Wrinkles and Aging Skin

Smoking Smoking is a significant way to expose our skin to free radical damage and increase the wrinkling on our face[10][11][12]. Smoking can significantly increase the aged look of skin, particularly around the mouth, as free radical exposure from cigarettes injury the skin in a way similar to the free radical damage of the sun.

Preventing Aging Skin

Prevention of sun damage is key in protecting our skin from further harm[13], even after we have skin rejuvenation therapies. Sun avoidance is one way to prevent sun damage, however this can be difficult, especially for people who work in the sun. The best way to prevent sun damage is to WEAR SUNSCREEN. Be sure that the sunscreen you buy contains both UVA and UVB protection in it as sunlight has both. UVB causes skin cancer and UVA is the most significant cause of wrinkled skin. Another thing you can use to protect yourself while driving (which incidentally is the place most of us receive the majority of our sun exposure) is clear window film which blocks UVA.

Skin Rejuvenation Treatment

The damage done to our skin from sun exposure can be treated. The last decade has seen an explosion of breakthroughs in lasers, dermal fillers, IPL and radiofrequency devices, topicals and other methods. Below I will attempt to review each and provide some understanding about the options now on the market. The first aspect of treatment really comes with prevention (see above). It’s critical to wear high SPF sunscreen with both UVA and UVB protection. If you do you will see a little benefit just from this, the body will start to repair itself. From protection we go up the ladder of treatment aggressiveness, and I usually start with topicals.

Topicals

Yes, I will mention sunscreen for a third time just to drive the point home further. It’s that important. In addition to sunscreen though, topicals are a great place to begin the skin rejuvenation process. It’s easy, generally inexpensive, and can make a dent in nature’s years of harm. The first thing is to understand what works and what doesn’t. Most patients I see have a medicine cabinet full of products that either don’t work or that they have simply given up on. You must first buy products recommended for you specifically by your dermatologist, then follow through and use them religiously. It’s important to follow the recommended regimen of your dermatologist if you expect the products to have the desired effect. The only topical treatment with FDA approval for treating wrinkles are retinoids, such as Retin-A[14][15]. Tretinoin is effective topically at reducing and improving the look and texture of fine lines and wrinkles. Moisturizing the skin can also be helpful as dry skin can often look more wrinkled than skin that is effectively moisturized. Removing dead skin cells, which is a good place for make-up to get stuck and increase the prominence of wrinkles, is also helpful topically. This can be done a number of ways, however a good topical solution is a glycolic or citric acid peel (see chemical peels). Earlier we mentioned free radicals and the havoc they can wreak on our skin. A great way to battle these topically is with antioxidants. Antioxidants protect our skin from the inflammation caused by free radicals, and they are a good part of any topical regimen.

Chemical Peels

Chemical peels come in a variety of strengths and formulations. Their name signals their mechanism of action, which is to remove skin cells with a chemical solution to produce a desired result. There are chemical peels which can remove the entire surface of skin, similar to a complete skin resurfacing via laser surgery. These deep chemical peels, in my opinion, have largely been replaced by lasers which have more predictable outcomes and can be better controlled. Such peels may include Phenol peels, which have significant risks such as hyperpigmentation (skin darkening) and cardiac risks. Popular chemical peels which are used commonly in my practice are the Alpha Hydroxy Acid (AHA) peels and Glycolic Acid peels[16][17][18]. These peels may be used in low concentrations, which can be used for in-home products, and in higher concentrations in clinical settings. These are great for acne treatment and for mild skin rejuvenation. They are effective at removing dead skin cells and improve some unevenness in pigmentation.  Trichloroacetic acid peels (TCA peels) are also highly popular. Generally applied in a clinical setting, these peels will provide some skin tightening and some reduction in brown spots and surface blemishes[19][20].

Microdermabrasion

Microdermabrasion refers to a class of devices which remove the stratum corneum, the skin’s superficial protective layer of dead skin cells. By removing this layer we are able to get topical products deeper into the skin[21]. I typically use microdermabrasion as a product delivery device in conjunction with topicals, rather than a stand-alone procedure.

Lasers

Laser rejuvenation is among the most popular methods available for treating fine lines and wrink les. There are a wide range of laser treatment options available today, some with really impressive results. There are non-ablative lasers (lasers which do not injure the skin’s surface), fractionated lasers (lasers which partially injure than skin’s surface) and ablative lasers (which may be used to remove the skin’s layers).

In my own practice I use two different types of visible light lasers in addition to infrared lasers for non-ablative treatment of photodamaged skin. These may be used to safely treat all five signs of sun-damaged skin[22][23][24]. Fractionated lasers are new lasers used for skin rejuvenation. These lasers use fiber lasers, which are also used for telecommunications in fiber-optic networks. They use a glass-fiber cylinder through which microscopic laser beams are transmitted and create small injuries to the surface of the skin. These microscopic injuries are distributed across the treatment area in a way which minimizes downtime but maximizes efficacy (think of a lawn that has been aerated). These can be very effective for wrinkles, scarring, and other indications as well[25][26]. Fully ablative lasers, such as CO2 laser resurfacing, was one of the first laser skin rejuvenation methods developed. Initially we used laser resurfacing to completely remove the surface of the skin, which often produced impressive results with a great deal of skin tightening. The trouble, however, with this method is the high risk of side effects and difficult wound care. By and large this is reserved for highly damaged skin in certain specific types of patients[27][28]. In general lasers are an extremely effective treatment option for skin rejuvenation, especially when used by highly-trained and experienced physicians with multiple lasers and a variety of treatment options at their disposal.

Radiofrequency

Radiofrequency rejuvenation is another energy-based treatment technique which aims radiofrequency energy into the skin to affect skin tightening and lifting of sagging skin. Most systems do this by stimulating the body’s natural healing response through delivery of heat/light to layers beneath the epidermis[29][30].

Intense Pulsed Light

Intense pulsed light (IPL) is another light-based method to remove brown spots and wrinkles associated with sun damage. A broad spectrum light source is used to target melanin or blood vessels in the treatment area. It can improve hyperpigmentation and skin tone. There is little to no downtime with IPL as it leaves the skin intact. There may be some redness or swelling at the treatment site afterward, however this is generally mild and will fade. Several treatments may be needed to obtain desired results[31].

Injectable Fillers

Injectable fillers are the most popular method of rejuvenating skin in the world. Of the 11.7 million cosmetic procedures performed in the US in 2007, the #1 and #2 procedures were injectables (Botox® and Hyaluronic Acid fillers, respectively)[32]. Injectables can be used to smooth out the surface of the skin, reducing fines lines and wrinkles around the face, or to immobilize muscles which exaggerate wrinkling around the face. The substances which comprise fillers differ. Some fillers are made of artificial substances, others are hyaluronic acid-based gels which aim to replace hyaluronic acid deficiencies in the skin. Collagen fillers have been popular for many years as well. The length of time the materials remain affective deepens on their materials and how long it takes the body to naturally dispose of them. Generally fillers last for up to a year.

Botox®

Botox is the highly popular product made by Allergan which works well to address dynamic lines, lines made by muscle movement. It’s important to note that wrinkles are not “made” by moving our facial muscles. Notice children, they move their faces all day long and they do not have wrinkles. The reason for this is their facial skin has yet to be damaged by the sun. Their skin is still healthy and can “bounce back” into place[33][34].

Botox works well on dynamic lines by preventing muscle movement. It is a protein produced by bacteria, clostridium botulinum. Initially it was used in ophthalmology for patients whose eyes went in opposing directions, thereby immobilizing the errant eye. Today it is widely used to treatment forehead lines, brow lines, and lines above the bridge of the nose[35][36]. Side effects from Botox may include excess immobilization of the face. Botox usually will last no more than four months, so side effects will wear off.

Surgery

Plastic surgery is the most invasive option for patients considering skin rejuvenation. It also produces significant results, particularly for sagging skin. Blepharoplasty can be used to treat sagging eye lids. The face lift can be used to tighten loose facial skin. Liposuction may also be used to remove fat below the chin (“double chin”). Generally these surgeries have risks and side effects similar to other surgeries.

Choosing a Treatment

It is very hard for a lay person to know which treatment is ideal for them. The best thing for anyone who is considering skin rejuvenation to do is to seek out an expert in skin, for example a cosmetic dermatologist, for a consultation. Don’t be afraid to get multiple consultations with different physicians. What you want is someone with access to a variety of treatment options at their disposal. If you see someone who only has one option for skin rejuvenation, they are going to steer you towards the device or option they have. It is always good to spend a little time with several providers, and then make a choice. Never rush into a decision. A little patience, research, and consultation will help you get the results you want.

Choosing a Physician

As mentioned in Choosing a Treatment, in my opinion it is critical to see a physician with experience in treating the skin, preferably a dermatologist. You want a physician with a variety of treatment choices, has treated many patients with similar concerns as you, and is directly supervising treatment. Ask question like:

• What is your specialty?
• Are you a board-certified physician? If so, in what?
• Do you own your lasers?
• Is this laser/treatment good for my skin-type?
• What other treatments are available to me?

 

Cost Matrix

Cost is an important part of choosing a treatment course. Generally cost will be determined by where you live (demand-supply), which treatment(s) you are choosing, the office you are going to and a number of other variables. Your physician will usually discuss your cost options during your consultation. Find more about the specific costs of wrinkle treatment at The Patient's Guide to Wrinkles.
There is one very important thing to note about cost. There are no bargains in cosmetic medicine. This is a field where you truly will get what you pay for. Quality care will come at a premium. I have treated many patients who have gone out looking for the “best deal” only to greatly regret it when the treatment was ineffective or, in the worst cases, they were injured because of poor care.

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