The evolution of thought and process in cosmetic medicine and surgery has united specialists from various backgrounds with the goal of providing safe, reproducible techniques to improve the various elements of the aging face from within and without. The realization that the aging face is both vector and volume based has dramatically altered the approach to reversing the signs of aging. Ultimately, it was the joining of forces from multiple specialties that provided a blueprint for impressive improvement in the return of a youthful, natural look.
The more things change, the more they stay the same
In many disciplines including those outside medicine, the thought that there really is no change, only a realization that new things do not cause a change, has been held to be true for decades. This idea does not apply to the thought and process in reversing the signs of an aging face. Although the aging face has been treated for centuries, only recently it was recognized that the process occurred at multiple levels, from the bony structural support of the facial soft tissues and included the muscle, fat, and skin. It has been known for decades that environmental factors such as smoking, climate, and sun exposure have profound influence on the appearance of the face, and considerable energy has been devoted to informing the patient that there are ways to minimize the effect of environmental factors that accelerate facial aging and may lead to skin cancers. There are, of course, genetic influences on how and when the face ages visibly, but, at this time, the genetic forces that determine how and when the face ages cannot be modulated. A sentinel article on the “senility of the aging face” by Gonzalez-Ulloa and Flores was an important attempt to understand the cause and effect of facial aging. They understood that the changes that were observed occurred at both bony and soft tissue levels. This monumental publication makes one wonder why more intellectual energy was not devoted to reversing the signs of the aging face at multiple anatomic levels rather than working solely on the skin. The early facelifting procedures had been used for decades before there was a shift in thought with regard to how and why the face ages and the understanding that merely pulling on the ptotic skin was not enough to reestablish a youthful, harmonious shape to the rejuvenated face.
Architecture and volume: master teachings
The number of available options for both medical and surgical reversal of the aging face has dramatically increased because it is now understood how and why these changes occur, and this understanding has fueled commercial interest in providing what is needed to accomplish these goals. Over the centuries, there was an understanding of what constituted a beautiful face, not only with Cleopatra but also with others (the imprint in the ruins of Persepolis in Shiraz shows all of the desired facial contours that were visible in the ancient Iranian queen). The “universal symbols of beauty” have been captured in the minds and hands of notable artists (Bill Little has repeatedly shown us how the renaissance artists knew what Ralph Millard called the “ideal normal”). Bill also taught that a beautiful face had to include an Ogee curve, architecturally understood, and once we saw it, we knew that Bill was correct in applying this form to the goals in facial rejuvenation. When I looked back at the history of brow and midface lifting, I did not appreciate that, despite the understanding of facial aging as described by Gonzalez-Ulloa and Flores in 1965, at least 75 years of facial aesthetic surgical techniques before and after this publication failed to address volume-based deficiencies. The early surgical procedures directed at repositioning ptotic facial soft tissue failed to address the volumetric loss including bone and soft tissue. These techniques were well intentioned but principally involved undermining skin and repositioning it under tension. The stretched, unnatural look was often justified by trying to convince the viewer that “my patients are happy.” It was the work of Ed Terino, who, although not the first to use autologous or alloplastic implants, was the first to logically approach skeletal deficiencies with specific alloplastic implants based on his 3-dimensional understanding of facial shape. His zonal analysis clearly provided an easily understandable way to address regional volume-based deficiencies. Those surgeons who understood the profound effect that volume restoration had on facial shaping clearly showed that some techniques worked better than others. The work of Hester and colleagues in the 1990s directed attention at shifting the midface soft tissues vertically to augment this anatomic area and blend the lid-cheek junction. Other major contributors also recognized the profound effect that mobilizing the ptotic midface had on facial rejuvenation. However, some of these more aggressive techniques, including the subperiosteal and extended superficial musculo-aponeurotic system approaches, carried the added risks of prolonged edema, possible neurapraxias, eyelid malposition, and, in some cases, a new look that required weeks to “look natural.” As is always true in aesthetic plastic surgery, selecting the right technique for a given patient largely determines the success achieved. So, some patients do well with a given technique, others do not (understanding the negative-vector orbit taught us why vertical lifting techniques could be associated with higher morbidity, including, but limited to, lid malposition). The longevity of these results was impressive, but less-aggressive means of facial rejuvenation also showed impressive longevity. Vector-based correction as a sole means of reversing the signs of aging is, although well intentioned, wrong minded in light of the profound influence of the works of Lambros and Pessa and colleagues. Loss of facial fat and absorption of skeletal support affect the shape of the face. Therefore, facial reshaping may require moving the tissues to their prior, youthful position, as well as augmenting the soft tissues, and, where indicated, augmenting the skeletal support to produce a harmonious rejuvenation. Younger patients may show significant improvement in reversing the early signs of aging by merely adding soft tissue volume and/or skeletal support without moving soft tissue. As if that were not in itself an intellectual and technical challenge, facial compartments lose fat in varying amounts. Therefore, efforts can be directed at augmenting compartments to effect a change in an adjacent compartment (eg, filling the deep medial cheek fat compartment to soften the arcus marginalis and blend the lid-cheek junction). There were many early contributors to facial soft tissue augmentation with autologous fat, who showed that fat grafts survive and the elements to ensure survival were found to be based on appropriate donor sites, graft harvesting, graft preparation, and injection of small amounts of purified fat into tension-free recipient areas.
The economy and aesthetic procedures
Whereas these techniques were widely embraced and used, patients began to demand less-aggressive procedures with shorter “down times.” Although it seemed that providing a shorter pathway to enduring facial rejuvenation was not the best way to approach the aging face, the “perfect storm” occurred when economic influences on consumer spending triggered a strong interest in less-aggressive and less-expensive procedures that produced visible results with a shorter recovery period. Sure, the more aggressive option could be provided, but the economy and the interest by the public would not support traditional or more aggressive procedures. Less was not merely more; it was merely more than enough based on consumer demands. After 9/11, there was a severe downturn in the request for consultations and for aesthetic plastic surgery procedures that lasted for several weeks. I went back in time to the early part of the twentieth century and looked at the history of sentinel national and world events and how they influenced cosmetic medicine and cosmetic surgery. I found that after events such as the Great Depression and Black Monday in October, 1987, women, on average, waited no longer than 6 weeks before they began to ask for and obtain cosmetic medicine products and/or cosmetic surgery techniques to allow them to look better, and certainly, looking better was the best way to feel better. The current recession that started in 2007, but was more palpable in 2008, is the only time in more than 90 years that consumers have waited longer than 6 weeks to reenter the cosmetic medicine and cosmetic surgery markets. Concerns about job security, adequate funds for retirement, decrease in home equity, the volatility of the stock market, and so on are all factors that play into the decision to invest in looking better. The discretionary spending was more closely scrutinized and rationed, as these concerns simply would not disappear. The need to remain in the job market has encouraged many to seek cosmetic medicine and cosmetic surgery solutions to reverse the signs of the aging face and make one more competitive in the job market. Many of these consumers sought a less-expensive quick fix; however, many also understood that it would be necessary to invest more so that one could obtain panfacial rejuvenation or a result that would last longer than the time required for the deduction of funds from their savings and checking accounts.
The economy and aesthetic procedures
Whereas these techniques were widely embraced and used, patients began to demand less-aggressive procedures with shorter “down times.” Although it seemed that providing a shorter pathway to enduring facial rejuvenation was not the best way to approach the aging face, the “perfect storm” occurred when economic influences on consumer spending triggered a strong interest in less-aggressive and less-expensive procedures that produced visible results with a shorter recovery period. Sure, the more aggressive option could be provided, but the economy and the interest by the public would not support traditional or more aggressive procedures. Less was not merely more; it was merely more than enough based on consumer demands. After 9/11, there was a severe downturn in the request for consultations and for aesthetic plastic surgery procedures that lasted for several weeks. I went back in time to the early part of the twentieth century and looked at the history of sentinel national and world events and how they influenced cosmetic medicine and cosmetic surgery. I found that after events such as the Great Depression and Black Monday in October, 1987, women, on average, waited no longer than 6 weeks before they began to ask for and obtain cosmetic medicine products and/or cosmetic surgery techniques to allow them to look better, and certainly, looking better was the best way to feel better. The current recession that started in 2007, but was more palpable in 2008, is the only time in more than 90 years that consumers have waited longer than 6 weeks to reenter the cosmetic medicine and cosmetic surgery markets. Concerns about job security, adequate funds for retirement, decrease in home equity, the volatility of the stock market, and so on are all factors that play into the decision to invest in looking better. The discretionary spending was more closely scrutinized and rationed, as these concerns simply would not disappear. The need to remain in the job market has encouraged many to seek cosmetic medicine and cosmetic surgery solutions to reverse the signs of the aging face and make one more competitive in the job market. Many of these consumers sought a less-expensive quick fix; however, many also understood that it would be necessary to invest more so that one could obtain panfacial rejuvenation or a result that would last longer than the time required for the deduction of funds from their savings and checking accounts.
Topicals for aging skin
Techniques and products that work from the outside have been an enormous influence on reversing the signs of facial aging. These techniques would not have evolved had there not been a need both professionally and from the consumer to provide more comprehensive options for facial rejuvenation. It was the forward thinking of Fritz Barton in the 1990s who saw the need to legitimize skin care by placing their annual society meeting immediately preceding the American Society for Aesthetic Surgery Annual Meeting. This gave the Skin Care Society the platform and the validation that it needed to “convince us” that we need to pay attention what was happening on the outside as importantly as what was happening on the inside of the aging face. The aging facial skin includes both internal changes such as cellular apoptosis and genetic influences and external changes resulting from environmental influences. The aging skin is primarily related to a fragmentation in the dermal-collagen matrix, producing a visible change in the appearance of the skin, in turn becoming a major indicator of facial aging. The use of chemicals for facial peeling advanced profoundly with the introduction of the Baker/Gordon phenol/croton oil peel. Although loss of pigmentation was an issue based on the depth of the peel and the skin type, many patients were pleased with the improvement in the appearance of their skin. The environmental causes of skin aging were largely reversed by this easily administered procedure. It was decades later that Hetter and Kligman and colleagues provided convincing evidence that the concentration of croton oil was more important than the phenol concentration in producing the desired result, and we began to rethink how this worked and how could it be made to work better with fewer adverse side effects. “Off the shelf” filling of lines and depressions began with the introduction of bovine collagen in the 1970s. This product, although only providing a short period of correction (duration of correction determined by increasing the cross-linking), was quickly embraced by clinicians and patients and its use became widespread. Complications were few with appropriate allergy testing, and patients were mostly pleased with the temporary improvement in the appearance of facial lines and folds. Patients returned frequently for additional injections, but, of course, both patients and clinicians sought a solution to facial wrinkling and contour deformities that would be longer lasting. Permanent solutions such as the injection of medical grade silicone and other nonautologous substances were available and continually changed to allow a palette of products that had risks associated with each product. It was desirable to have a permanent correction, but often, the risk of long-term sequelae discouraged the use of permanent or semipermanent injectables, particularly in the highly litigious US market (with the notable exception of fat grafting and stem cell grafting). The introduction of topical tretinoin (vitamin A) to remove the superficially damaged skin brought enormous attention to the role that topical agents can play in facial rejuvenation. A sentinel event in the evolution of skin care occurred when Obaji introduced his technique of facial peeling with modified trichloroacetic acid (TCA), adding other agents to varying percentages of TCA. Specialists from many disciplines embraced this approach to facial peeling and quickly adopted his techniques and formulas. Obagi added multiple products to his line, allowing the treatment of other skin changes that were genetic and/or environmental, including, but not limited to, the treatment of hyperpigmentation with different causes. The level of awareness of what could be done to improve the signs of aging of the skin was elevated to a new level by Obagi’s pioneering work, and many clinicians began to offer various concentrations of TCA peels, as well as peels such as kojic acid peels and salicylic glycolic acid peels. The introduction of vitamin C–based cosmeceuticals was another in a series of new solutions to the aging skin. There is a seemingly endless introduction of new topical preparations to improve the texture of the skin, diminish rhytids, and correct areas of hyperpigmentation or solar damage. Some are dispensed only in physicians’ offices, whereas many more choices can be found in MedSpas, drug stores, retail department store outlets, or online. The public is justifiably confused, as are physicians, in knowing what to use, where, how, and when.
Related posts:
Cosmetic Medicine and Surgery: A Shift in Perspective
An Overview of Botulinum Toxins: Past, Present, and Future
Principles and Practice of Cutaneous Laser and Light Therapy
Injectable Therapies for Localized Fat Loss: State of the Art
Noninvasive Body Contouring with Radiofrequency, Ultrasound, Cryolipolysis, and Low-Level Laser Therapy
Lifting and Wound Closure with Barbed Sutures
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