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The Skin Game

By Mary L. Hughes
Posted On May 16, 2012

By: Mary Hughes

Skin. It is the body’s largest organ, and our barrier against the world outside. It’s also one of the clearest indications of our age: Smooth as a baby’s bottom when we’re born, rosy and radiant in our youth, then dull, sagging and wrinkled as we age.

What happens to our skin as we grow older? Why does it betray us? How is it that every woman over thirty periodically catches something in the mirror and
wonders: “When did that happen?” Bags under the eyes. Droopy eyelids. Incipient jowls. Fines lines. Deep lines. Age spots. And elasticity? Gone.

So how do we keep our skin youthful looking? And, what can we do to undo the damage of time? For that matter, what causes skin to age in the first place?

What follows is our report on why your skin ages and why it makes your face look older—and what you can do about it.

Skin: Coming of Age

First things first: How does our skin age? Doctors will tell you there are two sets of culprits, “extrinsic” and “intrinsic.” The extrinsic factors are controllable things like sun damage, exposure to toxins, smoking, diet, alcohol consumption and how you care for your skin. Intrinsic factors are less controllable, and refer mostly to the inner programming we call genetics.

Want to know what your skin will look like in a couple of decades? “Look at your grandparents and it will give you a good idea,” says Dr. Ava Shamban, a cosmetic dermatologist in Beverly Hills, Calif. This will show you what your DNA has in store for you: The slow decline of your skin cells. “It’s not completely understood, but we’re zeroing in on the intrinsic causes of aging,” says Dr. Shamban. “In the shortest version, the cells stop renewing. It’s… genetic programming that we don’t know how to reverse yet.”

As the cells begin to slow down, the effects are apparent in myriad ways. In terms of skin, “There seems to be a timer in our cells that signals them to act differently,” says Dr. Anna Guanche, another top Southern California cosmetic dermatologist. Take our levels of elastin, for example—the all-important elastic protein in skin tissue that lets it resume its shape after stretching or contracting. Our elastin level peaks before we’re born, and then declines until we’re about 40, after which there is no production. “So whatever you have at 40 is what you’ll have ‘til the end,” says Dr. Guanche.

Other effects of aging include: Deflated fat cells in the skin, which lose firmness and don’t hold shape well; a loss of collagen, the connective tissue that keeps skin together; and a slowdown in the turnover of the epidermis, the skin’s outer layer, leaving it dulllooking. We also lose bone and muscle that support the skin. As Dr. Guanche explains: “When I see an aging face, it’s a loss at every level. It’s a global thing.” In general, our cellular renewal processes have stalled if not completely ceased. The result is a loss of volume, definition, elasticity and tone, along with an increase of lines, wrinkles and pigmentation.

The good news is that while doctors are still unraveling the mysteries of intrinsic aging, they already know a great deal about extrinsic aging, and how to prevent it.

In the extrinsic arena there is no worse contributor to aging skin than the sun, says cosmetic dermatologist Joel Schlessinger, MD, of Omaha, Neb. “Stay out of the sun, because ultraviolet creates free radicals that destroy cell membranes,” warns Dr. Schlessinger. If not, “collagen goes from fluffy, straight and elastic to a shrunken bundle like a balled up rubber band.” The result? Early wrinkles, not to mention photo-aging and those unsightly sun and age spots.

Dr. Shamban’s list of culprits to avoid include pollution, toxins and substances that cause inflammation. That means no smoking and less sun exposure, of course, but also includes staying away from a diet rich in meats, processed foods and white sugars (sodas included). In a process called “glycation,” high levels of glucose get deposited on collagen and destroy it. So, high sugar foods accelerate the aging of skin. “Tissues are less flexible when glycolated,” Dr. Guanche explains.

The Arsenal Against Aging Skin

So what can be done? Dermatologists and cosmetic surgeons have an arsenal of fixes for everything from wrinkles and sagging jowls to lip lines and crepey eyes. Most doctors prefer a multimodal approach, using several tools in a tailored approach. “No two cases are the same,” says cosmetic surgeon Joe Niamtu, MD, of Northern Virginia. “One has to break down the problems in order to decide on the best treatments.”

The top tools in the cosmetic arsenal include lasers, fillers and botox for wrinkles; peels and lasers for pigment changes and acne scarring; radio and sound frequency tools for skin tightening; and regenerative techniques like stem cell-rich fat transfer to restore volume loss, and regenerate collagen and elastin.

Cosmetic physicians typically combine procedures for the best overall outcome. There is also the trend toward using non-invasive techniques, rather than plastic surgery. “The client who wants dramatic change… it used to be a facelift,” says Dr. Schlessinger. “We docs have to reprogram patients who think in terms of allat- once-techniques. The problem is you end up not looking like yourself. It used to be tuck and pull. Now it’s revolumize with fillers to change face shape, motion prevention with botox, and non-invasive lasers for wrinkles.”

In the end, it all depends on what the individual wants, the price in time and money she (or he) is willing to pay, and the skills (plus aesthetic understanding) of the physician involved. For the face in particular, a combination of procedures often produces the best result. As cosmetic physician Dr. Tom Barnard of Ontario, Canada says, “There’s nothing like a combination of all techniques applied in a good practitioner’s hands. The results can be astonishing!”

Smooth Skin: Lasers & Peels

One of the oldest techniques in the world to remove wrinkles and discoloration is the chemical peel. This goes back to the days of Cleopatra. And while chemical peels are still used by cosmetic doctors today, lasers have largely replaced them. High-tech aside, they work in a similar fashion: They ‘burn’ the skin, which triggers the skin to heal. As it heals, collagen production is stimulated and a ‘new skin’ emerges, smoother, less wrinkled and less pigmented.

There are different kinds of lasers, but they come down to two main types: The ‘ablative’ lasers that wound the surface of the skin aggressively (ablative means to vaporize), and the ‘non-ablative’ lasers that poke a pattern of tiny holes in the
skin, stimulating collagen production and skin tightening under the surface.

When it comes to getting rid of wrinkles, “Laser resurfacing and chemical peels are the gold standard,” says Dr. Niamtu, and both can have lasting effects when it comes to resetting the clock. The difference is the way the skin is injured. With a chemical peel, or dermabrasion, a wound is created and when it heals there is new epidermis and no age spots. Lasers use light energy to burn the skin and force the building of new collagen.

Dr. Niamtu prefers the old CO2 laser, which vaporizes the entire skin surface. While there are risks of permanent and temporary scarring, extended redness and infection, “It’s the go-to method for wrinkles,” he says, because it forces the entire surface to remake itself. Other limitations include the fact that necks areas cannot be treated aggressively, and that it requires two weeks of downtime for carefully monitored healing. But these are small prices to pay for smooth skin.

<The newest laser treatments are designed to get around these problems. Topping the list are the ‘fractional’ lasers, which send light energy in a pattern that hits only parts of the skin—sort of like touching only the red squares on a checkerboard. These lasers are gentler, leaving surrounding healthy tissue to help in the healing process. With these lasers, the neck and décolletages can be done effectively. They also require only a couple of days for recovery. The downside is that they are far less profound in their effect, and require a series of treatments spread out over a period of months. Full results are seen only after six months.

Most doctors agree that the more aggressive the laser treatment, the better the result—but that means more discomfort, more downtime and more risks of side effects. There is also some controversy over which of the new lasers work best. “We’re still looking for the holy grail of reproducible results with lasers that are not invasive and it’s still not happened yet,” says Dr. Schlessinger.

Either way, lasers can smooth skin texture, remove wrinkles, and make your skin look ten years younger or more. But the procedures don’t come cheap; either all at once or spread out over time, the treatments will run between $4,000 and $6,000. But doctors point out that since the results are enduring—they last for five years or more—it’s money well spent.

Full Volume: Fillers & Neurotoxins

By now everyone should have heard about Botox, or similar neurotoxins such as Dysport and Xeomin, which put a stop to the dynamic movement of muscles that cause wrinkles around the eyes and brows. All work to paralyze the offending muscles for months at a time, which not only reduce the wear and tear on your skin, but actually make some of those deep lines—like the famous ‘elevens’ between the eyebrows—just go away. For those who want no downtime, they are a good option.

But that is really just the first part of the story, because neurotoxins don’t actually erase wrinkles, or improve the volume or shape of the skin. For that you need something called ‘fillers.’

Fillers, like Juvéderm, Restylane, Radiesse, Sculptra and Belotero, mimic the natural materials found in our cells and are injected into skin folds, deep wrinkles and lines to lift and reshape the face. There is even some level of new collagen production, particularly with Sculptra as it stimulates the body’s own collagen production to plump folds and wrinkles.

“They don’t tighten,” explains Dr. Joseph Eviatar, a cosmetic surgeon who practices in Manhattan, NY. “Fillers improve contour … For deep wrinkles, you have the option of deep-acting lasers or a combination of botox and fillers. If downtime is an issue, fillers are the way to go.”

Because most clients want something quick and easy that does not interrupt their lives significantly, large volume fillers have become increasingly popular. “They’re efficient, cost less and are instantly transforming,” says Dr. Schlessinger. “I had an older woman in my office who had lost all volume in her lower face. Six syringes later, she cried. It is rewarding. Before, only facial implants could do that.”

Each product comes with different durations of effectiveness. Radiesse lasts one to two years, while Sculptra lasts two to three years, a duration that is reflected in price. A syringe of Juvéderm can run from $700 to $800; Sculptra, on the higher end, can run from $1000 to $2000. Overall costs depend on how many syringes are needed.

“Each product has slightly different properties,” says Dr. Eviatar. “It’s not about the products as much as proper placement, and the understanding of facial anatomy and technique.”

In fact, what’s new about fillers is how they’re being placed. “Fat volume is lost in areas around the eyes and cheeks. Skin becomes less taut. You get folds around the mouth because of loss of support,” says Dr. Eviatar. Older methods would have dictated filling in the fold itself, sometimes leading to a puffed-up appearance. Now, he says, “We address the underlying cause in the supporting tissue around the folds, address the loss of fat volume and tighten the skin.”

In other words, fillers were once primarily used to ‘fill in’ facial depressions, such as deep wrinkles. Now they are being used to lift and re-sculpt the face.

“You restore fat pads around the cheeks and that pulls up the jowls and the nasal labial folds [the parenthesis lines one either side of the mouth],” says Dr. Shamban. “You can do injections, for example, along the jaw line to define that. Or you can revolumize the lips… You’re trying to define the features better because everything shrinks and sinks.”

As with all procedures, fillers are both an art and a science. Proper training is needed. “In the wrong hands, people can look terrible,” says Dr. Eviatar. “You need to be able to analyze the face, understand facial anatomy, understand the aging process and know where to place the fillers to get the correction you want.”

Tighten Up: Radiofrequency & Ultrasound

While lasers work on the surface, and fillers restore volume to that surface, another approach to improving the appearance of skin is below-the-surface heat.

Today there are a variety of technologies that use radiofrequencies (like Thermage or Pellevé), ultrasound (Ulthera) or infrared light to tighten sagging skin and smooth wrinkles from the inside. No matter what the source of energy, the goal is to target tissue deep below the skin’s surface with heat, which causes damage that tightens the skin (think shrink wrapped), while stimulating collagen and elastin production.

Among the benefits to this approach is recovery: There is no downtime. Sessions take about one to two hours and cost $250 to $450 dollars, depending on the scope of area to be treated. These treatments won’t do the work of a deep laser on deep wrinkles, but can yield great results for face contouring as well as body sculpting.

“They are just types of energy along the electromagnetic spectrum—light energy, sound energy—but all induce a healing response that stimulates production of collagen and elastin and result in tightening,” explains Dr. Barnard.

Dr. Barnard particularly likes the Ion Genius and Ion Magnum for the face as well as body sculpting.

“Whatever energy you use, you would like not to damage the skin surface, but to enhance it,” he says. “These [devices] fire energy past the surface of the skin to the sub-dermal layers. With some of these ionic machines, you go past that to the muscle to stimulate them… tightening muscle while you’re tightening the skin.”

Dr. Darab Hormozi, a cosmetic surgeon who practices in Towson, MD, uses an Ellman device around the face and eyes, as well as Pellevé, both of which use radiofrequency. As he describes, “Its like a microwave. It vibrates the molecules, heats collagen and stimulates the body to produce more.” Hormozi says the ideal patient is 40 to 50 years old because “they still have collagen. In an 80-year-old you won’t see improvement because they don’t have enough collagen left to stimulate.”

Dr. Hormozi says there is an incremental improvement over time. One session is not enough; instead a series of four or five ($400 each), with a few weeks in between is required. “It’s not like a laser where you see results in two weeks. It takes six months to see final effect.”

The advantage is no downtime and the result is firmer, tighter skin. “You are constantly upping the collagen. If I start with 1,000 fibers and do a treatment, it will increase to 2,000 fibers. If I do it again, I will get 4,000…so there is an exponential improvement with each treatment.”

Get Glowing: Stem Cell Fat Transfer

Undoubtedly the most revolutionary of procedures to repair and rejuvenate the skin at a cellular level is the use of the stem cell-enriched fat, which takes advantage of the growth factors in stem cells. “We are about to enter a new era in maintaining and rejuvenating tissue,” says Sharon McQuillan, MD, who practices aesthetic and anti-aging medicine in South Florida.

The stem cells in question are not the controversial embryonic stem cells of yesterday, but are ‘adult’ stem cells found in human fat that can be activated once the fat is removed via liposuction. They have the power to become other types of cells, but more importantly release what are called ‘growth factors’ that tell various kinds of tissue (including skin) to rebuild itself.

Dr. McQuillan uses stem cells in two ways. In a unique procedure she calls “cell-assisted resurfacing,” she uses stem cells to enhance a resurfacing procedure by applying stem calls topically afterwards to cut healing time in half and achieve better results. The other more common use is for patients that need volume enhancement. For this she will inject stem cell-enriched fat to achieve a stable and enduring fat graft. Sometimes, she will use both procedures on the same patient. “It’s attractive to rejuvenate the skin in a nurturing supportive way rather than just with a controlled thermal injury,” she says.

In the past, fat from one part of the body was injected into areas of the face to revolumize it, but these procedures proved unstable. Often, much of the fat was reabsorbed into the body, and the volume was lost. With stem cell-enriched fat transfers, stem cells are isolated and harvested from a portion of the fat to create “supercharged fat” that remains stable and rich in growth factors, for a long-lasting rejuvenation that also improves the tone and quality of the skin.

Cosmetic physician Dr. Joseph Broujerdi of Los Angeles describes how it works: “The procedure involves removal of fat from undesirable places like the abdomen or thighs. This is not regular liposuction, as you need techniques that don’t damage the fat cells. In a special separation process the stem cells are isolated and counted, then reconstituted and reintroduced.” Stem cells are the “building blocks of the body, construction workers that repair,” he says, and if you mix a high concentration of stem cells into the fat, most of it will not only survive, but thrive—rejuvenating the skin, adding stable volume and repairing damage.

Dr. McQuillan warns that while there are doctors performing this technique and getting good results, because standardization is lacking for the procedure, there are many doctors advertising stem cell transfer procedures who are not qualified and may only be injecting simple fat. Separation and injecting techniques vary, as well as the artistry involved in the placement of the stem cell-enriched fat, which must be injected in micro-droplets so that all stem cells have a good blood supply to thrive.

A stem cell fat transfer to the face can cost anywhere from $5,000 to $8,000. But doctors say it is one of the most dramatic and enduring corrections. While the techniques are new, follow-up studies tracking stem cell-enriched fat transfers show stability more than two years later, since the fat is “alive.”

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