Introduction
In the last 10-15 years, there has been a surge in the array of cosmetic procedures available to patients. Improved surgical techniques, technological advances in lasers, and robust scientific research on injectable agents have led to safer and better cosmetic results. Moreover, the media has made the notion of cosmetic surgery mainstream, and it has become socially acceptable. As the demographics of our population change – and growing numbers of Baby Boomers enter into older age – we see more patients asking about ways to improve their physical appearance.
The Aging Face and Why It Happens
We have a good understanding of the changes associated with the aging face. Cumulative sun exposure over the course of a lifetime is the primary reason for unwanted pigmentary and textural changes. Development of darker or lighter patches of skin (dyschromia), brown spots called lentigines and seborrheic keratoses, telangiectasia (“broken” or dilated capillaries), and a sallow color all contribute to a spotty complexion.
Textural changes from formation of keratoses (scaley lesions that can be benign, pre-malignant - see Actinic Keratosis Knol, or malignant) and wrinkles, transform that one baby-soft smooth skin, into rough and uneven skin. All of these effects are directly related to ultraviolet (UV) damage. The sun’s UV rays stimulate melanocytes in the skin to make pigment. It also destroys dermal (layer of skin beneath the outer skin) elastic tissue. Loss of skin elasticity - its “snap back” quality - results in persistent wrinkles even when the face is at rest (1).
Textural changes from formation of keratoses (scaley lesions that can be benign, pre-malignant - see Actinic Keratosis Knol, or malignant) and wrinkles, transform that one baby-soft smooth skin, into rough and uneven skin. All of these effects are directly related to ultraviolet (UV) damage. The sun’s UV rays stimulate melanocytes in the skin to make pigment. It also destroys dermal (layer of skin beneath the outer skin) elastic tissue. Loss of skin elasticity - its “snap back” quality - results in persistent wrinkles even when the face is at rest (1).
Also as we age there is gradual loss of facial fat beneath the skin. Babies have very full, round faces. Our own childhood pictures would reveal a fuller appearance of the upper 2/3 of the face. With gradual loss of fat and downward descent of the facial soft tissues, the overlying skin “deflates” onto the skeletal structure, and the skin begins to sag. The end result is hollows around the temple and eyes, lowered eyebrows and heavy upper eyelids, cheek hollows, flattened cheekbones, and development of jowls. The overall impression is that over time the lower 1/3 of the face appears heavier.
Ultimately, permanent wrinkles and folds develop. In contrast to the hollows described above, wrinkles are the result of repeated movement of the underlying facial musculature, combined with loss of skin elasticity. An expressive person will have more lines and wrinkles than someone who is less animated. With elevation of the eyebrows, horizontal wrinkles develop on the forehead. Initially these wrinkles are only apparent with movement. Over time, however, these wrinkles set in, becoming visible and deep, even at rest. The glabellar region, between the eyebrows, is another area where this commonly occurs. With repeated kneading of the eyebrows, permanent vertical furrows develop, giving a worried or angry appearance. Crow’s feet refer to lines that develop around the eyes from smiling or squinting. Repeated pursing of the lips from speaking, smoking, or playing an instrument cause vertical lines to develop around the mouth.
Ultimately, permanent wrinkles and folds develop. In contrast to the hollows described above, wrinkles are the result of repeated movement of the underlying facial musculature, combined with loss of skin elasticity. An expressive person will have more lines and wrinkles than someone who is less animated. With elevation of the eyebrows, horizontal wrinkles develop on the forehead. Initially these wrinkles are only apparent with movement. Over time, however, these wrinkles set in, becoming visible and deep, even at rest. The glabellar region, between the eyebrows, is another area where this commonly occurs. With repeated kneading of the eyebrows, permanent vertical furrows develop, giving a worried or angry appearance. Crow’s feet refer to lines that develop around the eyes from smiling or squinting. Repeated pursing of the lips from speaking, smoking, or playing an instrument cause vertical lines to develop around the mouth.
Cartilage and bone remodeling also occur but is less obvious. The shape of one’s nose changes, often appearing wider and the nasal tip droops as a person ages. Another example is protrusion of the chin and deepening of the chin crease (2,3).
What treatments are available to improve my appearance?
There are a number of excellent treatments that can make one look more youthful, but first your doctor should systematically address each of these signs of aging. The advantage of many of the minimally invasive cosmetic procedures is reproducible results with short recovery periods.
Topical agents
At baseline, all patients should be using a sunscreen with broad-spectrum UVA and UVB protection. Full spectrum coverage will be stated on the sunscreen label. The most recent breakthrough in sunscreens is superior protection against the sun’s UVA rays. Whereas previous sunscreens contained UVA blockers that quickly broke down after application, new UVA blockers are more stable, so that the sunscreen remains effective for much longer. At present writing, our recommended sunscreens include Anthelios, Neutrogena with helioplexTM or Aveeno with active photobarrier complexTM. Since the sun protection factor (SPF) only measures UVB blockage, looking at the SPF alone is not sufficient. (See Sunscreen Knol for additional information).Topical tretinoin (the acid form of Vitamin A) as a prescription cream can be used to improve fine wrinkling, especially around the eyes. The skin around the eyes is thin and therefore, permits deeper penetration of the cream. It generally takes 6 months of daily applications to see clinical improvement as supported by several controlled studies. To our knowledge, tretinoin is the only topical agent that has unequivocal histologic evidence demonstrating that it can thicken the epidermis and increase dermal collagen synthesis. Clinically, this translates into “firmer” skin and improvement of fine wrinkles. (4). Glycolic acid (alpha hydroxy acid) and salicylic acid (beta hydroxy acid) are found in over the counter products that can induce exfoliation or remove dead skin cells to improve skin surface smoothness and color. Hydroquinone, a prescription bleaching agent, can lighten sun-induced lentigenes and hyperpigmentation (where patches of skin become darker than normal skin), so long as the melanin (which causes the darkening) is mainly in the epidermal layer of skin.
Lasers
There have been many advances in the field of laser surgery. Lasers can be classified by their wavelength and their intended target (chromophore).For facial telangiectasia and redness, the pulsed dye laser (PDL) and millisecond pulsed 532 nm green light lasers are excellent treatment modalities (5,6). One factor in deciding which laser to use is the diameter of the target blood vessel. The PDL has a larger spot size which would allow treatment of larger areas at once. Its primary disadvantage is the possibility of bruising with more aggressive treatments. Bruises may last up to two weeks after treatment. The 532 nm green light lasers can treat vessels up to 1 mm in size without producing bruising. The number of treatments required for either laser depends on the aggressiveness of treatment and the diameter and rate of blood flow in the vessels.
Q-switched Nd:YAG, Q-switched ruby, and Q-switched alexandrite are the 3 lasers primarily used to treat brown spots. The decision to use one laser over the other depends on whether the location of the melanin pigment is in the epidermis, dermis, or both, as well as on the patient’s background skin color. In general, patients with darker skin color should be treated with caution at lower energies and with the longer wavelength lasers. Patients with suntans should be treated with caution because they are at risk of blistering and hypopigmentation (white discoloration).
Resurfacing
As the degree of photoaging (skin damage from cumulative sun exposure) proceeds, wrinkles persist throughout the face, and the skin develops a thickened quality with a yellow-gray color. At this point, one treatment option is facial resurfacing. The modalities for resurfacing procedures include dermabrasion (“sanding” down the outer layer of skin), chemical peels, and carbon dioxide (CO2) and erbium YAG (Er:YAG) resurfacing lasers. The choice of technique depends largely on the physician’s experience and skill with the modality. Advantage of laser resurfacing is precise control of depth of resurfacing. In addition, laser resurfacing “tightens” skin secondary to heat-induced collagen contraction (shortening of the collagen fibers in the dermis). A recent advance in laser resurfacing is utilizing fractional technology with either the CO2 or Er:YAG laser. With this technology, the laser beam is fractionated into many smaller beams, so less skin is treated with each pulse, which facilitates faster healing.Chemical Peels
Chemical peels can also be used to improve photoaged skin. Chemical peels are classified as superficial, medium, and deep, based on their depth of penetration into the skin and clinical effect. Glycolic and salicylic acid peels, as well as the Jessner’s peel are considered superficial. Trichloracetic acid (TCA) peels are medium-depth peels, and phenol is used for deep peeling. The physician can custom fit the chemical peel for treatment of everything from the most superficial aspect of the skin all the way to the reticular dermis to improve deep wrinkles. Before deciding on treatment, the physician must not only assess the patient’s degree of photoaging, but also take into account the amount of post-peel wound care and downtime the patient can accept. In general, deeper peels result in more redness, swelling, pain, and crusting – and carry a greater risk of scarring.Intense Pulse Light (IPL)
The Intense Pulse Light (IPL) or “photofacial” is a light source that delivers a broad range of wavelengths. This device is technically not a laser. It delivers wavelengths that are preferentially absorbed by melanin as well as wavelengths that are absorbed by hemoglobin. Brown spots (lentigines) and blood vessels can be treated simultaneously. Another advantage is the large spot size allows treatment of large areas quickly. In general, IPL targets melanin better than blood vessels and consequently lentigines typically resolve sooner than the admixed telangiectasia (surface blood vessels) and reddness. An average of four treatments is required for clearing of telangiectasia (7). If not operated correctly or by an experienced physician, this device, as is the case with lasers, can result in adverse effects such as pigmentary change, blistering, and scarring,.
Botulinum toxin A (Botox, Allergan, Irvine, CA)
The use of botulinum toxin has revolutionized the treatment of the aging face. Prior to its use, rejuvenation of the upper face was primarily done with surgery such as forehead lifts. Botulinum toxins relative ease of use and excellent safety profile has made this nonsurgical agent far and away the most frequently performed cosmetic procedure by physicians (8). Wrinkles of the forehead, glabellar lines (the area between the eyebrows), and crow’s feet lines (wrinkles around the eyes) – all of which develop over time because of repeated movement of photoaged skin – can be at least halted, if not erased, with injections of botulinum toxin. It works by chemically denervating or temporarily relaxing the treated muscles. The effects of the treatment are noted within the first one to two weeks, and generally remain for three to five months. For the most part, there are no restrictions after treatment and there is no downtime. In the person with deep glabellar furrows at rest, treatment with botulinum toxin may not yield complete resolution. Botulinum toxin can also safely be used to treat the bunny lines of the nose, vertical lines above the upper lip, dimpling of the chin, turn up the corners of the mouth, and give a subtle lift to the lateral eyebrows.Filling Agents
Fillers can be injected with very small needles to correct loss of facial fat (hollows and depressions). Currently, this process is most effective for restoring facial volume and contours rather than to fill in wrinkles and lines. The list of fillers available worldwide is long and more are on their way. Fillers can be classified by the filling substance and by how long they persist in the skin. The choice of filler should be based on the location of the defect, depth of defect, potential for hypersensitivity reaction, desire for permanency, and the “feel” of the agent once in the skin. Lip augmentation with injectable fillers remains one of the most frequently sought after cosmetic procedures. Nasolabial folds (area between the nose and upper lip), marionette lines (area extending from the corner of the mouth down to the chin), and tear trophs (hollows underneath the eye) can also be successfully corrected. More creative uses include restoring volume in earlobes so earrings sit flush, supporting and raising the eyebrows, enhancing cheekbones and supporting the cheeks, and improving the appearance of thin-skinned, skeletonized hands.For patients not interested in exogenous filling agents, the patient’s own fat can be used through techniques of fat transfer. Fat is harvested from sites such as the abdomen or hips, and then reinjected in the desired areas of the face. The aesthetic results are often very natural in appearance, although the longevity of the fat transfer is less predictable.
Blepharoplasty and Neck Liposuction
Blepharoplasty (eyelid surgery) and face-lifts are two commonly performed surgical facial cosmetic procedures. When there is too much lax, redundant, droopy skin, surgery may be necessary. Blepharoplasty of the upper eyelids refers to excision of excessive eyelid skin, with or without removal of muscle and orbital fat. Aging of the lower eyelids can present as either a hollowing, or as a lower eyelid bulge from protruding orbital fat. If the concern is lower eyelid bulge, a surgical option would be a transconjunctival (incision performed through the inner surface of the eyelid) blepharoplasty of the lower eyelid with subtle removal or often repositioning of the orbital fat. The goal is to achieve a smooth contour without accentuating the groove between the lower eyelid and the cheek.Some patients have mild jowl formation or moderate submental fat (fat under the chin) and request a sharper jaw line. Tumescent (anesthesia by local infiltration of diluted lidocaine) liposuction can be a definitive treatment alone or it can be performed in conjunction with a submentalplasty (neck lift). Ideal candidates are ones with good skin tone and elasticity since they’ll benefit most from retraction of the skin during the healing process.
How do I decide which treatment is right for me?
Resist the temptation to jump on the bandwagon of every new fad, laser, or injectable material. It is easy to be swayed by media. Just because you saw it on television, or read about it in a fashion magazine, doesn’t make the latest cosmetic procedure a sensible option. WIth the help of your doctor, you should have a clear understanding of what you dislike about your appearance and what can be achieved. For example, a face-lift without addressing the unwanted surface pigmention and textural changes or underlying loss of facial volume will not necessarily make one look more youthful. Often a gradual process with a combination of therapeutic techniques is necessary for optimal facial enhancement.Who performs these types of cosmetic procedures?
Specialties such as dermatology, plastic surgery, oral and maxillofacial surgery, and oculoplastic surgery have all participated in the academic process of improving cosmetic procedures to enhance appearance. Seek out a physician who is board certified and trained in performing these cosmetic procedures. Your doctor should be able to evaluate and address your cosmetic concerns in a thoughtful, systematic and artistic manner.Web Resources:
The American Academy of Dermatology www.aad.org
The American Academy of Cosmetic Surgery www.cosmeticsurgery.org
The American Society of Laser Medicine and Surgery www.aslms.org
Reference book about cosmetic surgery:
Kaminer MS, Dover, Arndt KA, Atlas of Cosmetic Surgery
References:
- Yaar M, Gilchrest BA. Aging of the skin. In: Freedberg IM, Eisen AZ, Wolff K, et al, eds. Fitzpatrick’s Dermatology in General Medicine, 5th ed. New York: McGraw-Hill, 1999:1697-1706.
- Glogau RG. Chemical peeling and aging skin. J Geriatr Dermatol 1994: 2(1):30-35.
- Hoefflin SM. The youthful face: tight is not right, repositioning is right. Plast Reconstr Surg 1998; 101(5): 417.
- Creidi P, Vienne MP, Onchonisky S, et al. Profilometric evaluation of photodamage after topical retinaldehyde and retinoic acid treatment. J Am Acad Dermatol. 1998; 39:960-5.
- Ruiz-Esparza J, Goldman MP, Fitzpatrick RE, et al. Flashlamp-pumped dye laser treatment of telangiectasia. J Dermatol Surg Oncol 1993; 19:1000-1003
- Goldberg DJ, Meine JG. A comparison of four frequency-doubled Nd:Yag (532nm) laser systems for treatment of facial telangiectases. Dermatol Surg 1999; 25:463-467.
- Raulin C, Weiss RA, Schonermark MP. Treatment of essential telangiectasias with an intense pulsed light source (Photoderm VL). Dermatol Surg 1997; 23: 941-946.
- Hruza GJ. Botulinum toxin. J Watch Dermatol 1999; 7:59-62
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