{SCA}Although wrinkles can signify wisdom, most people nowadays would rather not have them. Many products and procedures promise to reduce wrinkles. Some do little or nothing (like the products that claim they reduce “the appearance of fine lines,” which means that they don’t reduce the lines themselves). Others can achieve a fair amount of success.

Skin ages all over the body, but much more so where there has been sun exposure. Changes brought on by sun damage (photoaging) include “dryness” (really roughness), sagginess, skin growths like keratoses (“liver spots”), and wrinkles.

Most wrinkles appear on the parts of the body where sun exposure is greatest. These especially include the face, neck, the backs of the hands, and the tops of the forearms. Wrinkles come in two categories: fine surface lines and deep furrows. Wrinkle treatments are in general much more effective for fine lines. Deeper creases may require more aggressive techniques, such injection of fillers or plastic surgery.

What factors promote wrinkles?

Factors that promote wrinkling include:

1. Smoking
2. Light skin type (people with blue eyes and easily burned skin are more prone to sun damage)
3. Heredity (some families wrinkle more)
4. Hairstyle (some styles provide cover and protection against sun damage)
5. Dress (hats, long sleeves, etc.)
6. Occupational and recreational habits (farming, sailing, golfing, using tanning booths, and so forth)

Some of these factors are beyond our control. The main preventive measures we can take are to minimize sun exposure and not smoke.

SPF numbers on sunscreen labels refer to protection against UVB radiation (shortwave ultraviolet light, the “sunburn rays”). More and more sunscreens offer protection against UVA radiation (longer-wave ultraviolet light) as well. UVA rays are the ones you get in tanning salons; they may not cause immediate sunburn but do promote sun damage and skin cancer risk over time. (Sorry, but there is no such thing as a “safe tan.”) Sunscreens that block UVA indicate this on the label and include such ingredients as Parsol 1789. The FDA has recently approved Mexoryl, another UVA-blocking ingredient, which has been available in Europe for some time.

What medical treatments and cosmetic procedures are available for wrinkles?

There are several medical (topical medicines and creams) and cosmetic techniques available for reducing wrinkles. They include both medical and surgical methods:

Medical Treatments:

• Vitamin A Acid. (tretinoin, Retin-A, Renova). This ingredient, available by prescription, has the longest track record of success in treating aging skin and fine lines. Creams containing tretinoin must be used on an ongoing basis. They may produce redness and peeling at first, but discomfort can usually be minimized by lowering the cream’s concentration or applying it less often until the skin gets used to it.
• Alpha-hydroxy acids. These so-called “fruit acids” include glycolic and lactic acid. Preparations containing these fruit acids are quite safe and cause no more than mild and temporary irritation. They produce only subtle improvement, though.
• Antioxidants. These include preparations that contain the vitamins A, C, and E, as well as beta-carotene. Such creams may provide a certain amount of sun protection as well as mild improvement of fine wrinkles.
• Ordinary moisturizers. Creams that don’t contain any of the above substances can only make wrinkles look temporarily less prominent (“reduce the appearance of fine lines”).

Cosmetic Procedures:

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

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