FROM HEAD TO TOE
There is a continued pressure to be smart and either be youthful
or look that way. Regardless, most patients I see just want to look
more like the youthful person they once were.
Since facial rejuvenation constitutes the majority of the rise of
these procedures and naturally is a great part of our identity, let’s
focus on what aging is doing to us and our faces, and what can we
do about it. The aging process manifests itself in complex changes
in all tissue types of the face including skin, fat, muscle, fascia and
bone. Skin changes include dermal collagen thinning, elastin de-
cline and pigmentary changes. The fat starts to thin secondary to
redistribution from hormonal changes and dietary changes. The
muscle becomes more prominent without the softening effect of
the overlying fat and lastly, the facial skeleton resorbs and remod-
els over time. The suspension ligaments attenuate from gravity
and elastin decline. In some patients, the tissue becomes malpo-
sitioned or ptotic. The expressive genetic effects of aging and en-
vironmental stressors including psychological stress are current
topics of discussion as well.
By examining the underlying structural changes in the face,
the clinician can create a long-term comprehensive plan to ad-
dress immediate problems and develop strategies to prevent fu-
ture problems. In aging patients, some present with malabsorptive
problems for iron, B12, zinc and other nutrients, or present with
early symptoms for hypothyroidism or Type 2 diabetes. These
problems have to be addressed in any potential surgical or min-
imally invasive candidate to minimize complications. Early in the
aging process, patients start to lose volume in their cheeks or lips.
A popular treatment option is what is called dermal fillers. The
majority of these fillers are made of a basic substance in our body
called hyaluronic acid. Depending on their processing and chem-
istry, they will have different characteristics making some more
suitable for subdermal placement versus placement in the deeper
soft tissue of the face to substitute for the missing facial volume.
The body resorbs this material over the course of a year for the
most part. The use of autologous fat is a popular filling material
and some of this material has a chance of surviving long term as a
fat graft. The objective is to replace the volume without distortion
of the area in repose or in animation. This is where knowledge of
anatomy, depth perception and patience come together.
For areas of the face that are affected by animation, there is an-
other cosmetic modality. As facial skin and fat tissue is thinning,
there is deepening of skin tension lines (expressive wrinkle lines),
such as the glabella (frown lines), forehead lines and periorbit-
al lines (crow’s feet). The treatment options may include what is
known as muscle chemodenervation with agents such as Botox or
a combination of chemodenervation and dermal fillers. Subtle and
conservative treatment is often a wiser approach.
The envelope of the face, of course, is the skin. It displays both
the short and long-term effects of our nutrition and our lifestyles.
The damage is expressed by scar deformities, pigment changes,
adult acne and thinning of the skin to name a few. The funda-
mental treatment plan must address nutrition and, if pertinent,
smoking cessation. The treatment options start with a basic skin
care program to promote turnover of the skin cells. This can be
started with products that break the outer skin layer bonds such
as Retin-A which promotes exfoliation and starts the dynamic
process of skin and collagen growth. This usually gives a healthier
appearance to the skin and can treat some of the skin damaged
as a result of UV radiation. There are synthetic chemical acids
such as trichloroacetic (TCA), or fruity acids such as glycolic acid,
that denatures the outer skin layer. These agents are commonly
used around the world to exfoliate the outer skin layer and more
aggressively stimulate skin turnover. In areas in the world where
lasers are not affordable, these agents are the mainstay of a skin
treatment procedure known as a chemical peel. The contemporary
treatment for stimulating healthier skin is laser ablation. The laser
best known for this is the carbon dioxide laser, or CO2 laser. The
target chromophore is the water in the skin cell, which is precisely
ablated on the surface resulting in exfoliation of the outer layer,
which stimulates skin production and increases the collagen in the
dermis, resulting in a healthier appearance. There is a plethora of
information on lasers to treat different pigmented lesions, but it is
important to know that you are not ablating a skin cancer, which
is why experience both with the skin lesion and the laser’s capa-
bilities is critical.
As the patient ages, more invasive surgical procedures are re-
quired including elevation of the deeper fascial structures such
as the superficial musculoaponeurotic system (SMAS). Face and
necklift procedures in conjunction with volume replacement such
as the patient’s own fat tissue, are the mainstay of treatment meth-
ods to restore the more youthful features of the face. Often other
restorative procedures are concomitantly performed on the eye-
lids, brow, neck and skin. Unfortunately, these procedures do not
halt the aging process, so you should expect a basic maintenance
skin care program. At the end of the day, the boring habits of a
healthy lifestyle including good nutrition (I think the plant-based
diet approach and its sugar-reducing variants are compelling),
exercise, low stress and sun protection go a long way in keeping
the person you see in the mirror looking like the vibrant youthful
person you are.
Dr. Chariker is a practicing plastic and reconstructive surgeon specializing in cra-
niofacial and hand surgery at the Kentucky Center for Cosmetic and Reconstructive
Surgery.
APRIL 2020
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