Dr. Bryan Forley Puts the Tweakment in Treatment

Diet, exercise, and genetics are all important factors in the maintenance of youthful appearing skin. The skin is often a reflection of a person’s diet. A well-balanced diet that includes all the essential amino acids, the building blocks of proteins, will enhance the quality of the skin and improve its barrier function. This helps the skin to keep out damaging environmental toxins and free radicals that can degrade collagen and elastin fibers in the dermis resulting in worsening wrinkles and skin discoloration over time. 

Exercise combined with a healthy diet helps to maintain a steady weight throughout life. The consistency of weight is an important factor in reducing the early onset of skin laxity and wrinkling that is more commonly seen in a younger age group that has a pattern of episodic weight gain and loss.

UV radiation is a key determinate of premature aging of the skin due to its detrimental impact on collagen and elastic fiber integrity. Skin pigmentation that is genetically pre-determined affects the ability of the skin to resist the damaging effects of sun exposure. 

Patients frequently say “I don’t want to look like that…” when referring to a face they have seen with too much filler or a surgical procedure that is not harmonious or balanced with the underlying anatomy that is characteristic of that individual.  

Non-surgical and surgical procedures both have the capacity to achieve a natural result. I find the most common reason a patient looks “done” is the improper application of a procedure: too much filler that doesn’t respect the patient’s pre-existing anatomy; not considering well planned surgical procedures that yield a far more natural result than excessive use of fillers; and agreeing to perform a procedure when it is in the best interests of the patient to say no.

Facelifts are an essential part of the traditional armamentarium of the plastic surgeon to treat aging of the face and neck. However, it is important for patients to understand that there is not a generic facelift. There are a variety of advanced techniques that utilize the deep layer known as the SMAS. How the SMAS is used will frequently determine the quality and longevity of the outcome. Properly directed tension on the SMAS and the avoidance of skin tension in achieving the lift is a key factor in a natural result. 

Recent advances in skin tightening radiofrequency (RF) energy procedures such as FaceTite and the fractionated RF used in QuantumRF and Morpheus8 treatments have offered a safe and effective non-surgical alternative to a facelift for many patients in the earlier stages of aging. 

The RHA Collection is a group of 4 hyaluronic acid (HA) fillers that provide an extremely natural outcome of 12-18 month duration that is evident immediately. The principle differences when comparing RHA to other HA fillers is that the molecular structure is closest to the HA that is naturally present in the skin. In addition, the molecules are cross linked in a way that enables them to adapt to facial expression without appearing or feeling stiff. 

RHA4 is very effective at restoring the natural convexity of the cheek or blending the folds and creases of aging to provide a softer, more youthful look without surgery. RHA Redensity has been extremely useful in blending fine lines and wrinkles of the lips and chin. Rather than volumizing the area, the density of the skin is restored enabling it to resist the underlying forces of repetitive muscle contraction that are responsible for creating the lines.

Injectable fillers such as RHA can produce some swelling for a few days that can be minimized with the use of intermittent ice packs for the first 3-4 hours after the treatment. Bruising is possible with any procedure that requires the use of a needle. Bruising most commonly occurs when RHA is used more superficially and within the dermis or when used for lip treatments. Usually, it will gradually resolve or become minimally apparent within 5-7 days. Patients are advised to avoid aspirin, ibuprofen, multivitamins, Vitamin E, fish oils and omega 3 supplements, and garlic for at least 7-10 days prior to the procedure to reduce the likelihood of bruising. Arnica Montana is a homeopathic product that can be used to manage bruising.

Morpheus8 is a fractional radiofrequency (RF) system that uses microneedles to selectively deliver multiple pulses of RF energy at various depths below and within the skin. It generally involves a series of 4 sessions at monthly intervals to achieve skin tightening and, when desired, fat remodeling. RHA complements the benefits of Morpheus8 with the use of injectable HA to achieve a synergistic effect with volume restoration.

Thread lifts use absorbable sutures that are deployed under the skin to create a lifted appearance. They typically dissolve in 6-9 months but have an ongoing collagen stimulation effect that is said to continue to improve the quality of the skin even after the threads are gone. The results can vary depending on a variety of age related and lifestyle factors that may limit the efficacy and longevity of the results. 

My experience with RHA injectable fillers has been a very consistent and predictable benefit of restoration of facial contours and improvement of folds and wrinkles in all age groups with a duration of 12-18 months or longer.

Many patients are concerned with aging of their face and neck but desire an alternative to a surgical approach and prefer local anesthesia. They need more than neuromodulators and fillers but don’t want a facelift or at least don’t want a facelift yet. I have combined the MyEllevate suture suspension system with the new QuantumRF and Morpheus8 Burst fractionated radiofrequency (RF) treatments to create a synergistic benefit that has yielded dramatic results.

The MyEllevate system enables enhanced structural neck definition with the placement of a permanent suture immediately below the lower edge of the jawline via a series of tiny punctures. The suture is then anchored deep to the skin behind each ear before being tightened at the midline. The system also allows for a non-surgical division of the prominent muscle bands of the midline of the neck to further improve neck contour. 

The structural neck definition provided by MyEllevate is complemented by liposuction of any excessive neck fat and the QuantumRF and Morpheus8 Burst duo of fractionated bipolar RF skin tightening treatments. The pulsatile nature of these two technologies enables the safe and effective delivery of a multilevel, high energy RF environment that triggers a gradual evolution of skin tightening in the neck without scars. The benefit is evident as early as 1 month but continues to improve over the ensuing 4-6 months. 

When a patient has excessive skin laxity and redundancy that would improve more from an excisional approach than radiofrequency energy skin tightening, the MyEllevate Plus “mini-lift” can be utilized. It combines the MyEllevate structural neck definition procedure previously described, liposuction of the neck when indicated, and use of an incision behind the ear for the redraping and excision of excessive skin. This approach is not a substitute for a SMAS facelift but can achieve meaningful improvements in the appearance of the jowl, jawline, and neck in selected patients.

Men have different concerns at various stages in life. In their 20s, 30s, and 40s men are often concerned with body contouring and male breast enlargement known as gynecomastia. Radiofrequency (RF) energy devices like BodyTite, QuantumRF, and Morpheus8 have enhanced our ability to not only reduce volume with liposuction but also tighten skin without scars. 

As men age into their 50s and 60s, they frequently are concerned with the baggy appearance of their lower eyelids and their sagging neck. Advanced surgical and new minimally invasive non-surgical procedures combining RF energy for skin tightening and the MyEllevate suture support system to define the jawline have given men additional options to appear more youthful with minimal downtime.

I have been involved in medical missions to Peru, Micronesia, and Palau where birth deformities such as cleft lip and palate are often untreated due to lack of access to specialized surgical care. We coordinated a concentrated effort during each trip to help as many of the locals as possible by focusing on complex reconstructive procedures spanning a 2-week visit. Part of our time was also dedicated to educating the local surgeons in techniques they could utilize to help people after our departure.

In 2024, I participated in the Habitat for Humanity program in a village in India to help construct housing for locals who were living in ramshackle tents routinely washed away during the monsoon rains. During our stay, I dedicated time to instruct the villagers in proper sanitation techniques and provided them with supplies and education in how to care for wounds they often sustained when performing manual labor with inadequate protection.