In recent years, there has been an explosion of interest in, and media coverage of anti-aging treatments and procedures. Men and women of the baby boom generation have taken pride in their attention to fitness and healthy lifestyles and it’s no surprise that they would also want to maintain a youthful look into middle age and beyond. After all, most of us would like to look as good as we feel. We are lucky that we live in a time when there are so many new options for rejuvenation besides the traditional facelift.
With the plethora of new techniques and products out there, it is easy to become confused. Most people have heard of Botox, lasers, collagen and chemical peels, but knowing which procedure is right for any individual will usually require professional help.
To clarify the confusion, it is helpful to think about the different components of the aging face. Starting from the outside and working in, the five main components of the aging face are:
1.sun damage (also known as photodamage)
2.dynamic wrinkles
3.volume loss
4.gravity
5.bone loss
I. Sun Damage
We all know that the sun damages the skin. But how does this happen? Ultraviolet radiation from the sun (which is present even on cold or overcast days) can overwhelm our skin’s natural defenses and cause damage to cellular DNA, which, over time can lead to the development of skin cancers. Ultraviolet energy also causes the formation of free radicals in the skin. Free radicals are charged, highly unstable molecules that trigger chemical reactions that lead to collagen breakdown (and thus, the formation of wrinkles). Sun exposure also stimulates pigment production leading to freckles and brown spots and to the formation of enlarged and broken capillaries. Finally, the sallow, dull skin tone we associate with aging is due to an irregular thickening of the outer layer of skin, also triggered by chronic sun exposure.
Treatment Options
Sunscreens/Sun Protection
The daily use of a broad spectrum sunscreen is obviously of paramount importance in keeping our skin young. There are two types of sunscreens: chemical and physical. Chemical sunscreens absorb the damaging ultraviolet energy, converting it into heat energy. (This is why many people complain of feeling “hot” when using sunscreens.) Physical sunblocks containing zinc oxide or titanium dioxide, deflect the ultraviolet rays from reaching the skin, with zinc oxide being the most effective. Both chemical and physical sunscreens are effective, but chemical free sunscreens (which contain only physical sunblocks) may be a better choice for people with sensitive skin. The term “broad spectrum coverage” means that a sunscreen blocks both harmful types of ultraviolet radiation, ultraviolet A and ultraviolet B. Most sunscreens do a good job of blocking ultraviolet B, which is the shorter wavelength and is responsible for sunburn. In fact, the SPF rating refers to ultraviolet B protection and is based on the amount of time one can safely stay in the sun before getting a burn. However, sunburn is not the only adverse effect we need to protect ourselves against. Ultraviolet A is a longer wavelength of light, and can come through glass. This is the wavelength that causes most of our aging changes, such as freckles, darks spots, and wrinkles. If you’ve ever wondered why you have more sun damage on the left side of your face (the driving side), it is because of the ultraviolet A. This is also the main wavelength used in tanning beds (along with some ultraviolet B), so why pay for sun damage when you can get it for free? There currently aren’t any good standardized ratings systems for ultraviolet A protection, so the best thing to do is look for a sunscreen that contains one or more of the following ingredients: zinc oxide, titanium dioxide, avobenzone (also known as Parsol 1798), and two newer ingredients, Helioplex and Mexoryl SX. The American Academy of Dermatology has recently announced that it will start bestowing the AAD Seal of Recognition to sunscreen products that meet its high standards.
Many people have heard that sunscreens with an SPF over 15 are unnecessary. This might be true if people used sunscreens correctly, but to compensate for inadequate application, we recommend using an SPF of 30 for every day, and even higher if you plan to be outdoors all day. Ideally, sunscreens should be reapplied every 2-3 hours. It should take 1/2 teaspoon to cover the face, and one teaspoon for each arm. One to two teaspoons is needed for each leg and for the trunk. If you still have leftover sunscreen in the bottle at the end of the summer, you haven’t been using enough! There are many moisturizing sunscreens that can be used as an under makeup moisturizer. There are also some sunscreens that are more appropriate for oilier skin types.
Aside from the use of sunscreens, remember that sun avoidance is probably more important. Try to avoid mid-day sun, between 10:00 and 4:00, or the period when your shadow is shorter than you are. Wear a broad-brimmed hat to protect your face and ears (ball caps just don’t protect much) and clothing with a tight weave. Wear long sleeves, if possible. Remember that the sun can reflect up onto your face from water, sand, and concrete. Don’t be fooled by cloudy days, as 80% of the ultraviolet rays come through clouds. Remember, there is no such thing as a safe tan. Tanning is the skin’s response to injury.
Recently there has been some press, mainly sponsored by the indoor tanning industry, warning the public of vitamin D deficiency resulting from too much sun protection. It is true that Vitamin D is “the sunshine vitamin” and is synthesized by the skin in response to sun exposure. However, it only takes 7 to 10 minutes of unprotected sunlight on our face or arms once or twice a week to generate adequate Vitamin D levels. Nevertheless, we do recommend a daily Vitamin D supplement of 1000-1200 units daily, especially for people at risk for osteoporosis. (More about that below).
Retinoids
Topical retinoids, such as prescription Retin-A, Renova, Avage, and Tazorac, as well as over-the-counter retinol, are all vitamin A derivatives that have many beneficial effects on the skin, including induction of new collagen formation (decrease in fine wrinkling), lightening of pigmentation, and improvement of skin tone and texture. Retinoids are the gold standard when it comes to treating the signs of sun damage. However, they can be irritating and may not be tolerated by sensitive skin types. They also make your skin more sensitive to the sun, so daily sunscreen use is mandatory with these products.
Topical antioxidants
Antioxidants are molecules that can neutralize free radicals. Skin products containing antioxidants can be useful in addition to sunscreens, as sunscreens only block 55% of free radical formation. There are many topical antioxidants on the market now, including vitamin antioxidants B, C, and E, botanical antioxidants such as green tea, flavones, grapeseed extract, coffeeberry, curcumin, soy, and others, as well as idebenone and Co-Q-10. Many products contain multiple antioxidant ingredients. Some still require human clinical studies to prove their efficacy, but all are promising.
Our favorites: a. Skinceuticals CE Ferulic serum: proven antioxidant activity in the
skin, as well as pigment-lightening and collagen-inducing effects.
Also doubles the photoprotection of your sunscreen. Apply in the
morning, under your sunscreen.
b.Replenix serum, cream: These products contain green tea polyphenols
for antioxidant and anti-inflammatory activity. They make a nice addition to acne and rosacea therapies.
Alpha-hydroxy acids, beta-hydroxy acids, polyhydroyacids
This group of products are mainly known for their ability to induce microcopic
exfoliation, leading to smoother skin and improved tone and texture. However, they also stimulate collagen synthesis and improve skin barrier function (helping to maintain moisture). Alpha-hydroxy acids include fruit acids from citrus, apples, and grapes, and glycolic acid from sugar cane. They are useful in treating photoaging changes. Beta-hydroxy acid, also known as salicylic acid, is more fat soluble, and targets oil glands, making it useful for treating oily, acne-prone skin. Polyhydroxy acids are structurally similar to alpha-hydroxy acids, and have the same beneficial effects, but are more gentle and moisturizing, making them a good choice for sensitive skin types.
Our favorites: a.. M.D. Forte glycolic acid products. This is a line of glycolic acid
products for the face and body. Buffered to minimize irritation.
b.Topix Gly/Sal pads. These single use pads can be wiped on the face,
back, or arms to treat photoaging, acne, or rough skin.
c.Neostrata Bionic Face Cream, Ultra-moisturizing Face Cream.
Polyhydroxy acid containg facial moisturizers, good for dry, sensitive skin.
Other Cosmeceuticals
There are newer products on the market, such as growth factors, pentapeptides, and hexapeptides that show promise in skin regeneration, but there is less clinical data proving their efficacy. Pentapeptides, such as Strivectin and Olay Regenerist may help to induce new collagen formation, and some studies do show a clinical improvement in wrinkles. Growth factors, such as TGF-B1, which is found in TNS Recovery Complex, have been shown to decrease wrinkling. These products are expensive, and more studies are needed. Hexapeptides, such as Argireline, are purported to have some similar effects to Botox on muscles, but it is unclear whether they can penetrate deep enough to have a significant effect.
Bleaching Agents
Freckles and dark spots can be addressed in several ways. Sunscreens are an important first step, of course, because improvement cannot be achieved if the affected areas are still getting stimulated by the sun. A prescription bleaching agent called hydroquinone is very effective in lightening dark spots. It works by inhibiting the formation of pigment by melanocytes (pigment producing cells). It is often used in conjunction with topical retinoids, which enhance their penetration. Hydroquinone can be irritating in some people, and can be combined with a mild topical steroid to counteract this effect. Several months are required to see maximum effects. There are also other compounds that can lighten pigmentation, including prescription azelaic acid (Azelex, Finacea), and non-prescription products including Kojic acid, ascorbic acid, alpha and beta hydroxy acids, polyhydroxyacids, arbutin, soy proteins, and niacinamide (vitamin B3). Many of these agents are better tolerated than hydroquinone. All of these topical agents can be used in conjunction with more aggressive treatments, including chemical peels, microdermabrasion, and laser/light treatments.
Chemical Peels
Chemical peels are in-office procedures in which mild acids are applied to the face to produce exfoliation. The top skin cell layers are then shed, and replaced with fresh new cells. These procedures can be very effective in treating pigmentation problems as well as fine lines and dull skin tone. Chemical peels are classified as superficial, medium-depth, and deep, depending on the strength of the acid used. The stronger the acid, the deeper the exfoliation and the more benefit obtained. However, deeper peels will require longer healing times. The popular “lunchtime peel” is a glycolic acid peel, which usually has no downtime. Benefits are subtle, with improved skin texture and tone the most noticeable. Pigmentation can also be improved with these peels, though it takes a series that are administered in conjunction with topical bleaching agents. Salicylic acid peels are also superficial peels, and are most beneficial for oily and acne-prone skin. Medium depth peels are more helpful in treating pigmentation and fine lines, and will cause visible peeling for five to seven days. A series of four monthly peels is usually required to obtain optimal results. Deep peels are rarely performed anymore, as they have been associated with scarring and other complications.
Lasers, IPL
Most of the manifestations of sun damage (uneven pigmentation, broken capillaries, surface wrinkling, poor texture/tone) can be addressed with lasers and light treatments. There are many different lasers and light devices on the market. Laser (which is an acronym for “Light Amplified by Stimulated Emission of Radiation”) light consists of a column of monochromatic light (light of just one wavelength) that can generally target only one thing, such as hemoglobin, pigment, etc. Intense pulsed light devices emit a broad range of light wavelengths, with filters to cut off unneeded wavelengths. These devices can be used for a broader spectrum of uses, including treatment of vascular or pigmented lesions, or for hair reduction. The term “photofacial” treatment refers to treatment with an IPL device. Non-facial areas such as the neck, chest, and hands may be treated, as well as the face. Three to five treatments at two to four week intervals are usually needed to achieve optimal results. These treatments are best suited for lighter skin types. Photofacial treatments are ideal for targeting surface irregularities such as dark spots and red spots. The effect on skin texture and wrinkles is more subtle.
Laser resurfacing is the most aggressive way to treat sun damage and wrinkling, and can also treat acne scars. A carbon dioxide or erbium laser is used to vaporize the entire top layer of skin. As the skin heals, there is tissue contraction and tightening of the collagen, leading to a smoother surface and decreased wrinkling. This procedure, while very effective, has become less popular over the past 5 years due to the prolonged healing times and potential for complications. Other lasers have been introduced in recent years for “non-ablative” resurfacing; that is, tightening of collagen without producing an injury to the epidermis (outer layer of skin). These lasers, such as Cooltouch, Smoothbeam, and N-lite, have had the advantage of no downtime, but only achieve modest results.
Fractional laser resurfacing is a relatively new collagen-tightening procedure for the treatment of fine wrinkles and acne scarring. This new technology results in less downtime than the old resurfacing lasers by fractionating the delivery of laser energy into thousands of microthermal zones, with intervening normal skin, thus allowing for tissue tightening and much faster healing. Fraxel and other fractionated resurfacing lasers have been around for a few years and represent an exciting new addition to our anti-aging armamentarium. Newer generation fractional carbon dioxide resurfacing lasers (which penetrate deeper) are now in development, and promise to deliver significant results in just 1 or 2 treatments, as opposed to Fraxel and current offerings, which require 4-5 treatment sessions.
II. Dynamic Wrinkles
Dynamic wrinkles form on the face because, unlike in other parts of the body, the facial muscles insert directly into the skin. When muscles of facial expression are used, they pull on the overlying skin. Over time, repeated contractions create a crease. This is most noticeable in the forehead (horizontal creases), the frown area (vertical creases), and the crows’ feet areas (radial creases).
Treatment Options
The best way to address these lines is with the use of Botox to relax the underlying musculature. Botox is a protein that interferes with the transmission of nerve impulses to the muscle. It is highly effective and very safe. Botox has been used for over 20 years for various eye and neuromuscular disorders and has been used for cosmetic purposes for over 15 years. The effects of Botox wear off in 3 to 4 months, on average. Contrary to some popular misconceptions, Botox treatments do not create a “frozen” expression and do not affect skin sensation. In addition to the above-mentioned areas, Botox can also be used for lines around the mouth (“smokers’ lines”), chin dimpling, downturned mouth corners, and platysmal banding (prominent neck cords).
III.Volume Loss
As we enter middle age, our faces start to lose some of the fat and subcutaneous tissue that once gave us the soft rounded contours of childhood. This loss of volume is most noticeable in the cheeks, lower face, and lips
Treatment Options
A group of injectable products called “fillers” can be used to restore the lost volume, and are commonly used in the “smile lines”, the lips, and marionette lines (the creases from the mouth corners to the chin.) The three main groups of fillers in use now are collagen, hyaluronic acids, and calcium hydroxylapetite. Collagen is the oldest filler, and was first introduced in the 80’s. At that time, it was only available as bovine-derived collagen, and a skin test was necessary to test for possible allergy. However, there is now a bioengineered human collagen (CosmoPlast and CosmoDerm) that does not require skin testing. These products last 3 to 4 months, on average.
The second generation filler is the hyaluronic acid group, which includes Restylane, Juvederm, Hylaform, Captique, and Perlane. Hyaluronic acid is a complex sugar that is normally found in our skin and joints. It is the substance that gives our skin its suppleness by binding water. The hyaluronic acid fillers, with the exception of Hylaform, are non-animal derived, and have no requirement for skin testing. The chance of allergic reaction is extremely small and they are very safe. They generally last 6 to 9 months.
The third generation filler is Radiesse, which is a suspension of calcium hydroxylapetite microspheres in a gel carrier. The microspheres form a scaffold that supports and stimulates new growth of collagen. Over time, the spheres gradually break down and are naturally absorbed by the body. These injections are very safe, and no skin testing is required. The effects can last up to 18 months. It usually requires two treatment sessions, 8 weeks apart, to get final results. Radiesse , unlike other fillers, can also be used for cheek augmentation, cheek hollows and facial sculpting.
There are two other fillers, Artefill and Sculptra, which give long lasting results. Artefill is composed of polymethylmethacrylate spheres suspended in a bovine collagen carrier. It is the first permanent filler on the market, but there have been some reports of granulomas (allergic nodules) with this product. Sculptra is composed of poly-L-lactic acid, and, like Radiesse, provides a scaffold for new collagen formation, but there have also been concerns about granulomas with this product.
Volume restoration can also be done with own’s own fat. (Autologous fat grafting) This is obviously a more involved procedure, as it requires liposuction to harvest the fat from another part of the body.
IV. Gravity
Gravity eventually takes its toll on all our faces. As our cheeks descend, the fat pads under our eyes that had previously been concealed, become visible, making us look tired. The nasolabial folds (smile lines) deepen into grooves, our brows drop, and the jawline sags, forming jowls.
Treatment Options
Fillers, such as the hyaluronic acids and Radiesse, can be used in the cheeks, nasolabial folds and chin to prop up the cheeks, but in severe cases, surgery may be the best option.
Radiofrequency skin tightening is a non-laser procedure in which radiofrequency energy is used to heat the deep layers of skin, while the epidermis is protected by a cooling device. The result is heat injury to the collagen, which leads to wound healing/remodeling and tightening of the skin. These procedures (Thermage, Themacool, Titan) are somewhat painful, but can be moderately effective in tightening areas such as the forehead, cheeks, jawline, and neck and may be a good alternative for those who do not wish to have surgery.
Threadlifting (Contour threads) is a new procedure in which barbed suture material is inserted under the skin of the cheeks, forehead, and neck and anchored to the bone to provide an upward pull of the tissue. It is marketed as a “lunchtime facelift.” However, there are no long term studies showing its efficacy past 6 months.
V. Bone Loss
In addition to the volume loss discussed above, bone loss is also a factor in the aging face, especially the lower face. To maintain optimal bone health, it is important to get adequate vitamin D (1000-1200 units per day) and calcium (500-700 mg per day for women). Weight bearing exercise is important in maintaining bone mass, especially for women who are at an increased risk of osteoporosis.
Finally, a few more thoughts. Our skin reflects our general health, so it is important to keep our bodies healthy by eating a well-balanced diet with plenty of fresh fruits and vegetables (especially those that are high in antioxidants) and avoidance of processed foods and saturated fats. The best antioxidant foods are beets, blueberries, broccoli, brussel sprouts, kale, oranges, plums, red grapes, spinach, and strawberries. A multivitamin supplement with minerals(but not iron unless you are iron-deficient) is a good idea. Other supplements to optimize skin health would include:
1.Long-chain omega-3 fatty acids (fish oil): 1-3 gm per day. Fish oil decreases insulin levels, improves circulation, increases energy levels and decreases hunger.
2.Co-Q-10, 100 mg per day: Also known as ubiquinone, this antioxidant is
present in all cells and is necessary for cellular energy production. It also neutralizes free radicals.
3.Alpha-lipoic acid: 100-200 mg per day: This antioxidant plays a central role in cellular energy production. It also decreases insulin resistance.
Getting adequate sleep and exercise are important for your skin tone and circulation. Smoking decreases the skin’s circulation and healing ability, and many studies have shown that smokers are more prone to wrinkling than nonsmokers. If you smoke, please try to quit! Your skin (and lungs) will thank you.
The Aging Face
