O ne of the most common concerns I come across in my facial rejuvenation patients is the appearance of facial wrinkles. Facial wrinkles start appearing in your late twenties to early thirties, but not all wrinkles are the same!
In this episode I uncover the three types of wrinkles, when and why each type develops, and the best treatment options for each type so that you know exactly how to address facial wrinkles as they appear.
Dr. Hall: Welcome to The Trillium Show, where we help you make the changes you want to see in your body, in your mind, and in your life. I'm your host, Dr. Jason Hall.
Dr. Hall: When people come to see me for consultation for facial rejuvenation, one of their primary concerns, across the board, is wrinkles. And this is a problem that we start seeing in late-20s, early-30s is people start complaining about lines and wrinkles around their face. And that is where the younger patients start using toxins, Botox and Dysport and Jeuveau and all the other ones. In this show, what I really want to focus on are the three major types of wrinkles, how they're different, and how the treatment for each type of wrinkle is different because if you understand where the wrinkles come from, then it makes it much easier to understand why and how we go about treating these lines and wrinkles.
I'll break these down into three major categories. There are lines of motion, there are lines of surface damage, and then there are lines of gravity. And as you'll see here in just a minute, the way that we treat these is very different based on what exactly they are. First off, let's talk about the lines of motion. Now, these are typically lines that we start seeing around our eyes, forehead, in between the eyebrows.
So, these are lines that are typically treated with toxin: Jeuveau, Dysport, Botox, and the like. Now, these lines, the lines of motion form, from muscle activity. When you raise your eyebrows, your frontalis muscle, which is a sheet-like muscle that goes from your hairline down to your eyebrows, contracts, helps you lift your eyebrows, and creates those transverse or horizontal creases in your forehead. Those creases can be relaxed with toxin which is placed into that muscle and relaxes that muscle. Any of these lines of muscle activity or lines of motion can be minimized with an appropriate dose of toxin.
Likewise, the corrugator muscles which create the dreaded eleven lines in between your eyebrows, and these, I can't do very well because of my own toxin, those are muscles that connect, kind of go from the middle part of your eyebrow down to the inside of the upper part of your nose, and are responsible for depressing your eyebrows. And so, what we can do there, just like with your forehead, is we inject some toxin into those muscles—actually around those muscles—it relaxes those muscles and keeps you from creating those lines. Around the eyes is another very common place for toxin and these lines of motion. You hear about them referred to all the time is crow's feet, and when you smile, you see your eyes squint up and you get these little radial lines around your eyes from the circular-shaped orbicularis oculi muscle, which goes all—it's a circle and it goes all the way around your eyes, and as it contracts, you think about a circle contracting, that contraction, wrinkles the skin over the top of it. So, by relaxing the outer part of that muscle, we can keep that outer part of that circle from contracting, we can keep those lines from forming.
It's important to note that lines of motion start in the 20s, and that is when we start seeing patients notice these lines and start complaining about them to the point that we need to treat them. The amount of toxin that we use in each area differs from person to person and depends on how strong the muscles are, exactly the configuration of the muscles in your forehead. So, everybody has a little bit different muscle configuration in their forehead and by diagnosing that correctly, we can figure out, give or take, how many units of toxin—which is typically how those are dosed—how many units of toxin is necessary to give you a relaxed look and minimize those lines of motion. Any toxin that we use—at least the popular ones now that we've mentioned before—typically lasts about three months, and once that three-month period is gone, you'll see that motion start to gradually come back over the course of a few weeks. Because of that, we typically recommend people come in about once a quarter, once every three months, three-and-a-half months and keep up that treatment to prevent those lines from coming back.
Because what happens is, those lines of motion that we can initially treat with toxin will progress with time to lines of surface damage. And this really is our second type of line and wrinkle that we have to address when we are talking about facial rejuvenation. Lines of surface damage are just exactly what they sound like. They are lines that show up from repetitive muscle activity, combined with progressive ultraviolet damage and environmental damage to the surface of your skin and to the entire depth of your skin, which combines to start forming lines that we call static lines. So, they're there all the time, whether you're moving or not.
And like I said just a minute ago, these lines of motion will progress over time to lines of surface damage. What that means is that we have to start changing our treatment once we start seeing these lines of surface damage. Toxin by itself won't be nearly as effective once that happens. Treatment for lines of surface damage involve multiple different things. It involves filler, so restoring some volume to kind of help to pop those little wrinkles out.
You can think about it if you think about peaks and valleys, we think about raising the valley floor with a little bit of filler, we also have to bring the peak down and that's done with resurfacing. And in my practice, the most effective way to do resurfacing like that is to use laser resurfacing. And we can do this with a number of different laser modalities. The microlaser peel is a good one. And so, a combination of treatments is needed to really help improve those lines.
Now, if these lines of surface damage are the same lines that we previously treated with toxin—so the lines of motion that we talked about, the forehead lines transverse for headlines that are eleven lines, the crow's feet—then a combination of treatments is needed because we want to continue to relax those muscles so we're not continuing to create those lines and make them worse, and at the same time, we want to fill and resurface to help them go away. And when we're doing this, it's important that we relax the muscles before we start filling things in otherwise, we're going to be putting an injectable filler, a soft tissue filler, into a line that's still getting squeezed on for up to two weeks while your toxin is starting to work, and you end up squeezing out part of the filler that you put in. So, when we're talking about these combination treatments of toxin, filler, and resurfacing, I like to get the muscle as relaxed as we can and then start working on the filling things in from the bottom or resurfacing from the top.
The third type of line that we need to really address are the lines of gravity. These are lines that show up, as you guessed it, as the result of the gravity and tissue descending over time. You start to see these in the upper eyelids and the brow. You see that in the mid-face, so this area we call the tear trough and the undereyes. You start seeing them around the lower part of the mouth and cheek, as well as in the neck, both lines that go from chin to collarbone and also lines that go kind of across your neck.
And these are lines that are the result of tissue sagging and volume loss. Typically there are three areas where this shows up. In the late-30s we start seeing descent of the brow and the upper eyelids. And so, you'll notice brows drop, they flatten a little bit. And this can actually be made worse with Botox or neurotoxin that is used to treat these lines of motion, but the injector isn't really looking at the brow position and taking that into account.
You can make one problem better and create problems by treating forehead lines, but then making the lines around the outer eye and the drooping and descent of the eyebrows worse with time. Into the mid-40s, you start seeing volume loss in the mid-face, in the cheek, under the eyes. And this is when you start to see development of the nasal labial fold. So, these creases, just kind of—they call them the parentheses lines that run kind of from the base of your nose down around the corner of your mouth, as well as the marionette lines which are from the corner of your mouth down towards your chin. And those are the result of volume loss and gravity, kind of, dragging some of these tissues down.
Lastly, in the late-40s, early-50s, we start seeing the SMAS layer—so the muscle layer of the face which is where all of the muscles that allow your face to move live—we start seeing that get a little bit looser and volume loss in that area making that sagging even worse. That's when we start seeing jowling start to show up—so this droopiness here—you start seeing deepening of the marionette lines, and you start seeing laxity of the muscles of the neck both in the, you know, up and down direction as well as the transverse direction. And these lines of gravity are all areas that we need surgery to treat. Volume can help, so a little bit of filler in the early stages can help improve these lines, but you're really not going to get a significant treatment without surgically lifting the muscles, repositioning the structures that have dropped, and then securing those under the skin. This is where a lot of our surgical treatment is based, and a lot of the consultations that I have with patients, we spent a lot of time talking about how most of what our facial surgery does, really is muscle surgery.
There's very little traction on the skin that we do to help elevate and reposition things because, one, the skin is not very strong. We're treating skin that has gotten weak and loose with time, so to expect to pull it up, hold it there with a couple of what a relatively small sutures, and then expect those things to be durable long-term results just doesn't make a whole lot of sense. It's the muscle that we're repositioning underneath the skin that really does the trick, helps to provide a natural look because we're restoring things back to where they should be, as well as prevents scars and other problems with skin surgery only from really ever showing up in the first place. So, your brow surgery, your facelift surgery, your lower eyelid surgery, neck lift surgery, all of these procedures really are muscle procedures, they're muscle tightening procedures and muscle repositioning procedures, not pulling on the skin. In all actuality, the only procedure where we're really removing skin as our primary treatment is with upper blepharoplasty, and even that surgery, there is still a little bit of muscle manipulation that's done to help make that procedure a durable, natural, long-term result.
Reviewing what we've talked about already, there are three types of facial lines and wrinkles that we address. First, we have our lines of motion, which are most commonly forehead lines, the eleven lines, and the crow's feet. Those are typically treated with a neurotoxin to relax the muscles that cause those lines. The second type of line are lines of surface damage. Not only are those these lines that we treat the lines of motion, but that's when you start to see lines, these kind of radial cheek lines that start to show up and lines that are there when you're not making movements with your face.
These are lines that need a combination treatment of a toxin if it is a line of motion that has become a static line instead of just an active line, as well as filling and resurfacing. And then the third type of line are the lines of gravity. And these are lines that show up kind of midface, lateral brow, around the mouth and jowls, and in the neck, and these are typically lines that surgery is required to correct.
I hope you found this episode helpful. If there are any questions please shoot me an email firstname.lastname@example.org. Leave a comment in the comments below if you're watching this on YouTube, and we'll see you back soon.
Dr. Hall: Thanks for listening to The Trillium Show. You can keep up with the latest on the podcast at jhallmd.com. Be sure to follow us on Spotify, Apple Podcasts, or wherever you listen to podcasts. If you want to connect with us on social media, you can find us at @jhallmd on Instagram and Twitter and @DrHallPlasticSurgery on Facebook. Remember, be the change you wish to see in the world.