Old Face, New Face

Round about my mid-40s, i noticed a different me than I was used to seeing in the mirror. Gravity had taken a toll, as had sunshine, genetics, my ready smile and an annoying ex-husband.

It was a nice coincidence to get this assignment and start interviewing local cosmetic surgeons about procedures for the face that would be nonsurgical and still help me look years younger. So like Nancy Drew on The Case of the Compromised Face, I set out to get answers.

How would I know I was choosing a qualified surgeon? Dr. W.G. Eshbaugh of South Florida Plastic Surgery in Bonita Springs provided the first clue. "Five words," he says. "American Board of Plastic Surgery. You want to find a surgeon who's [board-certified and] proficient in the full spectrum of procedures, not someone who has gone to a half-day workshop and is calling himself a plastic surgeon. Because if the only tool you have is a hammer, then the whole world starts looking like a nail."

Hammers and nails certainly weren't what I had in mind. Neither was a scalpel. But I wasn't sure exactly what tools would be involved.

"First you have to diagnose the problem," says Dr. Andrew Turk of the Cleveland Clinic Florida Naples. "Is it the skin, its elasticity? Is it the muscles of the face causing the wrinkles? Strong expressions may be causing them. Could it be a loss of collagen? Is the problem under the skin: Is there fat atrophy? You lose volume in the face as you age. Or is it the color of your skin that's troubling?"

Turk explained that the answers to these questions would determine whether a patient was a candidate for Botox injection, which relaxes or weakens targeted muscles, reducing or eliminating the wrinkles; or a filler substance such as Restylane or Radiesse, if the problem is a hollow area; or even liposuction to remove fat from one place on the body and put it elsewhere. If color inconsistency were the problem, a patient might be looking at spot "sanding" of skin areas with dermabrasion; for lack of skin elasticity and deeper wrinkles, laser resurfacing might be in order. A combination of those procedures might be the best answer of all.

Dr. Manuel Peña of Naples says Botox lasts two to four months, is relatively painless and highly effective. The amount he uses depends on whether the muscles are to be relaxed or paralyzed. For the fine lines around the mouth, he'd just weaken the muscles a bit. For deeper lines, the muscles would be paralyzed to keep the skin from scrunching up-as a result, the wrinkles would temporarily disappear. But this would mean I couldn't whistle or kiss or roll my lips under in the beaver face that makes my youngest daughter laugh hysterically.

"You have a lot of power in your syringe," Peña says. "So you have to use it wisely, be artistic about it."

Dr. Ralph Garramone of Fort Myers helped me sort out the great variety of substances and procedures. "For a long time, Botox has been available for both men and women to treat lines and wrinkles due to activity or overactivity [of facial muscles], and it's a good way for a younger person to avoid getting wrinkles," he says. "But then at a certain age, you get a wrinkle that is established and no longer dependent on facial activity.

"So there are injectable materials that work on the wrinkle directly, creating a smooth surface. Collagen in several forms has been the gold standard, but there are several products that last longer now," Garramone says. One of those is Restylane, a synthetic form of hyaluronic acid, which is a naturally occurring substance in the body. The difference is that collagen lasts two or three months, and Restylane eight to 10, before either substance is reabsorbed by the body.

For deeper grooves, cosmetic surgeons have Radiance, a product used for years in reconstructive surgery and now sold under the trademark name Radiesse. The chemical compound is calcium hydroxylapatite. Although it has yet to be labeled for cosmetic work by the Food and Drug Administration, it has been approved for other purposes-therefore physicians use it off-label for cosmetic procedures. It can last from 18 to 24 months.

The temporary nature of these procedures requires follow-ups, if desired, but Dr. Larry Lickstein of the Cleveland Clinic Florida Naples says this is actually a benefit for the patient.

"Faces change as they age," Lickstein says. "And one of the jobs of a surgeon is to keep facial harmony. A permanent injectable isn't necessarily a good thing. The full lips you have today may not look so appropriate 20 years down the road. Styles change, aesthetics change."

In fact, what happens to the face after 50 isn't the lines and wrinkles of the 40s, it's a shape shift, says Dr. Mark Prysi of Naples. "People say a husband and wife start looking alike. But the truth is all middle-aged people have the same issue," he says.

"The face goes from looking like a heart to looking like a box, from heart-shaped to square," Prysi says. At that point, a patient becomes a candidate for a more invasive procedure, perhaps a facelift.

In the meantime, the most overlooked thing a person can do, particularly in Florida, is wear sunscreen every day, says Lickstein. "Everybody who lives here should do that."

The Price of Looking Younger:

Although the costs vary with region, skill and qualifications of surgeon, and demand, here is an estimate of what you can expect to pay for procedures discussed in this story.

Botox, the trade name for botulinum toxin, which is injected to relax or paralyze muscles or reduce wrinkles primarily on the forehead and around the eyes. Cost: one site on the face, about $325.

Collagen is ejected from a variety of sources: cow skin, the patient's skin or a cadaver (sterilized and purified). This filler is injected under a wrinkle to bring all of the skin to the same level. Cost: one site, about $375.

Restylane is a hyaluronic acid found naturally in the human body. It is injected by syringe, but does not interfere with muscles as Botox does. Cost: A procedure can cost anywhere from $350 to $1,500, depending on how many sites are injected and how much is used. The cost of .5 cubic centimeters of Restylane is about $350.

Radiesse, an injectable created with calcium hydroxylapatite delivered in a clear gel base. Over time, it is believed to stimulate the creation of the body's own collagen. Cost: One cubic centimeter of Radiesse costs about $1,200.

Fat transfer by liposuction is a more complicated procedure, in which a patient's own fat is taken from one area of the body and injected into the face to add definition to the cheeks and chin. Cost: $2,000 to $3,000 or more.

Dermabrasion is controlled surgical scraping to flatten the surface of the skin. Laser resurfacing uses a carbon dioxide laser to remove layers of damaged or wrinkled skin. Cost: about $2,300 or more for each.