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These shots show the changes in a 48-year-old woman's face after she received a facelift, browlift, eyelid surgery and laser skin resurfacing from Dr. Abdullah. (Special to The Forum)

Putting your best face forward: What ages us, and what we can do about it

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Sad-looking. Sinking. Sagging. Spots.

Those are some of the most common complaints patients have about their appearance when they come to see Dr. Susan Mathison.

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"They'll come in and say their skin is tired and dull. They want to get that glow back," says Mathison, who specializes in ear, nose and throat, head/neck surgery and facial plastic surgery at Catalyst Medical Center, Fargo. She is also a SheSays columnist.

Dermatologists and plastic surgeons also hear statements like, "People say I look mad when I'm not," "I look tired," or "My eyes look hollow."

All are code for aging skin.

We asked local experts - Mathison, Dr. Ahmed Abdullah of the Plastic Surgery Institute in Fargo, and Dr. Rick Becker of Becker Plastic Surgery in Bismarck - to identify the most common signs of facial aging.

The doctors were also asked for solutions, ranging from less-expensive options to more-invasive surgical procedures.

Here's what they had to say.

A skin-deep issue

Sometimes, beauty really is skin deep.

Early signs of aging show up in the top layers of skin in the form of fine wrinkles, dullness, rough texture, increased pore size, spider veins or acne.

Some of these developments stem from genetics or hormones. Others are triggered by lifestyle factors like sun exposure, smoking and diet.

Either way, our skin's ability to rejuvenate new cells slows as we grow older. As a result, we develop a thick layer of dead-skin cells and debris, also called keratin, on our top layer of skin. In response, the dermis underneath, which gives our skin strength and flexibility, grows thinner, Abdullah says.

Our skin also will produce less collagen and elastin - the proteins which keep our skin firm, flexible and young-looking.

Here are a few common surface problems, and their treatments:

'Sad' skin: Many patients complain that their skin looks dull, rough and uneven - the results of decreased cell renewal and less collagen. Mathison will talk to them about nutrition, stress-reduction and sleep habits, which all can put a damper on a healthy complexion. She may also recommend skin-friendly supplements like Omega 3 fatty acids.

"A lot of people are choosing less drastic things to start off with," Mathison says. "It's nice to have the more moderate options."

The key to rejuvenating skin is exfoliation, Abdullah says. Exfoliation not only sloughs away the stubborn layer of dead skin cells, it stimulates the body to produce more collagen and elastin.

Effective exfoliants include microdermabrasion, a mechanical treatment which uses fine crystals to help the body get rid of dead skin.

Chemical options include peels, which use acid-based agents to dissolve away the keratin, or dead skin cells.

Mathison sometimes prescribes Retin-A, a vitamin A derivative that induces a light chemical peel and ramps up new collagen production.

Other options are the newer, gentler, non-ablative lasers, which trigger the body's wound-healing response and subsequent collagen production without burning the skin's surface.

One approach that won't work is a collagen-enriched cream, Abdullah says. "The only collagen that's good for you is your own collagen."

The Fargo doctor has developed an over-the-counter skin cream which he says triggers collagen production in a less damaging way. Abdullah's AloeGlyC contains glycolic acid, which helps the skin shed dead cells, absorb moisture and produce more collagen. But Abdullah says the cream won't cause the burning, redness and inflammation caused by some of the stronger prescription products.

Age spots: Extreme exposure to heat and cold as well as changing hormone levels can cause pigmentation cells to migrate to the outer skin layer, according to the consumer information site, yourplasticsurgeryguide.com. These cells may then be trapped, appearing as discoloration or brown spots on the skin's surface.

Spots that are red can be caused by rosacea or sun damage, Mathison says.

Mathison often treats those discolored patches with hydroquinone, a skin lightener; Retin-A; chemical peels; and broad-band lasers like Photofacial, which penetrates the skin with an intense pulsed light to cause the body to produce new collagen and connective tissue.

Spider veins occur when tiny capillaries right under the skin become inflamed, Abdullah says. They usually occur because the underlying dermis is unhealthy and collagen production is down. Treatments like laser therapy, which uses light to destroy the tiny blood vessels, work well.

Fine wrinkles. The same spectrum of treatments - lasers, microdermabrasion and Retin-A - can reduce the appearance of fine wrinkles. Another solution is Botox, which essentially paralyzes the muscle beneath a wrinkle and stops it from contracting. It generally lasts anywhere from three to six months.

"It's such a wonderful add-in, and the risks are so low," says Becker, adding that the substance - a highly purified preparation of botulinum toxin A - works well for forehead lines, nasolabial folds and crow's feet.

Turn up the volume

As we grow older, our faces starts to lose the plumpness and volume of youth.

"We lose fat in our faces. We get hollow cheeks. We lose bone actually, too," Mathison says.

To combat this, doctors may inject different types of fillers made of hyaluronic acid, a substance that is naturally present in the human body. Sometimes used to treat osteoarthritis, hyaluronic acid works by acting as a cushion in our joints and other tissues, according to WebMD.

There are different types of hyaluronic acid-based fillers out there - including Restylane, Purlene and Juviderm. All are formulated with different particle sizes so they can be used for different applications, says Becker.

"The downside is that it only lasts six months to a year, so it's temporary," Becker says.

Another filler, Radiesse, is made of calcium hydroxylapatite, and can last up to two years. It works well for wrinkles around the mouth, nasolabial folds, marionette lines (creases extending from corners of mouth to chin), and deep chin creases.

Yet another tool in the re-plumping arsenal is Sculptra, which stimulates the body's own collagen to re-sculpt the face, Mathison says.

Initially approved by the FDA for facial wasting in people with HIV, the filler has now been OK'd to treat deep smile lines and other facial wrinkles.

Fillers can yield great results, although they don't work as well on older patients with deeper wrinkles, Abdullah says.

They also are expensive - costing as much as $700 per cubic centimeter, he adds.

For that reason, he sometimes opts to do fat transfers, which involve suctioning fat out of areas where there's plenty of fat, cleaning and processing it and then re-injecting it into the face to correct dermal depressions.

The procedure takes several treatments and yields cumulative results.

Fat transfers used to be less effective because doctors didn't completely understand the physiology of it, Abdullah says.

Now the fat is treated more gently so that the stem cells are preserved, meaning better, longer-lasting results.

"Now when we put fat in, we get at least half to 70 percent of the fat which survives," Abdullah says.

Sag but true

At some point, even Heidi Klum will lose her battle with gravity.

First, our brows and lower eyelids begin to drop. Then we develop turkey necks and drooping jowls.

Years ago, the only solution was a full facelift.

"We used to do these big facelifts," Abdullah says. "You saw these results like Joan Rivers or Kenny Rogers. We were trying to tighten things to make it look tight, not really younger, and we were getting these weird-looking results."

Nowadays, there are many types of facelifts, including short scar, endoscopic and thread lifts (the latter involves looping barbed threads under facial tissue to lift sagging skin).

Overall, today's surgical procedures yield smaller scars, shorter recovery times and more natural results. They also are paired with other procedures, like fat transfer or a brow lift, to yield a more youthful visage.

"My goal when I do facelift now is to have someone say, 'You look great, you look rested. What did you do to your hair?' " Abdullah says.

Becker says he still prefers full facelifts for older people who have a lot of sagging skin in the jaw and neck area. Problems like "the turkey warbler can never be improved with anything but surgery," he says.

The price of beauty

Here are some national averages of plastic surgeon fees in 2010, courtesy of the American Society of Plastic Surgeons:

Facelift: $6,231

Forehead lift: $3,161

Botox injection: $375

Chemical peel: $706

IPL laser treatment: $470

Laser skin resurfacing (ablative): $1,156

Microdermabrasion: $146

Poly-L-Lactic acid (Sculptra): $940

Calcium hydroxylapatite (Radiesse): $650

Hyaluronic acid: $547

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