Amid a growing trend for youngsters seeking treatment, journalist Allie Anderson explores some of the issues surrounding preventative ageing and asks: how young is too young?
As the adage goes, prevention is better than cure. Ageing is inevitable, but if one can delay it both on the inside and on the outside, then for many it’s an option worth serious consideration. Having the odd nip and tuck to push back the hands of time was once the domain of people in their 40s and older. But with increasing pressure on young Millennials to look flawless – thanks, in part, to the popularity of social media – requests for aesthetic treatments from those in their early 20s are on the rise.
In the US, the number of botulinum toxin procedures performed on 20 to 29 year olds has increased some 28% since 2010, while it’s reported that enquiries for anti-wrinkle procedures from patients aged 18 to 25 have swelled by more than 50% year on year.Some argue that offering treatments like injectables to patients so young potentially raises ethical questions: quite simply, most people in their early 20s don’t need it.
But, according to aesthetic nurse prescriber Melanie Recchia, if there is a clinical sign that the patient would benefit from a treatment, then it’s acceptable. “Some people in their 20s have a very strong frown line, for example,” she says, explaining, “A little bit of botulinum toxin there will help stop those lines from developing into deep wrinkles.”
Cosmetic dentist and aesthetic practitioner Dr Rikin Parekh explains that injectables can have a preventative mode of action. “As we age, our muscle activity changes, so our muscles get stronger in some areas and weaker in other areas. We can treat these areas with botulinum toxin to limit the activity of these muscles, so the lines and wrinkles don’t become as prominent as they might otherwise do,” he comments.
As such, he tends to offer botulinum toxin as a preventative treatment to patients who are exhibiting “very early signs of ageing” – typically from the age of around 25. “It’s then that we begin to see volume changes in the face, when production of collagen and elastin is reducing, so I would consider a very light-touch treatment,” Dr Parekh explains.
However, when thinking about preventing or delaying the ageing process, it’s best to approach it from the inside out, according to board-certified dermatologist Dr Stefanie Williams. “Preventative ageing involves doing little things, starting with lifestyle adjustments and good skincare to slow down the skin’s ageing process before you even begin to see visible changes like lines, wrinkles and loss of elasticity,” she says.
At her clinic, Dr Williams promotes a ‘step-wise’ system of preventative ageing, the cornerstone of which is adopting a healthy lifestyle: a nutritious, balanced diet, regular exercise, refraining from smoking or drinking too much alcohol, and daily use of a broad-spectrum, high-SPF sunscreen. “These are things that one should do at any age, alongside a good skincare regime, which forms the next step up,” she says. For Dr Williams, cosmeceutical skincare is essential, and this should comprise two key ingredients. “You should include a high-grade antioxidant serum – which could be a 10-15% vitamin C – in the morning straight after cleansing, and sun protection of between SPF 30 and 50. This is an extremely preventative regime for any age,” she says. The second crucial ingredient, she adds, is vitamin A for patients approaching their late 20s – sometimes earlier if they have sun-damaged skin. She explains, “We add this in the evening, either in the form of retinol or retinaldehyde, or – in certain cases – it might be a prescription-strength tretinoin.”
Following the introduction of a topical vitamin A, the next step in Dr Williams’s system is a medical-grade, results-driven facial. “This could incorporate a mild chemical peel or transmicrodermobrasion, to help skin to regenerate itself and prevent ageing,” she says, adding, “The final step up would be to introduce minimally invasive, in-clinic treatments like platelet-rich plasma, medical needling, non-ablative laser treatments and carboxytherapy – all of which are regenerative treatments that are great to slow down the ageing process.”
At Dr Martin Kinsella’s Re-Enhance Clinic, the team offers a different option for preventative ageing, known as bioidentical hormone replacement therapy. Similar to conventional HRT – common among women in their 40s and 50s to minimise undesirable symptoms of menopause – bioidentical hormone treatment uses synthetic compounds that are identical in chemical structure to naturally occurring human hormones.3
“This alternative form of HRT is customised and tailored to the individual patient,” Dr Kinsella says, explaining, “We take a blood test and examine the levels of all the major hormones. That helps us to determine which hormone levels are low or out of balance, and we can restore those individual hormones back to their optimum range.”
Dr Kinsella says that female patients often come to him seeking a solution for all manner of age-related physical problems like hot flushes, night sweats, ‘brain fog’, heavy or irregular periods, irritability and lethargy. Alongside those, women will often experience weight gain, reduced muscle tone and loss of libido.
But, as well as leading to physical symptoms, hormonal imbalances tend to become evident in facial aesthetics. “Most of the signs of ageing we treat in the specialty are down to changes in the skin, and a great deal of that is due to changes in oestrogen,” Dr Kinsella comments, explaining, “Women age rapidly from the age of 50 onwards and start to look markedly older, and that’s because they’ve lost the oestrogen in the skin. The skin oestrogen has a huge effect on the dermal thickness, on hydration and on pigmentation, so rebalancing oestrogen is absolutely fundamental.” This is equally true, he adds, for younger patients in their 30s and 40s who wish to prevent the visible signs of ageing on their skin. As such, bioidentical hormone therapy can be used as a preventative ageing treatment, as well as a corrective one.
Dr Kinsella explains that the treatment regime involves giving patients a combination of hormones based on the results of the initial blood test. The hormones are given individually so the dosage of each can be tailored to the patient’s specific hormone levels; that way, patients get exactly what they need in the dose they need. He says, “As the treatment progresses, we monitor how the patient is responding, and we can adjust the doses of the hormones accordingly. We might need to tweak the dose of progesterone, while maintaining the dose of oestrogen, for example.”
“The longer you wait for wrinkles to take hold, the harder it’s going to be to manage them”
Professor Bob Khanna
Typically, the hormones will be given as a capsule, in the form of transdermal gel or cream, or sometimes by injection, depending on the patient’s requirements. The hormones that can be tested and given therapeutically are:1
Treatment rounds last three months, but notwithstanding any side effects or adverse reactions – of which, Dr Kinsella has not experienced – a patient would stay on the required combination long term, as determined by six- and 12-monthly blood tests. It is worth being aware, however, that although anecdotal evidence is positive, the NHS notes that there isn’t any good evidence to support the fact that bioidentical hormones are safer than HRT or exactly how effective they are.4
According to cosmetic and reconstructive dental surgeon Professor Bob Khanna, there is a noticeable rise in under-25s seeking preventative ageing treatments, particularly among young women visiting his clinic with their mothers. “Quite often I have a patient I’ve been treating for a while and I’ve built a relationship with, and they come in with their daughters,” he says. “They might ask me what they should be doing to prevent visible ageing, and I’ll tell them to start with a good skincare regime.”
Professor Khanna would confidently offer prophylactic botulinum toxin to patients as young as 20. “If they show early signs that they will develop hypertrophy in certain areas – such as the masseter and glabellar muscles – then I would be totally at ease using careful, small amounts of toxin to help regulate that muscle activity,” he says.
As a preventative measure, botulinum toxin would be performed every four to six months – less frequently than when it’s used correctively (every three months). Other minimally-invasive treatments such as PRP and hyaluronic acid skin boosters can be given to aid neocollagenesis once every 12 weeks, Professor Khanna adds.
However, some argue that when very young patients request aesthetic procedures, practitioners have a duty to recognise potential insecurities that run deep. “If young people already have insecurities about themselves and how they look, and you treat them, you’re effectively agreeing that they need the treatment and feeding those insecurities,” says Recchia.
Evidence suggests that the popularity of photo-editing apps is fuelling the rise in youngsters seeking to change how they look, because they give a distorted view of beauty. Such is the growth in demand to look more like one’s filtered images that the phenomenon even has its own name – ‘Snapchat dysmorphia’.5
According to a recent Journal of the American Medical Association (JAMA) Facial Plastic Surgery study, there has been an upsurge in requests for preventative ageing in order to emulate the ‘flawless’ image projected by photo filters.6 In the UK, the most vulnerable cohort are those aged 18 to 24: the most prolific users of Snapchat.7
If a patient presents with no strong visible signs of ageing, suggests Recchia, the better option is to encourage them to consider all their options. “I would urge them to look at other treatments than injectables, such as quality skincare,” she says, adding, “As well as not being necessary, when you start having injectables it can be very difficult to stop” – which of course can have financial as well as psychological implications. “It’s important that, as practitioners, we educate our patients so they understand how the skin works and how it ages, so they can learn what to do about it early on,” emphasises Recchia.
Professor Khanna, on the other hand, says early clinical intervention is important. “The longer you wait for wrinkles to take a hold, the harder it’s going to become to manage them,” he comments.
Whatever age one regards as old enough to embark on preventative ageing, the key is to maintain a realistic idea of what’s achievable – and that applies to patients and practitioners alike. “If you see something often enough, it starts to become normal in your perception,” says Dr Parekh. “I feel like in the aesthetics specialty too many people are over-treating, and some practitioners lose sight of what ‘normal’ is, and what is aesthetically pleasing.”
And younger patients could be particularly vulnerable to this, since they may be more influenced by unrealistic and unattainable ideas of beauty perpetuated by celebrity culture and media.
Experience and in-depth knowledge of the anatomy and physiology of the face helps to preclude this, comments Dr Parekh, adding that practitioners also have a duty to turn patients away if treatment is either unnecessary or inappropriate.
The practitioners agree that they have a role in promoting the importance of preventative skincare – most crucially sun protection – to all patients, especially those at the younger end of the spectrum who might not even have considered anti-ageing treatments.
According to Dr Williams, pointing out the health benefits of using sun protection can be a starting point for conversation. “Unfortunately, we still see a lot of young people sunbathing and using indoor tanning, and that – as we know – is not only a significant cause of ageing, but also increases the risk of skin cancer,” she says. “That can make a good entry for discussion about the benefits of sun protection; if you don’t want to talk about it in the context of ageing, you can talk about it in terms of protecting the skin and reducing the risk of skin cancer and other chronic damage.”
Here, a thorough consultation is essential, allowing practitioners to assess what approach is most likely to strike a chord with each patient. It can also enable them to pick up on a patient’s nuances – like the way they talk and express themselves – which, in turn, can indicate how and when they are likely to begin showing visible signs of ageing, according to Professor Khanna. He says, “When you observe someone in conversation, in dynamic action, you can tell a lot about that person. People tend to wear their personalities on their face.” Thus, he explains, a person who is often stressed or angry is likely to frown a lot, which will be apparent on their face and in the pattern of lines and wrinkles that are developing. The reverse is also true, whereby a more happy-go-lucky person will typically have fewer static lines.
Practitioners agree that the results of a corrective procedure are often immediate and objectively measurable. A patient in their 50s who has extensive toxin and fillers will notice a reduction in lines and wrinkles, and increase in volume, straight away. The same often can’t be said of younger patients undergoing preventative ageing, because they have fewer visible ageing signs to begin with.
Practitioners agree they have a role in promoting the importance of preventative skincare
Professor Khanna says high-quality clinical photography at the start of a preventative ageing regime and at regular intervals thereafter can shed some light. “In terms of preventative ageing, this allows you to monitor changes in a patient’s appearance over time,” he says. “I take photographs of all my patients, so I can look back to when they started and compare to when they finish, and follow the progress of every single patient at every step of the way.”
Regardless of what we do to our faces in the pursuit of eternal youth, there’s no doubt that making healthy lifestyle choices can help. For example, there is some evidence that a diet rich in fresh fish, fruit and vegetables might help prevent damage that causes premature skin ageing, and conversely, a diet high in refined carbohydrates can speed up the ageing process.8 And for that, it’s never too early.
When it comes to taking things further, however, there is a worrying pattern emerging, with aesthetic procedures becoming increasingly more accessible to an ever-younger cohort. Responding to news of Superdrug launching botulinum toxin and dermal fillers in some of its stores, the British Association of Aesthetic Plastic Surgeons (BAAPS) said the availability of high-street injectables signalled a ‘reckless disregard for safety and responsibility to patients’.
Even though Superdrug’s treatments are only being offered to over-25s, the fact they are available at all in a retail environment that attracts teenage customers arguably runs the risk of normalising aesthetic procedures among that group.
In a statement, consultant plastic surgeon and BAAPS council member, Mary O’Brien, said, “Many young and vulnerable people who associate certain high-street stores with ‘beauty products’ may be misled by unscrupulous marketing into believing that botulinum toxin injections are risk-free and just another ‘beauty product’, rather than a medical intervention.”9
As far as Dr Parekh is concerned, the specialty is duty-bound to make patients aware of the gravity of aesthetic procedures, and effective training plays a part. “Most practitioners are aware of what is ethically right and wrong,” he concludes, “And, as a training provider, it’s my position to set standards and give moral guidance to my delegates. The main emphasis, essentially, is on treating only where there is a real need. If there isn’t, we can usually assume it’s a skin concern that can be addressed with a simple skincare regime.”
1. Valenti, L and Atkins, C. Preventative Botox in Your 20s is Real – But it Could Be Aging You. (Vogue, August 2018) <www.vogue.com/article/preventative-botox-injections-twenty-somethings-expert-guide-wrinkles-fine-lines-eyes-lips-forehead>
2. Kremer, D. How young is too young for Botox? (Harley Street Aesthetics, April 2016) <www.harleystreetaesthetics.com/blog/dr-kremers-blog/2016/04/22/how-young-is-too-young-for-botox>
3. Re-Enhance, Bio-Identical Hormone Replacement Therapy in Women (Re-Enhance Medical and Dental Clinic) <www.re-enhance.com/see-all-treatments/hormones-and-health/bio-identical-hormone-replacement-therapy-in-women/>
4. NHS Choices, Alternatives: Hormone Replacement Therapy (HRT) (UK: NHS, 2018) https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/alternatives/
5. Tweedy, J, Cosmetic doctor reveals alarming rise in cases of ‘Snapchat dysmorphia’ as Generation Z becomes obsessed with looking like their ‘perfect’ filtered photos (Mail Online, August 2018) <www.dailymail.co.uk/femail/article-6082589/Cosmetic-doctor-reveals-alarming-rise-Snapchat-dysmorphia.html>
6. Rajanala, S et al, Selfies—Living in the Era of Filtered Photographs, JAMA Facial Plast Surg. 2018;20(6):443-444 <www.jamanetwork.com/journals/jamafacialplasticsurgery/article-abstract/2688763>
7. Statista, Share of Snapchat users in the United Kingdom (UK) in January 2018, by age group (Statista, 2018) <www.statista.com/statistics/611255/snapchat-users-in-the-united-kingdom-uk-by-age-group/>
8. American Academy of Dermatology, What causes our skin to age? (AAD, 2018) <www.aad.org/public/skin-hair-nails/anti-aging-skin-care/causes-of-aging-skin>
9. British Association of Aesthetic Plastic Surgeons, BAAPS Statement on high street Botox injections (BAAPS, August 2918) <www.baaps.org.uk/media/press_releases/1617/baaps_statement_on_high_street_botox_injections>