According to a recent study of the American Aesthetic Plastic Surgery Community, the total face lift occupies the 6th place in the ranking with the most popular aesthetic surgical procedures.

The scientific name of face lifting is facial rectification and is defined as a type of aesthetic surgery. The facial stimulation procedure applied for the reconstruction of facial points and to improve the appearance of giving account of youth in each patient.

Face lifting may include an operation to raise the upper third of the face, fore-head or brow-lift, or mid-face lift or the lower third of the face. It can also be combined with all of the above procedures, or combined with upper-lower blepharoplasty and/or liposuction of cheeks [1]. The face lift is usually done under the skin in the Superficial Muscle Aponeurus System (SMAS) by replacing the facial muscle and reducing the excess skin.

All face support through face lifting focuses on the redesign of the Superficial Muscle Aponeurus System (SMAS). In the so-called SMAS lift, the plastic surgeon restores not only the skin but also the tissues on their normal position. Restoring the skin and facial tissues we have the inversion of the so-called triangle of youth (Figure 1).

Figure 1: Triangle of Aging and youth.

Based on the basic principles of facial anatomy and the theory of surgical face lift, doctor Sotiris G. Tsioumas began the implementation and application of this bloodless HLH Therapy^® technique. Below find photographic material depicting the key points to the musculoskeletal structure of the face (Figure 2).

Figure 2: Musculoskeletal structure of the face (A: Muscle structure; B: Fat areas of the face; C: Ligaments of the face).

The term HLH Therapy^® is an abbreviation of the three words Hybrid Lifting Homologous-Hybrid Lifting Homologous. After five years of experience of the ophthalmologist in non-surgical blepharoplasty using the Plasma Exeresis method [2] and the Plexr^® device, as well as its five year experience on autologous threads using the Needle Shaping medical device and the homonymous method, it was inspired and then applied the new treatment of total bloodless and natural face lifting [3].

The term hybrid is used as the two above-mentioned techniques (Plasma exeresis & Needle shaping) are applied simultaneously during the application of the treatment. Two different techniques are used, combinatorial and concurrent, and applied in the same patient at the same time. The term lifting is used, as the result after the application of the method, is total face and neck lift having reversed the direction of the triangle of youth from downward to upward. The term Homologous is used because a basic part of the method is the use of the autologous thread method. Based on SMAS's basic theory of tissue repositioning, Dr. Tsioumas G. Sotiris, using the Needle Shaping technique, recreates existing aged tissue and reposition it by altering the density and direction of the facial elastic fibers without intervene surgically. Autologous technique means, when taken by an organism and given to itself. In this method, the existing aging elastic fibers are obtained and new ones are given, which are regenerated by Needle Shaping technique.

The new therapy HLH Therapy^®, based on its plasma (Plexr^®) and autologous techniques (Needle shaping) simultaneously [4], can be applied without fear and without complications to people with autoimmune diseases, people with a history of cancer even in people with diabetes.

In surgical techniques of upper eyelid with a scalpel, a radio scalpel or laser, the patient must enter a sterilized operating room, to be anesthetized with xylocaine adrenaline injection and this is done by having incisions and sutures. Another purpose of the study is to demonstrate that the method of non-surgical blepharoplasty with Plexr enables the medical treatment of patient without the use of anesthesia (using only anesthetic cream) and sterilization and most importantly, after treatment the patient leaves without incisions and sutures [5]. Basic advantage point for cases of eyelid surgery, Plexr is a dynamic non-invasive method that allows the operator to urge the patient at any time during the proceedings to open his eyes, highlighting aspects of skin that still need to be treated and avoiding going after gradual and controlled maneuvers that may have cost image lagofthalmos or excessive opening of the eyes. Regarding any corrective surgery the obvious advantage of Plexr is that is also the perfect choice to avoid further suffering of the patient with correction in his private clinic in infinitesimal time.

Histological studies from the University of Cheti and the University of Athens (Department of Pathology-Anatomy) also proved that the spots of Plexr not pass the basement membrane of skin, but make shrinking of the elastic fibers and also after one month, collagen type III [6] is created. Using Plasma Exeresis method is effective not only because the patient avoids surgery having the same effect with less cost but also for histological reasons. Histological analyzes before and after show that in regions that was applies Plasma Exeresis, the area not only reconstructed but created and type collagen III after application (Figure 3).

Figure 2: Regions a, b, c shows the Plasma Exeresis application on skin which not only reconstructed but created type collagen III after its application.

The sample of patients that was used to apply the new HLH therapy^® by Tsioumas Sotirios method was 6 women and 1 man, aged 50-80 years old, non-smokers and without having any surgical lifts operations in the past. The treatment process begins with the doctors taking photos. The doctor photographs the patient's face from a 45 and 90 degree angle, enface and profile. After that the doctor moves on with the complete antisepsis in the area of the face and neck and then applying anesthetic cream to the same areas. The patient waits for an hour in order to act the anesthetic cream. Within one hour, the application of the anesthetic cream is repeated. After one hour the patient is ready to start the treatment. The doctor then follows the two main lines that are used as his guides, which are called hinderer lines (Figure 4).

Figure 4: Hinderer lines.

As soon as the hinderer lines are designed, the first phase of the treatment begins. The doctor is using the large diamond acupuncture needle and inserts the first needle into the skin.

The patient holds an electrode of the Needle shaping device and the doctor holds the second electrode with his naked hand. At this point the doctor pulls the acupuncture needle upwards and turns the needle with outwards direction. At this point, external superficial zones and wrinkles are created from the excess of skin. At the same time that the doctor revolves and moves the acupuncture needle upwards, through the doctor-patient electrodes, the energy is delivered from the doctor's hand to the needle and from the needle into the elastic fibers.

These electrodes create micronoses that penetrate the elastic fibers. What happens internally is that the elastic fibers vibrate and engage (like sticking) on the acupuncture needle. By pulling upwards and outwards, the elastic fibers follow the same upward course. At the same time, due to the sticking on the acupuncture needle the elastic fibers become denser, more compact, thick and upwards directed (Figure 5).

Figure 5: Sequence of events during first phase of treatment (a: Structure of skin, b: Inserting the acupuncture needle, c: Vibration and catching of the elastic fibers, d: Elastic fibers sticking on the needle, e: Depictting thickness of elastic fibers, f: ).

At this point the elastic fibers have been re-positioned and their quality improved. The doctor with his second hand, simultaneously using the microsurgical device Plexr^®, sublimates at the same time the excess tissue that is created. With sublimation, what is achieved, is the disappearance of the wrinkles, as well as the fixing of the elastic fibers (autologous threads) at the point where the doctor has delimited them. We have flattened the external superficial zones and locked the elastic fibers to the right point.

Once the sublimation has been completed, the doctor removes the acupuncture needle, which due to the locking of the fibers at the key point of the retraction the needle is removed with some difficulty [7]. Because of sublimation, at the areas where HLH therapy^® is applied, some crusts are created that fall down on average 5 days after treatment. After the crusts fell down, the skin has a slight irritation which, over the next 20-30 days, has disappeared, using an anaplastic cream. Just after treatment, a special protective makeup with a high sun protection factor is applied to the patient and he can immediately leave the clinic.

At this point, we should mention that after the treatment no antibiotics will be needed, no bandages or total anesthesia. All of these elements make the treatment absolutely safe and of course it reduces its cost compared to a traditional surgery.

As far as the methodology for non-surgical upper eyelid blepharoplasty is concerned, all patients accepted antisepsis, and then photos were taken of their face before the treatment and profile in order to see the difference after the treatment. The next step was to apply the anesthetic cream wait for 30 minutes until the cream act so the patient won't perceive any pain while the treatment is going on. After the action of the cream, we remove it and apply the technique first on the right eyelid and then on the left. The point where there is excess skin is sublimated. We did not enter wrinkles but areas of excess skin. For the machine to operate, it should not touch the skin as ionization gas [8] are needed, so while the micro spots were pulled out, we leave little spaces of healthy tissue. In each session we sublimated 30% of the excess skin. In cases of the lower eyelid non-surgical blepharoplasty we need to notice that we can do Plexr only in cases of dermatohalasis or small fat bags. If we have medium or big fat bags the procedure is a little different because first we need to dissolve the fat (via O.f.f machine for lipoaptosis with the use of acupuncture needles and Needle Shaping– Autologous Threads or via injectable solution vitamin C) and then move on with Plexr^® method [9].

Before moving on to the photo presentation of the HLH method^® we need to mention the two categories of skins that we may face during the procedure. If our patients have quite thin skin, without any fat, we move directly to the HLH method^®as we analyze above. But on the case that our patient has a lot of fat areas and his skin is more thick and fatty we add one more step in the method. This step is the well-known method of Needle Shaping – Autologous Threads, combined with the machine O.f.f – machine of lipoaptosis with acupuncture needles. This extra step is necessary because first we need to make the lipolysis throughout O.f.f (machine of lipoaptosis with acupuncture needles) and then the skin is ready to accept the HLH method^®. In simple words, if our patients have thick skin and many fat areas, we start our session doing Needle Shaping method and O.F.F then we move on to the HLH method^® [10]. At this point, we mention that the photographic material that follows is consisted of only pictures of the neck area as we have not obtained the permission from other patients to publish their face photos (Figure 6).

Figure 6: Photo presentation of HLH Therapy^® Steps.

The results are obvious from the first session and the patient has the ability to see the change in face and deck (depending on the area he has chosen to intervene). So we see the immediate reconstruction of the face contour and the immediate sublimation of the areas that had excessive tissue due to old age and gravity. The patient leaves the clinic, already seeing the difference in his face with a strong sense of pulling and tightening. First, due to the use of Plasma Exeresis (Plexr^®) method, we have the creation of collagen type III in sublimation areas after one month after the therapy.

Past histological examinations for the use of Plexr^® have proven it. Secondly, through the Plasma Exeresis technique and the Plexr^® machine, we have complete sublimation of the ceratinocytes. Through the Needle Shaping technique we achieve the creation of autologous threads as well as the change of the direction and quality of the elastic fibers. The elastic fibers become shorter and thicker. Again, histological analyzes for Needle Shaping have showed that new elastic fibers are created after 28 days. Summarizing the most important effect is that through the simultaneous use of the needle shaping and Plexr techniques we have the simultaneous sublimation of excess tissue in combination with the fixation of the elastic fibers and their shrinking. In simple words with HLH Therapy^®, we shrink the elastic fibers, we make them thicker, organize them, change their direction from vertical to horizontal, and at the same time through Plexr^® we make the fixation of the autologous threads. All this give the effect of reshaping the whole face.

Finally, with HLH Therapy^®, due to the fact that we have a combination of techniques and tools, we can intervene and provide solutions to areas that could not be intervened with the scalpel, such as the areas in the crow’s feet and neck. As far as the patient's psychosomatic balance is concerned, the patient is not subjected to any procedure of total narcosis that can cause complications, so he feels safe, feels fearless and can return directly to his daily routine. But above all, the patient directly sees the result without having to wait and undergo long recovery times. We also have no complications during recovery as Keloid hypertrophic scars, facial deformities and numbness from nerve section. Finally none of the 7 cases experienced any complications either during or after treatment.

As far the efficiency of the non-surgical upper eyelid blepharoplasty via Plexr^® is concerned, compared with classical upper eyelid surgical blepharoplasty, outcomes were excellent without sutures any incisions, ectropion and entropion, slanted eyes, lagofthalmos and other complications. The recovery takes place in a period of time (7-15 days) and allows the patients to return to their activities even after treatment. The overall results showed that Plexr^® as the method for non-surgical blepharoplasty has superiority over the surgical procedure because of the low financial implications; the patient can repeat the procedure as many times as he or she likes, there are no complications, no change in look. Regarding the scientist engaged in aesthetic medicine need not own high specificity (Figures 7 and 8).

Figure 7: Photo presentation of HLH method^® before and after results

Figure 8: Photo presentation of before and after of non-surgical blepharoplasty.

The need of the physician to provide improved innovative non-invasive techniques to patients with less pain and cost, but also the need of the patient for cosmetic procedures that avoided them in the past for fear of surgery. The major advantage of Plasma Exeresis and all the autologous therapies that were discussed above is security that it provides to the patient on undesirable effects.

Although Plexr is a new method, it is gaining more patients thanks to the fast recovery, lack of pain, no sutures and excellent results. The patient after having been informed in detail by the doctor, feel safe, and the majority of patients decide to do their application immediately after updating, unlike surgery that there must be some preparation before. Even the most skeptical patients after their first session, recommended the technical to people who are looking for innovative non-invasive methods for aesthetic medicine.

Now in all fields, so in medicine, the trend has changed and is directed towards the natural, the bloodless and the autologous. Based on the trend and the need for the more natural and bloodless results , the need for treatments that do not require long recovery times, treatments that do not cause fear and are not economically unbearable, HLH Therapy^® has been created combined with non-surgical upper or lower eyelid blepharoplaty. The next step in the treatment is the scientific documentation of the results of this combination through new histological examinations that will be carried out in the following period and will be exclusively about HLH therapy^®. HLH is an innovative method which promises plenty of benefits for doctors’ infirmaries.