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

The procedure is most beneficial for the following areas:

• Best around the mouth and eyes. Recent evidence suggests CO2 lasers may be even better than dermabrasion for the upper lip.
• Slightly less beneficial for the area around the nose.

Used alone, current laser therapy does not eliminate crow's feet, broken blood vessels, or dark circles under the eye.

Standard laser dermabrasion is too harsh for thinner skin layers, such as on the neck. Newer and gentler laser techniques, however, stimulate collagen without taking off skin layers and may prove to be useful for necklines.

The evidence of the effects of lasers on acne scars is unknown.

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

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

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

• The carbon dioxide (CO2) laser is the most powerful laser treatment and is used for deep wrinkles and skin imperfections. People who have had silicone injections should not have CO2 procedures, which can burn and scar the skin over the implanted area.
• The erbium:YAG (Er:YAG) laser is gentler than the CO2 and is effective for mild wrinkles and for providing a smooth texture. It has a shorter recovery time. Some experts have even found the YAG laser as effective in removing deep wrinkles as CO2 when used to sufficient depth. A so-called variable pulse YAG laser can shift between pulses that destroy skin to tissue to those that heat the skin; this process effectively resurfaces the skin with fewer side effects than CO2 laser therapy.
• A gentle laser procedure called non-ablative laser resurfacing (NLite), also called photorejuvenation, is now approved for the treatment of all facial wrinkles. The procedure uses light energy to gently stimulate new collagen, and possibly elastin, without removing the skin tissue itself. Its effects are less pronounced than those of other laser procedures. However, because it does not injure the external layers of skin, it can be used on delicate skin areas, such as the neck and around the eyes. It also causes very little irritation afterward.
• Some surgeons are using combination techniques that employ more than one laser technology in one session to achieve different effects. For example, one combination technique uses CO2, YAG, pulsed-dye laser, and one other laser technology to both improve wrinkles and clear under-eye dark circles and acne scarring. Pretreatment with botulinum injections before laser resurfacing significantly improved the treatment of crow's feet in one 2001 study.

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

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

Other Exfoliation Procedures

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

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

Implants

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

Botulinum

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

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

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

Face Lifts (Rhytidectomy)

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

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

• SMAS (superficial musculoaponeurotic system) is the most common face-life procedure. The surgeon makes an incision at the hairline and separates the skin from the underlying tissue and muscles. The muscles are tightened and excess fat and tissue, such as fat under the chin and neck, are removed.
• The endoscopic subperiosteal or subgaleal face-lift is a less invasive surgical technique. The surgeon raises facial structures rather than cutting away flaps of skin. Only a few half-inch incisions are made, and scarring is minimal.

Neither SMAS nor the endoscopic version is effective for the middle part of the face, particularly the deep lines (naso-labial folds) that run down from the nose beside the mouth. Some time after the SMAS facelift, the upper face begins to age again while the lower area still retains its shape, causing the face to look imbalanced. Other approaches, such as one called composite facelifts that lift most muscles in the face are being investigated.

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

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

Other less common complications may include the following:

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

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

Procedures for Eyes

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

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

Procedures for the Neck

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

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American Society of Plastic and Reconstructive Surgeons, Inc., 444 East Algonquin Road, Arlington Heights, IL 60005. Call (888-4PLASTIC) or (http://www.plasticsurgery.org/).

This group offers educational materials on choosing a qualified surgeon and referral listings of plastic surgeons. They will also verify the credentials of a plastic surgeon.

American Academy of Dermatology and American Society for Dermatologic Surgery, 930 E. Woodfield Rd., Schaumburg, IL 60168-4014. Call (847-330-0050) or to locate a dermatologist (888-462-3376) or (http://www.aad.org/) and (http://www.asds-net.org).

FDA Office of Consumer Affairs, Office of Cosmetics and Colors, Center for Food Safety and Applied Nutrition, Food and Drug Administration, 5100 Paint Branch Parkway, College Park, MD 20740-3835. On the Internet (http://vm.cfsan.fda.gov/~dms/cos-toc.html).

The Food and Drug Association (FDA) offers good, reliable information on a number of skin products and cosmetic procedures.

The Environmental Protection Agency provides information on the UV Index. Call (202-564-9361) or (http://www.epa.gov/sunwise/uvindex.html)The UV index ranges from 1 to 10+; the higher the index number the greater the exposure to UV rays. This index is valid for about a 30-mile radius around the city from which the broadcast originates. Currently, the computation of the UV Index does not include the effects of variable surface reflection (e.g., sand, water, or snow), atmospheric pollutants, or haze.

Society of Cosmetic Chemists, 120 Wall St., Suite 2400, New York, NY 10005-4088. Call (212-668-1500) (http://www.scconline.org/).

American Society for Aesthetic Plastic Surgery, 11081 Winners Circle, Suite 200, Los Alamitos, CA 90720. Call (888-272-7711) or (http://www.surgery.org).

American Society for Laser Medicine and Surgery Inc., 2404 Stewart Square, Wausau, WI 54401. Call (715-845-9283) or (http://www.aslms.org).

The following two companies offer sun-protective clothing. Their (change "their" to "their") products have not been reviewed by our editors. Other companies also offer similar products.

Sun Precautions, Inc., 2815 Wetmore Avenue, Everett, Washington 98201. For a catalog call (800-882-7860) or (http://www.solumbra.com/).

Sun Protective Clothing, 598 Norris Court, Kingston, Ontario K7P 2R9. . Call (613-384-3230) or (800-353-8778) or on the Internet (http://www.sunprotectiveclothing.com).