When we start to unpack plastic surgery, or at least the part most people think about — aesthetics or cosmetic surgery, we can broadly define two categories: restoration and augmentation. In a sense, restoration takes you back to the way you were and augmentation takes you somewhere new.
Plastic Surgeons doing restorative work may be working on patients disfigured by trauma or cancer, but the most common (and most lucrative) part of plastic surgery is restoring age-related changes… a broad area of beauty we sometimes call rejuvenation.
As aging is a reality for all those that get the benefit of a long life, it is here that I wanted to start. In this post, I want to explore what happens as we age? And ask what if anything can we do about it? And even broader, should we do anything about it?
Aging 101
I’ll save the biochemistry of aging for another day but the big ticket item involves changes in the ratio and structure of two important proteins: Collagen and Elastin. Collagen provides rigidity to tissue and Elastin allows it to stretch. Changes at the molecular level of these and other proteins ultimately translate into changes at the macro-structural level, or put another way, changes in the way we look.
These macro-structural changes can be classified into 4 broad categories:
- Changes in Skin Texture (i.e. wrinkles)
- Descent (ie. Sagginess)
- Volume loss or Volume Redistribution
- (Changes in the shape of bone and cartilage)
#1 and #2, i.e. wrinkles and sagginess, are probably pretty easy to understand for those of us who have watched our features change over time. #3, volume changes, is a newer concept that has been better understood over the last decade. I won’t spend much time on #4, because truthfully, there’s not much we can do about it, but if you want to learn more, check out this article by one of my Stanford colleagues Dr. David Kahn.
Rejuvenation
Each of the above changes has its own treatment. Skin texture changes are treated with resurfacing (e.g. peels or lasers), descent and sagginess is treated with lifting (e.g. facelift) , and volume loss is treated with volume restoration (e.g. fillers or fat grafting). I’ll get into each of the truths and misconceptions about each of these in subsequent posts, but for now, there’s two main ideas that I think are important to share:
1. The key to good plastic surgery is to recognize that while each of the processes above happen in each of us, they happen to different extents in different people.
One person may have aging dominated by skin texture changes, another may have a lot of volume loss. Patients look most natural when the underlying mechanism is first understood and then the correction is applied only to the extent that it is happening in that person. The best way to achieve this is to bring along a picture of your younger self and show the person treating you so they can systematically identify the changes.
And 2. Treating problems in one area using a solution from another area rarely looks good. We see this sometimes when patients gets care by someone who doesn’t fully understand the dynamics of aging and instead are trying to sell their products or services. For example, if a clinic has an expensive laser and needs to sign people up for laser resurfacing… patients may be talked into getting lot of resurfacing treatment and end up looking smooth and waxy but not younger. Or if a Doctor you only does facelifts, patients may end up looking tight or pulled but again, not younger. Or lastly – and perhaps most pervasively today – patients that are promised that fillers can meet all their needs without any other treatment can end up looking overfilled and bloated as volume is used as a cure-all.
Beauty
To return to aging at a holistic level, we are forced to ask is aging ugly? Most of us probably don’t think so. We can look into the wrinkles of our parents or older loved ones and see tremendous beauty in their smile lines and features. The question of ugliness, or maybe more specifically unattractiveness and undesirability is a complicated one and full examination probably requires thinking in part about the role of evolution and the biological imperative, but at least anecdotally, most of my patient’s don’t want to necessarily look younger, they want to grow old gracefully.
Here it may be worth diving a little deeper. Grace is a reflection of being unburdened and to be unburdened typically we have to have resources or wealth.
Put another way, it may be that rejuvenation is often less about beauty or youth and more about class. Through this lens, the sequelae of rejuvenative treatments may be better thought of as class indicators. From this perspective, it then sometimes makes sense why someone would prefer to look “done” then either younger or their previous self as it satisfies a specific function. This thereby creates a third aesthetic all to its own.
Finally we come to the question, should we do anything about aging? This, of course, is a personal question but despite the perhaps overly-critical social lens above, my personal opinion is not so concrete. I think that grace is something we can all understand wanting a little more of in our lives. And if a patient is at a point where ridding themselves of a reminder of a burden is achievable and a priority, then I think that is something we can all empathize with choosing.
