Dr. Buckingham’s Philosophy My ultimate goal is that I can take a “before” and “after” picture of a person and have anyone who looks at those photos say, “Wow, that person looks a lot more youthful in the ‘after’ photo.” But if you take away the “before” photo, and you only show someone the “after” photo, they would have no idea that person had ever seen me. All they would see is a completely rejuvenated, natural-looking face without any evidence that anything’s been done. Intrinsic factors are internal things that help determine how your skin looks and shows signs of aging. For example, your ethnicity. Extrinsic factors are external factors; They’re the things we do to ourselves that cause skin changes, and can often be prevented. Fair skin tends to be more susceptible to damage and thinning, which means you tend to get more wrinkles and brown spots. The effects of aging often aren’t as evident for individuals with darker skin types. Their skin is typically more resistant to UV damage from the sun. Darker skin is often thicker, though that varies from person to person; and thicker skin tends to be more resistant to wrinkles. As we get older, a drop in hormone levels, especially the loss of estrogen in women, is associated with more signs of skin changes because of collagen thinning. Fine lines and wrinkles start to show up in different parts of our face because of repetitive muscle activity from years of frowning, squinting, or even smiling. Just because you may have a skin type that makes you more likely to show the changes associated with aging doesn’t mean that you have no control over how your skin ages. That’s where the extrinsic factors come in. The most important of those is ultraviolet damage or sun exposure, but can also include things like smoking cigarettes, vaping, or air pollution. The result of these intrinsic and extrinsic are the wrinkles, brown spots, rough spots, and thinning skin that we associate with aging. I think the easiest place to visualize that is the lower eyelid area. People come to me and say, “Everyone tells me I look tired all the time, and I have these circles under my eyes.” Most of the time that’s a shadow that’s developed because of loss of volume. There are lots of reasons this happens. All the layers of skin get thinner, there’s possible fat loss in some areas of the face but maybe not in others, and even our facial musculature gets thinner. But one thing that we do understand is that as we get older, our skeletal structure changes. To go back to our eye example, the orbital rim area that goes all around your eye socket is quite circular in dimension when you’re young. As you age, that orbital area stretches both down and across and creates a more oval appearance. As that happens, it creates a volume deficiency or a hollow under the eye. Very often what we perceive as sagging skin on the face isn’t because of extra skin, but because of bone loss. Your overall health impacts skin health too, so I recommend eating a healthy diet and exercising and not gaining excess weight. People ask me what the most important components of skincare are, and I think it’s helpful to view those priorities in the same way we use the food pyramid to eat the right amount of certain foods for a healthy diet. On that base layer of the pyramid is sunscreen, that’s the most important thing. Put that on after using a good facial cleanser to wash away the dirt and oil on your face. The middle box is a vitamin A derivative such as retinol or Retin-A. We have research that shows if you use these products consistently, you can increase your collagen production and your elastin as well as increasing the epidermal turnover. This can keep the skin looking healthy and less dull. The little box at the top of the pyramid is topical antioxidants like vitamin C, peptides, and pigment-reducing agents. Once you have that good skincare foundation, there are interventions we can do to reverse the effects of aging. These include neuromodulators, such as Botox, which can temporarily cause the muscle to not contract as robustly as it should, which reduces the appearance of wrinkles. Microneedling uses a pen-shaped or roller device with fine needles that penetrate the dermal level and create very tiny punctures in the skin. It heals within a day and promotes the growth of new collagen and elastin. Radiofrequency microneedling uses an actual plastic plate that has needles embedded in it that are stamped or inserted into the skin. While the needles are in the face, it emits radio frequency heat energy, which amplifies the effect of microneedling. There are several laser treatment options depending on the amount of intervention needed. By using concentrated light in different wavelengths, these treatments can rejuvenate skin by increasing the production of collagen and elastin. Chemical peels can range from very light peels that cause just a small amount of flaking to more intense peels that can require up to 10 days of recovery and continuous application of healing ointment. An early intervention that I think most people are familiar with are injectable fillers. Most of these contain hyaluronic acid, which sounds kind of scary, but it’s actually a natural molecule that’s found in our skin and throughout the body. There are different types of fillers, some that are more appropriate for fine lines and wrinkles, and others that are a deeper, thicker filler that we use for more skeletal changes. My preferred method of replacing volume-related skeletal and shadowing changes is to use a patient’s fat cells in a surgical procedure called an autologous fat transfer. We take fat from somewhere on the body and use that to fill in the shadows and hollows in the face to recreate a youthful face. One advantage of using fat cells as filler is that it results in a much softer appearance and it can look very natural. When these lifts are performed in conjunction with procedures that address volume deficiency, you can get a very natural, profound, and long-lasting lift that looks completely natural.
