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Facial cosmetic surgery aims to improve any signs of aging on the face and neck without apparent surgical intervention. Clinical experience shows that combining multiple aesthetic therapies targeting numerous aspects of the aging process provides optimal results, with greater overall efficacy and higher patient satisfaction
The First step for successful treatment is to diagnose skin problems; dark spots, red spots, scars, wrinkles, or skin folds. Improving the skin’s condition is done chiefly with resurfacing procedures, laser and light therapy, daily skincare, and ultraviolet (UV) protection. Type two rejuvenation is more profound, and targets decreased collagen, disorganized glycosaminoglycans, and elastin, manifested by superficial rhytids and is best treated with non-ablative mid-infrared lasers and intense pulsed light (IPL). Rejuvenation type three is most in-depth and targets deep dermal collagen disorders and skin laxity; here comes the role of fractional lasers, radiofrequency, infra-red light, and ultrasound. Loss and redistribution of sub-¬dermal fat in aging is with Liquid facelift (Botox, fillers, and fat). Correction of soft tissue ptosis is usually surgically treated with a brow lift or non-surgically by energy-based technologies such as radiofrequency. Clinical experience shows that combining multiple aesthetic therapies targeting numerous aspects of the aging process provides optimal results, with greater overall efficacy and a higher level of patient satisfaction.
The periorbital region is one of the first facial regions to show signs of aging. It is critically important to understand precisely what feature of the periocular area is of the most concern to the patient before making therapeutic recommendations. Aging skin is characterized by the appearance of fine and coarse rhytides (wrinkles), rough and uneven texture, dryness, and changes in pigmentation. Fat atrophy occurs in the upper and lower periorbital region leading to progressive skeletonization of the orbit. Fat atrophy in the lower periorbital complex leads to a more prominent infraorbital rim, increasing the height of the lower eyelid and the overall soft tissue vertical dimension of the orbit. Typically, the nasojugal crease is more evident with aging, the malar fat pad has atrophied, the temples have hollowed, and the brow and upper lid have lost volume. In general, changes in skin texture, tone, laxity, or pigmentation are treated with physician skincare cosmeceuticals, chemical peels, lasers, or energy-based solutions. I can augment volume loss with the use of fillers, Autologous fat injection, and BOTOX A. Hyaluronic acid (HA) is the workhorse for the periorbital area because of its good efficacy and predictability and an excellent choice for correcting static rhytides that cannot be treated with BoNT alone and to recontour. Millifat, microfat, and nanofat with the addition of SVF and PRP for more massive volume deficits around the eyes may also be beneficial.
Dark Circles refer to conditions that present with relative darkness of the under eyes eyelids. This condition affects individuals of a wide range of ages, both sexes, and all races. It can be a significant cosmetic problem, and many individuals seek treatment for this condition. Having under-eyes dark circles makes you look tired, sad, or hungover. General fatigue, especially lack of sleep, worsens dark circles under the eyes. Dark circles also worsen with the aging process of skin sagging and altered subcutaneous fat distribution. The therapeutic modalities must differ depending on the cause because under-eyes dark circles are due to multiple factors. Physician Skincare products (Dr. Derm cosmeceuticals), chemical peels, lasers, light sources, fat, and filler injections, Botox injections, and eyelids surgery are used to address skin darkening around the eyes.
Rhinoplasty is technically demanding surgery, and even in the best of hands, postoperative healing and the most exceptional aesthetic outcome can be unpredictable. In addition to the risks of general anesthesia and a protracted postoperative convalescence, rhinoplasty may lead to adverse cosmetic results. Even in patients with a first satisfactory outcome, slight asymmetries, depressions, and contour irregularities may present several years after surgery. Correcting these minor problems often requires surgical revision, and the available surgical options are limited in number, expensive, time-consuming, and prone to further complications. Non-surgical rhinoplasty, injection rhinoplasty (filler, fat, or botox), has gained popularity for primary and revision nose enhancement procedures. In selected people, injection rhinoplasty can give a ready to vise result in the convenience of the office setting. The process is minimally invasive and has an excellent safety record. It has been proposed for patients. However, unlike surgical rhinoplasty, it is limited in its ability to produce a notable change in the caudal aspects of the nose.
The world places a high value on looking young and fit, that is why cosmetic surgery is up, and men are a big part of the increase. More men today are having cosmetic surgery to help them look younger and attractive. Like their female counterparts, they have discovered the benefits of cosmetic surgery not only personally but also professionally. Men are changing their attitude about several issues that were previously reserved for women. Feeling the need to look youthful and dynamic, well into your 40s, 50s, and sixties has led to men rethinking their attitudes to pills, diet, exercise, face-care products, and cosmetic surgery. In a society that values youth, 50-year-old executives are competing with younger, fitter, and more competitive 30-year-olds, who are often willing to work harder, and for less money. On the home front, men are also finding they want to keep pace with younger-looking wives.
The elements that characterize a youthful neck include a distinct inferior mandibular border, visible sub-hyoid depression, noticeable thyroid cartilage bulge, visible anterior sternocleidomastoid line, and 90_ angle with the submental line and cervical mental angle of 105 to 120. These criteria are seen in glamour models. In evaluating the neck properly, the neck aging changes may be due to skin excess, fat accumulation, platysma laxity, digastric hypertrophy, submandibular gland abnormalities, or anatomic variants such as a low hyoid bone. Surgical approaches to neck rejuvenation include liposuction, anterior or submental incision, direct skin excision, and Z-plasty. Straightforward neck procedures include the following: defatting superficial to the platysma, subplatysmal and inter-platysmal defatting, medial platysmaplasty tightening, platysma plication over the submandibular gland resection, and alloplastic anatomic chin implant placement when indicated.
The two principal categories of temporary fillers approved by the U.S. Food and Drug Administration for facial rejuvenation are hyaluronic acid and calcium hydroxyl apatite. The selection of HA implant is based on the indication and site of placement. For lifting and restoring volume, improving the structural foundations and facial contour, a high-density HA implant is injected deeply into the supra-periosteum. To treat medium-deep depression, we used a mid-density hyaluronic acid filler injected subdermally. For treating the periorbital area and the area around the lip, giving finished facial refinements, a low-density hyaluronic acid filler is selected with a water-like consistency filler. The most significant limitation of a filler compared with fat transfer is the potential cost compared with the latter as each syringe can be pretty expensive. The greatest benefit of a filler is accuracy. The other benefit is that a filler is bioinert and does not increase with patient’s weight gain but obviously may not look good when a patient does gain or lose weight as the filler has been injected to match a person’s current weight status.
The platelet-rich plasma (PRP) has been applied in androgenic alopecia in both males and females successfully. Although PRP microinjection is new in aesthetics, PRP has been recognized as an effective treatment in sports injury, diabetic ulcer treatment, and orthopedics, to name a few. Platelets have essential growth factors that, when secreted, handle tissue regeneration and rejuvenation, increase collagen production, recruit other cells to the site of injury, induce cell differentiation and extracellular matrix formation. It has an anti-inflammatory effect that will speed up healing time and ease recovery time after resurfacing procedure. With PRP therapy, we stimulate long-term collagen growth, eliminating skin wrinkles, rejuvenating the skin, improving the appearance of acne scarring, and hastening the healing process after a facial peel. PRP is injected subcutaneously into the area of alopecia with many growth factors and stem cells. Hair transplantation is no exception, and MSI is at the forefront in developing these applications.
People want to look better with as little as possible downtime. Although a quick fix is not possible for severe wrinkles, newer treatment options such as fractional lasers and fractional radiofrequency are available to slow down the aging aspects that affect the face, neck, décolleté, and the back of the hands. Vampire Facelift is a name for a non-surgical cosmetic procedure involving the injection of platelet-rich plasma (PRP) derived from a patient’s blood back into multiple areas of the skin of their face to treat wrinkles and “rejuvenate” the face. Platelets have essential growth factors that, when secreted, handle tissue regeneration and rejuvenation, increase collagen production, recruit other cells to the injury site, induce cell differentiation and extracellular matrix formation. It has an anti-inflammatory effect that will speed up healing time and ease recovery time after resurfacing procedure. In an innovative approach, Prof uses fractional ablative lasers to overcome the epidermal barrier and increase topical agents’ penetration as laser-assisted drug delivery (LADD). Prof Moawad offers his patients a full-face fractional CO2 laser or fractional radiofrequency (FRF) to make tiny holes into the skin to overcome the stratum corneum to enhance PRP and /or nano-fat. The results are doubles. You will enjoy both the rejuvenating effect of fractional skin resurfacing systems and the regenerative effect of growth factors and stems cells present in PRP and/or nano-fat.
The basis of microneedling (MN) relies on physical injury. It has been proposed that the trauma generated by needle penetration in the skin induces dermis regeneration. This results in the deposition of collagen by fibroblasts. The technique of microneedling has been well-exploited to increase the penetration of drugs across the skin barrier, including macromolecular biopharmaceuticals and drugs such as minoxidil, tretinoin, and L-ascorbic acid, vitamins and hyaluronic acid (Mesolift), platelets rich plasma (PRP), and nanofat (vampire facelift) and even botulinum toxin microinjection (mesobotox) into the deep layer of skin and subcutaneous tissue. Microinjections and microneedling are successful in skin rejuvenation, hair loss, and scars therapy.
Many ablative skin resurfacing techniques are available at MSI, broadly grouped as mechanical, chemical, and laser abrasion. All ablative techniques result in upper to the mid-dermal wound. Dermabrasion relies on mechanical ‘cold steel’ injury, acid peels result in a ‘caustic’ injury, and lasers result in a thermal injury. All ablative resurfacing treatments work the same way. First, the outer layers of damaged skin are stripped away. Then, as new cells form during the healing process, a smoother, tighter, younger-looking skin surface appears. Superficial or medium resurfacing is limited to the epidermis and papillary dermis. For deeper resurfacing, it can also remove the upper levels of the reticular dermis. Unlike chemical peels and dermabrasion, laser skin resurfacing (LSR) with the CO2 laser generates heat, which results in immediate tightening because of shrinkage of collagen, which forcefully shortens the collagen fibers by 30%. This translates clinically into the smoothing out of superficial irregularities, including wrinkles, acne scars, nevi, epidermal growths, and even tumors, as well as a tightening effect that improves the skin’s overall appearance. The laser continuously stimulates healthy new collagen and elastic fibers in the skin for six months after resurfacing. Therefore, any wrinkles or scars will continue to improve for up to one year. Nonablative or minimal ablative fractional CO2 holds great promise in both treatments of skin textural abnormalities (acne scarring, wrinkles, and skin mottling associated with photoaging) as well as pigmentary variation (melasma, hyperpigmented scars, lentigines, and dyschromia).
Fractional radiofrequency (FRF) delivers energy and creates zones of affected skin adjacent to unaffected areas. The treated areas result in thermal damage in the deep dermal collagen, stimulating wound healing, dermal remodeling, and new collagen, elastin, and hyaluronic acid formation. The unaffected areas serve as a reservoir of cells that promote and accelerate wound healing. FRF improves acne scars and large facial pores, wrinkles, and facial laxity reduction. The most common sequence effects are erythema and edema, which are transient (few days). You may use a topical anesthetic cream before the treatment to minimize pain. In a new approach, Prof Moawad offers his patients a full-face FRF to make tiny holes into the skin to overcome the stratum corneum to enhance PRP and /or nanofat. The results are doubles, and you will enjoy both the rejuvenating effect of the FRF resurfacing system and the regenerative effect of growth factors and stems cells present in PRP and/or nanofat. Recently, we applied FRF before botox treatment of excessive sweating or hyperhidrosis of the axilla.
There is a demand for compounded pharmaceuticals in dermatology because they can offer medications for patients that are not commercially available. Cosmeceuticals can be cleansers, toners, moisturizers, serums, and masques that hold active ingredients such as retinoids, alpha-hydroxy acids, polyhydroxy acids, skin lightening, antiacne, growth factors, peptides, and vitamins. Medically based skincare products target three cellular components that contribute to aged skin: keratinocytes, melanocytes, and fibroblasts. Instituting the correct routine will slow the progression of aging and work towards reversing the extrinsic and intrinsic aging changes. In aesthetic practice, using cosmeceuticals in combination with cosmetic procedures is a new treatment ideal for skin rejuvenation. Pre-treatment with cosmeceuticals can prime the skin for procedures, and post-treatment can reduce complications. Patients with conditions such as rosacea, eczema, seborrhea, and acne require specially selected products that will enhance skin appearance without irritating their underlying conditions.
Recognition of this volume loss in the upper face and its effects has changed our understanding and treatment of facial aging. A brow lift, also commonly called a forehead lift, rejuvenates the face above the eyes to restore a more refreshed appearance that better reflects a patient’s natural vibrancy. By removing excess sagging skin on the forehead and repositioning the underlying muscles and tissues, a brow lift can correct a heavy, sagging brow, eliminate deep furrows, and restore a smoother, more youthful contour to the upper one-third of the face. Through fat augmentation, the brow is directed outward and can support the overlying skin without raising the brow to an unnaturally elevated position. The superior orbital rim is approached through a lateral forehead entry site. A midline entry site is then utilized to blend the fat into the medial rim and glabellar region, totaling 1 to 2 mL per side. Upper eyelid sulcus grafting may take place at this time utilizing an entry site in the brow.
Blepharoplasty surgery is shown when the eyelids require recontouring. Specifically, blepharoplasty is most useful when excess skin needs to be removed, the muscles are enlarged or require tightening, or eye fat needs to be removed or redistributed. Upper eyelid lift surgery typically involves an incision made in the natural crease above the eye, through which your cosmetic surgeon will remove a precise amount of excess skin and fat and adjust the surrounding muscles to make the desired improvements. There are a variety of surgical techniques that cosmetic surgeons can use to improve the lower eyelids; incisions are located on the outer edge of the lower eyelid, just beneath the eyelashes, or inside the eyelid. Depending on the case, excess, sagging skin may be removed, or the lower eyelid muscle may be tightened to supply the most natural, effective results.
Rhinoplasty is still one of the most performed aesthetic surgical procedures. Over the past 20 years, the trend has shifted from ablative techniques involving reducing or dividing the osseo-cartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support. The foundation for a successful experience for both patient and surgeon involve accurate preoperative analysis and clinical diagnosis, identification of both the patient’s expectations and the surgeon’s goals, and a thorough review of the plan of care and expected postoperative recovery. Rhinoplasty remains one of the most challenging procedures in cosmetic surgery. I can achieve excellent surgical outcomes only through a thorough understanding of the multiple nasal anatomical variants and a comprehensive knowledge of the ultimate long-term effects of various surgical techniques on the overall appearance and function of the nose. I should practice a philosophy of balance, preservation, and restoration of tissues (rather than a purely deductive approach, which can introduce tissue spaces and uncontrolled scarring of tissues).
Today's facial surgeons have more options than ever before to rejuvenate the perioral area. It is essential to have a thorough understanding of both perioral anatomy and perceived signs of aging to put the correct treatment plane. The patient and physician need to understand the types of defects that can be improved using noninvasive techniques and those that require a surgical approach. Many products and devices are available to physicians to address these issues and obtain favorable results from dark lips to perioral wrinkles. In general, changes in skin texture, tone, laxity, or pigmentation are treated with chemical peels, lasers, or energy-based solutions. Dermal fillers, Autologous fat, surgical lip implants, botulinum toxin A, and micro-pigmentation are all adjunctive therapies that may be used to augment or rejuvenate the lips. It can modify Orbicularis oculi muscle function via botulinum toxin (BTX) injections or surgery.
The social implications of ear deformities for the developing child are well documented. Protruding ears are a frequent source of ridicule by peers and may contribute to various developmental abnormalities, including social phobias and outright behavioral disturbances. Correction of even minor deformities can have profound benefits to appearance and self-esteem. The ear development is virtually completed by the age of five when I can undertake adequate measures. Correction ear surgery, also known as otoplasty, can improve the ear's shape, position, or proportion. Otoplasty creates a more natural form while bringing balance and dimension to the ears and face.
The elements that characterize a youthful neck include a distinct inferior mandibular border, visible sub-hyoid depression, noticeable thyroid cartilage bulge, visible anterior sternocleidomastoid line, and 90_ angle with the submental line and cervical mental angle of 105 to 120. These criteria are seen in the glamour model. Unfortunately, as we collect birthdays, we also tend to gain a bit of weight, and sometimes fat begins to accumulate in the under the chin region. Storing fat in the neck region can also be genetic (thanks, Mom, and Dad). When treating the neck, the goals are often the restoration of a slender neckline, a well-defined neck to chin angle, treatment of the vertical bands that can form, reduction of neck fullness due to fatty tissue, and wrinkle control. Neck liposuction creates a firmer, smoother, and more refined appearance to the neck and chin and helps restore balance to facial features by providing a better-defined jawline that frames the rest of the face.
Botox is the most effective tool in cosmetic medicine and should be used first and most often. BOTOX dosing and injection points should be based on an assessment of the patient’s anatomy, goals, preferences, and the physician’s own professional experience with prior treatments. Gender, cultural, and ethnic standards of attractiveness may significantly influence the patient’s preference. Each patient’s treatment should be individualized for the best results. The use of cosmetic BOTOX in the mid and lower face and neck has increased drastically over the past few years. Indeed, there is now a greater appreciation that BOTOX-A is one part of overall facial rejuvenation therapy, in which all aspects of aging are addressed in the same individual. Finally, new esthetic indications are starting to emerge, including the treatment for scars, the horizontal upper lip line, musculus risorius excessive gingival display (‘gummy smile’’), and masseter reduction to improve facial shape. BOTOX is also beneficial with other aesthetic modalities, such as dermal fillers, laser, skin resurfacing, and surgery. Several more general applications push BTX-A toward an ‘‘art,’ rather than a clinical procedure.
The clinical applications of adipose tissue have undergone a remarkable expansion in recent years. The loss of subcutaneous fullness results in pan-facial deflation, the results of which were previously attributed solely to skin redundancy and descent. Recognition of this volume loss and its effects has changed our understanding and treatment of facial aging. Surgeons can no longer excise or reposition tissue in a singular vector and claim to have achieved a correct restoration. Aging is a three-dimensional process and must be treated as such. To ignore either the gravitational descent of the soft tissue and fat pads or the loss of facial volume will lead to consistent sub-optimal results. The minimally invasive technique using Fat autologous transfer has become a standard procedure in facial rejuvenation. I can use autologous fat to augment facial structures, rejuvenate rhytids, or fill depressed scars or defects of the face. The areas of the face that I can enhance include the cheeks (malar, sub-malar), lips, and chin (mentum). I may lift the brows with fat transfer to the forehead, and I can improve indentations in almost any facial area. Rhytids in the glabella, nasolabial fold, and marionette lines can be improved. Any area of the face can have a depressed scar elevated by subcision and fat transfer. At the current time, structural autologous lipo-augmentation is the most effective way to change the framework of the aging face. Prof. Moawad adopts a pan facial technique that allows for even and complete volume replacement with minimal downtime and superior results. Although many surgeons have approached fat injection as the only correct method to rejuvenate the face, Prof Moawad contends that fat injection can serve more effectively to complement other rejuvenation techniques. In the midface, aging is treated with a combination of soft-tissue fillers to bolster structural support and replace lost volume; skin tightening devices to improve laxity; and lasers and light-based therapies, along with topical cosmeceutical products, to reduce fine rhytides, improve surface texture, and hyperpigmentation, and brighten the skin. Because of fat grafting, facelift techniques have evolved significantly and can now avoid the signs associated with classical approaches. They now involve moderate dissection of tissues to allow fat transfer in the central areas of the face. There is also a growing tendency toward combining techniques, making it possible to meet more natural and complete results.
In today's active, outdoor lifestyle, it is not just time that is aging us anymore. Sun exposure damages the skin, breaking down cells, hardening lines, and leaving freckles and blemishes every day. Coupled with dehydration, stress anxiety, and exposure to smoke and pollution, it is no surprise that people are looking for ways to make their skin look younger and more revitalized. The Meso-lift is a Mesotherapy approach to treat aging, sun-damaged, and wrinkling of the skin involving the face and neck. This minimally invasive treatment delivers vitamins, minerals, and amino acids directly into the skin to nourish and rejuvenate, promote the production of collagen and elastin, and stimulate your metabolism. Mesohair is used for hair loss both in men and women. A tiny amount of active ingredients of minoxidil, finasteride together with all vitamins and trace elements are injected via microinjection needles into the mesoderm of bald areas—platelet-rich plasma or (PRP) or nano-fat (meso-fat) microinjection is performed subcutaneously above the galea and in proximity to the hair bulb, which is the region where stem cells exist.
Looking great in public is demanding. Whether you are trying to look your best for job interviews or get attention, Skin Rejuvenation, resurfacing or a skin peel is the way to go. MSI Skin peel (thigh-tech) is a comprehensive antiaging, anti-acne, scar treatment program that uses state of the art aesthetic medicine. It is tailored precisely to your skin condition, needs, and expectation. It includes steam, masks, exfoliation, comedones extraction, cosmeceuticals, PRP, chemical peels, LED, IPL, laser, ultrasound, and radiofrequency. In addition, we apply new techniques to enhance skin penetration of cosmeceutical ingredients, such as whitening, vitamins, and anti-acne, antiaging dermal roller, Derma pen, no needles mesotherapy (electroporation), microdermabrasion, fractional laser, and radiofrequency. Skin Rejuvenation (high-tech skin peel) can be performed anywhere on the body, but most generally are shown on the face, neck, hands, arms, and legs.
Looking great in public is demanding. Whether you are trying to look your best for job interviews or get attention, Skin Rejuvenation, resurfacing or a skin peel is a way to go. MSI Skin peel (thigh-tech) is a comprehensive antiaging, anti-acne, scar treatment program that uses state of the art in aesthetic medicine. It is tailored precisely to your skin condition, needs, and expectation. It includes steam, masks, exfoliation, comedones extraction, cosmeceuticals, PRP, chemical peels, LED, IPL, laser, ultrasound, and radiofrequency. In addition, we apply new techniques to enhance skin penetration of cosmeceutical ingredients, such as whitening, vitamins, and anti-acne, antiaging dermal roller, dermapen, no needles mesotherapy (electroporation), microdermabrasion, fractional laser, and radiofrequency. Skin Rejuvenation (high-tech skin peel) can be performed anywhere on the body, but most generally are shown on the face, neck, hands, arms, and legs.
Photo-rejuvenation encompasses many procedures using light or laser-based technology to reverse the effects of photoaging. Non-ablative photo-rejuvenation refers to the controlled use of thermal energy to carry out skin rejuvenation without disturbing the overlying epidermis and with minimal to no downtime. Currently employed non-ablative modalities include primarily intense pulsed light (IPL), visible wavelengths including 585nm pulsed dye laser (PDL), and 532 nm green light (KTP laser). Different infrared wavelengths with water as the target are used for remodeling dermal collagen. The primary mechanism of action is thermal injury either by heating the dermis to stimulate fibroblast proliferation or by heating blood vessels for photocoagulation. The newest way to deliver these wavelengths is by fractionating the dose. The non-thermal mechanism, which represents a fundamental change in thinking, is the theory of photo-modulation. This novel approach to photoaging uses non-thermal light treatments to regulate the activity of cells and not to invoke thermal wound healing mechanisms. The two types of Photo-facial or Photo-rejuvenation are available are the Intense-Pulsed Light (IPL) and the Light-Emitting Diode (LED) treatments; however, to get the results you hope to do, it’s essential to understand the difference between these facial rejuvenation technologies before you book an appointment. Your best bet for minor skin problems is to schedule an LED (often called a non-IPL) treatment, and for more severe conditions, you’ll book to IPL.
Antiaging Basic Skin Care Products
Cleansing
Proper cleansing is an essential component of skin care. The face accumulates endogenous and exogenous soils. Sebaceous gland size and density are most significant on the face, upper back, and chest. The natural oils, sweat, and sebum secretions create a hydrolipid film on the skin surface that, in addition to applied cosmetics, traps and accumulates environmental pollutants such as dust, airborne irritants, and compounds from cigarette smoke. Care must be taken to accomplish thorough cleansing without irritation or drying. Therefore, a gentle, effective cleanser is of utmost importance.
Components of surfactants can bind to the stratum corneum proteins, decreasing the skin’s ability to bind and hold water. With continued, frequent use, surfactants can damage the skin barrier. New synthetic surfactants improve cleansing with minor irritation.
Other components of cleansers include polypeptides and synthetic polymers to make the product smooth and soften skin, polymers to moisturize, preservatives, opacifying agents, and fragrance. These ingredients can cause sensitivities or contact allergies in specific individuals with frequent washing. Because cleansers are rinsed off, their contact time with the skin is reduced, causing more minor contact allergies. Newer cleansers are less alkaline than older formulations, making them less drying.
In recent years, antibacterial agents (e.g., triclosan and triclocarban) have been added to hand cleansers. Surprisingly, these agents are rarely skin irritants. However, some physicians voice concern, fearing developing bacterial resistance to these antibiotics with frequent use. Originally, triclosan was thought to kill bacteria by a “broad-based” mechanism, like alcohol and peroxide. However, recent research demonstrated that triclosan acts at a specific gene site in Escherichia coli to inhibit replication so that resistant strains could evolve. Thorough washing with gentle cleansers removes dirt and is as effective as using these antibacterial compounds.
Cleansing the face should be accomplished with lukewarm water and the fingertips. The face and neck should be washed with upward, outward motions. On the forehead, cheeks, chin, and neck, rub up and out; above the upper lip and under the eyes, the strokes should be horizontal, then upward at the edges. On the face, one should always rub perpendicular to the direction of those wrinkles that could develop later. Sunscreen, moisturizer, or other treatments should be applied immediately after gently towel-drying to seal the remaining water on the skin’s surface.
Exfoliation
Exfoliation is the rejuvenation treatment providing the most immediate improvement in appearance. Exfoliation removes the outer layers of the stratum corneum and thus treats the hyperkeratosis of dry skin. Exfoliative rubbing perpendicular to the direction of wrinkles (with upward, outward strokes) minimizes small wrinkles because the surface is smoothed.
Exfoliation can be chemical or mechanical. Chemical exfoliants such as hydroxyacids and retinoic acid remove dead surface cells by keratolysis. Mechanical exfoliants include cleansing grains, waxy creams that adhere to the surface cells, slightly abrasive terry washcloths, non-woven polyester polishing pads, brushes, loofas, or mechanical brushes – all of which physically “sand” the skin surface by rubbing. Grainy exfoliants with aluminum oxide crystals can be effective, but the user must be careful not to get the grains into the eyes.
Exfoliants to be avoided are apricot or almond kernels, walnut shells, and pumice – all have irregularly shaped particles with sharp edges that can be too rough for delicate skin and dangerous if they get into the eyes.
Masks are among the oldest face mechanical exfoliants. Masks can “wash off” or “peel off.” Some “wash off” masks are made of clay, which hardens and is removed with water rinsing. “Peel off” masks contain synthetic polymers that are pretty safe and effective. Some masks may irritate the skin; it is advisable to test the inner wrist before treating the face.
Protection
The single most effective therapy for aging skin is sun protection. Avoid sun exposure between 10 am and 4 pm, and beware of “hidden sun”: UVA is not filtered by glass, and neither UVA nor UVB are filtered by clouds. People get their worst burns on cloudy days, especially when skiing, on the beach, or in the water when reflected rays double exposure. If one’s indoor workspace is in direct sun, that person can become sunburned through the window and suffer severe photoaging.
Sunscreen should be applied often and generously every 90 minutes. Frequently missed areas with sunscreen application are just in front of the ears, around the eyes, above the lip, fingertips, and the scalp under thinning hair.
Sunscreens are classified as organic filters (which absorb photons of UV light) or inorganic filters (which reflect or scatter UV radiation)
The inorganic filters with microfine titanium dioxide and zinc oxide are total UVB blocks, titanium dioxide blocking low wavelength UV and zinc oxide almost all UVA. Thus, zinc oxide provides better protection than titanium dioxide. The new technology with microfine particles makes them non-opaque and cosmetically appealing. The microparticles’ concentration and size determine SPF efficacy.
The ability of a sunscreen to prevent UVB-mediated erythema is measured by the internationally accepted standard sun protection factor (SPF), the ratio of equivalent exposure by UVB in sunscreen-protected compared with unprotected skin.
UVA protection is measured by the degree of either immediate pigment darkening (dependent upon radiation-induced darkening of preformed melanin) or persistent (delayed) pigment darkening (as in a more complex response that induces production and transfer of melanin as well as the proliferation of melanocytes).
The SPF should be at least 30. Sunscreen labels may specify the degree of UVB protection by stating the SPF as 30+ or 50+; higher SPFs may no longer be stated.
After SPF, the second important criterion for sunscreen is “highly water-resistant,” meaning it is effective for about 80 minutes. (Labels read water-resistant (40 minutes) or water-resistant (80 minutes).) The terms “waterproof” and “sweatproof” may no longer be written on sunscreen labels since these are considered to be “false promises.” Many individuals prefer a different sunscreen for the face than for the body. Further protection with topical antioxidants and sun-protective clothing, hats, and sunglasses are indicated.
SKINCARE PRODUCTS TREATMENT OF AGING SKIN
There are several medical treatments for antiaging purposes. These include retinoic acid, hydroxy acids, and topical antioxidants. Many products are advertised, but rigorous placebo-controlled, double-blind clinical trials may not have demonstrated their efficacy.
Hydroxyacids
Hydroxyacids (HAs) have been used for centuries. Cleopatra routinely applied HAs, and Marie Antoinette washed with red wine, benefitting from tartaric acid. AHAs act rapidly (within two weeks) to smooth the skin’s surface by reducing epidermal corneocyte adhesion. Epidermal damage of photoaging is corrected in 14–16 weeks. An increase in epidermal intercellular hyaluronic acid improves surface moisturization by water retention.
Salicylic acid is unique among hydroxyacids because of its lipophilic characteristics and its y attraction to sebaceous orifices. Further, its keratolytic properties smooth surface wrinkles, decrease pore size, and prevent acne. It is also bacteriostatic.
Polyhydroxy acid (PHAs) has several advantages. They have larger molecules, so they penetrate the skin gradually and are therefore less irritating than AHAs or SA. PHAs are recommended for patients with sensitive skin, rosacea, or atopic dermatitis. They can even be used in conjunction with retinoic acid without irritation. PHAs also give improved moisturization of the stratum corneum when compared with AHAs. PHAs have anti-inflammatory and antioxidant activity, further enhancing the repair of cutaneous photoaging.
Three key factors determine HA efficacy:
There is a delicate balance in attaining efficacy without irritation. The concentration and pH determine the strength and clinical benefits of each type of hydroxyacid or mixture thereof.
Retinoids
Retinoids are the “gold standard” for reversing photoaging of the skin. Retinoic acid (tretinoin) has been used for more than 35 years to treat acne. In the late 1980s, the remarkable clinical improvement of wrinkles and solar lentigos after treatment with topical tretinoin.
Retinoids directly induce collagen synthesis and reduce collagen breakdown by inhibiting the UV-induced MMPs, correcting wrinkles. Retinoids causing epidermal thickening promote the deposition of glycosaminoglycans intercellularly. It promotes epidermal proliferation and inhibition of excess melanogenesis.
Topical tretinoin also reverses intrinsic aging, perhaps even more significantly in non-sun-exposed than in photoaged skin. Previously, topical tretinoin was postulated to make the skin more sensitive to UV exposure. However, minor UV damage occurred with tretinoin treatment.
Irritation (retinoid dermatitis) can occur, especially when beginning treatment. However, its avoided by starting with lower concentrations or using modern formulations and less frequent applications.
Patients with sensitive skin should begin with a mild formulation, applying each three days initially and increasing daily over several weeks or months. Most improvement occurs within the first year; improvement is maintained with continued use, as proven by 4-year histologic studies.
Other “second generation” retinoids have been proven effective in treating photodamage. Retinaldehyde cream (0.05%) and retinol cream (up to 1.6%) is comparable to tretinoin in efficacy but are more irritating. Tazarotene (0.5% and 0.1%) may give faster improvement but is also more irritating. Adapalene (0.1% cream and gel) is less irritating but probably less effective than tretinoin.
Antioxidants
The skin naturally uses nutritional antioxidants to protect itself from photodamage, and topical application has been investigated. The challenge is to make topical antioxidant formulations that are stable and that give percutaneous absorption to deliver high concentrations of the active forms to the dermis as well as the epidermis.
The advantage is that only a once-per-day application of topical antioxidants provides a reservoir of protection that cannot be sweated or washed away, markedly enhancing sun protection. Vitamin C If the retinoids are the “gold standard,” topical vitamin C is the “silver standard” for reversing skin photoaging.
Vitamin C (L-ascorbic acid) is the body’s major aqueous-phase antioxidant. Dietary vitamin C is required for life. Although vitamin C is not a sunscreen, topical vitamin C protects against solar damage. As an antioxidant, vitamin C deactivates the UV-induced free radicals, decreasing erythema and sunburn. Vitamin C also inhibits tyrosinase, thereby lightening solar lentigos.
Vitamin C helps the natural moisturization of the skin, but it also enhances the skin’s protective barrier function. Lightening of solar lentigos can be appreciated after only 1–2 months, while all other agents require at least 3–4 months before lightening is noted.
Creating an effective topical delivery system is crucial and quite tricky. Many products contain stable derivatives, either (or both) not absorbed or not metabolized. The formulation is key to optimizing percutaneous absorption of vitamin C. Because L-ascorbic acid is such an excellent antioxidant, it is inherently unstable when exposed to oxygen.
Vitamin E (d-α-tocopherol)
Natural vitamin E is the most crucial lipid-soluble, a membrane-bound antioxidant in the body. The natural non-esterified form must be applied in concentrations greater than 2% (5% is optimal).
Most commercial products containing “vitamin E” contain a mixture of 32 synthetic isomers, esterified, and in relatively low concentrations. Vitamin E has also been demonstrated to reverse photoaging dramatically. Topical d-α-tocopherol is also anti-inflammatory and accelerates healing. Frequent application is very effective in healing acute burns, and when applied after laser surgery, healing is accelerated.
Vitamin C with vitamin E
In cells, vitamins C and E interact synergistically to provide antioxidant protection. Fortunately, mixing these hydrophilic and lipophilic antioxidants in a topical formulation stabilizes each. Compared to twofold protection for either vitamin alone, topical L-ascorbic acid (15%) with α-tocopherol (1%) gives fourfold protection.
Ferulic acid alone absorbs some UV and therefore is itself a weak sunscreen. However, when mixed with vitamins C and E, it stabilizes the formulation and doubles the photoprotection from fourfold to eightfold. This triple antioxidant combination has been made into the SkinCeuticals product C E Ferulic (15% vitamin C, 1% vitamin E, and 0.5% ferulic acid).
Coenzyme Q10
Coenzyme Q10 (ubiquinone or CoQ10) is a mitochondrial electron transport chain component in all plant and animal cells, including human cells, especially in organs with high metabolism rates, such as the heart, liver, and kidney. CoQ10 acts as an antioxidant in the skin, although the level is naturally relatively low, with ten times more in the epidermis than the dermis. CoQ10 has been shown to reverse intrinsic natural aging as an energy generator, an antioxidant, and a regulator of gene induction.
CoQ10 treatment increases rates of cell division as well as the synthesis of natural hyaluronic acid and collagen type IV and elastin. CoQ10 further reverses hyperpigmentation by inhibiting tyrosinase activity, decreasing melanin synthesis. CoQ10 treatment also protects from UV-induced degradation of collagen..
Conclusions
The appearance of aging skin can be treated non-invasively. Strategies include primary prevention (with changes in lifestyle by not smoking, avoiding excessive sun exposure, and assiduous protection when in the sun) and treatment. New therapies for photoaging are promoted, but many have not been subjected to extensive, placebo-controlled, double-blind clinical trials.
The Contribution of Dietary Nutrients and Supplements to Skin Health
The skin is one of the largest organs in the body and is exposed to many environmental factors affecting its appearance and health. Additionally, changes occur over time in the skin, determined by our genes and hormones. It is often said that the appearance of the skin can predict overall health or is a window to health inside of the body, and there is much interest in maintaining a healthy skin appearance and function.
One approach to achieving an optimal skin appearance is using topical products, such as cosmetics. However, a growing body of research indicates that diet and oral supplementation can also influence skin appearance.
Historically, dietary deficiency of many essential nutrients (e.g., thiamine, zinc, and vitamins A and C) was first noted due to disruption of skin integrity or a change in the skin’s appearance [1]. Many nutrients are essential co-factors in biochemical processes occurring within skin cells, and therefore, deficiencies are manifested by changes in the skin.
There is apparent interest in whether dietary supplementation of these critical agents can also benefit the skin and how this compares with providing these actives via the topical route. Vitamin C has several different biologic roles in the skin, including participating in collagen synthesis, skin regeneration, and wound healing.
Nutrients provided in the diet or through dietary supplements can benefit overall skin health and appearance and, in some cases, can reverse a wrinkled or aged appearance. There is also evidence that providing several nutrients together is more beneficial than providing single nutrients in isolation. The benefits of nutrients, such as carotenoids, flavonoids, CoQ10, α-lipoic acid, minerals, and omega-3 fatty acids are related to their antioxidant potential.
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