Physiological reminder

Bone volume

The volume of facial bone dictates the shape and appearance of the face. Over time, the facial bone mass undergoes resorption, i.e. a reduction in volume, with the lower jaw in particular receding, and the entire facial bone mass receding, resulting in a reduction in the support capacity of the overlying tissues.

Fat volume

The shape of the face is also indexed by the deep and superficial fat compartments that make it up. The SOOF (Sub Orbicularis Oculi Fat) is located deep under the malar bone. This deep fat compartment is well known to aesthetic physicians, as it is a privileged area for injecting hyaluronic acid. It’s a privileged area, because its sagging has repercussions on all the lower levels of the face. It is therefore essential to restore volume to this area before treating the consequences on the lower face.

Ligaments

Facial retention ligaments keep the various fat compartments in position. These ligaments also loosen over time. Loosening of the retention ligaments (and SMAS) induces ptosis of the deep fat compartments. But the bony insertion of the ligaments remains fixed. The skin and fat upstream of the retaining ligaments will rest on these ligament insertions, which are firmly anchored to the periosteum. As a result, the famous “furrows” appear downstream, on the face as it ages or loses weight.

From top to bottom: the ORL (Orbicularis Retaining Ligament), the cutaneous zygomatic ligament around the eye, the nasolabial fold ligament (masseteric cutaneous ligament) and the jowl ligament (mandibulocutaneous ligament).

This ptosis, which “rests” on the ligament insertions, is responsible for the appearance, from top to bottom, of: the ring, the valley of tears, the nasolabial fold, the bitterness folds, and the jowls, leading to a break in the oval of the face.

SMAS

The Superficial Musculoaponeurotic System (SMAS) is made up of the facial skin muscles and fascias, which anatomically combine to form a single layer. In fact, the skin muscles are the only muscles in the human body to have both a bony and a cutaneous insertion, enabling facial expression. Over time, the SMAS also tends to loosen, reducing its retention effect on the fat compartments, leading to general facial ptosis and the appearance of the grooves mentioned in the ligaments paragraph.

The skin

The most superficial layer of the face, made up of the epidermis, dermis and hypodermis, undergoes ageing phenomena of its own, such as loss of elasticity and tone, linked to reduced collagen and elastin production by fibroblasts. But it also bears the full brunt of the loss of support due to a reduction in underlying fat and bone volumes.

So youth rhymes with volume

The youthful appearance of the face is therefore based on a combination of physiological and anatomical entities that all undergo degradation over time and/or, for some, with weight loss:

• The bony facial mass on which the deep and superficial fat compartments rest.
• Deep and superficial fat compartments held and set in motion by the SMAS and fat compartment retention ligaments.
• The skin is then positioned like a mask over the whole.

It’s easy to understand that when one of these elements decreases, there will be an impact on skin tension. When fat or bone volumes decrease, skin tension itself decreases. As a result of reduced cutaneous support, the skin sags and grooves appear where there are retention ligaments.

The GLP 1 analog phenomenon

How does it work?

Definition

GLP stands for Glucagon like Peptide. A peptide is a micro-protein. GLPs are so-called incretin hormones, because they act primarily in the pancreas to regulate insulin secretion, and glucagon secretion, which acts on blood glucose levels.

These incretins are naturally secreted by the intestine. They are now available in injectable form through GLP-1 analogues.

GLP-1 analogues have multiple actions. Here is a summary:

Pancreas: increased insulin secretion, decreased glucagon secretion

Stomach: reduced gastric emptying, so feeling of satiety as stomach remains full

Brain: hypothalamus, increased sensation of satiety

Kidney: increased natriuresis and diuresis (increased urine output)

Fat: indirect lipolysis linked to the caloric deficit created by GLP -1 analog intake.

These treatments are indicated in the management of diabetes. They lead to progressive weight loss. They are now authorized for the treatment of obesity, and are increasingly used for weight loss in healthy subjects.

Available GLP-1 analogues :

1. Semaglutide:
   • Brands:
     • Ozempic (treatment of type 2 diabetes)
     • Wegovy (weight management)
   • Administration: subcutaneous injection (weekly)
   • Indications: type 2 diabetes, obesity, cardiovascular risk reduction.
2. Liraglutide:
   • Brands:
     • Victoza (treatment of type 2 diabetes)
     • Saxenda (weight management)
   • Administration: subcutaneous injection (daily)
   • Indications: type 2 diabetes, obesity.
3. Dulaglutide:
   • Brand: Trulicity
   • Administration: subcutaneous injection (weekly)
   • Indications: type 2 diabetes, cardiovascular risk reduction.
4. Exenatide:
   • Brands:
     • Byetta (daily injections)
     • Bydureon (sustained-release formulation, weekly injections)
   • Administration: subcutaneous injection
   • Indications: type 2 diabetes.
5. Lixisenatide:
   • Brand: Lyxumia
   • Administration: subcutaneous injection (daily)
   • Indications: type 2 diabetes.
6. Tirzepatide (not strictly GLP-1, but GIP/GLP-1 agonist) :
   • Brand: Mounjaro
   • Administration: subcutaneous injection (weekly)
   • Indications: type 2 diabetes, obesity (currently being approved for weight management in some countries).

And what about aesthetic medicine?

As you can see, beyond their therapeutic indications, the arrival on the market of GLP-1 analogues is causing a veritable revolution in the world of weight-loss protocols.

As I mentioned at the beginning of this article, weight loss has a direct impact on the face through reduced support of fat compartments and consequent skin ptosis, leading to a prematurely aged or tired face appearance.

Fortunately, our wonderful profession enables us to counter these effects harmoniously, effectively and safely. I’d like to remind you of the importance of training in aesthetic injection techniques through the acquisition of theoretical fundamentals and practical training courses.

So, how are we going to manage these patients in aesthetic medicine? Well, as always, with a synergistic combination of different procedures.

First, support for volumes:

Hyaluronic acid injections:

Hyaluronic acid injections will restore the loss of fat volume associated with weight loss. Hyaluronic acid is injected into the periosteum using cross-linked techniques. We’ll use cannulas to inject deep into the SOOF, but also needle injections more laterally towards the zygomatic arch. Restoring volume will recreate the cutaneous support lost during weight loss, and give the face a fresher appearance.

Second, the management of skin laxity:

Biostimulator injections:

Even if sagging skin is not directly linked to weight loss, we know that it is an aggravating factor and therefore needs to be managed in parallel with volume restoration. For this purpose, biostimulants can be injected subcutaneously by cannula, using the Fanning technique. These injectables are essentially represented by calcium hydroxyapatite (Radiesse) and Poly-Lactic Acid (PLA), (Sculptra).

Energy Based Devices (EBM) for biostimulation :

Energy-Based Devices will enable the 2 treatments of the 2 previous procedures to be potentiated. The most commonly used are HIFU and high-intensity radiofrequency. This will stimulate the fibroblasts previously stimulated by the injections, thus potentiating the overall effect. HIFU is unique in that it can also tension the SMAS.

All these techniques, the global approach to the face and the synergies between treatments, can be taught to you through high-quality training courses. You must first master the fundamentals of aesthetic medicine to access these advanced treatments.

The perfect protocol?

It’s true that in the future, we could imagine a protocol of GLP-1 analogues for controlled weight loss. Then, once the weight has been lost and stabilized, cosmetic medicine procedures combining hyaluronic acid injection, biostimulant injection and Energy Based Device treatment to counter the aging effect of weight loss on the face.

As always, for both GLP-1 analogues and aesthetic medicine procedures, these must be supervised by medical doctors who can give personalized indications and monitor their patients as a whole.

Conclusion

There’s no doubt that we’ll be major players in the weight-loss market environment. The arrival of GLP-1 analogues and the promises they hold are enormous. We need to remain vigilant about side effects and undesirable side effects in the years to come. That said, the prospects are incredible, and once again, aesthetic medicine will have a major role to play in this coming revolution.