WHAT CAUSES WRINKLES?

Aging Process and Wrinkles

As a person ages, skin undergoes significant changes:

• The cells divide more slowly, and the inner layer of skin (the dermis) starts to thin. Fat cells beneath the dermis begin to atrophy (diminish). In addition, the ability of the skin to repair itself diminishes with age, so wounds are slower to heal. The thinning skin becomes vulnerable to injuries and damage.
• The underlying network of elastin and collagen fibers, which provides scaffolding for the surface skin layers, loosens and unravels. Skin then loses its elasticity. When pressed, it no longer springs back to its initial position but instead sags and forms furrows.
• The sweat- and oil-secreting glands atrophy, depriving the skin of their protective water-lipid emulsions. The skin's ability to retain moisture then diminishes and it becomes dry and scaly.
• Frown lines (those between the eyebrows) and crow's feet (lines that radiate from the corners of the eyes) appear to develop because of permanent small muscle contractions. Habitual facial expressions also form characteristic lines.
• Gravity exacerbates the situation, contributing to the formation of jowls and drooping eyelids. (Eyebrows, surprisingly, move up as a person ages, possibly because of forehead wrinkles.)
• Wrinkles can have a profound impact on self-esteem. Indeed, the stigma attached to looking old is evidenced by the fact that Americans spend more than $12 billion each year on cosmetics to camouflage the signs of aging. Our current society places a premium on youthfulness, and age discrimination in the workplace, although illegal, has stalled many a person's career. Indeed, the emotional ramifications of aging explain in large part why the cosmetics industry and plastic surgeons thrive.

Ultraviolet Radiation, Sunlight, and Photoaging

The role of the sun cannot be overestimated as the most important cause of prematurely aging skin (called photoaging) and skin cancers. Overall, exposure to ultraviolet (referred to as UVA or UVB) radiation emanating from sunlight accounts for about 90% of the symptoms of premature skin aging, and most of these effects occur by age 20:

• Even small amounts of UV radiation trigger process leading to skin wrinkles.
• Long-term repetitive and cumulative exposure to sunlight appears to be responsible for the vast majority of undesirable consequences of aging skin, including basal cell and squamous cell carcinomas.
• Melanoma is more likely to be caused by intense exposure to sunlight in early life.

Initial Damaging Effects of Sunlight. Sunlight consists of ultraviolet (referred to as UVA or UVB) radiation, which penetrates the layers of the skin. Both UVA and UVB rays cause damage leading to wrinkles, lower immunity against infection, aging skin disorders, and cancer. They appear to damage cells in different ways, however.

• UVB is the primary agent in sunburning and primarily affects the outer skin layers. UVB is most intense at midday when sunlight is brightest. Slightly over 70% of the yearly UVB dose is received during the summer and only 28% is received during the remainder of the year.
• UVA penetrates more deeply and efficiently, however. UVA's intensity also tends to be less variable both during the day and throughout the year than UVB's. For example, only about half of the yearly UVA dose is received during the summer months and the balance is spread over the rest of the year. UVA is also not filtered through window glass (as is UVB).

Both UVA and UVB rays cause damage, including genetic injury, wrinkles, lower immunity against infection, aging skin disorders, and cancer, although the mechanisms are not yet fully clear.

Processes Leading to Wrinkles. Even small amounts of UV radiation trigger the process that can cause wrinkles. :

• Sunlight damages collagen fibers (the major structural protein in the skin) and causes accumulation of abnormal elastin (the protein that causes tissue to stretch).
• In response to this sun-induced elastin accumulation, large amounts of enzymes called metalloproteinases are produced. (One study indicated that when people with light to moderate skin color are exposed to sunlight for just five to 15 minutes, metalloproteinases remain elevated for about a week.)
• The normal function of these metalloproteinases is generally positive, to remodel the sun-injured tissue by manufacturing and reforming collagen. This is an imperfect process, however, and some of metalloproteinases produced by sunlight actually degrade collagen. The result is an uneven formation ( matrix) of disorganized collagen fibers called solar scars . Repetition of this imperfect skin rebuilding over and over again causes wrinkles.
• An important event in this process is the over-production of oxidants, also called free radicals. These are unstable molecules that are normally produced by chemical processes in the body, a process called oxidation. With environmental assaults, however, such as from sunlight, they are produced in excessive amounts and damage the body's cells and even alter their genetic material. Oxidation may specifically contribute to wrinkling by activating the specific metalloproteinases that degrade connective tissue.

There is a possible upside to wrinkles and sun exposure. A 2001 study reported that people with more wrinkles were less likely to develop basal cell carcinomas, even among high-risk groups. Some experts suggest that people prone to wrinkles may respond to sun exposure with biologic mechanisms that protect against basal cell carcinoma. More research is needed confirm this.

Other Factors Responsible for Wrinkles

In addition to sunlight, other factors may hasten the formation of wrinkles:

Cigarette Smoke. Smoking produces oxygen-free radicals, which are known to accelerate wrinkles and aging skin disorders and increase the risk for nonmelanoma skin cancers. Studies also suggest that smoking and subsequent oxidation produce higher levels of metalloproteinases, which are enzymes associated with wrinkles.

Air Pollution. Ozone, a common air pollutant, may be a particular problem for the skin. One study reported that it might deplete the amount of vitamin E in the skin; this vitamin is an important antioxidant.

Rapid Weight Loss. If weight loss occurs to rapidly, the volume of fat cells that cushion the face are also decreased before chemicals in the skin can react. This not only makes a person look gaunt, but can cause the skin to sag.

WHO IS MOST LIKELY TO HAVE WRINKLES?

Age and Risk

Exposure to Sun in Childhood. It is estimated that 50% to 80% of skin damage occurs in childhood and adolescence from intermittent, intense sun exposure that causes severe sunburns. In spite of this now well-known effect, many people still believe that a tan in children signifies health. And, even many parents who are concerned about sun exposure still rely too much on sunscreen and not enough on protective clothing.

The Elderly. Most people over 70 have at least one skin disorder and many have three or four. Everyone experiences skin changes as they age, but a long life is not the sole determinant of aging skin. Family history, genetics, and behavioral choices all have a profound impact on the onset of aging-skin symptoms.

Activities Leading to Overexposure to Sunlight and Ultraviolet Radiation

Of all the risk factors for aging skin, exposure to UV radiation from sunlight is by far the most serious. Indeed, the vast majority of undesirable consequences of aging skin occur in individuals who are repetitively exposed to the sun, including the following:

• Outdoor workers, such as farmers, fishermen, construction workers, and lifeguards.
• Outdoor enthusiasts.
• Sunbathers.
• People who regularly attend tanning salons or use tanning beds. A 2002 study indicated that regular use significantly increases the risk for nonmelanoma skin cancers. Fair women under age 50 were at particular risk.

Skin Types

Experts have devised a classification system for skin phototypes (SPTs) based on the sensitivity to sunlight. It ranges from SPT I (lightest skin plus other factors) to IV (darkest skin). [ See Table ] People with skin types I and II are at highest risk for photoaging skin diseases, including cancer. It should be noted, however, that premature aging from sunlight can affect people of all skin shades.

Tanning and Sunburn History

Gender

It is commonly believed that women are at greater risk for wrinkles than men are. Some evidence suggests, however that, given the same risk factors, men and women in the same age groups have comparable risks for skin photoaging. In fact, in one 1999 study, long-term sun exposure caused a greater number of wrinkles in men than in women. In a French study, the evidence of moderate to severe photoaging was observed in the following:

• In 22% of women and 17% of men between the ages of 45 and 49.
• In 36% of women and 38% of men by age 54.
• Nearly half of both men and women by age 60.

In fact, some studies report that men are more likely to develop nonmelanoma skin cancers.

Smokers

According to one study, heavy smokers are almost five times as likely to have wrinkled facial skin than nonsmokers. In fact, heavy smokers in their 40s often have facial wrinkles more like those of nonsmokers in their 60s. Studies of identical twins have found smokers to have thinner skin (in some cases by as much as 40%), more severe wrinkles, and more gray hair than their non-smoking twins. And even worse, cigarette smokers are more prone to skin cancers, including squamous cell carcinoma and giant basal cell carcinomas. [For more detailed information, see Smoking.]

WHAT ARE WAYS TO AVOID SUN EXPOSURE?

Staying out of the Sun

The best way to prevent skin damage in any case is to avoid episodes of excessive sun exposure. The following are some specific guidelines:

• Avoid exposure particularly during the hours of 10 AM to 4 PM when sunlight pours down 80% of its daily UV dose.
• Avoid reflective surfaces, such as water, sand, concrete, and white-painted areas. (Clouds and haze are not protective, and in some cases may intensify UVB rays.)
• Ultraviolet intensity depends on the angle of the sun, not heat or brightness. So the dangers are greater the closer to the summer-start date. For example, in the Northern Hemisphere, UV intensity in April (two months before summer starts) is equal to that in August (two months after summer begins).
• The higher the altitude the quicker one sunburns. (One study suggested, for example, that an average complexion burns at six minutes at 11,000 feet at noon compared to 25 minutes at sea level in a temperate climate.)
• Avoid sun lamps and tanning beds. They provide mostly UVA rays, and some experts believe that 15 to 30 minutes at a tanning salon are as dangerous as a day spent in the sun.

Sunscreens

The use of sunscreens is complex and everyone should understand how and when to use them. The bottom line is not that people should avoid sunscreens or sunblocks but that they should always use them in combination with other sun-protective measures. [ See Box Sunscreen Guidelines.]

Protective Clothing

Wearing sun-protective clothing is extremely important and protects even better than sunscreens. Special clothing is now available for blocking UV rays and is rated using SPF ratings or a system called the UPF (ultraviolet protection factor) index, with 50 UPF being the highest. (According to one study, this is a very reliable indicator of protection.) The clothing is expensive, however. The following are some tips for anyone:

• Everyone, including children, should wear hats with wide brims. (Even wearing a hat, however, may not be fully protective against skin cancers on the head and neck.)
• People should look for loosely fitted, unbleached, tightly woven fabrics. The tighter the weave the more protective the garment.
• Washing clothes over and over improves UPF by drawing fabrics together during shrinkage. An easy way to assess protection is simply to hold the garment up to a window or lamp and see how much light comes through. The less the better.
• Everyone over age one should wear sunglasses that block all UVA and UVB ray.

Chemical Tanners

Some research suggests that melanin and dihydroxyacetone (DHA), the active ingredients in many self-tanning lotions, may help filter out UVA and UVB radiation and so be protective against sun damage. More research is underway.

WHAT ARE SOME HOME CARE TREATMENTS FOR REDUCING WRINKLES?

Healthy Lifestyle

Needless to say, the best long-term prevention for overly wrinkled skin is a healthy lifestyle including the following:

Eat Healthily. A diet with plenty of whole grains, fresh fruits and vegetables, and the use of healthy oils (such as olive oil) may protect against oxidative stress in the skin. In fact, a 2001 study reported that people over 70 years old had fewer wrinkles if they ate such foods. Diet played a role in improving skin regardless of whether the people in the study smoked or lived in sunny countries. Benefits from these foods may be due to high levels of anti-oxidants found in them.

Exercise. Daily exercise keeps blood flowing, which brings oxygen to the skin, an important ingredient for healthy skin.

Reduce Stress. Reducing stress and tension may have benefits on the skin.

Quit Smoking. Smoking not only increases wrinkles, but smokers have a risk for squamous cell cancers that is 50% higher than nonsmokers' risk. Smokers should quit to prevent many health problems, not just unhealthy skin. [For more detailed information, see Smoking.]

Daily Preventive Skin Care

Some daily measures for skin protection are as follows:

• Don't wash face too often with tap water. (Once a day is enough.) It strips the skin of oil and moisture. In addition, chlorinated water, particularly at high temperatures, poses special risks for wrinkles.
• Wash the face with a mild soap that contains moisturizers. Alkaline soaps, especially with deodorant, should be avoided.
• Pat the skin dry and immediately apply a water-based moisturizer.
• Always apply sunscreen, even if going outdoors for short periods.
• Avoid drinking alcohol within three hours of bedtime. Alcohol increases the risk for leaks in the capillaries, which allows more water in and causes sagging and puffiness. Capillary leakage increases when one is lying down.
• Lie on the back when sleeping. This helps offset the effects of gravity.

Antioxidant Products: General Information

Antioxidants are substances that act as scavengers of oxygen-free radicals, the unstable particles that can damage cells and which are implicated in sun damage and even skin cancers. Antioxidants in the skin are depleted when exposed to sunlight and must be replaced. Antioxidant topical products (such ointments, creams, and lotions) may help reduce the risk of wrinkles and protect against sun damage. Unlike sunscreens, they accumulate in the skin and are not washed away, so the protection may last. The antioxidants marketed for skin protection include vitamins A, C, E, selenium, coenzyme Q10 (CoQ10), and alpha-lipoic acid.

Some research has been conducted on the effects on wrinkles using oral antioxidant supplements. One small study found that taking a combination of vitamins oral C and E supplements may help reduce sunburn reactions, although the protection is much less than from sunscreens. (Taking the vitamins singly does not appear to have the any effect.)

Antioxidants: Vitamin A Topical Products

Vitamin A is important for skin health and UV radiation produces deficiencies in the skin. Topical products containing natural forms of vitamin A (retinol, retinaldehyde) or vitamin A derivatives called retinoids (tretinoin, tazarotene) have proven to be beneficial for skin damaged by the sun and also by natural aging.

Tretinoin (Retin-A). Tretinoin (known commercially as Retin-A) is the only topical agent approved for treating photoaging and is available in prescription form (Avita, Renova, Differin). This agent produces a rosy glow and reduces fine and large wrinkles, liver spots, and surface roughness. It also may help prevent more serious effects of ultraviolet radiation. Tretinoin may be applied to face, neck, chest, hands, and forearm and should be applied at least twice a week. Noticeable improvement takes from two to six months. Because Retin-A increases a person's sensitivity to the sun, a thin coat is best administered at bedtime. A sunblock should be worn during the day, and overexposure to the sun should be avoided.

Almost all patients experience redness, scaling, burning, and itching after two or three days that can last up to three months. In women who experience irritation, a daytime moisturizer or low-dose corticosteroid cream, such as 1% hydrocortisone, may help. There is some concern that overuse of high-dose tretinoin may cause excessive skin thinness over time. Studies now suggest that low concentrations (as low as .02%) of tretinoin can produce significant improvements in wrinkles and skin color, with less irritation than at higher doses. Oral tretinoin causes birth defects, and women should avoid even topical Retin-A when pregnant or trying to conceive.

Retinol. Retinol, a natural form of vitamin A, could not, until recently, be used in skin products because it was unstable and easily broken down by UV radiation. Stable preparations are now sold over the counter. In the right concentrations, retinol may be as effective as tretinoin and studies indicate that it has fewer side effects. An animal study suggests that adding antioxidant creams (such as those containing vitamins C or E) may offer added protection against degradation of retinol, but not tretinoin. The FDA warns that over-the-counter retinol skin products are unregulated; the amount of active ingredients is unknown, and some preparations, in fact, may contain almost no retinol.

Tazarotene. Tazarotene (Tazorac, Zorac) is a retinoid used for acne and psoriasis. One short-term study suggested that it may be as effective as tretinoin and even slightly better at high doses. At such high doses, however, it can cause very severe irritation. Redness and peeling may be reduced by administering tretinoin first to get the skin acclimated. More research is needed to determine if it produces any long-lasting significant benefits. As with any vitamin A derivative, it should be avoided by pregnant women and those who may become pregnant.

Antioxidants: Other Topical Products

Although there are wide claims about the benefits of antioxidants for wrinkles when used in skin creams, to date, only vitamins E and C and selenium applied topically have been proven to have any benefits for reducing sun damage in the skin. Even with these antioxidants, however, most available brands contain very low concentrations of them. In addition, they are also not well absorbed and they have a short-term effect. New delivery techniques, however, may prove to offset some of these problems.

• Vitamin C, or ascorbic acid. This is a very potent antioxidant and most studies on the effects of antioxidants on the skin have used this vitamin. In laboratory studies, large amounts reduced skin swelling and protected immune factors from sunlight. It may even promote collagen production. Vitamin C by itself is unstable, but products that solve the delivery problem are now available (e.g., Cellex-C, Avon's Anew Formula C Treatment Capsules, and others). One 2002 study using Cellex-C reported reduction in wrinkles around the mouth, on the cheek, and around the eyes. The product also appeared to improve skin thickness.
• Vitamin E. Studies suggest that topical vitamin E, particularly alpha tocopherol (a form of vitamin E) cream decreased skin roughness, length of facial lines, and wrinkle depth. Studies on mice have also reported reductions in UV-induced skin cancer with its use.
• in the form of L-selenomethionine has protected against sun damage and even delayed skin cancer in animal studies. It is not known if such benefits apply to people.
• One 1999 study found that topical application of the antioxidant Coenzyme Q10 (CoQ10) improved the skin's resistance to the oxidative stress of UV radiation, and when applied long-term, could reduce crow's feet.

Alpha Hydroxy Acid and Home Exfoliation

One of the basic methods for improving skin and eliminating small wrinkles is exfoliation (also called resurfacing), which is the removal of the top layer of skin to allow regrowth for new skin. Methods for doing this run from simple scrubs to special creams to intensive peeling treatments, including laser resurfacing. [See What Are Professional Resurfacing Procedures for Skin Wrinkles?] People with darker skin are at particularly higher risk for scarring or discoloration with the more powerful exfoliation methods.

Abrasive Scrubs. Scrub gently with a mildly abrasive material and a soap that contains salicylic acid to remove old skin so that new skin can grow. The motion should be perpendicular to the wrinkles. Use textured material or cleansing grains with microbeads. Organic materials, such as loofahs or sea sponges may harbor bacteria. Avoid cleansing grains that contain pulverized walnut shells and apricot seeds, which can lacerate skin on a microscopic level. Cleansing grains with microbeads don't have sharp edges and remove skin without cutting it. Exfoliation using scrubs, however, can worsen certain conditions, such as acne, sensitive skin, or broken blood vessels.

Topical Alpha Hydroxy Acid and Similar Substances. Alpha hydroxy acids facilitate the shedding of dead skin cells and may even stimulate the production of collagen and elastin. They are found naturally as follows:

• Lactic acid (milk).
• Glycolic acid (sugar cane).
• Malic acid (found in apples and pears).
• Citric acid (oranges and lemons).
• Tartaric acids (grapes).

Lactic and glycolic acids are used most often in commercial products. The preparations containing lactic acid may be slightly more effective than those made with glycolic acid. Products have also been developed that are made from larger molecules called poly-alpha-hydroxy acids and others from beta-hydroxy acids or BHAs (usually containing salicylate acid, the primary ingredient in aspirin). Manufacturers claim that such products are less likely to irritate the skin.

Acid concentrations in over-the-counter AHA preparations are 2% to 10%. One clinical study suggested that 8% concentrations showed modest improvement. Some examples include Avon's Anew Intensive Treatment (8% glycolic), Pond's Age Defying Complex (8%), Elizabeth Arden's Alpha-Ceramid Intensive Skin Treatment (3% to 7.5%), and BioMedic's home product (10%). Prescription strength creams contain at least 12% glycolic acid, and glycolic acid peels of 30% to 70% concentration may be administered in a doctor's office at weekly or monthly intervals.

Response to AHA varies, and the treatment is not without risk, particularly in high-concentration products. Side effects from over-the-counter creams, prescription products, and professional AHA peels can include burns, itching, pain, and possibly scarring. Studies also suggest that AHA may increase sun damage, even at concentrations as low as 4%. Experts advise that people should purchase products with AHA concentrations of 10% or less. If any adverse effects occur, the product should be stopped immediately. In all cases, people are advised to avoid sunlight or use proper sun protection when using them.

Experts are further concerned because part of the wrinkle-reducing effects of alpha hydroxy involves calcium loss, which in turn may promote cell growth and impair differentiation. Theoretically, this might increase the risk for skin cancer. There is no evidence of this at all, but more research is warranted on long-term effects of AHA.

Moisturizers

Moisturizers help prevent dryness, bruising, and tearing but have no effect on wrinkles by themselves. They should be applied while the skin is still damp. These products retain skin moisture in various ways:

• Occlusives, such as petroleum jelly, prevent water from evaporating.
• Humectants, including glycerin, act by pulling water up to the surface of the skin from deep tissues. People with oily skin generally should use the humectant type.
• More powerful compounds, such as one called monolaurin (Glylorin), contain mixtures of fatty molecules called lipids, which may help restore the skin's natural barriers against moisture loss and damage.

Most moisturizers contain combinations of these and usually have other ingredients, such as AHA, sunscreens, collagen, and keratin. (Collagen and keratin leave a protein film and temporarily stretch the skin.) They range widely in price, and a major consumer organization found little difference in general between the more and less expensive products.

Under-Eye Creams

The skin under the eyes is very thin and does not produce as much of the protective oils that keep skin soft and supple. Under-eye gels are aimed at reducing puffiness and dark circles. They typically work in one of two ways:

Temporarily constricting blood vessels to prevent the build-up of fluids.

Firming the skin with an invisible film.

Never rub under the eyes, as this may cause more wrinkles to form. Instead, apply these products with a light tapping motion to stimulate the skin.

Other Skin Treatments

Other Natural Anti-Wrinkle Remedies. The following natural substances have antioxidant properties and are being tried for wrinkle-protection.

• Both green and black tea and ginger appear to have properties that may provide some protection against skin cancers and photoaging. A 2001 study using extracts of topical green tea suggested that it might protect against ultraviolet damage. More research is warranted. Green tea skin care products are now available, but their quality is unregulated.
• The substance silymarin, found in the milk thistle family (which includes artichokes), may inhibit UVB-promoted cancers in animals.
• Aloe, lemon oil, grape seed extract, and coral extracts contain antioxidants and are promoted as being healthy for the skin, although evidence of their effects on wrinkles is weak.

Warning Note: A wide range of herbal products, both oral and topical, may contribute to dermatological problems. Some Chinese herbal creams have been found to contain corticosteroids, and some may contain mercury or arsenic contaminants have been reported in some Ayurvedic therapies. In addition, a number of oral herbal remedies used for medical or emotional conditions may produce irritation in reaction to sunlight (photosensitivity). The include but are not limited to St. John's Wort, kava, and yohimbine. St. John's Wort, in fact, has been associated with severe toxicity in a patient who had laser treatments.

Furfuryladenine. Furfuryladenine (Kinetin, Kinerase) is a naturally occurring growth hormone found in plant and animal DNA; it has antioxidant and anti-aging properties. Some small laboratory studies suggest that it may both delay the onset and decrease the effects of aging on skin. However, no well-conducted human trials have been performed.

Vitamin K. Microsponge-based vitamin K is being promoted to clear bruises spider veins, and other small blood vessel damage. Vitamin K is important for blood clotting.

Cosmetics

Cosmetics, if properly applied, can be surprisingly effective in camouflaging the signs of aging skin, including wrinkles and age spots. Moreover, they offer additional benefits by retarding water loss and providing a physical barrier to UV radiation. However, as women age, less is more. Here are some suggestions for older women:

Moisturizers. Moisturizers should be applied before foundation. If reddish discoloration is extensive or the skin is sallow, tinted moisturizers may be helpful and can be worn alone or under foundation.

Foundations. Caking on make-up will cause cracks at the wrinkle lines and only increase the appearance of aging. Large areas of the face are best covered with a moderate-coverage foundation with a matte or semi-matte finish. Facial powder reflects light and thus minimizes wrinkles but should be avoided by people with dry skin.

Correcting Color. When blemishes are especially prominent, applying color correctors under the foundation can be very effective:

• Green neutralizers mask red lesions.
• Yellow will camouflage dark circles and bruises.
• Mauve (a purplish-pink color) helps neutralize sallow skin or yellowish blemishes.
• A white, pearled base helps to minimize wrinkles.

Blushes. Blushes and color washes can help conceal the spidery network of dilated capillaries on the nose and cheeks. Powder blushes are preferred because they blend easily on top of foundation.

Eyes. Powder eye shadows applied on top of a moisturizer are preferred to cream-based shadows. The appearance of deep-set eyes is best offset with light-colored shadow, which should be applied along the upper eyelid crease and above the iris. A slightly deeper shade of the same color should then be applied to the lower part of the eyelid and drawn out to the corner.

Lips. A lip-setting cream or facial foundation should be applied before lipstick to help prevent it from bleeding into surrounding wrinkles. Try using a stiff bristle brush instead of a lip pencil. The brush will help keep the lipstick on and prevent bleeding. (Some women use the pencil itself for the full lip, which gives color but appears natural.) Some make-up artists recommend cream lipsticks instead of matte.

WHAT ARE PROFESSIONAL RESURFACING PROCEDURES FOR SKIN WRINKLES?

The outward manifestations of age represent hard-won experience and character, and those who wear its natural signs with a healthy and happy outlook should be regarded with respect as role models. Before embarking on an expensive and ultimately futile attempt to keep time at bay, consider the real bases for self-esteem and the pursuit of a lifestyle that will bring true health and youthful vigor rather than an imitation of it.

For people who make the decision to pursue intensive treatments, individuals should consider the following factors, among others, and discuss them with their dermatologist or plastic surgeon:

• The ability of the procedure to safely reduce wrinkles.
• The ease and safety record of the procedure.
• The skill of the doctor.
• The length of recovery.
• Possible complications.
• The duration of the benefits.

A person's age also helps determine the procedure:

• For people in their thirties, a simple chemical peel is sufficient.
• After age 40, people may benefit from collagen or fat implants.
• At age 50 and over, plastic surgeons recommend laser resurfacing and customized treatments for individual needs.

In older individuals, combination procedures may be beneficial. Some examples include the following:

• Laser surgery may be used for deep lines (such as those around the mouth) and chemical peels used over the rest of the face.
• For enhancing the eye by correcting droopy eyelids and bags and raising the brow, combinations of blepharoplasty (eye lift), Botox, and laser resurfacing may be used.

Resurfacing Choices

There are many choices for skin resurfacing (also called exfoliation) and the patient must discuss a number of different factors that affect the choice. Resurfacing can achieve the following:

• Removal of abnormal tissue and rough skin.
• Stimulation of new skin growth.
• Stimulation of collagen and elastin production.

In addition to determining the skill of the surgeon and the safety of the procedure, the patient must discuss the desired depth of the resurfacing and the capability of each procedure to reach this safely. All resurfacing procedures require a healing period afterward, during which the skin is red and sensitive. And it should be noted that the deeper the procedure, the higher the risk for complications, including delayed healing, infection, loss of pigment (skin color), and scarring.

Chemical Peels

Chemical peels, also known as chemosurgery, help restore wrinkled, lightly scarred, or blemished facial skin. Much like chemical paint strippers, chemical peels strip off the top layers of skin, and new, younger-looking skin grows back. The procedure is very effective for the upper lip. It cannot be performed around the eyes. Partial peels are often done in conjunction with a face-lift.

The Procedure.

• Dermatologist applies chemicals to the skin. They include trichloroacetic acid, high concentrations of alpha hydroxy or beta hydroxy acids, or combinations of them.
• In some cases, tretinoin (vitamin A derivative) or alpha hydroxy is applied four to six weeks before and starting one day after the peel. Such treatments can enhance the effects of a peel and reduce the risk of discoloration in people at risk for this complication. (Tretinoin itself is being tested as a chemical peel. In one small 2001 study, it effectively reduced wrinkles with no side effects.)
• A crust or a scab generally forms within 24 hours after surgery, which can be removed by gentle cleansing with soap and water.
• The skin takes six or seven days to heal.
• After the scab disappears, the visible skin is deep red but gradually lightens as it regenerates.

Complications. Complications include white heads, cold sores, infection, scarring, numbness, and permanent discoloration, particularly in people with darker skin. Refinement of chemical peel techniques are now permitting doctors to reach deeper skin, improvements which make it easier to apply peels to non-facial skin and to individuals with darker skin.

Dermabrasion

Dermabrasion affects deeper layers of skin than chemical peels, and may be useful for removing disfiguring marks, such as deep acne scars or deep wrinkles. As with chemical peels, it is effective for wrinkles on the upper lip and chin and cannot be used around the eyes. Some experts prefer dermabrasion to lasers for skin surfacing of people with darker skin colors.

The Procedure.

• Standard dermabrasion uses a rotating brush that removes the top layers of a person's skin. As with chemical peels, dermabrasion selectively strips away the upper layers of skin, leaving the underlying dermal layers exposed.
• As with chemical peels, after the procedure, the treated skin oozes and forms a scab, a reaction that is both unsightly and uncomfortable, but only temporary.
• Postoperative care is similar for both procedures.

A gentler variation called microdermabrasion uses very tiny crystals to polish the skin and a vacuum technique to remove them. Results are similar to light chemical peels. Patients can have this procedure done on their lunch hour and return to work. Only mild redness occurs after treatment, although for best results five or six repetitive treatments are needed every one or two weeks. To date, overall patient satisfaction has been very high.

Laser Resurfacing

Lasers are currently the most effective exfoliation tools for eliminating wrinkles. Their unique advantages over other resurfacing methods are their ability to tighten the skin. A successful procedure can make patients look 10 to 20 years younger, and the results can last up to 10 years. It should be noted, however, that a 2002 study indicated that this procedure may not protect against skin cancers.

The procedure is most beneficial for the following areas:

• Best around the mouth and eyes. Recent evidence suggests CO2 lasers may be even better than dermabrasion for the upper lip.
• Slightly less beneficial for the area around the nose.
• Used alone, current laser therapy does not eliminate crow's feet, broken blood vessels, or dark circles under the eye.
• Standard laser dermabrasion is too harsh for thinner skin layers, such as on the neck. Newer and gentler laser techniques, however, stimulate collagen without taking off skin layers and may prove to be useful for necklines.
• The evidence of the effects of lasers on acne scars is unknown.

The Laser Resurfacing Procedure. In general the procedure works in the following way:

• Laser pulses penetrate the skin quickly, vaporizing water and surface skin without damaging the deeper layers, allowing new top skin to grow.
• In addition, enough heat is applied to shorten collagen fibers, restoring some elasticity to the skin.

Choice of Lasers . The lasers used depend on skin type and severity of the condition:

• The carbon dioxide (CO2) laser is the most powerful laser treatment and is used for deep wrinkles and skin imperfections. People who have had silicone injections should not have CO2 procedures, which can burn and scar the skin over the implanted area.
• The erbium:YAG (Er:YAG) laser is gentler than the CO2 and is effective for mild wrinkles and for providing a smooth texture. It has a shorter recovery time. Some experts have even found the YAG laser as effective in removing deep wrinkles as CO2 when used to sufficient depth. A so-called variable pulse YAG laser can shift between pulses that destroy skin to tissue to those that heat the skin; this process effectively resurfaces the skin with fewer side effects than CO2 laser therapy.
• A gentle laser procedure called non-ablative laser resurfacing (NLite), also called photorejuvenation, is now approved for the treatment of all facial wrinkles. The procedure uses light energy to gently stimulate new collagen, and possibly elastin, without removing the skin tissue itself. Its effects are less pronounced than those of other laser procedures. However, because it does not injure the external layers of skin, it can be used on delicate skin areas, such as the neck and around the eyes. It also causes very little irritation afterward.

Some surgeons are using combination techniques that employ more than one laser technology in one session to achieve different effects. For example, one combination technique uses CO2, YAG, pulsed-dye laser, and one other laser technology to both improve wrinkles and clear under-eye dark circles and acne scarring. Pretreatment with botulinum injections before laser resurfacing significantly improved the treatment of crow's feet in one 2001 study.

Post-Procedure Recovery. The procedure itself is relatively painless, but the redness and irritation that occur during the healing process can be severe. (Non-ablative laser resurfacing does not have the same severe after effects as other laser treatments.) For eight to nine days, the face looks skinned and swollen and requires continuous moisturizing. (Some experts suggest that people with very sensitive skin who can not tolerate the medications and lubricants should avoid laser resurfacing.) Redness and sensitivity can persist for one to four months. The patient must stay out of the sun as much as possible during this time and should always avoid sunbathing and damaging their skin again. Early research suggests that silicone dressings may reduce post-procedure pain and crusting.

Complications. Scarring and infections can occur in about 1% of procedures, with risk increasing or decreasing depending on the experience of the surgeon. People with a history of herpes simplex may experience flare-ups of fever, facial pain, and flu-like symptoms for five or six days afterward. In addition, people with darker skin may wish to avoid the procedure because it can cause unpredictable and dramatic lightening of the skin.

Other Exfoliation Procedures

Cold Ablation. Cold ablation, called coblation for short, delivers saline (salt water) to the skin through which a cool electric current is passed. A subsequent reaction heats and vaporizes the top shallow layer of skin. The procedure is very specific and appears to minimize any damage to other areas of the skin.

Radiofrequency Resurfacing. A new technique uses low radiofrequency energy to resurface the skin. Preliminary research indicates that this procedure may eventually be as effective as laser surgery in reducing severe wrinkles around the eyes and mouth, with minimal pain and a shorter recovery time.

WHAT ARE THE IMPLANT PROCEDURES FOR REDUCING WRINKLES?

Implants

A number of materials are currently being used for deep wrinkles, depression under the eyes, lip enhancements, and for acne scars. None to date are wholly satisfactory. Biologic fillers from animal, bacterial, or human sources do not last. Synthetic fillers are permanent but may provoke an allergic reaction, which can cause chronic problems. Such reactions are not common but they can be painful and unattractive. [ See Table for description of different implant options.]

Botulinum

Botulinum, the deadly toxin found in uncooked foods, is also a powerful muscle-relaxant, and tiny amounts of a purified form (Botox) are being injected into wrinkles to relax the surrounding muscles. It may benefit forehead and frown lines, crow's feet, lower eyelids, lines on the side of the nose, and the area between the upper lip and the nose. It is also useful for treating involuntary muscle movements that can occur after a face-lift.

The injections need to be repeated every few months, since the effects wear off. The treatment decreases the ability to frown or squint and may cause the corners of the mouth to turn down. When used for areas around eyes, it produces a rounder appearance afterward, which patients should be aware of before they undertake the procedure.

The drug does not cross the blood-brain barrier, and, to date, the only side effects are temporary muscle weakness near the injection site. Although there have been some reports that Botox can reduce migraine and tension headaches, Botox also causes headaches in about 1% of cases. In some cases, the headaches can be very severe and long lasting (from eight days to a month). Some experts suggest that either a contaminated batch of Botox or a specific injection technique may be the cause, but additional investigation is needed.

WHAT IS PLASTIC SURGERY FOR WRINKLES?

Face Lifts (Rhytidectomy)

A number of face-life procedures (called rhytidectomies) are available. Facelifts can provide individuals with a more youthful, if not necessarily younger, look. The degree of improvement, however, depends on a number of factors including age, bone structure, skin type, and personal habits, such as smoking and sunbathing.

The Procedure. When a face-lift is a relatively simple procedure, it can take about two hours under local anesthetic in a doctor's office. Complicated face-lifts are done under general anesthesia in a hospital and can take three to six hours. The face lift procedure may be one of the following:

• SMAS (superficial musculoaponeurotic system) is the most common face-life procedure. The surgeon makes an incision at the hairline and separates the skin from the underlying tissue and muscles. The muscles are tightened and excess fat and tissue, such as fat under the chin and neck, are removed.
• The endoscopic subperiosteal or subgaleal face-lift is a less invasive surgical technique. The surgeon raises facial structures rather than cutting away flaps of skin. Only a few half-inch incisions are made, and scarring is minimal.
• Neither SMAS nor the endoscopic version is effective for the middle part of the face, particularly the deep lines (naso-labial folds) that run down from the nose beside the mouth. Some time after the SMAS facelift, the upper face begins to age again while the lower area still retains its shape, causing the face to look imbalanced. Other approaches, such as one called composite facelifts that lift most muscles in the face are being investigated.

Recovery Process. Recovery normally lasts from several weeks to several months. Swelling and discoloration are common. Some patients report tingling or numbing sensations after surgery, which generally subside as damaged nerves regenerate.

Complications. Rhytidectomy is not without risks. A postsurgical hematoma is a collection of blood that can occur after a rhytidectomy. In one study major hematomas occurred in 2.2% and minor hematomas in 6.65% of patients. They generally develop within two weeks of the surgery and require drainage. Even minor hematomas need fast treatment to prevent greater complications, including infection, changes in pigmentation, fluid buildup, and prolonged recovery time.

Other less common complications may include the following:

• Infection.
• Excessive bleeding.
• Asymmetrical facial muscles.
• Delayed healing.
• Scarring.
• Permanent injury to the nerves that control facial movements.

It should be noted that these complications are rare, particularly with a skilled surgeon, but the more complex the face lifts, the greater the risk.

Procedures for Eyes

Blepharoplasty. Blepharoplasty is the primary surgical procedure for eye lifts. Results usually last between five and ten years. Although simple, it has potential complications, including permanent difficulty in closing the eyes or making a stern expression. Newer techniques, however, are preventing this complication. Assuming the surgeon is experienced, laser surgery is now preferred to the standard surgical scalpel approach; bleeding and bruising are reduced, and both the operation and recovery are faster.

Transconjunctival Upper Blepharoplasty. An innovative procedure called transconjunctival upper blepharoplasty removes fat from the membrane that lines the eyelids (the conjunctiva) and is an effective technique for treating both the upper and lower eyelids. Unlike traditional blepharoplasty, this procedure does not cause scarring in the nasal area. In patients who have scars from previous surgeries, transconjunctival removal of fat can also make existing scars less obvious. Long-term side effects and efficacy of this procedure have not been studied.

Procedures for the Neck

Laser Liposculpture and Platysma Resurfacing. A procedure called laser neck and jowl liposculpture and platysma resurfacing may prove to be an alternative to facelifts. The procedure requires only a one-inch incision under the chin and removing excess fat. After the fat is removed, the surgeon tightens the platysma, the thin muscular sheet under the skin of the neck, which improves the shape of the neck. Only local anesthetic is needed and the patient can return to normal activities in two days. The patient's skin should be elastic enough to be able to reform without sagging.