The Four Horsemen

The Four Horsemen

The face ages in four different ways and when lecturing I commonly refer to these as the Four Horsemen of the Apocalypse. This Biblical reference is somewhat melodramatic, but it leads into a discussion of what can be done to stop your face from reaching its “End of Days”.

Firstly, and particularly so in our sun-drenched part of the world, the face manifests ageing in skin changes. These run from discolourations which may be brown or red, through to wrinkling and fine lines, coarseness of the top layer of the skin, thinning of the deep layer of the skin and all the way through to the development of skin cancer.

Twin studies have demonstrated very clearly that the twin in the colder climate shows less signs of skin ageing than the sibling who lived in a sub-tropical or tropical environment.

The cornerstone of improving these changes is, of course, prevention. One gets approximately half the sun exposure of an entire lifetime by the age of 15 years. Therefore, being a nagging parent and doing your very best to prevent young skin from being overexposed to the sun is a seemingly thankless task that is, in fact, well worthwhile. Sun protective clothing, sun block and sensible timing of sun exposure all contribute to this.

Skin care however has advanced a lot in the last 20 years. Modern skin care employs multiple active ingredients to stimulate cells in the skin to replenish the collagen that is depleted from sun exposure. These agents can also improve the discolourations of the skin and improve the coarseness of the skin and the fine lines, and topical antioxidants provide further UV protection that doesn’t wash off.

Light based modalities such as laser and intense pulse light have an important role to play in further rejuvenating the skin. Again they deal well with discolourations and laser resurfacing is effective in improving lines.

The “Second Horseman” refers to the lines that develop on the face as a result of repeated expression. Frown lines, crow’s feet, smile lines, the horizontal lines on the forehead – these are all the result of chronic activity of muscle groups related to facial expressions.

While we don’t want to create an inert, expressionless face, many people create these strong expressions without being aware of it and the expression persists long after the emotion has past. Judicious use of injectables can help to soften and reverse these lines without removing the capacity for facial expression.

The treatment is temporary and has to be repeated, but it is a rapid, predictable and effective modality that has almost no down time or morbidity.

The “Third Horseman” refers to atrophy – the loss of volume of the face that occurs with ageing. Plump luscious lips become a thin line, full round cheeks develop hollows and depressions, the jaw line loses its strong distinct shape as the soft tissues of the face and even the bones shrink in size as we age.

This area has been revolutionised by the advent of modern soft tissue injections. The preparations are safe, reversible, and predictable and a meaningful duration to the correction can be obtained. Modern techniques with fillers can produce quite a remarkable rejuvenation to the face with minimal down time or morbidity.

Duration of the correction can vary from six months to two years depending upon the type of product that is used and the part of the face treated.

A surgical option also exists here. Fat grafting has been around for many decades but was really revolutionised as a science in the late 80s by Dr Sydney Coleman from New York. He refined and standardised the treatment of fat grafting helping to produce more predictable results and demonstrated that there was a multi-factorial correction obtained to the face.

While these initial improvements were observed, the causation was not entirely clear. It has since, however become clear that fat is a very rich source of stem cells and although the actual mechanism is not yet completely understood, it seems likely that they, along with the re-volumising effect of the fat, have this rejuvenating effect on the face that can be quite remarkable.

Fat, however, requires an operation, albeit not a very large one. With this comes more discomfort and morbidity although again these are relatively minimal, apart from swelling.

Re-volumising the face is not the entire answer. The “Fourth Horseman” is the sag that one sees as a result of facial ageing. This is most likely to affect the brow, the upper lids and the face and neck. Surgical correction is the treatment of choice here and this can entail eye lid surgery, brow, face and neck lift as determined by the signs of ageing in the individual’s face.

It is the individualisation of treatment of ageing that is bringing forth the more natural and profound improvements that we see these days. By using combinations of treatments we are able to specifically target these Four Horsemen and turn the clock back much more naturally and effectively then previous generations of plastic surgeons were able to do. We all remember the too tight face lift and the eye lids that are too tight to close. Hopefully these days we have seen the last of those and we are using surgical lifting of tissues where appropriate and combining it with fat grafting and laser resurfacing to further enhance the overall result.

Naturally, surgery carries with it the most down time of these options. Even simple eyelid surgery can result in bruising which can hang around for more than a week.

Many of the modern techniques are designed to minimise the bruising and swelling. However, accepting that at least in some people a significant amount will occur, one often attempts to do a rejuvenation using multiple modalities in one session. This combination of eyelid surgery, lifting of brow, face and neck, fat grafting and limited laser resurfacing can be done in one operation with a single night in hospital. Sutures are usually out by a week and generally one’s appearance is quite presentable by 10 to 14 days.

The emphasis these days is on as natural an appearance as possible, avoiding at all costs the overdone look by tailoring the procedure to match the specific ways in which the face ages. Make sure you get a careful assessment and good advice and get a jump start on the “Four Horsemen”, whatever your stage in life.

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