Sterling Baker

Erin L. Holloman

‘Beauty is truth, truth beauty.’ Keats

This concept was studied by Keats while observing a painting on a Grecian urn. Keats further suggested that if we understand truth and beauty, we know all we need to know. As with many abstract concepts, we humans have a difficult time understanding this relationship. Truth is a concept that seems to defy definition. Yet, we seem to comprehend beauty on an intuitive basis, even though that intuition is greatly influenced by time and culture. To a major extent, we have historically and collectively equated beauty with youth. This youth portion of the equation frequently becomes the pursuit of vitality. With all of the hyperventilation we can muster, we enshrine vitality as a basic urge, if not a primal right, to live our allotted time as fully as possible. Then the beauty portion of the equation not so subtly suggests that the appearance of youth is as important – if not more so – than the possession of vitality. Keats and indeed many others remind us not to succumb to the myopic assertion that this generation and this time have somehow discovered a universal truth about beauty.

Even a cursory review of our history on the planet shows that we have long assumed appearance, which conceals chronologic progression, is a desirable goal, therefore are we now providing some new (and some not so new) methods that are mainly extensions of ancient practices? Perhaps lasers, which are arguably the newest set of our tools, are no more than sophisticated, high-tech ways to produce thermal damage to a graded depth in the relatively superficial dermis. Even if the aesthetic practitioners of ancient societies who used fire to singe the skin did not know the complexity of the target organ, they did know that they had to avoid full-thickness damage to prevent scarring. Some might contend that all modern practitioners should be so well informed.

Early efforts often were mechanical or thermal. These methods share a commonality with their modern equivalents. Energy is applied directly to the surface. Outer layers of the dermis are damaged. In a modern extension, these applications are altered to preserve the surface, usually by dynamic cooling delivered just prior to and immediately following the application of energy. Fractionated deliveries of energy leave areas of normal tissue between ‘islands’ of treated tissue to speed recovery. Rejuvenation is accomplished through regeneration of the damaged collagen in the papillary and upper reticular dermis. The efficacy of reepithelialization is a function in large part of the density of appendages in the treated area. In both of these applications, the skill of the practitioner is obvious to all. Knowledge of the territory and cultivation of a light touch can be summarized in the time-honored admonition to ‘first do no (permanent) harm’.

Since early antiquity, rejuvenating lotions and potions have been concocted from all manner of secret ingredients. Early efforts involved cytotoxic and lytic agents that produced partial-thickness damage to the dermis. Understanding the target tissue, predicting the penetration depth and knowing the neutralization process were of critical importance if scarring was to be avoided. Surely, the exaggerated claims for the many proprietary agents and practices currently being promoted remind us of Bob Dylan’s reference to his lost love in Tangled Up in Blue : ‘The past is close behind.’ If the past is indeed the recent prologue to our time, will the future be a refined version of the present? Or will it be unrecognizable?

So now we have arrived at the risky business of predicting. And, dear reader, you might be tempted to ask by what authority we represent our opinions as having value? Well, the authors of this book asked for our opinion and you acquired the book. In truth, our ability to see past our own noses is probably no better than yours. As you read this, do not take us (or yourself) too seriously! Enough already. What is out there?

Over the last two decades, we have learned that surgical wounds heal without scarring when cleft lips and palates are repaired intrauterine. The healing process occurs in an environment that lacks inflammatory cell proliferation. Histological analysis of these wounds shows increased deposition of hyaluronic acid. Perhaps, altering the wound environment with substances such as hyaluronics during surgery and postoperative recovery will decrease the presence of scarring.

Surely, somewhere in the future we will abandon the relatively gross insults to tissue that we now offer as therapeutic interventions. Patient complaints of prolonged side effects and lengthy recoveries do not now fit comfortably into our therapies and that is not likely to change in the future. Genomic studies may provide an early step in our understanding of how to arrest (or slow) the decline in peak performance as a result of the aging process by manipulating tissue to maintain maximum vitality. Understanding genetic coding could lead to ways to manipulate function at the cellular level. Or perhaps new cells will be developed from an as yet unknown source of stem cells. Given the ethical debate over embryonic stem cell use and the difficulty in obtaining those cells, an alternative source of resident cells with either inherent or inducible pluripotent potential may represent a more acceptable early effort. In fact, our initial efforts with fat autographs suggest that we may even now be at an early stage of grafting undifferentiated cells that will mature. At a more advanced cellular level, will specific specialized cells be reengineered by the insertion of new genetic information? For example, recombinant genetic technology has been utilized to ‘teach’ bacteria how to make human insulin. Early efforts to treat some forms of Leber’s congenital amaurosis, an autosomal-recessive group of blinding retinal diseases, by inserting genetic material attached to an adenoviral vector into the eye have been encouraging.

Our understanding of intercellular communication is limited. Pathways and transmitting agents are not clear. Some of the ‘cross-talk’ at the cellular level can produce effects that can be either beneficial or disastrous, depending on the tissue involved. Vascular endothelial growth factors (VEGF) have recently gained much interest, especially in the eye, because the neoangiogenesis they promote in hypoxic tissue can lead to new vessels that are not competent. In advanced cases of diabetes and macular degeneration, these new vessels tend to leak blood and serum that can obscure the visual axis, leading to irreversible damage of the retina. Anti-VEGF treatments are employed for targeted therapy in these diseases. However, VEGF has other modulating activities in vivo that can be useful in other locations. It affects a broad spectrum of neuronal and glial proliferation, cell migration, cell survival and proteolysis. Might it or other as yet unidentified modulating agents be useful in promoting rejuvenation locally at specified targets? Human growth hormone supplementation has been promoted rather vigorously as an antiaging agent. But many are concerned because of the possible pro-neoplastic potential of such activities. The goals of beauty and sustained youth seem direct enough, but what are the ‘trade-offs’? Product liability is an issue that no one can ignore. Perhaps, viral stimulation will become a way to alter intracellular activity. Production of new collagen and elastin in the dermis is less important than the amount produced. Certainly, our early insights into modulators and receptor sites place us at the brink of an exciting and as yet poorly understood internal universe that seems to offer limitless possibilities. Will the beauty industry in its exponential and escalating growth modulate or be modulated by patient’s needs and expectations in the search for the fountain of youth and vitality?

If the aging process is stopped or even reversed, what will the goal be? Who will decide what our allotted time is? Will we review the family album with succeeding generations who all are chronologically arrested at the same time in life? Who decides what are the optimal parameters for a prolonged existence? Will there be an ideal attainable by all of us? What sacrifice of individual phenotypic expression will we be willing to tolerate? A new organ (you specify which one) for someone who suffers with a failing one truly represents a medical miracle. New skin, forever youthful, may not be far behind. In his song With Every Wish Bruce Springsteen reminds us that we ‘better think first, with every wish there comes a curse’. We cannot all live forever or even for a very long time – whatever that is.