Wrinkles Be Gone! Skin Treatment Choices -- Leroy Young, MD -- 06/25/03

Last Editorial Review: 10/19/2004

By V. Leroy Young
WebMD Live Events Transcript

Considering a change to the image in your mirror? From temporary to permanent, from creams to injections and surgery, there are more choices than ever for those in search of younger-looking skin. Aesthetic and reconstructive surgery expert V. Leroy Young, MD, joined us to discuss the best, and safest, options for you and your skin.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD Live, Dr. Young. Let's start by finding out what we should do to prevent wrinkles .

Young: That's an excellent place to start. The two most important things that the average person can do to prevent wrinkles are:

  • Minimize sun exposure.
  • Don't smoke. Smoking appears to damage the collagen in the skin and also probably dehydrates it.

When I say minimize sun exposure, that doesn't mean that you can't be in the sun at all, it means that you should be judicious in exposure and you should wear proper sunscreen and never, never, never get a sunburn. The ultraviolet light from the sun causes genetic damage to the skin cells, some of which is irreversible. It's particularly important to minimize sun damage when you're young, especially avoiding sunburns before age 18. Beyond the fact that this causes your skin to prematurely age, it significantly increases the risk of skin cancer.

It's interesting to look at the incidence of malignant melanoma now compared to 20 years ago. The current incidence is 1 in 67 people, whereas several years ago it was about half of that. This has been shown to be directly related to sun exposure.

So if you're young and you haven't done these things, don't do them; if you are doing them you have to stop, because many of these changes are reversible.

Some other preventative measures:

  • Avoid large fluctuations in weight, because that stretches the skin.
  • Use sunscreen. Currently the best and most effective sunscreens contain zinc oxide in a micronized form, which doesn't make your skin look pasty or white, but it gives excellent sun protection. One example of that is Z-Cote.
  • Be on a good skin management program. There are several of those available. The key elements of this are that it be systematized, and it should also probably be supervised by an aesthetician that is supervised by a physician, usually a plastic surgeon or dermatologist. Two of the really good skin care programs are Obagi and Biomedic. These programs have a balance of all of the steps you need to cleanse, to hydrate, to exfoliate, to protect the skin, and to adjust its pH, so that it makes your skin healthier and it helps protect it from some of those things we talked bout earlier. Proper systematic skin care that's supervised is very analogous to changing the oil in your car to get your car to last longer.

Moderator: You mentioned weight change as a cause of wrinkles. For those who are trying and succeeding at weight loss, what can they do to improve their skin while improving their overall health by losing weight?

Young: I think there are two elements to that question. On is the general health of the skin, and that relates to what I said about sun exposure, smoking, and systematic skin care. The other relates to excess skin that may result from the skin being stretched and not having sufficient elasticity to contract and re-drape after weight loss. If the primary problem is excess skin, then the only way to manage that is surgical excision. Typically you can expect excess skin when weight loss is in the range of 30 to 50 pounds. The areas that are typically affected by this are the face and neck, arms, breasts, abdomen, and thighs. Each of these areas has procedures that are designed to manage the excess skin. An example of that in the fact would be a facelift.

Member question: Regarding Obagi and Biomedic: 1. Are these by prescription, over the counter, or do you buy them from distributors? 2. Do you have a connection to either of them (just curious)?

Young: I have no financial connection to any of the companies. The product lines are sold in physicians' offices, and we do carry both Biomedic and Obagi in our office. They are not available over the counter because they have concentrations of active ingredients that exceed the limitations set by the FDA for over-the-counter products, and in large part, that's why they're more effective than over-the-counter products. If you were to get a sample of a product that is an over-the-counter product and compare it to one of these physician-based treatment products, many of the ingredients would appear to be the same, but the difference is the concentration of the key active ingredients. That's why the products that require physician supervision are more effective.

Member question: What do you feel is the most important ingredient in facial care products for aging skin? Antioxidants? Herbs? Vitamin C? Alpha hydroxy?

Young: There isn't a simple answer to that question, because each individual's skin care regimen needs to be individualized based on a skin analysis to classify their skin type. For example, a person with oily skin would need a different treatment protocol than a person with sun-damaged skin.

Skin types are further divided into a classification scheme devised by Dr. Fitzpatrick, and this classification scheme has five different types. They range from very fair skin to very dark skin. Obviously the fair-skinned people are more prone to sunburn and to sun damage than the darker-skinned individual. So each person needs an analysis done by a trained person such as an aesthetician or skin care specialist to determine which program they go into. For example, a person who has hyperpigmentation or uneven complexion may need hydroquinones. In contrast, a fair-skinned individual with skin damage may need increased Retin-A. Almost everyone benefits from the exfoliant effects of the alpha-hydroxy acids.

In summary, different ingredients are important to different individuals, depending on their skin type and classification, including the effect of acne.

Moderator: How do you choose an aesthetician? And is it better to see a dermatologist or a plastic surgeon?

Young: I don't think it matters which board you're certified by, as long as the individual has taken the time to become experienced in managing skin care. The important thing is that the physician that you see and the physician's staff are trained and experienced in skin care and that they have spent the time and effort to get the proper equipment and proper products. Our skin care specialists are all fully trained aestheticians, and I think that's an important component of that.

For example, although so far we have only talked about skin care products, other treatments may be involved, such as microdermabrasion, glycolic peels of various strengths, and even beyond that there may even be the need for TCA peels, dermabrasions, fat injections, collagen injections, or Botox. The point I'm getting at here is that you want to personalize the treatment plan for each patient to give them the best possible result for them as an individual rather than to just taking what's available. A good way to look at this is that you're providing customized skin care as opposed to an inventoried skin care, where you just buy whatever's available.

Moderator: What factors determine the need for one of these procedures? What should you consider when deciding to go beyond skin care products?

Young: The level of treatment that's required can depend on the location of the wrinkling, whether the wrinkles are static or dynamic.

What I mean by static or dynamic, dynamic wrinkles are present only when you animate your face, whereas static wrinkles are present all the time. Dynamic wrinkles, if they're in the forehead, crow's feet area, can be treated very well with Botox. However, Botox would not be a good treatment for a static wrinkle or for a nasal labial fold wrinkle.

The vertical lip lines, which are a common problem in smokers, can be dynamic or static, and in some instances, Botox can be helpful with the dynamic wrinkles. However, if too much Botox is injected in the lips, it can distort the smile or create other problems. Other treatments for vertical lip lines could include collagen injections, dermabrasion, or fat injection.

Part of the exciting news about treating wrinkles in the facial area today are that there are several new filler options under evaluation that hopefully will be available in the near future. Examples of these are Restylane, Radiance, and Artefil. Advantages of some of these fillers are longer-lasting results and a more complete correction of the deformities. Again, though, the choice of the treatment modality depends on multiple factors. Therefore, patients need to be aware of this and seek proper consultation from physicians and staff who are properly trained to evaluate them and individualize their treatment and management.

Member question: I had laser skin resurfacing back in 1997 by a top doctor in Los Angeles, which turned out wonderfully, but years later I sat out by a pool in February not meaning to get any sun. I did not realize the effects of winter sun! Well to the point, my face got sunburned pretty badly on my forehead and area around my nose (and being that it was only two to three months earlier that I had laser). It peeled, and to this day it stays red often and does not look attractive. I try to cover with makeup, but it doesn't help. I am wondering if I am able to have laser or some other kind of something done to correct this. I also have large pores on my nose. My face does not look as good as it once did. I don't go out in sun anymore. What can I do?

Young: First of all, it's extremely important, after you've had any resurfacing procedure, laser, dermabrasion, or chemical peel, to minimize your sun exposure and to wear proper sunscreen. When you get a resurfacing procedure, some of the protective skin pigment cells are either killed or altered so that they lose their protective value. This increases your sensitivity to both UVA and UVB sunlight.

That said, the redness that you experienced might still be temporary and reversible. Typically after a resurfacing procedure, there is redness that persists for three to six months. The redness after the sunburn will almost certainly last longer than that and will probably be present for at least a year. This represents a re-injury to skin that has already suffered an insult. In the meantime, you should minimize sun exposure and be on a good skin maintenance program designed to protect the skin and to keep it moist. Again, I would recommend Z-Cote to protect the skin. It gives the most complete protection.

If there are small blood vessels, or telangiectasia, associated with this, intense pulse light may be beneficial. Until the redness resolves, camouflage makeup can be applied to achieve a reasonable skin color balance, and if you work with a properly trained aesthetician that person should have available the kind of makeup and skills to teach you to apply so that you can achieve a normal skin color until your skin repairs the damage. There are no specific medications, drugs, vitamins, minerals, or herbs to speed this process.

Member question: I get Botox treatments twice per year for the expression line between my eyebrows. I am considering getting pregnant. How long after a Botox treatment should I wait before trying to conceive?

Young: The data on Botox and pregnancy are probably insufficient to completely answer that question, and therefore I would say discuss it with your obstetrician, but certainly the completely safe approach is to stop the Botox until the pregnancy is finished. There are other treatments for vertical forehead lines that can be used if that were important. An example would be an endoscopic brow lift.

Moderator: How often can you get Botox treatments?

Young: How often you get Botox depends on the problem being treated. Typically for facial wrinkles, treatments last approximately six months. One of the other major uses of Botox is for hyperhydrosis, which is excess sweating in the hands or feet or armpits. The duration of the effect of Botox for sweating is dependent on the dose used. But some people can get up to a year of relief from sweating with one treatment of Botox for these areas. People who have jobs where either excess sweating stains their clothes or excess sweating in their hands can get long-term relief from Botox injections

Member question: What is the new light treatment for wrinkles, excess hair, etc., and where do we get it?

Young: There are a number of light-based treatments. The laser treatments are probably the best-known light-based treatment. There are a number of different lasers available for skin treatments. Some, such as the CO2 laser, or the erbium laser, are used for skin resurfacing. Others are used for hair removal and for treatment of blood vessels.

The intense light pulse treatments are not true lasers and have been used to treat fine wrinkles, age spots, blood vessels, and in general, to smooth the skin. Intense pulse light treatments have relatively few adverse effects and seem to produce excellent results for many of the things that I listed.

In general, the lasers and other light modalities are evolving rapidly and anyone who decides to pursue one of these treatment modalities should be sure to ask the physician about the data demonstrating the effectiveness of the proposed treatment for their individual problem. They should also inquire about the potential risks and possible side effects that can occur with the treatments.

Member question: What can microdermabrasion do for skin? I don't have wrinkles, but do have enlarged pores on my nose; it feels like a bit of a bump on the end of my nose, tags on my eyelids, a few shallow marks from teen acne, one small blood vessel showing on my cheek, and a patch of something (like a scale?) on my cheek under my eye. Would microdermabrasion smooth out the surface and get rid of the bumps and shallow pits and reduce the pore appearance? Would it have any effect on the hair growth on the face?

Young: Microdermabrasion is analogous to sandblasting. The skin is abraded with small aluminum oxide particles. In that, the superficial layers of the skin are removed; therefore, microdermabrasion is effective for fine wrinkles, superficial scaly lesions, such as superficial keratosis or pigment irregularities. It is not particularly effective for large pores, deep wrinkles, severe acne scarring or moles or other raised growths. Similarly, it is not effective for blood vessels. Deeper pigment abnormalities, large pores, and blood vessels would be better treated with intense pulse light. Raised lesions, such as moles, usually require direct excision. The small skin tags can simply be clipped off.

Member question: Does Preparation H cream help facial skin look younger or benefit the skin in any way?

Young: This is not such an unreasonable question. Although Preparation H, per se, is not recommended for the face, there is a new drug called Aldara, which is a modulator of wound healing, that is being used to treat actinic kerotisis and skin cancers with excellent results. Efudex also can be used to treat some keratosis and superficial skin cancers. None of these have been used in a systematic investigation for cosmetic purposes.

Member question: Understanding that, as you say, each person needs an individualized plan, what is your opinion of approaches such as the Perricone Prescription as a general preventive approach or even as help for damage that has already taken place?

Young: The Perricone treatments are predicated, in large part, on antioxidants, and although antioxidants are important, their efficacy is incompletely documented. They sound very appealing from a theoretical basis, but from a practical standpoint, we need additional information to prove that they are truly better than the other things we've been talking about.

I would summarize that by saying we need to go back to the basic things that are proven to work, and those are: minimize sun exposure, don't smoke, avoid weight changes, have a systematized skin care program that is individualized for you, and practice a healthy lifestyle of nutrition and exercise. I think those elements make more difference than a specific brand name or treatment.

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