On 60Minutes recently, there was a feature showcasing the decisions of women in their 50s such as Justine Bateman of Family Ties fame and 80s supermodel Paulina Porizkova, and their decision to not have injectables and to age the way nature intends. I’ve yet to watch the whole feature, but it continues to bring up important key points, which I’ll reflect on here. When I meet women of a certain age, they usually tend to fall into one of two main camps: Young at Any Cost  This is the camp that has been having “tweakments” since a youngish age in an effort to stay ahead of the ageing curve, with enhancement as needed. Think, preventive anti wrinkle treatment because “the best wrinkle is the one you’ll never have” and lip, cheek and tear trough filler to address volume issues. Over the decades, they’ve ended up having most things, and in their 5th or 6th decade, are seriously considering surgery; “anything to stop ageing” is a comment I sometimes hear, which worries me in clinic. Social media is rife with accounts by injectors who share these ideas, showcasing examples in young faces, of “temple fillers to balance out this beautiful face due to hollowing created by cheek fillers”  Ageing as a privilege the other camp, is women who are older, and for any number of reasons, have decided that injectables are not for them for a variety of reasons they’re constantly exposed to bad work everywhere they see it as a sign of bad feminism they have daughters they want to set a good example for, by abstainin a combination of the above. What’s striking to me as an observer, is the very marked black and white thinking prevalent in these two groups, with little to no nuance to consider a middle ground. The first camp, as one may surmise, who begin at a young age, normalises the use of preventative anti ageing procedures, and over time, risk becoming overfilled or having filler migration because it becomes a habit and a means to feel good, as a pick me up, and as preparation prior to special events. Perception drift is so slow they may forget, over time, what they used to look like.  Given how heavily advertised medical aesthetics is to the public at large, who remains largely unaware of the rare but real risks, it’s easy to see how packages, specials and 0.5ml here and a few top-up units there can add up over time- to a lot of money, and possibly an overfilled, frozen or unattractive look which is often when I first meet them. The second camp, is one I rarely meet, but occasionally they see me for help with ageing  limited to a very narrow range of skincare options they may be open to - they may wish to minimise signs of ageing by focusing on beautiful skin, help with their adult onset acne, or be open to skin therapies without injectables.  They, or their spouses are bombarded daily, with overdone faces and in their minds, this is what ALL medical aesthetics looks like - bad - so they don’t want anything to do with it. Alternatively, they may have seen on social media frequent posts about “botched treatments” and even rare but real complications and decided the risk is not worth it. In these cases, I help with their concerns, without trying to influence their aversion to injectables unless asked for my opinion. Sometimes, over months of working together and with trust, they may reopen the door and ask again, but often they won’t.  So who chooses the middle ground and what does that look like?  The middle ground group is my ideal patient.  I came to medical aesthetics reluctantly in 2015/2016, largely due to my background in surgical work and procedural work which I didn’t get enough of as a Specialist GP. I had, and continue to have, reservations around the unregulated industry, the lack of ethics and the lure of easy money by untrained injectors who work unsupervised after a 2-day or 2-week boot camp with minimal procedural skills.  Equally, I identify with the desire to not look “done”, “fake” and more. It’s a topic that I continue to grapple with and for many years I struggled with the ethical issues I saw lacking in this industry.  As to my own aesthetic journey, all I did was practice rigorous sun avoidance until  my early 40s, when I noticed that despite my best effort, Oil of Olay SPF and Dove soap were no longer cutting it.  At the age of 42 I added active skincare to the mix.  The year I turned 45, I added a sprinkle of anti wrinkle, initially to avoid wasting a vial that needed to be discarded and loved the subtle but effective results.  Since then, I’ve had judicious use of non surgical and minimally invasive treatments to help me continue to like what i see in the mirror. My face is my brand, and many patients who choose to see me tell me my face, the fact that it moves, isn’t frozen and looks natural, is among the reasons they chose to see me despite their fears.  For these patients, when it comes time to meeting me, usually after a period of anywhere from 6-18 months of lurking and following my posts on Instagram, their motivation for doing so is different from the two camps above - they’ve seen firsthand evidence of the middle ground that I refer to as “ageing well” with a heavy focus on caring for the skin first and foremost, with judicious use of injectables - anti wrinkle treatment AND fillers - and then maintained by collagen stimulating therapies. The results for those who stay the course, have been nothing short of stupendous and life affirming, which is ultimately what matters especially as most of them, like me, aren’t open to surgery (yet).  So where do I stand on this issue?  I respect every woman’s

The most seasoned business owners know firsthand that in order to succeed, you have to be willing to fail, sometimes many times over. Each time this happens, you pick yourself up and keep moving, learning from what worked, and what did not. Why do this to ourselves? While it seems like an exercise in self flagellation, the key is in the mindset it teaches you. I’ve learnt far more from my failures than I ever have by cruising and through success, even if none of us actively chases failure. In many ways, failure teaches us what we are truly made of, and teaches us grit and resilience. So why is this relevant in 2023 to Skin Essentials? In 2023 I am bringing about changes to the way I do business and I’m terrified if I am honest. Terrified because it’s raw, honest and comes from a place of wanting good for my patients, my staff and myself. Terrified because honesty, no matter how kind, can always be taken the wrong way when people receiving it feel defensive. Terrified because there’s always the fear that in making the changes, I will lose business and my business will tank and…and…and… I’ve done a lot of hard things in my life, as we all have; and one of the things I love about myself is my innate optimism, my ‘glass half full” approach to things especially when they are hard, and the immense privilege I have of having an education in a field where, even if Skin Essential does tank and I do close, I’ll have other options. So what are the changes and why? I entered medical aesthetics reluctantly in 2015/2016. I really didn’t want to do it because of all the fake faces I saw around me. It seemed fake, vapid and entirely unnecessary. At the same time, I was beginning to see early signs of ageing in my own face and a visit or two to the local chain clinic for skin needling left me with disastrous and painful results. I was stumped for next steps based on evidence rather than hype and fads. So I began to look into it, initially for myself, then as my knowledge increased I met patients and friends who wanted someone reputable, who would do good work, give them results and a longterm plan for ageing well. Like me, they were mostly women who had tried many things and had little success, and occasionally bad outcomes and they wanted someone they trusted to do the planning for them, so they could just show up, and get the work done and be told what to do. These are my best longterm patients, who come in when told to, get on the chair and say “whatever you think best doc!”. They trust me, trust the process, are realistic about what is achievable including over what period of time; they are patient, they remain calm with common side effects such as bruising, swelling, lumps and bumps and they show up. These are, quite simply, my ideal patients. Price is important, but not the most important factor, and as long as they know what they need to save in time for the next appointment, they plan appropriately. In 2023, I am moving away from a lot of the interactions that I found draining in 2022 with patients who, quite simply, were not aligned with me and the way I work, in part as I was not clear enough about it. So what are some examples of patients for whom I am unlikely to be the right doctor?  1. They are not looking for a longterm plan to help them age well.  Full face rejuvenation is my signature treatment and the one that gives me the greatest joy and the best results for my patients.  I am really not a fan of just some anti wrinkle to one area and  lip/ cheek filler as and when a patient feels they need more and orders some. It is not how I work. I look at the whole face as pieces of a jigsaw puzzle - as the ageing process begins to take hold, pieces of the puzzle go missing, and it takes more than just 1-2 mls of filler or some anti wrinkle treatment initially, to begin to correct this. For those patients who start at a good time, as early as their 20s and early 30s, it’s true that initially there’s not much to do beyond a focus on the basics including excellent, personalised skincare but having a comprehensive plan allows us to stay on top of it and to plan for what is likely to come and to prepare for it. These patients may need either occasional enhancement eg lip filler or maintenance by way of some anti wrinkle treatment to target early lines and wrinkles, some undereye correction and any other early signs of ageing. Costs are usually around $3000 a year or thereabouts depending on where you start and what’s needed. The older patient, as early as mid 30s and up, needs far more work if nothing has been done until then. This is the work I refer to as restorative. Many pieces of the jigsaw puzzle are missing and there are changes under the skin that need to be looked at. For these patients, the work involved at the beginning is more extensive over several months, usually in stages to get to maintenance and involves skin improvement as well as injectables and possibly permanent fat dissolving. Costs are typically $6000-10000 during this period depending on what is needed then maintenance is closer to $3000 a year or thereabouts. I won’t do just tear trough filler when what you need is mid face support to your temples and cheeks also. I won’t do just lip filler if you also need support around the mouth and to the chin to avoid a Marge Simpson lip. I won’t do just some anti wrinkle so your forehead and upper

There is a recent trend of famous actresses and models embracing ageing and encouraging other women to do likewise. It is refreshing, certainly far more so than the famous women of similar vintage claiming all they use is olive oil. We now have some famous and beautiful faces that are showing us firsthand what ageing in our 40s and 50s can look like, if we simply allow nature to take its course: Paulina PorizkovaSarah Jessica Parker to name a few. It is certainly brave of these women and others like them to do so, especially in an industry where looks are seemingly everything. At Skin Essentials we don’t believe in defying ageing, or helping patients look like mutton dressed as lamb, rather we recognise that ageing is a disease, a decline in our bodies and our skin, that over time, for many of us, can also affect our self esteem, our morale and especially if we are working, how others see us. For us, the aim and goal is always a holistic approach to ageing well, whatever that may look like for each individual, man and woman, though our society disproportionately places a heavier emphasis on women than on men to look ageless forever. With that in mind, I though I’d do a case study on some famous faces and their aging process in their 50s, which is the decade of peak decline for most women, if nothing is presumably done. Caveat - as actresses and models, each of these women had stunning bone structure in her youth to begin with, which offsets a lot of the signs of ageing in our 40s and 50s - high cheekbones, strong chin and jawline, when most of us begin to notice sagging and jowling as early as our late 30s if our lower face is not strong and well defined. Sarah Jessica Parker 56       At 56 the actress is openly and freely embracing the ageing process and good on her!  Note - she has a strong side profile to begin with and being always slim, she never really developed any significant jowling, except where the skin has sagged due to 3 factors:  - bony loss - around mouth, including chin and angle of jaw; around orbits of the eyes - fat pad loss and movement downwards  - ligament laxity due to loss of support  - hooding of her eyes in part due to bony loss around the eye sockets but I also suspect, due to drooping eyelid skin  Many of these are amenable to tweaks not to hide the fact she is 56 but to help her appear less tired and grumpy, what I refer to as “negative signs”. The signs in an ageing face that elicits unwanted comments about looking tired, sad, angry and may lead others to see us as being untrustworthy.  Paulina Porizkova 54  A supermodel with impeccable bone structure as evident in her youth, the perfect heart shaped face, she continues to wear it well into her 50s, with only noticeable changes due to her bone structure. Paulina is another one ageing naturally and she does it well!  In fact, barring anti wrinkle treatment, and skin therapies (which she takes up consistently to improve skin structure and quality) her bone structure will likely continue to carry her for years to come with minimal drooping even around the eyes and lower face.  My main issue when women in their 40s and 50s urge others to embrace ageing is this:  - it is admirable that they do so and encourage us mere mortals to accept ourselves as we are - it is equally telling that these are often individuals who, by virtue of their career choices, are usually in the top 1% in terms of looks and have at their disposal, immeasurable amounts of money and staff as well as genetic advantage that the rest of us simply do not have.  - just as telling, many of these supermodels and actresses have made more money in their youth than most of us will see in our lifetime, such that they can afford to retire far earlier than we would. For those of us who continue to work till 65 or later, especially if in customer facing roles, we still have to look well enough that we don’t solicit unwanted comments or pity because we look “like you should be retired”, a comment made to one of my patients in her 60s.  Ultimately what anyone does or does not choose to do, we ought to be supportive and if we cannot, simply go past. As a doctor, like all doctors, I see and hear firsthand the impact careless comments have on someone’s self esteem and psyche, and the very real fears some have around their careers in their 40s and 50s when competing against younger fresher faces.  I advocate for looking your best at every age and stage, rather than looking like the latest face or trend of the day.  Just as we advocate for exercising regularly to keep your heart strong, and keeping your brain young through exercising it with mental activities, learning a new language and more, so it is with our skin and faces if we want to invest for years to come - we must make the time, effort and budget to enable us to indulge in our faces and our skin that will allow us to like what we see in the mirror for years to come.     

If you've followed the series from your 20s through to now, you know the basics:  sun protection is the holy grail to ageing well  good longterm lifestyle habits are key - eating mostly well, limiting alcohol, not smoking (or quitting) and exercising regularly are all good habits to implement sooner than later  obtaining personalised medical guidance for your skin is just as important as obtaining advice on other aspects of your health as is prioritising preventive care such as regular skin checks. Prevention is not sexy, or heroic, but it is the best bang for your buck longterm and far easier than undoing damage.  In saying all that, it is never too late to begin exactly where you are, as long as you are mindful that the longer you leave it, the harder it is to reverse some of the changes, the more expensive and healing may be impeded from minimally invasive surgery due to thinner more fragile skin.  Our life expectancy is now well into our 80s in countries like Australia, and many if not most of us, will work till 70 or beyond if we hope to maintain a similar standard of living post retirement.  Focusing on judicious medical aesthetics is then not only about vanity but about continuing to look our best at every age and stage, to look functional and competent to our colleagues and if we are in a service role, to our clients and patients, as well as informing our sense of self and healthy self esteem.  The desire to continue to like what we see and to feel good about ourself goes far beyond mere vanity for most of us, and at Skin Essentials we take a holistic view of this, with a roadmap drawn up especially for you, over time - weeks, months and years to come to help you age well. In return we ask for your commitment, consistency and your budgeting to allow you to follow recommended treatment plans. Without this investment, we cannot attain success.  The fact remains, however that in our 60s, no matter how diligent we were in the earlier decades, there will be inevitable changes in our skin over our entire body but treatment and care in the earlier decades can influence how much the ageing process shows up on your face and body.  Volume loss continues to be the biggest issue as we age in this decade:  there is loss of fat pads and their migration south in the face as well as bony loss around the mouth such that skin can seem to hang off a frame there is loss of skin elasticity, giving rise to fine lines and wrinkles and crepeyness in skin - around the eyes, around the mouth, and on limbs.  continued collagen loss also means that skin lacks the usual plumpness and glow of youth. In the 5 years immediately post menopause, there is as much as 30% collagen loss, and thereafter 2% per year instead of the previous 1% per year from our 20s.  So what can we do in our 60s, if we are still active and our outside seems a mismatch to our inside?  1. Surgery  As always, beyond an age, I usually raise the idea of a face and neck lift with patients in this age group and their willingness to consider it. Will their budget and lifestyle allow for it? If so, it may be a feasible option and I can help refer to a plastic surgeon.  2. Minimally Invasive Fat Loss and Skin Tightening  For many people, surgery may not be an option or a path they wish to go down. Minimally invasive fat loss and skin tightening procedures may then be a suitable alternative as discussed also in the 50s age group.  3. Volume Replacement  It is important for patients to recognise that surgery along will not replace volume loss in the face - specifically, in the temples, around the forehead, in the cheeks and more. Even if they opt for surgery, to reposition ligaments and muscles and to remove excess skin, they will also need volume replacement for best results, otherwise they risk looking windblown, as the old face and necklift cases of the past often show. Some may opt to have the surgery first and then return to us for volume replacement via dermal fillers, skin therapies that replenish collagen, or both.  4. Ablative Laser Resurfacing  With deeply etched lines and wrinkles due to sun damage, this may be a sound choice and option for patients. There is usually downtime of 7-10 days and is a treatment undertaken in clinic if you are a suitable candidate.  5. Medium Depth Chemical Peels  Medium depth peels are another way to resurface superficial skin layers and reveal fresher less lined skin underneath. They can be used on the face, neck and decollete as well as hands, depending on the concern and like lasers, have an associated downtime of several days.  6. Focus on other areas - hands, neck, decollete  For many patients who start at a younger age, the 50s and 60s can often be a time to shift focus from the face to the other exposed areas of our body that can age us - our hands, our neck and decollete.  They are all subject to sun exposure and ageing. Hardworking areas such as our hands may look thin, heavily veined and far older than our chronological age depending on how much work we do with our hands, while the neck has thinner skin and not a lot of fat, which is progressively lost with age, such that from our 40s onward, it can begin to age quite rapidly without a commitment to improvement.  As always, at Skin Essentials our aim and goal is a longterm holistic relationship with you, personalised for you and your specific concerns with a focus on honest, ethical beauty. Ready to start a conversation?