355 – Skincare strategies, the science of facial aging, and cosmetic-intervention guidance

KEYPOINTS

• 01

  Facial aging means losing scaffolding: bone, fat pads and skin.

  Oculofacial plastic surgeon Tanuj Nakra and dermatologic cosmetic surgeon Suzan Obagi describe about 11 plump fat compartments on each side of a young face, most of which shrink with age. CT studies following the same people over 15–20 years (Rohrich and Pessa) show the eye sockets widening and the cheekbones, maxilla and mandible receding. Retaining ligaments that tether skin to bone then show up as tear troughs and folds. Nakra frames it as four changes: skin, volume, gravity and bone.

• 02

  Women's faces age about 20 years faster than men's between 50 and 60–70, largely because of hormones.

  Obagi says facial bone loss mirrors the post-menopausal drop in hip bone density. As the mandible recedes the neck loosens, which is why 50-year-old women often say 'I hate my neck'. She argues for discussing hormone replacement early in menopause. Weight cycling also thins the face: each pregnancy's gain and loss comes off the face and doesn't return there.

• 03

  Facial fat behaves differently from body fat, and chronic stress may speed up its loss.

  Why facial fat shrinks while body fat grows isn't understood. Fat pads even differ in color within the eyelid, partly from beta-carotene. Nakra sees peak-stress decades (30s–40s) accelerating facial volume loss and changes in collagen and elastin, and Peter suggests cortisol may break down facial fat even as it builds body fat. Fat grafted from the abdomen keeps behaving like abdominal fat and swells if the patient gains weight.

• 04

  Daily sunscreen is the non-negotiable first step. Obagi insists on mineral formulas.

  An Australian randomized trial found that four years of daily sunscreen meant fewer lines and wrinkles. UVA ('aging') and UVB ('burning') damage DNA, collagen and elastin, and visible and infrared light add pigment and possibly deeper changes. Obagi prefers zinc oxide or titanium dioxide, citing absorption of avobenzone and oxybenzone into the blood and possible hormone effects. She and Nakra say chemical filters degrade within about an hour in strong sun and that nothing above SPF 50 is meaningful. Those are their clinical views. Darker skin ages more slowly, mainly because melanin forms a 'parasol' over the cell nucleus.

• 05

  Retinoids are step two, and the strength should rise with age.

  Collagen production peaks around 18. Retinol (over the counter, weakest) converts to retinaldehyde, which converts to retinoic acid (prescription: 0.025/0.05/0.1%, about $80–100 a tube that should last about 3 months). Obagi starts sensitive patients on retinaldehyde five nights a week and tretinoin two, and says skin adapts within 6–8 weeks. Nakra builds up from 2–3 nights a week or mixes in 1% hydrocortisone. Use a fingertip unit including under the eyes, never stop in summer (sensitivity to light fades), and keep it beside your toothbrush.

• 06

  Simple routine: gentle cleanser, antioxidant serum, then sunscreen or retinoid.

  In the morning: a non-foaming glycerin-based cleanser (body soap strips the face), a vitamin C serum, then sunscreen. At night: cleanser, serum again (Obagi says the day's oxidative load depletes it), then retinoid, applying thinnest to thickest. Vitamin C supports collagen synthesis, acts as an antioxidant and evens pigment, and topical application reaches far higher skin levels than oral doses. It degrades easily, so stabilized formulas are worth paying for, unlike retinoids and sunscreen. Nakra's 'cheapest trick': nightly petroleum jelly visibly thickens and smooths skin within 30 days.

• 07

  Treat cystic acne early, because the scars last a lifetime.

  Obagi calls cystic acne, which affects perhaps 20% of adolescents, a dermatologic emergency because of scarring and psychological harm. She avoids long antibiotic courses because of the gut microbiome and moves quickly to isotretinoin, about 5 months, which clears roughly 85% of people. It requires pregnancy prevention, no alcohol, and checking triglycerides and liver enzymes. She considers the depression scare poorly supported, since depression scores often improve. Photodynamic therapy with ALA and red light is an alternative.

• 08

  Obagi's 5 Rs of rejuvenation: relax, refill, resurface, redrape, renew.

  Relax overactive muscles with neuromodulators, refill volume with fat or filler, resurface the skin (Obagi says better skin gets noticed before a lift does), redrape with energy devices or a facelift, and renew with ongoing maintenance, mostly through skincare at home. Resurfacing runs from non-ablative options (light peels, IPL/BBL, fractional lasers) to ablative ones (CO2, deep TCA or phenol peels). A full CO2 treatment means 7–10 days in dressings, about 3 weeks of redness, and is done every 5–10 years. Ablative lasers are riskier for darker skin types.