For those new to aesthetics, Dr Vincent Wong, clinical pharmacist Marie Line El Helou, and clinical dietitian Marie-Elizabeth Ragi present an introduction to the modalities that can help your patients maintain a youthful appearance
The past decade has witnessed a significant global increase in the use of minimally-invasive
cosmetic techniques for aesthetics and rejuvenation.1
Interestingly, this was also paralleled with a rise in the use of social media platforms with photo-filtering options like Snapchat, especially by younger adults.
Indeed, according to an online survey involving 2,092 participants, 77% of people aged
between 18 and 24 and 38% of people aged between 35 and 44 reported using Snapchat
in the UK, versus only 2% of people aged 75 and above.2
The advent of image-based social
media has put photo editing and filters in everyone’s arsenal and has standardised the
perception of beauty worldwide, such as creating smooth young-looking spotless skin.3
Skin health is indeed considered one of the principal factors indicating overall wellbeing in humans.4 The skin is altered with ageing due to the loss of elasticity and the appearance of expression lines and, later, wrinkles. In this article, we will explore and introduce many of the minimally-invasive techniques for age prevention and reversal, which include neurotoxin, fillers, skin peels, resurfacing treatments, medical-grade skincare, as well as modifications in lifestyle habits and nutrition.
The phenomenon of ageing is a fundamental feature of life.5
Skin ageing is characterised
by decreased synthesis and increased degradation of collagen, elastin, and hyaluronic acid
(HA), the main components of the skin’s connective tissue, leading to reduced skin resilience
Moreover, youthful skin seems to retain its turgor and pliability, due to its high content of water. The crucial molecule involved in skin moisture is HA, which has a distinctive capability to bind and retain water molecules. Skin ageing starts in the mid-20s with progressive hormonal changes, such as the gradual decrease in production of sex hormones and the latter decrease in oestrogens and progesterone associated with menopause in women.7 The production of collagen also slows down from around the age of 25, with a reported 1% loss of collagen production yearly.8
Meanwhile, collagen degradation is promoted by external factors such as UV-light exposure, smoking, vitamin C deficiency, and some diseases (e.g. osteoarthritis).9,10 Thus, maintaining a proper amount of collagen in the skin is of high importance to maintain skin health and relies on techniques that stimulate collagen production (also called collagen-banking techniques) and interventions that prevent collagen breakdown.
The success of cosmetic procedures does not depend only on improving individual features, but also on establishing facial harmony and preventing or correcting ageing aspects.11 Symmetry, averageness, and gender-specific traits play important roles in determining the attractiveness of a face.12 In particular, smaller than the average chin, smaller than the average nose, and higher than the average forehead, all are traits associated with a female’s attractiveness according to male study participants.13 Female preferences for male faces are thought to be less specific. Preferred features were influenced by cultural, psychological and hormonal factors and included masculine eyes (narrower and more deep set than female eyes), but not particularly masculine facial outlines.13
Preventing ageing through skincare, lifestyle changes, and diet management is as important as cosmetic interventions
However, the aim of cosmetic procedures should be to treat conservatively and not to give an unrecognisable appearance. Moreover, correction of the skeletal facial structure is increasingly regarded as the new objective in facial rejuvenation as certain areas of the facial skeleton such as the maxilla and the pre-jowl area of the mandible undergo resorption with ageing.14 Indeed, enhancing certain features can, at the same time, improve facial harmony and help prevent ageing. For instance, according to Dr Wong’s experience, favouring a prominent chin and jawline can help prevent the development of jowls in older age. Similarly, correcting a negative vector in the cheeks with fillers can help restore harmony and youth to the face.15
Countless minimally-invasive approaches are available to address skin ageing and enhance facial rejuvenation, with many of them acting on maintaining skin collagen and elastin. Infiltrative therapies, such as filler injections, employ filling substances (e.g. collagen, HA, or autologous fat) to target soft tissue augmentation and large wrinkle improvement.16 They have also been utilised to correct volume distribution and achieve balanced facial contouring.17
Conversely, mesotherapy uses micro-injections in the superficial layer of the skin,
to help improve skin brightness and texture,
notably eye wrinkles and dermal thickness.18
Indeed, HA micro-injections have become
very popular as a ‘youth booster’ thanks to
their ease of use, efficacy to reverse early
signs of ageing by improving skin elasticity
and complexion radiance, and positive safety
profile, including low immunogenicity.6,7,19,20
On the other hand, radiofrequency therapy as well as resurfacing procedures, such as chemical peeling, microdermabrasion, microneedling, laser, and intense pulsed light (IPL), have been applied to effectively protect existing collagen and stimulate new collagen synthesis, thus promoting skin repair, skin tightening, alleviating acne, scarring, wrinkles and photoageing, and correcting hyperpigmentation.17,21-23 The type of laser is chosen based on the degree and severity of defects, with ablative lasers being used for severe skin damages and deep creases, and their non-ablative counterparts being favoured for moderate imperfections.21
Sun exposure remains the predominant causative agent of skin cancer and photoageing, creating skin atrophy, pigmentary changes, wrinkling, and malignancy
Chemical peels, which contain varied strength of acids, are also popular as a means to exfoliate the superficial epidermis and correct superficial skin damages.21 Contrastingly, radiofrequency therapy uses radiowave energy to heat the deep layer of the skin (dermis and subcutaneous tissue) to stimulate collagen production for a natural rejuvenating effect.22,23 PRP treatments and stem cell-derived therapy using growth factors are beneficial to promote collagen production and reduce hyperpigmentation.24,25
However, notable side effects might ensue from all these approaches such as procedure-related pain, scarring, discolouration, and infections.21,22 These modalities also vary in the degree of clinical changes and most often require multiple sessions, prolonged treatment and follow-ups to sustain their effects, although studies are needed to assess their long-lasting outcomes.21 Finally, preventing ageing through skincare, lifestyle changes, and diet management is as important as cosmetic interventions.
Botulinum toxin type A injection is one of the most frequently performed cosmetic procedures for the treatment of facial wrinkles. Wrinkles are formed by dermal atrophy and repetitive contraction of the underlying facial musculature. Injection of small quantities of neurotoxin into specific overactive muscles causes localised muscle relaxation that smooths the overlying skin and reduces wrinkles.26
Neurotoxin inhibits the release of the neurotransmitter acetylcholine from axon endings at the neuromuscular junction, thereby promoting muscle paralysis.26 In clinical practice, neurotoxin is mainly used for wrinkles located in the upper one-third of the face, such as glabellar lines and lateral canthal lines, commonly called frown lines and crow’s feet, respectively.
Patients with dynamic wrinkles demonstrate the best improvements from neurotoxin compared to those with static wrinkles, who require a longer treatment duration and more frequent injections.27 Interestingly, clinicians’ experience and case studies have pointed out that repeated neurotoxin injections in targeted areas (particularly forehead, glabellar and periorbital areas) can prevent the development of expression wrinkles by promoting localised muscle relaxation, especially in younger patients before these wrinkles are definitively settled.28-31
However, overuse of neurotoxin may also result in undesirable outcomes such as a frozen look due to decreased facial expressions, or a skeletal look because of muscle atrophy due to prolonged muscle chemodenervation.32 It should be noted that muscle atrophy has been particularly reported in the masseter muscle after repeated neurotoxin injections for lower face contouring.33 Nevertheless, physicians can manage those side effects by minimising the dose and/or the frequency of neurotoxin injections and should reassure patients about the temporary and reversible effects of neurotoxin-induced muscle atrophy.34
Lately, the aesthetic practice has been favouring the combined use of dermal fillers and neurotoxin.35 Indeed, this appears to restore facial appearance by the dual mechanisms of reflation and relaxation, and by increasing the longevity of tissue dwell time of the filling agent.36 According to an open label clinical study with 57 participants conducted over six months, combination treatment resulted in high patient satisfaction (96.5 %) and good tolerability.37
Patients possess individual control over the ability to maintain skin youth and rejuvenate damaged skin by adopting preventive measures. With the availability of various options that might create confusion to the patients, practitioners should be aware of the latest treatments and educate patients on the most appropriate products to adopt, and continuously follow-up to maintain a targeted treatment plan.
Indeed, numerous changes contributing to the aged appearance are attributed to modifiable factors. Among them, sun exposure remains the predominant causative agent of skin cancer and photoageing, creating skin atrophy, pigmentary changes, wrinkling, and malignancy.38
Long-term continuous exposure to ultraviolet radiation has been shown to notably inhibit the synthesis of HA and stimulate the production of advanced glycation end products (AGEs), where collagen is rendered incapable of repair. It may also induce oxidative stress in epidermal cells, subsequently generating the production of reactive oxygen species (ROS), causing DNA damage, inflammation, impairment of collagen and elastin synthesis, and potentially leading to tissue destruction and dermal degeneration.9,39-41
However, UV-induced skin damage can be prevented by avoiding sun exposure and applying sunscreens, with a minimum SPF of 30.42,43 Topical vitamin A in the form of retinoids have also gained favour for the ability to prevent oxidative stress, and promote collagen and elastin production.44 Indeed, topical creams with antiageing properties have become very popular due to their ease of use, minimal adverse effects, and affordable price. They are reported to maintain skin smoothness, repair superficial skin damages and prevent photoageing by virtue of their sun protection (titanium dioxide or zinc oxide), prolonged moisturising effects, antioxidants components (coenzyme Q, vitamins C and E), and peeling properties (alpha or beta hydroxy acids).44
Recent concerns are also directed toward the increasing exposure to short-wavelength blue light emitted by electronic devices. Indeed, even short exposures may stimulate the production of ROS, increase oxidative stress, and induce skin damage, but more research is still needed on their long-term effect on skin ageing.45
Many other lifestyle habits and nutritional components are closely involved in skin health: some hold antiageing properties, while others might contribute to skin damage.43 Smoking and excessive alcohol consumption have been linked to increased oxidative stress, facial ageing, wrinkling, and changes in skin thickness and pigmentation, as a result of elastic tissue breakdown, with the degree of facial skin damage proportional to the amount and time of exposure.9,10,40,41,46
Studies comparing twins have supported this, as higher tobacco and alcohol consumption, as well as sun exposure, were found to be associated with the perception of an older appearance.47-49
While avoiding smoking and limiting alcohol consumption is crucial to delay facial ageing, it is however advised to indulge in moderate consumption of red wine, which contains resveratrol, a polyphenol with potent antioxidant properties.42 Indeed, food antioxidants and phytochemicals, majorly present in fruits and vegetables, of which flavonoids (red cabbage, berries), lycopene (tomatoes), proanthocyanidins (grape seeds), and polyphenols (green tea, coffee), have been reported to possess substantial skin photoprotective effects.50
Copper, zinc, selenium, and vitamins, specifically A, C, and E, are also powerful antioxidants that protect against skin ageing.9 For instance, according to a literary review, studies have shown that copper plays an important role in improving skin elasticity, reducing facial fine lines and wrinkles, and promoting wound healing.51 In contrast, excessive intake of sugars and fried food has been associated with the accelerated production of AGEs, while high-fat diets have been found to promote skin oxidative stress and inflammatory responses.9,52 Indeed, limiting dietary carbohydrates, same as caloric restriction, are reported to reduce the production of glycosylated collagen and delay ageing.9,52
These practices should, however, be avoided as they can compromise our health by generating malnutrition and deficiencies in essential nutrients.53,54 Instead, findings report that spices and herbs (cinnamon, cloves, oregano, and allspice) inhibit the production of AGEs,42 and are to be included in a balanced diet, rich in a colourful variety of fruits and vegetables, along with regular physical activity and adequate sleeping.55,56 Finally, consultations with specialists are necessary to help identify each patients’ nutritional needs, set up a targeted dietary plan and advise on the lifestyle changes to be followed.
With the rise of social media platforms and influencer movements, young millennial adults have been seeking approaches to preserve a younger-looking appearance and improve their facial features according to popular aesthetic standards.
Minimally invasive modalities such as
neurotoxin, fillers, and resurfacing treatments,
are being chosen thanks to their rapid
satisfactory aesthetic outcomes and relatively
favourable safety profile. These techniques
should however be aimed at promoting
facial balance and proportion, and effectively
correcting age-related skin features rather
than changing one’s facial appearance.
The resort to topical skincare and lifestyle
modifications, including proper nutrition
and regular exercise, are also key factors
to maintain proper skin health and to age
gracefully. With the successful integration of
many of these modalities, a complete facial
rejuvenation regimen can be established
to ensure patients’ goals and maximise
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