further visible improvements includes the improvement in the skin texture, reduction of pore size and number, a healthy youthful glow, and an overall improvement in wrinkles and skin tightening.

At the end of the day, improvement of visible descent of the jowl fat pad may have to be tackled surgically. But in a large number of patients, excellent results can be achieved non-surgically by combining the treatments listed above.

 Dr. Alek Nikolic Written by A2 Expert Panel member: Dr Alek Nikolic
Dr Alek Nikolic is a Cape Town based Aesthetically Trained Physician – visit the website for more info
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Dear Fat, Bon Voyage!

Who among us hasn’t stood in front of the mirror and wondered how our junk took up residence in our trunk? 

Lorraine Forbes investigates a safe way to zap that jellyroll above the waistband in low-rise jeans.

Willowy, svelte and toned, Dr Kirsten Rinne MBBCh (Wits) is the best advert for her comprehensive, hi-tech body shaping programme.

The procedure combines Cryo-Radio frequency, high frequency Ultrasound and Virtual Mesotherapy in a series of treatments that gives astonishing results, without breaking the bank.

“Using these three methods (acting synergistically) on a localized area can produce remarkable results when it comes to fat cell destruction, body shaping and improving the skin tone,” says Dr Rinne.

With the Body Health BHS 156 machine, Dr Rinne dislodges defiant fat deposits and sculpts the client into a more chiselled version of herself.

An added bonus is that the procedure is painless and a reduction of up to two centimetres can be seen after a 40-minute session.

Dr Kirsten Rinne and Client

First, high frequency cavitation is used to disintegrate the fat cells in localised areas. Then these fat cells turn into a liquid substance that is eliminated through the lymphatic system and urine.

“It’s like having non-surgical liposuction. However, once you have lost the fatty deposits, you may be left with stretched, flabby skin. This is where Cyro-Radio frequency comes in… it tightens the skin and targets cellulite,” states Dr Rinne.

The hand piece operates at minus 10 degrees Celsius, which keeps the epidermis cold. At the same time, radio frequency waves create the desired internal bulk heating necessary to stimulate collagen and elastin.

The effects are instant (resulting from thermal shock caused by the hot/ cold interface) and this mode of treatment may be used anywhere on the body, including the face and around the eyes.

Finally, Virtual Mesotherapy (VMT) is used to increase the permeability of the skin’s cellular membrane to allow the penetration of micronutrients. Again, any area may be targeted, and VMT may be utilized to treat ageing skin, pigmentation, stretch marks, cellulite and scarring.

“The resultant improvement in tone and texture of skin cannot be achieved by taking in nutrients and antioxidants orally. They need to penetrate the skin to be most effective. The VMT current pushes the micromolecular solutions directly into the dermis, to a depth of 7mm. I use the MTS Vital solutions (they were developed for microneedling), with the VMT. In fact combining microneedling and VMT has delivered exceptional results,” Dr Rinne states.

“Obviously you have to still pay attention to your diet and exercise with these treatments. Drinking lots of water to flush out the system is also advised.

“A series of treatments yields impressive results, without the pain, financial outlay, downtime, risks and potential complications related to surgical liposuction under general anaesthetic”, Dr Rinne adds.

The Body Health BHS156 is distributed by Ergon Medical Supplies (011) 454 1876

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Lip Service: No Trout Pouts Here!

Dr Sly Nedic from 8th Sense Medi-Spa recently returned from the IMCAS/ Paris 2013 Congress - one of the biggest events in Aesthetics and Plastic surgery. The congress reports on all the latest devices, products and techniques which deliver the best results. This time, the highlight belongs to Volbella: a revolutionary new filler which treats the lips and peri-oral (mouth) area.

You can finally have beautiful lips with minimal swelling or bruising. Even more importantly, your husband and your best friend will never notice anything artificial about your new look. Allergan R developed this revolutionary filler for the specific purpose of avoiding the infamous and aesthetically unpleasant ‘trout pouts’.

What is Volbella Filler?

This new dermal filler is specially designed to not only gently restore natural-looking lip volume, but also to precisely define lip contours and treat ‘downward’ lip corners. It’s suitable for women and men of all ages – as well as ethnic groups. Even those who have fine peri-oral lines (known as ‘smoker’s lines’ or ‘barcode’ lines) can be efficiently erased, thereby restoring a youthful look.

Developed by using the Allergan’s R proprietary Vycross TM technology, Juvéderm’s Volbella is formulated with an innovative technology that combines low and high molecular weight technology. This improves the cross-linking efficiency of Hyaluronic Acid (HA) chains. As a consequence, lower concentrations of HA can be used, thus decreasing swelling to a minimum. Ultra-smooth gel results in a natural look and feel, while still improving on the duration.

In addition to this innovative technology, the filler contains painkilling Lidocaine anaesthetic - making this procedure less painful. Lip augmentation can be done without any bruising, largely due to the fact that the needles used are super thin.

There is no other filler on the aesthetic market that has all these properties. “For me, Juvéderm’s Volbella with Lidocaine is a real evolution in peri-oral treatment. It has been uniquely designed for a natural look, with less swelling compared to other lip fillers. This enables my patients to return to everyday life more quickly,” says Dr. Hervé Raspaldo, a facial plastic surgeon and board member of the European Academy of Facial Plastic and Reconstructive Surgery (EAFPRS), who has done one and a half years of clinical trials with Volbella.

He adds: “This is the only dermal filler clinically proven to last up to 12 months in the lips with a single treatment, so it gives a long-lasting effect. I look forward to including it in my portfolio of dermal fillers”.

Clinical studies showcased an excellent safety profile, while proving long lasting results, a natural looking effect and a high satisfaction rate in patients. In fact, 86% of patients reported improvement in the look and feel after nine months, while 57% reported an improvement after a year. These findings were published in the Clinical, Cosmetic and Interventional Dermatology Report.

What to Expect?

The lips will look naturally enhanced, smooth and well hydrated immediately after the procedure. Patients will be able to resume their duties straight after the procedure - without worrying that someone will notice the swelling.

”You don’t have to send your husband on a business trip to enhance your lips, nor will you have to hide the whole weekend until the swelling goes away,” Dr Nedic tells her patients. “With this amazing filler, extensive swelling will simply not happen. And thanks to the science behind Volbella, there is no danger of acquiring “duck” looking lips… which South African women are largely afraid of”.

How successfully can this filler erase ‘smoker’s lines’?

Very successfully! ‘Smokers lines’ are related to Collagen and Elastine decrease in the mouth area. It usually happens at the time when Estrogen depletion reaches its peak in ageing women, or Testosterone depletion in men.

Until now, aesthetic doctors and plastic surgeons did not have a good product to inject into this area without the risk of creating an unnatural look.

It was really difficult to erase those lines, even in combination with other techniques such as lasers, microdermabrasions and peels. This product’s latest technology allows it to be injected superficially… without having an uneven or an unnatural look.

Volbella is available at 8th Sense.

Dr Sly Nedic Written by A2 Expert Panel member: Dr Sly Nedic MBChB (Bel)
Dr Sly Nedic is a Johannesburg based Aesthetic & Anti-Ageing trained Practitioner and is the owner of 8th Sense Medi-Spa in Sandton. Visit the website for more info www.8th
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What is Conscious Sedation?

Dr Wicus Nienaber shares some useful information on the comparatively new sedation technique.

Conscious Sedation is a relatively new technique in anesthesia which is used mainly for pediatric dental cases, adult endoscopies and more recently for plastic surgery and aesthetic work. It is a combination of medicines to help you relax (a sedative) and to block pain (an anaesthetic). Conscious sedation allows you to recover quickly and return to everyday activities sooner rather than later after your procedure.

In hospitals, it is regularly used for short and minor surgical cases.

How does it feel?

When Conscious Sedation is administered with adequate local anesthetics, you will have an awake but dreamy and pain free operation.

You will still be able to talk to the staff and will have normal reflexes like coughing and will be able to breathe normally.

Patients doze off most of the time and we have to talk to them every minute or so to make sure they are still at the correct level of anesthesia. Most patients will remember nothing of the procedure afterwards.

For people like me who are pretty scared of operations this is the ideal solution - I am awake but I feel no pain and I am still in control of myself and afterwards there is little or no memory of the procedure.

Now, you may be thinking, “Why is this miracle of anesthetics not used for all operations?” Well, there are certain operations, for instance – orthopedics and obstetric work – that require specialised procedures like spinals  or stronger anesthesia (often referred to as full anesthesia), where the anesthetic effect is longer and deeper.  

How Do We Get Started?

In our practice, after the consultation with the Aesthetic Surgeon a week or two before the procedure, we start with getting to know the patient’s medical history. Basic tests like blood pressure, pulse, oximetry and urinalysis and a few blood tests are taken.

For patients who suffer from any chronic, uncontrolled diseases or any condition that could cause anesthetic problems, they do not qualify for Conscious Sedation.
Their operation will only be done in a hospital theatre once their conditions are under control.

On the day of the operation a pre-anesthetic examination will be performed and as a patient, your anesthetic and the implications of the procedure will be fully explained.

You will be expected to sign an informed consent form and will often receive some form of pre-medication. It is also expected that you will be fasting for at least six hours before the operation.

How Does it Work?

Conscious Sedation uses complex combinations of very specific anesthetic drugs that are carefully administered with infusion pumps. This is done with rigorous monitoring of blood oxygen levels, automated blood pressure readings, ECG and more recently, CO2 levels.

Most importantly, like any invasive surgical procedure, there must be the ability to resuscitate the patient if necessary with good equipment inclusive of a portable defibrillator, medicines and oxygen.

Conscious Sedation, when performed with this level of care, is as safe, if not safer, than any other form of anesthesia, as a large number of studies have proved.

I believe that Conscious Sedation is the way forward for smaller procedures done in day theatres worldwide not only for cost saving, but also for the comfort of patients. It is also by far the fastest growing technique of anesthesia in western medicine.


In any surgical procedure, it is always important to be aware of the dangers.

Unfortunately, due to lack of training or availability of trained Conscious Sedationists, and because of the enormous pressure from medical aids to perform the technique (due to massive savings on hospital theatre costs), Conscious Sedation procedures are sometimes performed in the rooms of doctors or dentists who are not certifiably trained to do so, nor are their theatres properly equipped. 

It is thus important to note the following:

General Practitioner anesthetists or even specialist anesthetists are not automatically allowed to perform Conscious Sedation on patients. A patient must check that their doctor and are specially trained, certified and equipped. Also, make sure that the doctor who does the procedure is never the same person who does your sedation. 

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