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  • Genetic and environmental factors impact the development, extent, and unique patterns of skin laxity in aging.

  • The facelift is a longstanding treatment for correcting sagging skin, but recently patients are choosing less invasive approaches.

  • Currently, patients can choose invasive or less invasive tissue laxity treatments including utilization of lasers and light sources, radiofrequency energy, focused ultrasound, laser-assisted lipolysis, or a combination of approaches.

  • Nonablative lasers are a widespread therapy for skin laxity, noted for their relative safety in skin of color patients and for a shorter recovery period.

  • Infrared light techniques are a less painful treatment option, whereas radiofrequency modalities are the mainstay of skin laxity therapy with long-proven results.

  • Focused ultrasound and laser lipolysis are newer modalities that have demonstrated greater efficacy than lasers and light source treatments.

  • Most patients require a combination of treatments and modalities to achieve desired results.

  • Larger, controlled trials are necessary to achieve an objective comparison of various tissue-tightening treatments, especially with regard to the use of these modalities in people with skin of color.

Tissue laxity is one of the most recognizable signs of aging. Both genetic and environmental factors contribute to the morphologic appearance of aged skin. Extrinsic aging, caused by external factors, results from a cumulative exposure to ultraviolet light and is manifested by signs of photodamage such as dyspigmentation, roughness, and keratosis.1,2 Intrinsic aging, which is tied to internal factors, is linked with an individual’s unique biological makeup and is largely genetically predetermined. Due to the photoprotective effect of epidermal melanin, aging in skin of color is considered to be more heavily influenced by intrinsic, rather than extrinsic, factors.3 Therefore, both one’s gender and genetic makeup have a defining impact on the progression, degree, and distinct pattern of skin laxity in aging.

The sagging of facial skin was compared between Japanese men and women in a study by Ezure et al.4 Although both males and females were found to have similar age-related decreases in tissue elasticity in the mid-face, men, when compared with women, were noted to have an increased laxity in the lower eyelid area.4

The connection between pigmented and fair complexions and the rate and presentation of facial aging has been well studied. Thong et al5 demonstrated that melanosomes in keratinocytes differ in both size and distribution among African Americans, Asians, and Caucasians. Using electron microscopy, they found that the melanosomes of lighter skin types are smaller and clustered, whereas the melanosomes in those with darker skin of color are larger and more widely dispersed.5 The distribution and size of the melanosomes in darker skin of color, grossly noted as pigment, confer a protection against exposure to ultraviolet light, which would otherwise promote an aged look.

Although the presence or lack of epidermal melanin is central to the differential phenotype of aged skin, recent research has begun ...

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