My forty-fifth birthday is less than three weeks away. The thought of which makes me swallow hard.
I’ll pull on my big girl pants and power thru, but want something stronger than layer-cake to ease the transition.
Before I reach for one more overpriced cream, or take a spontaneous approach to Botox, peels and lasers, I’m going to take a big step back and make a plan. A plan for what really needs to be done…if anything. Maybe what I really need is a personal trainer or guided meditation?
So I’m embarking on an adventure called “Laser, Needle, Knife…or Nothing”.
Over the course of the next several weeks, I’ll pick the expert brains of cosmetic plastic surgeons, dermatologists and get their take on how to freshen me up to without breaking the bank…or my face.
I’ll start with the trickier areas, like the eyes and the neck/jowl/chin zone, where identifying the problem can be like chasing greased piglets and understanding the treatment options, vague at best. Advances in skin care procedures, smile make-overs and the body will also be covered.
Before we begin, let me introduce my face at Ground Zero. Lighting and make-up can make a big difference, so the most natural shot I could muster was this post gym snap in natural light with nothing on my face.
My first stop is a visit to Dr. W. Matthew White, Director of Facial Plastic and Reconstructive Surgery at NYU Langone Medical Center. He caught my attention during an interview at ASAPS when he told me I was thinking about aging the wrong way;
“Historically we’ve thought about facial aging as in the skin but it goes much deeper,” says Dr. White. “The reality is we’re only scratching the surface….we’re learning there’s a tremendous amount that’s happening on deeper levels”
If you need further proof at just how subtle and complex the aging process is, check out the picture of a young vs. aged face, compliments of Dr. David S. Balle a like-minded Grosse Pointe dermatologist.
Dr. White helps me break this down by explaining there are essentially 4 layers of facial aging. They don’t all happen at once and where it shows up first – eyes, chin/jowl/neck or skin – depends a lot on genetics, environment and how well you take care of yourself. But, understanding what they are, and how one impacts the other is key to being smart about what your treatment options are.
We all know this, and like a lot of women, I’m certainly no stranger to the age creep of fine lines, unevenness, and brown spots. Not only is the skin the skin thinner and drier, it’s less elastic due to loss of collagen in the dermis, the middle layer of the skin.
Fortunately, the medical community has smorgasbord of effective treatment options from prescription cremes like Retinol, chemical peels and lasers.
2. Volume Loss & Shift
As we get older, we lose fat in places like our cheeks, temples and forehead, while accumulating in others, like the lower face and neck. But did you know our fat undergoes it’s own continental drift? Just like pieces of a floating iceberg, your fat can separate and migrate, making the contours of your face less smooth.
“This is essentially fat loss, due to either loss of subcutaneous fat or “shifting” of the fat, but the jury is still out on the actual cause,” says Dr. White.
While there’s no shortage of filler options available (hyaluronic acids, Radiesse, Sculptra and sometimes fat), the bigger question is which one and where to inject. To be continued…
The next layer down is the SMAS or superficial muscular aponeurotic system, a muscular layer between the bone and the fat. During a facelift, this is often the area that plastic surgeons lift. Dr. White explains why this is important:
“After the bony support is lost in the face, the soft tissue canvas of the SMAS sags, similar to removing the supporting poles under a tent. A sagging SMAS layer leads to a lot of changes in the lower neck such as banding, and coupled with volume loss, contributes to shapeless cheeks, jowling, nasalabial folds and droopy eyebrows.”
Sometimes, only a facelift will help in this area, but for mild to moderate laxity Dr. White tells me there’s hope in Ultherapy, a non-invasive technology that uses ultra sound that’s been FDA approved for not just tightening the neck/chin area, but lifting. A big step forward from where we were with Thermage, especially since it has a 75% worth it rating from Real Self versus only 38% with Thermage. Consider my curiosity piqued.
Now here’s a surprise that should motivate us all to take our calcium – bony changes impact the eye, nose and jaw.
“As we age bone gets resorbed. The bony eye sockets enlarge and the mandible (jaw) loses vertical height. After you lose that height in the mandible, the neck starts to sag, the mid-face caves in and looses projection,” says Dr. White.
“So for example, when you lose bony support around the eye, you can develop a tear trough deformity, so you have less of the fatty padding around the eye that actually makes it look smoother. On the other hand, as the orbital septum loosens, the fat can herniate out and that’s where you get the fatty, puffy bagging”.
All this bone aging has an impact on your nose too.
“We have this bony support of the nose, called pyriform aperture. Also there’s less cartilage support, so the nose sags. lengthens and sometimes come down into a hook.”
Well this is depressing. Dr. White goes on the explain that while we don’t have bone in a jar or syringe, fillers can do a remarkable job of compensating, but again, it’s a matter of which one and where to inject.
“So Dr. White, where do you see the bulk of my aging issues?” I ask.
“I mean you look amazing for your age, let’s be honest. You have a lot of good stuff going on. You have great cheekbones and a very nice structure to your face. You have some little lentigines (freckles) on your cheeks but they work well for you”
Off to a good start…
“What I see is that you have two different sides to your face and this is very common. The left side of your face is smaller than your right. As a result, your brow and nasalabial fold are more droopy on the left side because you don’t have the bony support.”
“You are walking, living proof of this 4 layer aging phenomenon about because your bones on the left hand side of your face are aging more rapidly or they’re absorbing more rapidly than the other side.”
Yay, I’m a teaching moment. Still, I suspected as much. A few years ago, I noticed my smile and eyebrows looking more crooked, but dismissed it as my imagination working overtime.
“It’s very important for me as a clinician to note the asymmetries when I’m doing your treatments, because it affects the dosage of Botox and fillers on the smaller side. But some asymmetry is natural,” says Dr. White.
An additional conversation with noted Beverly Hills cosmetic plastic surgeon, Dr. Brent Moelleken, confirms that indeed, on my left side I have something that sounds like my Native American Indian name; low brow, small eye, flat cheek.
“Asymmetry is a very, very artistic thing. You don’t necessarily want to fix it completely but you want to fix it a little. Maybe you augment the more sunken cheek a little bit more but you don’t get it to the point of the right cheek and unless you’re looking at it aesthetically with the juxtaposition of the cheek, the eye and the brow, you’re going to miss that. Very, very few people are attentive to that detail,” says Dr. Moelleken.
This explains why I’ve had inconsistent results with Botox and fillers in the past, with my eyebrows sometimes uneven, like they’re going to fly off of my face.
Both Dr. White and Dr. Moelleken assure me my asymmetry is perfectly normal, but that it’s always been a part of me since birth. The bony changes of aging are just making it more prominent.
The more important take-away is role of a good doctor in the process. Dr. Moelleken advises interviewing several doctors and asking:
“What are your plans for my face? Ask the question and just sit back and listen to the answer. Look for someone who is actually analyzing your face and taking a little time; it’s your face. If someone doesn’t care enough to look at the little nooks and crannies and you go somewhere else”
Later that day, I find an email from Dr. White. Concerned that his clinical honesty had bruised my ego after I peppered him with questions about whether symmetry equals beauty, he gave me the closest thing to Chicken Soup for the Asymmetric Soul; links to good looking asymmetrical celebrities.
I guess if facial asymmetry is good enough for Blake Lively and Ryan Reynolds, it’s good enough for me. And I’ll keep reminding myself that Picasso’s asymmetrical portraits were works of art.
Next up on Laser, Needle, Knife or Nothing…the sagging lower face. Or, how to get along better with your neck.