Harvard Health Letter

Harvard Health Letters

Between acceptance and defiance there's a middle way of relatively small tweaks that will make an old face look younger.

Age affects every nook and cranny of the body, but nowhere are the consequences on such open display as on our faces. Dozens of changes take place as the years add up, some of them obvious and familiar: Foreheads expand as hairlines retreat, for example. Ears of an older vintage often get a bit longer because the cartilage in them grows. Tips of noses may droop because connective tissue supporting nasal cartilage weakens.

There are also structural rearrangements going on behind the scenes. When we're young, fat in the face is evenly distributed with some pockets here and there that plump up the forehead, temples, cheeks, and areas around the eyes and mouth. With age, that fat loses volume, clumps up, and shifts downward, so features that were formerly round may sink, and skin that was smooth and tight gets loose and sags. Meanwhile, other parts of the face gain fat, particularly the lower half, so we tend to get baggy around the chin and jowly in the neck.

The bones in the face also change with age. Like the rest of the skeleton, the upper jaw, lower jaw, and cheekbones shrink. Less bone can make a face look wider and more angular and contributes to looser skin.

And, of course, there are the wrinkles. Those deep ones in the forehead and between the eyebrows are called expression, or animation, lines. They're the result of facial muscles continually tugging on, and eventually creasing, the skin. Other folds may get deeper because of the way fat decreases and moves around.

Finer wrinkles are due to sun damage (more on that below), smoking (which has some of the same effects on skin as sunlight), and natural degeneration of elements of the skin that keep it thick and supple.


If our faces show our age, so be it -- in fact, we should celebrate it. Some lines here and there connote character. That's one -- and perhaps the best -- response to age etching itself into our faces. And American attitudes toward an older look seem to be shifting now that many baby boomers are in their 60s.

Counter to "old and proud of it" is the age-defying facelift, which surgically removes excess tissue and -- as the name indicates -- lifts sagging skin in the lower part of the face. Facelifts have improved, so people look more natural afterward. But the surgery is expensive (the surgeon's fee alone averages just under $7,000), and other procedures may be needed to make the top half of the face look just as young as the lower half.

Plenty of Americans still get facelifts. According to the American Society for Aesthetic Plastic Surgery, about 94,000 people got one in 2009. But the procedure is only the 20th most popular cosmetic procedure, and now there are plenty of alternatives for altering an aging face.

Most of these rejuvenating procedures are nonsurgical. And while they're not inexpensive -- especially when you factor in the need for repeat treatments -- you don't need a movie star-sized income to afford them, nor a star's vanity. "Getting a little work done" has become increasingly mainstream.

Here's just a sample of the things that you can do -- or get done -- to give your face a more youthful appearance:

Sun protection.

As we get older, the collagen in the dermis -- the next-to-the-top layer of the skin -- changes character, so the skin feels thinner and stiffer. Add sun exposure and you get solar elastosis: tangles and clumps of collagen and elastin (a protein that, as the name suggests, makes skin springy). With solar elastosis in the dermis, the skin loses its flexible, supporting structure, so fine wrinkles form around the mouth and across the cheeks. Sun exposure is also the main cause of crow's feet, the wrinkles at the outside corners of the eyes.

Protecting your face from the sun is the single best way of keeping it youthful, according to Dr. Kenneth Arndt, a member of the Harvard Health Letter's editorial board and a dermatologist at SkinCare Physicians outside of Boston, Mass. Much of the damage comes from the UVA part of the light spectrum, so you need to put on sunscreen that protects against it and UVB light, which causes sunburn. Wearing a wide-brimmed hat is also a good idea.

Creams and lotions.

Moisturizers soothe dry skin and may temporarily make wrinkles less noticeable. Moisturizers for the face contain water to make them less greasy, and many have substances -- glycerin, for example -- that may help bind water to the skin. Exfoliant creams can improve the appearance of older skin by getting rid of dead skin cells that don't slough off as readily as they did when we were young.

Several prescription creams (Avita, Avage, Renova, Retin-A) have been shown to reduce wrinkles and so-called liver spots caused by sun exposure. These FDA-approved creams contain retinoids, compounds related to vitamin A that seem to work by inducing collagen production in the dermis and altering melanin, the pigment that causes liver spots. There are several varieties of retinoids. Tazarotene and tretinoin are the ones used in the FDA-approved products.

Using a retinoid cream is a fairly pricey proposition. A single tube costs between $100 and $200. The cream must be applied pretty much daily (usually at bedtime) and continually for the wrinkles to stay away. Less expensive generic versions of some of the prescription retinoid products are now available. Over-the-counter creams containing retinol, another retinoid, may be worth a try but are probably not as effective as the prescription products.

Dozens of products containing other vitamins and ingredients are available. For the most part, there isn't much evidence for these "cosmeceuticals" having much of an effect. More often than not, they're probably not worth the money.

Botulinum toxin injections.

These injections are used to treat the expression lines of the forehead and between the brows. They work by partially immobilizing the muscles that form expression lines so the skin smooths out, although some deep expression lines may not go away. Botox is the familiar brand name. Other FDA-approved botulinum toxins are Myobloc and Dysport. The FDA issued a new warning in 2009 about the botulinum toxin spreading from injection sites, although there have been no reports of that happening when the injections were for expression lines.

Botulinum toxin injections cost between $400 to $500 for each area treated. They tend to wear off after several months, so people need to come back for more injections, although the effect seems to last longer when injections are repeated.

Dermal fillers.

Dermal fillers are used to treat lines created by lost collagen and fat. After Botox injections, dermal filler injections are the most common cosmetic procedure performed in the U.S. Prime locations for the injections are two sets of parentheses: the pair of lines that extend down from the nose to the corners of the mouth, known as the nasolabial folds, and another pair that extends down from the corners of the mouth to the chin, known as marionette lines.

Many different materials are used as dermal filler. Collagen has fallen out of favor. Currently, the most popular one is hyaluronic acid, a complex sugar found naturally in many tissues. As a filler, it expands the dermis by occupying the spaces between collagen and elastin. Hyaluronic acid is more expensive than collagen but lasts longer -- up to six months in the nasolabial folds. Injections cost between $600 and $900. Like Botox injections, the effect of the dermal filler shots wears off after several months -- how long depends on the injection site -- but with repeat injections it seems to last longer.

Laser treatments.

Lasers can be used to home in on certain pigments: brown, if the goal is to get rid of freckles and liver spots, red if the target is broken capillaries. They're also used for wholesale resurfacing of facial skin. The uppermost layers are stripped away, and with them, wrinkles from sun damage and scars from acne. In effect, the skin's wound-healing capabilities are being harnessed, explains Dr. Arndt, who performs many laser procedures: smoother layers of tissue replace the old, damaged layers that have been lasered away. The energy from some "nonablative" resurfacing lasers passes through the outer layer of the skin to work at a deeper level, in the dermis, to stimulate inflammation, which leads to collagen formation.

Skin needs time to recover after most laser treatments. It can take a couple of weeks to heal, depending on the type and extent of the treatment. The nonablative treatments tend to heal a bit faster.

Treatments vary in price. For pigmented or vascular lesions, charges range from $400 to $800. Nonablative resurfacing of the face will cost about $1,500 and full face ablative resurfacing several times as much. But the effects from the treatment can last for years. Some people get Botox injections after laser treatments so new expression lines don't form. Sun exposure can discolor laser-treated skin, so patients are advised to be very careful about using sunscreen and taking other precautions when they are outside.

Eyelid surgery.

The medical term for eyelid surgery is a pleasing mouthful: blepharoplasty. Eyelids sag and get puffy for several reasons. With age, the little muscles that support your eyelids weaken. Extra skin and fat accumulate, so they look puffy. If the upper eyelid droops too low, it can block your vision. Almost 150,000 Americans had blepharoplasty in 2009, and it's the most common cosmetic surgery among people over 50. The procedure involves removing the excess skin and fat, so the eyelids tighten up. Sometimes the fat can be removed through the palpebral conjunctiva, the membrane that lines the inner surface of the eyelid, without making an incision.

People may get other procedures done at the same time as blepharoplasty to improve the appearance of the whole area around the eye. The average surgeon's fee for blepharoplasty is slightly under $3,000. - Harvard Health Letter

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Health - The Aging Face: Small Tweaks Can Help You Look Younger