• The Basics of Maintaining Youthful Skin

    July 11, 2016
  • This is a broad topic and certainly not meant to be the answer for every skin problem you have ever had nor will it review every factor affecting changes in the skin with age. However, the below steps will hopefully serve as a basis for excellent skin health and in turn, dramatically slow the aging process, prevent skin cancers later in life and improve your complexion. Some of you may be asking, why does skin care matter to a plastic surgeon? This is a fair question and in short, because the skin provides the external covering for all of the work I may do. For instance, if I perform a facelift or a blepharoplasty, I may greatly improve the facial and eyelid contour and wrinkles, but if there continues to be sun spots and hyperpigmented areas then my results will be less than acceptable. This is why I have my esthetician see every patient I book for any facial cosmetic surgery. Improving the appearance of the skin in conjunction with quality surgery will lead to amazing results. 

    Globally, there are intrinsic and extrinsic factors that affect the health and appearance of your skin. Intrinsic factors like your genetic makeup are important but not really modifiable. The extrinsic factors like UV damage, cigarette smoke and nutrition can be altered to prolong the youthful appearance of your skin. Cigarettes are probably the single most damaging habit a person can have. With the billions of dollars the government spends every year on anti-smoking campaigns, even the youngest children know smoking is unhealthy and causes cancer, but the skin damage it causes are not as often publicized. Everyone has a relative who has smoked two packs of cigarettes a day for most of their life and now exhibit all the signs of early aging due to smoking. First of all they usually appear 10- 15 years older than their actual age due to the increased facial wrinkling, especially around the eyes, lips and cheeks. They also have that gray, thick-skinned complexion with a gaunt appearance to the cheeks characteristic of chronic tobacco smoke and this is not to mention the changes that occur to the voice made so famous by Marge Simpson’s sisters (Patty and Selma) or the tobacco smell that lingers everywhere they go or the yellow, enlarged finger tips. Can I stop now?

    The mechanisms in which cigarettes cause these changes to the skin are numerous. There are over 1500 ingredients in cigarette smoke and without being too scientific it is believed cigarette smoking activates an enzyme in the skin that breaks down elastin and collagen. These are two components in the skin that help the skin keep its youthful tightness. Furthermore, tobacco smoke also leads to a decrease in vitamin A levels in the skin. Vitamin A is a powerful anti-oxidant which neutralizes free radicals known to contribute to the pathway of skin aging. These skin changes are linear, meaning the more you smoke the faster the facial wrinkling and adverse skin changes occur. I hope you get the point. If you smoke cigarettes and want to maintain some resemblance of youth as you age then you have to stop. Get an e-cigarette, talk to your primary care physician, get nicotine gum or a patch, but get motivated and do what you have to do to stop. 

    Not as bad as smoking in my humble opinion, but definitely damaging to the skin is ultraviolet radiation from the sun. The damage to the skin caused by prolonged exposure to UV radiation is called photoaging. Clinical findings of photoaged skin include deep wrinkles and pigmented lesions such as freckles, brown spots, solar lentigines (sun spots), increased skin fragility, small vascular growths, loss of skin tone and increasing numbers of benign lesions. This is not to mention the increased risk of skin cancer and melanoma associated with prolonged sun exposure. On a microscopic level even the collagen which helps give the skin its youthful tightness, is markedly fragmented and thickened in sun- damaged skin. Not convinced? Look at the back of your forearm compared to the front of your forearm and see which side appears more youthful. I am not suggesting a person never go outside and enjoy the sun, but if you love to lay out in the sun for hours on end expect to look 10 years or 20 years older than you are. Below is another good Hollywood example – Magda from Something About Mary.

    The good news is there are things you can do to combat and prevent the effects of photoaging. There are numerous multi-step skin care products on the market that usually involve a combination of cleansing agents, anti-acne agents, lightening or depigmenting agents and finally a daily sunscreen. Two effective topical medicines that work very well to improve the appearance of the skin are retinoids and hydroquinone. Retinoids are a family of compounds derived from vitamin A that include brand names like Retinol and Tretinoin. These were originally used for acne treatment and besides helping with acne many women began to report their skin felt smoother and less wrinkled. This anecdotal evidence has been followed by many good clinical trials showing improvements in photo-aged skin. The most common side-effect of topical retinoids is redness and skin dryness. This side effect can be mitigated by using a lower concentration or using the topical retinoid every other or every third evening rather than every evening. 

    Finally, hyperpigmented lesions including the brown spots on the skin seen so often with age are unacceptable for anyone who wants to maintain a youthful appearance. Numerous over-the-counter products are sold as “lightening creams” but unfortunately they may take months of use for any improvement to be seen. A topical medicine called hydroquinone is used in most of these over-the- counter products and when used in slightly higher doses, prescription concentrations (4%) can be very effective in reversing the brown spots or melasma seen in the skin with age and sun exposure. Hydroquinone works by turning off the DNA that controls the enzyme tyrosinase which produces melanin and melanin is what gives the photoaged skin the brown spots. Without the function of the enzyme tyrosinase, melanin does not get produced and the brown spots go away. The disadvantage is the effect of hydroquinone on tyrosinase is reversible, so if you stop using it the brown spots come back. Other very effective options for hyperpigmentation include laser facial treatments and superficial or “day” peels.

    Finally, no article on the topic of maintaining youthful skin would be complete without discussing botulinum toxin. Brand names include Botox® Cosmetic (Allergan Inc, Irvine, CA) and Dysport® (Ipsen Products, Maidenhead, Berkshire, UK). Botulinum toxin is a cornerstone in aging prevention. The toxin temporarily inhibits the contraction of muscle by inhibiting the release of acetylcholine, a neurotransmitter, at the location where the nerve meets the muscle. If the last sentence did not make any sense then just understand the toxin temporarily stops the contraction of the muscle it affects. The effect usually lasts 3-4 months and without muscle contraction, no wrinkles occur. This is amazingly effective in treating and preventing wrinkles in the forehead, the frown lines between the eyebrows and the crow’s feet.

    From the perspective of age, if you are fortunate enough to still be in your 20’s then your skin cells regenerate quickly and you have strong collagen and elastic fibers giving your face a plump, healthy appearance. Get out of the tanning bed and start applying a daily sunscreen!! Consider an antioxidant, use a vitamin A topical derivative like tretinoin or retinol, along with an occasional superficial chemical peel and hydrodermabrasion. These will be effective in the treatment of acne, remove the dead cells on the outer layer of the skin surface, improve skin texture and lighten melasma.

    In your 30’s and 40’s you may have some mild wrinkles and the goal is to recapture the youthful appearance. Fine lines and wrinkles become more prominent and as a result of 30 to 40 years of sun exposure freckles and sun spots become more visible. In your 30’s the skin care to do list includes a daily sunscreen (spf 30 or greater – the spf in make–up is not enough), an antioxidant, intermittent superficial peels and a retinoid (tretinoin or retinol). One should also consider a medium depth chemical peel to improve the wrinkles and texture of the face as well as beginning botulinum toxin injections. The only difference between the 30’s to–do list and the 40’s to–do list is in your 40’s one should consider adding a filler (Juvederm or Radiesse) to the regimen. The youthful face is plump and full of volume and a filler is often necessary as we enter our 40’s. 

    In the 50’s and 60’s wrinkles become significantly more pronounced with sagging and obvious jowl lines. The goal becomes restoring the appearance of health and to look good for one’s age. The 50’s to–do list includes all of the recommendations of the 40’s but laser resurfacing becomes more important as well as moisturizing. Consider a glycolic body lotion to exfoliate and hydrate the skin. Also, the 50’s is a good time to consider or discuss a face/neck lift. In the 60’s and beyond moisturizing becomes more important along with medium–depth chemical peels, laser resurfacing and cryosurgery for benign growths that occur with age. 

    Finally, this all may seem overwhelming and expensive but the good news is we are here to help. I have created multiple packages referred to as our Black Diamond Memberships accommodating varying budgets providing the “biggest bang for your buck” in skin care. These include everything from botulinum toxin at $9 per unit, hydrodermabrasion, and skin care packages with carefully selected Obagi and Skin Medica products. Call today and make an appointment with Kim to start the process in improving your skin. Patients tell me all the time how amazing it feels when their friends compliment them on their skin and ask them what they do.

    1. Lahmann C, Bergemann J, Harrison G, et al. Matrix metalloproteinase-1 and skin aging in smokers. Lancet. 2001; 357-935
    2. Baumann L. Cosmetic Dermatology 2nd Edition. McGraw Medical, New York, NY. 2002.