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Introducing Laser, Needle, Knife..or Nothing


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.


8 am this morning, apre gym, sans make-up, natural light

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.

aging face

Illustration compliments of Dr. David S. Balle


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.

1. Skin

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.

Facial fat age

Illustration courtesy of Dr. David S. Balle dermatology

“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.

4. Bone

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.

Photo courtesy of Dr. David S. Balle

Photo courtesy of Dr. David S. Balle

“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.


  • Interview with Dr. W. Matthew White
  • Interview with Dr. Brent Moelleken
  • Facial Aging (Dr. David S. Balle)
  • Observations on Periorbital and Mid Face Aging (Dr. Val Lambros)
  • Twin Study Reveals Secrets To Looking Younger (NBC/Allure)
  • Can Facial Asymmetry Be Corrected? (Real Self)
  • Face Symmetry of Celebrities (You Beauty)



  1. I had an under eye lift when I was 45, I was getting heavy bags which my mother has so I went for it. I wish he would have went tighter.

    I’ve since gotten fillers, luckily free as I worked at a medi spa and was a “model” for new instructor’s. I am now 52 and get Botox regularly on my forehead and laugh lines. The previous botox on my 11′s must be working since I don’t use that muscle as much and don’t need the botox there. I love Juvederm and am need of it again and I feel it’s somewhat inexpensive way if nothing really needs to be “lifted” I need to save up for. Just stopping buying expensive creams pays for my botox.

    Looking at your picture you look very youthful, I think a bit of botox on your laugh lines is all you really need to freshen up.

    • Ha, I feel the same way, that ditching my expensive creams (except for prescription Retinol) helps fund my Botox. Thanks for stopping by Cheryl and hope to hear more about your experiences.

  2. I applaud your honesty and I agree with Cheryl. You look fantastic! To take a picture in bright light with no make-up, why are you even worrying? Of course, I’m turning 56 next month so not only does everyone under the age of 50 look fantastic to me, but I expect that most women over the age of 60 would think that I look great. I look forward to reading your future posts and hearing about what you learn. I’m also hoping that you’ll find some reasonably priced alternatives to lifts and fillers. Since I’m a background actor and unpublished (as of yet) writer, I can’t afford expensive treatments!
    Thanks for doing the research!!!

    • I agree with Dr. White and the other ladies that you look great for your age. I’m 48 and went to see my dermatologist last week for Botox and Juvaderm. Botox on forehead, smile lines and corners of mouth. Also had Juvaderm injected on each side of chin due to sagging and dimpling of chin. 3 months ago I had Venus Freeze on face and neck. I have a symmetrical face as well and don’t like it, but hey we can’t be perfect. ha I would be lying if I say I’m taking this aging process gracefully. I’m middle of the rode on it. Some on my appearance were gifted to me genetically, for that I’m thankful! Just like a car, a little tune up now and then does wonders.
      I love your blog and appreciate all the time you take to research this great information!! Looking forward to reading future material from you:)

      • I’m glad you’re enjoying it Sherry, and I’m curious to hear more about your Venus Freeze! I’m doing a piece on the lower face later this week and am busy exploring all the options. Did you get the Juvaderm to smooth out your jawline in the pre jowl sulcus (those little notches on either side of the chin)? I think that’s what I need. My lower face really bothers me. I like your attitude though, about being thankful for the things that went right in my gene pool.


    • Thanks Laila, I have to say I was pretty shy about going full frontal with my face, so it’s nice to hear the reassuring words:) You’re so right, how your perspective of aging and looks change depending on the perch you’re sitting on. I look back at what I worried about at 30 and think, if only I appreciated what I had at the time.


  3. First of all, you’re gorgeous!!! Secondly, thank you, thank you, thank you for sharing this very helpful information.

    • Thank you for the lovely compliment. I was terrified to do it, so it’s nice to hear. I’m glad you’re finding the series helpful. I have to say, from the research I’ve done so far, I’m astonished at what we don’t know. Hope to hear from you again.


  4. I agree with Dr. White and the other ladies that you look great for your age. I’m 48 and went to see my dermatologist last week for Botox and Juvaderm. Botox on forehead, smile lines and corners of mouth. Also had Juvaderm injected on each side of chin due to sagging and dimpling of chin. 3 months ago I had Venus Freeze on face and neck. I have a symmetrical face as well and don’t like it, but hey we can’t be perfect. ha I would be lying if I say I’m taking this aging process gracefully. I’m middle of the rode on it. Some on my appearance were gifted to me genetically, for that I’m thankful! Just like a car, a little tune up now and then does wonders.
    I love your blog and appreciate all the time you take to research this great information!! Looking forward to reading future material from you:)

  5. Well, I was expecting a travesty after I saw the drawings of women at different stages of aging. Plus, knives!? But when I saw your au natural face, I was like – WTH, Seriously? Um, you look great. I see eye lines, which I’ve seen 20 year olds with. I am in my 30′s and I am becoming more aware of how my skin is changing. I, however, cannot wait for my cheeks to lose their fat. Preferably, to disintegrate…I don’t need it elsewhere. I have one of those fatty round faces that will never be confused for sexy, but cute. Bring on the CHEEKBONES!!!

    Thanks so much for all the research! So informative.

    • Finished reading your post – I always knew it would be my nose I would have to get done when I got older…I always noticed how fuller noses became fatter and spread. Now, I know why. Nose job in my 40′s! Again, thanks so much for all this info!

      • I know, I thought the nose was sort of immune to aging, but I guess it’s all fair game to father time. You’ve given me an idea for a post though; treatments for the aging nose that don’t require surgery. There’s a lot that can be done with fillers (who knew)!


    • Oh just wait, I have some lovely bad angles up my sleeve:) I’ll tell you that I love my leaner upper face since I always had a round one, BUT I feel like it’s slid down to my lower half, which I’m trilled with. Glad you’re finding the research helpful – I’m surprised at what I’m learning talking to a bunch of doctors (and getting a whole lot of different perspectives).


  6. I love your blog, your humor, and your all the little details only a good friend would divulge. You look fantastic, asymmetrical and all..though now I suddenly realize I am asymmetrical too..when did that happen? :)

    As for my fat face sinking into the sunset…I am 39, and did have ultherapy done on my lower face and neck. I was happily surprised, or rather shocked, when it worked on my jowls…not that you need it, but I certainly did.


    • Thanks for the kudos Sue. I’ll be sharing some jowling on my post about the lower face. Trust me, those jowls there:( Glad to hear you liked Ultherapy – when did you begin to see results? Did you do one session or two? I know Ultherapy isn’t the same as facelift, but it’s nice to hear there’s an interim step that can help. Very curious about it.


  7. I know you didn’t post the photo of you au naturel to fish for compliments. We all look in the mirror and see a million imperfections. But you look fantastic, and that is the truth from a sister who would rather shut up than dole out an empty compliment. I find your research fascinating. So far, I decided to leave my face completely untouched, with deep furrows on my forehead and laugh lines that are getting deeper. No Botox, no fillers, no nothing. My saving grace are my wide eyes and very few lines around them but I am open to suggestions. I am sure that, around 55, I will want my eyes to look more youthful. I am still very torn between accepting natural aging and wondering “why should I”? Reading you might help make up my mind

    • Thanks Camparigirl! You bring up a good point in that I am not trying to change that much, just want to erase some of those OMG moments when I see myself in a picture and am like “Do I really look like that? What is that? That was never there before!”.

      The thing is, when you start to wander down this path, there aren’t any patient best practices nor a good roadmap, so you’re at the mercy of the doctor and moment. I hope by sharing other women will feel more empowered and educated about their options because I feel there’s a fine line between wrinkle free and freaky.

      I’ve had my share of bad things happen (just you wait, I’ll post my bad botox pictures in the near future) where I just wound up looking different, but not necessarily better. And this doesn’t need to happen.

      The other part of the dialogue I can’t wait to get into is what exactly should we look like as we age? I’m not sure wrinkle free is the answer to be honest. But I’ll be damned if I’m going to be jowly:)


  8. Well I would like to say you look great, period! I kind of think that saying “you look great for your age” is a backhanded compliment, albeit, you do! I have been really diligent in taking good care of my skin since I was 18, staying out of the sun, always using sunscreen, and had some good genes thrown my way….people guess I am usually 10 years younger than I am (at least to my face) :) As I approach my, gulp, 43rd birthday, my head seems to be shrinking??? I have a small oval shaped face, I have used fillers starting at 40….they have really made a difference…but I have kept my body weight under control, or lost several pounds, and every pant size I go down, my face and neck looks like it its sliding off the skull! My question is, should I keep on using the fillers, or take a leap and try the thermage or ultra therapy? Will “tightening” my skin only make it look thinner??? As for people like Gweneth, who have a square jawline and a wider face, the results look amazing…..I am trying to keep a non jowly neck, but a naturally looking cheek. Your cheeks look great and youthful btw! Would love to hear some opinions! thanks!

    • Aly, I think you raise a great point about the shape of the face. I hadn’t thought about that in terms of the results you get with Ultherapy or Thermage. From what I know from the doctors I interviewed, everyone recommends Ultherapy (some Thermage), but used in combination with fillers. I’m afraid as we get older, it’s not an either or, but a combo of stuff:(


  9. Great article! Ultherapy is offered at Skinpossible Laser and Light Solutions in Calgary, Alberta. It is the new gold standard at non-invasive skin tightening and the only FDA approved technology in the world for skin “LIFTING.”


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