E27: 7 Domains of Our Aging Face

Every day you get up and you go to the bathroom, do your morning routine, or whatever, and you look in the mirror. At least I do. Now, who do you see when you look back at you?

Do you smile at yourself? I do. I want to be sure that I'm greeted each morning with a smile, even if it's my own.

Do you look carefully, see the changes that time brought to your face? Well, I don't look too carefully.

Do you put on some makeup before you face the world? Do you like this face that greets you, or would you like to change it in some way with makeup, with a facial, with more than that? Is there anything you could have done that might've yielded another face over time? And is there anything you could or should do now?

The "7 Domains" will be exploring aging, the aging face, the aging body, and the aging mind in podcasts coming up. But today, we're going to talk about the aging face.

And here, in the virtual Scope studio with us, is someone who can help us with the 7 Domains of the Aging Face. Dr. Payam Tristani is a dermatologist at University of Utah Health who specializes in the very delicate surgery to remove skin cancers with the least amount of skin necessary, a really important skill when you're removing skin cancers from the face. And she also specializes in cosmetic dermatology.

Dr. Jones: Welcome, Dr. Tristani.

Dr. Tristani: Thank you so much for having me on the program. I really appreciate it.

Dr. Jones: Oh, I am really personally excited about this. Now, in the interest of full disclosure, many years ago Dr. Tristani removed a skin cancer from the top of my ear. And it was enough that some of the curl at the top of my ear was cut off. And I was a little worried that I might have one ear that was like a hobbit, not that I'm vain or anything like that, but as it healed, it revealed her magic and now the little curl in the ear looks perfect. So, thank you, Dr. Tristani.

Dr. Tristani: My pleasure. Thank you.

Dr. Jones: I have a really cute right ear. It's really great.

So what are some of the physiologic or expected changes in the skin that lead to an aging appearance in women's skin? So what are those things that happen?

Dr. Tristani: So there are a number of physiological changes that happen with aging. So the first thing is that . . . well, the skin is predominantly composed of three layers. The top layer is the epidermis. That's the layer that continuously sheds. Then there's the second layer of the skin, which is called the dermis. That's the layer that kind of gives the thickness of the skin, which has the collagen and the elastin fibers. And then below that is the fat layer.

So there are changes in all three layers of the skin. Over time, with aging, you have thinning of the epidermis. Basically, there is kind of a decrease in the cellular turnover of that top layer of the skin. So, overall, what happens with that is the skin overall becomes thinner and it sort of develops more sort of a translucent appearance and also becomes more dry.

As we age, that second layer of the skin, the dermis, becomes thinner as well. We lose some of the elastin or the collagen fibers. And also, that collagen fiber becomes less able to bind water over time as well. So then you get the appearance of wrinkles and sagging.

And then, in addition to that, there's also loss of fat with time. And so you get sort of a shifting in the appearance of the face with sort of a redistribution of fat. We lose fat in the face and, unfortunately, we gain fat in other parts of the body. So these are all sort of changes that we see. Those would be some of the major things.

In addition to that, there's loss of, for example, oil glands. So the skin, again, becomes kind of more dry and sort of loses its overall luster that a more youthful skin has.

Dr. Jones: Well, I want luster without makeup. Can you make luster without makeup?

Dr. Tristani: I mean, there are some things that we can definitely do. For example, this sort of goes to what are some of the things that we can do topically that will help with the thickness of the skin, with the cellular turnover?

Yeah, for example, there are agents that we can use like Retin-A that help to increase that cellular turnover, that can increase the amount of collagen in the skin.

There's a variety of antioxidants that you can use. And those can combat or reverse some of the changes that can happen with aging. There are other agents like peptides that you can apply.

And then there are some of the things that we talked about, like our laser procedures, that help to kind of reinvigorate the skin, create new collagen, help with that thinning of the epidermis.

So those are things that we can address when we see our patients in the clinic and help them to achieve a more youthful appearance of their skin.

Dr. Jones: Right. Well, we did a "7 Domains of Personal Grooming," which had a section on facial hair as some women are born with a tendency to make more facial hair and some women have endocrine problems. But women tend to have more hair as they age, particularly as they go through menopause.

Is there anything that you've got for that? Because that's a common . . . it used to be when I was a clinician, with menopause patients. They'd say, "What am I going to do with these little hairs?" Is that something you guys can do with your lasers, or not really?

Dr. Tristani: Yeah, that's a little bit trickier because also, as we get older, some of that hair, as you know, has that kind of a finer texture. And sometimes it can be a little bit more grayish or whitish in certain areas. In other areas, it can be a little bit more coarse and dark. And so many of the hair lasers can treat kind of the darker hair, some of the coarser hairs. The lighter ones are a little bit tougher to treat with lasers because the laser needs basically a chromophore or a pigment in the skin so that it can target what it's supposed to do.

So sometimes doing electrolysis is a good option in addition to the laser treatments. There are other types of topical creams. There's one called Vaniqa that can help with reducing the amount of hair. But yeah, that can be a more challenging issue for older women. I agree with you 100%.

Dr. Jones: How about diet and routine facial care? Do you have recommendations for even your 20- or 30-year-old patients that say, "Well, you don't want to have your face look like this when you're 60"? Or even when you're 60, these are the things that will help you maintain the face that you want to look at in the mirror in the morning?

Dr. Tristani: That's a really good question. I think the number one recommendation that I have for all of my patients is really that they need to get into the habit of wearing sunscreen.

I mean, we know that sun exposure, and especially chronic sun exposure, can really accelerate aging. And that's been shown really nicely with some of our great basic science research and also just with other types of clinical research as well.

So if there's one advice that I can give my patients at an early age, it's to get into the habit of wearing a daily sunscreen. And that's actually pretty easy these days because even kind of our regular moisturizers have some SPF in them. So I would say sunscreen is number one.

Number two is just get into the habit of using an agent like Retin-A that helps, again, with combating some of the effects of aging like loss of collagen, like changes in the cell turnover. And also using something like an antioxidant on their skin. So I think all of those topical agents will help to reverse some of the signs of aging.

I explain to my patients that if you have someone that has not used Retin-A versus someone that has been using Retin-A and sort of fast-forward their face about 10 years, that there is a significant difference between these two faces. So it's not something that's going to make a significant change within a year or so, but it's something that really makes a huge change just down the line.

Dr. Jones: As I said, I always smile at myself when I look at the mirror just because it's nice to see a smile, but there are effects of aging which make your face kind of turn down. And I have been reading about the concept of the resting bitch face. Some people have it when they're young. But certainly, when people get older, their face turns down.

I don't know what I look like when I'm resting because I don't look at myself when I'm resting, so I'm left with . . . My husband has to tell me, "Wow, are you sad?" and I say, "No, I'm just getting old."

So can you talk a little bit about how you might change that, this kind of aging that changes your emotional expression in your face?

Dr. Tristani: Yeah. First of all, that concept of the resting bitch face, I actually just heard about it a couple years ago. But I understand that it's kind of a relatively new term. I think came maybe around 2013, 2014. And it really refers to . . . well, it can be kind of a derogatory term.

Dr. Jones:Oh, it is.

Dr. Tristani:Yeah. But I guess it refers to predominantly a woman who looks angry or upset, even though she might be completely at ease or just completely fine.

In actuality, I get a lot of patients that come in and say, "People just say I look angry or I look like I'm frowning, but I'm really not angry. What can we do about this?" A lot of this has to do with repetitive facial movements that we might make, sort of repetitive frowning or lifting up of our eyebrows, even sort of inadvertently when we're not really even thinking about it.

And so that's where something like using some of our agents, like our neuromodulators like Botox, can help us. There's also a variety of procedures, like the fillers, that can help to kind of improve the appearance of the lines and some of the wrinkles and some of the changes in the shape of the face.

For example, putting a little bit of volume in certain parts of the face can help to lift another part of the face. It's basically the concept of this mimetic or muscle cooperation between one part of the face with the other. So, for example, injecting filler in one part of the face can help to lift another part of the face.

So those are things that we can do very easily in our clinic to help patients that say, "I have these changes in my face that kind of show a different type of emotion that I might have, but that's really not who I am."

Dr. Jones: You said you have people, women and men, that would like to see some changes in their face so they could feel better about themselves. But feeling good about yourself is a multi-layered phenomenon. It includes who you see in the mirror, but it also includes other issues of self-esteem.

So when you have people come who you feel have maybe unrealistic expectations, and maybe there are other parts of their self-esteem or there are other parts of their emotional life that might need some help, what are your thoughts about trying to help people look at their whole selves?

Dr. Tristani: I mean, I think that's a really important concept that you touched on. We do have some patients that come in and they have some emotional reasons why they're seeing us. For example, they might say something like, "I just got a divorce and I just need to really feel better about myself." Or maybe just kind of entering the dating arena and want to feel better about themselves. They might be just entering the workforce after being home for a while and they just want to really feel better.

It's really important to set the expectations with any of the procedures that we do and to just make sure that our patients understand that there are some limitations, definite limitations, to what we can achieve with our procedures, and to really set really realistic goals for them.

Being in the cosmetic field and in the aesthetic field, it's obviously very important to really build a connection with the patient and find the reasons why the patients are there and try to address all of that.

Unfortunately, some patients have unrealistic expectations, and they sometimes might be just sort of shopping around or you get the sense that whatever you do is just not going to be giving them the satisfaction that they need. So you have to be careful with that as well.

Dr. Jones: Do you think there are some social pressures for women to look a certain way compared to men? Although I think many men are, unfortunately, or fortunately, climbing on this wagon of having to look a certain way. But do you think there are certain social pressures or certain social jobs that require women to have a certain appearance?

Dr. Tristani: Oh, absolutely. We think that it's only for women that are going to be in front of a camera, like I am right now, or if they're journalists or an anchor person, that they really just need to look great in front of the TV. But I think women in all aspects of the workforce have a certain amount of pressure to look better.

I've had even patients who are, for example, in the academic arena who come in and say, "I feel the pressure not to even compete with the younger females in my department because sometimes I feel like I'm being overlooked and they may not be giving me the position to be in front of others because I'm getting older."

And I'm seeing that now also, with some of our male patients as well, they come in and just say, "I just need to look a little bit younger to be able to compete with my younger male colleagues."

So I think this is definitely something that all women face in their workforce, and I think some men are beginning to feel the same way as well.

Dr. Jones: Yeah. Well, I read that, during the pandemic, the use of Zoom let people get up close and personal with their face, because there you are looking at your face, and that the requests for cosmetic surgery or cosmetic dermatology has gone up.

I will say I find myself wearing a turtleneck. I think, "Oh my gosh, what is that? I think I have little things hanging off my chin. I'm going to wear a turtleneck all the way up." Or I sit with my hand in my face so people can't see my neck. And I've never done that before. So social media . . .

Dr. Tristani: I agree with that 100%. Unfortunately, the Zoom camera is terrible. It really hasn't done us any justice at all. On a personal note, I had to go and get my driver's license picture this morning. So I was looking in my closet today and I'm like, "I'm going to wear something that has a high collar because I don't want my neck to be in this picture."

Dr. Jones: In the intellectual domain, let's pick Botox. I hear about Botox parties. I know Botox is a brand name and there are other neuromodulators, but how do women find out about what's available and who should do it? Who should be injecting your face? I don't want just anybody sticking needles in my face, but I think a lot of people are just sticking needles in their face.

Dr. Tristani: As we all know, the internet and all the websites that are available now is really the main way that people are getting their information. The good thing is that there are a lot of really good informative websites. And really, many of the good reputable aesthetic and dermatology and other specialties, like plastic surgery, have really great websites. And when a consumer or patient refers to them, I think there's great information.

Dr. Jones: Does the American College of Dermatology have some . . .

Dr. Tristani: Yeah. I was going to say also that a lot of our different societies, like the American Academy of Dermatology or the American Society for Dermatologic Surgery and many of the plastic surgery societies, have really great information for patients.

And on those websites, there are the names of people within their communities who are basically members of the society and who, I think, that patients can feel very safe and comfortable seeing those providers and to have these procedures performed safely.

On the flip side, unfortunately, there's also a lot of bad information and there are a lot of people, because the regulation is not that great, that can just inject these neuromodulators or fillers or do some of the other procedures. And unfortunately, we know that there are some bad outcomes.

You referred to these Botox parties. I think, in general, they're really not a good idea just because, obviously, with anything that has the "party" designation to it, it just makes it really difficult because there's no regulation. You don't know who's doing the injecting. There's very little oversight.

And I think consumers or patients can also be lured by discounts or cheaper prices and what have you. And I've had patients that I've seen for years and they say, "Oh, the last time I went to a Botox party . . . I mean, fortunately, nothing bad happened, but also nothing good happened. So I wasted my money."

I don't have any issues with . . . For example, I know that there are some very excellent family practitioners that do provide these services and they do a really good job. I just think it really comes down to your level of expertise and how much you're doing the procedure. It's really not just a cookie-cutter procedure. You need to really understand your patients and you have to be able to understand what are the complications of the procedure as well.

Dr. Jones: Right. Well, I was thinking some about the financial domain because certainly some cosmetic or aesthetic procedures aren't covered by insurance. But if I were in a workplace where I had to look a certain way, let's say I was a TV anchor, do you think I could get my face work covered by my insurance as a workplace need, as a workplace expense?

Dr. Tristani: Unfortunately, it doesn't work that way. No.

Dr. Jones: Oh, no.

Dr. Tristani: You could argue for that. That's a really interesting thought. You could say, "Well, this is just part of my job. I need to look the best as I can." We could argue for all of us. But unfortunately, it doesn't work that way.

Some states, I know, for certain conditions like rosacea or for acne, some of the insurance companies will cover some procedures like lasers. But at least in Utah, that has not been the case.

Dr. Jones: Oh, rats. Well, I was looking forward to having more videos with my podcast and taking this all as a business expense. But I think I'll just keep my face for radio instead.

Dr. Tristani: That's an interesting thought. I think that needs to be explored further. Yeah, for sure.

Dr. Jones: Well, I'm thinking about environmental factors like air pollution and cigarette smoking. So there are things that are outside of us that might affect the aging of our skin, like air pollution. And then there are things that we do, like being around cigarette smoke, that probably are pretty bad for our skin.

Dr. Tristani: That's exactly right. So, with the process of aging, we have what we call the intrinsic aging, which is what we talked about earlier with the changes in the three layers of our skin. But then also, as you just pointed out correctly, we have our extrinsic factors that result in aging and that can really accelerate the process.

So the number one factor is sun exposure or chronic sun exposure. Yeah, that really causes loss of collagen, pigmentation changes in the skin, changes in the texture, and then just accelerated appearance of wrinkles, both fine and kind of the coarser wrinkles. And of course, most importantly leading to development of precancerous lesions and then, ultimately, skin cancers. So that's what the effects of the sun are, chronic UV exposure.

But then also exposure to cigarette smoke. And now there's a lot of good research that shows that pollution can also cause damage to the skin and accelerated aging as well. And unfortunately, in an environment like Utah, that can be a real problem.

Dr. Jones: Yeah. We have bright sun. We're at high altitude. We're prone for more ozone, which is an accelerant of aging. And so we've just got to clean up our air and don't smoke and wear sunblock.

I know in the reproductive/endocrine domain there are a number of concerns about what's in some of the facial products that you can buy over the counter, including some things which aren't very good. Phthalates, which have been associated with binding to different kinds of hormonal receptors in your body.

I've always recommended the Environmental Working Group's website, ewg.org. They have a campaign for clean cosmetics so that you can kind of pick what you're going to put on your face and make some decisions whether this is something you think . . . Once you get an analysis of what's in it, you can then make a better choice.

I know all the dermatologists who I've talked to, they recommend pretty clean moisturizers. Not with a lot of fragrances, not with a lot of additives. It's pretty clean stuff. And that's what we recommend, I think.

Dr. Tristani: You're absolutely right. I mean, there are a lot of ingredients. If you look at the ingredient list of any facial moisturizer or agent, it can have up to 30 or 40 different things in it. And we know that some of those ingredients can not be very beneficial to the skin.

We know that, for example, in the area of dermatology, a lot of those things like fragrances, like preservatives, can cause things like allergy contact dermatitis for the skin. Yeah, we do need to be careful as far as what we recommend to our patients and what our patients use.

Dr. Jones: Right. And "dermatologist recommended." You know how there are some moisturizers that say, "Dermatologist recommended"? That doesn't carry a stamp of the National Board of Dermatology, probably.

Dr. Tristani: It probably doesn't. I think, unfortunately, that particular recommendation can be used kind of loosely. And I don't know what the exact strictest of definitions or guidelines are for that. So it could be like, "Oh, I talked to Dr. Tristani and she said it's a good product."

Dr. Jones: "She really likes this."

Dr. Tristani: Yeah. "It's dermatologist recommended."

Dr. Jones: "They pass this out at the derm clinic, and so that's what I'm going to use."

Dr. Tristani: Right. Hopefully, it's a little bit better than that.

Dr. Jones: Well, I think about who you see in the mirror. And for me, I want to see my spiritual life or I want to see the wholeness of my person in my face. Now, that's just me, of course, but I think that as I try to calm my mind in these really difficult times, I want the face that people see around me to be one that's calm and accepting and loving.

How you can transform your spiritual life into a face that helps others, that's a really interesting thing for me. And I think in the very process of trying to make your face be a loving and gentle one, you connect yourself with bigger stuff.

So I think that dermatology or helping the face become the face that you want . . . For me, it's a face that shows, hopefully, love and acceptance and care.

I want to give a shout-out to my wonderful producer who took a picture of me for this podcast, the best picture ever. She captured everything I wanted in my face. So thank you, Chloé, my producer.

Dr. Tristani: Chloé, can you do the same thing for me, please, too? I need all the help I can get also, please.

Dr. Jones: Whatever she did, it's like, "Wow, that's the best photo ever."

Well, I want to thank you for your time, Dr. Tristani. And also, the concept of the dermatologist or the aesthetic dermatologist being someone who's really trying to look at the whole person, trying to help someone come to a sense of both acceptance of a more refreshed face or a happier face but having that trickle down to their whole person, I would think that would be a very gratifying thing to do.

Thanks to everyone who's listening for joining us, and stay tuned for more episodes on aging to share and start conversations.

And as we always do, I'm going to end with a little haiku. The "7 Domains of the Aging Face" haiku.

This, your mother's face
Looking back from the mirror
At the girl you were