Skin rejuvenation procedures

Date Posted: March 1, 2007

Skin rejuvenation procedures

If Ponce de Leon returned today to search for the fountain of youth, he might find it filled with chemical skin smoothers, wrinkle fillers, and powerful lasers that literally remodel aging skin. In recent years, dermatologists have developed an array of procedures that can remove fine lines, fill in deeper ones, and lighten unsightly pigmented areas or spots. These procedures help rejuvenate skin worn by time and sun exposure with few side effects and far less recovery time than that required for surgical techniques such as facelifts.

One of the most important factors for people seeking skin rejuvenation is the amount of downtime required. People want to return to work and social activities as quickly as possible, which has led to the introduction of less-invasive techniques that don't penetrate the skin as deeply and thus require less recovery time. The trade-off is that their effects are not as significant and they often require a series of initial visits as well as follow-up "maintenance" visits. The choice is yours. You can go for a deeper treatment with a longer healing time or for a lighter treatment that requires more follow-up visits and probably more long-term expense. This section will describe such procedures as Botox injections, chemical peels, laser procedures, light-based treatments, microdermabrasion, and fillers and implants.

Doctor or aesthetician?

Some procedures that affect only a superficial layer of skin can be performed by nurses or skin aestheticians, while others require the skills of a dermatologist or other physician. Quite often these techniques are used in combination or along with surgery. Whom you trust to perform a procedure is a crucial factor in whether the outcome will be successful.

While less invasive procedures such as microdermabrasion can be performed by cosmetology professionals, cutaneous (skin) surgeries, including laser procedures, are performed by physicians from a number of specialties: dermatologists and dermatologic surgeons, plastic surgeons, facial plastic surgeons (otolaryngologists), oculoplastic surgeons (ophthalmologists), and other cosmetic surgeons.

Choosing a doctor

One way to start is with a dermatologist who can advise you about which procedures are best handled by a physician. Some physicians who perform cosmetic procedures also have aestheticians on staff to handle the less invasive treatments. To find a reputable physician, begin by asking your own physician for recommendations. Or contact professional societies that have sophisticated referral services and Web sites that contain information about physicians' training and experience, the articles they've written, and the procedures they perform (see "Organizations"). In some areas, city or county medical associations can provide names of physicians to contact.

You can also ask friends, co-workers, or family members who've had cosmetic procedures if they were satisfied with the results and whether they would go back to the same physician again. But remember that physicians who are popular or who advertise heavily may not be highly skilled, or they just may not be right for you.

Once you have the name of a physician, the next step is to check whether he or she is board-certified. Most consumers know to ask about certification, but many don't ask which board has done the certifying, or whether it's overseen by the American Board of Medical Specialties (ABMS). The ABMS oversees 24 approved medical specialty boards in the United States. A number of other groups may call themselves "boards," but they aren't overseen by the ABMS. Their certification requirements may be less rigorous than boards under ABMS purview. More than 100 of these self-designated boards exist throughout the United States, and there are virtually no legal requirements for their formation. Some may be no more than glorified public relations offices. To check qualifications, contact the ABMS's Doctor Verification Service at 866-275-2267, or online at www.abms.org.

The American Board of Dermatology certifies physicians to perform hair transplants, laser procedures, dermabrasion, sclerotherapy, liposuction, chemical peels, and soft-tissue augmentation. In fact, dermatologists developed most of these procedures. In addition to medical school, internship, and residency training, some dermatologists pursue an additional year or two of training to specialize in dermatologic surgery.

The American Board of Plastic Surgery certifies physicians to perform the complete array of cosmetic and reconstructive surgical procedures. Physicians who are ABPS-certified have a medical degree from an accredited institution, at least two years of residency training in general surgery, and at least two years of additional training in plastic surgery.

If you're going to have a surgical procedure in the physician's office, ask if the office is accredited by one of the following organizations: the American Association for Accreditation of Ambulatory Surgery Facilities, the Accreditation Association for Ambulatory Health Care, or the Joint Commission on Accreditation of Healthcare Organizations.

These organizations have referral services and can give you the names of physicians in your area (see "Organizations"):

the American Academy of Cosmetic Surgery

the American Academy of Dermatology

the American Society for Dermatologic Surgery

the American Society for Laser Medicine and Surgery

the American Society of Plastic Surgeons.

Questions to ask a doctor

It's important to ask how many procedures of this type the physician performs per month or year. Also find out how long the physician has been doing this procedure, and whether he or she has written about or taught the procedure in an academic setting. Expertise levels can vary, but you want someone who has had specialized training, perhaps a fellowship in an academic medical center, rather than just a course or two. How many procedures of any kind does the physician perform per day? You don't want a surgeon who is rushed or who won't give you full, personal attention.

You'll also have questions regarding cost. For example, is there a consultation fee, and if so, can it be deducted from the cost of the procedure? What is the complete fee for the procedure, including the physician's fee, anesthesiology, and operating room costs? Who delivers the anesthesia? Ask if the physician charges extra for corrections or repairs, and make sure you understand the complications that could occur and exactly what is involved in recovery. The healing process for some procedures can be lengthy and tedious. Another important consideration is whether the procedure will need to be repeated and how often. Some of the less invasive procedures have shorter recovery times, but require several treatments or even periodic maintenance procedures every few months.

And don't forget to trust your gut. Choose a physician with whom you feel comfortable and can establish an easy rapport. It's helpful, too, if the physician has a courteous, knowledgeable staff. Finally, keep in mind that no matter how talented or experienced your physician is, no amount of lifting, lasering, or peeling is going to make you look 18 years old again.

Choosing an aesthetician

Not long ago, professional training in nonmedical skin care came under the umbrella of cosmetology. Anyone who wanted to specialize in skin care also had to learn how to cut, color, style, and perm hair and how to do nails. More recently, the health and medical aspects of skin care have been recognized with specialized aesthetician training and licensing.

Aestheticians perform a variety of skin care procedures — deep cleansing, facials, low-grade chemical peels, and microdermabrasion (true dermabrasion should only be performed by an experienced physician). While most aestheticians work in salons and spas, don't be surprised if your dermatologist or cosmetic surgeon has an aesthetician on staff. In addition to performing noninvasive treatments, an aesthetician may assist your surgeon in presurgical and postsurgical skin care and help you learn makeup techniques to cover redness or scars as your skin heals after surgery.

Licensing requirements for aestheticians vary from state to state. For example, aesthetician licensing in Massachusetts requires 300 hours of training. In Wisconsin, 450 hours of training are needed. Contact your state's department of licensing and regulation to learn about licensing requirements in your area. Many states offer this information online.

Botox (botulinum toxin)

Since Botox injections were first used for cosmetic purposes in the late 1980s, this therapy has gained quite a following. According to the American Society for Aesthetic Plastic Surgery, in 2005 doctors delivered more than three million treatments with Botox (a brand name for botulinum toxin type A), making Botox injection the leading nonsurgical cosmetic procedure in the United States among both sexes and nearly all age groups (the only exception being those ages 18 or younger). Why is this treatment for wrinkles and frown lines so popular? Botox is relatively affordable, starting at about $300 per treatment; has very few risks; and requires no recovery time. And it's quite effective at temporarily smoothing a wrinkled face, brow, or neck.

Botulinum toxin type A is a protein produced by Clostridium botulinum . If you ingest this bacterium in improperly preserved foods or if it infects a wound, it can cause botulism, a rare but potentially deadly disease. But when tiny doses of sterile, purified botulinum toxin are injected into specific muscle sites, the solution doesn't enter the bloodstream, and the procedure causes no harm. The amount used in a cosmetic treatment is far less than the amount necessary to cause illness.

Botox works by blocking the release of the neurotransmitter acetylcholine, which helps trigger muscle movement (see Figure 4). By blocking acetylcholine in a few strategic areas, Botox interferes with the ability of the selected muscles to contract, effectively immobilizing them. The muscles controlling facial expressions relax, and creases in the skin smooth out. Because the muscle can't contract, new creases don't form.

Botox procedures take just minutes and don't cause much discomfort. You may notice mild redness for a few hours or, occasionally, minor bruising, which you can camouflage with makeup. You should notice a change in your appearance in three to seven days, and the results usually last for about three or four months. With continued use, the effects tend to last longer.

Many people worry that Botox injections will leave them with an unnatural expression or with frozen or asymmetrical features. But when done well, Botox injections shouldn't drastically change your ability to form facial expressions. In rare cases, injections near the upper eyelids may make them droop temporarily. You may also get a temporary headache. But side effects are typically uncommon and minimal.

However, safety with Botox is a real concern when poorly trained, unlicensed practitioners deliver it. Experts warn that a "Botox party" in someone's home or office is not an appropriate or safe way to receive a medical treatment, even a cosmetic one.

Botox acts on dynamic wrinkles: the lines etched by facial expressions such as laughing, smiling, frowning, wincing, squinting, and pursing your lips. These expressions eventually leave you with lines in the forehead and between the brows, as well as crow's feet and other lines. A skilled physician can use Botox to approximate the results you'd get from facelifts, neck lifts, brow lifts, and eyelid lifts; of course, Botox injections will need to be repeated regularly to maintain the effect.

Botox does not effectively treat the deep creases from nose to mouth, known as nasolabial folds. And sometimes a dynamic scowl line is too deep and entrenched to relax. In these cases, you may also need fillers to raise the depressed surface area left by the lines. Botox also doesn't improve the appearance of static wrinkles, which form because of photoaging or chronological aging. Laser resurfacing techniques do a better job of erasing these lines.

Botox is often used along with other cosmetic procedures. Doctors sometimes recommend it with laser resurfacing, since skin heals better when it's not in constant motion, or with soft-tissue augmentation to enhance results. Botox makes a good touch-up after a facelift or skin resurfacing, keeping the newly smooth face and skin from becoming creased again.

While Botox is the most widely known product, other brands of botulinum toxin are on the market. A similar product, Myobloc, contains the botulinum B toxin. Another botulinum A toxin, sold as Dysport in Europe, is in FDA trials and may soon be available in the United States under the name Reloxin. Its arrival could create more competition and help drive down the cost of treatment. Recent trials show Dysport's effects do not last as long as those of Botox.

Botox has other uses as well. Studies have found that Botox injections into the muscles of the forehead, the brow area, and the sides and back of the head near the neck can relieve some types of migraines and prevent their recurrence for several months. Botox is also effective for treating severe underarm sweating and excessive sweating of the hands and feet. Botox inhibits the nerves that activate sweat glands, thus stopping perspiration in the same way that it relaxes muscles. Results last about six months.

Chemical peels

Once the first choice for facial rejuvenation, chemical peels now play second fiddle to newer, less invasive techniques, but still have a significant role. Peels are used to treat wrinkles, age spots, discoloration, precancerous skin growths, and superficial scarring. An acid solution is applied to the skin, dissolving skin cells and removing the top layers of the epidermis. Just how deeply the peel penetrates, and the effects, vary depending on the strength of the solution used. Chemical peels can be done on the hands as well as the face.

For a superficial peel, doctors use alpha hydroxy acids, beta hydroxy acids, or salicylic acid, typically in mild 10% to 70% solutions, to remove only the outermost layer of the epidermis. This peel can improve skin tone, enhance texture, and somewhat minimize fine lines and wrinkles. You'll be happy with these peels if you have only mildly sun-damaged skin or just want to make your skin look brighter without a dramatic change in appearance.

For best results, repeat the treatment monthly for about six months, and then quarterly. Superficial peels are often called lunchtime treatments because they take just 15–20 minutes, are painless, and don't require any recovery time. Some people with very fair or sensitive skin may have some redness for a few hours, but most people feel comfortable going out in public immediately afterward. Expect to pay about $75–$250 per treatment.

You can also get similar results with microdermabrasion or its newer cousin, Vibraderm, for about the same price for a similar series of treatments. These methods physically sand away the very top skin layer, leaving the skin smoother and fresher.

If you have more advanced sun damage or if you want a more noticeable improvement to mild wrinkles, skin tone, and coloring, you may consider a stronger peel. These peels dissolve the skin into the top layer of dermis and require a longer recovery time. A solution of 35%- to 50%-strength trichloroacetic acid (TCA) is commonly used. You may find that it stings a bit. The session will last about 35 to 45 minutes. Afterward, you'll have mild discomfort, and a few days to a week after the treatment, the superficial skin will darken, turn stiff, and peel off. Your skin may appear flushed for several weeks, but you should not have other side effects. Most people report noticeable improvement in medium-depth lines and wrinkles and coloration. Results last up to two years, but many people get annual repeats before the improvements fade over time.

Deep peels use phenol, a caustic chemical, to penetrate into the dermis. These peels are used to reduce deeper wrinkles, to smooth out blotchy skin, and to improve sun-damaged areas. Because they may lighten skin, they are best reserved for people with fair skin. This procedure, which takes about an hour, is more painful than other peels and requires more healing. You'll need sedation during a phenol peel. Afterward, expect mild to severe discomfort and to wear dressings on your skin for a few days. You may not be able to eat solid food during this time and might need to enlist someone to help care for you. Once the dressings are removed, your skin will be red, swollen, and oozing. Then over the next few weeks, the skin will darken, flake, and peel. When the peeling subsides, the skin will appear bright red for two to three months. Usually only a single treatment is needed. But because of the often painful, slow healing process and the risk of unwanted color changes, phenol peels have fallen out of favor.

After any chemical peel, you'll be more sensitive to sun exposure, so take extra precautions when outdoors.

Laser and other procedures

Improvements in laser technology have sparked a revolution in the treatment of photoaged skin. Lasers remove moderate to deep lines and wrinkles while significantly improving skin tone, texture, and tightness. Their ability to target very specific types of cells in distinct skin layers enables them to treat conditions that were previously impossible to treat, such as port-wine stains, pigmented birth marks, and spider veins. They can also erase acne pits and many other scars.

Laser procedures are bloodless and can be controlled precisely, reducing the risk for injury or scarring. Recovery times for laser procedures vary depending on the individual and the depth of treatment. Although newer, less invasive treatments have little or no recovery time, repeat visits are usually necessary to achieve the best results.

Lasers work by emitting intense beams of bright "light" that transfer high levels of energy to a target in or on the skin. There, the energy is converted to heat. Lasers literally vaporize skin cells by heating up the water or pigments in the cells. Each laser produces a specific single wavelength, or color, of light — from the invisible infrared to visible reds, yellows, and greens. A laser's wavelength influences how deeply it penetrates the skin and how it will affect the skin. Because different wavelengths work on different problems, your physician will select the one that will treat your specific condition. For example, yellow and green wavelengths target the red pigments of port-wine stains, while infrared lasers are typically used to remove wrinkles, fine lines, and crow's feet.

Lasers also vary by the duration of their pulses. The duration of the pulse of light determines how a laser affects targeted tissue. A highly focused, continuous beam cuts through skin like a scalpel, but almost all cosmetic procedures require lasers that emit pulsed light, which confers the precise control needed to vaporize the intended skin layers or pigments.

The oldest type of laser treatment is ablative laser resurfacing. It triggers the skin's wound-healing response, promoting new collagen growth and leaving you with fresh, smooth skin. The skin also tightens, which is why laser resurfacing can act as a surrogate mini-facelift. Ablative laser resurfacing is most effective against damage to the epidermis and superficial layers of the dermis, including lines and wrinkles from sun damage, acne scars, actinic keratosis, freckles, liver spots, and dull patches caused by photodamage. Laser resurfacing may not be able to remove very deep lines and wrinkles; for those, you may need soft-tissue augmentation.

Over the last several years, newer, less invasive procedures have become popular because they achieve significant results with little or no recovery time. They include fractional resurfacing, plasma skin regeneration, and nonablative laser treatments. All of these techniques can treat fine lines, wrinkles, and scars, but the degree of improvement is greater with fractional resurfacing and plasma skin regeneration than with nonablative laser treatments.

How lasers work

Back in 1917, lasers were but a gleam in Albert Einstein's eye. His work "On the Quantum Theory of Radiation" laid the foundation for the development of lasers that decades later would be used in clinical applications. In dermatology, lasers came into use in the early 1960s. Laser procedures increased in the 1970s, with the introduction of lasers that could treat vascular marks such as port wine stains. But although lasers successfully faded these red discolorations, a risk of scarring existed. Since then, an array of technological improvements has produced much more precise lasers that can target specific areas within the skin without damaging the surrounding tissues and remodel the collagen without residual scarring. Today, some lasers are computer-controlled for optimum precision.

The word laser is short for "light amplification by stimulated emission of radiation." To produce their intense beams of bright light, lasers have to generate electrons. Some use gases to do this, while others use a solid or an organic dye. When the electrons are bombarded with energy from an outside source like an electrical current, they produce an intense beam that exits the chamber through a fiber-optic cable. The choice of gas, liquid, or solid will determine what wavelength of light the laser emits, and that will determine how the laser will be used.

The techniques described in this section may be used alone, but increasingly they are used in combination or with other cosmetic techniques to treat deeper wrinkles or scars on one area of the face, and finer lines or superficial lesions on another. Botox treatments and soft-tissue augmentation also are being used with laser resurfacing to get the most effective results in wrinkle reduction.

Ablative laser resurfacing

While once the only laser treatment for skin rejuvenation, ablative laser resurfacing is now reserved for advanced photodamage and severe acne scars. The carbon dioxide (CO₂ ) and erbium:YAG lasers are most commonly used. Both lasers generate invisible infrared wavelengths that are absorbed by the water in skin cells. Because skin consists largely of water, the laser strips away superficial layers of skin, removing lines and wrinkles from sun damage and facial expressions. While the lasers share some features, there are differences as well, and your physician will determine which type of laser will work best for your skin type.

The CO₂ laser penetrates more deeply than the erbium laser and vaporizes a thicker slice of skin — the entire epidermis. It also creates more thermal damage in the dermis, so it produces the most dramatic results in erasing deep lines and wrinkles. In addition, it can tighten the skin significantly. The intense heat of the CO₂ laser is painful, but you'll receive a local anesthetic to blunt the pain. Because this laser sometimes lightens skin, it requires extra caution when treating people with olive-colored or dark skin.

The erbium laser generates less heat and removes a thinner skin layer on one pass. Because the erbium laser penetrates the skin only about one-fifth as deeply as the CO₂ laser, it is usually selected for treating less severe lines and wrinkles. With one or two passes, the erbium laser moderately improves severe photoaging and eliminates many wrinkles. But your doctor can also make multiple passes to achieve the same dramatic results as with the CO₂ laser.

The erbium laser has a number of advantages over the CO₂ laser: It causes less pain during the procedure, requires less sedation and anesthesia, has fewer side effects, and requires half the recovery time. In addition, it's less likely to lighten the skin, so it may be safer on olive and dark skin.

There are some drawbacks to the erbium laser, though. The erbium laser doesn't seal blood vessels completely, so the skin oozes more. Also, it doesn't cause quite the same amount of thermal damage in the dermis as the CO₂ laser, so it may not induce as much skin tightening.

One trend is combination therapy, which involves using both types of lasers during a treatment. For example, to remove moderate to deep lines and wrinkles, the physician makes two passes with the CO₂ laser and a final pass with the erbium laser. This approach draws on the strengths of each laser while minimizing side effects: Patients may get better results than with the erbium laser alone and quicker healing and less redness than if only a CO₂ laser was used.

Another new approach is to get the effect of combination therapy by using a single tool, a dual-mode erbium:YAG laser. This laser works like a traditional erbium laser, but has properties that make it quite similar to the CO₂ laser as well. It can emit longer pulses as well as short ones, meaning the light stays on for a greater amount of time and heats the dermis to a degree equivalent to the CO₂ laser. So the physician can use the longer-pulsed mode for two passes and then switch to the shorter pulses for the final pass. By using both modes sequentially, he or she can get results similar to those derived from using the CO₂ and erbium lasers in combination.

How ablative laser resurfacing is done. Laser resurfacing is usually performed in your physician's office or a surgical suite, and it may take two or more hours, depending on what you are having done. You may have your entire face treated or just a trouble spot. Before the procedure, your doctor will prescribe antibiotic and antiviral medicines to reduce the risk of skin infections, as well as pain medication for afterward. You should avoid medications and supplements that may increase bleeding, including aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve), and vitamin E.

During the procedure, all people in the room — including you — will wear goggles to protect their eyes from the laser's intense light. Your skin will be cleaned. You'll remain conscious, but you'll have twilight sedation to minimize your anxiety and discomfort. Your doctor may also apply a topical anesthetic cream or give you local anesthesia to further numb the area for the procedure.

The laser itself consists of a handheld wand and various adjustable dials. Your doctor will move the wand over the treatment area as it emits beams of light.

After the procedure, your skin will need to recover. If you've had a CO₂ procedure, plan on taking two full weeks off work and social engagements; for an erbium laser treatment, plan on one week. Your doctor may apply a dense ointment to your face, but more commonly you'll wear a bandage for three days to keep the skin moist. The skin heals more quickly and evenly if it stays moist. You may need pain medication to reduce the throbbing that's common after laser resurfacing.

After you remove the bandage, using cool compresses for 20 to 30 minutes every few hours and applying a thick, moisturizing ointment can help relieve pain and speed healing. If a crust forms, roll a cotton swab over the area to remove it. Within two weeks, the wounds will heal. You'll still look like you have a bad sunburn, but many people feel ready to go out in public at this time. It's a good idea to curtail aerobic and other strenuous activity while the redness remains. Depending on your complexion, your skin may stay slightly red for two to six months. Your doctor will let you know when you can wear water-based makeup to cover the redness.

Your skin will look and feel remarkably smooth and wrinkle-free as soon as it heals, and it will continue to improve for three to six months. Results from one treatment should last for many years. Of course, laugh lines and other wrinkles caused by facial expressions will eventually recur with time, and wrinkles will develop as you age. Some people get Botox injections to prevent new expression lines from forming. If your laser resurfacing removed acne scars, you'll enjoy lifelong benefits.

Because sun damage can take years to appear, you may develop spots triggered by previous sun damage. You'll need to be extremely careful to prevent sun exposure, which can discolor areas of the skin.

With a skilled doctor, the risk of scarring is very low, but some people have permanently lightened skin. This complication is less common with the erbium laser than with the CO₂ laser.

Costs vary, but they may start around $2,700 for a portion of the face and $8,000 for the full face.

Fractional resurfacing

This innovative technique uses a device called a fractional laser to treat fine lines, wrinkles, sun spots, age spots, and other kinds of sun damage, as well as acne and surgical scars. Fractional laser energy is more precisely targeted than other ablative lasers — it produces microscopic columns of thermal damage, leaving the surrounding skin cells intact. While fractional resurfacing doesn't bring about the same degree of improvement as conventional laser resurfacing, it is becoming an attractive alternative because it demands little downtime.

Experts usually recommend three to five treatments, often spaced a week to a month apart. Treatments require only topical anesthesia to control pain. The skin is usually red for five to seven days following a treatment, and you may have mild swelling for a couple of days. Reduction of wrinkles and improvement in skin texture, pigmentation, and tightness may be seen almost immediately, but the results are progressive, with the best results appearing in about two to three months.

In addition to the face, fractional resurfacing can be used to treat other areas of the body, including the neck, chest, arms, and abdomen. The cost is about $1,500 for a full-face treatment and $1,000 for the neck. Many doctors offer price reductions for treating more than one area at once.

Plasma skin regeneration

This is a nonlaser technique that diminishes fine lines and wrinkles, including those around the eyes, as well as brown spots and other signs of sun damage. It also improves skin tone. Its effectiveness is comparable to that of fractional resurfacing.

Plasma skin regeneration uses a machine that emits a stream of plasma (ionized nitrogen gas) to heat the skin. The plasma has a lilac glow that changes to a yellow light. Like the ablative laser resurfacing, it superficially wounds the skin to improve its appearance. The plasma heats the skin either on the surface or deeper, depending on the need. The treated skin dries and comes off in three or four days, revealing fresh new skin. There's no oozing or crusting during recovery. The improvements increase for a year following treatment.

Plasma skin regeneration can be done in one high-energy treatment, which penetrates to layers beneath the surface of the skin, or in one or more low-energy treatments, which penetrate the surface layers. The cost is about $4,000 to $6,000 for the high-energy treatment and about $1,500 for each low-energy treatment.

Non-ablative laser resurfacing

Unlike ablative laser resurfacing, which is most effective against damage to the epidermis and superficial layers of the dermis, non-ablative laser resurfacing penetrates deep into the dermis while leaving the surface of the skin intact. It can treat scars and wrinkles, as well as moderate photodamage of the dermis. But because it doesn't alter the outer layers of the skin, it has no effect on discoloration or freckles caused by sun exposure. Non-ablative lasers work by shoring up collagen levels and stimulating new skin cell growth in the dermis.

The most commonly used non-ablative lasers are the SmoothBeam laser (1,450 nanometer diode laser) and the CoolTouch laser (1320 nanometer neodymium:YAG laser). Your doctor will choose one depending on his or her preference or the type of machine available. Both lasers emit invisible infrared wavelengths that penetrate beneath the epidermis, while spraying a cooling cryogen liquid on the skin to reduce surface damage.

While non-ablative laser treatments don't require the lengthy recovery time of laser resurfacing, the treatments themselves, which last 15 to 30 minutes, are painful. Before starting the procedure, your doctor may apply a topical anesthetic cream to your face to numb it. The cooling spray also helps.

Your skin may be red for an hour or two after treatment. But you can generally cover this redness with makeup, and there is usually no recovery time. Occasional complications include lightened or darkened skin, very mild skin pitting, and small, superficial blisters.

You'll need four to six treatments to get the full benefit. Costs vary, ranging from about $400 to $600 per treatment for the face. Many physicians offer package prices for the series. Some people get touch-ups yearly, but others find that the results last many years. You will see improvement after two or three treatments, and improvements may continue for a year or more. Because collagen grows slowly, changes happen gradually over time, and you may not notice them until you look at photos of yourself from months earlier.

Lasers for pigmentation, hair removal, and other problems

Lasers aren't used only for skin resurfacing. They can correct a variety of specific problems, too, including port-wine stains, red cheeks and noses, dilated blood vessels, spider veins, liver spots, and freckles. They are also used for removing tattoos and hair. In these cases, your doctor will use a different kind of laser than for skin resurfacing. The type of laser selected depends on the problem, particularly the color of the spots or pigmented areas to be removed.

Red spots, dilated blood vessels, spider veins, and broken capillaries require lasers that target the red pigments in hemoglobin, a component in blood, to eliminate these imperfections. Pulsed-dye lasers, which emit a yellow light, target these reddish pigments. These lasers are also used for minimizing wrinkles and increasing collagen and elastin in the skin. Side effects include swelling for a day and sometimes bruising. Potassium titanyl phosphate (KTP) lasers, which emit green light, can also treat broken capillaries. Treatments produce very mild redness or puffiness.

For brown pigment such as age spots, freckles, and some permanent makeup lines and tattoos, your doctor will use a Q-switched laser. Q-switched lasers, which emit very short, high-energy pulses, include the alexandrite, the 1064 Nd:YAG, and the Ruby. Extra-short pulses of these lasers give off bursts of energy that are absorbed by brown pigments. Tattoos usually require at least two different lasers that target different dyes.

Longer pulses of the same wavelength used to treat pigmented lesions destroy larger targets and are used in removing unwanted dark hair. To date, no laser effectively removes light or gray hairs, which lack dark pigments.

The length of time for treatment and recovery varies depending on the laser, the size of the treated area, and the extent of the problem. Your doctor can provide you with detailed information about how the procedure will be done and what you will need to do during the recovery period.

LED photomodulation

LED photomodulation, which uses light without a laser, can induce subtle improvements in the skin for people with mild to moderate sun damage. Photomodulation, which is painless, doesn't damage the surface or deeper layers of skin. It can complement almost any other procedure on your face and works on all skin types. It can also rapidly treat a large area in one brief session, with no aftereffects. Its effects may be subtle, however. Photomodulation won't provide the dramatic results of laser resurfacing and non-ablative laser treatments, and it won't noticeably improve severe photoaging.

Photomodulation uses the same kind of light-emitting diodes (LEDs) that you see on many phones, VCRs and DVD players, and treadmills. This device does not heat or wound the dermis, but it signals cells that remodel the collagen in the dermis. Photomodulation works by delivering short pulses of a narrow band of low-intensity yellow or red light to skin cells, which use the energy in a manner similar to the way plants convert sunlight into food during photosynthesis. Scientists theorize that the light stimulates the skin cells' "engines," the mitochondria, which then energize other cellular activities and make the cells act young again. Youthful skin cells send out more signals to the fibroblasts to produce the collagen and elastin that makes young skin so plump.

A small study published in 2005 in the journal Lasers in Surgery and Medicine looked at the effects of eight treatments of yellow-light LED photomodulation on 90 patients. The device used was GentleWaves, which is so far the only LED photomodulation device approved by the FDA for treating sun-damaged skin. (Other systems, such as Lumiphase, are in widespread use in Canada.) The researchers found some improvement in the skin of 90% of these patients, including smoother skin, fewer wrinkles around the eyes, and less redness. Still, more studies are needed to establish how well the device lives up to these claims.

During this procedure, your face will be exposed to continuous or pulsed yellow or red LED light for 30 seconds to 3 minutes. The process is painless, and you won't feel any heat or unpleasant sensations. Because there aren't any side effects, such as redness or peeling, you can return to normal activities right away. According to the makers of the devices, improvements are usually noticeable after five to seven treatments.

Typically, patients have 8 to 10 treatments, with no more than 2 treatments per week. Results last from months to years. To maintain results, ongoing treatments — typically about four a year — are needed.

Microdermabrasion

Another quick and painless treatment that can moderately improve fine lines, wrinkles, age spots, or mild acne scars is microdermabrasion. Microdermabrasion lightly sands the skin with aluminum hydroxide crystals or other similar crystals applied under high pressure. The physician then lightly suctions off the crystals and skin debris. A similar, newer device known as Vibraderm uses a lightly vibrating paddle to sand the skin. In either case, you may have some redness or swelling around the eyes, but it usually subsides the same day.

Each treatment takes about 20 to 30 minutes. Typically, you'll schedule a series of six treatments, one every two weeks, and then periodic follow-up treatments to maintain the effect.

Photodynamic therapy

In addition to removing actinic kerotisis (see "Photodynamic therapy"), photodynamic therapy is being used to reduce fine lines and blotchiness from photoaging, as well as to rejuvenate the entire face and treat acne. Each treatment takes 45 to 90 minutes, and one to six treatments may be needed, with a cost of $800 per treatment.

Photorejuvenation with intense pulsed light

For improving mild to moderate photodamage with no recovery time and few complications, many people are turning to a procedure called photorejuvenation. Photorejuvenation uses an intense pulsed light (IPL) device. It's not a laser, but it emits bursts of broadband light energy that heats the epidermis and dermis and promotes new collagen growth.

Photorejuvenation dramatically improves the skin's texture and tone and may improve wrinkles. It can diminish freckles, red spots, age spots, and dilated blood vessels. It's also used to treat unwanted dark hair and the red cheeks or nose seen with rosacea. A clinical trial published in 2006 in Archives of Dermatology looked at the effects of pulsed light by giving volunteers treatments on one side of the face. After three treatments, 82% of patients had improved appearances on the treated side, most significantly with a reduction in dilated blood vessels and uneven pigmentation. There was no effect on wrinkles in this study. The researchers also noted that side effects were minimal and temporary.

For the procedure, the physician will coat your face with a gel and cover your eyes to protect them from the flash of light. When the device flashes, you'll feel a quick zap of heat, like the snap of a rubber band. Each flash treats an area about the size of a quarter, and you may have two or three passes in a 30 to 60 minute session. Afterward, you may have some redness or blotchiness for a day or two.

Most practitioners recommend five to six sessions, each costing approximately $600, spaced three or four weeks apart. Improvement is gradual, with most people able to notice a difference after three treatments. Maintenance treatments are required a few times a year.

Radiofrequency

Radiofrequency's claim to fame is its ability to tighten lax, sagging skin on cheeks, jowls, and brows. It is also effective on other areas of the body, such as the abdomen, hands, and feet. Unlike laser or light treatments, radiofrequency does not affect the surface quality of the skin, so it will not improve the appearance of fine lines or pigmentation problems.

The ThermaCool radiofrequency device is FDA-approved for treating fine lines around the eyes, forehead wrinkles, sagging jowls and cheeks, and other areas on the body. This device is made by Thermage Inc., and the term thermage is sometimes used to identify the radiofrequency treatment itself.

A radiofrequency device delivers an electromagnetic current to the skin, while a cooling spray protects the epidermis. The doctor can control the amount of energy delivered by the device. The skin's natural resistance slows the flow of electrons, which creates an intense, uniform, and sustained heat to the tissues underneath the skin's surface. The heat penetrates more deeply into the dermis and subdermal layers than lasers do in resurfacing. The dermis contains collagen fibrils, which give the skin its strength. When the dermal tissue is heated, the collagen fibrils become disrupted, then contract and thicken, tightening the skin layer below the surface. As the fibril layers heal, they are reshaped, and new collagen forms. This tightens the skin even more. The skin tightens in the three dimensions of the face — horizontally (from side to side), vertically (from top to bottom), and in depth (from the surface to the interior) — the way a wet sponge shrinks three-dimensionally when it dries.

Radiofrequency is one of the best ways to tighten the skin and change the contour of the face. Therefore, it's often touted as an alternative to a facelift. It is less expensive than a facelift, and it takes little to no recovery time, compared with two to three weeks for a facelift. But it doesn't offer the same amount of lift that surgery does. Unlike a traditional surgical facelift, radiofrequency doesn't lift muscle, so it's not likely to be as useful for people with advanced wrinkling and very saggy skin. It is more helpful to people in their late 30s to early 60s who have mild skin looseness and wrinkling.

It's impossible to predict exactly how much radiofrequency will tighten any individual's skin. According to experts, the success of radiofrequency depends heavily on the doctor's skill and familiarity with the latest techniques, which are evolving rapidly. Data on the technique's effectiveness are limited. One small, six-month study of ThermaCool that involved 86 patients who were treated on the forehead and temple area found improvement in 83% of those treated for wrinkles around the eyes, and reported that 50% of the patients were satisfied with the treatment.

Preparing for radiofrequency is simple. You may be asked to apply an anesthetic cream one hour before your procedure. Just before the procedure, your doctor may give you an injection or medication for the burning or pinching you'll feel when the machine fires. The sensation lasts only seconds, but it can be uncomfortable. Treatment takes about an hour or two, depending on the size of the area being treated and the number of passes the doctor makes. When first introduced, doctors believed that one pass over the face sufficed, but experience shows that additional passes over specific areas significantly improve results.

You can get back to your daily life immediately. You may have a little redness for an hour, but rarely any swelling, bruising, or pain. You won't need any special care, unless you're the unusual patient who has some crusting. In that case, your doctor will give you ointments to speed healing. Side effects are uncommon and usually temporary, but risks include blisters, burns, scars, and temporary bumps. Rarely, patients develop small, permanent indentations or dimples in the skin.

Usually only one treatment is needed. You may see immediate improvement, but the full benefits appear gradually over four to six months as the fibril layers heal and collagen production continues. Results may last for up to two years. Treating the lower face costs approximately $3,000, the upper face $2,000, and the full face $5,000.

Home treatments

Mild chemical peels, kits for microdermabrasion, and even a skin care laser are now available over the counter for use at home. The chemical peels and microdermabrasion kits use the same ingredients as professionals, but in lower concentrations. They can remove dead skin and diminish scars and fine lines, safely and conveniently, and for a fraction of the cost of professional treatment. But the results are less dramatic. They work best for minor skin flaws. For home laser treatments, thus far, there is no scientific evidence documenting their effectiveness.

Soft-tissue augmentation: Fillers and implants

Soft-tissue augmentation can create fuller lips, add height to cheekbones, improve the jaw line, diminish acne or surgical scars, and restore fullness to hollow cheeks and eyes. It can also fill in the nasolabial folds, the deep creases that run from the outside of the nostrils to the corners of the mouth that virtually no other skin rejuvenation procedure can correct. This technique minimizes deep lines, wrinkles, and grooves by lifting the surrounding skin and concealing surface imperfections. Fillers and implants are both beauty enhancers and buffers against telltale signs of aging.

Materials used include injectable fillers, like collagen, and semisolid implants that mimic the look and feel of the lips, cheeks, and plush layers of the skin. Some materials are permanent, while others are absorbed by the body after a few months, making the results temporary. There has been much innovation as new products have entered the marketplace. The sands have also shifted, with once-favored materials becoming less popular and once-feared materials being reborn in safer formulations (see "Choosing a filler or implant").

Choosing a filler or implant

With so many old and new selections, deciding which filler or implant might suit your needs has become a complicated process. Do you want something temporary that has a very low risk, or would you prefer something permanent, even if it has a higher complication rate? Are you willing to try a new product, or do you want something that has a proven track record?

You'll also need to consider the area you're having filled. For instance, using fat to fill an area that once had fat, such as the cheeks, can give that area a natural look. But fat may not take as well in areas that have very little fat, such as the forehead. Some lip fillers can have long-lasting complications. Permanent or semi-permanent fillers, such as Radiesse and ArteFill, can cause lumps when injected in the middle of the lips. Hyaluronic acid fillers give better results with lower risk. You should also take your doctor's expertise with a particular material into account. Different fillers require different techniques and may be difficult to use correctly.

Your doctor can help you decide what's best for you. The following information on commonly used fillers and implants may also help guide you.

Hyaluronic acid

Hyaluronic acid is a complex sugar that all vertebrate animals produce. It's found in numerous tissues, including the skin and cartilage. It has been produced for medical purposes from rooster combs, plants, and bacteria. Because it is the same from species to species, it carries little risk of allergic reactions. In the skin, hyaluronic acid is the natural cushion that occupies the spaces between the collagen and elastin fibers, adding bulk to the skin's dermis.

The FDA has approved several brands of hyaluronic acid as skin fillers, including Restylane, Hylaform, Captique, and Juvederm, and several other brands are awaiting approval. Hyaluronic acid gels come in a variety of viscosities that can treat a range of wrinkles and other problems. Thin solutions treat finer lines and wrinkles such as crow's feet, while thicker solutions fill in deeper nasolabial folds, add volume to the face, and make the lips fuller. Hyaluronic acid fillers last longest in the areas of the face that move the least — six months in the nasolabial folds and three to four months in the lips. Hyaluronic acid is more costly than collagen, but it can last twice as long, so it may be more cost-effective in the long run.

Collagen

Collagen used to be the mainstay of soft-tissue augmentation, but its use has declined as newer materials with fewer side effects and longer-lasting results have hit the market. In the past, the most common form of collagen was bovine collagen (Zyderm and Zyplast), derived from cows raised under conditions that minimize microbial contamination. However, pregnant women and people who are allergic to cow products may not use this product. Most people now opt for human-derived collagen. Two such products — CosmoDerm and CosmoPlast — come from cultures of human fibroblast cells, which produce collagen. They work almost identically to bovine collagen, without the risk of contamination.

You could use your own collagen, too, through a more complicated process called Autologen. If you're having a facelift or other surgery that will remove excess skin, your doctor can send the skin to a laboratory that will extract and process the collagen. In about four to six weeks, you can receive injections of your own collagen.

Collagen fillers are sometimes used with hyaluronic acid for lip augmentation, with collagen injected into the edges of the lips to add definition and hyaluronic acid injected into the middle of the lips. Collagen treatments last for two to four months.

Autologous fat transplants

Who doesn't have a bit of fat to spare? If you have some extra fat padding your hips, thighs, buttocks, or abdomen, it could become a filler. Using a limited liposuction procedure, physicians extract fat from the area chosen, process it, and then inject it to fill lines or contour hollow areas of your face. This is known as an autologous fat transplant. Most people have a touch-up in three or four months; your doctor will have frozen some of the extracted fat for this purpose. After the second treatment, many people find that results will last 5 to 10 years.

In many ways, fat is an ideal filler. It's readily available, easy to get, and inexpensive. It's noncarcinogenic, and if it comes from your own body, it won't cause an immune reaction. Once implanted, it stays in place and is extremely long-lasting. It works best when injected into another fat-containing site, such as areas around the nose and mouth, cheeks, cheekbones, or jaw line.

Using fat is more complex and expensive than other procedures, however, so some doctors and patients prefer other products. And because your wrinkles have formed in skin, not fat, some experts contend that fat isn't very effective, but others swear by it.

Gore-Tex

Made of the same material (polytetrafluoroethylene) used in waterproof, breathable clothing, Gore-Tex has had mixed success as a cosmetic implant. Gore-Tex implants become permanent because the body's tissues entwine themselves in the nonbiodegradable synthetic fibers, which anchor the implant in place. However, it can also cause infections. And for reasons not fully understood, the body's tissues sometimes reject the implant and push it out through the skin, although this is a rare complication.

Microdroplet silicone

Unlike collagen, which fills the small groove of a wrinkle, silicone works by inducing the skin to produce more tissue. Just as a grain of sand can be the start of a pearl in an oyster, silicone initiates a reaction in the skin, causing collagen-producing fibroblasts to grow around the tiny injected beads.

Silicone has a checkered past in the cosmetic world. Previously, silicone solutions were not regulated, and impurities caused serious adverse reactions, sometimes years later. In other cases, the problem was the technique used. Doctors thought silicone behaved like collagen, which shrinks a few weeks after injection. Instead, the injected areas expand as the skin's tissues build up around the silicone, so the treatment areas appeared overfilled.

As of 2006, silicone has FDA approval for treating a detached retina in the eye, and the material is regulated for purity. Although it isn't FDA-approved as a soft-tissue filler, doctors may use it in this way. According to experts, safety studies are expected to be submitted to the FDA so that silicone can be considered for reapproval as a cosmetic filler. Only time will tell if some patients develop a late reaction to the silicone used today.

Silicone fillers and implants are permanent, so be sure your doctor is well schooled in the art of injecting them. Today, most doctors fill the area slowly and carefully over many months, since it's easier to add more filler than to remove it. Many consider it to be the filler of choice for problems such as HIV-related loss of underlying fat and some types of acne scars.

Radiesse and ArteFill

Successful use of these synthetic, permanent injectables depends on the technique used and the skill of the physician.

Radiesse (formerly Radiance) is a combination of gel and particles made of calcium hydroxylapatite, a substance found in teeth and bone. This material is used in orthopedics as a bone cement. As a filler, it provides a scaffolding for fibroblasts to inhabit while secreting collagen. The material usually lasts for a year or more before diminishing. Radiesse is approved by the FDA for use in the nasolabial folds and for the treatment of fat loss in the cheeks associated with HIV.

ArteFill, approved in 2006, contains tiny plastic beads of polymethylmethacrylate suspended in bovine collagen. The body absorbs the collagen, and the beads are engulfed by your own collagen to form a lasting implant that lifts lines, wrinkles, scars, and atrophic areas. Aside from uncommon allergic reactions to bovine collagen, side effects may include inflammation and small bumps in the skin.

With aging, many people lose collagen and fat under the skin. This process is called soft-tissue atrophy. Soft-tissue loss commonly affects the lips and corners of the mouth, chin, cheeks, the areas under and between the eyes, and the nasolabial folds. As these areas become less plump, they wrinkle more easily. Soft-tissue augmentation can often remedy this. However, if aging has changed the underlying bones and cartilage in your face, a better option may be a facelift. (Aging can also deposit tissue in some areas, such as in the jowls and neck. A facelift may also be the best remedy for these problems.)

People of all ages — from young starlets to grandparents — get fillers and implants. In 2005, doctors performed more than 1.6 million facial soft-tissue augmentation procedures. The procedures enjoy popularity because they can accentuate the positive and minimize the negative in your face. They aren't as invasive or costly as a facelift, the main alternative, and they don't require much recovery time.

Injectable fillers come in different concentrations and formulations, depending on the depth of lines and wrinkles to remedy. For example, a thicker formulation more effectively fills in deeper wrinkles and fills out thin lips. Most fillers come in preloaded syringes, making the doctor's job easier.

With fillers, it's likely that you'll receive injections at several sites. Usually, the doctor inserts tiny amounts in the superficial dermis, carefully layering the material up to the desired fullness. He or she then gently rubs the area to spread the material evenly. Otherwise, a lumpy texture can develop. A session typically takes 15 to 30 minutes, and costs vary with the material used. You'll need little follow-up care, other than ice to reduce redness and swelling during the first few hours. The hyaluronic acid fillers such as Restylane and Juvederm cause some redness and swelling in the first two to four days, but collagen doesn't.

Implants, whose use has declined in recent years, are more complicated and painful to place than injectable fillers, and you'll need local anesthesia for the procedure. Implants often come as thin sheets rolled up into tubes. The doctor makes an incision, inserts the tube, and molds it into place. To augment your lips, for instance, the doctor makes incisions at the corners of your mouth, eases the material into the lips, molds gently, and closes the incision with small sutures that will remain for five to seven days. The process may take one or two hours and is often performed in the physician's surgical office. You can return to your regular activities as soon as any sedation has worn off. The local anesthesia will leave your mouth feeling numb for one to three hours. You might have minor bruising or swelling for three days or more. Some people get Botox injections at the same time to quiet the muscles so the implanted materials don't shift while they are still pliable.

A disadvantage of fillers is that the results depend heavily on the doctor's technique. In some cases, though, overfilling is the result of the client asking for more material to be deposited. In addition, occasionally a solid implant extrudes through the skin, sometimes years after the initial procedure. If the filler naturally diminishes with time, irregularities will disappear soon. But if the material is permanent, the mistake can be too. Surgically removing or correcting an imperfect solid permanent filler or implant can be difficult, if not impossible. Therefore, take extreme care in learning about your doctor's proficiency with a particular technique, especially if it is new. It's a good sign if the doctor has experience with several different materials.

If you are considering soft-tissue augmentation, here are some questions to ask your doctor:

How long have you used this product or technique? How often do you use it?

What material is the filler or implant?

Is the material natural or synthetic?

How often do you see side effects or complications?

Are the results temporary, long-lasting, or permanent?

If the procedure is permanent, can I have it modified or removed?

How widely used is this product? If it is new or uncommon, is it substantially better for my needs than other products?

Review Date: 2007-03-01

Harvard Medical School does not endorse products or services.

Skin rejuvenation procedures

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In-Depth Report

Skin rejuvenation procedures

Doctor or aesthetician?

Choosing a doctor

Questions to ask a doctor

Choosing an aesthetician

Botox (botulinum toxin)

Figure 4: Down with the frown

Chemical peels

Going out of style: Deep peels and dermabrasion

Laser and other procedures

Finding the right combination

How lasers work

Ablative laser resurfacing

Fractional resurfacing

Plasma skin regeneration

Non-ablative laser resurfacing

Lasers for pigmentation, hair removal, and other problems

LED photomodulation

Microdermabrasion

Photodynamic therapy

Photorejuvenation with intense pulsed light

Radiofrequency

Home treatments

Soft-tissue augmentation: Fillers and implants

Choosing a filler or implant

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