The Scene: A DIVE - A SCUBA DIVE, THAT IS

You're spending a weekend on a live-aboard yacht, just off the coast of Belize.

Epidermal etiquette:

Before you don your wetsuit, apply gobs of thick moisturizer all over your body. The rubbery suit will help the emollients sink into your skin. The moment you emerge from the surf, slap on more of same. After you've been in and out of the water countless times a day, the evaporation rate of the moisture on your skin goes up, says Dr. Glogau. If you don't armor your skin by applying lotion while it's still damp, it will soon have the texture of fish scales.

The Scene: TELLURIDE

You've booked a cunning chalet for the first-ofthe-eason ski weekend.

Epidermal etiquette:

Protect your lips. We involuntarily lick our lips a lot in the cold, remarks Dr. Glogau, and this can lead to painful peeling and cracking. Smooth on an SPF 45 lip balm liberally and often, especially on the more vulnerable lower lip

Journal Of The San Francisco Medical Society

As we head into the next century, medicine is confronted with the aging of the so called "baby boomer" generation. At present writing, one person in the United States turns 50 years old every eight seconds. As this group reaches their own half-century mark, the problem of aging appearance has never been more in the forefront of consumer consciousness. The various reasons for this include increasing pressures in a downsizing, competitive, highly technocratic job market, a high rate of divorce and successive remarriage, increasingly visual and incessant media communications, wider availability of cosmetic services, sustained economic growth and increased discretionary income, and a wider acceptance of cosmetic rejuvenation procedures as they become more commonly used.

Medical response to this consumer driven demand has not been stagnant. There has been a logarithmic explosion of medical and surgical techniques introduced to the standard armamentarium. Many techniques, such as liposuction surgery, were beyond the realm of imagination only two decades ago and are now among the most common cosmetic procedures performed in the United States in the last year.


ANATOMIC BASIS FOR AGING APPEARANCE

One can approach the analysis of the aging face using an anatomic model to provide a systematic framework to counsel patients and rationally select among a wide variety of therapeutic options. Inappropriately applying the wrong therapy to misunderstood cosmetic defects leads to frustrations for both physician and patient. The end result is usually with mediocre results at best and occasionally a disaster in extreme cases.

The human face ages in response to the following factors which appear in varying degrees in different individuals:

Identifying the relative mix and proportion of these factors in the patient, selecting the proper procedure knowing the risk/benefit ratio, and communicating this information to the patient constitutes the essential ingredients of the cosmetic consultation.

TRENDS TOWARD AMBULATORY PROCEDURES

Along with the increasing demand for rejuvenative procedures, a parallel trend can be seen in the patient's desire for minimum "down time." Busy personal and professional schedules make many traditional cosmetic procedures beyond the reach of many patients. The trends appear to be strongly in favor of "the minimal" approaches: minimal down time, minimal invasion, minimal cost. Some of the therapies being developed and touted are more successful at addressing these "consumer" issues than others.


THERAPIES FOR ULTRAVIOLET LIGHT DAMAGE

Resurfacing using chemical peel solutions of trichloroacetic acid or carbolic acid (phenol) and mechanical dermabrasion were the mainstays of resurfacing for years. Laser resurfacing using the carbon dioxide laser and Erbium lasers have given benefits of greater precision in skin wounding but have introduced new paradoxes: the significant morbidities of prolonged healing periods and persistent erythema appear to be inversely related to ultimate skin smoothing and tightening.

Gentler forms of resurfacing under current investigation include the use of repetitive particle peeling using aluminum oxide crystals forced under pressure against the skin, producing so-called "microdermabrasion." These procedures repeated over time appear to effect consistent changes in the epidermis associated with photoaging (freckling, discoloration, texture, and pore size) without significant morbidity.

Utilizing existing radiofrequency technology, surface skin ablation (Coblation®, McGhan Corp.) can be damage and appears to be another modality that can address skin photoaging. A plasma flow is created at the tip of the application device which causes disruption of the tissue at the molecular level without associated neighboring tissue being affected by heat damage. This is an example of "cross-over" technology coming from one area of medicine to another since it originally was developed for intra-articular sculpting in orthopedics and was tweaked to be applicable to skin surgery.

Other new modalities being explored at the present time include the possibility of selective subsurface heating of the dermis with the long wave Nd:YAG laser at 1320 nm (CoolTouch®, New Star Laser, Inc). This wavelength may produce collagen shrinkage without damaging the overlyingepidermis, giving a tightening effect without the morbidity of the ablative lasers. The pursuit of dermal tightening without excessive epidermal morbidity remains the holy grail of laser therapy in facial rejuvenation. One apparent disadvantage at present is the need for multiple treatment sessions over time and relatively modest improvements in comparison to more established resurfacing techniques.


TOPICAL SKIN THERAPY

Developments in topical therapy have not been ignored. An explosion of topical retinoid products reached the markets in the past year. Stabilized retinol preparations are now widely available without prescription and appear to convey many of the improvements seen with chronic topical retinoic acid (Retin-A®, Ortho Pharmaceuticals) without products. Other topical therapies new to the anti-aging scene include plant kinins (Kinerase®, ICN Pharmaceuticals) which appear to have both anti-irritant and photoaging reversal properties with no perceived irritation. These products will be marketed directly to the consumer as moe clinical experience is gathered.


THERAPIES FOR LOSS OF VOLUME

Aging produces a profound loss of subcutaenous fat in the peri-oral area, the temporal fossae, the pre-malar areas, chin and forehead. The older face has a flattened quality to the cheekbones, a sunken appearance to the lips,a bulging of the inferior fat pads of the eye and, in general, a loss of the fullness and roundness of youth.. Experiences plastic surgeons have recognized this and are moving away from excessive fat removal to fat repositioning or augmentation.

For example, the routine removal of the infraorbital fat as a part of blepharoplasty, which often accentuated the deep grooves between the lower eyelid and the cheek , has become outdated. Now surgeons prefer to utilize an arcus marginalis release and mobilize the fat medially and anateriorly to fill in that groove and return a more youthful appearance to the lower eyelids through resotration of fullness. Similarlly, repositioning of the pre-malar fat has become an important part of routine face lifting, reversing the aged appearance that comes from flattening of the cheekbone contours.

The ultimate recognition of the importance of the subcutaneous volume of the face comes from the work of surgeons who have evolved techniques of fat transfer to restore the volume contours of the aged face. Microlipoinjection in small and larger volumes, placed subcutaneously and intramuscularly has been used with great success to reshape the aging face. While difficulties remain in the predictability and longevity of fat transfers, the aesthetic effects are often impressive in the naturalness of the resulting appearance. Restoration of loss of volume lies behind the appeal of injectable fillers such as collagen (Zyderm®, Zyplast®, McGhan Corp.), hyaluronic acid (Hylafor®, Biomatrix, Inc.), cadaver tissue (Dermaologen® Collagenisis, Inc.), cultured autologous fibroblasts (Isolagen®) and autologous collagen (Autologen®). Bovine collagen now has a 25-year track record and remains the material of choice for injectable augmentation. Cultural perceptions of risk and bovine spongiform encephalopathy have made the material unsellable in the U.K. So the search for newer, less antigenic materials continues.

Newere technology now exists for production of human recombinant collagen (Fibrogen, Inc.) which is moving slowly toward the commercial application. This potentially "pure" form of collagen will likely eliminate many of the other injectable products now on the market since it will offer augmentation without risk of rejection or allergy, which remain the greatest clinical problem with injectables to date.


LIP AUGMENTATION

Lip augmentation with injectables remains one of the most frequently sought after cosmetic procedures performed in aesthetic medicine today. The market is literally overflowing with new injectable agents and alloplastic implants of expanded polyterra-fluorethylene (SoftForm, McGhan Corp., Gore-Tex). While initially introduced as a cosmetic tool, SoftForm shows great promise in restroration of facial contours in individuals afflicted with the lipodystrophy associated with HIV disease and protease inhibitors.


SELECTIVE MUSCULAR DENERVATION WITH BOTULINUM TOXIN

Botulinum A extotoxin (BTX-A) is a neurotoxin produced by the anaerobic bacterium Clostridium Botulinum. Botulinum toxin (BTX) is actually present as seven different serotypes (A-G), but it is BTX-A that is commercially avalable (BOTOX®, Allerghan, Inc.) BTX-A inhibits the release of acetylcholine from the pre-symaptic membrane of the neuromuscular junction of striated muscle leading to the onset (1-14 days) of muscle weakness and paralysis. Over time (3-4 months) new neuromuscular junctions are formed and muscle function slowly returns. Inhibition of acetylcholine release from sympathetic nerves innervating eccrine sweat glands likewise produces a profound loss of sweating in the treated area. These two sites of pharmacological action lie behind the recent explosive increase of the use of BTX-A in cosmetic dermatology for hyperhidrosis and for movement associated wrinkles.

First used in monkeys by San Francisco's own Dr. Alan Scott in 1973 - who demonstrated reversible ocular muscle paralysis lasting three months - BTX-A was soon reported as a successful treatment in humans for strabismus, blepharospasm and spasmodic torticollis. In 1986, Jean and Alastair Carruthers, a Vancouver-based husband and wife team consisting of an oculoplastic surgeon and a dermatologist, identified the cosmetic use of BTX-A for movement-associated furrows in the glabella area leading to their seminal publication in 1992. In 1994, they reported their experience with other movement-associated wrinkles on the face and thus the era of cosmetic BTX-A treatment was born.

Perhaps nothing else has driven home the impact of facial musculature on facial aging like the introduction of botulinum toxin for selective chemical denervation of selected muscles of the face. Paralysis or partial weakening of the glabellar corrugator/procerus complex, the forehead frontalis and the laterial orbicularis muscles has simply revolutionized the managment of the third of the aging face. Deep glabellar lines, which could be only briefly improved with injectable fillers, now melt away with the placement of botulinum toxin in the corrugator/procerus complex. Crow's feet lines, which routinely reappeared after deep resurfacing, now vanish in a few days. Even the troublesome horizontal lines and creases of the lower eyelid, which persisted after blepharoplasty and/or resurfacing, now can be treated with botulinum toxin. The toxin is both safe and temporary. It has now become a mainstream tool in cosmetic surgery.


TRENDS TOWARD COMBINATION THERAPIES

Optimal improvement in appearance can more often be obtained by combining procedures. At one end of the therapeutic spectrum, topical medical therapy utilizing agents like tretinoin, alpha-hydroxy acids, hydroquinones and and 5-fluoruracil can inhibit or referse ultraviolet-associated changes in aging skin. At the other end of the therapeutic spectrum, rhytidectomy, blepharoplasty, brow lift and suction-assisted lipectomy often provide dramatic results in facial rejuvenation. The choice of therapy rests on the ability of the surgeon to look at the face, analyze the antomic components of the aging appearance, and then prioritize them, mathcing procedure risk/benefit ratio to each.

Dr. Glogau is a dermatological surgeon practicing in San Francisco. He is a clinical professor of dermatology at UCSF, a member of SFMS and has authored several texbooks and numerous articles in the field of cosmetic dermatology and dermatologic surgery. His current research interests are in substances for soft-tissue augmentation, lasers and the cosmetic uses of botulinum toxin, including hyperhidrosis. As part of disclosure of potential conflicts of interest, he wishes the reader to know that he serves as a consultant to Allergan, Inc., the manufacturers of BOTOX®.