Skin Care and Repair

All your life, your skin has been making a first impression for you. It can reveal whether you're hot or cold, tired or rested, sick or healthy. As you age, your skin changes in response to the elements that assail it, particularly the sun. On the inside, you may feel as good as ever, but the toll of years on your skin may send a different message. Medical conditions ranging from dryness to skin cancer become more likely. Meanwhile, cosmetic changes alter the tone and contour of your skin.

To some extent, your genes determine how well your skin stands the test of time. But environmental factors play a big role as well. Each year, physicians diagnose more than one million cases of two highly curable forms of skin cancer — basal cell carcinoma and squamous cell carcinoma. But for nearly 45,000 people, the diagnosis will be melanoma, a potentially deadly form of skin cancer. For the past three decades, melanoma cases have increased by about 3% per year. That's why it's so important to take steps to prevent skin cancer by avoiding the sun's ultraviolet rays, and this report describes the most effective ways to do so.

There has been significant progress in treating aging skin and skin disorders, including cancer. In addition to treatments for medical conditions, effective techniques that rejuvenate the skin are rapidly entering the market. But it's important to choose your treatments with care. Check and double-check the reputation and accreditation of clinicians performing invasive skin procedures. Choose skin care products wisely. The market for anti-aging creams and cosmetic surgery is skyrocketing. Anti-aging skin care products comprise an estimated $1.6 billion market worldwide. Cosmetic procedures such as Botox injections and laser therapy to improve the skin's appearance rose to 4.9 million in 2005 in the United States, a 20% increase since 2003.

This report will help you make informed choices about skin protection, procedures, products, and treatments. You'll find authoritative, up-to-date information about the ingredients in lotions and creams that help reduce wrinkles and other signs of aging. A detailed section on techniques ranging from laser resurfacing to cosmetic fillers can help you decide whether such procedures might be right for you. These are highly personal decisions. Whatever choices you make, you have more options today than ever before.

What is skin?

The skin is the body's largest organ, weighing about nine pounds. It carries out a number of functions that help maintain health. Skin is a complex fabric of tissues working together to form a basic control system (see Figure 1). Skin helps control your body temperature by sweating and dilating its blood vessels to cool you down. When you're cold, those blood vessels constrict to conserve heat deep inside your body.Figure 1: More than skin deep

Structures

Figure 1: More than skin deep

Functions

Protective barrier

Temperature control

Vitamin D manufacture

Fights infection

Sensory organ

Skin is more than just a cosmetic covering for the body. Its blood vessels and sweat glands regulate body temperature. Its immune cells ward off infection. Tiny nerve cells detect pressure and temperature, and other skin cells manufacture vitamin D.

The skin is also a sensory organ. Nerve endings on its surface pick up and relay information about the surrounding environment to your brain. Your brain then translates these nerve impulses into the sensations of heat and cold, as well as touch, pressure, and pain.

In addition, the skin helps ward off infection by way of its Langerhans cells, part of the immune system that fights off foreign invaders such as bacteria and viruses. The skin is also a manufacturing plant, using the sun's energy to make vitamin D, essential to making bones strong.The outermost layer

The epidermis is a protective, physical barrier. The outermost layer of skin, the epidermis is about as thick as a piece of paper. The very top portion of the epidermis is known as the stratum corneum. It's composed of cells called keratinocytes that produce a tough protein called keratin, forming a flexible outer shield. The keratinocytes die as younger living cells from the lower part of the epidermis rise to the surface from below. Finally, the older cells are rubbed off or fall off. This continuous cycle completely renews the skin about once a month.

This outermost layer of skin plays a key role in protecting you from the sun's radiation. In particular, pigmented cells called melanocytes are located at the bottom of the epidermis. These cells produce the melanin, or pigment, that colors skin and helps protect against ultraviolet radiation. When exposed to sunlight, the melanocytes churn out more melanin, and the skin darkens to help shield against further damage. If the melanocytes become cancerous, the condition is termed melanoma.

The middle layer

The dermis lies directly beneath the epidermis. It is a thicker layer that contains collagen, blood and lymph vessels, nerves, hair follicles, and glands that produce sweat and oil. Blood vessels in the dermis expand or contract to maintain a constant body temperature. White blood cells patrol the dermis to fight infectious microbes that manage to break through the epidermis. Cells called fibroblasts secrete collagen, which gives the skin its strength and firmness. Elastin fibers made of protein in the dermis give skin its elasticity.

The deepest layer

The subcutaneous tissue, which consists of connective tissue and fat, lies between the dermis and underlying muscles or bones. It, too, contains blood vessels and infection-fighting white blood cells, but not to the same extent as in the dermis. Fat in the subcutaneous layer stores nutrients and insulates and cushions muscles and bones.

Nails, skin, and hair

Your nails are skin, too. They're a thickened, hardened form of epidermis. Nail cells originate from the base of the nail bed. They die quickly, but unlike the keratinocytes, they aren't sloughed off. They're also composed of a much stronger form of keratin. Thus, a nail is simply a much harder and thicker sheet of keratin than the topmost layer of skin. Hair, however, is a thin fiber made of many overlapping layers of keratin, which is produced in the hair root.

Skin and the aging process

It seems a paradox: The top layer of skin is replaced about once a month, so why does skin age? Part of the aging process is genetic. Just as your genetic makeup determines your eye color and whether your hair is curly or straight, genes also have some say in whether your skin retains a firm texture into your 60s and 70s, or begins to wrinkle and sag during your 40s. The breakdown of collagen and elastin that leads to droopy, lax skin occurs at different rates in different people.

Chronological aging

Time takes its toll. As the years go by, skin undergoes a number of biochemical changes. Epidermal cells don't slough off as easily, and the supportive fibers of collagen and elastin break down. Skin doesn't retain as much moisture as it once did. The skin's ability to fight infection, feel sensations, and regulate body temperature also diminishes. Over several decades of sending instructions for new cell production, the DNA can become damaged and allow cells to grow out of control, with skin cancer as the result.

The deterioration of collagen and elastin and the pull of gravity can result in some of the classic signs of aging skin: fine lines around the eyes, deepened expression lines at the corners of the mouth and across the forehead, and sagging skin. The nails usually become more brittle, and hair may begin to thin.

Photoaging

The single biggest cause of damage to skin as you age is not aging itself — it's sun exposure. This damage is called photoaging. Over the years, sun exposure causes fine and coarse wrinkles; baggy skin with a yellow, leathery appearance; and dry, scaly skin. It also increases the risk for skin cancer. Because sun exposure diminishes collagen, which supports a network of blood vessels, photoaging can cause skin to bruise more easily.

You can easily distinguish the effects of photoaging from those of chronological aging. Look at the lines and pigmentation of the skin on your face and the back of your hands; feel its texture. Now do the same on a part of your body that hasn't received much sun exposure, such as your lower abdomen or buttocks. The difference can be great, especially if you've been a sun worshipper throughout your life. People are spending billions of dollars annually to try to counteract the effects of photoaging (see "Skin rejuvenation procedures").

Skin damage from sun exposure is caused by ultraviolet (UV) radiation. Not all the sun's rays are created equal. Some wavelengths of UV radiation penetrate the skin more deeply than others. Realizing this difference has prompted researchers to question whether some types of UV rays mainly cause wrinkles and the brown spots (sometimes called "age spots" or "liver spots") while others speed the development of skin cancer.

Three types of UV radiation

The wavelengths of UV radiation fall between those of visible light and x-rays. The sun's UV radiation reaches the earth in three main wavelengths (see Figure 2).Figure 2: Three wavelengths of skin damage

Figure 2: Three wavelengths of skin damage

Three different wavelengths of ultraviolet (UV) light come from the sun. UVA is the longest wavelength and penetrates most deeply. UVB is the next longest and causes burns to the skin's upper layer. UVC, the shortest wavelength, normally is blocked by the ozone layer in the atmosphere. Which type causes the most damage? No one knows for sure. That's why the most effective protection is to stay out of the sun or wear protective clothing.

UVC. This wavelength is the shortest of the three. It also has the highest energy level and is the most damaging. UVC rays are capable of destroying the skin, but they're usually absorbed in the atmosphere by the ozone layer before they reach the earth's surface. However, in places such as Australia, where scientists suspect the ozone layer is thinning, UVC rays pose a risk for very serious skin damage.

UVB. These rays are slightly longer and lower in energy than UVC rays, so they're less damaging to skin. UVB rays penetrate the epidermis, and the visible result of their damage is a sunburn. Experts generally believe that the more often you've been

sunburned, the more likely you are to develop skin cancer. Research suggests that UVB rays cause a distinctive genetic mutation that permits unabated cell growth, giving rise to cancer. In fact, more than 90% of squamous cell cancers have this specific mutation.

UVA. The rays with the longest range of wavelengths, called UVA, also play a role in photoaging and in the development of skin cancer. Because of their longer wavelength, these rays penetrate more deeply into the dermis. Only about 10% of UVB rays reach the dermis, but researchers believe that 50% of UVA rays do so. And when you're in the sun, you're exposed to more UVA: The sunlight that reaches the earth contains about 10 times as much UVA as UVB (see "Don't get burned by improper sunscreen use").

Risks of UV exposure

If you're taking certain medications, sun exposure can cause additional damage to your skin. Such drugs, called photosensitizers, increase your sensitivity to UV radiation. Reactions include overly reddened skin, hives, swelling, and itchy, scaly skin. Cataracts and damage to blood vessels or the immune system also may occur.

Some of these drugs are more commonly taken by people as they get older — for example, antiarrhythmics, such as amiodarone, and diuretics, including hydrochlorothiazide. Some antibiotics, such as doxycycline, can also cause photosensitivity. It's important to check with your doctor to determine whether any of the medications you're taking could cause photosensitivity.

A less common cause of skin damage is exposure to infrared radiation (heat). It's not a major cause of skin damage, but researchers believe that it may add to the effects of UV rays. Some exposures may occur on the job — think of the short-order cook who stands in front of infrared heat lamps all day. Infrared heat lamps also are used to heal some muscle injuries or to relieve pain and stiffness from osteoarthritis.

Other sources of skin damage

In addition to the sun and the normal effects of aging, your skin can take a beating from many other sources.

Cigarettes. Cigarette smoking has long been recognized as a cause of wrinkles. Researchers haven't determined exactly how this happens, but they know that cigarette smoking damages the connective tissue, which is the basis for the skin's smooth appearance. Smoking-related wrinkles may not appear for a decade or more after the first puff, but damage occurs with every cigarette smoked. The combination of smoking and sun exposure is particularly toxic. Considering how harmful smoking is, not just to your skin but to every other part of your body, the healthiest choice is to avoid cigarettes. If you're trying to quit, support groups, nicotine gum and patches, and the drugs bupropion (Zyban) and varenicline (Chantix) can be useful smoking-cessation tools.

Irritants. Skin becomes thinner and doesn't heal as easily as you age, so take care in handling and working with irritants. Substances that are very acidic or alkaline can damage the skin's top layer and leave it susceptible to infection. You may encounter them in on-the-job exposures in industrial settings where solvents or cutting agents are used. Dusts, such as those from tobacco and wood, and gases, such as mace or tear gas, can damage skin, too. But if you wonder about the kind of irritation caused by vigorous scrubbing of your skin, you can rest easy. Scrubbing generally doesn't damage skin or cause wrinkles. If your skin is irritated by harsh chemicals, apply topical or oral corticosteroids followed by a nonirritating moisturizing cream to help the skin heal. Antibiotics may be needed if infection sets in.

Facial expressions. Laughter may be the best medicine, but it can add to creases and lines that develop through the years from repeated facial expressions. Every time you smile, squint, or frown, facial muscles contract and cause accordion-like lines and creases to form in your skin. Young skin bounces back. But as aging skin loses its elasticity and firmness, those lines and creases tend to become etched in the skin. Even sleeping with your face scrunched in a pillow at night may cause some lines to gradually appear.Three-step daily skin care

For daily skin care, limit your regimen to three simple steps: cleaning, protecting your skin from the sun, and tending to any specific skin problems you may have such as dry skin, acne, or fine lines and wrinkles. Products for all three steps are available for very little cost at retail stores. Buying expensive skin care lotions with exotic or pseudoscientific names will not produce better results.

Cleaning: Choose your skin cleanser based on whether your skin is dry or oily. If you have dry skin, choose a mild cleaning agent and avoid products containing alcohol, including toners. For oily skin, choose a soap that removes the oil and cleanse more frequently throughout the day.

Protecting your skin from the sun. Choose a broad-spectrum sunscreen with an SPF of 15 or higher and wear it every day. Higher SPFs are useful if you plan to spend hours outdoors but if you spend most of your time indoors, SPF 15 is generally sufficient. If you have sensitive skin, choose a sunscreen product designed for sensitive skin.

Customize this last step to your particular skin needs. For dry skin, effective and inexpensive moisturizers are available (see "Dry skin"). For adult acne products, see "Adult acne." If you want to try a product that moderately reduces lines and wrinkles or fades brown spots, see "Cosmeceuticals."

Common skin conditions

Your skin becomes vulnerable to a number of conditions as you get older. Some are caused by hormonal shifts or occupational exposures. Others are caused by exposure to the elements, wear and tear on blood vessels, or infections. Dermatologists have a number of treatments available (see Table 1).

Table 1: Choosing the right treatment

Condition

Treatments

Dry skin

Petroleum jelly, mineral oil, or moisturizing lotions applied immediately after bathing

Sun damage, photoaging, and related skin conditions, such as lines and wrinkles, sagging skin, liver spots, actinic keratosis, loose eyelid skin

Sunscreens and sun blocks, cryotherapy, topical creams for actinic keratosis, laser therapy, chemical peels, soft-tissue augmentation, botulinum toxin injections, microdermabrasion, surgery

Hair loss

Minoxidil, finasteride, hair transplantation, scalp reduction, scalp flap surgery, tissue expansion

Birthmarks, tattoos, growths

Laser surgery, surgical excision, cryosurgery, chemical peels

Cysts, moles

Surgical excision

Fat deposits

Aerobic exercise, liposuction

Scars resulting from acne or injury

Laser therapy, soft-tissue augmentation, dermabrasion, surgical scar revision, chemical peels

Skin cancersSurgical excision, Mohs' micrographic surgery, laser surgery, cryosurgery, topical chemotherapy

RosaceaTopical antibiotics and other topical medications and systemic antibiotics to reduce papules and pustules; laser or light treatments for red or dilated blood vessels

Spider veins and varicose veinsLaser therapy, sclerotherapy

Dry skin

Just about everyone has dry skin at some time in his or her life, but it becomes much more common with age. A tendency toward dry skin can be inherited, but experts estimate that at least 75% of people over age 64 have dry skin. Although you may take it for granted that skin becomes dry as a result of chronological aging, much of the loss of moisture is due not to aging, but rather to the cumulative effects of sun exposure. Sun damage results in thinner skin that doesn't retain moisture.

Over time, the production of natural oils in the skin also slows, and skin isn't as well lubricated as it once was. The outermost layer of the skin can be likened to a brick wall: The skin cells are stacked in layers with a "mortar" of keratin and natural oils that maintains the skin's suppleness. Just as a brick wall dries and crumbles with time and exposure to the elements, so, too, can skin become dry, cracked, and itchy. Some medical conditions, such as hypothyroidism, diabetes, and kidney disease, increase the likelihood of developing dry skin.Symptoms of dry skin

Scaly patches of skin

Itching

Scaly redness

Overall dryness

Treating dry skin with moisturizers

The first line of defense against dry skin is an effective moisturizer that softens and smoothes skin with water and lipids (fats). Some of these products attract water to the skin and seal it in, while others prevent skin from losing water by coating it with a thick, impermeable layer. One of the most effective products is petrolatum, also known as petroleum jelly. It's used in a number of moisturizers and ointments because it's inexpensive and stops water loss without clogging pores. Lanolin is another widely used

ingredient. But despite their ability to soothe the irritation of dry skin, moisturizers can't prevent or reduce lines and wrinkles.

Petroleum jelly, although effective, isn't very popular as a moisturizer by itself because it feels greasy. And people with arthritic hands find such thick moisturizers difficult to apply. Moisturizing oils, such as mineral oil, are effective without being as greasy. Petroleum jelly and moisturizing oils contain no water. Because they don't add water, they're best used while the skin is still damp after bathing to seal in moisture, which prolongs their skin-softening effect.

Lotions and creams are emollients that contain basic ingredients of water and oil and can be used at any time to help add moisture to the skin at least temporarily. For commercial appeal, many have fragrance and color added. Lotions and creams are more popular than petroleum jelly or oils because they're less greasy and more cosmetically appealing. Lotions have a thinner consistency than creams because they contain more water. Most also contain an emulsifier to keep the product from separating. Humectants, including sorbitol and glycerin, are used to bind water to the skin and help it absorb moisture.Fast fact

When you shop for a moisturizer, don't assume that a hefty price tag will buy you a more effective product. Moderately priced moisturizers, available in drug stores and supermarkets, can be equal to or better than the expensive brands sold in department or specialty stores. One of the most effective products is one of the cheapest: petroleum jelly.

Six ways to prevent dry skin

Along with moisturizers, a few changes in lifestyle or your environment can help alleviate dry skin:

Add moisture to the air with humidifiers or a pan of water set atop the radiator.

In the shower or bath, use water that's lukewarm instead of hot; hot water can further dry the skin by stripping it of natural oils.

Choose nondrying soaps that contain no abrasives or irritants. Super-fatted soaps or cleansing bars are less drying than regular, liquid, or antibacterial soaps.

Instead of rubbing, pat your skin dry after you bathe.

Apply moisturizer immediately to retain the water your skin absorbed while bathing.

Wear soft fabrics that won't scratch or irritate the skin.

Adult acne

A common problem in adolescence, acne may appear for the first time or worsen in midlife for reasons not fully understood. Hormonal fluctuations associated with menstruation and menopause make women more susceptible to adult acne.

Acne is generally attributed to an excess of male hormones known as androgens. Androgens stimulate the production of oily, waxy sebum by sebaceous glands in the dermis associated with acne. Overproduction of sebum may lead to blocked pores in the skin and a rapid growth of normal skin bacteria.Symptoms of adult acne

Whiteheads (closed, plugged oil glands)

Blackheads (open, plugged oil glands)

Pustules (swollen red bumps), sometimes filled with pus

Treating adult acne

Several effective treatments for acne are available. If you have mild acne that's not inflamed, treatment with a nonprescription cream or lotion that contains benzoyl peroxide will help keep pores open and inhibit bacterial growth. Salicylic acid and sulfur in nonprescription lotions, creams, or gels can't prevent new eruptions, but they can cause existing ones to dry and peel.

Topical antibiotics — erythromycin, clindamycin, and others — kill bacteria and are available with a prescription. So are oral antibiotics, which are even more effective. Both kill Propionibacterium acnes, the bacterium involved in the development of acne.

Retinoids, available by prescription, are derived from vitamin A and are a common and useful acne treatment. They cause several changes in skin cells that reduce the formation of pimples. Retinoids are especially effective when used with antimicrobial drugs — either antibiotics or benzoyl peroxide. Using a retinoid and an antimicrobial agent works better than using either drug alone. Tretinoin (Retin-A) is the retinoid most commonly used for treating acne, but it can irritate your skin. A microencapsulated form of tretinoin is less irritating. Tretinoin and two similar drugs, adapalene and tazarotene, are available only by prescription. Another treatment is azelaic acid, an antibacterial agent for mild or moderate acne.

The most powerful retinoid is isotretinoin (Accutane), which you take orally rather than apply topically like tretinoin. Isotretinoin is very effective for severe acne, but has some side effects, such as dry skin and chapped lips. Less common side effects are increased sun sensitivity, muscle and joint aches, headache, hair thinning, and impaired night vision. The drug is known to cause severe birth defects and must not be taken during pregnancy. A few patients taking isotretinoin have developed psychiatric problems including depression and, more rarely, suicidal behavior. As a safeguard, the federal government placed further restrictions on isotretinoin prescriptions. Doctors must register

each patient in a national database and see the patient monthly, renewing the registration with each office visit.

Many women — up to 60%, according to the American Academy of Dermatology — show no response to routine acne treatment or find that their medications become ineffective over time. Because of this, isotretinoin has become a more common option, despite its drawbacks.

The same is true for hormonal treatments. Estrogen-dominant oral contraceptives often are effective in treating adult women with acne. The combined estrogen and progestin that they contain decrease androgen levels. Undesirable effects include nausea, headache, and breast tenderness, but oral contraceptives may help decrease bone loss and lower the risk for ovarian and colorectal cancers. The anti-androgen drug spironolactone may be added if oral contraceptives alone are not effective.

Women with hypertension or a history of stroke, blood clots, breast or uterine cancer, or who still smoke after age 35 should not use oral contraceptives. Alternatives include spironolactone, used with antibiotics or by itself. Light and laser treatments are also useful for treating acne and acne scars.

Rosacea

This condition is sometimes confused with adult acne because it causes pimples on the face, affects mainly adults, and responds to some acne medications. But acne and rosacea are separate disorders. Rosacea is a chronic condition that affects the skin and sometimes the eyes. Symptoms may include pimples and enlarged blood vessels, causing redness and swelling mainly on the middle of the face. Eye irritation is another symptom, often referred to as ocular rosacea. Rosacea affects 14 million Americans. It's not clear what causes the condition, but genetics and environmental exposures seem to play a role. Rosacea runs in families. Some experts think that exposure to certain mites or bacteria may trigger rosacea by causing inflammation.Symptoms of rosacea

Flushing of the face and neck

Pimples

Enlarged blood vessels (called telangiectasia)

Redness and swelling of the nose

Irritation of the eyes

Treating rosacea

Rosacea has no cure, but treatment can help control pimples and prevent the most severe symptoms — enlarged blood vessels and redness and swelling of the nose. Treatment often involves applying topical medications, taking oral antibiotics, or both, as well as avoiding substances that irritate the skin and trigger symptoms.

Some of the same medications that are used to treat acne pimples are also used to treat pimples from rosacea, including antibiotics and benzoyl peroxide cream or lotion. Metronidazole and azelaic acid creams and gels are very helpful topical antibiotics. It can take at least a month to see results from topical medications.

For enlarged blood vessels, doctors often recommend laser surgery, light treatments, or electrosurgery with an electric needle. All of these procedures destroy the blood vessels that cause red lines and blotches.

Self-help measures are essential for controlling symptoms. Anything that increases blood flow to the face can potentially cause a flare-up of symptoms. This includes drinking hot drinks or alcohol, eating spicy foods, taking hot baths or showers, and rubbing the face while washing. Avoid lotions and cosmetics that contain alcohol and fragrances because these chemicals can irritate the skin and aggravate rosacea.

Hair loss

Hair loss affects about 50 million men and 30 million women in the United States. Age-related hair loss usually results from hormonal changes and genetic predisposition. In recent years, topical medications and refined techniques in hair transplantation have helped ease the distress that hair loss causes.

A number of factors can cause hair loss, including immune disorders, exposure to toxic chemicals, stress, burns, and various skin disorders. But more commonly, hair loss is caused by aging or an inherited predisposition to premature thinning called androgenic alopecia. Often referred to as male pattern baldness, androgenic alopecia is more common in men because it develops in response to higher androgen levels. In women, a similar condition is called female pattern baldness. It may occur in women before age 40, but is more likely to coincide with menopause.Symptoms of hair loss

Hair loss may follow one of several patterns depending on the cause:

receding hairline and gradual loss of hair on top of the head

even thinning of hair over much of the scalp

scattered areas of hair loss

Treating hair loss with topical medications

Minoxidil (Rogaine), a nonprescription lotion which is applied topically, and finasteride (Proscar, Propecia), a prescription drug taken orally, are the only two medications the FDA has approved to treat hair loss in men. For women, only minoxidil is approved.

Minoxidil increases the anagen, or growth, phase of hair, and returns shrunken hair follicles to a more normal size. In one study, men who used minoxidil for 96 weeks experienced a 30% increase in hair weight, compared with a slight decrease in men who did not use the drug. A more concentrated solution of minoxidil — 5% versus 2% — has been found to be more effective in increasing the number of hairs in studies of men. In women, minoxidil has been shown to promote new hair growth, but there has been no difference between the two concentrations.

Finasteride, a drug also used to treat prostate enlargement in men, lowers levels of dihydrotestosterone, a hormone involved in hair loss, without disrupting testosterone activity. In a study of 1,215 men who used finasteride for two years, two-thirds had significant improvements in hair growth and the remaining third had as much hair as when the study began. On the other hand, finasteride has not been effective in postmenopausal women.

Thus far, only one study has directly compared minoxidil and finasteride, and it found finasteride more effective. For a year, 40 men with androgenic alopecia took finasteride once a day, and 25 men with the condition used a 5% solution of minoxidil twice a day. At the end of the study, 80% of the finasteride group and 52% of the minoxidil group had thicker hair. Because the medications promote hair growth in different ways, some people choose to use both at the same time. However, there's little evidence that simultaneous use results in more or faster growth.

Hair transplants

Decades ago, the results of hair transplants weren't always attractive. Because transplants moved large "plugs" of hair to thinning, balding areas, the effect often was artificial-looking. Today, refinements in hair transplantation techniques offer a much more natural appearance.

To achieve natural-looking transplants and minimize scarring in the area from which hair has been transplanted, surgeons no longer "punch" pieces of hair-bearing skin from the back of the head. Instead, they cut a small strip of skin from the back of the head, which then is dissected into tiny sections. These micrografts and minigrafts contain as few as one to five hairs. Minigrafts and micrografts provide a natural look around the hairline, but larger grafts can be used behind the hairline to achieve greater density.

Surgeons may choose among several grafting techniques. Needles and blades commonly are used to create the small slits or holes into which the grafts are placed. Sometimes lasers are used. While lasers may result in less bleeding and scarring, regrowth of the transplanted hair may be slower than with more traditional methods. Automated grafting devices that resemble a ballpoint pen with a retractable needle may be used, too. On

average, it takes about four hours to transplant 1,000 grafts by hand. But one of the automated devices has been clocked at 38 grafts per minute. Despite their speed, these automated devices may be more expensive to use because they have to be replaced more often than needles and blades, and results with fine hair may not be as good as with coarse hair.

Surgeons perform graft procedures on an outpatient basis with local anesthesia. Bandages can be removed the next day, and most people can resume their everyday activities, with the exception of strenuous exercise. It takes a week to 10 days for scabs or crusting to heal, but many people feel comfortable going out in public wearing a hat or scarf three to five days after the transplant. The transplanted hair begins to grow within three to six months. Within ten to twelve months, most people can expect to see their transplant reach its maximum density.

Most hair transplants will not be completed in one session. Two or three sessions are often needed, depending on the desired result, and they should be spaced about four months apart so the scalp heals adequately between surgeries.

Other hair-restoration techniques

A less common procedure is called skin flap surgery. A section of scalp with healthy hair is cut and moved with one end still attached to maintain blood supply. Essentially, it replaces a piece of bald scalp with a piece that has growing hair. New hair grows and covers the scars.

Another technique, scalp reduction surgery, reduces the size of bald spots at the crown. In this procedure, the surgeon cuts out the hairless area of skin, stretches the scalp, and then sutures it so the areas that are covered with hair will meet. Sometimes physicians combine scalp reduction surgery with the use of scalp extenders or tissue expanders that stretch areas of skin, which is then excised, further reducing the size of the bald area. Physicians also can use these techniques along with grafts or topical minoxidil. Some procedures may require general anesthesia. You can determine which approach is best for you by consulting a dermatologic surgeon.

Excessive hair growth

Just as hormones influence hair loss, they can also cause an overgrowth of hair. This condition is called hypertrichosis. It's most common in women and often occurs around the time of menopause because of increased androgen levels. Hypertrichosis is characterized by excessive growth in locations that already have fine, light-colored hair, such as the upper lip or along the jaw line. It differs from hirsutism, which causes women to develop male hair growth patterns. While hypertrichosis is related to age and hormonal changes, hirsutism is caused by underlying endocrine disorders such as adrenal gland tumors or polycystic ovary syndrome. Regardless of the cause, excess hair growth can be embarrassing. A variety of solutions, including new laser treatments, are available.Symptoms of excessive hair growth

The appearance of thick dark hair in areas where light hairs ordinarily grow

An increase in dark hair on the body following menopause

Treating excessive hair growth

The most common, temporary solution is shaving the excess growth. Plucking, waxing, and depilatories also offer temporary solutions. Traditionally, the only permanent means of removing excess hair has been with electrolysis, which uses a shortwave electrical current to destroy the hair follicles. Electrolysis can be used safely on most parts of the body except the underarms, where there is an increased risk for bacterial infection, and the delicate skin under the eyebrows.

Physicians have discovered how to permanently destroy hair growth using lasers or intense light sources. Certain laser light frequencies are absorbed by the dark pigment in hair, causing selective thermal damage to or destruction of the hair follicle. A single treatment can destroy up to 30% of follicles in the area treated. Hairs that do grow back are thinner and softer. Three treatments may destroy about half of the follicles in the area treated.

One type of laser used for this purpose is the long-pulsed alexandrite laser, which, in its Q-switched version, is also used to eliminate brown pigmented areas. People with fair skin and dark hair are most likely to obtain the best results with laser hair removal, while the treatment is ineffective in people with blond, white, or gray hair. In order to work, the light has to be absorbed by pigment in and around the hair follicle. Light-colored hair has little or no pigment and therefore does not absorb laser light. For most people, laser hair removal is faster, safer, and more effective than electrolysis. The cost depends on the size of the area being treated and the number of treatments needed.

In addition to lasers, a different kind of light source, called intense pulsed light, is effective in removing hair. (For more information on different types of lasers and cosmetic laser procedures, see "Laser and other procedures.")

Actinic keratosis

Actinic keratosis (AK) is a precancerous skin condition that appears as scaly pink or red-brown raised, rough patches on sun-exposed skin. Fair-skinned people are more likely than darker-complexioned individuals to develop AK. The condition can cause discomfort and itching, but its biggest danger is as a precursor to squamous cell carcinoma (see "Basal cell and squamous cell carcinoma"). The FDA has estimated that almost half of all skin cancers begin as AK spots. Most treatments can remove these crusty patches without scarring.Symptoms of actinic keratosis

Rough, scaly red or brown patch on skin

Most likely to appear on face, back of hands, or other areas commonly exposed to sun

Treatment for actinic keratosis

Several methods exist for removing areas of actinic keratosis:

Cryotherapy. The standard treatment for AK is to freeze the area with liquid nitrogen. Inflammation, swelling, and occasionally blistering may occur. A small scab forms, and healthy new skin emerges as it heals.

Topical medications. A prescription cream containing the chemotherapy drug fluorouracil (5-FU) can be used once or twice a day for several weeks or on two consecutive days a week for several months. The cream removes the AK patch, but it causes sun sensitivity and, often, considerable discomfort. A topically applied drug called imiquimod is also very effective in treating AK spots. Imiquimod stimulates the immune system to release cytokines, chemicals that fight cancer cells and viruses. Imiquimod causes AK patches to become inflamed, crust over, and heal.

Deeper treatments. Widespread facial patches may warrant deeper treatments such as laser resurfacing (see "Laser and other procedures"), which vaporizes the epidermis and upper dermis, or a chemical peel, which dissolves the outer layers of the skin with a chemical solution. Laser resurfacing and chemical peels can involve local or general anesthesia. Depending on how deeply the skin is penetrated, they may result in considerable swelling. Still another effective treatment is electrodesiccation and curettage (see "Treating basal cell and squamous cell cancers."

Photodynamic therapy. This is a relatively new treatment, which uses light exposure to activate a therapeutic agent. In this case, the agent is Levulan, a topical solution of aminolevulinic acid, which occurs naturally in the body to process heme, a red blood cell component. First, Levulan is applied to AK spots, where it is converted into a light-sensitive molecule. Several hours to a day later, light or laser treatment activates the drug and destroys the AK cells. In a few days, the spots crust over and heal. Photodynamic therapy is appropriate when there are many AK spots on the face and scalp.

Shingles

Shingles, also known as herpes zoster, is a viral infection of the nerves that causes a painful, blistering rash. The virus responsible, the varicella-zoster virus, is the same one that causes chickenpox.

Most people born before the chickenpox vaccine became available have been exposed to this virus. After the initial exposure, the virus lies dormant in the spinal nerves and, most of the time, remains inactive throughout life. But sometimes, particularly in people over age 60 or those who have a weakened immune system, the varicella-zoster virus "reawakens" and causes shingles. Initially, shingles causes sharp, burning pain near the

surface of the skin. Several days later, a rash of red raised bumps appears. These bumps turn to itchy blisters loaded with viral particles. If your immune system is weakened by other health conditions, the complications from shingles can be life-threatening.

The blisters form distinct patterns along nerve pathways, often appearing in a band over the ribs on one side of the body, or on the face. They usually disappear in two to three weeks, crusting over and occasionally leaving scars. Pain may persist for weeks or, less commonly, for several months. The affected area can become so sensitive that even light bed sheets or clothing cause intense pain, a condition called postherpetic neuralgia. This condition, which results from damage to the nerves, affects about 10%–15% of people who get shingles. For some, antidepressants, corticosteroids, capsaicin cream, or the antiseizure drug carbamazepine have been useful for relieving the pain. Postherpetic neuralgia often disappears on its own over time.Symptoms of shingles

Tingling, itching sensation on skin

Sharp burning pain on skin

Clusters of small fluid-filled sacs

Extreme sensitivity to touch

Chills, fever, nausea, diarrhea occur in some people before other symptoms

Treating shingles

If you suspect that you have shingles, it's important to see a doctor immediately for treatment to shorten the course of the condition, minimize pain, and reduce the risk for nerve damage. Your doctor may prescribe an oral antiviral drug such as acyclovir, famciclovir, or valacyclovir. Analgesic drugs (pain relievers) may be useful in relieving pain and discomfort. Corticosteroid drugs may help reduce swelling, inflammation, and postherpetic neuralgia. Keeping the skin clean is important to avoid secondary bacterial infection. Applying cool compresses also may help ease the discomfort.

Two vaccines can help prevent shingles. The varicella-zoster vaccine is recommended for children and adults who haven't had chickenpox. This vaccine cannot help people who've already been infected with the virus; that includes the vast majority of today's adults, who had chickenpox before immunization was available.

A newer shingles vaccine was approved in 2006 for adults ages 60 and older. A major clinical trial of more than 38,000 adults found that the vaccine cut the incidence of shingles by half. Vaccinated adults who did get infected had milder cases with fewer complications than people who weren't vaccinated.

Herpes simplex

There are two types of herpes simplex viruses. HSV-1 is the main cause of oral herpes, or cold sores. HSV-2 causes most cases of genital herpes, although HSV-1 can cause it, too.

More than 90% of people have been exposed to HSV-1 by the time they reach their 40s. It is transmitted by kissing or other contact with saliva. The first sign of a cold sore is pain, burning, or tingling followed about 24 hours later by a tender bump, which quickly becomes a blister. Within a week, the blister opens, leaving a shallow ulcer that crusts over and heals.

About 45 million people in the United States have genital herpes, a sexually transmitted disease that usually spreads through kissing, contact with infected skin, and intercourse. Small, itchy, burning blisters form in the genital area and, in some people, around the mouth. A pregnant woman with HSV infection can pass the virus to her baby during delivery, causing infections of the baby's skin, mouth, lungs, or eyes.

Symptoms of both may occur just once or in recurrent bouts. Cold sores usually appear for no apparent reason, but they can be triggered by intense exposure to sunlight, fever, skin trauma, menstruation, and emotional distress. Once you are infected with a herpes simplex virus, it remains in the body for the rest of your life.Symptoms of herpes simplex

Tender bump or cold sore that develops into a blister on the lips or inside the mouth (oral herpes)

Small blisters in the genital area (genital herpes)

Itching, burning, and soreness (oral and genital herpes)

Pain during urination from contact (genital herpes)

Enlarged or painful lymph nodes in the groin (genital herpes)

Headache, fever, and generally sick feeling (genital herpes)

Treating herpes simplex

Oral and genital herpes have no cure, but your doctor may prescribe an oral antiviral medication such as acyclovir, famciclovir, or valacyclovir to shorten the duration of the symptoms and help prevent recurrences or make them less severe. Newborns of mothers with genital herpes receive antiviral medications intravenously.

For cold sores, antiviral medications are most effective when taken as soon as itching and burning begin but before the blisters form. Sometimes doctors prescribe antiviral drugs to people before exposure to a cold sore trigger such as intense sunlight or a skin procedure such as dermabrasion. When herpes outbreaks occur frequently, doctors may prescribe

antiviral medications to be taken regularly to minimize recurrences. Over-the-counter anesthetic ointments such as Zilactin can temporarily relieve pain and protect the affected area from cracking and irritation.

Drug-resistant skin infections

Skin infections are usually minor, causing small pimples or boils that go away without antibiotics. But a growing number of skin infections are severe or life-threatening and do not respond to most antibiotics.

More than half of skin infections treated in emergency rooms in the United States may be caused by a persistent bacterium called methicillin-resistant Staphylococcus aureus, or MRSA. Until recently, MRSA infections occurred mainly in patients in hospitals and long-term care facilities, but new studies show that they are becoming increasingly common in the general population, including previously healthy children and adults. One study in 2003 estimated that 12% of the infections were in the population at large.

While everyone is at some risk of getting an MRSA infection, you can help protect yourself with good hygiene such as washing your hands frequently, not sharing personal items like towels, and cleaning and covering any cuts or other skin wounds.Symptoms of drug-resistant skin infections

Pimples or boils that are red, swollen, and painful or are filled with pus

Painful red sores that look like spider bites

Wound infections

Blood infections

Pneumonia

Bone infections

Heart valve infections

Treating drug-resistant skin infections

If you have symptoms of a skin infection, see a doctor right away. Treatment depends on its location and severity. For a local pimple, boil, or abscess, the doctor will probably surgically drain it and may prescribe antibiotics. However, about 25% of people with MRSA infections need to be hospitalized because the infection can be difficult to treat and can be deadly.

MRSA infections are resistant to antibiotics in the penicillin family, but other classes of antibiotics appear more effective, including linezolid, daptomycin, and quinupristin-

dalfopristin. Sulfa drugs, clindamycin, and some tetracycline derivatives may also be effective. If antibiotics are prescribed, it's essential that you finish the entire prescription, even if the infection is getting better.

To prevent the infection from spreading, practice commonsense hygiene: Wash your hands regularly with soap and water, clean and cover all open skin wounds with a bandage until they heal, and don't share clothing or other personal items.

Varicose veins and spider veins

More than 56 million people in the United States — 40% of women and 15% of men — have varicose veins or spider veins (telangiectasia). One of the most important distinctions between these conditions is that varicose veins sometimes develop into a serious medical problem.

Although these conditions may mar the appearance of the skin, they aren't actually skin conditions, but rather circulatory problems. In your legs, veins have the unenviable job of working against gravity to push the blood upward. Healthy veins do this with pulsing movements and one-way valves that encourage the blood to flow up and prevent it from flowing back down. As you age, the valves can malfunction, and the veins may stretch. Blood can stagnate, causing the veins to dilate. Heredity and hormonal changes also can influence the development of varicose veins.

For most people, varicose veins are more a cosmetic issue than a medical one. Often you can treat them by wearing elastic support stockings, avoiding standing for long periods, and sitting with the feet elevated. Exercise such as walking, jogging, or bicycling can help. However, advanced cases of varicose veins can result in blood clots, inflammation of the veins, or ulcers. Signs that medical attention is needed include muscle cramps, fatigue or swelling in the legs, excessive tenderness, or any indication of an ulcer. Larger varicose veins may require surgery.

Spider veins form when groups of blood vessels close to the surface of the skin dilate. As a result, fine networks of red, blue, or purple veins — each barely more than the width of a hair — appear on the thighs, calves, and ankles. They may form patterns resembling a sunburst, spider web, or tree branches, or they may appear just as short, unconnected lines. Age, heredity, hormonal changes, or external injuries increase the likelihood of spider veins.

One of the best ways to prevent spider and varicose veins is with regular exercise that keeps blood from pooling in the veins. Walking, jogging, bicycling, and swimming are good choices.Symptoms of varicose veins and spider veins

Generalized swelling and aching in the legs

Aching in the area where the veins are swollen

Leg muscles that tire easily

Itching around the veins

Leg cramps

Sores on your skin, especially near the ankle

Spider veins

A fine network of red, blue, or purple veins close to the skin

Treating varicose veins

The oldest procedures for getting rid of varicose veins involve open surgery, but a newer, less invasive approach, called endovascular ablation, has become more popular. This method employs heat to collapse and close varicose veins.

Endovascular ablation is done with a thin catheter that contains either a laser (called endovascular laser ablation, or EVLA) or a device that generates high-frequency radio waves (called radiofrequency ablation or VNUS closure). Both procedures can be performed in a doctor's office. Local anesthesia is used to numb the area being treated, and then the catheter is inserted into an enlarged vein in the lower leg and directed to the varicose vein, heating the vein wall. The heat makes the vein collapse and seals it shut. Once the varicose vein is closed, other healthy veins take over and circulate blood from the legs, and symptoms significantly improve. Most people can return to their normal activities after a day or two.

Studies show that endovascular ablation is as effective as surgery for up to two years after treatment, but with less pain, scarring, and recovery time. As a result, endovascular techniques have replaced longstanding surgical procedures in most cases.

One traditional surgical technique is stripping, which involves removing the vein through small incisions and diverting the blood flow to another vein. Ligation is similar to stripping, but instead of removing the vein, the surgeon ties it off at a point close to the source of the blood flow, and the blood is rerouted to another vein.

A less invasive surgery called ambulatory phlebectomy may be recommended for removing varicose veins that remain after endovenous ablation. Using an instrument that hooks the vein, the surgeon removes it by pulling it through a series of tiny punctures created along the length of the vein.

Treating spider veins

Spider veins pose no medical risk. They can be treated with a painless, nonsurgical procedure called sclerotherapy. Sclerotherapy involves injecting a solution, usually a highly concentrated saline, into the blood vessel cluster. The vessel collapses, and blood easily diverts itself into nearby healthy veins. In addition, improvements in laser technology now permit the use of these devices in the successful treatment of spider veins and other enlarged veins. Smaller varicose veins, those 3–5 millimeters long, can also be treated with these procedures.

Skin cancer

As a child, you probably never suspected that carefree days spent sunning and swimming could be a prelude to skin cancer. But those hours outdoors elevated your risk of developing skin cancer today. Experts estimate that by age 18, you've accumulated 85% of your lifetime exposure to ultraviolet rays.

Skin cancer is the most common cancer in the United States, diagnosed in more than one million Americans each year. Skin cancer causes about 10,000 deaths annually. Most are from melanoma, the most severe form of skin cancer, which has become far more common in recent decades as people have spent more leisure time outdoors. In most cases, skin cancer is not fatal, but it can be disfiguring. The good news is that with early detection and treatment, more than 90% of cases can be cured. The three major types of skin cancer (see Figure 3) are described below.Figure 3: Three kinds of skin cancer

Figure 3: Three kinds of skin cancer

Squamous cell cancer: Begins in the middle layer of the epidermis and affects only the surrounding area, but eventually forms a raised patch with a rough surface.

Basal cell cancer: The cells of this type of cancer resemble the cells in the lowest layer of the epidermis, the basal layer. The cells invade and destroy surrounding tissues, forming a painless bump or nodule that later becomes an open ulcer with a hard edge.

Malignant melanoma: The deadliest form of skin cancer occurs when melanocytes, pigment-making cells in the basal layer or in surface moles, begin reproducing uncontrollably, spreading to distant parts of the body.

Basal cell and squamous cell carcinomas

These two types of skin cancer are generally not life-threatening and are treated in similar ways.

The most benign form of skin cancer — and the least likely to spread to other parts of the body — is basal cell carcinoma. It's also the most common form, accounting for about 80% of cases. Basal cell carcinoma originates in basal cells located deep in the epidermis. The most common cause of this cancer is cumulative damage from sun exposure. A basal

cell carcinoma may first appear as a pearly pimple or bump, a white- or yellow-colored scar, or a scaly red patch. Some basal cell cancers appear as an ulcer that won't heal. Basal cell cancer is very slow-growing, and will not develop into the potentially fatal melanoma. Sunscreens do not protect against basal cell carcinoma, according to one large long-term study on the subject. The reason is not yet understood.Symptoms of basal cell carcinoma

Small, smooth white or pink bump

May become an ulcer or open sore

Less commonly, a small, flat, red spot or recurring scar

Another 16% of skin cancers are squamous cell carcinomas. This form of cancer arises from flat, scale-like cells in the epidermis. Although squamous cell cancer usually isn't fatal, it can be life-threatening if it spreads to lymph nodes or internal organs. But even then, the cure rate is around 50%. Four times more men than women develop squamous cell carcinoma. It usually starts as a small, scaly bump and grows slowly until it resembles an ulcer or wart. Squamous cell cancers frequently occur on the face, lips, ears, or backs of the hands, and they too result from cumulative sun damage. Early detection is key to preventing the spread of squamous cell cancer. Like basal cell cancer, it will not develop into melanoma. Long-term sunscreen use reduces the risk of squamous cell carcinoma by about 35%, according to one large study.Symptoms of squamous cell carcinoma

Raised crusty bump

Size ranges from that of a pea to a walnut

Less often, a flat or slightly elevated area of skin

Treating basal cell and squamous cell cancers

Options for treating basal and squamous cell cancers are similar. Depending on the size and location of the tumor, both types can be surgically removed. The procedure involves removing the cancer and the tissue around it, called the margin, to ensure that all cancer cells have been removed. If they haven't, another procedure will be required. Most experienced dermatologists are quite skilled at estimating appropriate margins. The surgical scar can take several months to heal, especially if a tumor was removed from the face.

A technique called Mohs' micrographic surgery has the highest reported cure rate for basal and squamous cell cancers and is less likely than other forms of surgery to damage surrounding healthy skin. Named after Wisconsin surgeon Frederic Mohs, the technique consists of surgically removing cancerous tissue one layer at a time, and then immediately examining the specimen's entire surface area microscopically to see if there

are any cancer cells at the outer edges of the tissue. If there are, more of the surrounding tissue can be removed. If not, only a small wound is left. This technique eliminates the guesswork from determining margins. Mohs' surgery is beneficial for cancers near the eyes and prominent areas of the face. In some cases, wounds from Mohs' surgery may not need surgical reconstruction.

Electrodesiccation and curettage — more commonly called scraping and burning — is a simple, effective treatment for very superficial basal and squamous cell carcinomas. The procedure uses a sharp scraping tool called a curette to scoop out the tumor and a small margin of surrounding skin. The area is then cauterized with an electric needle. The main drawback of this method is that there is no tissue left to examine to determine if all cancerous cells have been removed.

Other options include cryosurgery with liquid nitrogen, which is highly effective; laser surgery for superficial cancers; or treatment with fluorouracil or imiquimod cream, also for superficial cancers.Fast fact

Melanoma causes about 7,500 deaths annually, while other, more common skin cancers result in far fewer fatalities.

Melanoma

Melanoma is a form of cancer that originates in the melanocytes, cells deep in the epidermis or in surface moles that produce pigment. Each year, malignant melanoma is diagnosed in about 45,000 Americans. Although it accounts for only 4% of cases of skin cancer, it's responsible for more than 75% of all skin cancer deaths. Without early detection and treatment, it can spread (metastasize) to the lymph nodes and internal organs. The lungs and liver are common targets when melanoma spreads. Its incidence has risen dramatically, from 1 in 5,000 in 1930, to about 1 in 65 in 2004.

Melanoma has several distinguishing characteristics that experts call the ABCDs of melanoma. These are asymmetry, meaning that each half of the growth looks different from the other; border irregularity, in which the edges are ragged or blurry; color that's unusual; and a diameter that exceeds 6 mm, about that of a pencil eraser. In general, experts recommend that any mole or growth that has enlarged or changed in any way be examined by a dermatologist.Symptoms of melanoma

Look for the ABCDs:

A for asymmetry

B for border irregularity

C for color: various shades of tan, brown, blue, or black

D for diameter: the width of a pencil eraser or larger (can be smaller in early stages)

Treating melanoma

If a growth or mole looks like a melanoma, the doctor will take a biopsy to confirm the diagnosis. This entails removing either a sample of tissue or else the entire growth and some surrounding skin, and examining the tissue under a microscope to determine whether it's cancer. Depending on how deep a melanoma is, further tissue may have to be removed. In some cases, lymph nodes may be removed, too. A procedure called sentinel node biopsy is becoming more common to determine if the lymph node nearest the tumor contains any cancer cells. If it does, surgery to remove additional nodes right away can improve survival, according to a study published in 2006 in the New England Journal of Medicine .

In addition to surgery, standard treatments for melanoma include chemotherapy, radiation therapy, and biological therapy, which strengthens the immune system against the cancer. For reasons still not understood, chemotherapy generally helps only a small number of people with melanoma, and there is no standard treatment regimen.

Melanoma survival rates are good — 95% or higher if the tumor is less than 1 mm thick. But beyond 4 mm in thickness, the cure rate drops to 45%. As with most other forms of cancer, if the tumor has spread to distant organs, overall survival is lower, about 18%.

Protecting your skin

The single most important thing you can do to prevent skin damage and reduce your risk for cancer is to avoid sun exposure. Take steps to protect your children or grandchildren from sun exposure, too, because most sun damage that leads to skin cancer occurs early in life. For enthusiasts of the great outdoors, sun protection is not an easy task. But careful selection of a sunscreen, protective clothing, and wise timing of activities can go a long way toward preventing further skin damage. One additional reason to use protective hats and other clothing is that sunscreen use has not been shown to protect against basal cell carcinoma as it does against other forms of skin cancer.

Sun block, sunscreen, and more

There's a difference between sun blocks and sunscreens. True to their name, sun blocks prevent the sun from reaching your skin. If you've ever been a lifeguard, you're probably familiar with the sun-blocking agent zinc oxide, the creamy white coating that has saved many a nose from too much sun. Zinc oxide and its chemical cousin, titanium dioxide, are sun blocks because they reflect ultraviolet radiation away from the skin surface. Both are available in skin tones and fashion colors, while titanium dioxide is also available in a clear formula. These ingredients are used in some commercial lotions such as those labeled as "non-chemical" or "for sensitive skin." Sun blocks are highly effective in

protecting against UVA and UVB rays (see "Don't get burned by improper sunscreen use").Don't get burned by improper sunscreen use

It's simple, right? Use a sunscreen, and you won't get a sunburn. Wrong. Every summer, throngs of beachgoers head out with their SPF 15, 30, or 45 in tow, but still manage to get burned. In interviews with 67 adult sun worshippers at a popular beach in Galveston, Texas, researchers from the University of Texas Medical Branch in Galveston reported that 73% of those who used sunscreen became sunburned.

The problem isn't with the sunscreen, but how people apply it. Most people don't apply enough, or they don't apply it frequently enough to be effective. A major problem, according to the researchers, is failure to apply more sunscreen after swimming. The American Academy of Dermatology (AAD) recommends reapplying sunscreen immediately after swimming, or every two hours if you stay out of the water. In fact, the academy says that people who wait more than two and a half hours to reapply have five times the chance of getting sunburned as those who reapply every two hours.

The AAD also advises people to use about a shot glass full of sunscreen for adequate coverage of exposed areas of the body and to apply sunscreen about 15–30 minutes before going outdoors.

Sunscreens, on the other hand, absorb rather than reflect UV radiation. In recent years, the most widely used sunscreen ingredients have included benzophenones, which protect against UVA, and cinnamates and salicylates, which protect against UVB. You'll see these ingredients listed as oxybenzone, octyl salicylate, or octyl methoxycinnamate, to name a few. A major drawback is that many of these ingredients break down after several hours when exposed to sunlight, which means that the sunscreens need to be reapplied to be effective.

But two new sunscreens — Anthelios SX and Helioplex — provide longer-lasting protection against UVA and UVB rays. Research shows that Anthelios SX, which was approved by the FDA in 2006, retains 80% of its UVA protection and 90% of its UVB protection five hours after application. The product combines a new UVA absorber called ecamsule with an older UVA absorber (avobenzone) and an older UVB absorber (octocrylene). Helioplex is a stabilized formulation of avobenzone and oxybenzone, a longstanding UVB and UVA absorber. Helioplex and Anthelios SX appear to be comparable in sun protection and stability.

When choosing a sunscreen, most people look at the product's sun protection factor (SPF) rating. The American Academy of Dermatology (AAD) recommends using sunscreen with an SPF rating of at least 15. People with fair skin or at high risk for skin cancer may want to go higher. The higher a sunscreen's SPF rating, the longer it protects against sun exposure.

But that's just part of the equation. The SPF rating only measures how well a sunscreen blocks or absorbs UVB rays. Therefore, the academy and federal public health agencies advise using a sunscreen that protects against both UVA and UVB rays. Products labeled "broad spectrum" often contain several different sun protection ingredients in order to cover the broadest possible range of UV radiation. But to what extent they do so is difficult to determine because there is no good method of measuring how well a sunscreen protects against UVA. It's an issue the FDA is grappling with in developing new sunscreen labeling regulations.

Beyond sunscreen

Because sunscreen and sunblock lotions can't protect you from all of the sun's rays, here are some other protective measures:

wearing clothing made from tightly woven fabrics or those that absorb UV light

avoiding the sun from 10 a.m. to 2 p.m., when its rays are most intense

wearing a wide-brimmed hat to keep UV rays off your face

watching for news reports that give the UV index in your area.

Lotions and potions

A widely advertised face cream sells for $135 per 6-ounce tube. Its claim to wrinkle-smoothing fame: a "patented oligo-peptide." Would you buy it? Another skin care company contends that its "mineral complex of magnesium, zinc, and copper has been optimized to provide visible reductions even in deep wrinkles." Do you believe it? Because the FDA doesn't regulate these claims, how do you know which to believe? Even if the ingredients aren't harmful, at often exorbitant prices they could remove more cash from your wallet than wrinkles from your skin.

With the exception of colors and certain prohibited ingredients, a cosmetics manufacturer can use essentially any raw material in a product and market it without prior FDA approval. This gap in oversight is a cause of concern because of the growth in recent years of cosmeceuticals, chemicals in cosmetics that have physiological effects, such as boosting collagen production and inhibiting sun damage to reduce wrinkles (see "Cosmeceuticals"). Several cosmeceuticals have therapeutic effects, but because they are not classified as drugs, they are exempt from government regulations.

Although cosmetic claims are allowed without scientific substantiation, if a cosmetic makes a medical claim, such as removing dandruff or altering skin structure or function, the product is regulated as a drug for which scientific studies demonstrating safety and effectiveness must be submitted to the FDA.

If you're wondering whether a lotion or cream will do what it claims, remember that only a few substances have a scientifically demonstrated ability to reduce or prevent wrinkles in controlled studies. Such substances are discussed in the following pages. Most of the ingredients in skin care products aren't harmful, but while you may enjoy their fragrance, texture, or temporary effects, think twice about investing too much hope or cash in unproven promises.Fast fact

There are no government standards for the use of words on cosmetic labels such as "dermatologist-tested," "allergy-tested," "hypoallergenic," "non-irritating," "herbal," "natural," or "cruelty-free, non–animal tested." These terms are often employed solely for marketing purposes. The ingredient list on the label is the only source of reliable, government-required information.

Moisturizers

A good moisturizer is one of the foundations of an effective skin care regimen for dry, older skin. Moisturizers can soothe dry skin and make wrinkles less noticeable, even though the effect is temporary. But with so many to choose from, how do you pick one?

Petroleum jelly is one of the best and most inexpensive products, especially when used right after bathing to seal in moisture. But most people dislike using it on their face because of its greasy look and feel. Likewise, thick, greasy-feeling emollients and ointments are best left for other parts of the body. Instead, creams and lotions usually are the facial moisturizers of choice for a couple of reasons. They contain water (ointments are all oil), so they don't feel as greasy. And many creams and lotions are humectants, an oil-free class of moisturizer that binds water to skin, so the smoothing, softening effects may last longer.

Most moisturizers contain water, glycerin, petrolatum, stearic acid, propylene glycol, and lanolin. Some contain botanical ingredients, such as jojoba oil, coconut oil, safflower oil, and linoleic acid, which help maintain the skin's outer layer of keratin and natural oils that keeps skin supple. Manufacturers use other ingredients, such as cetyl alcohol, palmitic acid, and dimethicone, to give moisturizers a creamy, velvety, or translucent look and feel, and to help shore up the "mortar" that keeps skin soft and smooth.

Many moisturizers also contain sunscreens and cosmeceuticals, which may help prevent or even correct fine wrinkles, uneven skin pigmentation, and other signs of aging and photoaging.

Exfoliants

Moisturizers that contain exfoliant ingredients can improve the appearance of the skin by removing dead surface skin cells. As a result, they can smooth the skin's appearance and even out some discoloration from too much sun exposure. Exfoliants can be particularly

useful for aging skin that appears rough and sallow, because older skin doesn't slough off dead surface skin cells as easily as younger skin does.

Two chemical exfoliants, alpha hydroxy acids (AHAs) and beta hydroxy acids (BHAs), are considered superior to many exfoliating scrubs, masks, soaps, toners, and abrasive cloths (see below). That's because they change cell growth patterns and may help renew collagen.

Cosmeceuticals

Some cosmetics contain ingredients, known in the cosmetic industry as cosmeceuticals, that have medicinal or druglike benefits. These agents, which include vitamins, growth factors, and peptides, are found in products prescribed by dermatologists and many others that are available over the counter. The FDA does not recognize the term cosmeceutical but regulates some of the substances and makes recommendations on others. Several cosmeceuticals show promise against skin aging and photoaging. Studies show that they diminish wrinkles and age spots, smooth skin texture, and reduce the yellow hue that comes with age.

Alpha hydroxy acids

AHAs are obtained from various fruits, including grapes, citrus fruits, and apples. Look for them on product labels as glycolic acid, lactic acid, malic acid, hydroxycaprylic acid, alpha-hydroxyoctanoic acid, triple fruit acid, or sugar cane extract. Although the FDA does not regulate AHAs as drugs, it has issued guidelines on their safe use because they can cause skin irritation and increase skin sensitivity to UV rays. The FDA has cautioned consumers only to use products that contain an AHA concentration of 10% or less and a pH of 3.5 or more (lower pH numbers are more acidic), and to use a sunscreen in conjunction with AHA-containing products. AHAs, particularly glycolic acid, are used in chemical peels in concentrations of 20%–30% and higher. An FDA review panel concluded that cosmetologists or skin aestheticians could safely use glycolic acid and lactic acid at concentrations not greater than 30% and with a pH not lower than 3.0 for brief skin care sessions provided that thorough rinsing and daily sun protection follow. In higher concentrations, AHAs are applied by physicians.

Beta hydroxy acids

BHAs, another type of cosmetic exfoliant, are believed to smooth skin without some of the irritating effects of AHAs. The most widely used BHA is salicylic acid, a relative of aspirin. That salicylic acid has anti-inflammatory properties and doesn't penetrate to the dermal layer may explain why it's less irritating than AHAs. Moreover, salicylic acid is more effective than AHAs for exfoliating oily areas of the skin, which makes it useful if you have oily skin or if you're having problems with adult acne.

Salicylic acid and other BHAs can be found in many acne products at effective levels of 1.5%–2%. But antiwrinkle products containing these ingredients tend not to list the

percentage on their labels, so it's difficult to know whether they contain sufficient amounts to be effective. Other BHAs include beta hydroxybutanoic acid, tropic acid, and trethocanic acid.

The FDA recommends that you first test BHAs on a small patch of skin to see if irritation occurs, and that you use a sunscreen with BHA products because they can increase the skin's sun sensitivity.

Vitamins and antioxidants

Some of the most confusing questions in skin care concern the use of vitamins and antioxidants (such as vitamins A, C, and E) and ubiquinone (coenzyme Q10). In theory, the use of these substances in moisturizers and other cosmetics makes sense. At the cellular level, antioxidants ward off damage from molecules called free radicals, which cause oxidative deterioration.

Some vitamins and antioxidants are beneficial when applied to the skin. Derivatives of vitamin A are active ingredients in retinoids, drugs that reduce photodamage and increase collagen production (see "Retinoids"). A 10% concentration of vitamin C significantly reduced fine wrinkles, made skin smoother, and improved skin tone and sallow hue in one 12-week clinical trial. Other studies have reported that vitamin C helped repair elastic tissue and increase collagen, and that vitamin B

Coenzyme Q10, a naturally occurring antioxidant, has also been shown to reduce wrinkles and guard against ultraviolet light damage. A 12-week clinical trial of lipoic acid, another antioxidant, reported a significant decrease in wrinkles, age spots, and roughness. Copper, an antioxidant metal, may play a role in collagen and elastin production.

Some moisturizers and other skin care products contain vitamin E, but no clinical studies have shown that it can prevent or reverse signs of photoaging.

Growth factors

Hundreds of growth factors occur naturally in the human body to help heal wounds by promoting new tissue formation. Several studies have found that creams with different combinations of these substances diminish wrinkles. A study published in Dermatologic Surgery in 2006 compared the effects of two different creams containing growth factors with a third cream that contained vitamin C. After three months, physicians, not knowing which subjects used which cream, found that those who had used the growth factor products had the greatest reduction of wrinkles.

Peptides

These compounds, which have various roles in the body, are used as cosmeceuticals for different effects. Some peptides stimulate the production of collagen and elastin. Others

stabilize copper (an antioxidant metal shown to reduce wrinkles), improve skin elasticity, and reverse other signs of photoaging.Do you need a skin toner?

If your skin has become dry through the years, it may be best to avoid many skin-toning products because they often contain drying, irritating ingredients such as alcohol or acetone. Some also contain a highly acidic citrus, camphor, or menthol. However, toners made of water, glycerin, and agents that bind water to the skin offer a bit of extra cleansing and moisture. Skin toners provide no real skin improvement.

Retinoids

Topical vitamin A–based drugs called retinoids reduce wrinkles. Tretinoin (Retin-A, Renova), adapalene (Differin), and tazarotene (Avage) are prescription drugs used in skin care. Tretinoin, under the brand name Retin-A, was first used as an acne treatment in the 1970s, but researchers later discovered that it fades actinic keratosis spots and speeds the turnover of superficial skin cells. In 1996 the FDA approved Renova, an emollient cream containing a 0.05% concentration of tretinoin, as the first drug to treat wrinkles. Similarly, the retinoid tazarotene is prescribed under the brand name Avage as a wrinkle treatment. Other retinoids are undergoing clinical trials.

Retinoids reduce fine lines and wrinkles by increasing the production of collagen. They also stimulate the production of new blood vessels in the skin, which improves skin color. Additional benefits include fading liver spots and softening rough patches of skin. It takes 3 to 6 months of regular use before improvements in wrinkles are apparent; the best results take 6 to 12 months. Because retinoids can cause skin irritation, doctors often recommend using them only every other day at first and then gradually working up to nightly applications. Wear a sunscreen during the day, because retinoids increase the skin's sensitivity to sunlight. These drugs must be used continually to maintain their benefits.

Several over-the-counter products containing retinoids, such as Retinol, are now available. They may not be as effective in reducing wrinkles as tretinoin, but they do improve the appearance of photoaged skin. Tretinoin can be used with AHAs for additional skin-smoothing effects.

Other skin care products

Muds, etc. What about the salts, mud, and clay that are purported to have natural minerals that restore youthful softness and luster to your skin? The size of their molecules is generally too large to penetrate the skin, and there are no scientific data to back up their claims.

Products from plant sources. Lotions and creams with extracts from plants such as seaweed, fruits, or herbs may have a pleasant scent and come attractively packaged. In addition to AHAs, some other plant-based ingredients may reduce or prevent wrinkles,

but so far the evidence comes from small clinical studies and animal research. Green tea, an antioxidant, may protect against UV damage and inhibit photoaging; genistein, an antioxidant derived from soy, may also inhibit UV damage; kinetin (N6-furfuryladenine), an antioxidant, may improve skin texture and tone and reduce wrinkles; and date palm extract may reduce wrinkles around the eyes.

Dimethylaminoethanol (DMAE). This is a neurotransmitter, a substance produced in the brain. An 18-week clinical trial found that a gel containing a 3% extract of DMAE reduced forehead frown lines, tightened sagging neck skin, and decreased dark circles around the eyes.

What to avoid

It's always important to read the ingredients labels of creams and lotions, especially if you have sensitive skin. Some may contain substances that will irritate it. The American Academy of Dermatology says these skin care product ingredients should be avoided by people with sensitive skin:

preservatives; the least irritating preservatives are parabens, such as methyl paraben and butyl paraben

botanical or antibacterial ingredients

solvents that penetrate the skin, including propylene glycol and ethanol. A better alternative is polyethylene glycol, which does not penetrate the skin.Quick guide to product ingredients

The labels of anti-aging products promote some impressive-sounding ingredients. What are they? Can they help your skin? This glossary can help you see through the hype on the cosmetics shelves. The evidence supporting the benefits of these ingredients is incomplete.

Alpha lipoic acid: An antioxidant that may decrease skin roughness and wrinkles.

Antioxidants: Substances that neutralize free radicals, damaging molecules that accelerate skin aging and promote skin cancer.

Coenzyme Q10: Ubiquinone, an antioxidant, that reduces wrinkle depth and protects against UVA.

Copper peptide: Copper is a metal with antioxidant properties found in every cell in the human body. Copper peptides (see "Peptides," below) enhance wound healing and may increase collagen and elastin production.

Date palm: An extract from the date palm tree (Phoenix dactylifera); a topical product containing date palm got results similar to the antiwrinkle drug Renova in at least one clinical trial.

Dimethylaminoethanol (DMAE): A neurotransmitter produced in the brain; an extract in gel form may reduce wrinkles, neck sagging, and circles under the eyes.

Genistein: A derivative of soy and an antioxidant; it inhibits UVB damage to the skin.

Green tea: An antioxidant and an anti-inflammatory agent; it may inhibit UV damage and photoaging.

Growth factors: Substances that occur naturally in the human body and in plants; they contribute to wound healing and may repair photodamaged skin.

Kinetin: N6-furfuryladenine; a plant growth factor and an antioxidant that may reduce wrinkles, smooth skin texture, and even out skin tone.

Niacinamide: Vitamin B

Peptides: Short-chain amino acids that may assist with production of collagen and elastin and have other beneficial effects on the skin.

Vitamin A: An antioxidant vitamin and the active ingredient in Retinol, a drug that reduces photodamage and increases collagen production.

Vitamin C: An antioxidant vitamin; topical preparations reduce wrinkles and improve skin texture and tone.

Vitamin E: An antioxidant vitamin; its effect on aging skin is unknown.

Skin rejuvenation procedures

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

One of the most important factors for people seeking skin rejuvenation is the amount of downtime required. People want to return to work and social activities as quickly as possible, which has led to the introduction of less-invasive techniques that don't penetrate the skin as deeply and thus require less recovery time. The trade-off is that their effects are not as significant and they often require a series of initial visits as well as follow-up

"maintenance" visits. The choice is yours. You can go for a deeper treatment with a longer healing time or for a lighter treatment that requires more follow-up visits and probably more long-term expense. This section will describe such procedures as Botox injections, chemical peels, laser procedures, light-based treatments, microdermabrasion, and fillers and implants.

Doctor or aesthetician?

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

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

Choosing a doctor

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

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

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

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

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

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

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

the American Academy of Cosmetic Surgery

the American Academy of Dermatology

the American Society for Dermatologic Surgery

the American Society for Laser Medicine and Surgery

the American Society of Plastic Surgeons.Questions to ask a doctor

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

You'll also have questions regarding cost. For example, is there a consultation fee, and if so, can it be deducted from the cost of the procedure? What is the complete fee for the procedure, including the physician's fee, anesthesiology, and operating room costs? Who delivers the anesthesia? Ask if the physician charges extra for corrections or repairs, and make sure you understand the complications that could occur and exactly what is involved in recovery. The healing process for some procedures can be lengthy and

tedious. Another important consideration is whether the procedure will need to be repeated and how often. Some of the less invasive procedures have shorter recovery times, but require several treatments or even periodic maintenance procedures every few months.

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

Choosing an aesthetician

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

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

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

Botox (botulinum toxin)

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

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

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

Figure 4: Down with the frown

An injection of botulinum toxin can eliminate deeper lines and wrinkles around the forehead, between the eyebrows, and at the corner of the eyes. Botox works by blocking the release of the neurotransmitter acetylcholine, which helps trigger muscle movement, from nerve cells. Impairing the muscle movement allows the creases in the skin to smooth out and prevents the formation of new expression lines and wrinkles.

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

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

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

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

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

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

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

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

Chemical peels

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

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

For best results, repeat the treatment monthly for about six months, and then quarterly. Superficial peels are often called lunchtime treatments because they take just 15–20

minutes, are painless, and don't require any recovery time. Some people with very fair or sensitive skin may have some redness for a few hours, but most people feel comfortable going out in public immediately afterward. Expect to pay about $75–$250 per treatment.

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

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

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

After any chemical peel, you'll be more sensitive to sun exposure, so take extra precautions when outdoors.Going out of style: Deep peels and dermabrasion

Many people once opted for deep chemical peels or dermabrasion (mechanical removal of the skin's surface using abrasive materials) to treat problem skin. These treatments can dramatically improve lines and wrinkles, age spots, and pigmentation, but they may leave telltale traces, such as unnaturally whitened skin (particularly with deep peels) and even scarring. Today, laser resurfacing has largely replaced these once very popular procedures.

Laser and other procedures

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

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

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

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

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

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

Clinicians often recommend a combination of procedures to achieve a desired effect. For example, for the older woman seeking more pronounced skin tightening and who is willing to put up with some downtime, a doctor might recommend Botox for frown lines and forehead lines, fillers for nasolabial folds, Q-switch lasers to remove freckling and diminish redness, plus fractional laser for all-over improvement.

How lasers work

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

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

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

Ablative laser resurfacing

While once the only laser treatment for skin rejuvenation, ablative laser resurfacing is now reserved for advanced photodamage and severe acne scars. The carbon dioxide (CO

The CO

The erbium laser generates less heat and removes a thinner skin layer on one pass. Because the erbium laser penetrates the skin only about one-fifth as deeply as the CO

The erbium laser has a number of advantages over the CO

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

One trend is combination therapy, which involves using both types of lasers during a treatment. For example, to remove moderate to deep lines and wrinkles, the physician makes two passes with the CO

Another new approach is to get the effect of combination therapy by using a single tool, a dual-mode erbium:YAG laser. This laser works like a traditional erbium laser, but has properties that make it quite similar to the CO

The CO

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

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

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

After the procedure, your skin will need to recover. If you've had a CO

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

Your skin will look and feel remarkably smooth and wrinkle-free as soon as it heals, and it will continue to improve for three to six months. Results from one treatment should last

for many years. Of course, laugh lines and other wrinkles caused by facial expressions will eventually recur with time, and wrinkles will develop as you age. Some people get Botox injections to prevent new expression lines from forming. If your laser resurfacing removed acne scars, you'll enjoy lifelong benefits.

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

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

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

Fractional resurfacing

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

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

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

Plasma skin regeneration

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

Plasma skin regeneration uses a machine that emits a stream of plasma (ionized nitrogen gas) to heat the skin. The plasma has a lilac glow that changes to a yellow light. Like the ablative laser resurfacing, it superficially wounds the skin to improve its appearance. The

plasma heats the skin either on the surface or deeper, depending on the need. The treated skin dries and comes off in three or four days, revealing fresh new skin. There's no oozing or crusting during recovery. The improvements increase for a year following treatment.

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

Non-ablative laser resurfacing

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

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

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

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

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

Lasers for pigmentation, hair removal, and other problems

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

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

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

The pulsed-dye laser (shown at left) is used to treat red spots, dilated blood vessels, spider veins, and broken capillaries. This laser emits a yellow light, which targets reddish pigments in the skin. The Q-switched laser (shown at right) gives off bursts of energy that are absorbed by brown pigments in the skin. As a result, this laser is used to eliminate liver spots, freckles, and some tattoos.

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

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

LED photomodulation

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

Photomodulation won't provide the dramatic results of laser resurfacing and non-ablative laser treatments, and it won't noticeably improve severe photoaging.

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

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

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

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

Microdermabrasion

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

Microdermabrasion can produce moderate improvements in skin texture. In this procedure, the aesthetician abrades an area with tiny aluminum hydroxide crystals to create smoother-looking skin. No recovery time is needed.

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

Photodynamic therapy

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

Photorejuvenation with intense pulsed light

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

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

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

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

Radiofrequency

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

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

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

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

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

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

sufficed, but experience shows that additional passes over specific areas significantly improve results.

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

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

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

Soft-tissue augmentation: Fillers and implants

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

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

With so many old and new selections, deciding which filler or implant might suit your needs has become a complicated process. Do you want something temporary that has a very low risk, or would you prefer something permanent, even if it has a higher

complication rate? Are you willing to try a new product, or do you want something that has a proven track record?

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

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

Hyaluronic acid

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

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

Collagen

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

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

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

Autologous fat transplants

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

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

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

Gore-Tex

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

Microdroplet silicone

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

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

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

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

Radiesse and ArteFill

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

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

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

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

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

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

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

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

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

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

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

What material is the filler or implant?

Is the material natural or synthetic?

How often do you see side effects or complications?

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

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

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

Glossary

actinic keratosis: Scaly pink or red-brown raised spots or patches caused by overexposure to the sun. Actinic keratosis may be a precursor to skin cancer.

aesthetician: Licensed skin care professional who performs procedures including deep cleansing, low-grade chemical peels, microdermabrasion, and postsurgical skin care.

alpha hydroxy acids: Fruit-derived acids used in creams and lotions to act as exfoliants.

autologous fat transplant: Removal of fat from one part of the body to use as filler in another part, for example, to fill wrinkles and lines in the face and lips.

basal cell carcinoma: The most common skin cancer. Basal cell carcinoma doesn't spread to internal organs.

Botox: Brand name for a substance made of botulinum toxin A that eases the appearance of some facial wrinkles by paralyzing the underlying muscles.

chemical peel: Use of mild to caustic chemical solutions to wound the outer layer of the epidermis and encourage new collagen growth.

collagen: A fibrous protein that's the main component of connective tissue.

dermis: Middle layer of skin that contains blood and lymph vessels, nerves, hair follicles, and glands that produce sweat and oil.

elastin: The protein that gives skin its elasticity.

epidermis: The outermost layer of skin.

fibroblasts: Cells in the skin that secrete collagen.

hirsutism: Excess hair growth, often caused by hormonal imbalances.

humectant: An agent used in moisturizers; binds water to the skin to promote hydration.

intense pulsed light (IPL): White light that's used in skin-resurfacing procedures and hair removal.

keratinocytes: Cells of the epidermis that produce a tough protein called keratin and form a soft, protective sheet for the body.

Langerhans cells: Cells of the immune system that work in the skin to fight infection.

laser: A word derived from the acronym of "light amplification by the stimulated emission of radiation." Lasers produce intense beams of light that generate heat used in surgery, removal of pigmented lesions, and skin rejuvenation.

melanocytes: Cells located deep in the epidermis that produce melanin, the pigment that colors skin.

melanoma: The most serious type of skin cancer, originating in the pigment-producing cells known as melanocytes.

photodynamic therapy: A treatment for actinic keratosis that uses light exposure to activate a therapeutic agent.

skin resurfacing: Improving skin texture, tone, wrinkle appearance, and discolorations by promoting new collagen growth. Chemical peels, dermabrasion, microdermabrasion, and laser procedures are skin-resurfacing techniques.

squamous cell carcinoma: A common skin cancer, rarely fatal, that can spread to the lymph nodes and internal organs.

stratum corneum: The most superficial layer of the epidermis.

subcutaneous tissue: The deepest layer of skin, which consists of connective tissue and fat.

ResourcesOrganizations

American Academy of Cosmetic Surgery 737 N. Michigan Ave., Suite 2100Chicago, IL 60611312-981-6760

Represents surgeons who work in postgraduate medical education in cosmetic surgery. Sponsors a surgeon referral service.

American Academy of Dermatology P.O. Box 4014Schaumburg, IL 60618866-503-7456 (toll free)888-462-3376 (toll free for referrals)

The largest of all dermatologic associations. Provides information on the diagnosis and medical, surgical, and cosmetic treatment of conditions of the skin, hair, and nails.

American Academy of Facial Plastic and Reconstructive Surgery 310 S. Henry St.Alexandria, VA 22314703-299-9291

An association of plastic and reconstructive surgeons who focus on surgery of the face, head, and neck. Sponsors programs of free care for those with deformities from congenital conditions and trauma, including domestic violence and war.

American Board of Medical Specialties 1007 Church St., Suite 404Evanston, IL 60201847-491-9091866-275-2267 (physician verification service)

Operates a phone and online service to help members of the public verify the board-certification status of physicians.

American Society for Aesthetic Plastic Surgery 11081 Winners CircleLos Alamitos, CA 90720888-272-7711 (toll free for referrals)

The leading organization of cosmetic plastic surgeons. Offers patient information about procedures and provides referrals.

American Society for Dermatologic Surgery 5550 Meadowbrook Drive, Suite 120Rolling Meadows, IL 60008800-441-2737 (consumer hotline)

Provides information on the subspecialty of dermatologic surgery and offers referrals to board-certified dermatologic surgeons.

American Society for Laser Medicine and Surgery 2100 Stewart Ave., Suite 240Wausau, WI 54401715-845-9283

Promotes research, safety, and quality standards in the field of laser medicine. Web site offers an online doctor referral service as well as information on new procedures in laser medicine.

American Society of Plastic Surgeons 444 E. Algonquin RoadArlington Heights, IL 60005888-475-2784 (toll free for referrals)

Represents surgeons certified by the American Board of Plastic Surgery or the Royal College of Physicians and Surgeons of Canada. Offers a surgeon referral service.

FDA Cosmetics Web Site

Informational Web site for consumers interested in the safety and effectiveness of cosmetics ingredients, as well as the regulation of cosmetics labeling.