Download Looking Your Best Without Surgery A Skin Rejuvenation Handbook

Looking Your Best Without Surgery
A Skin Rejuvenation Handbook
By
Mary Lee Amerian, MD and
George P. Anterasian, MD
Copyright © 2008
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Chapter 1 - Introduction
Somewhere within our DNA there are genes that make human beings wish to look their
best. Whether we are teenagers, young adults, or senior citizens, the desire to look one’s
best is universal and reflects a basic characteristic of what it is to be human. Simply put,
we wish to put our best face forward when we present ourselves to the world.
Over the years, creative physicians have developed many different techniques to enable
people to look better and more youthful. Unfortunately, many of these early techniques,
such as facelift surgery and deep chemical peels, were quite aggressive. It often took
from weeks to months to recover from these procedures.
For this reason, the trend in recent years has been to develop techniques of rejuvenation
that have either a very short recovery period or even no recovery period. These newer
methods of rejuvenation fit much more easily into today’s busy lifestyles. They fit into
our work schedules, our parenting schedules, and often into our lunch breaks.
This desire for quick recoveries has led to the development of literally hundreds of
different potential treatments. This, in turn, has led to confusion as to what would be the
most appropriate treatment for any one person.
The intent of this handbook is to help clarify these issues. The goal is to give readers an
overview of modern non-surgical facial rejuvenation so they can be better informed as to
what might be the most appropriate treatment for them. Once armed with this
information, readers will know what questions to ask their physicians and what they can
reasonably expect to achieve from their treatments. This in turn should lead to better
consultations with physicians and optimum treatment decisions.
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Chapter 2 – Your Skin and the Passage of Time
With the passage of time, your skin undergoes changes due primarily to two distinct
mechanisms. The first mechanism is medically termed “Photoaging” and refers to
changes in the skin that result from exposure to ultraviolet radiation, whether originating
from the sun or from other sources of ultraviolet radiation such as tanning booths. These
changes result in fine lines, coarse wrinkles, mottled skin pigmentation, brown spots, skin
laxity, and broken blood vessels (which are medically called telangiectasias).
The second aging mechanism is medically termed “Intrinsic Aging” and refers to changes
in the skin due only to the natural aging process. Intrinsic aging results in thinning of the
skin, reduction in collagen production, reduction in elastic fibers, and the appearance of
fine lines. Although all of us will undergo intrinsic aging of our skin, the rate that
intrinsic aging occurs will vary from person to person and is at least in part dependent on
our inherited genetics.
In addition to these changes within the skin, other changes occur under the skin. With the
passage of time, there is a reduction in the amount of fat below the skin, which leads to a
hollowing of the cheeks. In addition, there is also a reduction in the amount of bone mass
and muscle mass, which contributes to sagging of the skin.
It is the combination of these factors that results in what we see in the mirror.
Table 1 Features of Aging Skin
Brown spots
Telangiectasias
Fine Lines
Changes in texture
Coarse wrinkles
Mottled skin pigmentation
Skin laxity
Skin sagging
Hollowing of the cheeks
What Can Be Done To Treat Aging Skin?
The types of treatments available to treat aging skin fall into six broad categories: lasers
and light, dermal fillers, Botox, chemical peels, cosmeceuticals, and surgery. In the
chapters that follow, this handbook will address all of these categories except surgery.
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It is important to understand that even if surgery to tighten the skin is done, the skin itself
will still exhibit many of the features of aging skin that we just discussed. For this
reason, individuals who have surgery, such as eyelid or facelift surgery, would still
benefit from other non-surgical procedures to rejuvenate the skin and improve the skin’s
appearance. Otherwise the skin will appear tighter, but still aged.
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Chapter 3 - Lasers and light
Lasers and light are commonly used in treating aging skin. Over the past several years,
many devices have been introduced and collectively they have revolutionized the
treatment of aging skin. This chapter will review the most effective laser and light
devices that are available and provide guidelines as to which individuals are the best
candidates for a given rejuvenation technique.
Intense Pulsed Light (Also Known as FotoFacial™ and IPL)
Intense Pulsed Light skin rejuvenation is a non-invasive procedure that uses high
intensity light pulses to reduce the signs of skin aging. The intense pulsed light
procedure is ideal for patients who have relatively mild signs of aging skin, without fine
lines, wrinkles, or other textural changes. The procedure will reduce brown spots, red
spots, irregular discolorations, and the redness in the skin that results from broken
capillaries.
During the procedure, pulses of high intensity filtered light are delivered to the skin
surface while simultaneously chilling the skin. Abnormal brown areas absorb the light,
which begins the process of breaking down the brown pigment. Broken capillaries also
absorb the light, which begins a process leading to the shrinking of the broken capillaries.
The procedure takes approximately thirty minutes and has no downtime. Patients should
be able to resume their normal activities immediately after leaving the office. Intense
Pulsed Light rejuvenation is done as a series of 4 or 5 treatments at three to four week
intervals. The most commonly treated areas are the face, chest, neck, and hands.
While the Intense Pulsed Light procedure will improve brown spots, red spots, and
broken capillaries, it does not reliably improve skin texture or fine lines. For this reason,
individuals who have textural changes in the skin would be better served with other
rejuvenation techniques, such as the Fraxel laser.
Photodynamic Photorejuvenation
Photodynamic photorejuvenation is an effective method for treating the brown spots,
broken capillaries, freckles, and actinic keratoses (changes in the skin due to excessive
sun exposure that can turn into skin cancers) that result from sun exposure. This
treatment begins with a thorough cleansing of the skin. Then, a medication called
Levulan is applied to the skin for approximately 45 to 60 minutes, after which the
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remaining Levulan is washed off. (Levulan is a 20% solution of Aminolevulinic acid,
which is a naturally occurring substance found in every person.) Next, the facial skin is
exposed to intense pulsed light. The light activates the Levulan, beginning a chemical
reaction that ultimately leads to a substantial reduction in the number of sun damaged
skin cells. This treatment results in a reduction in skin pigmentation, a more uniform skin
color, improved skin texture, and a more youthful appearing skin. In addition, the
treatment also effectively removes many of the actinic keratoses that might be present.
Photodynamic photorejuvenation is very safe and has the advantage of treating the entire
face at one time. Because of the Levulan that is used in the treatment, patients will need
to remain indoors immediately after the procedure as well as the following day.
Generally, patients will need three or four photodynamic treatments to obtain an optimum
result.
Photodynamic therapy with Levulan has provided us with an additional option for
treating our patients. With photodynamic photorejuvenation, skin rejuvenation occurs
more rapidly than it does with intense pulsed light, and actinic keratoses are also
improved. The trade-off is the requirement that patients remain indoors after their
treatment until the following evening.
Pulsed Dye Laser (VBeam Laser)
The pulsed dye laser is considered by many physicians around the world to be the gold
standard for the treatment of the telangiectasias (broken capillaries) that occur in aging
skin. The ideal patient for the pulsed dye laser has redness in the skin from dilated or
broken capillaries.
The Vbeam laser works by shining a laser beam on the areas being treated. The laser light
is absorbed by the red hemoglobin in the blood, resulting in a heating and then a
narrowing of the blood vessels. The narrowing of the blood vessels reduces the redness
in the skin.
The Vbeam laser uses an exclusive technology known as Dynamic Cooling. With
Dynamic Cooling, the skin is chilled prior to each laser pulse. This protects the skin
surface and provides increased comfort during the procedure.
A full-face treatment with the pulsed dye laser takes approximately twenty minutes; if a
smaller area is being treated, then less time is required. There is no recovery downtime,
and patients should be able to resume their normal activities immediately after leaving
the office. Vbeam-pulsed dye laser skin rejuvenation is done as a series of 4 or 5
treatments at three to four week intervals. The most commonly treated areas are the face,
chest, and neck.
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The pulsed dye laser has been beautifully designed to treat redness. However, it will not
improve fine lines and is less effective on brown pigment. Therefore, patients
undergoing pulsed dye laser treatment for redness, who also have fine lines or brown
pigmentation, may also need to add a second modality to treat the fine lines and brown
pigment. Usually, this second modality is the Fraxel laser.
Fraxel Laser
The Fraxel laser is the ideal rejuvenation technique for patients who as a result of aging
have developed fine lines and brown pigment in their skin. Introduced in 2004 and now
in its second generation, the Fraxel laser has become one of the most popular skin
rejuvenation procedures. Its popularity results from the fact that it reliably improves
brown spots, brown pigmentation, fine lines, facial scars, and other textural changes in
the skin with either minimal or no downtime.
The Fraxel laser uses Fractional Resurfacing Technology to resurface the skin. With this
technology, the desired results are obtained by treating only a fraction of the skin’s
surface at a time. During the treatment, a series of microscopic closely spaced laser spots
is delivered to the skin while simultaneously preserving normal healthy untreated skin
between the laser spots. It is the preservation of healthy untreated skin between the laser
spots that is responsible for the rapid healing that occurs following the laser treatment.
The Fraxel laser is FDA approved for skin resurfacing, the treatment of wrinkles around
the eyes, and the treatment of age spots, sun spots, and brown spots. The Fraxel laser
will reliably improve fine lines, skin texture, skin color, and facial scars, including acne
scars, chicken pox scars, and surgical scars. The most commonly treated areas are the
face, neck, chest, and hands. To obtain an optimum result, most patients will need a
series of four or five Fraxel laser treatments given at three to four week intervals.
Fraxel Repair Laser
The Fraxel Repair is the newest member of the Fraxel family of lasers, and it provides an
additional option for skin resurfacing. The major difference between the Fraxel Repair
and the original Fraxel is that the light emitted by the Fraxel Repair laser is based on
carbon dioxide (CO2) instead of erbium. The use of carbon dioxide as the source of the
laser light results in the Fraxel Repair laser being a more effective skin tightener than the
original Fraxel laser. In addition, like the original Fraxel, the Fraxel Repair will improve
brown pigment, fine lines, acne scars, and other facial scars.
The Fraxel Repair is best suited for patients who have moderate skin laxity and relatively
deeper lines and wrinkles in their face and lips. It can be used to treat the entire face or it
may be used to treat smaller areas such as the upper lip and eyelids. When the upper lip
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or eyelids are treated, the result is a much smoother upper lip and more open upper
eyelids.
In addition to its use on the face, the Fraxel Repair may also be used to treat the neck and
chest. In these off-face locations, the laser treatment again results in skin tightening,
improved skin texture, and improved skin color.
The laser is FDA approved for the treatment of wrinkles, furrows, fine lines, textural
irregularities, pigmented skin lesions, and vascular dyschromia. (Vascular dyschromia is
the medical term for broken capillaries and diffuse redness.)
The use of carbon dioxide as the source of the laser light in the Fraxel Repair results in
more effective skin tightening. In addition, it allows us to complete the laser treatment in
only one or at most two treatment sessions. This is one of the major advantages of the
Fraxel Repair laser.
Like the original Fraxel, the Fraxel Repair utilizes Fractional Resurfacing Technology.
The laser delivers a series of closely spaced laser spots to the skin while preserving
normal healthy skin between the laser spots. This preservation of normal untreated skin
between the laser spots results in rapid healing after the treatment.
The Fraxel Repair may be used by itself or in combination with the original Fraxel laser.
When used in combination, the Fraxel Repair is used to treat the more affected areas of
the face where the lines are deeper and the tissues have more laxity, and the original
Fraxel is used to treat the less involved areas.
Treatment with the Fraxel Repair results in visible skin tightening and significant
improvement in wrinkles and pigmentation in the treated areas. The skin heals with an
improved texture. The result is smoother, tighter, and younger looking skin. Often, only
a single treatment is needed. Some patients, however, may wish to undergo a second
procedure to further enhance their results.
Fraxel Repair treatment does have some downtime. A full-face treatment generally has
three to five days of downtime.
Thermage
The Thermage procedure (also called the ThermaCool procedure) utilizes radio frequency
energy to tighten and lift the skin on the face and other treated areas. It is FDA approved
for the non-surgical treatment of facial wrinkles. The ideal candidates for Thermage have
mild to moderate laxity of their skin.
During the procedure, the treatment tip simultaneously heats the deeper collagen
containing layers of the skin while simultaneously cooling the skin surface. The heating
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action causes the collagen in the skin to tighten immediately. In addition, over the next
few months, the procedure stimulates production of new collagen, further enhancing the
result. Because the collagen that is produced after Thermage is living tissue, the results
from Thermage are long lasting and should persist for several years.
The combined action of the immediate tightening of collagen and the production of new
collagen results in a tighter skin, improved skin texture, and a more youthful appearance.
The optimum result is generally achieved approximately four months following the
procedure. At that time, the procedure can be repeated to further enhance the result.
The Thermage procedure has no downtime. Once the procedure is complete, patients
should be able to leave the office and immediately resume their normal schedule. The
most commonly treated areas are the face, eyelids, neck, and abdomen.
Treatment of the Eyelids with Thermage, Fraxel, and Fraxel Repair Laser
During the past four years, there have been dramatic and revolutionary advances in laser
technology. By applying these new technologies to the eyelids, it has become possible to
rejuvenate and tighten the eyelid skin in nearly all patients without surgery. Today,
surgery only needs to be done on the most severely aged eyelids.
In order to match the correct eyelid rejuvenation procedure to the right patient, we divide
the eyelid skin into three degrees of laxity: mild, moderate, and severe. Patients who
only have mild eyelid laxity are best treated with the eyelid Thermage procedure. Eyelid
Thermage is a procedure that smoothes the texture of the eyelid skin and deceases eyelid
hooding and wrinkling. Patients benefit from a single treatment that has no downtime.
Patients who have had eyelid Thermage, which is also known as the “Eyes by Thermage”
procedure, report that their eyelid sagging is improved and both the upper and lower
eyelids are tighter. The eyes look brighter and appear more open. In addition, the
improved smoothness of the skin makes it easier to apply eye make-up.
Eyelid Fraxel is intended for patients who have developed moderate laxity and crepiness
of the skin of the upper and lower eyelids. The procedure reduces skin crepiness, softens
lines and wrinkles, tightens the skin, and produces an overall skin rejuvenation effect.
Just like the Fraxel laser procedure on the face, the eyelid Fraxel procedure utilizes
Fractional Resurfacing Technology. The laser delivers a series of closely spaced laser
spots to the skin while preserving normal healthy skin between the laser spots. This
preservation of normal untreated skin between the laser spots results in rapid healing after
the treatment. Fraxel laser resurfacing is generally done as a series of four or five
treatments given at monthly intervals. The eyelid treatment is generally done in
conjunction with Fraxel laser treatment of the face. The procedure has minimal or no
downtime. After completing their treatments, patients can reliably expect the skin to look
more youthful and rejuvenated.
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Patients with more severe eyelid laxity are best treated with the Fraxel Repair laser. With
the Fraxel Repair, patients obtain significant tightening of their eyelid tissues in a single
procedure, which is a welcome advance. Fraxel Repair eyelid treatment can be done by
itself or it may be combined with treatment of the face. Patients who undergo Fraxel
Repair treatment should be prepared for three to five days of healing following the
procedure.
Eyelid Thermage, eyelid Fraxel, and Fraxel Repair all stimulate the production of new
collagen in the eyelid skin and promote tissue tightening. This new collagen is living
tissue, and for this reason, the improvement in the eyelids following any of these
treatments is long lasting and should persist for years.
Regardless of which technology is used to treat the eyelids, the rejuvenation may be
further enhanced with Botox and dermal fillers. Botox is used to soften the lines around
the eyes (crow’s feet lines). Dermal fillers such as Juvederm and Restylane are used to
soften the depressions and folds that form below the eye (known as the tear trough). By
combining Thermage or either of the Fraxel lasers with Botox and dermal fillers, nearly
all of our patients can achieve very natural eyelid tightening and rejuvenation without
undergoing a surgical procedure.
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Chapter 4 – Dermal Fillers
One of the cornerstones of modern facial rejuvenation is the use of dermal fillers. By
selecting and using the correct dermal filling agent, folds can be softened, lines and
wrinkles made much less noticeable, and the face sculpted in such a way that the face
looks much more youthful. In this chapter, we will review the most commonly used
dermal fillers so that the reader can be better informed regarding how these materials are
used.
Juvederm and Restylane
Juvederm and Restylane are very similar products containing hyaluronic acid as the
filling agent. The hyaluronic acid is produced under controlled laboratory conditions,
does not use any animal or human sources, and is chemically identical to the hyaluronic
acid found in human skin. For this reason, no allergy testing is needed. The hyaluronic
acid in Juvederm and Restylane, in addition to acting as a filling agent, has also been
shown to stimulate new collagen formation.
Juvederm and Restylane are used to treat mild to moderate lines and wrinkles, improve
skin folds, and augment the lips. After injection, Juvederm and Restylane will last for
five to six months.
Perlane and Juvederm Ultra Plus
Perlane and Juvederm Ultra Plus are very similar dermal fillers that, like Juvederm and
Restylane, also contain hyaluronic acid produced under controlled laboratory conditions
without using any animal or human sources. Again, since every human being has
hyaluronic acid in his or her skin, no allergy testing is needed prior to using these fillers.
The hyaluronic acid gel particles in Perlane and in Juvederm Ultra Plus are larger than
the gel particles in Juvederm or in Restylane. This gives these dermal fillers enhanced
lifting power, allowing them to easily fill deeper lines, wrinkles, creases, and folds. For
this reason, Perlane and Juvederm Ultra Plus are ideal fillers for the correction of
moderate to more severe facial wrinkles and folds, with Juvederm and Restylane used for
the shallower wrinkles and folds. In addition, Perlane and Juvederm Ultra Plus can be
used for facial sculpting to augment the cheekbones and jaw line. After their placement
in the skin, Perlane and Juvederm Ultra Plus will provide correction for approximately
six months.
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Cosmoderm
Cosmoderm is a dermal filler that contains collagen that is chemically identical to human
collagen. The collagen in Cosmoderm is grown under controlled laboratory conditions,
without using any animal or human sources of collagen. Because the collagen in
Cosmoderm is chemically identical to natural human collagen, no allergy testing is
needed prior to use. Cosmoderm is used to soften superficial and fine lines and wrinkles,
and to augment the lips. After placement, it will last for three or four months.
Cosmoderm is unique in that it is the filler that can be safely placed closest to the skin
surface. It may also be used in combination with Juvederm or Restylane. When used in
this manner, the Juvederm or Restylane is injected deeper into the skin to treat a fold,
wrinkle, or line and the Cosmoderm is layered on top to fill any remaining line.
Radiesse
Radiesse is composed of microspheres of calcium hydroxylapatite suspended in a gel
carrier. Calcium hydroxylapatite is completely biocompatible. Again, since calcium
hydroxylapatite is found in every human being, no allergy testing is needed. The calcium
hydroxylapatite microspheres serve as a lattice into which new collagen grows.
Therefore, Radiesse produces its effect not only by acting as a passive filling agent but
also by stimulating production of new collagen. Radiesse is injected deeper in the skin
than Juvederm and Restylane, and is most commonly used to treat relatively deeper folds
and lines. In addition, Radiesse can be used for facial sculpting to augment the
cheekbones or jaw line. Cheekbone augmentation with Radiesse has become particularly
popular recently. After injection, Radiesse will last for approximately one year.
Sculptra
Sculptra is poly-L-lactic acid, a material that has been used in absorbable surgical sutures
for many years. Because lactic acid is a material found in humans, no allergy testing is
needed prior to using Sculptra. Sculptra is injected into the deeper layers of the skin.
Following its placement, Sculptra stimulates the production of a patient's own new
collagen. It is this new collagen that ultimately produces the improvement in the
appearance of the skin that results from Sculptra. Sculptra is used to treat skin creases,
wrinkles, depressions, and folds. Generally two or three treatment sessions every four to
six weeks are required to obtain the optimum result. After completion of the treatment
course, Sculptra results will last for up to two years in most patients. After that, the result
can be maintained with minor touch-up treatments.
The currently available filling agents are truly outstanding, with unsurpassed safety and
efficacy. When properly used, they provide completely natural appearing facial
rejuvenation.
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Chapter 5 – Botox
The goal of a Botox treatment is to create a relaxed and youthful look. By relaxing the
facial muscles in the Botox-treated areas, lines and furrows are softened, and the skin
looks smoother and more youthful. The improvement following treatment with Botox
lasts for three to four months. Botox, when used in the very small doses required for
cosmetic procedures, is completely safe with absolutely no long-term adverse outcomes.
Because of the uniformly good cosmetic results with Botox and its unsurpassed safety
record, Botox treatment is the single most commonly performed cosmetic procedure in
the United States and worldwide.
A professional who injects Botox properly should not be attempting to create a “frozen
face.” A “frozen face” is an unacceptable result of Botox treatment, and if such an
outcome were to occur, it should be considered to be a result of over-treatment with
Botox.
Common Uses of Botox
By now, virtually everyone is familiar with the use of Botox to reduce horizontal
forehead lines, frown lines between the eyebrows, and crow's feet lines around the eyes.
The treatment of these three areas with Botox accounts for the great majority of all of the
Botox that is used for cosmetic purposes. Patients have been extremely pleased with
Botox when it is used in this manner. Indeed, after one or two Botox treatments, a
professional Botox injector should be able to develop for each patient a Botox treatment
plan that is unique and customized to that person’s individual needs. This allows the
Botox treatment to be reliably reproduced from one treatment to the next.
Botox “Finishing Touches”
Botox can be used in many other areas on the face and neck to soften lines and relax
muscles. The use of Botox in these other locations on the face is always individualized,
based on each person’s unique requirements. Think of Botox when used in these other
locations as the “Icing on the Cake.”
Eyebrow Injection – With age, the eyebrows start to droop. By injecting Botox into the
eyebrow, the eyebrow can be elevated. The resulting "Botox brow lift" not only restores
the eyebrow to a more youthful position, but it also opens up the upper eyelids.
Upper and Lower Lip Vertical Lines (Smoker's Lines) – Very small quantities of
Botox can be injected into the upper and lower lip to soften lines in these areas. Often,
Botox is combined with collagen, Restylane, or Juvederm to soften these lines.
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Depressor Anguli Oris (To treat down turned corners of the mouth) – The depressor
anguli oris is the muscle responsible for turning down the corners of the mouth. This very
unattractive facial feature can be significantly improved by injecting the Depressor
Anguli Oris muscle with Botox. Injecting the depressor anguli oris allows the corners of
the mouth to turn in a more upward direction, producing a far more attractive appearance.
Gummy Smile – When some people smile, their upper lip elevates above their upper
teeth, exposing their gums and producing an unattractive "gummy smile." An injection of
Botox into the upper lip can easily correct this.
Bunny Lines – "Bunny lines" are the lines that occur on the side of the nose when some
people smile. They are quite unattractive, and can be easily treated with a small amount
of Botox.
Chin – Many patients, especially when speaking, develop folds, creases, and wrinkling in
their chin. Two injections of Botox into the chin can significantly improve the chin's
appearance.
Neck – An overactive neck muscle will result in vertical bands below the chin, known as
"platysmal bands," and horizontal wrinkles across the neck. Injection of Botox into the
bands and wrinkles will soften the bands and significantly improve the wrinkles.
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Chapter 6 – Chemical Peels
Every year, millions of chemical peels are performed. Chemical peeling is a skin
rejuvenation technique that has been used by physicians for decades. During a chemical
peel, a solution is applied to the skin surface, causing the surface cells to separate and
peel off, thus allowing new skin to regenerate. The new skin is generally smoother and
less wrinkled, and has a more uniform skin color.
Chemical peeling can be used to treat fine lines, especially around the eyes and mouth,
and the wrinkles that result from sun damage. Chemical peeling can also be used to
improve the skin’s color. Thus, sunspots, age spots, and the blotchiness that can occur
with birth control pills or pregnancy (melasma) can all be improved by chemical peeling.
In addition, the pre-cancerous skin changes that result from excessive sun exposure
(actinic keratoses) can also be improved with a chemical peel. The procedure can also be
used to improve acne and to treat mild scars that were caused by acne. A chemical peel
will make dull appearing skin appear more vibrant and revitalized.
The best candidates for chemical peels have fine lines and wrinkles with minimal skin
sagging. They do not have severe skin excess. Patients with lighter complexions are
preferred because there is less of a chance of the skin getting darker (medically known as
hyperpigmentation) following the procedure.
Physicians have developed many different solutions for chemical peeling in order to
provide patients with a choice of treatment options. With so many different peels
available, the physician and patient can select a peel designed specifically for what the
patient wishes to improve and the amount of downtime the patient can allow.
A peel should be selected based upon the type of skin condition that needs improvement.
If the skin changes are confined to the upper layers of the skin, then a superficial peel will
be effective. However, if the changes in the skin involve the deeper layers of the skin,
then a deeper and more aggressive peel will be required to obtain improvement.
Changes limited to the superficial layers of the skin include increased skin pigmentation
and a roughened skin texture without wrinkles. When the textural changes include
wrinkling around the eyes and mouth, the changes in the skin have extended deeper into
the skin. The most severe changes in the skin include generalized deep wrinkling with a
leathery appearance and feel to the skin. These changes imply still deeper damage to the
skin.
Superficial peels are commonly performed with either TCA (10-25% trichloroacetic acid)
or Jessner’s solution (a mixture of salicylic acid, resorcinol, and lactic acid). Salicylic
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acid can also be used for superficial skin peeling. It has been used for decades and is a
good peeling agent for patients who also have acne. Alpha hydroxy acids, such as
glycolic acid at 30-50%, are also commonly used for superficial peeling. A superficial
peel has a rapid recovery period of a few hours to a few days, depending upon how
aggressive the peel was.
Medium depth peels are usually done with TCA (35-50%), glycolic acid (70%), or 35%
TCA augmented with Jessner’s solution or with glycolic acid. Recovery from a medium
depth peel generally takes about one week.
Deep chemical peels are generally done using phenol. Deep peels are generally only done
in individuals who have major changes in the skin and have deep wrinkles. As a general
rule, the deeper the peel, the longer the healing time. Thus, full face deep chemical peels
will have the longest healing time, and the redness can last for as long as six months. In
addition, deep chemical peels have a higher incidence of temporary and permanent
pigmentation changes. For these reasons, relatively few deep chemical peels are
performed today. Complete recovery from a deep chemical peel will take from several
weeks to several months.
Due to the increased risk with deep chemical peels, many patients prefer to undergo
repetitive superficial and medium depth peels. By repeating their peels, patients obtain
additional improvement that is far beyond what only one lighter peel can accomplish.
Generally speaking, a light to medium depth chemical peel is not painful. Most patients
experience a warm to somewhat hot sensation that lasts for five to ten minutes. This may
be followed by a mild stinging sensation. However, a deep chemical peel may require
pain medicine during and after the procedure.
Wrinkles that occur with facial movement (known medically as dynamic wrinkles), deep
scars, and skin sagging due to aging are generally not improved with chemical peeling.
For this reason, other procedures should be used to treat these problems.
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Chapter 7 – Cosmeceuticals
What is a cosmeceutical? Cosmeceuticals are skin care products that contain ingredients
that influence the physiological functioning of the skin. When a cosmeceutical is applied
to the skin, the biologically active ingredients within the cosmeceutical are absorbed into
the skin, resulting in improved skin appearance. The most commonly used active
ingredients in cosmeceuticals are vitamins, herbs, plant extracts (which are referred to as
botanicals), and oils. Regardless of what other facial rejuvenation techniques are used,
everyone should have a good cosmeceutical regimen to treat, nourish, protect, and
moisturize his or her skin.
The cosmeceutical market has grown rapidly over the past few years as the baby boom
generation has gotten older. This growth has led to the introduction of literally thousands
of different skin care products. Many individuals have become confused regarding how
the different active ingredients in cosmeceuticals help the skin. In order to better inform
the reader about cosmeceuticals, the paragraphs that follow will review the most common
ingredients that are used in today’s cosmeceuticals and how they help the skin look better
and more refreshed.
Retinoids – Retinoids are derivatives of vitamin A and are the most common type of
cosmeceutical used today. In the skin, retinoids act as antioxidants and they neutralize
the free radicals that result from exposure to ultraviolet light. In addition, retinoids
increase cellular turnover, stimulate a beneficial thickening of the epidermis, and promote
the removal of excessive skin pigment. The use of retinoids leads to the deposition of
new collagen in the skin. As a result of these actions, retinoids are known to reduce
wrinkles, decrease skin laxity, improve skin color, and produce a smoother skin surface.
Tretinoin (retinoic acid, Retin A, Renova) and tazarotene (Tazorac, Avage) are two of the
most commonly used retinoids. Skin care products that contain either of these two
ingredients are available by prescription. Retinol is another frequently used retinoid. It is
chemically identical to Vitamin A. Because it is a naturally occurring vitamin, skin care
products that contain Retinol do not require a prescription and are available over-thecounter.
Hydroxy acids – Hydroxy acids are another commonly used active ingredient in
cosmeceuticals. They are classified as either alpha hydroxy acids (AHAs) or beta
hydroxy acids (BHAs) depending on their molecular structure. Commonly used alpha
hydroxy acids are glycolic acid, citric acid, and lactic acid; the most commonly used
BHA is salicylic acid.
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The AHAs used in cosmeceuticals have been shown to produce younger looking skin.
Cellular turnover is increased, and the skin appears smoother and more uniform in color.
Salicylic acid is used as a skin conditioner and is especially useful in patients with oily
skin and acne. It is considered to be one of the most effective acne treatments. Salicylic
acid would be of particular benefit to individuals who have both aging skin and acne.
Antioxidants – Although it may seem obvious, an antioxidant is a chemical that prevents
living tissues from becoming "oxidized" and undergoing a chemical change. In the body,
highly reactive substances called free radicals are constantly being produced. Free
radicals can quickly damage the body's own cells. In living tissues, antioxidants remove
free radicals before they can damage normal tissues.
From the dermatology perspective, exposure to ultraviolet radiation from the sun and
other sources will result in the production of free radicals. Several studies have suggested
that antioxidants help protect the skin from the damaging effects of the free radicals that
result from exposure to ultraviolet light. The most common antioxidants that are used in
cosmeceuticals are Vitamin C, Vitamin E, Panthenol, Lipoic Acid, Ubiquinone,
Idebenone, and Niacinamide.
Depigmenting Agents – Depigmenting agents are skin-lightening ingredients. They
remove excessive melanin pigment from the skin. A depigmenting agent works best on
“epidermal melanin,” which is melanin in the top layers of the skin. When the excessive
melanin is located deeper in the skin in the dermal layer, a depigmenting agent may not
be as effective.
Hydroquinone is the most commonly used depigmenting agent; it works by decreasing
the production of melanin pigment. Some physicians also add tretinoin (retinoic acid) and
a steroid to the hydroquinone. The tretinoin increases cellular turnover, resulting in a
quicker response to treatment, and the steroid reduces inflammation in the skin. TriLuma cream conveniently combines hydroquinone, tretinoin, and a steroid in one
medication, and is available by prescription.
Other compounds that are used for skin lightening include azelaic acid, kojic acid, and
peels containing alpha hydroxy acids such as glycolic acid.
Botanicals – With the modern trend toward the use of more natural ingredients,
botanicals have become a component of nearly every cosmeceutical product available
and form the largest category of active ingredients used today. An appropriate botanical
can be chosen to reduce inflammation, sooth the skin, or act as an antioxidant. Some of
the most commonly used botanicals are prickly pear and aloe vera (for skin soothing),
ginkgo biloba, willow herb, and green tea (anti-inflammatory), and goji berry and soy
(antioxidants).
Peptides – A peptide can be thought of as a small part of a much larger protein molecule.
Peptides were developed for use in skin care to either increase the production of collagen
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or to reduce the breakdown of collagen. This is important because loss of collagen in the
skin is one of the causes of wrinkles.
One of the best-known peptides used in cosmeceuticals today is referred to as a
“pentapeptide.” This peptide is actually a small fragment of the protein that makes up
human collagen. This “pentapeptide” has been shown to increase collagen production.
Matrix Metalloproteinase Inhibitors (MMPIs) – Matrix metalloproteinases are
proteins found in the skin that break down collagen. They are activated by exposure to
ultraviolet light as well as by exposure to air pollution, smoking, and the natural aging
process.
There are two ways to block the activity of matrix metalloproteinases, and in so doing,
help to preserve the skin’s collagen. The first is with a good sunscreen that protects
against ultraviolet light. The second is with substances that actually block the activity of
the matrix metalloproteinases; these substances are referred to as matrix
metalloproteinase inhibitors (MMPIs). Substances that act as MMPIs include derivatives
of green tea, tretinoin (retinoic acid), beta-carotene, vitamin E, vitamin C, and flavonoids.
The use of MMPIs in cosmeceuticals is one of the newest and most exciting innovations
in skin care, and MMPIs are expected to receive much more attention in the near future.
Cosmeceuticals are formulated and available for purchase from a large number of
manufacturers, and their use has become a standard component of modern skin care.
Because there are literally thousands of skin care products in the marketplace from which
to choose, it can be quite confusing as to which products are best for a particular person.
For this reason, it is ideal for each patient to have his or her skin care program designed
by a skin care expert. These professionals are able to select from the large number of
available products those products that are best for an individual person.
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Chapter 8 – Getting Started
As can be easily seen from the information discussed here, there are a myriad of nonsurgical treatments and techniques that can be used to rejuvenate the skin of the face,
neck, chest, and hands, and achieve a younger looking appearance. Anyone who is
considering non-surgical skin rejuvenation should first consult with an expert in the field.
That professional is the most appropriate person to determine which treatments would be
most effective for any given individual. Depending on a person’s age, skin color, and
degree of sun damage, some procedures will be more effective than other procedures.
Each prospective patient should take advantage of a professional’s expertise to ensure
that only the most effective and beneficial treatments are selected.
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