This Doctor Compares Our Collagen Bank To A Bank Account, And Shares How To Start Saving Face

The first time I heard Sylvia Ramirez speak at an Ultherapy event, she compared our skin's collagen production to a bank account. She talked about our collagen's balance sheet, how we deposit and withdraw everyday, with deposits decreasing and the withdrawal rate increasing as we age—serving the most relatable beauty (and life) lesson about how spending more than you make can take its toll. It was then that I knew I had to interview her. Ramirez's resume is beyond impressive—the Medical and Scientific Director of Cutis Medical Laser Clinics in Singapore has over 25 years of experience in aesthetic medicine, chronic disease epidemiology, nephrology and transplantation, having also been an Assistant Professor at NUS, and established a national kidney disease and diabetes prevent programme for both the adult and paediatric populations in Singapore. It is with all that, combined with her glamorous disposition and healthy skin, that makes her one of the top, trusted sources for us to discuss aesthetics with—and to answer some truly burning beauty questions.

Straight from the doctor's chair, Sylvia Ramirez talks the changing face of ageing gracefully,  highly efficient ways of "saving skin", skincare versus treatments, blue light, and the reality of "anti-ageing" in this ever-evolving world of beauty.

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Can you tell us again, how our collagen production can be compared to a bank account?

Ok, so the way I look at collagen, is that it is very similar to a bank account and our muscle stores. We have a set base. It's like working or working out daily—we gain or deposit and spend or withdraw everyday. By age 20, we're already starting to deposit 1% less collagen, while still withdrawing the same amount. This pattern continues and by 40, the withdrawal rate will be higher than your depositing rate, so you are heading to bankruptcy unless you find a way to deposit more. How to do that? Treatments that rebuild collagen. That way once your collagen production becomes more positive, but you're still breaking down, at least you've changed and restored better balance, and gradually, with more care and the right treatments, you can achieve healthier skin. Another point to note is that when we get older, women can lose 30 percent of collagen within five years of menopause—it's a striking amount. Then it's 2.5 more percent every year thereafter. So it is vital that we seek care earlier. Even if you have nothing obvious to correct, a treatment like Ultherapy will improve the quality of your skin and benefit you in the long run.

Global beauty brands have started to stop or decrease using the term "anti-ageing". How would you say that affects this side of the industry?

I look at it as a positive. When you use the term "anti-ageing", it's almost promising you can stop, promising the impossible, and therefore the expectations are very high. We can't do that. And more importantly, ageing is not necessarily a bad thing. What we want to do is optimise that process, make you the best you can be at 50, 60 and 70—not make you 30 again and have time stop at that point, because that would look unnatural.

On the topic of looking natural, can one successfully reverse skin ageing or maintain youthful skin with products alone?

There are two sides to skincare: The preventive side, like vitamin C and sun block, and the corrective side, like retin A. So when it comes to the skin's surface, skincare is great, and it is important for the prevention and correction of concerns like pigmentation and uneven texture. But ageing isn't just on the surface—a big part of ageing is caused by losing collagen and losing volume in the deeper layers of the skin. You can never completely reverse these effects with products. But at the same time, you can't also just fix things with treatments either. You need to work on both the surface and deeper layers for the best results. Like when we meeting with patients, we ask things like 'What are we going to do for the top layer? Is that an issue for you? What are we going to do for the second? Is it time to botox? And what will we do for volume?" And then I come up with a plan that's comprises the various solutions to cater to their individual issues. We also plan what's the most immediate, and when they're ready, what should come next. It's a journey.

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Blue Light is the latest addition to the list of urban aggressors, and the skincare market is all over it. How can we reverse the damage, and protect against it?

The number one source of blue light is still the sun. So we've always faced that problem, and have necessary steps in place, like applying sunblock, taking vitamin C, and wearing UV-protection layers. But then blue light is added cumulatively by our computer and phone screens. We know that blue light penetrates deeper than UVA and UVB rays, so the potential risk is more, and we know they create free radicals and cause oxidative damage. So if you're constantly infront of a screen, remember to filter—wear the right glasses, take your antioxidants, do smart things for your skin. We know the important facts of blue light but there isn't much evidence on how much it is doing, at least the damage from our screens, so it's all about preventative measures now. What we do know is that blue light has been shown to destroy the back of our eyes and lead to macular degeneration, and potentially cause blindness. So always arm yourself with sunglasses outdoors and the right protective glasses when facing screens.

Ultherapy is touted as the leading safest face lift. How does it work and what are its benefits?

Ultherapy is a type of non-invasive skin-lifting treatment using ultrasound. I'm also a kidney specialist and we use ultrasound to scan and treat medical conditions as well. Ultrasound is very powerful—it can go as deep or as shallow as want—and in ultherapy, MFUV, or micro-focused ultrasound with visualisation is used to target specific layers of the skin. With Ultherapy, micro-focused ultrasound energy is converted to heat, creating TCPs (thermocoagulation points) at a very precise temperature range of 65 to 70 degrees in the different layers of the skin, from the dermis to an important, deep layer called SMAS (superficial muscular aponeurotic system) that connects the skin to the muscle, and gives structure to the face. Ultherapy is the only treatment that reaches this deep layer, together with other desired depths and causes micro changes to help jump start the reproduction of collagen and gradually but effectively lift the skin.

What are the key benefits of this treatment throughout the development process?

Right after the treatment, I'd say a person would typically not feel much difference, because the collagen building only really starts at least three to four weeks later. The real results come after three months, after you've accumulated enough new collagen so that it lifts and firms up sagging areas of the face. These effects are cumulative, so it can keep getting better.

Is there a minimum or maximum age for this, and can you describe the difference in benefits in terms of anti-ageing for mature skin and preventive care for younger skin?

Collagen loss starts from our twenties, so even younger patients can benefit from this. We have patients in their 20s but they don't need as many TCPs or lines, and only need to do it again maybe 18-24 months later—instead of the standard 12-18 months. The results for this situation is that you'll be generating more collagen at a younger age, which can benefit your balance as you age simply because you've started depositing more earlier. What we also know is that a person looks significantly younger than a person who has never done it, when they're older. Now for older patients, we have those who come see us in their 70s, we first ask if they are open to surgery because there is only so much we can do non-invasively. But for the particular set of older patients who don't want surgery, they can do Ultherapy twice a year. But we'd recommend combining that with fillers—that way you can create significant lift. With this, we can lift, firm and correct volume loss (in places like under the eyes, nasolabial folds, jowls and jaw line) with two efficient ways.

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People say that this treatment is painful, but you also said that no one has ever reached the point of having to stop midway. What's the treatment process and pain levels like?

After a detailed consultation where we go through your medical conditions, skin issues, areas of concern, and clinical guidelines, we start the numbing process. This is done with topical numbing cream and with oral medication if needed, like Ibuprofen or Panadol. We don't inject local anaesthetic, because that can actually affect the procedure's reactivity and results. Once ready, we recommend patients find forms of distraction, like chit chatting with us or watching a movie on their phones, to take their minds off the feeling—to me, it feels like hot needles, but some people can feel less, or experience it differently. Either way, no one has walked out of a treatment because of the pain. I typically start with the most uncomfortable area first, which is around the jaw because there's hardly any fat there. If you feel more pain in a certain spot, we'll move to the next to give that a break, and I have assistants who will be massaging and vibrating your shoulders to divert the sensations you feel. We then finish with a massage with some calming cream. Depending on skin's sensitivity, most patients can leave with minimal to no redness, and any swelling over the next few days will only be noticeable by you. Including numbing time, this entire process just takes over an hour.

Can one try Ultherapy before or after getting fillers and botox?

It all depends on the time in between. So, ideally, if you're going to do it fairly close to each other, we would do Ultherapy first. We can do fillers right after on the same day if the patient is comfortable with it; the only issue is that skin will feel more tender and may bruise more, due to the heat that may have dilated the vessels. In fact, we are currently doing a study, approved by MOH, to combine Ultherapy and Radiesse, a biostimulating filler that we use in dilute form, for a combination that effectively builds new collagen for sagging skin. If you're going to do fillers before Ultherapy, however, I'd say wait for a few months, and you definitely shouldn't do botox on the same day—you should wait a few months before or after to let the area settle.

What should patients keep in mind when planning for such treatments?

Firstly, always remember to go with what makes you feel comfortable. Secondly, you should go to a clinic that does that particular treatment a lot, so you know there's a proven track record of safety and efficiency. Research the clinic, doctors and patient reviews if any, and check if all the technology and procedures are original and FDA- and MOH-approved. Aesthetics is elective but not something you should ever experiment with—you do not need to do this but you are doing this because you want to look or feel better, so be sure to opt for what is safe and proven.