The term "photoaging" describes the progressive structural and functional alterations in skin tissue that are primarily attributed to chronic exposure to ultraviolet radiation, especially ultraviolet A and ultraviolet B radiation [1]. While intrinsic aging is a natural process with progression over time and triggered by genetic and lifestyle factors, photoaging is an external factor that can cause the skin to appear older than it really is and can cause changes that may be more noticeable in areas of the skin exposed to sunlight. Common clinical symptoms consist of fine and coarse wrinkles, dyspigmentation, telangiectasia, rough skin texture, laxity, loss of elasticity and uneven skin tone [2,3]. The face is the most frequent area of concern because of its constant exposure and cosmetic value, and these changes may occur on the face, neck, upper chest, forearms and hands. The mechanism of photoaging is multifactorial and includes oxidative stress, collagen breakdown, abnormal deposition of elastin, disruption of the dermal extracellular matrix and changes in melanocyte function [4]. Exposure to the sun and other UV sources leads to an increase of production of Reactive Oxygen Species (ROS) and the activation of Matrix Metalloproteinases, which cause the degradation of collagen and other structural proteins in the dermis [5]. Over time, these changes cause skin to become less firm and elastic and can create wrinkles and a drooping skin. Further, chronic photodamage may also cause irregularities in the epidermis and pigmentary alterations, which can also occur alongside deeper changes, such as laxity and soft-tissue support loss in the face [6].

Thus, the evaluation of photoaging is an integral part of both dermatologic and cosmetic surgery. In a detailed assessment, there is a breakdown of wrinkling, pigmentation, vascular change, textural irregularity, skin laxity and distribution of sun damage [7]. The severity of photodamage can be documented using clinical grading system, standardized photography, dermoscopic evaluation and patient-reported concerns to set the goals of treatment. Accurate assessment is especially important since patients frequently exhibit a combination of superficial skin changes and deeper skin structural changes secondary to age and many treatments cannot effectively treat all of these changes [8]. The typical goals of dermatologic treatment of photoaging are to correct abnormalities in the superficial and epidermal dermis. There are topical retinoids, chemical peels, laser and light therapies, resurfacing, microneedling and other energy-based treatments available. The treatments can help to improve the texture and quality of the skin, as well as fine wrinkles and pigmentation. In patients with excessive skin redundancy, deep folds, jowling or advanced facial laxity, however, a structural correction may be required, and their effectiveness may be limited in these cases [9,10].

Plastic surgery procedures are important complementary procedures in such patients. Other surgical procedures, like blepharoplasty (eyelift), blepharo-brow lift, facelift, neck lift, fat grafting and other rejuvenation surgery can help address tissue descent and restore facial contours which dermatologic therapy alone may not be sufficient. However, surgery primarily corrects deeper anatomical changes and might not be enough to correct dyschromia, fine textural abnormalities or surface photodamage [11]. Because of this, a multi-disciplinary method of the dermatologic evaluation and surgical planning may lead to an individualized treatment based on the extent and severity of photoaging changes. Superficial pigmentation and textural changes are treated with dermatologic procedures and may be treated surgically if significant laxity and structural changes are present [12]. This can help to achieve a more aesthetically pleasing result, lower unrealistic expectations, and offer a more even correction by addressing several factors of ageing. Worldwide, photoaging is very common and worsens significantly with aging and UV exposure over time [13]. In the large French SU.VI.MAX cohort of 6,663 subjects aged 45-60 years, moderate-to-very-severe photoaging rose from 22% of women aged 45-49 years to 42% of women aged 55-60 years and from 17% to 45% of men.  A Queensland study found that 83% of adults under the age of 55 were prematurely photoaged, and that there was a correlation between the degree of photoaging and the level of occupational and recreational sun exposure [14].

Objective

To assess the severity and clinical features of photoaging and evaluate the outcomes of surgical correction using a combined dermatologic and plastic surgery approach.

A prospective interventional study was conducted at Pak Italian Burn Centre Multan from June 2025 to June 2026. Consequently, a total number of 85 patients were selected through non-probability sampling technique of consecutive sampling. Patients with all the following criteria were included until the sample size was met: eligible patients presenting during the study period, and who met defined inclusion criteria. Patients between the ages of 30 and 70 years of both sexes with clinically visible photoaging of the face, such as wrinkles, pigmentation, irregularity, laxity, or other indicators of chronic photodamage were included. Patients were eligible who were willing to undergo dermatologic evaluation and indicated surgical correction and who gave informed consent in writing. The exclusion criteria included the presence of active facial infection, uncontrolled systemic disease, connective tissue diseases, bleeding disorders, a previous major facial surgery within a year, active malignancy, severe psychiatric illness with decreased treatment expectations, and pregnancy or lactation. Data collection All patients were thoroughly assessed by a dermatologist and a plastic surgeon.A detailed dermatologic and plastic surgical assessment was performed for each patient. Data on the length of sun exposure, previous cosmetic procedures, smoking habits, and medical history was obtained, together with demographic information, such as age, sex, occupation, and whether they had ever used sunscreen, on a predesigned proforma. Clinically, the severity of photoaging was assessed by the presence of fine and coarse wrinkles, dyspigmentation, telangiectasia, skin texture, elastosis and facial laxity. A standardized clinical photoaging grading system was used to classify patients into different levels of photoaging. Facial photographs were taken in standardized manner before treatment using similar lighting, background, positioning, and camera settings. Treatment planning was tailored to the degree and photoaging characteristics. Pigmentation, fine wrinkles and other abnormalities of the superficial cutis were treated with applicable dermatologic treatments including chemical peeling, laser or light therapy, resurfacing or other indicated treatments. Patients with more severe changes, such as facial skin laxity, jowling, deep folds, eyelid redundancy, brow descent or neck laxity were corrected with appropriate plastic surgery techniques. Surgical techniques used were blepharoplasty (lift of the eyelids), brow lift, facelift, neck lift, fat grafting or all these procedures as per individual clinical needs. Qualified specialists handled all procedures, and all performed in accordance with standard aseptic and perioperative procedures. Patients were followed treatment at predefined postoperative intervals. Baseline and post-treatment clinical findings as well as standardized photographs were used to assess outcomes. Wrinkle and pigmentation improvements, skin texture, facial laxity and aesthetic appearance were noted. Data Analysis The data were inputted into SPSS version 26.0 and analyzed. The Shapiro Wilk test was used to test quantitative variables for normality, and were presented as mean ± standard deviation or median with interquartile range. Paired samples t-test or Wilcoxon signed rank test were used to compare pre- and post-treatment quantitative data, depending on the normality of the data. Chi-square test or Fisher's exact test was used to detect associations between categorical variables as appropriate. A p-value ≤0.05 was considered statistically significant.

Table 1 summarizes the baseline demographic, sun-exposure, skin phototype, and photoaging characteristics of the 85 study participants. The mean age was 47.8 ± 10.6 years, and females constituted the majority of the sample (64.7%). Most participants were aged 40–59 years, with 29.4% aged 40–49 years and 31.8% aged 50–59 years. Urban residents accounted for 63.5%, while 43.5% had outdoor occupations. Daily sun exposure of at least 3 hours was reported by 61.2% of participants, whereas only 27.1% reported regular sunscreen use and 72.9% used sunscreen irregularly or not at all.

Table 1. Baseline demographic, sun-exposure, skin phototype, and photoaging

Characteristics of study participants (n = 85)

Fine wrinkles were the most frequently observed feature, affecting 78.8% of participants, followed by dyspigmentation in 76.5% and uneven skin texture in 69.4%. Facial laxity was present in 62.4%, while coarse wrinkles and solar lentigines were observed in 56.5% and 52.9%, respectively. Melasma or irregular facial pigmentation was noted in 45.9%, solar elastosis in 41.2%, and jowling in 37.6%.

Table 2. Clinical manifestations of photoaging among study participants (n = 85)

Topical retinoid or depigmenting therapy was the most commonly used dermatologic treatment, reported in 65.9% of participants, followed by chemical peeling in 40.0%, microneedling in 34.1%, laser or light-based treatment in 25.9%, and skin resurfacing in 23.5%. Among surgical procedures, facelift was performed in 34.1%, blepharoplasty in 31.8%, fat grafting in 28.2%, neck lift in 21.2%, and brow lift in 12.9%.

Table 3. Dermatologic and plastic surgical treatment modalities used (n = 85)

The mean wrinkle severity score decreased from 3.38 ± 0.82 at baseline to 1.91 ± 0.71 after treatment, corresponding to a mean reduction of 1.47 points (t = 12.52, p < 0.001). Pigmentation severity decreased from 3.44 ± 0.79 to 1.96 ± 0.73, with a mean change of −1.48 (t = 12.67, p < 0.001). Similarly, the skin texture score improved from 3.21 ± 0.81 to 1.79 ± 0.68 (mean change −1.42; t = 12.32, p < 0.001), while facial laxity decreased from 3.16 ± 0.89 to 1.75 ± 0.76 (mean change −1.41; t = 11.10, p < 0.001).

Table 4. Comparison of clinical photoaging parameters before and after treatment

In the present study, clinical evaluation of photoaging in a Pakistani population was done and the outcomes of combined dermatologic and plastic surgical approach were evaluated. The results showed that the main population was middle aged, with almost two-thirds of the study population being female. The majority of the participants experienced moderate to severe photoaging and Fitzpatrick skin type IV was the most common skin phototype. The most common clinical findings were fine wrinkles, dyspigmentation, uneven skin texture and facial laxity. Importantly, clinical parameters improved significantly after treatment in all major clinical parameters, and patients receiving combined dermatologic and surgical treatment had better overall clinical parameters compared to patients receiving treatment with one modality [15]. Mean age of the subjects was 47.8 ± 10.6 years, in which most of the subjects were aged between 40 and 59 years. This is a clinical phenomenon that occurs with progressive exposure to UV light and with aging, and is clinically predictable. Previous studies have also shown that wrinkles, pigmentation, elastosis, and skin laxity worsens gradually as a person ages and overexposes themselves to the sun. It is also noted that there is a higher percentage of women in the current study which may also be a reflection of a higher cosmetic concern and a higher incidence to seek dermatologic or aesthetic surgical treatment. One of the significant findings was that there was a significant burden of ultraviolet exposure among participants. More than half of the patients reported at least three hours of daily sun exposure, whereas only 27.1% regularly used sunscreen [16]. The findings are relevant especially in the context of Pakistan as the intense sunlight, occupation outdoors, hot climatic conditions and insufficient photoprotection can be responsible for cumulative damage of skin. A few previous studies conducted in Pakistan have also reported inconsistent sunscreen use and poor compliance with frequent photoprotection habits, especially regarding young people. Therefore, low usage of routine sunscreen may potentially be a risk factor for earlier onset and more severe photoaging in predisposed individuals [17]. The treatment pattern identified in this study was in line with the dual nature of photoaging. The most common dermatologic procedures used were topical retinoid, depigmenting therapy, and chemical peeling and microneedling. These modalities are frequently used to enhance epidermal turnover, pigmentation, fine wrinkles and skin texture. Less frequently used were laser and light-based treatments, possibly due to cost factors, availability of such treatments and skin phototype concerns, as well as the higher likelihood of post-inflammatory hyperpigmentation in darker skin types [18,19]. The most popular surgeries were facelift, blepharoplasty and fat grafting. This is in line with the fact that a significant number of patients had face laxity, jowling, eyelid changes, and volume loss related structural ageing that were unresponsive to dermatological therapy alone. Surgical intervention is especially crucial when the predominant aging changes are caused by deeper soft tissue changes, fascial support issues or redundant skin as opposed to epidermal abnormalities. An important conclusion of this study has been the marked improvement seen in all the clinical parameters after treatment. Wrinkle severity decreased from 3.38 ± 0.82 to 1.91 ± 0.71, pigmentation severity from 3.44 ± 0.79 to 1.96 ± 0.73, skin texture score from 3.21 ± 0.81 to 1.79 ± 0.68, and facial laxity from 3.16 ± 0.89 to 1.75 ± 0.76. The mean photoaging score decreased from 13.19 ± 2.47 to 7.41 ± 2.08, with all of the photoaging changes being statistically significant. The results suggest that a holistic approach to management can yield clinically significant results in several aspects of facial aging and not just one [20]. The dermatologic and surgical treatment was the most beneficial treatment. When treated with combined therapy, 88.1% of patients achieved excellent or good outcomes vs 61.5% with a single modality (p<0.001). This corroborates the idea that the process of photoaging is multi-dimensional and needs to be treated at various anatomical levels. The dermatology therapies are mainly aimed at surface pigmentation, fine lines, epidermal irregularity and superficial damage to the dermis while plastic surgery procedures correct tissue descent, laxis, loss of volume and deeper tissue changes. A combination of these methods will thus provide the more complete correction than either modality alone. In summary, the results of the present study are consistent with a multi-specialty treatment program in which both dermatologists and plastic surgeons treat the aging together in determining the depth, severity and predominant characteristics of the aging. This seems especially applicable in patients from Pakistan, who may have pigmentary changes, darker skin phototypes, lower sun protection levels, and higher sun exposure rates, which could affect presentation and treatment outcomes. Combined management is not only a dermatological or a surgical problem, but the treatment can be customized to address both structural and cutaneous abnormalities in the case of photoaging. There were a few limitations to this study. The study was done at a single center with a small number of patients (85 patients) and the results may not be representative of the larger population of Pakistan. Second, the study population comprised patients actively seeking cosmetic treatment, which could result in selection bias and restrict the applicability of the study to those with photoaging who seek clinical care. Third, although clinical severity scores and standardized photographs were used, instrumental measures of skin elasticity, pigmentation, hydration, dermal thickness or collagen remodeling were not included. Fourth, treatment varied by clinical presentation, patients receiving different combinations of dermatologic and surgical procedures, thus making it hard to assess the independent effects of each treatment. Long-term studies and follow-up with standardized treatment methods, validated photoaging scales, objective imaging, and larger multicenter prospective studies are suggested.

The results indicate that skin changes due to photoaging were common in the studied population of Pakistan and were more or less commonly manifested by wrinkles, dyspigmentation, uneven skin texture and facial laxity with moderate to severe changes predominant. The dermato-plastic surgical (DPSS) combination therapy was shown to cause a substantial improvement in all the major clinical photoaging parameters, and was found to be better at achieving overall improvement than either modality alone. The results observed were good to excellent with high degree of satisfaction reported by most patients with minor and manageable complications.