Facial Rejuvenation: Lotions, Potions, Lasers and Peels

Introduction
The goal of restoring a more youthful appearance motivates many patients to consult specialists in a variety of medical disciplines.

New innovations in skin rejuvenation continue to develop, ranging from topically applied (directly to the skin) prescription medications and over-the-counter "cosmeceuticals" to innovative facelift, browlift, and blepharoplasty (reconstruction of the eyelid) surgery techniques; soft tissue augmentation (implants); botulinum toxin; and new laser technology.

A thorough understanding of how your skin changes as you age and how the sun affects your skin can help you decide with your doctor which treatments are best.

What causes skin changes?
The major factors contributing to skin changes include normal aging, exposure to the sun (photoaging), and loss of subcutaneous support (the fatty tissue between your skin and muscle). Secondary factors causing skin changes include gravity, facial movement, and sleep position.

Primary skin changes

Skin changes related to aging
Changes caused by normal aging include:

• Roughness
• New, abnormal tissue growth (called benign neoplasms)
• Loss of elastic tissue. The quality of elastin (elastic fibers) and collagen (important protein in the skin) deteriorates with age, so the skin is slack and hangs loosely.
• Transparent quality of the skin, caused by thinning of the epidermis (surface layer of the skin)
• Increased skin fragility caused by flattening of the area where the epidermis and dermis (layer of skin under the epidermis) come together
• Easy bruising caused by thinner blood vessel walls

Skin changes caused by exposure to the sun
Excessive sun exposure through jobs, recreation, and tanning booths causes several changes in the layers of the skin. The epidermis becomes thinner, and changes in keratin (a fibrous protein) causes roughness. In addition, poor distribution of pigment (melanosomes) causes a dull skin color.

In addition, sun exposure can cause the following skin changes:

• Fine and coarse wrinkles
• Freckles
• Discolored areas of the skin (mottled pigmentation)
• Sallowness (yellow discoloration of the skin)
• Telangiectasias (dilation of a group of small blood vessels)
• Elastosis (destruction of the elastic tissue), which causes lines
• New, abnormal tissue growth (benign neoplasms)
• Precancerous and cancerous skin lesions (caused by a loss of the skin's immune function)

Subcutaneous skin changes

• Subcutaneous fat loss in the cheeks, temples, chin, nose, and eye area may result in loosening skin, sunken eyes, and a "skeletal" appearance.
• Bone loss, mostly around the mouth and chin, may become evident after age 60 and cause puckering of the skin around the mouth.
• Cartilage loss in the nose causes drooping of the nasal tip and accentuation of the bony structures in the nose.

Secondary skin changes
Gravity, facial movement, and sleep position are the secondary factors that contribute to changes in the skin.

When the skin loses its elasticity, gravity causes drooping of the eyebrows and eyelids, looseness and fullness under the cheeks and jaw (jowls and "double chin"), and longer ear lobes.

Facial movement lines become more visible after the skin starts losing its elasticity (usually as people reach their 30s and 40s). Lines may appear horizontally on the forehead, vertically above the root of the nose, or as small curved lines on the temples, upper cheeks, and around the mouth.

Sleep creases result from the way the head is positioned on the pillow, and may become more visible after the skin starts losing its elasticity. Sleep creases are commonly located on the side of the forehead, starting above the eyebrows to the hairline near the temples, as well as on the middle of the cheeks. Changing sleep position may improve these sleep creases or prevent them from becoming worse.

Before facial rejuvenation
Before deciding on any facial skin treatment, you will meet with your health care provider, who will assess your skin changes. First, your health care provider will thoroughly review your medical, surgical, and psychological history. He or she will also ask if you have had previous cosmetic surgery and if you were satisfied with the results.

By asking you a series of questions, your doctor will evaluate which skin changes concern you the most. Then, your doctor will work with you to determine the most appropriate nonsurgical and/or surgical treatment options.

The type of treatment your doctor recommends will depend on your goals, expectations, and willingness to invest recovery time and money. Unfortunately, some consumer publications have, at times, provided unrealistic pictures of what various cosmetic procedures can and cannot do. You should fully discuss all of your expectations with your doctor before your procedure so you know what type of outcome to realistically expect. These misconceptions should be discussed before your procedure so you know what type of outcome to expect.

Evaluating your skin type
Before the procedure, your skin type will first be evaluated. In general, patients with skin types I to III (those with whiter complexions who usually burn when exposed to the sun) are good candidates for chemical peels, dermabrasion, and laser resurfacing. Patients with darker skin types IV to VI (those with moderate brown to dark brown complexions who tan easily and rarely burn) may not be good candidates for these procedures.

Treatment options for skin damaged by the sun
The following table provides guidelines for treating varying degrees of sun damage.

Treatment options

Tretinoin (Retin-A and Renova)
Retin-A was approved by the FDA in 1971 for the treatment of acne. It was later noted that skin texture and color were improved with prolonged use of Retin-A. Tretinoin increases the thickness of the epidermis, expands skin collagen and blood vessels, and reduces the outermost layer of the skin (which consists of dead cells that continually flake away). Many patients can benefit from using a tretinoin product at bedtime and a cream or lotion containing glycolic acid and sunscreen in the morning.

Side effects of tretinoin include redness, peeling, tightness, and swelling. Tretinoin makes the skin more sensitive to the ultraviolet rays of the sun, so patients being treated with tretinoin therapy must use a broad spectrum sunscreen with at least an SPF of 15 every morning.

Renova is a relatively new formulation (emollient base) of tretinoin. The concentration of tretinoin in this product is 0.05%. Because of its formulation, Renova may be better for patients who are unable to tolerate Retin-A because of the irritation it causes.

Vitamin C
Topical vitamin C (L-ascorbic acid, brand name Cellex-C) has been shown to improve skin color and texture. Preliminary studies with this formulation have demonstrated that it protects against ultraviolet rays (UVA and UVB) and prevents ultraviolet-induced immunosuppression. Vitamin C's activity as an antioxidant may protect the skin from damage produced by ultraviolet light exposure.

Alpha hydroxy acids (AHAs)
The alpha hydroxy acids (glycolic, lactic, tartaric, and citric acid) have become increasingly popular over the last five years;  there are approximately 185 manufacturers of alpha hydroxy acid-containing products in the United States. Topically applied creams and lotions containing alpha hydroxy acids, used alone or in combination with a series of glycolic acid peels, can reduce fine lines, even out pigmentation, and decrease enlarged pores.

Salicylic acid
Salicylic acid, a beta hydroxy acid, has also been studied for its effect on photoaged skin. Because salicylic acid is lipid-soluble (in contrast to water-soluble alpha hydroxy acids), it may penetrate oil-laden follicle openings into the hair follicles. Studies have shown salicylic acid to be less irritating than alpha hydroxy acid-containing products, while providing similar improvement in skin texture and color.

Chemical peels
Chemical peels are effective for removing fine lines and smoothing out the skin. Chemical peels remove the upper surface of the skin to expose newer, clearer skin. After the upper layers have been removed, a new layer of skin develops. Chemical peels can be used in areas that are not improved by a facelift, such as the eyelids and around the mouth.

Depending on the patient's skin type and degree of sun damage, a surface, medium, or deep chemical peel may be the appropriate treatment:

• Surface (superficial) peels produce a wounding of the epidermis and papillary dermis, and include glycolic acid, Jessner's (salicylic acid, resorcinol, and lactic acid), and low strength (10 to 25 percent) trichloroacetic acid peels.
• Medium-depth chemical peels produce a wounding of the upper reticular dermis, and can be performed using 35 to 50 percent trichloroacetic acid or full strength phenol 88 percent.
• Deep chemical peels penetrate to the mid-reticular dermis. These peels can be performed using a combination product containing phenol, called the Baker's phenol peel. Baker's phenol peels may improve deep facial wrinkles, but carry the risk of causing heart and kidney problems, in addition to hypopigmentation (diminished skin coloration).

Swelling of the treated area is common for about 7 days after medium and deep peels. Immediately after peeling, the skin loses its ability to tan, so sunblock should always be used. The recovery time from chemical peels is generally short, but depends on how deeply the peel affects the skin.

Complications of chemical peels include hyperpigmentation (increased skin coloration), hypopigmentation, scarring, bacterial infections, herpes simplex infection, prolonged redness and itching, in addition to the systemic complications from deep chemical peels mentioned above.

Dermabrasion
Dermabrasion is performed to remove lines and some scarring and can be used to treat moderate to severe photodamage (sun damage). Dermabrasion has similar side effects and complications as medium and deep chemical peels. However, because of the bleeding associated with dermabrasion and variations in skill and technique, the control of wounding is not as accurate and easy to reproduce as current laserabrasion technology. Dermabrasion is not done on the thin skin around the eyes, which may be chemically peeled at the same time. Care must also be taken when dermabrading the skin around the mouth.

Laser resurfacing
In the past few years, the development of high energy carbon dioxide lasers has enhanced physicians' ability to improve photoaged skin, various types of scars, and other dermatologic conditions. The precise depth control and ability to treat large areas in a relatively short amount of time make these carbon dioxide lasers valuable tools.

Before laser resurfacing
Before laser resurfacing is performed, your doctor will discuss with you other treatment options, what to expect during recovery, how to take care of your skin after the procedure, and possible side effects and complications. Camouflage makeup suggestions will also be discussed.

Patients with skin types I to III (those with whiter complexions who usually burn when exposed to the sun) are the best candidates for resurfacing. Patients with darker skin types (those with moderate brown to dark-brown complexions who tan easily and rarely burn) are at greater risk for postoperative hyperpigmentation, and may be placed on a medication containing hydroquinone for two to four weeks before surgery to minimize this risk.

Usually, oral antiviral medications (such as acyclovir or valacyclovir) are prescribed before the procedure. These medications  should also be taken for seven to 10 days after the procedure to decrease the risk of developing the herpes simplex infection. A broad spectrum antibiotic may also be prescribed to decrease the risk of bacterial infections.

During the procedure, you will receive anesthesia and your eyes will be protected with eye shields. Individual wrinkles may be treated, or the entire facial area may be resurfaced. In general, superior results are achieved when treating entire cosmetic units, such as the skin around the mouth and eyes.

After laser resurfacing
Touch-up laser abrasion for deep lines or scars may be performed six to 12 months after laser resurfacing. Resurfacing of the skin around the eyes may be performed at the same time as a facelift. The skin around the eyes may also be resurfaced at the same time as a blepharoplasty.

Skin will begin to grow over the treated area about seven to 14 days after the procedure. Camouflage makeup may be worn at this time. Green-based makeups are especially helpful in camouflaging the redness, which usually lasts two to three months after the procedure (up to six months in fair-skinned people). Skin peeling may occur for up to four weeks after the new skin growth. You may receive a low-potency steroid cream to apply as needed to relieve itching during the healing phase.

After the procedure, sun protection is essential. You will need to try to avoid the sun and use a broad spectrum sunscreen every day when going outside. Six to eight weeks after the procedure, retinoic acid, glycolic acid, and hydroquinone preparations may be restarted, as prescribed by your doctor.

Potential complications of laser resurfacing include a skin irritation or rash (reaction to topical medications), post-traumatic eczema, herpes simplex virus, bacterial infections, yeast infections, persistent redness, hyper- or hypopigmentation, scarring, or ectropion (turning out of the skin, possibly the edge of the eyelid).

How effective is laser resurfacing?
Studies to date have shown that the procedure tightens the skin. Results are still being discovered, since the technology is fairly new. The results of the procedure also will vary, depending on the patient's age, degree of sun damage, postoperative skin care, and sun protection.

The Erbium:YAG laser uses a wavelength of 2.94 microns, which is ten 10 times better absorbed by water than the 10.6 micron C02 laser. Preliminary comparative studies of resurfacing results and healing course using both lasers have shown that the Erbium:YAG laser provided a quicker recovery from postoperative redness and new skin growth over the treated area. The Erbium:YAG laser causes less thermal damage, with comparable line improvement in many cases. The pulse duration and variable spot size allow rapid treatment, requiring less anesthesia.

Summary
The physician's palette of resurfacing options continues to expand. In patients with early skin aging changes, nonsurgical treatment methods such as tretinoin, vitamin C, and alpha hydroxy acids may provide satisfactory improvement. Chemical peels, dermabrasion, and laserabrasion may be used alone or in combination with other surgical procedures to treat moderate to severe degrees of facial photodamage.

Deeper facial lines may be treated with botulinum toxin or soft tissue enhancement, including collagen, autologous fat, and Gore-Tex implants. Patients with more sagging, excess skin will benefit from additional procedures such as facelift, browlift, and blepharoplasty. Treatment must be individualized according to the patient's facial characteristics and cosmetic concerns.