Understanding the Aging Process
To better understand the treatment options for the aging face (and more importantly, to better understand the limitations of the treatment options), it helps to understand the different components that make up the aging process.
Loss of skin elasticity
Loss of skin elasticity is the most important component of the aging process and it is the most difficult to treat. Think of your skin as a container. It holds the fat, muscles, and bones that make up your face and neck. A youthful container is elastic like a rubber band; it stretches with movement, and then snaps back into its original shape and position. An older container has lost its elasticity; it is like a stretched out “Slinky”. It no longer stretches, snaps back, or holds its original shape. To make matters worse, since the older container is stretched out, it is larger than a younger container.
The loss of elastin, the component of the skin that allows it to stretch, can be exemplified by the age related changes seen in the upper eyelid skin. When you were younger and you closed your eyes, the skin of the upper eyelid would stretch, and when you opened your eyes the skin of the upper eyelid would snap back and contract like a rubber band. When we get older the upper eyelid skin becomes stretched out and redundant. So when you open your eyes, instead of the skin retracting and contracting, it rolls up like a roman shade. Another example of the loss of skin elasticity is in the area of the neck, just below the chin. Again, in youth, the skin would stretch as you turned your head or opened your mouth, and then it would snap back and retain its shape when you returned your head and mouth to a neutral position. Once our skin looses its elasticity, when we return our head to a neutral position the skin does not retain its contracted shape, and we start to get crepe like skin hanging down under the chin.
Prevent Elastin Breakdown and Improve Elasticity = Sunblock / RETIN-A / Topical Vitamin C & E
Make the Stretched Out Container Smaller = Endoscopic Approach Browlift / Upper Eyelid Blepharoplasty / Facelift / Necklift
Loss of skin collagen
As we age, our skin becomes thinner and it takes on a sallow appearance. The thinning of our skin is due to the loss of collagen. There are many factors that go into the loss of skin collagen (hormonal changes, sun exposure, genetics, smoking, chronic medical conditions, etc). SUNBLOCK / RETIN-A / TOPICAL VITAMIN C & E / MICRODERMABRASION / CHEMICAL AND ENZYME PEELS / LASER SKIN RESURFACING
Loss of volume in our face
As we age, we seem to put on fat all over our body, but ironically we tend to lose fat in our face. The fat in our temples and our cheeks atrophies and gives us a gaunt, (cadaveric), hollowed out appearance. At the same time, we lose bone mass from our facial bones and the facial bones remodel (change shape) over time. If you were to look at a skull from a 20 year old and compare it to a skull from a 60 year old, you would easily be able to tell which is which. The 60 year old skull has larger orbits (eye sockets), the cheek bones are smaller and the jaw bone is smaller (all due to bone loss). So, combine the loss of facial fat and the loss of bone mass with the stretched out skin container and you get depressions, concavities, and areas of flatness where there were once plump, full, convex features. These concavities appear as dark shadows running across your face when you see your reflection in a window or in a mirror. RESTYLANE / JUVEDERM ULTRA / RESTYLANE LYFT / JUVEDERM ULTRA PLUS / RADIESSE / SCULPTRA / FAT TRANSFERS
We can not escape it. Gravity pulls on the stretched out inelastic skin and the remaining fat of our face and neck and causes the soft tissues to sag. The lateral brow ptosis (heavy eyebrows), the bulging lower eyelids, the nasolabial (melolabial) folds, the marionette lines, the jowls, and the vertical bands of the neck are all the direct result of gravity pulling on the skin and soft tissues of our face. ENDOSCOPIC APPROACH BROWLIFT / UPPER BLEPHAROPLASTY / LOWER BLEPHAROPLASTY / PRE-TRECHAL BROWLIFT / FACELIFT / NECKLIFT
Treatment options for the aging face
The path to total facial rejuvenation starts with the consultation. During the consultation I examine and evaluate the patient’s face to determine which components of the aging process – bone loss, skin texture, and pigmentation – are present and determine the severity of each component.
As you can see, the aging process is multi-factorial. It is a combination of loss of skin elasticity, loss of skin thickness, loss of volume, and the sagging of the skin and soft tissues of the face and neck. Each person ages differently, and each face is unique in its composition of these changes. Therefore, the treatment options are very much individualized. One person may benefit more from volume replacement, while another person may benefit more from topical creams, while another may benefit more from surgery. However, most patients would benefit from a combination of treatment modalities. Case in point, surgery does only two things; One, it removes excess skin (makes the container smaller) and Two, it repositions skin and soft tissue that has fallen due to gravity into a more youthful position. Surgery does not replace volume, nor does it make your skin more elastic or thicker. Therefore, as an example, say a patient has loss of volume in their cheeks, their skin is now stretched out and the skin container is bigger than it was in youth, and gravity has pulled the remaining skin and soft tissue of the face down to make jowls and marionette lines. Surgery would reposition the skin and soft tissue into a more youthful position and make the skin container smaller, but there would still be volume loss and inelastic skin. To achieve total facial rejuvenation, this patient would benefit from a multi-modality approach by incorporating retin-a to make the skin more elastic, and injectable fillers to replace the volume in their cheeks, in addition to a facelift and necklift.