Decades of Face: The Fifties, The Landslide Decade

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator. The title of today's episode is "Decades of Face: The 50s, The Landslide Decade." Dr. Bass, we're now onto the fifties. Tell us where does the title come from and what does it mean?

Dr. Lawrence Bass (00:34):
As we discussed, we definitely see a lot more going on in the forties, but the fifties is a very active time for facial aging. This is especially true for women due to the onset of menopause, which has an average age in the United States of 51 following this, the withdrawal of estrogen takes a significant toll on facial appearance. So this decade is the beginning of the landslide and typical major aging changes will show over the course of the decade, everything in the face is moving in an unfavorable direction, usually down and changing in an unfavorable way, a landslide. That's a rough ride. There's so much going on and so much that needs to be done. We hoped we'd never get there, but this is our reality now, a lot to consider and decide about. So buckle your seatbelt and get ready for a bumpy ride.

Doreen Wu (01:39):
I'm not really sure I want to know the answer to this question, but I'm going to ask it anyway. Can you go over with me the typical changes that occur in this decade?

Dr. Lawrence Bass (01:48):
So as I said, it's a little bit of everything. Skin quality is definitely rougher and duller, obviously older skin to even a casual glance. That's thanks again for women to loss of estrogen, which we loved when it was around, and it's so sad when it's no longer there. There's obvious volume loss in the folds, cheeks and jawline and some degree of skin laxity. This varies a lot from person to person, but there's at least some visible jowl, loose skin in the neck and loosening of the jawline and loss of the sharpness and straightness of the jawline. Usually there's some vertical banding in the neck, which is from muscle spreading and presence of wrinkles. The amount of wrinkling varies a lot depending on the skin type, smoking, and sun exposure, but this is often a prominent feature, at least in certain parts of the face, like the crow's feet and lipstick bleed lines, and the eyelids have a multitude of changes, hanging skin, crepiness, wrinkles, deepening of the tear trough that just at a glance make you look obviously older.

Doreen Wu (03:13):
So what does all of this sum up to Dr. Bass?

Dr. Lawrence Bass (03:16):
Well, all of these changes are almost always moderate to severe. They're no longer mild. They might've been in our forties if we were aging pretty well, at least at some point in this decade. So there's always an exceptional individual who's beating time for the moment, but to be honest, they're probably one percenters. They're the exception and not the rule. So really all of us, regardless of how good we think we look, are showing a number of obvious aging changes.

Doreen Wu (03:53):
Okay, so what does all of this mean? How should I be approaching this decade? I'm hoping there's a silver lining to all this.

Dr. Lawrence Bass (04:01):
It's simple. When a landslide is coming at you, immediate action is required, where you get caught and swept away, no going into the decade that there will be a time during this decade when beauty items are essential to preserve your appearance and slow the aging process where you'll end up leaving this decade looking old.

Doreen Wu (04:26):
That is certainly reassuring. Alright, can you break this down for me so I understand what kind of treatments are typical for most people in their fifties?

Dr. Lawrence Bass (04:35):
The basis is picking options for the same four issues. We've been talking about having an organized rational plan that coordinates all the modalities, and we talk about having a plan an awful lot on the podcast, and in this decade especially putting some effort into organizing a plan really pays big dividends. A plan at this stage in the fifties is going to involve more components and bigger components, translated as cost, recovery time, doing things more frequently. Aging is no fun, but at least we have options that can make a meaningful difference. You'll get more in terms of results with a rational coordinated plan with fewer overall treatments and less dollars spent than if you chase individual things without considering what overlap and combined benefits could be produced for multiple issues at once.

Doreen Wu (05:37):
I'm following so far, but can you give me an example of how combining can be more efficient?

Dr. Lawrence Bass (05:44):
In my marketplace in New York City, a lot of people have different doctors for their laser treatments, their surgery, their Botox and injectable fillers, and for skincare. There are a number of ways that experienced providers understand how to combine things. And I'll illustrate this to prove the point. Let's say you have a lot of pigment on your face, sunspots, which medically we call solar lentigos and some redness, rosacea or telangiectasias, little broken blood vessels, things like IPL, intense pulse light treatments might be a good choice, but if you also have wrinkles, there are energy-based options that will treat all three and there are options that don't really address the wrinkles but will chase redness with pigment and others that will chase the wrinkles and pigment but not the redness. Picking the right option will kill two birds with one stone. There are also treatments that will put a mild laxity improvement into the mix.

(06:53):
So it's all about what you need, not what your friend had. He or she may have different needs even at the same age. A professional eye can see this and advise you. Also, there are trade-offs with cost, recovery time, number of treatments and degree of improvement. I'm a minimalist by temperament, so I'm always looking for the simplest option that will get you where you need to go rather than pulling the trigger on the big items too early. You should save them for when you really need them since they're not going to be repeated or not repeated often.

Doreen Wu (07:30):
So what I'm hearing is I need a plan now more than ever, I really want to keep my looks and my appearance. I'll partner with an experienced plastic surgeon for advice and planning Dr. Bass. Now, can you remind me what the big four categories are again?

Dr. Lawrence Bass (07:47):
The four categories are skin quality, volume preservation, dynamic control, and skin laxity and skin quality is something that we sometimes call skin surface in the old days, but more and more nowadays as being talked about as skin quality. These are the same things we've been chasing early in the aging with non-surgical options and early in aging. These are easy problems because they're mild. So almost whatever we pick that fits in with your lifestyle, it fits in with your budget is going to make a meaningful difference. Now the job gets a lot tougher. We have to pick and perform much smarter to get real results because the problems are now bigger in magnitude.

Doreen Wu (08:42):
Let's take these one at a time, starting with skin quality. Tell me about some skin quality options for your fifties.

Dr. Lawrence Bass (08:50):
You're going to continue to use skin products at home, but you may have more them now. Certainly more than one, and they really need to be medical grade skin products. A low level skin product from the pharmacy or the cosmetic store is less likely to really make an impact. Almost everybody should have some energy treatments two to four times a year. These are often no recovery treatments and there are new superficial fillers that plump the surface layers of the skin and give the skin a smoother more even appearance. And laser and energy-based treatments are going to chase the pigment and redness. As I said, they tend to be no recovery or minimal downtime treatments that are done in a series, but pretty much these should be universal at this point for people in their fifties, everyone should be doing two to four a year. I do. And treatments for wrinkles? There are a lot of options and it depends heavily on exactly how extensive and how deep the wrinkles are. Light to medium chemical and laser peels, microneedling radiofrequency, platelet rich plasma are all things that are used to chase in particular wrinkles as well as skin quality overall.

Doreen Wu (10:22):
Okay. It's basically an extension of what most of us are doing in our forties. Let's talk about volume now.

Dr. Lawrence Bass (10:29):
With volume, we're moving on from energy and products and peels to injectable fillers and fat grafting.

Doreen Wu (10:38):
When should I consider which?

Dr. Lawrence Bass (10:40):
Well, it depends which areas you're treating, how many different areas you need to treat and how much volume loss you have. The advantage of fillers is that it's a 15-minute treatment in the exam room at the doctor's office, usually with no downtime and you can return immediately to normal activities, but you're paying for the filler syringe by syringe. And if there are many areas or a great deal of volume is needed that can break the budget after a while. Fat has the advantage of providing a lot of volume all at once, which lets you chase many areas. It has more durability and does not need to be repeated as often as the injectable fillers, but it is a little bit of a procedure that always has a little bit of bruising and swelling and recovery time. So that's kind of the trade-off and we don't have the same kind of precision in shape control that we get with injectable fillers.

Doreen Wu (11:51):
But why do I need volume? I don't want a fat face per se.

Dr. Lawrence Bass (11:57):
That's an important point. So we all experience volume loss with aging. Adding back volume, particularly in this age group is about restoring shape and volume, basically putting you back where you were maybe when you were 35. It's universally needed at this stage and really part of the plan for everyone without exception. Now, some people may choose to chase a lot of the areas, some people may just chase one or two of the most prominent areas. That's a personal preference, but everyone medically could benefit at this stage of the game. At the same time, it's a mistake to overdo volume restoration in order to chase laxity. Some people are so desperate to avoid a surgical fix for skin laxity that they get pumped up with more filler than is natural looking and they do get a fat face or an unnatural look, and that's a big mistake. Everything has its role and trying to escape other options by overdoing something just leaves you unnatural. It's obvious to others and the risk of complications goes up.

Doreen Wu (13:15):
Moving on to the third category, can you clarify what you mean by dynamic control?

Dr. Lawrence Bass (13:21):
This is a big issue right now again, so this is about neuromodulators. Basically, medicines like Botox that are injected prevent the nerve signal from getting to the muscle, reducing the resting tension in the muscle, which evens out certain kinds of wrinkles, particularly those in the upper face. There's some controversy though because there are some new devices that are trying to train muscles and stimulate them to improve aging face appearance rather than relaxing the muscles. And this controversy has been going on since the 1990s, but with the recent introduction of some devices for the face which are being heavily promoted, it's causing a reexamination. This is very new and the jury is still out and we'll know more. But again, whatever we decide about training muscles and stimulating them, relaxing muscles has been the number one aesthetic treatment in the US and in the world for the last two decades pretty much.

(14:45):
And that's not likely to change as we get further into the 21st century. The other important point about this is is not something that facelift will address. So it's part of the rejuvenation process, the global rejuvenation plan for your face, whether or not you do a facelift in your fifties and whether or not you've had a laser or energy-based treatment for skin tightening or wrinkle improvement. The neuromodulators also, even though they're relaxing muscles, can sometimes trick the forehead muscles into gently pulling up the brow. And this is the predominant approach for mild brow droopiness and the heyday of brow lifting, particularly for younger individuals, 50 and younger, is I believe really in its twilight at this point in time, although it's still used frequently in older individuals, especially laterally. And the last thing about neuromodulators that's happening is we're getting some neuromodulators like the newly approved Daxxify, which have a longer indication from FDA for the duration of effect. And again, this is very new. It's what everyone's been asking for. The number one thing patients ask for is more duration so they don't have to come in as frequently, but it's not while it's been approved, it's not quite on the market as of this recording. And so we'll figure that out a little better, how much impact that has on our planning once it gets to market and we can all use it.

Doreen Wu (16:39):
Alright, we're getting down to the real elephant in the room, skin laxity. I try not to look. I try not to think about it. I thought in my twenties I'd never consider surgery for facial laxity, but now I look at my face and I'm having more and more trouble passing off the growing laxity. I hate to say it, but biology is working its havoc. Kind of a nightmare I hoped I'd escape and be one of the lucky ones.

Dr. Lawrence Bass (17:03):
I understand we're all dreading the development of jowls and hanging skin in the cheeks, jawline, and neck, but it's coming for every one of us. No one will escape. Even if you're a one percenter somewhere between now and the time you're a hundred, you'll see it and you'll need a surgical intervention to chase it if you want to look your best. I do a lot of technology research in the aesthetic industry and I have my fingers on the pulse of what's coming currently. I don't see a meaningful substitute for surgical lifting in the next 10 to 15 years. Magazine, TV, and internet ads for liquid facelifts and filler or energy-based to lifting, have utility in the earliest stages of aging and to delay surgical lifting as well as for maintenance, but in my opinion, are not going to give a satisfying or useful result that supplant surgical lifting.

Doreen Wu (18:07):
I get it. There are no free lunches, so sum it up for me. Dr. Bass, what are the right moves in your fifties?

Dr. Lawrence Bass (18:15):
A lot of variation depending on when and how much laxity kicks in. Non-invasive energy options like Ultherapy and Sofwave may suffice for slowly aging individuals. Minimally invasive procedures like MyEllevate, FaceTite, which is an RF minimally invasive surgical procedure. Precision Tx, which is something similar, these may work for some, but we're getting into the range of surgical options, mini lifts, platysmaplasty and similar small surgical procedures are definitely in the mix depending where you are in aging and how you're feeling about it and facelift and neck lift, it may be the right time for some individuals, particularly in the second half of the fifties. Brow lifts again in some individuals are right and not too early, and it depends which brow lift. The endoscopic brow lift, which is done through small incisions behind the hairline, the lateral brow lift, which lifts the outer edge of the brow, but uses a longer incision behind the hairline or the direct brow lift, which is done through the upper eyelid plasty incision. The coronal brow lift, which had a very long incision across the top of the scalp, is largely historical these days and not commonly used. Certainly if you have not had a blepharoplasty, there are very few individuals in their fifties who would not benefit from that procedure.

Doreen Wu (20:04):
You raised the issue of the brow. Correct me if I'm mistaken, but doesn't Botox address that? What else approaches it and how is it different from my eyelids?

Dr. Lawrence Bass (20:14):
Botox is limited by your dynamics and your degree of laxity. Sometimes you'll lift enough and sometimes even with carefully placed and dosed Botox injections, you won't lift enough and still have some droopiness to the brows. Eyelid surgery, what's called blepharoplasty or eyelid plasty, peeling of the lower lid, crepeness fat grafting into the tear, trough and skin peeling energy-based treatments, lid support procedures. These are things that will chase changes in the eye area itself, but will not move the eyebrow. So pretty much everybody in their fifties is medically ready for eyelid surgery if they've not already done it in their thirties or forties. You may not choose to do anything there, but you would benefit from it. So you decide if it bothers you enough to be worth the procedure.

Doreen Wu (21:19):
This episode definitely gave me a lot to consider. It seems the whole face and every aging feature needs to be reassessed and the plan completely revised at some point in the fifties.

Dr. Lawrence Bass (21:30):
That's exactly right. We'd like to just coast, but this is a time to really reassess, make a new plan, start to think about when plastic surgery procedures need to be part of the plan.

Doreen Wu (21:43):
Right. And lastly, before we conclude Dr. Bass, can you share some important takeaways for our listeners?

Dr. Lawrence Bass (21:50):
As I said in the last decades of face episode, our mental self-image, we think we look sort of how we looked in our twenties. That's what's locked into our brain. But no matter how well you're aging, you don't look like that anymore in your fifties. We sort of know we're not exactly the same, but we don't realize how much we've changed. It's okay to like the way you look and not feel the need to chase aging changes. But I counsel my patients, if they don't take significant steps to maintain their appearance at this point, they will need big treatments and procedures to restore their appearance in short order. Again, you may never choose to pursue maintenance or big restoration, but you end up owning a lot more aging baggage, which would take a lot more work to undo if you ever change your mind. So it's important to think through things, be as sure as you can about your current direction, go or no go.

(22:56):
Don't kid yourself that all is well. Things are changing. Somewhat bigger treatments are needed to maintain and restore aging features than what you might've been using in your thirties and forties. We try to turn the wheel with recurrent treatments with energy and fillers and Botox as long as we can get away with it. But this is a typical time when we need to take it up a notch. The good news is we have a much wider range of treatments which can be matched to the severity of your aging changes and your tolerance for recovery. And this lets us fit things much more precisely rather than one size fits all, like in the old days. It's important to think about what you're going to do and when. Don't bury your head in the sand, partner with a plastic surgeon who will help you understand worthwhile options that will really make a meaningful change and what's involved in these. So you're planning with facts and not misimpressions of what recovery might be like for a procedure. A lot of the procedures have less recovery time, especially nowadays than you might expect. Finally, unless you're good with age and gracefully, recognize this is going to be a decade of action in a multimodality way.

Doreen Wu (24:25):
Thank you, Dr. Bass, for sharing your insight and expertise with us and helping our listeners gain a deeper understanding of this pivotal decade in facial aging. I, for one, am glad to know that we have a variety of options available to us in our fifties.

Dr. Lawrence Bass (24:38):
Thank you, Doreen, for your great questions, the things that people really want to know about.

Doreen Wu (24:44):
Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review, and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.