An Overview of Beauty
Different societies have different ideas of what constitutes ‘beauty’, but more and more people are coming around to the same opinion thanks, largely, to TV, film and music videos.
There is general acceptance that the eyes and lips make up the ‘central triangle’, the focus of the face. Full cheeks are a sign of youth. They also enhance the eyes.
Full, proportionate lips are also considered beautiful. A face is thought to be more feminine with arched eyebrows and a more pointed chin (male jaws tend to be more square). These features contribute towards the creation of the ‘central triangle’, or ‘V’ shape.
Restoring natural balance and beauty
As we age, the effects of gravity and repeated muscle contraction cause the skin, fat and muscle in the middle of your face, especially around the cheeks, to shift downwards. This makes the cheeks look saggy or flat. Lower eyelids can become puffy or hollow and circles begin to appear under the eyes. The lines between the nose and ‘marionette lines’ (properly known as nasolabial folds) at the corner of the mouth deepen.
As the tissues fall towards the nose, mouth and centre of the neck they give the face a more square and angular and relatively masculine look. The extra tissue at the bottom of the face in effect inverts the central triangle, or ‘V’ shape. One option to restore natural beauty is to add back some of the lost volume from ageing. This is especially true in the cheek and lip areas.
The effects of ageing
Skin aging is influenced by many factors some of which we can control and others which we have inherited. The factors under our control are primarily related to our lifestyles, e.g. diet, alcohol consumption and exposure to sunlight. The factors over which we have no control include skin colour and genetics.
There are two types of aging:
1. Intrinsic aging, or the natural ageing process, is a continuous process that normally begins in our mid-20s. Within the skin, collagen production slows and elastin, the substance that enables skin to snap back into place, has slightly less spring. Dead skin cells do not shed as quickly and turnover of new skin cells may decrease slightly. While these changes usually begin in our 20s, the signs of intrinsic aging are typically not visible for decades but they include:
- Fine wrinkles
- Thin and transparent skin
- Loss of underlying fat, leading to hollowed cheeks and eye sockets as well as noticeable loss of firmness on the hands and neck
- Bone loss leading to bones shrinking away from the skin causing sagging of the skin
- Dry skin that may itch
- Inability to sweat sufficiently to cool the skin
- Greying hair that eventually turns white
- Hair loss
- Unwanted hair
- Thinning of the nail plate causing the half moon to disappear and the developing of ridges
Genes control how quickly the normal aging process unfolds. Some notice those first grey hairs in their 20s while others do not see hairs beginning to turn grey until their 40s.
2. Extrinsic aging is caused by external, factors often acting together with the normal ageing process to prematurely age our skin. Most premature ageing is caused by sun exposure while other factors include repetitive facial expressions, gravity, sleeping positions and smoking.
Without protection from the sun’s rays, just a few minutes of exposure each day over the years can cause noticeable changes to the skin. Freckles, age spots, spider veins on the face, rough and leathery skin, fine wrinkles that disappear when stretched, loose skin, a blotchy complexion, actinic keratoses (thick wart-like, rough, reddish patches of skin) and skin cancer can all be traced to sun exposure.
“Photoaging” is the term we use to describe aging caused by exposure to the sun’s rays. The amount of photoaging that develops depends on a person’s skin colour and their history of long-term or intense sun exposure. People with fair skin who have a history of sun exposure develop more signs of photoaging than those with dark skin. In the darkest skin, the signs of photoaging are usually limited to fine wrinkles and a mottled complexion.
Wrinkles, lines, age spots
Wrinkles appear around the eyes, fine lines start around the lips and age spots appear on the hands. Although some of these factors are natural and unavoidable, many of the visible signs of ageing can be slowed.
Dynamic wrinkles are caused by movements of facial muscles and by expressions such as smiling and frowning and include crow’s feet, forehead lines, and lip wrinkles.
Static wrinkles are caused due to lack of elasticity of the skin caused by sun damage, smoking and genetics. Static facial wrinkles are visible regardless of muscle contraction.
There is a third type of skin ageing called skin folds and they are often due to sagging of the underlying facial structures causing the deep grooves between the nose and mouth known as nasolabial folds or smile lines.
Although we tend to put on weight in some areas as we get older, younger skin contains more fat cells than older skin. This is what makes older skin look more transparent and thinner than younger skin. The skin keeps growing and expanding as we age, despite the fact that the supporting fat tissues of the lower layers of skin are decreasing. This, combined with the fact that facial muscles lose their shape and firmness causes the skin to sag and droop.
The water-retaining and texture-enhancing elements in the intercellular structure such as hyaluronic acids (HA), ceramides, polysaccharides and glycerin are used up as we age and aren’t replenished.
Hyaluronic acid (HA) and wrinkles
Hyaluronic acid is present throughout our bodies and 50% of it is located in the skin where it helps to keep skin smooth and ‘plump’ through its ability to hold up to 1,000 times its weight in water. HA can be considered as our skin’s own natural and internal moisturiser.
HA also supports the formation and maintenance of collagen, an important connective tissue. The loss of collagen is believed to cause a decrease in skin tone and elasticity. HA is plentiful in our bodies when we are born but its levels gradually decrease over time and skin starts to lose its elasticity as lines and wrinkles appear.
The most noticeable lines that appear are the nasolabial folds that run down from the side of the nose to the corner of our mouths. As these deepen, they give us a sullen or unhappy look. The loss of volume is most noticeable in our cheeks and, as we age, our cheeks begin to take on a sunken or hollow appearance.
Collagen and volume
Collagen is the main component of the lower layer of the skin (dermis), which accounts for 75% of the dry weight of skin and is responsible for the skin’s strength. Collagen is produced in the dermis by cells called fibroblasts and it is a connective tissue, which holds all of our smooth muscle tissues together.
It’s also, along with elastin, a key structural component of the skin and provides structure and firmness to body tissues, while elastin provides flexibility.
As ageing occurs these cellular proteins change shape resulting in a loss of collagen and less volume and firmness to body tissues. It’s been estimated that we lose 1% of the collagen in our skin each year.
Lack of volume particularly affects the lips, which develop lines and become less defined. It also affects the cheekbones which become less prominent.
After the age of 30 changes start to occur in the nature of the skin and body as less human growth hormones (HGH) are secreted. The skin starts to age more rapidly as the skin cells die faster than the body can produce new ones. The quality and quantity of collagen is also reduced.
From 20 to 25: During these years, skin is reasonably smooth because skin cells are still regenerating at a fast rate and acne problems from teenage years are subsiding. Vertical wrinkles caused by frowning and other facial expressions on the forehead, also those that appear between the eyebrows, can just be visible. Fine lines at the external edge of the eyes are barely noticeable.
From 25 to 35: Depending on the level of unprotected exposure to sunlight and genetic factors, wrinkles may begin to deepen in the epidermis. A wrinkle at this stage will only be less than 0.5 microns (0.0005 millimetres) in depth. Slowdown of cell regeneration can make skin appear duller while freckles and sunspots begin to show up or become darker. Repeated muscle activity, such as squinting and smiling, can produce fine lines around eyes, between brows and at the corners of the mouth.
In your 40s: Your skin is more likely to show the consequences of unprotected exposure to sunlight. Deeper wrinkles and laughter lines appear and these are more than 0.5 microns in depth. Crow’s feet, fine lines around the lips, the lines between eyebrows and furrows alongside the nose are beginning to deepen. Skin begins losing its elasticity and facial features begin losing volume.
Over 50: In women, the onset of the menopause causes hormonal secretions to come to an end. Skin is much thinner and wrinkles formed in the previous years deepen. From this age the face suffers from bone loss and a decrease in the structural support of the face. The loosening of ligaments in eyelids may make them droop, impairing reading and vision while the ageing process starts to accelerate.
The loss of volume caused by aging results in an elongated face and hollows in the temple, cheeks and jaw appear, caused by fat loss under the skin. Folds appear around the nose and mouth while the jaw line and lips becomes less well defined. The loss of collagen is believed to cause a decrease in skin tone and elasticity.
Your skin plays a vital role in maintaining the health of your body. The skin is the largest, and fully exposed, organ in the body and in an average adult the skin can measure 2 square meters and comprises approximately 7% of an average person’s body weight. The skin is thickest at the soles of the feet and the palms of the hand and thinnest at the eyelids. One of the most remarkable characteristics of the skin is its ability to stretch.
Everybody’s skin is different, even people of the same age. The differences are primarily due to genetic factors but can be exacerbated by lifestyle choices.
The skin has many key functions including:
- Protecting the internal systems of the body
- Keeping water and other vital fluids within the body
- Alerting the body to potential risks e.g. fire
- Helping to regulate the body’s temperature
The skin has 3 tissue layers:
- The epidermis is the outermost layer of the skin. It is paper-thin (0.1 mm) and consists of cells and lipids and fat, which prevents the evaporation of water, protects against damage from outside influences and acts to prevent infections from entering the body. Melanin, a black pigment that is formed and contained by special cells in the epidermis, gives colour to the skin.
- The dermis or “corium” is the middle layer and is a living tissue composed of blood and lymph vessels and nerve fibres and contains hair follicles, sweat glands and sebaceous glands. There are several types of connective tissue cells in the dermis that support the repair of injury and protect the body by engulfing foreign materials. The fibres of the dermis are mainly composed of collagen which are tough and resistant but also very flexible. Collagen becomes harder as the body ages and so plays an important role in changing the elasticity and appearance of skin.
- The subcutis (subcutaneous fatty tissue) is another connective tissue layer and it specialises in the formation of fat. This layer is important in the protection of the deeper tissues of the body and also provides heat insulation.
There are 6 basic skin types and your type may influence the choice and extent of your treatment.
Type 1: Very light or fair skin, prone to sunburn. Usually have red or very light blond hair and usually suffer a deficit of melanin with the resultant higher risks of tanning.
Type 2: Also prone to sun burn but may slightly tan. People with this fairish skin type usually have blue eyes and blond or light brown hair.
Type 3: Usually light olive in appearance, patients with this skin type usually have brown or green eyes and will usually develop a medium to dark tan.
Type 4: Similar to type 3 but darker olive colour and usually accompanied with brown eyes and dark hair.
Type 5: Brown to light black colour skin with brown eyes and dark hair. Rarely suffers from sunburn.
Type 6: Darker skin, darker hair, tans deeply.
Irish people generally have fair skin and are therefore usually of skin types 1 and 2.
Taking care of your skin
1. Avoid the damaging effects of the sun
The effects of the sun have been clinically proven to be very damaging. UV rays that affect the skin are composed of two different types of waves, UVA and UVB. When UV rays hit the skin, pigment cells in the epidermis produce melanin. This is the process that gives you a tan, which is actually your skin’s attempts to block the damaging radiation from penetrating your skin.
UVA rays are able to penetrate deep into the dermis, damaging the collagen fibres and this results in the formation of wrinkles and leathery skin.
Repeated sun exposure can also cause what are commonly called age spots or liver spots, which are actually pigmentation caused by sun exposure.
Use sunscreen cream with an SPF number of 15 or higher. After many surgical and non-surgical skin treatments, a sunscreen of 30+ SPF is recommended. Also, look for products labelled broad spectrum (meaning they protect against both types of harmful sun rays—UVA and UVB) and water-resistant, so that they stay on your skin longer. Remember to re-apply the cream regularly, especially when swimming.
Cover up because your clothes protect you from the sun even better than sunscreen. So, wear loose, lightweight, long-sleeved shirts and long skirts when you are in the sun and a wide-brimmed hat to shade your neck, ears, eyes, and head.
Wear sunglasses that block 99% to 100% of the sun’s rays.
Avoid artificial tanning through sunlamps or tanning beds as they have been linked to skin cancers.
Try to stay out of the sun around midday when in warmer climates when the sun’s rays are at their most damaging.
Check your skin often and look for changes in the size, shape, colour or feel of birthmarks, moles, and spots. If you find any changes that worry you, see a dermatologist or RCSI surgeon.
2. Stop smoking
After sun exposure, smoking is probably the single worst contributor to premature aging of the skin.
Cigarette smoking causes biochemical changes in our bodies that accelerate aging. Research shows that a person who smokes 10 or more cigarettes a day for a minimum of 10 years is statistically more likely to develop deeply wrinkled, leathery skin than a non-smoker. White skin is more vulnerable to the effects of the sun compared to dark skin whilst smokers who have smoked for more than 15 years or more than 10 cigarettes per day are also very vulnerable.
Cigarette smoking can:
- Increase wrinkles, especially if you are a woman
- Make your complexion red or orange
- Produce pale or yellowish skin in places, e.g. finger tips
- Cause puffiness
- Bring about premature aging of your skin
- Cause hair to gray prematurely
- Result in thinning hair, more pronounced in men but also seen in women
- Slow wound healing
- Increase your risk of cell cancer
- Increase wrinkles around the mouth
Here’s what smoking actually does to your skin:
- It dries the surface of the skin as nicotine is a diuretic
- It reduces the vitamin A levels in the skin
- Smoking affects matrix metalloprotienases (MMPs) causing collagen to degrade and elastin to fragment
- While aging from the sun happens in the higher levels of the skin (dermis), smoking predominantly affects the lower, deeper part
- It lowers the blood supply to the skin and reduces collagen production, both of which slow healing in the skin. This slow healing has an influence after surgery, including after cosmetic surgery or laser resurfacing. It prolongs the healing process and increases the risk of complications
- Nicotine, carbon monoxide and hydrogencyanide have toxic effects on healing tissue
- Some studies suggest that nicotine may suppress the immune system to increase susceptibility to viral infections of the skin such as warts
These signs can be greatly diminished, and in some cases avoided, by stopping smoking. Even people who have smoked for many years, or who smoked heavily at a younger age, show less facial wrinkling and improved skin tone after they stop smoking.
3. Cleanse your skin gently
Cleansing is an essential part of caring for your skin but the key is to treat your skin gently:
- Use warm water and limit bath time
- Avoid strong soaps
- Avoid irritating additives
- Remove eye makeup carefully
- Pat dry
4. Moisturise regularly
If your skin feels tight, you should apply a moisturiser. If your skin is very dry, you may want to begin to apply an oil, such as baby oil, especially after showering while your skin is still moist.
5. Use good skin care products
There are many facial skin care products available and it is important to have a clear understanding of what the important and clinically proven ingredients are:
Alpha-hydroxy acids (AHAs or ‘fruit acids’) improve the skin’s appearance by speeding up the shedding of old, dead cells from the skin surface. The downside is that they can irritate the skin.
Retinoids make the skin produce new cells more quickly, making it thicker and more compact. After a month or two of use, the skin becomes smoother and very fine wrinkles are reduced but the beneficial effects may disappear when you stop using it.
Vitamin A can help diminish the depth of wrinkles, due to its light inflammatory action, which ‘puffs up’ the skin to make wrinkles look less deep.
Vitamin C is an antioxidant, which has a brightening effect on the skin as it can help to boost circulation and collagen production.
Idebenone helps correct the skin damage and protects the skin from future damage.
Also, drink plenty of water, avoid alcohol, caffeine and carbonated drinks, minimise stress in your life where possible and get plenty of sleep.
Here are some of the most common skin diseases in Ireland today along with suggested treatments:
Acne and acne scarring is a very common skin disorder and it is caused by increased production of oil by the acne or sebaceous glands which, in combination to blocked ducts, leads to the condition of acne. Acne usually starts around the time you reach puberty and usually it will be mild. Often the condition will last for about 5 years, but can persist for as long as 10-20 years in some cases.
About 25% of teens who have acne will still have it when they turn 25. The cause is not understood, but it is becoming more common for women who are in their 20s, 30s, and 40s to develop acne often for the first time. Temporary acne is often seen on the faces of newborns.
Possible treatment options for acne include:
- Long term antibiotics
- Retin A creams
- Fractional resurfacing lasers (sunken acne)
- Light chemical peels
- Microdermabraison (small acne spots)
- Injections of corticosteroids (large red bumps)
Psoriasis is an inflammatory skin condition. There are five types, each with unique signs and symptoms. Between 10% and 30% of people who develop psoriasis get a related form of arthritis called “psoriatic arthritis,” which causes inflammation of the joints.
Plaque psoriasis is the most common type of psoriasis. About 80% of people who develop psoriasis have plaque psoriasis, which appears as patches of raised, reddish skin covered by silvery-white scale. These patches, or plaques, frequently form on the elbows, knees, lower back and scalp. However, the plaques can occur anywhere on the body.
The other types are guttate psoriasis (small, red spots on the skin), pustular psoriasis (white pustules surrounded by red skin), inverse psoriasis (smooth, red lesions form in skin folds) and erythrodermic psoriasis (widespread redness, severe itching, and pain).
Regardless of type, psoriasis usually causes discomfort. The skin often itches, and it may crack and bleed. In severe cases, the itching and discomfort may keep a person awake at night, and the pain can make everyday tasks difficult.
Psoriasis is a chronic condition as there is currently no known cure. People often experience flares and remissions throughout their life while controlling the signs and symptoms typically requires lifelong therapy.
Treatment depends on the severity and type of psoriasis. Some is so mild that the person is unaware of the condition. A few people develop such severe psoriasis that lesions cover most of the body and hospitalisation is required. There also is a genetic component associated with psoriasis. Approximately one-third of people who develop psoriasis have at least one family member with the condition.
Research shows that the signs and symptoms of psoriasis usually appear between 15 and 35 years of age. About 75% develop psoriasis before age 40. However, it is possible to develop it at any age. After age 40, a peak onset period occurs between 50 and 60 years of age. About 10% of people develop psoriasis during childhood, and it can begin in infancy. The earlier the psoriasis appears, the more likely it is to be widespread and recurrent.
Possible treatment for psoriasis includes:
- Topical creams (applied to the skin) – for mild to moderate psoriasis
- Laser treatment – for moderate to severe psoriasis
- Systemic medicines – for moderate, severe or disabling psoriasis
Although typically caused as a result of trauma, some scars are attributable to skin disease. The word ‘scar’ is derived from the Greek word ‘Eschara’, meaning the scab on a burn or wound.
A scar is the fibrous tissue replacing normal tissues destroyed by injury or disease. The more the skin is damaged the longer it takes to heal and the greater the chance of a noticeable scar developing. The severity of a scar will usually depend on its colour, texture, depth and size. A person’s age can also influence the gravity and type of scar. In general scars can be treated although it is usually not possible to remove a scar completely.
The main types of scars are:
Keloid: Firm, raised, and reddish-purple scars that extend beyond the initial wound area and builds over time.
Hypertrophic: Firm, raised and pink scars that remain within the initial wound area and possibly naturally regress over time.
Atrophic: Depressed pin-like pockets in the skin that can result from skin conditions or diseases such as acne.
Possible treatment for scars includes:
- Minor superficial scars can be treated with prescription creams which incorporate vitamin A ingredients such as Tretinoin (Retin-A, Tazarotenic Acids (Tazarotene). You might also try short pulsed light lasers (some dark scars), microdermabraision or chemical peels.
- Raised hypertrophic scars can be treated with cortisone creams or injections, topical silicone treatments or pressure garment therapy.
- Large firmer keloid scars might be dealt with by cortisone creams or fractional resurfacing lasers.
- Saucer shaped sunken facial scars might need surgical elevation or skin filler injections.
Usually an inherited condition, eczema tends to be prevalent in children, the vast majority of whom outgrow the condition. Eczema can be triggered after lying dormant in adults for many years by stress, etc., and is a chronic recurring intensely itchy inflammation of the skin. It is known as atopic eczema as well as atopic dermatitis and can have significant psychological issues for those affected with resultant social implications.
Eczema occurs in both children and adults, but usually appears during infancy. Although there is no known cause for the disease, it often affects people with a family history of allergies. Eczema affects probably 10-15% of the population and is becoming more common for reasons that are not well understood. Three quarters of the time, eczema presents itself in the first six months of life and the condition increases and decreases over the years with frequent flare-ups.
Diagnosis of this condition, which has variable appearances, is dependent on a number of factors. The features or appearance in one person may be different from another. Skin in different locations in the same person may also have variable appearances which change according to the severity of eczema in that specific location. Eczema outbreaks can usually be avoided with some simple precautions:
- Moisturize frequently
- Avoid sudden changes in temperature or humidity
- Avoid sweating or overheating
- Reduce stress levels
- Avoid ‘irritating’ materials (e.g., wool)
- Avoid harsh soaps, detergents, and solvents
- Avoid environmental factors that trigger allergies (e.g. pollens)
- Be aware of, and avoid any foods that may cause an outbreak
Possible treatment for eczema includes:
- Using lotions or creams to keep the skin as moist as possible.
- Applying non-prescription cortisone based creams and ointments to reduce inflammation.
- For severe itching, sedative anti-histamines are sometimes used to reduce the itch and are available in both prescription and over-the-counter varieties.
Overexposure to the sun will prematurely age your skin and lead to conditions such as uneven texture, white and brown blotches or uneven red and brown colouring. Worse cases include cancer and the appearance of melanoma.
Sun damage of the skin, also known as photo damage, can be either acute, as in a sunburn or more commonly, chronic, seen as gradual changes in the skin caused by an accumulation of sun exposure throughout your life. Chronic photo damage results in either a cosmetic change in the skin’s appearance called photo aging, or changes that are of medical concern such as pre-cancerous lesions and skin cancers. The evidence is very strong that ultraviolet light is the cause of most of the changes that we consider to be associated with aging of the skin.
Fine and coarse wrinkles are seen on sun damaged skin. There is a roughness to the skin and a laxity or looseness in advanced damage, patchy or mottled darker patches of increased pigmentation are also seen.
Possible treatment for sun damage includes:
- Using products containing alpha hydroxy acids such as glycolic acid and lactic acid may have a smoothing effect on the skin.
- Vitamin C preparations will also have modest effects on reversing the appearance of sun damage.
Birthmarks can be in many shapes, colours, and sizes and may also appear in many body areas. The most prevalent type of birthmark is the flat, dark brown spot which usually first appears at birth. ‘Strawberry marks’ also appear at birth or very shortly afterwards and usually disappear without treatment over time. Another type of birthmark is the ‘port wine stain’ which can usually be treated quite effectively with lasers.
Possible treatment for birthmarks includes:
- Short pulsed lasers for some benign birthmarks
- Longer pulsed lasers for birthmarks such as the typical dark brown patches
- Blood vessel lasers for blood vessel birthmarks
- Surgical removal
This condition affects a lot of Irish people because of their typical fair skin colour and has been referred as the ‘curse of the Celts’.
The condition manifests itself through blushing like acne which appears just under the skin, usually around the central part of the face. Other signs include swelling of the nose and reddening of the eyes and eyelids.
Rosacea is a long lasting, non-scarring skin condition of the face that is often misdiagnosed as adult acne and its onset is usually between 20-40 years of age. It varies in severity and does not always worsen with time. Typically, you will experience inappropriate flushing that is not usually associated with sweating and/or persistent facial redness. It is common to have broken blood vessels (telangiectaisias) on your cheeks. You may also experience bouts of inflammation that cause red papules (small bumps) or pustules. However, comedones (blackheads and whiteheads) are not part of rosacea.
About 50% of those with rosacea suffer eye conditions such as conjunctivitis, blepharitis, dry gritty eyes and recurrent sties. Nose enlargement (rhinophyma) is uncommon but mostly seen in men. It is only very rarely seen in women.
Possible treatment for rosacea includes:
- Intense light and laser therapy
- Glycolic acid/ chemical peels
- Topical (applied to the skin) medications
- Oral antibiotics
If you are concerned by visible signs of aging, talk to the experts at C&RSI. There are a number of treatments you can consider. Injectable fillers and botulinum toxin are suitable for people with busy lifestyles who do not want the inconvenience of a long recovery. Laser resurfacing provides an alternative to the traditional facelift. Microdermabrasion, laser rejuvenation, chemical peeling and some topical treatments can rejuvenate your skin, giving it a smoother and refreshed appearance.
It is important to consult either with your C&RSI consultant to ensure that you receive the best possible advice and care for your particular condition or needs.