Strategies to Fight Father Time

by Cynthia Cobb, NP

The terms "midlife" and "middle-aged" once struck fear in the hearts of women between the ages of 38 and 55. Today, women are more interested in achieving midlife happiness than muddling through a midlife crisis. Interventions to help them look good as they age are essential tools in this attitude turnabout.

Aging is not a disease. Rather, it is a natural and inevitable process. The rate at which someone ages is governed by many factors. We can't stop our biological clock, but we can accelerate its movement with poor lifestyle choices. These bad choices include stress, excessive alcohol consumption, poor sleep quality, smoking, drug use, sedentary lifestyle, poor nutrition and untreated hormonal imbalances. All of these put aging on the fast track.

As women approach midlife, the ravages of time, sun, heredity and hormones begin to take their toll. People are affected to varying degrees by these factors. This article examines the medical and cosmetic concerns associated with aging of the face in midlife women.

The Aging Face

The face ages in response to many factors. The rate and the extent to which facial aging occurs vary according to each person's unique characteristics. Two factors that have a significant impact on aging are sun exposure and smoking; each tends to accelerate the aging process.¹Common skin issues in a woman's middle years are rhytids (wrinkles), skin laxity (sagging), hyperpigmentation (darkened skin pigment, sun or age spots, melasma), facial hair, dry skin, enlarged pores, acne, facial telangiectasia (spider veins) and rosacea. Skin cancer is also a concern, but it is not within the scope of this article.

Etiology of Aging

The face ages in several ways and via several etiologies. The primary causes are ultraviolet light damage, loss of subcutaneous fat, changes in intrinsic facial muscles, loss of elasticity as a result of gravity, and remodeling of underlying structures.

Sun exposure, or photoaging, emphasizes the changes of intrinsic chronologic aging.¹Cumulative sun exposure is the single most influential factor in the clinical aging of skin. The unwanted effects of this exposure can include changes in soft tissue (e.g., loss of elasticity, rhytids, hyperpigmentation, facial telangiectasia, lentigines), loss of collagen and disorganization of collagen. Sun exposure also can affect fat and muscles, resulting in a loss of mass.

Aging also leads to a loss of the fullness and roundness of facial contours seen in youth, resulting in a flattened or sunken appearance of facial structures.¹ uscles used for facial expression are unique because they insert directly into the skin. Years of repetitive facial expressions result in progressive development of rhytids or hyperdynamic wrinkles, which upon first appearance are only visible with facial movement. After a period of time, these rhytids may remain noticeable even when the individual muscles are at rest, or static. The rhytids are more prominent in areas where the underlying muscles and fascia have more direct attachments to the skin, such as in the frontalis (forehead), glabella (between the brows), lateral canthal area (crow's feet), infraorbital area, nasolabial fold (parenthesis lines), and superior and inferior orbicularis oris (perioral) areas.¹As a result of aging, soft tissues of the face lose their resiliency and ability to resist stretching. This causes sagging skin.¹ nother event is a decrease in apparent facial volume, often as a result of bone resorption. In addition, the gravitational stretch of cartilaginous structures may result in the drooping of structures such as the nasal tip.¹Deflation (volume loss) and rotational descent also occur with aging. These affect the middle of the face by extending the length from lower lid to soft tissue interface, increasing subcutaneous volume loss, and deepening the nasolabial fold. Deflation affects the lower face by producing an increase in the prominence of the nasolabial folds, a deepening of the nasolabial groove, ptosis of oral commissure (downturn of the corners of the mouth), thinning of the lips, flattening and lengthening of the upper lip, atrophy of the "Cupid's bow" (the double curve of the upper lip) and depression of the prejowl region.¹

Interventions

Since 1997, the number of cosmetic procedures performed in the United States has skyrocketed 457%.²Women received 91% of these procedures, and men received the remaining 9%. The most popular procedures in 2007 were, in descending order, botulinum toxin A administration, hyaluronic acid (Restylane, Juvederm, etc.) administration, laser hair removal, microdermabrasion and intense pulsed-light (IPL) laser treatment.

With the 45-and-older age group expected to grow three times as quickly as the general U.S. population, demand for antiaging products and services is expected to continue at high levels over the next 2 decades.³

growing number of midlife women choose nonsurgical cosmetic interventions to address skin concerns. Some interventions alleviate or improve these issues when used alone, but often a combination of therapies yields better outcomes. Some of the common interventions used to address midlife skin issues are botulinum toxin A, dermal fillers, lasers, chemical peels, microdermabrasion and topical preparations known as cosmeceuticals.

Botulinum Toxin A

Botulinum toxin A received an FDA indication for the treatment of glabellar lines in 2003. For many years, this substance has been successfully used off label to treat frontalis, lateral orbicularis oculi and superior and inferior orbicularis oris rhytids.⁴

Medical use of botulinum toxin predates its cosmetic applications - back to the 1950s for the treatment of strabismus, a use approved by the FDA in 1979. The substance's FDA indications expanded in 1989 to the treatment of blepharospasm and hemifacial spasm.⁵

The commercially branded cosmetic preparation of botulinum toxin A, Botox Cosmetic, is indicated for the temporary improvement of moderate to severe glabellar lines associated with corrugator or procerus muscle activity in patients 18 to 65.⁶Accordingly, the most common use for botulinum toxin A is to treat rhytids in the upper third of the face.⁴The effects of muscle weakness caused by botulinum toxin A are typically evident approximately 2 to 4 days after injection, with maximal muscle weakness accomplished 7 to 10 days after injection. The time ofonset is dependent on dose, with more rapid onset following higher doses of the medication. Muscle activity typically returns approximately 2 to 5 months after administration and is dose dependent as well.⁵

Botox Cosmetic differs from dermal fillers in that the results of Botox injection become noticeable after a few days, when muscles relax. Most dermal fillers, on the other hand, produce immediate results.

Dermal Fillers

Dermal fillers can be used to fill pre-existing facial defects or to augment existing structures.⁶Dermal fillers can also address nasolabial folds, oral commissures, rhytids in the marionette area, superior and inferior orbicularis oris, and lateral orbicularis oculi. These fillers are available in formulations that provide semipermanent, temporary or permanent results. Some of the fillers approved for cosmetic use are considered replacements, while others cause stimulation of collagen production. The visible effects of dermal fillers last 2 to 24 months.⁷

Patients commonly choose dermal fillers to fill in fine lines, deep rhytids and folds, and to contour lips and facial areas. Table 1 outlines some of the commercially available preparations. Hyaluronic acids are probably the most commonly used; they are more affordable and last longer than collagen. Hyaluronic acids are long-chain polysaccharides that are naturally occurring substances in the body. They must be stabilized through crosslinking to ensure durability in synthetic form.

The next sections provide more detail about how botulinum toxin A and dermal fillers are used in the face.

Upper Face Uses

The upper face includes the portions ranging from the trichion to the glabellar area. Changes in the upper face are usually a result of chronic ultraviolet light damage, the use of intrinsic muscles of facial expression, and gravitational changes resulting from lost tissue elasticity.

Botulinum toxin A can improve wrinkle appearance on the forehead and glabella. Fillers can also treat problems in this area, but only providers with advanced filler-injection skills should administer treatment here. The deep glabella rhytids may be treated with fillers in conjunction with botulinum toxin A treatment. Extreme caution must be exercised when injecting filler in this area due to increased risk for tissue necrosis.

Midface Uses

The midface ranges from the glabella to the subnasale. Aging of this area affects the eyelids and periorbital regions, the cheeks and the nose. Changes in these portions of the face primarily result from a combination of photoaging, loss of subcutaneous tissue, loss of cutaneous elasticity, and remodeling of underlying cartilaginous and bony structures.

Botox may be used to lift or open up the eyes using injections into the lateral brow area. Bilateral lateral canthal ryhtids may also be diminished by injecting botulinum toxin A into the bilateral lateral orbicularis oculi muscles.

Injecting filler under the lateral third of the brow provides elevation of the brow. Very fine threads of filler may be injected to assist with crow's feet; for best results, this should be performed in conjunction with administration of botulinum toxin A.

Filler injection can also be targeted to the hollows of the temporal area because depression of this area is often associated with aging. One approach involves injecting the lateral and inferior nasojugal groove where it extends into the orbitomalar groove bisecting the malar fat pad.⁶This helps by providing a more uniform smoothness of the tear trough. The patient loses the tired appearance caused by dark circles and has a more rested, energized look.

Acne scars on the cheek area can also be treated with dermal fillers. A sinking and effacing of the malar eminence is typical with age, resulting in hollowing and descent of the cheeks. Filler can be used to augment this area. The malar region can be directly built up by adding volume to the cheeks. This increases the malar prominence and enhances appearance.

The most popular treatment area for fillers is the nasolabial folds, also called smile lines or parenthesis lines. Nasolabial folds deepen over time. Based on my clinical experience practicing in a medspa setting, younger patients seek fill injections for this area more often. These folds develop as a result of expression rather than the aging process.

Lower Face Uses

The lower face ranges from the subnasale to the menton. Aging of this area has a most notable effect on the lips, chin, lower cheeks and neck. These changes are a result of a combination of factors that include chronic ultraviolet light damage, loss of subcutaneous fat, changes in the muscles of facial expression, gravitational changes from a loss of tissue elasticity, and remodeling of the underlying bony and cartilaginous structures.

Rhytids around the lips result from constant pulling of the orbicularis oris muscle on the progressively inelastic skin of the upper and lower lips, creating angular, radial and vertical lines.⁴The effects of gravity become obvious, as noted by lateral and downward droop of the oral commissures, often leading to a tired and sad appearance. Fullness of the lips and a strong definition of the philtrum are common in youth, but with advancing age the vermilion border thins, lip height diminishes, and an overall flattening of the lip occurs.

These issues can be addressed with the administration of filler in the vermilion border as well as the body of the lip. A small amount of botulinum toxin A may be injected into the superior and inferior orbicularis oris muscles to relax these muscles.

So-called marionette lines are caused by a combination of expression, aging, gravity and genetics. In some patients, they become pronounced. This phenomenon is caused by a loss of volume and support combined with loss of dermal elasticity. Filler can be used to augment and support this area. Adjunct use of botulinum toxin A injection into the depressor anguli oris muscle helps elevate the corners of the mouth via the zygomaticus muscles.

Jawline unevenness may also develop in the lower face. This is caused by loss of skin elasticity and the pull of gravity, which act together to highlight the jowl contour. Injecting filler in the melomental fold and prejowl sulcus creates a smoother mandibular line.⁶

Other Nonsurgical Treatments

Lasers such as the fractionated lasers (Fraxel) can address many patient concerns by resurfacing the skin. These lasers can treat hyperpigmentation, rhytids, acne scars and enlarged pores. Other light-based treatment modalities include such devices as Thermage and Titan, which address skin laxity and stimulate the production of collagen. Fotofacial orintense pulsed light can be used as well to address rosacea-related redness, facial telangiectasia, facial hair, hyperpigmentation, acne and overall skin rejuvenation.

Laser hair removal devices, such as Cutera's Nd:Yag 1064, reduce the growth of dark hair but do not affect gray, silver or white hair. Devices such as the Nd:Yag 1064 can also treat facial telangiectasia. They may additionally be used to treat skin redness.

Chemical peels can address many skin issues faced by women in midlife (Table 2). Peels superficially injure the skin and are usually well tolerated. Repeated peels can produce significant improvement. Peels are often used to treat skin issues such as large pores, rhytids, acne scarring, actinic keratoses, acne, rosacea and hyperpigmentation.⁸ Microdermabrasion is an alternate choice for many of the same issues targeted by superficial peels. Microdermabrasion resurfaces the skin to improve skin quality, reduce hyperpigmentation, soften fine lines and treat acne and acne scars. In the most typical scenario, microdermabrasion uses tiny grains of sodium chloride or aluminum oxide or diamond tips and vacuum suction to buff away the surface layer of skin.

Cosmeceuticals

Demand for aesthetic medical interventions is high, but so are demands on patients' pocketbooks. Many women seek economical or less invasive approaches.³A variety of topical or cosmeceutical products can provide benefits similar to the interventions discussed earlier. These products may be used alone or in addition to the medical interventions.

In 2003, the U.S. cosmeceuticals market was valued at $45.5 billion, with skin care products accounting for $15 billion of that total.³Heading that product list are antiaging and sun protection products. Some of the products found in many women's skin care arsenals are listed in Table 3. These agents contain substances presumed to be active; they do not meet the definition of efficacy, which encompasses proof of penetration, identifiable mechanism of action and evidence of clinical value.

Characteristics of cosmeceutical products should include immediate and long-lasting results, minimal side effects, preventive benefits and application to a large and varied number of skin issues, such as texture, pigmentation and laxity. Companies that develop these products are restricted from developing products that contain true active ingredients due to expensive and lengthy clinical trials, a highly competitive industry, and the need to keep pace with the fast-changing consumer market. Pharmaceutical companies have not been players in the cosmeceutical market, but with the lure of potentially high-priced products not requiring prescriptions, several are now venturing into the arena.³

Topical agents such as metronidazole gel (MetroGel) may be prescribed for the treatment of rosacea. Topical antibiotics are often prescribed to treat acne either alone or in combination with benzoyl peroxide or tretinoin. Eflorrithine (Vaniqa), a prescription ointment to slow hair growth, may be used in combination with other treatment modalities such as shaving, waxing, plucking or lasers to augment control of undesired facial hair. (Electrolysis is still an option for permanent hair removal, but trained electrologists are difficult to find in some cities.)

Oral medications may be used to address skin issues in midlife women, including hormonal interventions and antiandrogens that include spironolactone (Aldactone) for the treatment of acne and facial hair growth, and oral antibiotics for the treatment of acne. Prescribe these with caution to ensure that the benefits outweigh the risks.

Putting It Into Practice

The skin issues of midlife should be approached comprehensively. No single intervention will address all issues of concern. Combining interventions often optimizes results, providing higher patient satisfaction.

A common patient complaint is that many aesthetic interventions produce only temporary results. I view this as an advantage. Unlike cosmetic surgery or permanent fillers, the results of most treatments subside with time. This is good news for patients who might not be comfortable with the outcome or who, after a time, become more comfortable in their older skin.

Amid the plethora of choices available for addressing skin care issues in midlife women, remember that education of providers and patients is fundamental. Knowledge of the treatment options available, as well as the features, composition and mechanism of action for each, is required. NP

References

1. Tan S, Glogau R. Fillers esthetics. In: Soft Tissue Augmentation. 2^nded. Beijing, China: Elsevier; 2008:11-18.

2. American Society for Aesthetic Plastic Surgery. Quick facts: highlights of the ASAPS 2007 statistics on cosmetic surgery. Available at: http://surgery.org/press/statistics-2007.php. Accessed Jan. 22, 2009.

3. Gendler E, Rizzo C. Cosmeceuticals and the practice of dermatology. In: Cosmeceuticals. 2^nded. Beijing, China: Elsevier; 2009: 3-6.

4. Tan S, Glogau R. Botox esthetics. In: Botulinum Toxin. 2^nded. Beijing, China: Elsevier; 2008:1-6.

5. Rohrer T, Beer K. Background to botulinum toxin. In: Botulinum Toxin. 2^nded. Beijing, China: Elsevier; 2008:9-17.

6. Gladsone H, Somoano B. Background information on use of esthetic fillers. In: Soft Tissue Augmentation. 2^nded. Beijing, China: Elsevier; 2008:1-9.

7. Medical Education Collaborative and StrataMed. Injectable fillers: Products and Techniques. Aesthetic Health Dimensions: A CME educational program, 2007.

8. Brody H. Chemical Peeling and Resurfacing. 2^nded. St. Louis, Mo.: Mosby; 1997:11-27.

Cynthia Cobb is a women's health nurse practitioner who specializes in aesthetics at Coccolare Spa in Lafayette, La. She is a test administrator for the Association of Medical Esthetic Nurses' certification exam for medical esthetic professionals and the author and publisher of the Study Guide for the Medical Esthetic Practitioner Certification Examination. She is pursuing a doctorate in nursing practice.