In the age-old quest to defeat the ravages of time societies have devised ingenious tactics to try and turn back the clock — or at least to mitigate its effects on appearance. Today, consumers can choose from measures as conservative as avoiding the sun and quitting smoking to more aggressive measures, including injections, laser treatments, and cosmetic surgery.
Sometimes in their efforts to defy the appearance of aging, however, people undergo procedures that actually make them look older, or give them a stiff, artificial, “worked on” look. It can be a vicious cycle: the more someone dislikes the results of a procedure, the more procedures he or she may undergo to “correct” the “mistakes,” and the cumulative effect may truly backfire.
Avoiding a misstep onto that slippery slope is a matter of experience, an educated approach, and often a healthy dose of conservatism, says Brian S. Biesman, M.D., clinical assistant professor at Vanderbilt University Medical Center and director of the Nashville Center for Laser and Facial Surgery.
“Certainly we’re seeing younger and younger patients coming in to see if they’re candidates for procedures,” Dr. Biesman says. “There’s something to be said for not doing things too early,” and he says he does his best to avoid doing surgery before it’s absolutely necessary.
Sometimes that means reining in the patient.
“I had a patient recently, late 30s, and her friends told her she should have surgery before she needed it so it would look better over time.” Dr. Biesman says physicians need to make a distinction between an enhancement procedure in younger patients and more restorative procedures in older people. He believes in a healthy respect for people’s anatomy.
“I think younger people can look older when they get that plastic-y look that older people who are ‘trying too hard’ get. Folks who have too much filler or lasers and they get that pasty or artificial look. That, in a sense, is how younger people look older by looking too artificial at too young an age.”
Doing anything for aesthetic reasons in minors is ill-advised, in Dr. Biesman’s opinion. There are psychological as well as physiological issues involved, he points out. “I had a mother bring her 15-year-old daughter in for cosmetic eyelid surgery, and I told them absolutely not. Her mother had had a lot of aesthetic procedures done and had that sort of artificial look.” He cites another example: A 14-year-old who had undergone a blepharoplasty procedure with another practitioner and she didn’t like the appearance of the upper eyelid scars.
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A Picture Is Worth 1,000 Words
Dr. Biesman likes to use historical pictures to study, with the patient, how that patient’s face naturally changed over the years. For him, it’s the natural evolution of THIS patient, and how to “enhance” without compromising the intrinsic structure.
“I use old photographs as a guide when I inject. I like them to bring in high school graduation pictures, then progressive photos at 20 30, 40.” That way, he explains, he can study the evolution of the individual’s face. “You can see what’s changed over time, and what they’re like at present.” Maybe the patient comes in asking for a specific enhancement. “So you look at the photos; you can point out that the patient has always had a specific anatomical feature, and you can say, ‘look, you’ve always had that, and if I change that, it will change your basic look,’ and that’s when it starts looking different.”
There’s an element of sleuthing going on to help ascertain what the patient wants and needs — or doesn’t need, Dr. Biesman explains.
He says about half his patients come in with specific requests; the others just feel that they look older and ask for his suggestions. In any case, studying the timeline of photos is a huge asset. “It’s remarkable how often they look at the photos and realize what they thought they were most concerned about has always been there and that’s NOT what’s bothering them. So just sitting with the patients themselves, looking at photos, can help us identify what the issues may be.”
The Art of Dissuasion
When it comes to telling patients they’re asking for the wrong procedure, or at the wrong time or wrong age, Dr. Biesman says, “I’m fairly blunt with them. I tell them the risk/benefit ratio isn’t acceptable.” Particularly with very young patients or minors whose parents bring them, “There’s a risk sending the message to someone who isn’t yet comfortable in their own skin that they need cosmetic procedure to achieve some kind of look. It almost means there’s something wrong with them and they need to change.” As a result, he says, he’s fairly straightforward in discussing that concern with the patients and/or parents.
He also believes that sometimes less is more.
“I’m not at all a proponent of permanent fillers or aesthetic enhancements that one might come to regret. In my practice, I tend to see a lot of the dark side of things that didn’t work well. That’s another reason I’m pretty conservative about advising surgery.”
There is a prevailing opinion among consumers that non-surgical procedures are all excuses for not doing surgery and that if you want it done right, you just do the surgery. I try to explain to them that surgery is just a tool in the toolbox but that it doesn’t address all of the problems for all the physical signs of aging that we say, and we may need [to use] a combination of techniques. I encourage them to avoid the more permanent types of procedures until they’re really required. When it comes to surgery, I don’t want to do it too soon, but I don’t want to wait until people have so many things to correct surgically that they’ll look drastically different afterwards.”
He also helps patients understand that every surgical procedure results in scar tissue which will complicate any future surgeries.
Tips For a Long-term Approach
You don’t go to a dentist just once for your teeth — just the same, your face changes over time, so why use permanent procedures? “While it’s important to keep up with volume, you want to avoid a situation where every time you go for a visit you necessarily have volume correction done in the same area. I see so many people who have been having routine procedures by people who are maybe not sophisticated injectors, and they’re getting HA injections every six months, and after a while the patient knows he or she doesn’t look like themselves or even what they SHOULD look like.”
One thing Dr. Biesman thinks is important — looking back at patients he’s taken care of over the years, those who take care of their skin, stay out of the sun, don’t smoke, and have a good diet — “Through conservative procedures over the years, I can tell someone with quite high confidence that someone can look much the same in 10 years as they do today. And I am not prone to making hyperbolic statements — I’m quite conservative — but it is pretty cool. Some folks look better at 45 than they do at 35. I had a patient recently who’s 60; and we looked at pictures of her when she was 50, and we agreed she looks better at 60 than she did at 50.”
Dr. Biesman thinks there’s something to be said for staying with the regular maintenance, and a physician “who’s willing to say no, that’s enough, and who remains aware of how their patients are changing over time. It is important not to go into autopilot mode where the same treatment or treatments are automatically performed in the same way over many years. Keep the big picture in mind; try to make each visit like it’s the very first visit. It can be hard to look at someone you know so well objectively every time you see them, but doing so allows you to keep people looking really good for a really long time.”