Fundamentally, though, wrinkles occur because skin loses its elasticity with time and so it fails to perfectly conform to the underlying tissue structure and fails to stretch and rebound perfectly with movement.

The first approach to wrinkle management, therefore, has to be skin care. From inside and out. If we can prevent the processes by which skin elasticity is lost, or at least retard these processes, whilst encouraging repair and renewal of elasticity, we reduce wrinkle risk.

Hate to be boring, but you need to cease smoking altogether, cease excessive alcohol consumption (causes too much skin dehydration) get a high level of vegetables in your diet, sun protect every day, stay rested, avoid excessive exercise (might be good for the rest of you, but its not good for your skin) and avoid excessive grimacing.

From the outside, there are a handful of skin care ingredients that are proven beyond doubt to reduce the appearance of ageing in the skin. Go to the skin care section of the website, but in essence these ingredients are high-strength antioxidant vitamins, primarily vitamins A, C and E, and the alphahydroxyacids. Especially Vitamin A. Practically everyone interested in wrinkle management should have Vitamin A in their skin care, in high dose (not just retinyl palmitate).

Pick your wrinkle

Dr Richard Glogau came up with the idea there are four kinds of states wrinkle-wise
1. No wrinkles. Kids and adolescents
2. Dynamic wrinkles. The face looks smooth when at rest, but wrinkles up with movement. Young adults
3. Static wrinkles. The face has lines at rest. Obviously they worsen with movement. More mature adults
4. Wrinkles on wrinkles. The face is criss-crossed with wrinkles. These people are elderly (at least dermobiologically if not chronologically)

Simple though it may be, the classification is useful because different treatments are applicable for each wrinkle type.

I would further add that there are essentially three processes by which wrinkles occur, independent of the age of the patient. Each process implicitly suggests the correct treatment approach.
a) Muscle action wrinkles. The wrinkle arises due to the action of a muscle beneath the wrinkle
b) Tissue shift wrinkles. The wrinkle arises as one tissue moves (generally sinks with gravity) relative to another, more stable tissue
c) Tissue shrinkage wrinkles. The underlying tissue loses volume, giving rise to a local excess of skin relative to surface area and volume requirements.

Forehead wrinkles are muscle action wrinkles. In young adults at the Glogau Type 2 stage, they respond wonderfully to Agent B. In mature adults, Agent B is still needed but a filler such as Agent R is applied to manage the static part of the line. Collagen-inducing measures such as IPL, microdermabasion, Omnilux and peels can also help.

Brow wrinkles are also muscle-action wrinkles, and require the same approach as forehead wrinkles. They are usually deeper, and arise earlier, than forehead wrinkles, and are often the first wrinkles a given individual will have treated. In such cases Agent B is straightforward and without recognized site-specific side effects. Just do it.

Nasal wrinkles are sometimes called “bunny lines” Again, these are muscle-action wrinkles and respond well to a small dose of Agent B. At the Glogau Type 3 stage Agent R can be added

Eyelids can wrinkle due to all three of the processes I listed above. Combined treatments are often necessary, employing Agent B with fillers and even deep peels, laser resurfacing and surgery. Everyone is different and eyelid wrinkles should be discussed in consultation.

Crow’s feet, on the other hand, are muscle-action lines. They should be treated with Agent B first, and a fine filler added if required. If the treatment extends too far down onto the maxilla an inferolateral trough will develop after the treatment: this is a trick for young players. For safety, consult experienced Agent B users.

Maxillary and masseteric wrinkles tend to be due to tissue shifts and tissue shrinkage. Rearranging subcutaneous tissues with Aptos threads or other thread systems, or with surgery, is required, and well as replenishment of volume with fat or Agent A, and/or skin tightening procedures such as Agent S and the physical skin treatments such as omnilux/IPL/laser resurfacing. Of all these, Agent S and Aptos are the most straightforward and least risky combination.

Nasolabial folds are the archetypal tissue-shift wrinkles. With time, the fat in front of the cheek slips down with gravity, taking skin with it. Meanwhile, the skin on the front of the upper lip stays where it is, as it is quite closely adherent to the orbicularis oris muscle beneath it. So, the result is like a geological fault-line. The sinking cheek skin builds a bulge over the stationary edge of the upper lip skin, creating a fold.
Using a simple filler like Agent R over a nasolabial fold is like papering over a crack in the wall: makes it look better temporarily, sure, but doesn’t at all address the underlying problem and is bound to ultimately fail and look unnatural if large amounts are applied to try to fix deep wrinkles. On the other hand, many patients get a number of years of satisfactory camouflage of this fold with Agent R, and so we still do it, but eventually we have to do something different.
Agent S and Aptos threads are appropriate strategies in most people with these lines, as they help address the structural shift causing the lines to form.

Lips are something of an exception. People commonly complain of “smoker’s lines” in the upper lip, although it is kinder to call them “whistle lines”. These are muscle action lines, and so you would think that the first approach should be Agent B, but the problem is that applying Agent B to this spot can cause unwanted alterations to mouth movement. Which can cause changes to your speech. Not a desirable effect. So a filler such as Agent R is used far more commonly, with good results and satisfied patients.

We will sometimes apply tiny doses of Agent B into the upper lip, in conjunction with Agent B treatments elsewhere on the face, in experienced Agent B patients whose sensitivity to Agent B we know. The resultant desired reduction in upper lip movement helps reduce upper lip lines now and into the future for that patient. This we would discuss further in consultation

Agent R and other fillers are also used to improve lip texture. With time, a volume loss occurs in lips, making them look a little deflated. A small amount of Agent R can be used to re-inflate the lips without changing their shape or apparent volume. They then look pinker smoother and younger, but still very much your own shape. You would then need less lip-liner.

The Agent R can be applied under cover of local anaesthetic injections, or, if you prefer, we have an anaesthetic gel specifically designed to penetrate into lips. Patients love avoiding the swelling and bruising that will sometimes arise after local anaesthetic injections. We’d suggest you try the anaesthetic gel.

For a longer lasting reduction in upper lip lines, more extensive treatments are required. Full dermabrasion (as opposed to microdermabrasion) to the upper lip can bring about a permanent difference to your degree of “whistle lines”. In this procedure the upper lip is fully anaesthetised and then the skin of the upper lip is firmly abraded to the point of bleeding. Abrasion is focussed into the lines. The upper lip then looks very raw, and antibacterial ointments need to be applied for a week as the upper lip skin heals. During this time the treated upper lip skin cannot be covered with make-up, and so the “down-time” is genuine.

Jowls arise from gravitational effects on loose fatty tissue overlying your cheeks. Therefore, Agent B cannot help. In situations where there has been a sinking of tissue but the skin is still relatively firm, we like the effect of Aptos threads. These threads create a scaffolding under the skin to support and lift subcutaneous tissue, thereby reducing the jowl. They are straightforward to insert under local anaesthetic when the doctor has been properly trained and has carefully planned the procedure after analysing the vector forces applicable to the patient’s aesthetic needs.

If jowls have arisen and the skin is very loose, a surgical lift is required to both raise the sunken fat pads and to remove the excess skin.

Chin wrinkles. Some patients get a deep line above the point of their chin, called a “mental crease”. This can arise due to overaction of a muscle called mentalis, and so it follows that the treatment is Agent B. If the line is very deep it may be because there has been a loss of tissue volume as well, in which case a filler is applied. Fillers in combination with subcision can also be used to treat chin dimples.

Neck wrinkles, if horizontal, generally require a lifting procedure, but some people get vertical bands in the neck due to bowing of the vertically-orientated platysma muscle. These vertical folds stand out when you grimace, and they can be very easily and well treated with Agent B.

The decolletage can wrinkle from the effect of one breast folding over the other as you lie on your side asleep at night. So this is not really due to muscle action, nor tissue shifting, nor tissue shrinkage. Although there are reports of Agent S helping in this situation, our approach is to improve the elasticity and collagen levels in the decolletage skin by means of excellent cosmeceutical skin care, then augment collagen renewel by physical treatments such as Omnilux, microdermabrasion, or IPL. We’ve had our best results with IPL, with the treatment settings suitably modified to enhance dermal effects whilst minimising epidermal effects. Few IPL practitioners know how to so this: it is not in the textbooks nor in the company training, but by advanced understanding of the interactions that occur between light and skin we can get results.

In many wrinkly situations a combination of approaches works best. We hope to see you in consultation to go over these with you.