Wrinkles

• One of the most reliable signs of aged skin is an increase in the number and depth of wrinkles. Other signs include irregular pigmentation, skin thinning, and laxity.
• Many of the changes found in older skin, but not all, are due to the exposure to ultraviolet light.
• Wrinkles fall into two functional categories: fine surface lines (caused by ultraviolet light) and deep furrows (caused by muscle contractions from facial expressions). Wrinkle treatments are in general much more effective for fine lines. Deeper creases may require techniques that are more aggressive.
• Environmental and lifestyle factors that promote wrinkling include smoking, degree of pigmentation, heredity (some families wrinkle more), and most important, occupational and recreational sun exposure over the course of many years.
• Treatments available for skin wrinkles include topical medical treatments (such as vitamin A acid, alpha hydroxy acids, antioxidants, and moisturizer) and more invasive procedures (such as glycolic acids peels, deep peels, dermabrasion, laser resurfacing, surgical procedures, injection of fillers, and Botox).

Although wrinkles can signify wisdom, or at least some level of maturity, there is no question that newly born infants also have wrinkles. The real concern that most of us have is that certain types of wrinkling are associated with the aging process. In our current "pop" culture, people do not view aging positively. Generally, the treatment of normal skin aging that does not result in a functional abnormality is termed "cosmetic." Most cosmetic procedures are not covered by health insurance.

Many products and procedures promise to reduce wrinkles. Some do little or nothing (like the products that claim they reduce "the appearance of fine lines," which means that they don't reduce the lines themselves). Others can achieve a fair amount of success.

Although all of our skin ages, sun exposure dramatically enhances the rate at which this occurs. Changes brought on by sun damage (photoaging) include dry skin (really roughness), sagginess, skin growths like keratoses, lentigos ("liver spots"), and wrinkles. Just compare the skin on the face and neck of a poorly pigmented farmer to the skin of his buttocks.

Most wrinkles associated with aging appear on the parts of the body where sun exposure is greatest. These sites are the face, neck, the backs of the hands, and the tops of the forearms. Wrinkles come in two categories: fine surface lines and deep furrows related to muscular contraction. Some deep furrows are anatomical in nature and have little to do with aging.

Generally, it is only the aging wrinkles that really bother people. There are two basic approaches to the amelioration of these signs of aging: prevention and treatment.

Topical wrinkle treatments are, in general, much more effective for fine lines. Deeper creases may require more invasive techniques, such injection of fillers, local muscle paralysis, or plastic surgery.

There is a special form of wrinkling called "cellulite" that produces a "cottage cheese-like" appearance to the skin. Cellulite most commonly appears in the hips and buttocks of women and is due to fat deposition in certain anatomical areas in the dermis.

Factors that promote wrinkling include the following:

• Smoking
• Degree of natural skin pigmentation (more is better)
• Sun and ultraviolet exposure
• Heredity (some families wrinkle more)
• The loss of subcutaneous fat on a person's body (people with more subcutaneous fat have fewer wrinkles)

Some of these factors are beyond our control. The main preventive measures we can take are to minimize sun exposure and not smoke. These measures can, at best, delay wrinkles.

Sun protection factor SPF numbers on sunscreen labels refer to protection against UVB radiation (the "sunburn rays"). Higher SPF numbers (50) are better at protecting the skin than lower numbers. Broad-spectrum sunscreens offer protection against UVB and UVA radiation (longer-wave ultraviolet light). UVA rays are abundant in sunlight and produced by tanning salon light bulbs; they may not cause immediate sunburn but do produce aging and an increase skin cancer risk over time. (Sorry, but there is no such thing as a "safe tan.") Sunscreens that block UVA indicate this on the label and contain ingredients such as Parsol, Mexoryl, and benzophenones.

There are several medical (topical medicines and creams) and many invasive techniques available for ameliorating wrinkled skin. They are all effective to the degree that (1) they change the nature of aging collagen, (2) they stretch the skin, (3) fill in the depressions in the skin, or (4) they paralyze muscles that cause the skin to crease. They include both medical and surgical methods:

Medical treatments for fine wrinkling

• Vitamin A acid (tretinoin [Retin A, Renova]): This ingredient, available by prescription, has the longest track record of success in treating aging skin and fine lines. People must use creams containing tretinoin on an ongoing basis. They may produce redness and peeling at first, but people usually can minimize discomfort by lowering the retinoid cream's concentration or applying it less often until the skin gets used to it.
• Alpha-hydroxy acids: These so-called "fruit acids" include glycolic and lactic acid. Preparations containing these fruit acids are quite safe and cause no more than mild and temporary irritation. They produce only subtle improvement though.
• Antioxidants: These include preparations that contain vitamin A, vitamin C, and vitamin E, as well as beta-carotene. There is very little compelling evidence that these sorts of creams produce a significant cosmetic improvement.
• Ordinary moisturizers: Creams that don't contain any of the above substances can only moisturize the skin, making wrinkles look temporarily less prominent ("reduce the appearance of fine lines").

Procedural options

• Glycolic acid peels: These superficial peels can make a very slight difference in the intensity of fine wrinkles.
• Deeper peels: These peels use ingredients like salicylic acid and trichloroacetic acid and penetrate somewhat deeper into the skin. Deeper peels do a better job of smoothing fine lines. The deeper the peel, however, the greater the risk of side effects such as long-lasting pigment changes (changes in the color of the skin) and scarring. Such peels may require anesthesia. Mild sedation helps ease short-term but intense discomfort.
• Microdermabrasion: This refers to "sanding the skin" with a machine containing silica or aluminum crystals; many estheticians offer this service, usually in "packages" of six or seven sessions. Microdermabrasion does not change skin anatomy, though it may make the face feel smoother. Cosmetic products marketed as "home microdermabrasion" are just mild exfoliants -- harmless but not likely to produce any meaningful change in wrinkles.
• Dermabrasion: This is a true surgical procedure, often performed under general anesthesia. The treating physician uses a rotating instrument to sand the skin down. Depending a great deal on the skill and experience of the operator, dermabrasion can result in excellent improvement but can also produce significant side effects, including scarring and permanent changes in skin color.
• Laser resurfacing: Using instruments such as the carbon dioxide and erbium lasers, physicians can achieve results similar to those of dermabrasion with greater reliability and precision. A medical professional passes the laser several times over the area to be treated until the damage reaches the middle of the dermis, the skin's second layer. This helps stimulate the body's natural collagen synthesis (production), which plumps up sagging skin and wrinkles. Some dermatologists perform laser resurfacing under "conscious sedation," in which the patient remains awake and receives intravenous medications to calm and ease pain. Doctors combine this sedation with the application of topical anesthetic creams such as EMLA, as well as injections of local anesthetics like lidocaine. Patients may need to repeat procedures to maximize improvement. Skin takes a long time to heal (weeks to months) after resurfacing. In addition, this procedure, like dermabrasion, can cause permanent pigment changes and scarring.
• Fractional resurfacing: Newer lasers work through a modification of traditional laser resurfacing. Treatments affect not the whole skin but instead only evenly spaced spots surrounded by undamaged skin. Healing is much faster than traditional resurfacing, with less "downtime" afterward. Patients may need several treatments to achieve full benefit.
• Non-ablative laser resurfacing: Newer lasers attempt to stimulate collagen synthesis under the skin without damaging the epidermis. Studies and clinical experience suggest that such procedures can improve fine wrinkles, though not as much as laser resurfacing. Several treatments may be necessary. These procedures are almost painless and there is little or no redness, peeling, or downtime afterward.
• Heat and radiofrequency: Another variation of noninvasive facial rejuvenation is to heat tissue using radiofrequency devices and infrared light sources. Techniques are still in development, but results to date suggest that such treatments are safe and can produce visible and lasting improvement, though not as much as surgical techniques like facelifts (rhytidectomy).
• Cosmetic surgery: Surgical facelifts, brow lifts, and similar operations can be very helpful for selected patients.
• Thread lift: In this procedure, a barbed, medical professionals insert a stiff thread into facial skin in the appropriate direction and the tissue is pulled to catch on the barbs, producing a lifted appearance. Whether or not the effect is sustained is controversial, but there is no doubt that in the short term there can be a modest cosmetic benefit using only a local anesthetic associated with minimal downtime.
• Botox: Injection of botulinum toxin, the muscle poison, can paralyze facial muscles that produce the "frown lines" on the forehead, fine lines around the eyes, and other wrinkles. Improvement lasts several months, and patients must have repeated injections to sustain improvement.
• Fillers: Medical professionals inject fillers into the skin to increase volume and flatten wrinkles and folds. In the past, the most popular filler was collagen. More recently, health care professionals use new filler substances such as hyaluronic acid (Restylane, Juvederm) and calcium hydroxylapatite (Radiesse), lactic acid (Sculptra), and autologous fat transplants because their effects can last six to nine months or even longer.

Anyone considering any of the cosmetic procedures should be sure to consult doctors who have experience in one or several of these techniques. Patients should fully inform themselves about the risks and potential benefits of the procedure they are considering before going forward.