Skin laxity, also known as skin sagging, is one sign of aging where the skin loses the properties that provides elasticity. Facial aging varies according to individuals but after the mid-20s, there is a continuous decrease in collagen and elastin which contributes to skin laxity. Although the focus of facial sagging/laxity has been mainly on the skin, structures and layers below the skin such as the subcutaneous adipose tissue (“fat layer”), muscles and even bone changes are now known to contribute to sagging in the face and neck. As these structures collectively lose its elasticity and structural integrity, and as gravity continuously pulls downward on these structures, downward migration of facial/neck structures lead to what we observe as “sagging”. Common areas of sagging can be the eyebrows, upper eyelids, medial cheeks (“laughing lines”), jowls, mandibular margin (“jawline”), and neck. Since gravity cannot be altered, the focus to prevent and manage laxity is to stimulate collagen and elastin in all layers mentioned above. Although there have been challenges in preventing and treating bone reabsorption, tightening connective tissue which attach to the bone (specifically the skull in the face and neck) may be able to slow down this process of bone loss.

This loss in elasticity can be caused by a variety of factors, including genetics, lifestyle choices, and mostly exposure to environmental factors such as ultraviolet radiation.

Symptoms and Signs: The symptoms and signs of skin laxity can vary depending on the individual. Common symptoms and signs of skin laxity include:

1. Loose, sagging skin
2. “Droopy” eyelids
   
3. “Eye bags”
   
4. More prominent “laughing lines”
   
5. Downward sagging of jowls
   
6. Elongation of area above the upper lip
   
7. Reduced skin elasticity and firmness
8. Fine lines and wrinkles
9. Uneven skin texture and tone
10. Thinning and crepiness of skin
11. Sunkenness, Hallowness of forehead/temples/cheeks
    
12. Loss of jawline definition
    

Types of Skin Laxity:

1. Generalized skin laxity: This type of skin laxity affects the entire body and is often caused by aging, genetics, or significant weight loss.
2. Localized skin laxity: This type of skin laxity affects specific areas of the body and is often caused by intrinsic and extrinsic factors such as sun damage, smoking, or poor nutrition.

Diagnosis: Assessment by a medical professional is essential before deciding on treatment options. This starts with a thorough medical history including current and past illnesses, lifestyle factors (occupational factors, physical exercise, sun exposure, sunscreen application, previous related treatments, etc.) and family history. Unfortunately, there is still lack of consensus on objective measurements of laxity and applications in healthcare institutions. However, various types of medical photography taken over time can show localized areas of skin sagging.

Treatment:

1. Lifestyle Modifications: Reduce/Cease smoking, alcohol consumption.
2. Sun exposure related habit modifications: Reduce/Cease tanning beds, diligent and proper sunscreen application before sun exposure, avoidance of excessive unnecessary sun exposure. Utilizing hats, clothing, shade when in sun.
3. Routine health screening: to check for other health issues which may contribute to wrinkle formation.
4. Topical cosmeceuticals: Mainly to provide skin hydration, but some ingredients such as Vitamin A and C derivatives may be able to address certain factors of laxity.

In terms of treatments available in medical institutions, they can be divided largely into non-surgical/non-invasive/minimally invasive and invasive/surgical groups. Non-surgical options are done without general anaesthesia (GA) so the patient is awake and alert during the procedure but topical anaesthesia (“numbing cream”) may be applied for certain modalities. Multiple sessions are usually required, results are gradual in onset and not as immediate as invasive/surgical procedures. General anaesthesia allows the patient to avoid feeling pain but also have certain risks which need to be thoroughly discussed beforehand. However, invasive/surgical treatments are commonly able to provide immediate and visible results after a single session. Even non-surgical procedures have possible side effects, so it is essential that the patient and doctor have a through pre-procedural discussion on benefits and risks regarding any treatment to be undertaken.

Non-surgical/Minimally Invasive Procedures

1. Intense Pulsed Light (IPL): for upper skin layers, but more risk in darker skin types, those with more sun regular exposure and melasma patients.
   
    
2. Lasers: some types can stimulate collagen in the skin and usually require multiple sessions. Higher risk in darker skin types, those with more sun regular exposure
   
    
3. Ultrasound (US): Ultrasound treatments use sound waves to stimulate collagen production and improve skin firmness and elasticity. A common type is HIFU (High-Intensity Focused Ultrasound) which creates zones of heat at specific depths while preserving the upper layers from unwanted side effects. HIFU is able to reach deeper areas of the face and neck as mentioned above which are also important in laxity and sagging. HIFU is not a brand name but the name of the technology itself. There are many different companies and types of HIFU available. Also, as with any treatment, although the device may be the same, the skill, technique and experience of the physician performing the treatment is an important factor in obtaining effective results while avoiding unwanted side effects.
   
    
4. Alternating Ultra-High Frequency Ultrasound: Another type of US which can stimulate collagen and Heat Shock Proteins (HSP) while being painless with no downtime. In terms of intensity, it is less intense than HIFU therefore requiring more sessions to achieve effective results.
   
    
5. Radiofrequency (RF): Radiofrequency treatments use radio waves to heat the skin and deeper layers of the face/neck, which can stimulate collagen production and improve skin firmness and elasticity. Types of RF include monopolar, bipolar, multipolar, and microneedle. Pain, downtime, depth of energy and clinical results differ depending on the type used.
   
    
6. Local injections: “micro” botulinum toxin, “skin boosters” (polynucleotides, hyaluronic acid), “Biostimulators” (PLLA, PCL, Calcium Hydroxylapatite (CaHa)), exosomes. Injections require topical anesthesia due to pain from injection and entail some type of “downtime” where the skin will have “bumps”, redness and/or swelling for a few days after the treatment.
   
    

Invasive/Surgical Procedures

1. Thread lift: A thread lift is a procedure that uses synthetic threads to lift and tighten sagging skin on the face and neck. Different materials and lengths are available. (Due to regulations, these procedures are generally [exceptions exist] performed by plastic surgeon specialists in Singapore since 2019.)
   
2. Surgical procedures: In cases of severe skin laxity, surgical procedures such as facelifts or body lifts may be necessary to achieve the desired results. These surgeries are able to provide “one-off” more rapid results than non-surgical treatments. These surgeries are performed by plastic surgeon specialists.
   Skin laxity and sagging is a natural process of aging. The above treatments are just a general guideline and results will vary according to individuals. In the case of Non-invasive treatments, not only is the type of treatment important, but the interval of subsequent treatments is of equal if not more importance. Also, there is no single treatment which can treat all issues of laxity in all layers of the face/neck. A comprehensive approach with customization based on evidence is crucial in achieving desired results without adverse reactions.