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Saving Face – What Are My Options In 2014?


Facial aging is a complex process of changes that occur as a result of the long-term effects of gravity, sun exposure, environmental exposure, overall health status, stress, and smoking. All these factors coupled with progressive time related changes in the soft tissues of the face result in the undesired permutations that we observe in the mirror and cringe. In the spirit of New Year new beginnings let’s upgrade our knowledge and take a fresh look at aging and what options aesthetic medicine has to offer currently to help us stay youthful and verdurous. To better understand the changes taking place behind an aging face we need to take a brief look at our facial anatomy.


The face is comprised of layers of various tissues that form an individual’s unique appearance. The interplay of these tissues result in the wrinkles we observe while smiling, frowning or showing any other emotions. Skin is the outermost layer of our face and body. As we age, multiple changes occur in the skin. After the age of 20 years, our skin stops making new collagen and elastin, which coupled with regular wear and tear results in thinned out skin with loss of turgidity and elasticity. There are also changes in pigmentation and an increased development of benign age-related skin lesions (age spots, skin tags etc.). In addition, there is slowing down of body’s normal process of replacing aging or damaged skin cells with new cells, all these changes gradually result in a tired, wrinkled or leathery appearance of the skin.


Deeper to the skin, is a thin layer of interconnected muscles that allow an individual to convey facial expressions. This layer is called the superficial musculo-aponeurotic system or SMAS layer. These muscles are closely adherent to the skin, resulting in a constant pull on the skin surface. As the skin thins with age the continued pulling of theses muscles results in deepening wrinkles of the face in the forehead, around the eyes, and between the eyebrows.

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On either side of the muscle (or SMAS) layer, there are layers of fatty tissue. In a youthful face, the fat is evenly distributed giving the appearance of a full face. The fat distribution in a youthful face is always triangular in appearance: fullness at the top, tapering at the bottom. As the face ages, changes in these fat compartments occur, resulting in the inversion of the triangle of youth (heaviness at the bottom and sunken appearance on the top). The loss of fat in the upper areas of the cheeks and temples results in hollowing and prominence of the cheekbone outlines. Gravity pulls down fat pads in the mid cheek and along the jaw, resulting in deepening of the folds along the nose, jaw and mouth.


The underlying facial bones provide skeletal support to all of the tissues we have just talked about. Picture facial skeleton being similar to a clothes hanger in your mind. A clothes hanger gives shape to the garment on which it is hung. If a portion of the garment slides off of the hanger, it loses some of its shape and appears distorted. The combination of increased soft tissue laxity, loss of fat volume, downward displacement of fat and soft tissue, loosening of attachments to the underlying facial skeleton and loss of bone volume results in the overall noticeable changes that are seen with facial aging.


Treatment rationale and options for the ageing face: When we look at signs of aging with intention to treat aesthetically, one treatment rationale obviously cannot fit all. I like to categorize aging faces into 3 major time zones (20’s – 30’s – 40’s and beyond) with minimum, medium and aggressive changes. By understanding the changes we need to reverse and treat in each phase of senescence, we can address the signs of aging in a more accurate and realistic way.

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20’s: What are the first signs of aging? – Loss of freshness and reduced turgidity of the skin. Skin stops making collagen & elastin and the processes of wear and tear begin to go unchecked as early as 20 years of age. If antiaging measures are not taken early, you start to see appearance of fine lines and deepening of expression lines by late 20’s.


30’s: Aging begins to carve 3-D changes into the skin, muscles and fat compartments of face. Face looks tired and pulled down. Along with loss of collagen and elastin, the pull of gravity and changes in muscle tone potentiate the signs of aging; the skin starts to look more lax and fat start to droop. We see the lacrimal groves move southwards to the mid cheek, soft smile lines turn into deeper naso-labial furrows and marionette lines give the appearance of a sad face pulling down on the corners of lips.


40’s & Beyond: The 3-D aging process becomes more aggressive past forty years of age. The skin progressively starts to wrinkles heavily, as it becomes thinner with continuous loss of collagen and elastin. Fat compartments under the skin are pulled down further by gravity and sleeping habits. SMAS layer holding the face in its place becomes loose and gives in to the gradual yet constant pull of gravity. The muscles tone changes; in certain areas the muscles become hypertrophic creating deeper wrinkles and creases (smile-lines, crows’s feet, horizontal and vertical frown lines on the forehead). In the lower face, loss of muscle tone and drooping pads of fat present as hanging jowls and double chin.


Based on this simplified overview of the facial ageing processes, a comprehensive treatment plan can be mapped out to target specific anatomic structures categorically to achieve natural youthful results.

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Cosmaceuticals: Serums, creams and lotions are the starting point in implementation of an antiaging regimen and they are also vital for maintenance of results post any aesthetic procedure. The main philosophy behind cosmaceuticals usage is to boost collagen production and stop its depletion starting as early as possible. A good moisturizer and a broad-spectrum (UVA & B) sunscreen with SPF 30+ are the must-have staples of any antiaging regimen. Other most important ingredients while choosing dermo-cosmaceuticals are: vitamin C, vitamin A, Green Tea extract, and Peptides.


Injectables: Mesotherapy with multi-vitamins and antioxidants coupled with hyaluronic acid help nicely in regaining the turgidity and glow to a tired face.


Fillers: Cross-linked hyaluronic acids and calcium hydroxyapetite injectables can aid in restoring the “golden triangle of youth”. Fillers as we call them, help in reviving the lost volume in skin and the facial contours, they youthfully plump up the deepened furrows and smooth out deepening wrinkles with very natural results.


Autologous Fat Re-Injections: for volumizing and rejuvenating the face, décolleté and hands are another great natural option. In expert hands fat augmentation of aging tissues gives marvelous results. According to new research the stem cells present in the fat tissue provide added antiaging bonus to skin and underlying structures.


PRP & Stem Cell Treatments (Vampire Facelift): are recent advances in injectables; which help in 3-D restoration of aging face or hands.


Botulinum Toxin: A touch of botox works like magic on the expression-associated wrinkles.


Combination of deep and superficial injectables can help restore all damaged layers from bone to dermis. With the newer choices of injectables available in the market the results are more natural and long lasting.


Lasers, Radiofrequency & Ultrasound: There are a plethora of devices available in the market currently with proven results, that can correct the damage done by time and age.


Deep infra-red lasers, radio frequency and focused ultrasound devices have shown very promising results in antiaging medicine.


Fractionated devices (CO2 laser & radiofrequency) in particular can yield excellent results in expert hands.


All these devices work mainly by stimulating production of collagen and elastin tissue in the dermis.


Surgical options: From blepharoplasty, upper, middle, lower, or a full-face lift there are so many options available to defy aging. Key to a successful outcome while considering surgical options is to keep the over all look natural and not get carried away. Natural refreshed look and not “over-done” should always be the preferred targeted end result.

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In 2014 aesthetic medicine has plenty of valid antiaging treatment choices to offer to the young at heart who plan to match their exterior to their interior. Just keep in mind – to achieve an optimal outcome a thorough analysis of the aging face is mandatory before going ahead with any treatment or combination of treatments. Final take home antiaging message is, “Maintenance is the key to keep desired results last over time, as post 20 years of age keeping up with youth is an uphill battle”.

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