Aging skin: Think of a droopy tablecloth

March 4, 2014 by
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Photo of woman having face assessedOver the last decade, we’ve experienced a revolution in our understanding of how skin ages. The visible signs of facial and neck aging once were attributed exclusively to skin laxity or looseness. Today we know that the sagging, drooping, wrinkling, textural alterations and other physical signs that characterize the passage of time are a result of a number of anatomical and physiological events. These include:

  • Loss in the quality and quantity of collagen and elastic fibers. This is largely due to years of accumulated sun exposure and other environmental damage.
  • An increase in facial expression muscle activity (hyperkinesis).
  • Loss of facial volume. This is often due to decreases in fat, bone, cartilage and muscle.
  • Weakening of the retaining ligaments which suspend and hold the skin and underlying tissues in place.
  • Fragmentation and downward displacement of fat compartments due to gravity. These compartments are responsible for giving fullness, smoothness and youthful contour to the face and neck.

As a result of this gravitational pull on compromised, devolumized facial tissue, the face loses its youthful triangular shape and takes on a boxy look as the jowls and neck sag.

To illustrate what happens to our skin as we age, imagine a fully expanded dining room table covered with a beautiful, smooth tablecloth that hangs halfway down each side of the table. Now imagine removing both leaves from the table. Not surprisingly, the tablecloth that once draped so beautifully now droops down to the floor. To restore the tablecloth to its proper position, you wouldn’t conclude that it had gotten too loose and proceed to shorten it by cutting it down all the way around the table. You would simply reinsert the table’s leaves, and voilà! The tablecloth looks good as new.

For decades, however, physicians perceived jowls, turkey necks and sagging cheeks as issues of laxity (skin hanging) and merely cut away the “excess” tissue during surgical facelifts, neck lifts and eyelifts. This procedure often creates an artificial look, with skin pulled too tightly over the face and a cadaverous, skeleton-like appearance – the obvious and dreaded signs that someone has “had work done.”

The good news is that today we do in fact have several methods for non-surgically addressing age-related changes – methods that have stood the test of time and necessitate little or no downtime. For muscle overactivity, we have wrinkle-relaxing injections such as Botox, Dysport and Xeomin. For roughness, textural changes, skin dullness and mottled pigmentation, we have topical prescription medications, chemical peels and fractional medical microneedling. For fine wrinkles, we have dermal fillers. And for deeper furrows and volume loss, we have developed volumizing injectable fillers. And for sagging skin and apparent laxity, we have nonsurgical facelifts.



Nelson Lee Novick, MD, is a Clinical Professor of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City and an Attending Physician. He is a Fellow of the American Society for Dermatologic Surgery, American Academy of Cosmetic Surgery and the American Academy of Dermatology. He also maintains private practices devoted to cosmetic dermatology and cosmetic dermatologic surgery in Manhattan and in Israel. He is the author of nine trade books, including You Can Look Younger at Any Age.

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