The mid-face flattens with age as fat pads shrink and descend and as bone recedes. The temples hollow, the under-eye develops a trough, and the lips thin.
None of this is a skin-quality problem. No amount of resurfacing restores volume that is no longer there, and a medium peel over a hollow cheek produces a smoother hollow cheek.
The category for lost volume is the filler, an injected gel, most often a hyaluronic acid, placed to replace or support what has gone. Again, a separate subject with separate rules.
The diagnostic question is simple: is the concern a shadow or a surface? Shadows are volume, and surfaces are skin.
Folds and laxity
The nasolabial fold, the marionette line, the jowl and the loose neck are structural. They arise from descent of the soft tissue, loss of support and stretching of the ligaments and skin envelope over years.
Resurfacing tightens the skin a little, and repeated needling can improve its firmness somewhat. "A little" and "somewhat" are the operative words.
A fold that casts a shadow is a fold that resurfacing will not remove. Options in this category range from fillers placed to support the fold, through threads and energy devices that aim to tighten, to the surgical lift that repositions tissue outright.
Each is a larger conversation than this one. The reader's task here is only to recognise the fold as structural and take it to the right conversation.
Pigment that sits deep
Resurfacing is good at epidermal pigment, which comes off with the epidermis. It is unreliable at dermal pigment, which does not.
Some melasma has a dermal component. That is one reason melasma responds inconsistently and sometimes worsens with peels and needling.
Certain birthmarks, some drug-induced pigmentation and post-inflammatory pigment that has dropped into the dermis fall into the same category.
A practitioner who examines the pigment with a Wood's lamp or a dermatoscope before proposing a peel is checking exactly this. It is a good sign when they do.
Scars with structure
Rolling and boxcar acne scars, which are depressions, respond to microneedling and to medium peels. Ice-pick scars, narrow and deep, respond poorly to both because the needles and the acid cannot follow them down.
Tethered scars, held in place by fibrous bands beneath, need those bands released before any surface treatment will lift them. Hypertrophic and keloid scars, which are raised, are a different problem entirely and are made worse by careless resurfacing.
"Acne scars" is a category on a price list. On a face it is four or five different problems, and only some of them belong to the needle.
What PRP in particular will not do
PRP attracts the largest claims in this field, and they deserve the most scepticism. The trial evidence supports a modest incremental benefit when PRP is added to microneedling for acne scarring, and a modest effect on hair loss.
It does not support claims that PRP "regenerates" facial skin in any sense beyond what the underlying needling does. It does not support claims of lifting or volume restoration.
Nor does it support use as a stand-alone rejuvenation treatment on the strength of anything more than small and inconsistent trials. The PRP evidence guide sets out what is established.
A reader who is offered PRP for a fold, a hollow or a muscle line is being offered a surface treatment for a structural problem. The surface treatment's weakest evidence comes attached.
The honest diagnostic
Stand in front of a mirror in daylight and do three things. First, make your usual expressions and watch which lines appear or deepen: those are muscle lines.
Second, relax the face and look for shadows under the eyes, at the temples, beside the mouth: those are volume. Third, tilt the head down and watch what falls forward at the jaw and neck: that is laxity.
Whatever remains, the texture, the spots, the fine surface crepe and the shallow scars, is the skin. The skin is what resurfacing treats.
A consultation that starts with this kind of sorting is a consultation with someone who is diagnosing. One that starts with the treatment is a sales meeting.
For day to day decisions, the next point is the one that saves money. A clinic that offers only resurfacing will find resurfacing indications in every face that walks in.
The local angle
Los Angeles has no shortage of clinics offering the whole range, and the density along particular corridors is a business story as much as a medical one. Parents comparing clinics near Long Beach sometimes ask us about the school-holiday windows for recovery.
The Long Beach Unified term calendar answers that better than we can. A medium peel and a school run do not mix in the same week.
The same families ask for a dim indoor day while the peel settles. Anywhere with low light and cool air qualifies; the shore itself does not.
The Aquarium of the Pacific a few blocks from the shore is the standing recommendation for that day. Go on a weekday, when the halls are quiet.
Further up the coast, readers in the South Bay ask the same question and get the same kind of answer. Small, cool and uncrowded is the brief.
The Cabrillo Marine Aquarium in San Pedro does that job for the South Bay. It is small enough to see in an hour and shaded enough to wait out the afternoon.
Downtown has its own version, for readers who would rather be indoors among buildings than beside a tank. Lobbies and interiors beat streets, and the afternoon light off glass is the thing to avoid.
The building tours run by the LA Conservancy remain the best way to spend a shaded afternoon downtown without a beach in sight. Bring a hat for the crossings.
In brief
Resurfacing treats the skin. It does not treat the muscle under it, the fat beneath that, or the ligaments holding the whole arrangement up.
Sort your concerns into those four bins before you sit in a chair, and take each bin to the practitioner equipped for it.
The practical caveat is that the sorting must be done by someone who can treat more than one bin. A hammer sees nails.
A frown line, for instance, will not respond to any peel, so the clinic worth asking is one that treats both the line and the skin around it.
Ask that question directly. Judge the clinic by whether the answer refers to your face or to its menu.
