Aging Skin

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Skin aging 

General overview 

Issues with skin aging, whether due to laxity, wrinkles, or discoloration, are by far some of the most common reasons people seek consultation with a facial plastic surgeon. Skin is the largest organ by weight and not only serves as a protective barrier, but it also helps maintain temperature and hydration¹. The skin is also the most visible indicator of one’s age, and sometimes overall health. A methodical way to break down the aging process of skin is via intrinsic and extrinsic factors. 

Intrinsic aging is the process by which skin becomes less adept at self-repair, primarily by reactive oxygen species, which is a by-product of metabolism, as well as hormone imbalances. This occurs via reductions in fibroblasts, collagen production, and flattening of the dermal-epidermal junction². Over time this leads to thinner skin, loss of elasticity, dryness, and wrinkles. 

Extrinsic factors also impact the aging process of skin. The most well-known is ultra violet light, which causes DNA damage leading to less youthful cell replacement, and in some instances even skin cancer³. Other common causes include environmental factors such as pollution and smoke, as well as inflammation-inducing foods such as refined carbohydrates and sugars⁴. 

Treatments 

There are many ways to address skin aging. Although we cannot halt aging, there are a variety of ways to ameliorate the process. 

Nutrition is closely related to skin health. Foods rich in antioxidants, vitamins, and minerals aid in skin repair, while pro-inflammatory foods can promote skin damage. Water is of utmost importance. Dehydration has a direct impact on skin appearance, and studies have shown impacts of water intake on skin hydration and physiology⁵. Adequate protein is also vital, as it provides the building blocks for cell repair, with skin renewing every 28 days⁴. 

A skin maintenance program is also helpful. Arguably sunscreen is the simplest and most cost-effective prevention strategy, and the American Academy of Dermatology advises daily use of sunscreen with an SPF of 30 or higher⁶. For several decades, retinol therapy has been known to reduce photoaging effects and is available in both prescription and over the counter formulations^7-8. More recently, antioxidants such as vitamin C, resveratrol, ferulic acid, and many others have gained popularity. These agents neutralize free radicals, which help reduce overall skin damage burden⁹.  

Resurfacing procedures, whether via chemical or laser, are also efficacious methods for improving wrinkles, scars, and dyspigmentation. There are a plethora of treatments, ranging from mild resurfacing which results in slight redness and almost no downtime, to ablative resurfacing and deep chemical peels, which carry more downtime and risk but offer much more dramatic results¹⁰. 

Neuromodulators (Botox, Dysport, Xeomin, Jeuveau, Daxxify) are popular ways to address aging skin as well. Neuromodulators act by reducing muscle activity, thus when injected into facial muscles, they soften wrinkles that form with expression. In addition, they have also been shown to aid in decreasing severity of developing lines as well¹¹. Duration of action is dose-dependent, and the most commonly used doses will last several months¹². 

Lastly, depending on patient anatomy and goals, surgery may be an appropriate option to address aging skin. While surgery itself does not change skin quality or biological age, removal of skin excess and suspension of soft tissue are methods to improve appearance. Common facial plastic procedures include brow lifts, upper and lower eyelid surgery (blepharoplasty), lip lifts, facial implants, fat grafting, and face lifts. 

Overall, the most effective treatment regimens tend to utilize a combination of the above and will vary from person to person based on age, ethnicity, individual goals, and safety. 

Marc Polacco, MD, FACS 

References 

1. Tobin DJ. Biochemistry of human skin –our brain on the outside. Chem Soc Rev. 2006;35:52-67. 

2.  Russel-Goldman E, Murphy G. The pathobiology of skin aging: new insights into an old dilemma. Am J Pathol. 2020;190:1356-1369. 

3. Panich U, Sittithumcharee G, Rathviboon N, Jirawatnotai S. Ultraviolet radiation induced skin aging: The role of DNA damage and oxidative stress in epidermal stem cell damage mediated skin aging. Stem Cells Int. 2016;1-14. 

4. Cao C, Xiao Z, Wu Y, Ge C. Diet and skin aging-From the perspective of food nutrition. Nutrients. 2020;12:870. 

5. Popkin B, D’Anci K, Rosenberg I. Water, hydration, and health. Nutr. Rev. 2010;68:439-458. 

6. Zheng C, Choragudi S, Akhtar S, Rajabi-Estarabadi A, Nouri K. 2020 update on sunscreen compliance with American Academy of Dermatology recommendations. J Am Acad Dermatol. 2021;84:1174-1175. 

7. Mukherjee S, Date A, Patravale V, Korting H, Roeder A, Weindl G. Retinoids in the treatment of skin aging: an overview of clinical efficacy and safety. Clin Interv Aging. 2006;1:327-348. 

8. Baldwin H, Nighland M, Kendall C, Mays D, Grossman R, Newburger J. J Drugs Dermatol. 2013;12:638-42. 

9. Chen J, Liu Y, Zhao Z, Qiu J. Oxidative stress in the skin: Impact and related protection. Int J. Cosmet Sci. 2021;43:495-509. 

10. Loesch M, Somani A, Kingsley M, Travers J, Spandau D. Skin resurfacing procedures: new and emerging options. Clin Cosmet Investig Dermatol. 2014;28:231-41.  

11. Satriyasa. Botulinum toxin A for reducing the appearance of facial wrinkles: a literature review of clinical use and pharmacological aspect. Clin Cosmet Investig Dermatol. 2019;12:223-228. 

12. Polacco MA, Singleton A, Barnes C, Maas C, Maas CS. A double-blind randomized clinical trial to determine effects of increasing doses and dose-response relationship of incobotulinumtoxinA in the treatment of glabellar rhytids. Aesthet Surg J. 2021;41:500-511.