Approach to the Mature Cosmetic Patient: Aging Gracefully

Our population is aging and has accumulated a significant amount of UV exposure, resulting in sun damage, wrinkles, textural changes, and skin cancer.^1,2 These complications affect the economy as a whole, with skin care representing an ever-expanding $80 billion industry.³ Women ages 35 and older look at their face, on average, about 5 times per day, equivalent to approximately once every 3 waking hours. Forty-five million American women (60%) were likely to worry about “looking old and wrinkled,” and 60% of women think men would rather kiss a woman with a beautiful face. Our mature patients desire safe and effective techniques to “turn back the clock,” with most women preferring dermal injectables over surgery. Women on average would prefer to look about 13 years younger than their actual age, and 75% of women want their skin to look and feel new. As the aging population increases, dermatologists continue to be at the forefront of aesthetic treatments.⁴ Aging skin is a cumulative process that is a consequence of genetically programmed decreases in functional capacity and loss of the ability to repair damage. Fat redistribution and loss from facial fat compartments contribute to multiple changes in the aging face, including the increased prominence of nasojugal creases, nasolabial folds, marionette lines, and jowls.⁵ Patients in their fifties have usually already started or will start menopause, as well as start to develop changes in facial contour, reduced skin elasticity, and more brittle hair and nails. When patients reach their sixties, dyschromias become more prominent, as do seborrheic keratoses, actinic keratoses, dilated pores, lusterless hair, and vascular erythema. Past age 70, volume loss becomes more apparent, as lipoatrophy begins and bone resorption progresses. Skin laxity increases even further, as does easy bruising and hair thinning or loss.^5-8When a patient presents for a cosmetic consultation, the best way to start the conversation is by asking the patient what bothers them and then discussing what aspects can be improved. Asymmetry and other notable features can be documented with pretreatment photographs, which can then be compared to post-treatment photographs to show patients how their appearance has been improved. A wide variety of aesthetic treatment options are available to patients. Laser and light treatments can treat pigmentary alterations and telangiectasias, as well as help with evening skin tone.⁹ In contrast, neuromodulators and soft tissue fillers are essential tools for improving rhytides and volume loss. Men can also benefit from aesthetic procedures, although they typically require greater amounts of neuromodulator to be injected than that needed to achieve the same result in women. Tear troughs that have undergone lipoatrophy can give the eyes a sunken, tired appearance. Injecting hyaluronic acid into this region using a blunt-tipped cannula can take years off the face in a way that decreases the chance of running into vessels in this highly vascular area (Figure 1). Cannulas are an excellent way to inject filler into other highly vascular areas, such as the mid face, to minimize the risk of bruising and other vascular complications related to intravascular filler injections. However, cannulas are not suitable for revolumizing the temples since this procedure requires injection down to the level of periosteum. Cannulas are not appropriate for revolumizing thin ear lobules either, which is a simple procedure in which filler is injected into the ear lobules to give them a more plump, youthful appearance to counteract the sagging and thinning that results from years of wearing heavy earrings. With age, there is an overall loss of lip volume and structure. The upper lip becomes thin and elongated, Cupid’s bow