Daily Skin Fix

Skin and Sin

There are sins of omission, sins of commission, and just sin.

Sins of omission, is not doing something. For hair that could be not getting enough iron intake and having hair loss as a result. For nails it might be not keeping the edges filed, and getting splits at the ends. For skin it could be not wearing sunscreen daily and using a targeted anti-aging skin care program so your skin ages faster than it needs to, or having severe acne, but not treating it, and then getting scarring.

Sins of commission are things you do that are just the result of bad decision making, that affect the skin, hair and nails, and badly. For hair it is that really unfortunate hair color, or decision to resurrect your 80’s perm. For nails it is wearing acrylics continuously, rocking the ends and super gluing the loose areas yourself. For skin it is going to the tanning bed 5 times a week.

And just sin is when you do something you know is damaging, and that serves no purpose, but you do it anyway. For hair it could be over plucking the eyebrows until you look like a silent movie star from the 1920’s. For nails it is biting them to the quick and ripping the cuticles off so that you can’t show your hands in a job interview. For skin it could be picking at that pimple 4000 times using your 15 power magnifying mirror, when you know nothing will come out of it, but you can’t stop picking. And then when it is trying to heal, picking at it again.

Of course, there is a lot of overlap, as when you don’t do something, and it is bad decision making, and it really serves no purpose but you do it anyway. Like not wearing sunscreen on your face, neck, forearms and hands every day. Yes, it does take 20 seconds to do. As opposed to the 5 minutes it takes to apply a heavy foundation to cover up the effects of sun damage. Clear cut categories of sin are sometimes in the eye of the beholder. And some of my “skin sins” are really other sins that affect your skin, but as my grandmother used to say to me: “Little missy, don’t try to talk your way out of this one, I am on to you. Just admit you are wrong, say you are sorry, and don’t do it again.” And as usual, she was right. So without further ado, here are my top 10 Skin Sins.

Top 10 Skin Sins

1. Unprotected Sun Exposure. You knew it would be #1. I am not going to go into my usual tirade about the aging and damaging effects of the sun, except to say—daily sun exposure is one of the top 2 most aging things you can do to your skin, and causes skin cancer. It causes discoloration, broken blood vessels, wrinkles, large pores, loss of elasticity and that stiff, yellow cross hatched skin that is characteristic of chronic sun exposure. You know this, so put on your sunscreen every day.
2. Smoking. Do I really have to say this? Smoking reduces blood flow in the skin, exposes you to direct toxin exposure on the skin and in the blood. And, if that’s not bad enough, the facial expressions repeated over and over etch lines in the skin. It is the other sin in the top two most aging things you can do to your skin. Whatever you do– don’t do 1 and 2 together. The effects of chronic sun exposure in smokers are much more damaging than either one alone. The results aren’t pretty.
3. Procrastination. I see this frequently. Young people in their twenties and early thirties are more worried about hair style, eye shadow, and outfit than they are about the health of their skin. That’s because they are young, and by and large have good skin. And then in their thirties and early forties they are raising a family, busy at work. Mornings are too rushed to apply sun screen, and evenings never end so active skin care is not applied. Then all of a sudden at 45, they have an “OMG what has happened to my face” moment. And end up in my office. All of the easy stuff to slow down aging of the skin work best when you do them while your skin is still good. And they are not really complicated—sun screen every day, a retinoid (tretinoin, retinol etc.) every night, a peptide lotion and a combo botanical and fruit acid serum once a day. Add a little Botox when those frown lines start showing and a little dermal filler for smile lines and you are good. Yes, those things help later too, but it is always easier to prevent than try to fix the damage.
4. Following every fad. There are patients who jump from doctor to doctor and back again. They try this new procedure, that new skin care ingredient they read about. Some may be appropriate for them, some are not and some are bogus. But they never stick with anything long enough to see the results they could see if they picked one doctor, committed to a treatment plan and then followed through.
5. Ignoring your teeth. We all lose bone structure in our face as we age. When we do there is less structure to the eyebrows, cheeks, around the mouth and at the jawline. Soft tissues and skin sag when there is less underlying structure. Tooth loss leads to loss of supporting bone structure around the mouth. Teeth wear down and become discolored over time. The result is a collapsed mouth without enough underlying structure to fill out the skin. So take care of your teeth. You need them.
6. Yo-yo weight fluctuations. The weight goes on. The weight comes off. The weight goes back on again. Repeat. Skin is pretty elastic, up to a point, when you are young, but it loses elasticity over time. At any age, too many episodes of weight gain and stretching, or too large of weight gain and skin loses its ability to shrink back. The result is sagging skin on the face, and sagging and stretch marks on the body.
7. Picking, picking, picking. One of my pet peeves. So much so I wrote a whole series on why you should step away from the magnifying mirror before someone gets hurt.
8. Accentuating asymmetry with bad eyebrows. Another of my pet peeves. Eyebrows frame your eyes and balance your face. Symmetry is the hallmark of a young face. We all get more asymmetrical over time but funky eyebrow shape accentuates it. The biggest mistakes are tweezing the brow too thin, tweezing the center margin too far outward and starting the arch too far centrally giving a comma shaped eyebrow. Hold a pencil parallel to the outside corner of your nostril through the inside corner of your eye to your eyebrow. Only tweeze center of this line. Rotate the pencil through the outside corner of your eye to your eyebrow. This is where your eyebrow should end. Rotate through the outside edge of the colored part of the eye to the brow. This is where you arch. Do it right and it will make a big difference.
9. Wearing heavy, mismatched foundation. Heavy foundation actually makes texture abnormalities like large pores, lines and wrinkles look worse. It can cover red discoloration. So lighten up on the foundation. It you want to fill in some of the texture abnormalities like lines and pores, and then use silicon based translucent foundation primer, followed by a lighter liquid foundation or mineral powder applied with a sponge.
10. Rushing around, doing too much and not getting enough sleep. During sleep many of the body’s natural repair mechanisms are more active including those that repair your skin. Sleep deprivation leads to both decreased levels of some beneficial hormones and less time to repair damage. Missing sleep for one night makes you look bad the next day and missing sleep on a routine basis can affect your appearance long term. So let everyone else do some of the work and go to bed.

It takes little or no money to correct these 10 skin sins. Just consistency and a little determination. So follow my grandmother’s “advice”—admit you are wrong, tell your skin you are sorry, and don’t do it again.

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Dr Elaines’s Advanced Skin Treatment is a dermatologist developed clinical skin care line that combines effective cosmeceuticals with proven natural botanicals.  Cosmeceuticals are compounds that have effects on the skin. The main groups are the peptides, antioxidants, growth factors, alpha and beta hydroxy acids and vitamins. They improve fine lines, roughness, blotchy pigment, loss of elasticity, dullness, acne, and stimulate collagen production. Our botanicals are plant derived compounds that are used for their antioxidant, anti-inflammatory, exfoliant, moisture balancing, and collagen stimulating properties.

Our Ageless Effects Clinical Anti-Aging Skin Care is both a preventative anti-aging strategy and a repair strategy for skin that needs help. It is your everyday anti-aging health program for your skin, and the foundation of an anti-aging program.  Your skin is smoother with a healthy glow, reduction in appearance of lines, wrinkles, and brown discoloration.

Acne is a common problem, that affects people of all ages. Dr Elaine’s Advanced Skin Treatment Perfect Effects Acne Skin Care prevents and treats acne blemishes, pimples, blackheads, and reduces irritation, and red and brown discoloration that occurs after the pimple has healed. It also reduces the dryness that occurs with some acne medications and can be used effectively with prescription acne medications.

For Rosacea and sensitive skin try our hypoallergenic, fragrance free Gentle Effects skin care, to reduce redness, dryness and irritation.

Dr Elaine’s Silken Effects for hair and body care line, with both treatment and maintenance products help reduce dry, scaling or irritated skin and give you beautiful hair.

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If you already use Dr Elaine’s skin care, take advantage of this great sale to stock up. If you are considering trying it,  this is a great opportunity.

I always try to avoid a skin decision that will turn out badly.

And so should you–More skin decisions that are best avoided

6) Not doing the recommended patch test on the hair color box

I know, it seems stupid and you don’t want to waste time with it. You have used that brand/color before. And it is just hair color not poison. I used to think that way too.

But here is why you should do it. Paraphenylenediamine (PPD) is a chemical substance that is widely used as a permanent hair dye. PPD hair dyes usually come as 2 bottles, one containing the PPD dye and the other containing the oxidizer, and are most commonly seen in that beautiful blue-black color. Acute allergic contact dermatitis to PPD can cause severe swelling, redness, blistering, weeping, oozing, itching and pain of the entire scalp. Eyelids can swell shut. Patients who experience this unfortunate reaction are quite uncomfortable and also quite unsightly. And if they have also used it on the eyebrows, like a recent patient, the reaction extends over the face.

There are methods to try to neutralize the reaction by completing the oxidation of the PPD, and they may be of some help. But it is not uncommon for the reaction to persist for some time, until the hair grows out. Some patients even shave their heads to remove the treated hair.

And just because you have used it before, you are not safe from this reaction. Allergic contact reactions occur on the second or subsequent time that you are exposed to the chemical. It takes one exposure to sensitize you to the chemical, and then at some later exposure, you react. So it could be the second time you use it, or the hundredth. And it could even be the first time, if you have come into contact with PPD from one of its other non-hair related uses.

So if severe redness, swelling, blistering, weeping, oozing, itching of the scalp and eyelids is not the look you are going for, do the patch test.

7) Picking–and picking, and picking, and picking…..

Some people can see a pimple on their cheek, pop it once, and leave it alone. Some will dig a hole down through the muscle–really. There is a spectrum of picking from–don’t even see it and leave it alone–pick at it once–keep picking when you know it won’t help–pick at it every day because it is dry and flaky and makeup won’t go on right–pick at it several times a day and feel guilty about it–pick at it and keep the same spot going for months to years–dig a hole to China.

In my experience, women are 99.95% of the pickers. I am one, that’s why I went into dermatology, so I could do it legally.

No comments from men, please. In my experience, 99.95% of the patients who say “I just took out my pocket knife and tried to cut it off, and then it started bleeding and got infected” are men.

Here is a secret–If you keep picking at it, it will never heal and may very well scar.

8) Not knowing when to stop with plastic surgery

Natural, subtle, expertly performed plastic surgery is great. Unnatural, obviously operated upon, poorly performed plastic surgery is not. And one of the problems with going too far with plastic surgery, is that just like some other decisions in life, it can be really hard to undo the effects.

There are many reasons that people just keep going with plastic surgery, having procedure after procedure and not stopping when most others are happy with much less. It may be an attempt to fix something else like a failing marriage, Body Dysmorphic Disorder (BDD), an attempt to fix previous unsatisfactory surgical results, unrealistic expectations, peer group norms, or just that they have forgotten what they really look like. And there are plastic surgeons who don’t discourage this, although the good ones will tell you–stop.

The problem is that patients who have had too much plastic surgery look less attractive, not more. Everything looks unnatural and alien-like. Stop before you reach this stage and start looking like poor Michael Jackson.

9) Letting a poorly trained individual do something like pour acid on your face

We are seeing more and more of this kind of problem, patients coming in with complications after a medical treatment by non-medical, poorly trained, or poorly supervised individuals. Things that change your skin, change your skin. And they can change it for the better, or for worse. These cosmetic treatments are specialized medical procedures. Medical procedures need to be done by well trained medical professionals. These treatments seem easy, and when done right, usually go well. But they can, and do, go wrong. A big part of cosmetic dermatology practice is knowing and preventing the risks, by knowing what not to do, and especially knowing who is at increased risk of complications. And you better know what to do about any complications, and do it in a timely fashion.

I have been told–it was cheaper, she is my friend, I won the raffle (hint–everyone wins), they were practicing (practicing??? on your face???) and on and on.

Be a responsible consumer and patient, do your research before you commit to having a procedure. Your face and body deserve at least as much research as a flat screen TV. Maybe even more.

10) Ordering fillers, Botox or chemical peels off the internet and doing them at home

When I first heard about this, I thought it must be a joke. But yes, people actually order compounds of unknown composition, unknown sterility, unknown reactions off the internet and take a needle and syringe, and try to figure out where, how, how much to inject and stick it in their face. Many times these are either counterfeit or a non-tested “special brand”.

And these people vehemently argue that it is their right to order the most potent toxin known to mankind, one that is being counterfeited and sold by terrorist groups, off of the internet and inject themselves, because the “greedy doctors charge too much”. Because the internet is a completely trustworthy, ethical and safe system, worldwide. We are the world.

I have just two words–Darwin Award

So now we are on the last of the 5 R’s of treatments in a cosmetic dermatologist’s anti-aging aesthetic plan: Repair, Relax, Restore, Resurface, Redrape

• Repair Sun Damage–Reduce Lines, Wrinkles, Spots, Sagging
• Relax Muscle Action–Reduce Lines
• Restore Volume–Reduce Lines, Restore Fullness and Lift Sagging Skin
• Resurface Skin Texture–Reduce Lines, Wrinkles, Pore Size, Scars
• Redrape Sagging Skin–Lift and Firm Sagging Skin

On to Anti-Aging Skin Rejuvenation Plan Step #5–Redrape Sagging Skin

It is an unfortunate fact of life–gravity will win. But we can put up the good fight in the meantime.

Young skin is tight skin. It has a natural elasticity that causes it to rebound to its original position quickly when it is stretched. It holds everything up where it is supposed to be. The natural fat pads are held up under the eyebrow, up tight under the eye, and up high on the cheek. Skin feels firm. Eyelids are smooth and tight. The jaw line is tight, with the skin up against the bone. The operative word here is “up”.

With aging, collagen and elastic fibers are broken down and the skin looses elasticity as a result of repeated exposures due to damaging effects of the sun, gravity, smoking, environmental toxins, glycemic diet, weight fluctuations, and hormonal changes. Skin feels too loose. Everything starts to sag. Patients say “my face, and everything else, is falling”. The fat pads end up dragging the eyebrows down, as bags under the eyes, and the cheeks end up at the lower face as jowls. Neck is flabby. And let’s not even go below the neck.

Adding to the loss of elasticity is the loss of volume in the face. With aging, loss of fat, collagen and bone structure cause the skin to be too loose around too little volume. When this happens, gravity takes over and the skin sags. When this occurs, the skin needs to be tightened and everything needs to be lifted–it needs to be redraped. Sometimes volume needs to be replaced in the areas where it has been lost. Tightening, lifting,  and redraping restores tighter more youthful skin.

Lifting and tightening skin can be divided into: methods to prevent or slow down sagging, treatments to give modest tightening, and  procedures that are required when sagging is more pronounced.

Next: the best ways to prevent or slow down sagging skin

How do you know which aesthetic skin resurfacing treatment is right for you?

I am often asked this question and my answer is “what do you want to accomplish, how much improvement do you want, and how much time and money do you want to devote to it?” You can start at either end–want do you want or what are you willing to do to get it, but you have to start somewhere. Cosmetic skin resurfacing procedures that are more aggressive give more results. They cost more, usually because of the technology involved.

If you expect a lot of improvement, but don’t have the time or money to get there, you are going to be disappointed. Sometimes this is a hard pill for patients to swallow. They want the kind of results that the procedures that they can afford won’t give them. I try to be honest and explain the real world results that they can expect, and then the choice is to do the less expensive, less aggressive treatments and get some improvement, do financing and pay it off over time, or save up until you can afford what you need. On the other hand, if you don’t need or want more aggressive results, then the less aggressive procedures are right for you. That’s why the prevention strategies we discussed previously are so important. But if the horse is already out of the barn, you have to do what it takes to get him back in.

Remember if you are not my patient don’t pay attention to what I tell you. Pay attention to what your doctor tells you.

If you have these changes, then these are your options:

Dull skin:

• Home treatment: exfoliants, glycolic, salicylic or multi-fruit acids, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: light chemical peels, microdermabrasion (SilkPeel), LED (GentleWaves)
• More aggressive office treatment: not needed

Flat brown spots:

• Home treatment: some improvement if mild*–exfoliants, glycolic or multi-fruit acids, tretinoin (Retin-A, Renova, Refissa), skin bleach
• Less aggressive office treatment: light chemical peels, microdermabrasion, LED (GentleWaves)
• More aggressive office treatment: Intense Pulsed Light (IPL)

Raised brown spots:

• Home treatment: won’t work
• Less aggressive office treatment: lesions destruction with liquid nitrogen or electocautery
• More aggressive office treatment: lesion destruction + laser resurfacing

Fine lines

• Home treatment: glycolic, multi-fruit acids, peptides, growth factors, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: LED (GentleWaves), Botox, light chemical peels, microdermabrasion (SilkPeel)
• More aggressive office treatment: laser resurfacing

Skin colored bumps (milia cysts, moles, syringomas, fibromas, etc)

• Home treatment: milia only–exfoliants, glycolic, salicylic or multi-fruit acids, tretinoin
• Less aggressive office treatment: milia only–light chemical peels. All others–lesion destruction with shaving, electrocautery
• More aggressive office treatment: laser resurfacing

Broken blood vessels

• Home treatment: won’t work
• Less aggressive office treatment: electrocautery to isolated veins
• More aggressive office treatment: Intense Pulsed Light (IPL)

Non-etched wrinkles (go away when you stretch the skin)

• Home treatment: some improvement if mild*– glycolic, multi-fruit acids, peptides, growth factors, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: dermal fillers (Juvederm, Restylane etc), Botox
• More aggressive office treatment: laser resurfacing,dermal fillers and/or Botox + laser resurfacing

Etched wrinkles (don’t go away when you stretch the skin)

• Home treatment: some improvement if mild*– tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: dermal fillers (Juvederm, Restylane etc), Botox
• More aggressive office treatment: laser resurfacing, dermal fillers and/or Botox + laser resurfacing

Rough spots (pre-cancerous actinic keratosis)

• Home treatment: some improvement if mild*– tretinoin, more improvement with– prescription topical fluorouracil, imiquimod, diclofenac
• Less aggressive office treatment: liquid nitrogen
• More aggressive office treatment: photodynamic therapy (IPL/PDT)

Enlarged pores

• Home treatment: if plugged only–exfoliants, glycolic, salicylic or multi-fruit acids, tretinoin (Retin-A, Renova, Refissa), tazarotene (Tazorac), and adapalene (Differin)
• Less aggressive office treatment: if plugged only–light chemical peels, microdermabrasion.
• More aggressive office treatment: if permanently enlarged–laser resurfacing

Scars

• Home treatment: some improvement in acne scars if mild*– tazarotene (Tazorac)
• Less aggressive office treatment: some improvement in acne scars if mild*–light chemical peels, microdermabrasion, dermal fillers (Juvederm, Restylane etc)
• More aggressive office treatment: laser resurfacing, surgical removal

Loss of elasticity

• Home treatment: some improvement if mild*–glycolic, multi-fruit acids, peptides, growth factors, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: some improvement if mild*–light chemical peels, microdermabrasion.
• More aggressive office treatment: laser resurfacing

Elastosis (yellowish, stiff, bumpy, permanently creased or cross-hatched change from long term sun damage)

• Home treatment: won’t work
• Less aggressive office treatment: won’t work
• More aggressive office treatment: laser resurfacing

Note: “some improvement if mild*”–your definition and my definition of mild may not be the same.

Next: What’s it gonna take?

Moving down the 5 R’s of anti-aging treatments in a cosmetic dermatologist’s aesthetic plan: Repair, Relax, Restore, Resurface, Re-drape–

1. Repair Sun Damage–Reduce Lines, Wrinkles, Spots, Sagging
2. Relax Muscle Action–Reduce Lines
3. Restore Volume–Reduce Lines, Give Youthful Fullness and Lift Sagging Skin
4. Resurface Skin Texture–Reduce Lines, Wrinkles, Pore Size, Scars
5. Re-drape Sagging Skin–Lift and Firm

On to Anti-Aging Skin Rejuvenation Plan Step #4–Resurface Skin Texture

Young skin is smooth skin. When you look at a child’s skin you see smooth, plump skin without wrinkles, bumps, spots, scars. The pores are small, almost invisible. When you pinch it–gently of course–it rebounds to its original position immediately.

Over time, with continued sun exposure, gravity, repetitive muscle action, smoking, environmental toxins, a glycemic diet, weight fluctuations and hormonal changes, your skin begins to change. Lines develop, brown spots and broken blood vessels appear, pores enlarge, bumps and rough spots appear and skin develops a faint yellowish thickened “crepe paper” stiff appearance. Light doesn’t reflect as well giving a dull appearance with loss of glow. If you pinch it, it bounces back sluggishly as elasticity decreases.

When this occurs, the skin needs to be resurfaced. Just as when you refinish your floors to remove scrapes, dents, pits and ripples, your skin needs to have the etched wrinkles, crepiness, spots, bumpy surface removed and pore size reduced. Resurfacing restores smooth youthful skin.

The best way to slow down this progression is prevention: consistent daily sun protection with sun block every day; avoidance of weight fluctuations, toxins and smoking; eating a healthy diet; daily use of topical retinoids, antioxidants, peptides, growth factors, exfoliants,  fruit acids; and reducing excessive facial expressions with Botox.

For early signs of aging requiring gentle intervention: light or medium chemical peels, LED light treatments, and medical microdermabrasion.

If aging changes are more advanced options are: deeper chemical peels, and laser resurfacing.

Next: skin resurfacing at home treatment–the easy way–preventative maintenance

Let’s finish Restore Volume–Reduce Lines, Give Youthful Fullness and Lift Sagging Skin with my top 10 anti-aging cosmetic skin filler tips.

The first 5:

1) If you can only afford one anti-aging treatment–do cosmetic filler injections

Doing aesthetic filler injections is one of my very favorite procedures because it makes such an improvement in giving a healthy, youthful appearance. But you do have to be realistic about how many syringes you need, and the results that you can achieve with the number of syringes you can afford. It takes a certain volume to get a certain result. It is fine to do it a little at a time as you can afford it, but to say that “filler didn’t work” when you needed three syringes but only did one is not a fair test.

I always try to stay grounded in reality.

2) Don’t expect filler injections to remove etched lines

The hyaluronic acid fillers Juvederm and Restylane plump up wrinkles from below and provide lost fullness. But if the line is etched from being folded ten million times, you will need skin resurfacing to really smooth the sharp line. If you stretch the skin and the wrinkle totally disappears, usually filler is all you need. If there is still a surface crease, you will need resurfacing. But either way the line will look a lot better after filler.

It’s always better to see the glass half full.

3) Treat eyebrows and temples

Yes, the lips, the corners of the mouth, and the smile lines are the first priority; cheeks next. But don’t forget the eyebrows and temples. With age, the eyebrows thin and begin to droop, especially at the outer comers. The fat that sits on the brow bone begins to descend, taking the brows down with it. A relatively small amount of Juvederm or Restylane in the outside wing of the eyebrow gives 3 dimensional structure and helps reduce hooding of the upper eyelid. Sunken temples give you a skeletal look and are aging.

Halloween was last night.

4) Treat corners of the mouth

Turned down corners of the mouth make you look unhappy and older. Juvederm or Restylane is injected below and to the side of the corner to turn it up. It breaks up the line from the corner down to the chin. You look happy.

Even when you’re not.

5) With age, thin faces need volume

They do.

Believe me.

Next: Part 2 of  Top 10 Anti-Aging Cosmetic Filler Tips

Cosmetic dermatologists achieve a youthful, aesthetically pleasing, attractive face by following the 5 R’s of anti-aging treatments: Repair, Relax, Restore, Resurface, Re-drape.

• Repair Sun Damage–Reduce Lines, Wrinkles, Spots, Sagging
• Relax Muscle Action–Reduce Lines
• Restore Volume–Reduce Lines, Give Youthful Fullness and Lift Sagging Skin
• Resurface Skin Texture–Reduce Lines, Wrinkles, Pore Size, Scars
• Re-drape Sagging Skin–Lift and Firm

Let’s go on to Anti-Aging Skin Rejuvenation Plan— –Step #3–Restore Volume

One of the most aging changes that happens over time is the loss of volume in the face. With age there is a loss of  fat, muscle and bone causing an aged, hollowed out, haggard appearance. In youth fat is under the eyeballs, in the cheeks, the temples, and the eyebrows. Over time this is reduced and drops which causes a “flat” face. This can be seen most dramatically in profile. Patients tell me “my face is melting.”

In youth the widest part of the face is the cheekbones, narrowing to the chin; called the “triangle of youth.”  With aging, volume is lost under the eyes leading to under eye bags,  hollows, and dark circles. The eyebrows fall when fat is lost, causing hooding of the eyelids. The high apple of the cheek falls. As the cheeks descend they cause deep lines from the side of the nose down past the corners of the mouth. These lines are like an arrow pointing downward, and appear to drag the face and neck downward.  The temples are hollowed, often with visible veins. The jaw line widens and the upper face narrows. The “triangle of youth” becomes the “pyramid of age.”  The skin’s “envelope” becomes loose over too little underlying structure leading to sagging, a flat and aged appearance and with jowls.

Adding to this is loss of volume in the lips as they become thinner and roll inward. Loss of bone around the mouth compounds the collapse of the mouth. Both cause a pinched and wrinkled mouth with radiating lines.

So basically, everything is falling. Cosmetic dermatologists call this deflation and descent.

And let’s not even talk about anything below the neck.

In the past, the looseness of the skin and the sagging was treated with a face lift alone, But that often lead to a gaunt, skeletonized, “caught in a wind-tunnel” look. The loss of volume needs to be corrected for a natural, rejuvenated appearance.

In any individual patient, either the volume loss or the looseness may predominate. But often it is a combination of both. If so, the problem of loss of volume and loose skin both need to be corrected. Although some patients certainly require a surgical face lift, we see many patients who successfully receive volume replacement only, or volume replacement combined with non-surgical tissue tightening with Thermage, sometimes called Therma-Fill. We will talk about this aesthetic option later.

Volume loss changes occur over time in us all, but may occur earlier in some than others. Of course, smoking or sun damage to collagen and elastic fibers cause the face to fall quicker and increases severity of facial lines. Individuals who have lost a great deal of weight, runners, and very thin individuals often show these changes earlier than others. I have a saying, “At a certain age, you have to choose between your face and your butt.” But actually you don’t– if you are willing to restore the lost fullness to your face.

So what on earth are we going to do?

Next: What we are going to do.

As promised here are my top three anti-aging choices for repairing sun damage:

1. Daily sunscreen, year round. I have been doing it every single day for 27 years. Do I need to refer you again to the previous post “Quit complaining and wear your damn sunscreen“?
2. Daily retinoid (tretinoin 0.05% cream) use. Again I have done this every single night for 27 years.
3. A series of IPL photorejuvenation treatments–usually 3-5. Gives a creamy complexion and is very effective in reducing the signs of aging sun damage.

An often overlooked area in sun damage protection and  treatment–the backs of hands, backs of forearms and the neck. Look at the sun exposed back of your forearm. Now flip it over and look at the sun protected inside. Do I need to say more?

So here is your bonus secret–Just treat the skin on the back of your forearms and hands and your neck exactly the same as your face, especially sunscreen every single day. Many people can only tolerate retinoids to these areas every other night because of dryness and irritation. So alternate tretinoin 0.05% cream (Refissa) one night and a peptide cream or lotion on the other nights. I use our fabulous peptide and antioxidant serum Line Diminisher every other night alternating with Refissa.