Photos by Agberto Guimaraes and Cristian Newman

Hail, Queen Ravenna the evil queen of Snow White and the Huntsman, who dared to gaze upon the reflection of an aging female face, in terror and then devise a “solution”. Legend has it that she kept her good looks by “draining the youth” from the kingdom’s maidens in order to maintain the spell cast over her by her mother in childhood, namely perpetual beauty. So is this morbid preoccupation relevant for today’s woman? Absolutely. The Kardashian clan promote the “Vampire Facelift”, a cocktail of Platelet Derived Growth Factor mixed with a sample of the patient’s own blood. Considering that youth and attractiveness are high value 21st century commodities, the quest for eternal youth has undeniably permeated our collective sensibility. What’s a mere mortal to do? Define the problem before considering solutions.

If we subscribe to the notion that aging is inevitable, perhaps we should understand the pathophysiological processes as well as how they can be modified. I frequently quip that one of the “secrets” of successful aging is heredity, i.e. pick your parents well. But environmental influences (excess tanning, smoking, drinking, illicit drugs & other high risk behaviors) can often neutralize good “genetic potential”. Every cell line is programmed to undergo a certain number of cell cycles before undergoing apoptosis or programmed cell death, which in turn produces facial disharmony. Evaluation of the aging face must include assessment of each of the layers, so that a “complete” transformative strategy is proposed. Ignoring or emphasizing any one lamina or feature, without regard to balance is often perceived as being unnatural, even by the casual observer. Patients seeking facial rejuvenation are explicit in their disdain for certain over­done features, such as “trout pout”, “pillow face”, “Spock brows”. All of us in aesthetic medicine get it but Queen Ravenna was among the first to put it in words:

“When a woman stays young and beautiful forever, the world is hers”

Snow White and the Huntsman may not have been very riveting but the special effects deserved honorable mention, for the horrific representation of extreme feminine aging. No the above image isn’t a consequence of lack of moisturization but rather hormone depletion, which contributes to menopause’s systemic effects on facial aging.

  • Estrogens are responsible for elasticity, water retention & circulation;
  • Androgens increase sebum (oil) production;
  • Progesterones inhibit enzymatic depletion of connective tissue.

Skin is the largest organ of the body and the following changes may be observed:

  • Epidermis (superficial layer) thins and may develop spider veins, solar lentigos,
  • Dermis (deeper layer) loses up to 30% of collagen, during the first 5 years of menopause;
  • Skin matrix proteins involved in sebum and sweat production decrease. Net effect = thin crepey skin, through which fine veins are visible.

Facial fat compartments will either atrophy or droop, resulting either in

  • Hollows: Temporal, tear trough, lateral cheek bone, buccal fat pad and chin dimpling;
  • Accumulations: mandibular jowls, submental fat pads, etc.

Muscle hyperactivity may create

  • Hyperanimation lines glabellar, perioral, periocular, brow and neck lines;
  • Splaying of platysmal bands;
  • Habitual furrows over nasolabial folds and marionette’s lines.

Bone resorption is the ultimate frame shift, which causes loss of structural support. Its manifestations are most pronounced in loss of lower ⅓ rd vertical height.

Aging has diverse manifestations; erasing its nuances requires multiple strategies.

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