How Our Faces Age and What to Do About It (Ep. 6)

Dr. Hall: Welcome to The Trillium Show, where we help you make the changes you want to see in your body, in your mind, and in your life. I’m your host, Dr. Jason Hall.

Dr. Hall: Welcome to another episode of The Trillium Show. In today’s show, we’re going to talk about facial aging, specifically, the three main components of facial aging that must all be addressed separately for a treatment plan to be successful. So I see a lot of consultations for facial rejuvenation, and like any other part of cosmetic surgery—and this is a place where I think that people really get lost when we’re talking about cosmetic surgery—is that treatment is really based on anatomy and biology not on age, and facial aging is no different. Facial aging tends to happen in three areas that must each be addressed individually for us to really affect an adequate change.

Those three areas are number one, the skin; number two, volume, specifically fat, and number three is structure, underlying structure being bones, muscles, tendons, ligaments, things like that. And the big problem I see is that when people try to simulate facial surgery, they tend to pull on their face, their eyes, their cheeks, their neck, which not only lifts the skin, but also tightens the skin, and gives patients the wrong impression that lifting, a simulated in the mirror facelift will do the trick and is the answer to their problems. And the problem is—and this is where some junior plastic surgeons, kind of, get in trouble—is that it doesn’t, is that the shape may change but the skin doesn’t.

So in this episode, we’re really going to go into the three main areas of facial aging and break those down area by area, talk briefly about treatment recommendations for each area, and then in subsequent episodes, we will talk about specifically creating a facial treatment plan that not only will accomplish the goals that you set out with initially, but then will also maintain those results over time.

All right, so let’s talk first about aging of the skin. Now, aging of the skin is one of those things that really takes a long time to treat and is not really treated well with any surgical interventions. There is not a surgical silver bullet that’s really going to take care of skin aging. Skin aging happens and is the result of an accumulation of years and years of sun and environmental damage. Everybody knows about ultraviolet light.

Ultraviolet light leads to chronic inflammation, leads to telangiectasias—which are little blood vessels that are in the skin—and accelerates the loss of skin elasticity. This loss of elasticity is really what causes the wrinkles and the signs of aging that you can see externally. Additionally, things like nicotine will decrease blood flow in the skin which results in the loss of skin elasticity, which also occurs just as a general process of aging. Now, to turn back the clock really means minimizing wrinkling, not totally eliminating it. And this is where a lot of patients can get frustrated that they think that coming into the office and getting skincare treatments, spending money on skincare products, is really going to eliminate their wrinkles, and that really isn’t a realistic goal.

Really, the goal should be to minimize wrinkles over time, not totally eliminate them. Now, the other place that we get confused, that patients can kind of get confused is that pulling on the skin—which works in the mirror—is going to work in real life. And unfortunately, that really just doesn’t work. Pulling the skin that doesn’t have any elasticity is like trying to pull on an elastic waistband that has lost its stretch. It may look good for a short time, but after a very short amount of time that elasticity… and lack of elasticity is going to show up with things drooping and sagging.

Your pants that have lost their elastic stretch are going to end up around your ankles; your skin that’s lost its elastic stretch and you pull on it, is going to end up just sagging again. So pulling the skin that has lost its elasticity is doomed to fail unless we do something else. So this is why we go after skin treatments as a totally separate entity that is separate from surgery itself. Now, what are those treatments? Skin treatments really differ depending on the age of the patient and the patient’s specific skin anatomy and skin biology, like we kind of talked about at the very beginning.

For patients in their 20s, skincare really should focus on prevention of further damage. This is where skincare products that are focused on protection—sunscreen, topical forms of vitamin C, and topical forms of vitamin A which are we commonly know as retinol or retinoids—and the most common and well known being Retin-A—are very important in preventing the accumulation of that sun damage. As time progresses and the skin itself accumulates damage over time, we need to do more and more to rehab the skin, to rejuvenate the skin, and we’ll get into some of those here in a second. It’s important to note that skincare and taking care of your skin is very similar to taking care of your teeth. You can’t expect to have nice, clean, white teeth by just brushing your teeth once or twice a day—hopefully more than once a day–, but once or twice a day; you need to go to the dentist twice a year, get your teeth cleaned, do some additional whitening treatments and things like that for your teeth to really look their best.

Similarly with your skin, you can’t expect to come into the office once or twice a year, get a treatment here and then not do anything other than wash your face with the bar soap for the rest of the year and expect your skin to stay healthy. It’s important to have patients on medical-grade skincare treatment plan at home, coupled with in-office treatments. And those can range from things like microneedling to chemical peels to lasers to PRP injections. Things that are going to have a measurable impact on your skin health are going to be important over time not only as a treatment, but as a maintenance plan.

So for skin treatments, we’ll kind of delve into these really quickly. The skin treatments that we recommend pretty much for everyone who is over the age of 35 are three products. Your skin is very smart, the good Lord knew what he was doing when he put you together, and you don’t need a hundred different skincare products in order to have good looking skin. You really need three basic things. The first is protection in the form of sunscreen that you wear every day. We recommend a couple of skincare product lines. We’ll link to some of those in the [show notes 00:08:03] here.

The second is a form of topical vitamin A. Again, Retin-A is the most common brand that people know. There are other ones; again, we’ll link to the [show notes 00:08:14] the brands that we recommend. What a topical vitamin A does is helps that surface dead layer of skin that accumulates on the surface of your skin, what we call the keratinized layer of skin, it allows your body to slough that off which improves the surface texture. It also allows other skincare products to penetrate the skin better. Additionally, the topical form of vitamin A will help reduce the sweat glands, will shrink pores, and as a good treatment for fine lines and wrinkles that tend to show up around the eyes and around the mouth.

So sunscreen, vitamin A, and the third product that we recommend for anybody over the age of about 35 is a topical growth factor. The way our skin ages is that after about 35, give or take a few years, the skin quits producing something called growth factors which signals surrounding skin cells to stay young and continue to reproduce. This causes the dermal layer of the skin, which is the under the surface of the skin that you can’t see, to thin over time and is why as we age, our skin gets thin. By replacing that growth factor—and there are scientific studies out to back this up—that replacing the growth factor will physically thicken the dermal layer, the deep layer of skin where the collagen and elastin live and will increase the amount of collagen and elastin in the skin. This further helps reduce fine lines and ankles. And so that’s why a topical growth factor is vitally important in a long-term treatment plan for patients that are over the age of 35 or so.

The other way that we can do that is by giving the skin back your own growth factors in the form of nano fat injections or purified fat injections that we harvest. And this is typically part of a surgical or office-based skincare rejuvenation plan. And we can devote a whole podcast episode just to that in the future.

Those are the main products that we recommend for patients to use at home. Now we can transition to office-based skincare treatment. And the mainstays of office-based skin treatments are neurotoxins—so things like Botox, Jeuveau, Dysport, et cetera—and laser and light-based treatments. So just as a brief primer on the neurotoxins, so things like Botox help eliminate wrinkles by relaxing muscles. So they relax the muscles that cause the lines, the lines around your eyes—what we refer to as crow’s feet—the lines between your eyebrows, and then the forehead lines that run, kind of, across your forehead, are the main areas that we treat.

There are a lot of other areas that neurotoxins are useful that we can get into, but the way that these neurotoxins work is by relaxing muscles, which relaxes the lines. Once lines are there, then the toxins really aren’t going to do much. We have to talk about resurfacing and filling to really get those to go away. In general, light-based treatments, energy-based treatments, such as lasers and other things like that, are used to tighten and smooth the skin and also eliminate pigment. And those are also things that we can and will devote an entire podcast episode into discussing.

I think it’s important to take a little sidestep here that most treatments that offer no downtime, don’t work. In my opinion—and this is me as a surgeon—that if there’s not a downtime with a treatment, then we’re not doing enough to really make a significant change in your skin for those to really work. They work for maybe some really, really mild aging changes, but other than that, if it sounds too good to be true, it probably is. Lasers are, in my practice, a mainstay of skin treatments because they are so versatile. We can do so much with a laser platform that can rejuvenate the skin, from improving collagen, building up the under surface of the skin, to resurfacing the surface of the skin, that we can really do just about anything we need to do if we choose the right laser for the problem that we’re treating.

Now when I’m talking about lasers, I’m talking about something called an ablative laser. So this is a laser that actually works by destroying tissue, as opposed to a non-ablative laser, which works just by heating things up. Within that ablative category, there are really two subcategories of lasers: There are fractional lasers, and then there are what we call full field lasers. And when we talk about laser treatments, and ablative laser treatments specifically, I like to use a lawn care analogy to demonstrate to patients what exactly it is that we’re doing.

The fractionated lasers are exactly what they sound like. They treat a fraction of the skin at a given time. These lasers really work very similarly to aerating your lawn. They use laser light to make microscopic holes in the skin to get down deep into the dermal layer—so that thick layer of the skin where the collagen and the elastin live—and stimulate your body to grow more collagen and elastin to thicken the skin. So this is good for skin tone, this is good for general skin health and elasticity, it also works for mild to moderate depth, wrinkles, acne scars, surgical scars, things like that. It does require a few treatments. The more improvement we’re looking to make, the more treatments we need to do to get there, but is a great treatment option.

The other arm of the ablative laser category is the full field laser. And from a lawn care analogy, these are like resodding your lawn. These cover the entire surface of the skin when the laser is fired, and it strips off the surface layer of skin allowing new healthy skin to grow. You can really think about that as polishing the surface of the skin with laser light. The downtime and the effects of full field ablative laser treatments really depend on how deep we go, and that’s something that can be adjusted.

If we want to be very aggressive, we can go very deep, which will require fairly significant recovery for an office procedure, or if we want to take a slower route, we can not treat the skin as deeply and do multiple treatments with less recovery time. So full field lasers you can think of as polishing the surface of the skin. This is very similar to what we can do with chemical peel. But in my hands, we just have more precision with a laser, you can dial in the depth that you’re treating to and pretty much count on that, if you’re doing the procedure correctly, to get the results that you think you’re going to get. So we’ve spent a lot of time discussing skin treatments, primarily because this is an aspect of facial aging that I feel is largely overlooked, and is made much, much more complicated than it needs to be by a beauty care industry that makes billions of dollars every year by getting you to buy 15 or 20 different skincare products when really three good ones will work for most people.

So we’ve covered skin. The second part of facial aging is a loss of volume. Now, the volume loss in the face is fairly predictable and occurs in a predictable manner over time. We lose fat in our face, we lose bone in our bony skeleton, and those two things combine to give us the aging appearance that everybody kind of characteristically recognizes even if you can’t quite name what it is that you’re seeing. Volume loss tends to be most profound in the under eyes, around the mouth, in the temples, but it really happens all over the face.

Bone loss, which occurs primarily around the openings of the nose, around the eye sockets and around the jaw can exacerbate this soft tissue loss and make it appear worse. So when you start talking about replacing volume, the two options are off the shelf fillers, which are mostly hyaluronic acid-based, the gel fillers that everybody’s familiar with, or fat grafting using your own body fat to replace that volume that is lost over time. Like the lasers and skincare products, we’ll devote a whole podcast episode to volume replacement. It’s important to know that fillers do exactly what it is that they say they do: They will fill. Fillers do not lift.

It’s very common, if you look on the internet, you follow some well known injectors and see things that some of these filler companies put out. Fillers do not lift, they fill. They replace volume that’s lost over time. The only thing that is going to lift is an operation, and we’ll get there in just a second. And this is why I think we’re seeing a lot of people around town, people whose pictures or magazines that look overfilled. Filler can very easily be taken too far, and you go from looking nice and refreshed to getting this pillow face balloon look that has become really popular recently.

In my practice, fat grafting is my preferred treatment for substantial volume replacement because we can naturally replace volume that has been lost with the volume that has been lost; so we replace fat loss with your own fat. This is one of the fundamental principles of plastic surgery is replacing like tissue with like. So we replace lost fat with your own fat. It has a much more natural appearing look, and when done artistically really has a beautiful outcome. With fat grafting you have the added benefit that the cytokines, that the growth factors that are all naturally present in your own body fat, get deposited very close to the skin, and so you see an added skin rejuvenation effect in addition to volume enhancements.

So for those reasons, fat has really become a go to in my practice when we’re talking about surgical volume replacement, and is a part of every facelift, eyelid surgery, really any facial procedure that I do, fat grafting is a part of that now. So that then brings us to structural rejuvenation. The third aspect of facial aging that we need to touch on is structural aging. So we talked about when talking about loss of volume, that bone and fat tend to go away over time. The structure of the face—meaning muscles, tendons, ligaments—also become lax over time as the underlying volume—underlying and overlying, so bone and muscle—tend to go away, we tend to see the structure, the muscles of the face start to sag and loosen.

Facial surgery, specifically facelifts, lower blepharoplasties—even upper blepharoplasties—are muscle operations at their core. These are not pulling on the skin operations, but putting traction on the muscles, repositioning muscles that have loosened over time. Pulling on the skin, which was an early facelift technique, only tends to transiently or temporarily rejuvenate the face, leads to wide scars and a very [poled 00:21:38] kind of stuck in a wind tunnel appearance that is characteristic of bad facelifts from the ’70s and ’80s. And you can open a magazine and see pictures of that even now.

With facial rejuvenation surgery, we work through hidden incisions, typically around the ears, under the chin, to tighten, expose, and reposition loose muscles and let the skin passively follow those muscles as they become tighter to reshape the structure of the face and the neck. The main component of lifting comes from repositioning the muscle layer of the face, which is called the SMAS layer. And we’ll get into, again—I kind of feel like a [laugh] broken record; we keep saying in another podcast on this. But facelift surgery and muscle tightening really can be and will be an entirely separate podcast because there’s just a lot to talk about there.

But there are a number of techniques to tighten muscles, and the interesting thing about that—right now it’s December of 2021, and the deep plane facelift is all over the internet. Everybody’s talking about who does deep plane facelift and who doesn’t. It’s interesting because the deep plane facelift is not a new technique. It’s been around for a long time, since Dr. Sam [Hammer 00:23:04] really, is the one that kind of pioneer this back in the ’90s.

A couple of years after that technique had come out, there were—of course you get a bunch of surgeons together and everybody argues who does the best job—there was a very famous study that was done and published in our [white 00:23:24] journal—which is Journal of Plastic and Reconstructive Surgery—that studied facelifts on two sets of twins. And four different surgeons who used four different facelift techniques, and each surgeon did a facelift on twins that were very similar to start with. And they looked at these patients’ results over the course of ten years. And what everybody saw was that at the end of ten years, the technique really didn’t matter. Whether it was a deep plane technique, whether it was a subperiosteal technique, whether it was a SMASectomy technique, whether it was a high SMAS rotation technique—these are all things that you can kind of search around online and we’ll talk about later—the results were more surgeon-dependent than they were technique dependent.

It is interesting to note that good results are possible with any of these muscle repositioning techniques. So I bring this up to say, don’t get bamboozled on the internet by somebody doing one technique over another technique. This is really where you want to look at your individual surgeon’s work to make sure that you like what you see because that is going to be more indicative of your result than what technique they use and what you see on Instagram.

So we’ve been able to go over the three main areas that we need to consider when discussing treatment for facial aging: The skin, volume loss, and structure. And it’s really important to remember that each treatment plan is customized for each patient and each patient’s situation, and is really based on anatomy and biology, and not on chronological age.

So, as we’re wrapping up here, I would implore you that if you’re considering any facial intervention, whether that is Botox, whether that is filler, whether that is surgical treatments, whether that’s skincare and a laser, you really need to have a consultation with someone who knows what they’re doing, to analyze what your goals are and where you’re starting, and come up with a comprehensive treatment plan for you so that you don’t get caught on this merry-go-round of toxin and filler and toxin and filler, and going and spending hundreds of dollars on over-the-counter skin care products that really don’t have the active ingredients that you need to make a difference. And if you’re talking with someone who can’t speak to those three main areas of aging, that you really need to be careful because you may not be getting a complete picture. In terms of skincare, which was kind of what we’ve spent most of this podcast talking about, it’s important to start with a physician-dispensed medical-grade skincare line for skincare treatment and maintenance. Skincare does take time, but the end result of getting started on the right products at the right time will make your results orders of magnitude better than what you can do by just following somebody’s skincare treatment recommendations from somebody that you saw on YouTube.

We’ve got a [link below 00:27:03] to our store with the skincare products that I recommend personally in my office. I would encourage you, take a look at those. Go do your research, shop them around, look and see what other people are saying about them. But starting with a medical-grade skincare line is—no matter what age you’re starting facial treatment—is really going to be beneficial for you in the long-term.

Thanks for taking the time to listen today. Please give us a five star review if you like this, on Apple podcasts; it really helps the show. And subscribe so you keep in touch and can keep track of future podcast episodes. We’ll certainly be talking about a lot of these topics we covered today in much more detail in coming shows. So, thanks a bunch.

Dr. Hall: Thanks for listening to The Trillium Show. You can keep up with the latest on the podcast at jhallmd.com. Be sure to follow us on Spotify, Apple Podcasts, or wherever you listen to podcasts. If you want to connect with us on social media, you can find us at @jhallmd on Instagram and Twitter and @DrHallPlasticSurgery on Facebook. Remember, be the change you wish to see in the world.