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The naturally occurring aging process, or chrono-aging, normally begins in the mid-20s. There's a thinning of the skin, from the outer skin layer or epidermis, down to the deepest part of the skin, the subcutaneous fat layer. The number of pigment-containing cells or melanocytes decreases, causing a loss of natural sun protection. The skin appears more pale and translucent. Elastosis or loss of the skin's strength and elasticity sets in as the fibroblasts produce less collagen (for tissue support) and elastin (for flexibility or the ability of the skin to snap back into place). This eventually leads to that leathery, weather-beaten appearance of the skin, particularly in outdoorsy types.

Aesthetically, chrono-aging results in a fine wrinkling of the skin, noticeable loss of firmness in the hands and neck, a thinning and transparency especially in the under-eye area, loss of underlying fat in skin leading to hollowed cheeks and eye sockets, and among other effects, bones shrinking away from the skin due to bone loss, which causes the skin to sag. Meanwhile, prolonged sun exposure or photo-aging makes the effects of chrono-aging more pronounced, and could cause hyper-pigmentation and a mottling effect on the skin - the so-called age spots are in fact sun- induced. While in the past the effects of chrono-aging and photo-aging were treated separately, dermatologists are now beginning to realize a commonality in that the same fibroblasts crucial to maintaining the skin's functionality are affected by both photo-aging and chrono-aging.

"To clear up the confusion, what you need to know is that skin has different needs that are based on skin type, not on age. Not everyone in the same age group has the same skin type. Your skincare routine depends on how dry, sun-damaged, oily, sensitive, thin, blemished, or normal your skin is, all of which have nothing to do with age... What everyone needs to do is protect the outer barrier of the skin in exactly the same way - avoid unnecessary direct sun exposure (sun protection), don't smoke, don't irritate your skin, and do use state-of-the-art skincare products loaded with antioxidants and skin-identical ingredients," Ms. [Paula Begoun] noted. (Her book debunks several skincare myths and provides valuable information on the currently available skincare treatments. )

There's a saying that when you finally get your head together, your body starts falling apart.

One usually finds comfort in that mantra of "age is just a number," until that number actually corresponds with the visible signs of aging revealed by the looking-glass. When that happens, a woman of maturity probably won't throw a conniption fit while insisting on being "the fairest of them all," but she is entitled to attempt any means in her power to keep a youthful-looking countenance. So it goes for men who have to confront aging and feel the same desire to maintain their looks, applying the same techniques as women.

The naturally occurring aging process, or chrono-aging, normally begins in the mid-20s. There's a thinning of the skin, from the outer skin layer or epidermis, down to the deepest part of the skin, the subcutaneous fat layer. The number of pigment-containing cells or melanocytes decreases, causing a loss of natural sun protection. The skin appears more pale and translucent. Elastosis or loss of the skin's strength and elasticity sets in as the fibroblasts produce less collagen (for tissue support) and elastin (for flexibility or the ability of the skin to snap back into place). This eventually leads to that leathery, weather-beaten appearance of the skin, particularly in outdoorsy types.

There's a slowdown in cellular regeneration, a shortening of the telomeres (the DNA cap related to cellular replication) and so the skin's ability to repair itself is reduced. The blood vessels of the dermis or second layer of the skin become more fragile, which leads to bruising and bleeding under the skin or telangiectasia, and similar conditions. Sebaceous glands produce less oil, leading to dryness and itchiness. Because of a thinner subcutaneous fat layer, which provides insulation, risk of skin injury increases and the ability to maintain body temperature is impaired (which is why older people tend to be more susceptible to hypothermia). The sweat glands produce less sweat, it's harder to keep cool, and heat stroke becomes a risk too.

Aesthetically, chrono-aging results in a fine wrinkling of the skin, noticeable loss of firmness in the hands and neck, a thinning and transparency especially in the under-eye area, loss of underlying fat in skin leading to hollowed cheeks and eye sockets, and among other effects, bones shrinking away from the skin due to bone loss, which causes the skin to sag. Meanwhile, prolonged sun exposure or photo-aging makes the effects of chrono-aging more pronounced, and could cause hyper-pigmentation and a mottling effect on the skin - the so-called age spots are in fact sun- induced. While in the past the effects of chrono-aging and photo-aging were treated separately, dermatologists are now beginning to realize a commonality in that the same fibroblasts crucial to maintaining the skin's functionality are affected by both photo-aging and chrono-aging.

"I can see my husband and me shrinking as we grow older because the cells in the body shrink... the fibroblasts of the corium [or dermis] are spread out. The fibroblastic cells are like trampolines and they are in touch with the fibers and with each other. As you grow older, the trampolines begin to lose that connection, and we have less of everything, we have less of the fibers' collagen, less of the elastic fibers, less hyaluronic acid at the level of the corium, and less of the subcutaneous fat as well as less of the bone. So we actually should shrink. And we get it both from photo-aging as well as chronologic aging," noted Dr. Vermen Verallo-Rowell, Program Director of the VMV Skin Research Centre (VSRC) + Clinics and member of the American Academy of Dermatology and the Philippine Dermatological Society.

First defense: sunblock

Skin changes are largely influenced by genetic makeup, environmental factors, nutrition and lifestyle choices (e.g. smoking triggers bio- chemical changes that accelerate aging, to the extent that facial wrinkling can be seen under a microscope in 20-year-old smokers; these smokers also tend to develop leathery skin with a yellowish hue later) - the greatest single factor, however, is photo-aging.

Ask any dermatologist, and the no. 1 preventive measure is mitigating damage from ultraviolet radiation, whether UVB (primarily causing sunburn and melanoma) or UVA (causing many of the effects of photo-aging as well as skin cancers, including melanoma). Natural pigments do provide some protection against sun damage, which explains why fair-skinned folk show more aging skin changes than Filipinos and other people with darker and more heavily pigmented skin. Sunblock is essential to reduce the effects of skin aging.

"What it means to prevent skin-aging is to just delay it or at least reduce manifestations like pigmentation, wrinkling or sagging of the skin. Across the board, what's good for everybody is sunblock, just pure sunblock will help you... Always look for the minimum recommendation of SPF 30++ and it should cover for both UVA and UVB... If you are meticulous enough, you will find the suitable sunblock for your type of skin. You could subject yourself to a patch testing to find out if you are allergic to a particular chemical, and just look for sunblocks without that chemical," said Dr. Janet C. de Grano, director of dermatology at the Beverly Hills Medical Group and a member of the Philippine Dermatological Society.

Dr. Verallo-Rowell also stresses everyday use of sunscreen as the best defense against aging, remarking that most people look for the UVB protection factor (SPF) but forget about the UVA protection factor (PFA).

"It is UVA that produces a photo-chemical reaction, so you need to protect yourself against UVA because we are all exposed to chemicals which are stimulated by light... There are lots of plants that people are photo- allergic to and garlic is one of them. We also found that it is a significant correlation of visible light on the patch-testing with infrared heat. Cooking in front of the fumes of garlic with the heat, and light, no wonder Filipinas have hyper-pigmentation and melasma," she said.

To be forever young

Assuming one is using sun protection and practicing basic skincare already, application of anti-aging creams and solutions can also help improve skin appearance, especially with their exfoliating and moisturizing properties and touted skin-rejuvenation effects (e.g. stimulating collagen production). Several of these are bought over-the-counter and share the same ingredients, most commonly retinoids, alpha hydroxy acids (AHAs), beta hydroxy acids (BHAs), hyaluronic acid, and a number of antioxidants.

Dr. Verallo-Rowell is currently studying moringa's antioxidant properties and will be coming out with a full range of products, including anti-aging, next year.

"There are products which are a flash in the pan; there are products that are copycat... If you have sensitive skin, be careful about looking at ingredients in the back; the more ingredients that there are, the greater the chances that you are going to react. Do not be a shopper. There are people who will try anything new; stick with what's good and what's safe. Be scientific about it. Red flags are perfumes, which are very photo- sensitizing, nice color and smell - forget it. You want something with a clean smell," suggested Dr. Verallo-Rowell.

Given the sometimes exaggerated claims of anti-aging products, making your purchase becomes quite difficult. In The Original Beauty Bible: Unparalleled Information for Beautiful and Younger Skin at Any Age, consumer advocate and "cosmetics cop" Paula Begoun cautions against marketing ploys, pointing out that implications are far from fact, collagen and elastin are good water-binding agents but are too large to penetrate into the skin and bind with the collagen existing in the skin (as many products claim), eye cream is a waste of money as there is no valid research requiring different ingredients for the eye area and the face, and there are no skin-care products "better than Botox" or able to eliminate wrinkles, even products supposedly designed for a specified age segment.

"To clear up the confusion, what you need to know is that skin has different needs that are based on skin type, not on age. Not everyone in the same age group has the same skin type. Your skincare routine depends on how dry, sun-damaged, oily, sensitive, thin, blemished, or normal your skin is, all of which have nothing to do with age... What everyone needs to do is protect the outer barrier of the skin in exactly the same way - avoid unnecessary direct sun exposure (sun protection), don't smoke, don't irritate your skin, and do use state-of-the-art skincare products loaded with antioxidants and skin-identical ingredients," Ms. Begoun noted. (Her book debunks several skincare myths and provides valuable information on the currently available skincare treatments. )

Dr. De Grano is cautious about recommending any singular product for general use for this very reason, maintaining that commercially available anti-aging products are bound to work, but in a subjective manner.

Dr. Verallo-Rowell shares a similar view on treating skin type but when pressed for an answer, said "the gold standard" in topical anti-aging products is Retin-A (tretinoin or the acid form of Vitamin A), which she has been prescribing since the 1960s when it was still being used to treat acne only. Being an oil-based hormone, penetration is easy and topical application results in a peeling of the surface layer of the skin, triggering a regeneration of new, younger-looking skin cells.

There are also various chemical peels (e.g. the popular glycolic acid peels) supposedly resulting in a sloughing off of fine lines and wrinkles, skin discolorations, and scars, plus subtle collagen rejuvenation, and mechanical peels (such as the diamond peel which uses abrasive micro- granule crystals) to effect a similar transformation, even a jet peel that uses water to exfoliate the skin. Dermabrasion utilizes abrasion rather than heat used in chemical peels or lasers (light amplification by stimulated emission of radiation).

One may opt for other medical/cosmetic corrective procedures such as photorejuvenation (use of intense pulsed light to treat skin conditions and remove wrinkles from photo-aging), the mentioned laser resurfacing (light strategically targeting points, in the case of ablative laser resurfacing using exteme heat to remodel the collagen in the skin) and other energy- producing devices. Dr. De Grano, a cutaneous laser surgery and hair transplantation specialist, is particularly keen on the effects of laser treatment (incidentally, these start at P6,000 per treatment at VSRC).

Dr. Verallo-Rowell is "excited" over dermal filler injections a.k.a. tissue augmentation, soft-tissue fillers, or implants in the depressed areas of the face such as the nasal labial folds from nose to mouth, deep furrows between the eyebrows, and marionette lines along the sides of the mouth.

There are around 30 types of dermal fillers in the market, including the popular (but not necessarily most efficient) Botox (Botulinum Toxin A, averaging P8,000-P15,000) - used by ophthalmologists since 1973, now used to inhibit muscle movement for cosmetic purposes - and Restylane (a hyaluronic acid-derived filler, P25,000/cc at VSRC). Fillers may be nonpermanent, semi-permanent, or permanent and not without risk. Some dermatologists, however, prefer these over more aggressive and perhaps riskier if more permanent surgical intervention, whether the traditional face-lift or the newer SMAS-lift (a surgical realigning of the superficial musculoaponeurotic system, a gliding membrane of connective tissue and muscle responsible for facial expressions).

"Don't get a face-lift...You are actually getting this thinned out epidermis/dermis core and you're stretching out on a bone structure that's also thinner. So you have everybody looking like that, and they're all the same, with this cadaveric look... We're looking more into fillers to fill the face with material that would give you back a three-dimensional look - I'm older and I've lost most of my tissues, so things fall down; the light strikes me in a different way than it strikes a young person who has projection in the temples and the forehead, [because] my projection is a little bit lower now," said Dr. Verallo-Rowell

"We have a procedure wherein you draw blood from the patient, get the platelet-rich plasma containing the human growth hormones that produce collagen, and inject that directly into the tissue... The future for photo- aging and chronologic aging is how to get fillers there... using growth factors in stem cells to stimulate the fibers to start producing more hyaluronic acid inside you," she said, admitting that she has yet to make extensive studies on this procedure, having only used the platelet-rich plasma as a substitute for Restylase a few times.

What the patient decides to avail of depends entirely on the condition of their skin, their objectives, and their budget. A combination of procedures is optimal - topical, peel, laser treatment and filler - provided the doctor you're consulting is knowledgeable and experienced in the practice of such, and provided you as a patient are well-informed and will be meticulous in following instructions.

Again, it is best to have something tailor-made to the individual. However, to get an idea of what would be the likely trajectory of treatment, The Beauty Prescription: The Complete Formula for Looking and Feeling Beautiful (McGraw-Hill, 2008) by Dr. Debra Luftman and South Beach psychiatrist Dr. Eva Ritvo, devote several pages to recommended skin aging procedures (prices per treatment included) based on general manifestations of skin aging per age segment.

Individuals in their 20s and 30s are advised to go the extra mile with a glycolic acid peel or microdermabrasion ($150-$200) every three months. Meanwhile, the 30- to 40-year-olds are given Botox injections for dynamic wrinkles and frown lines every three to six months ($500-$1,000), monthly glycolic peels or dermabrasion for mild sun damage or dull skin, and for those who have hyper-pigmentation, intense pulse light (IPL) or photo facial or fractional laser (Fraxel) several times a year ($400-$600).

As the patients get older, the suggested treatments get more aggressive. The 40- to-50-year-old segment get Botox for forehead wrinkles, frown lines and crow's feet every six months ($700,P1,500), several recommended cosmetic fillers at one to two syringes every six to 12 months for lines around the mouth and "marionette" lines ($1,000-$4,000), and Thermage radio frequency or skin tightening every two years ($1,300- $6,000). Those with moderate sun damage may try IPL treatment several times a year ($400), whereas those with severe sun damage may opt for photodynamic therapy for three to four treatments, repeated every three to five years ($800), and Fraxel treatment at three to five sessions every one or two weeks ($,200-$2,000), with the effects lasting five to10 years

Meanwhile, the 50- to 60-year-olds get Botox for forehead wrinkles, frown lines and crow's feet every three to six months ($700,P1,500 per treatment); several fillers to choose from, at one to two syringes every six to 12 months, to smoothen lines around the mouth ($1,000-$4,000 per treatment); maintenance IPL treatment twice or thrice annually ($400); an eye-lift (blepharoplasty, $2,000-$4,000) or Thermage ($1,500-$2,000) once; and a Thermage lift on face and/or neck every two to three years ($1,300- $6,000). On it goes, with the 60-year-old and beyond bracket going much the same way, with a combination of botox, fillers (particularly hyaluronic acid fillers), radio-frequency treatment, and maintenance IPL treatment.

Utimately, it is best to consult a board-certified dermatologist as to what options are available for the type of skin one has. Some individuals are born lucky and will need little or no treatment; maybe you're one of them.

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