In Oscar Wilde's classic novel "The Picture of Dorian Gray", the title character sells his soul to the devil, winning for himself perennial youth in the form of a portrait that takes on the "lines of suffering and thought" that would have accrued on the 17-year-old's face as he aged.
In a modern variant of the 1870 novel, Dorian could sidestep a deal with the devil while still enduring as the picture of youth, by choosing from a menu of "skin rejuvenation" procedures developed in recent years. He could make a lunch-hour appointment with his plastic surgeon or dermatologist for a quick-fix microdermabrasion, or for a more dramatic result, might decide to take a couple of weeks out from his debaucherous lifestyle for laser resurfacing.
Of the many skin-refreshing options, laser resurfacing and microdermabrasion are among the most popular. They can help reverse the telltale marks of aging and sun damage—among them, smile and frown lines, forehead wrinkles, crow's feet around the eyes, brown spots, and dry, rough skin. Also, the skin rejuvenation treatments can be helpful in treating medical conditions such as precancerous skin lesions and acne.
But which procedure is best? "It's surprisingly easy to match the right procedure with a patient—just listen to the patient," says Rockville, Md.–based plastic surgeon Mark E. Richards, M.D. What bothers them? How far are they willing to go to get it corrected, in terms of risks, recovery time, and financial investment? "There's no free lunch," he points out. "The more downtime and the more inherent risks involved in the procedure, generally the more dramatic the changes are going to be."
Laser skin resurfacing offers the most striking results—"phenomenal," says Richards. "It can be a huge change, depending on how damaged your skin is to start with," says the surgeon, who has seen the procedure turn the clock back 20 years.
To achieve its dramatic—and long-lasting—results, laser resurfacing acts like a "souped-up microwave," Richards says, using high-energy light to vaporize the damaged outer layers of skin and de-emphasize wrinkles, superficial scars, and uneven skin pigmentation.
Two of the most commonly used skin-resurfacing lasers are the pulsed carbon dioxide laser, often referred to as the "CO2" laser, and the Erbium YAG laser. For advanced skin damage, doctors' technology of choice is the CO2 laser, based on its ability to penetrate deep into the skin.
Recovering from Laser Resurfacing: "No Picnic"
Richards chose the CO2 laser for Margaret Copeland (her name has been changed), a 74-year-old skin cancer survivor who wanted to rid herself of the health-threatening lesions that kept reappearing on her face.
Though the procedure is sometimes performed under local anesthesia, especially when limited to specific areas of the face, Richards performed Margaret's all-over facial resurfacing under general anesthesia. The former schoolteacher says of waking up from the outpatient procedure, "I knew my face was going to be bandaged, but I had no idea...I looked like the man in the iron mask."
After about 10 days, the "mask" was removed to reveal a bright red face. Though she kept up most of her routine for the three months it took to get her normal skin color back, Margaret admits that recovery was "no picnic." She experienced significant discomfort for some weeks after the procedure, and remembers the itchiness as the skin healed as the hardest part. But she is pleased with the results. "I have a healthy skin now, no question," she says, adding that one of the happy by-products of the procedure is that she lost her wrinkles.
The major healing takes seven to 10 days in most patients, says William A. Zamboni, M.D., a Las Vegas plastic surgeon and professor and chief of plastic surgery at the University of Nevada School of Medicine. But the red phase after healing can last for weeks or months.
For most patients, wearing makeup for that time period is all that's required. Sometimes, though, the skin's pigmentation remains permanently blotchy, with the laser-treated areas taking on a darker or lighter appearance than the rest of the face. With experience, Zamboni explains, doctors can learn which patients might be susceptible to such uneven pigmentation. In patients with darker skin and some others, doctors first apply the laser to a test patch in an inconspicuous area of skin to make sure the patient is a good candidate.
Laser resurfacing is very "technique-dependent," explains Richards, with both the quality of the machine and the doctor's skill greatly impacting the results. Clearly, it pays to find the right doctor. Bad results are rare in the care of an experienced doctor.
Fast Laser Treatments
Erasing her wrinkles was the singular reason that Yolanda Martir-Epalza sought laser resurfacing two years ago. The clerk in a dermatologist's office says she turned to skin rejuvenation for a pick-me-up to fix the fine lines around her eyes and upper lip. "My lipstick was already running," says the 45-year-old mother of three grown children.
Her dermatologist (and boss) performed the procedure with the Erbium YAG laser. The Erbium doesn't penetrate the skin as deeply as the CO2 technology, so it requires less healing time afterward, yet it is well-suited to de-emphasize fine facial lines like Yolanda's.
The most discomfort Yolanda felt from the laser procedure was a burning sensation immediately after. "I remember standing under the air conditioning vent because it made me feel better, but after half an hour it didn't hurt at all." Now, Yolanda boasts, "I get compliments all the time—'Wow, you look great!'"
The Erbium YAG laser is just one of 14 types of lasers (including the CO2) used in the office of Mark S. Nestor, M.D., where Yolanda works. Some of the instruments are "nonablative" lasers, meaning no skin is removed so no recovery time is needed. Says Nestor, "People can literally come in over lunch hour and go back to work or out to dinner that night."
Nonablative laser technologies include:
- NLite. Approved by the Food and Drug Administration in August 2000, the NLite technology improves the appearance of wrinkles without damaging the skin's surface. The technology, which makes a person gradually appear younger by increasing the skin's natural production of collagen, requires no anesthesia and no recovery time.
- Cool Touch. This technology, like the NLite, works to lessen wrinkles without producing an external wound. While applying a cooling spray to the skin's outer surface, the Cool Touch penetrates the skin and stimulates it to produce more skin-thickening collagen. Reservations agent Constanza Giraldo, who got the Cool Touch treatment for her acne scars after many other approaches proved unsuccessful, says of her results: "My skin looks smoother, and the scars are not that deep anymore. I feel more confident."
Constanza's procedure was less physically (and socially) taxing than some other techniques—she went right back to work afterward—and the rewards were correspondingly less dramatic, though they matched her expectations. "Less pain, less gain" aptly describes the realistic potential of the various laser skin rejuvenation technologies.
Other, nonlaser procedures also can rejuvenate the skin with a variety of risk-reward tradeoffs. Some treatments can be applied at home. Others, such as microdermabrasion, dermabrasion and chemical peels, are additional procedures performed by plastic surgeons and dermatologists.
Microdermabrasion: A Quick Fix for Light Wrinkles
Jean Trapani has undergone several consecutive once-a-week microdermabrasions—a treatment in which a highly controlled vacuum moves fine, sand-like crystals across the face to smooth out lines and lighten age spots "Sometimes I feel the granules, but there's virtually no pain," says the 52-year-old office assistant. "It's a very pleasant treatment."
By stimulating the skin to heal itself, the technique effectively treats fine wrinkles and can reduce skin imperfections like superficial acne scars, Richards says, but it can't be expected to reach the moderate and deeper wrinkles that laser resurfacing can.
Why choose microdermabrasion, then? Not everybody needs the deep-down reach of laser resurfacing, and microdermabrasion has two notable advantages over lasers, Richards explains: virtually no down time for recovery and no significant risks.
Losing Appeal: Dermabrasion and Chemical Peels
Dermabrasion is a far different procedure from the micro-form, with a far different risk profile, Richards says. Dermabrasion is described as a controlled scraping of the top layers of skin with a hand-held rotary wheel, but Richards says, "You're trying to have precise control of depth while basically holding a power drill in your hand." Richards prefers other techniques today, but acknowledges, "Done expertly, dermabrasion can produce very good results."
Because her father had skin cancer, 52-year-old Frances Maestas underwent facial dermabrasion three years ago to remove some skin growths, with hopes of diminishing her acne scars in the process. The dermabrasion effectively eradicated the growths and "softened" Frances' scarring but didn't eliminate it. Frances plans to pursue her doctor's initial recommendation to follow up the dermabrasion with laser resurfacing.
The trend among doctors, Richards says, is away from things like dermabrasion that are inaccurate as far as depth of penetration, in favor of more precise procedures like microdermabrasion and laser resurfacing. These days, Richards rarely performs the procedure called "chemical peel," either. Chemical peels, like dermabrasion, remove the top layer of skin, but use a caustic solution instead of a rotary wheel. Chemical peels can be done with mild "glycolic acids" or with the stronger chemicals phenol or trichloroacetic acid for a deeper reach. In Richards' view, strong chemical peels are inaccurate and risky compared to newer skin rejuvenation techniques.
The list of youth-restoring cosmetic procedures doesn't end there. A couple of additional examples: so-called Botox injections that temporarily paralyze facial muscles for a more youthful look, and injections of collagen to plump up wrinkles and decrease creases.
One on one, a doctor can help you choose your optimal rejuvenation treatment (or combination) from the modern cosmetic surgery menu. Or you may choose to wear your wrinkles proudly, as a badge of wisdom of sorts, as has England's Elizabeth, the Queen Mother. It is said that the elderly British monarch, who has just celebrated her 100th birthday, once politely refused an offer to retouch her photograph to conceal a few facial wrinkles, saying, "I would not want it to be thought that I had lived for all these years without having anything to show for it."