How to Get Rid of Wrinkles Safely

In the elderly, the skin in sun-protected areas is likely to have normal wrinkles that have deepened over time.

• Wrinkles are normally found in healthy skin. Wrinkles are furrows, crinkles, or creases in the skin that often result from the skin's loss of firmness and elasticity over time. Even newborn babies, however, have wrinkles in the areas of the joints where flexion and contraction tend to occur in the womb.
• In the elderly, the skin in sun-protected areas is likely to have normal wrinkles that have deepened over time.
• Wrinkles do not resolve spontaneously except under very unusual circumstances, such as infiltration of abnormal cells or other substances into the skin as part of a systemic disease process.
• Wrinkles also tend to occur in areas of muscle contraction. For example, the frontalis, corrugator, and orbicularis oculi muscles of the upper face are intimately connected to the superficial fascia and characteristically produce permanent horizontal furrows on the forehead and vertical skin wrinkles between and around the eyes.
• This type of wrinkling has been labeled intrinsic aging.
• Extrinsic aging is associated with exposure to environmental factors such as ultraviolet radiation (sun or tanning booth exposure) and firsthand cigarette smoke. This type of wrinkling is confined to sun-exposed areas and appears as diffuse fine, shallow lines. Microscopic examination of the skin involved in extrinsic aging shows tinctorial (stained) and structural changes in the normal collagen called elastotic degeneration (degenerative change in the elastic tissue).
• The predisposition to this sort of change is in some way related to genetic predisposition. Certain ethnic groups, the Scottish, Irish, and English people, for example, seem to be much more susceptible than those darkly pigmented ethnic groups.
• There is a special type of wrinkling popularly known as "cellulite." This is most common in women but may also be present in some men. Cellulite is often associated with obesity. It typically appears in the hips or buttocks. The affected skin appears to have an "orange peel" appearance. Cellulite is related to fat tissue that herniates into the lower deep layer of the skin (dermis).

Since wrinkling does not seem to affect one's general health, the decision of when to visit a physician depends on one's economic situation and one's personal feelings. A reasonable alternative to fixing this external problem is to work on the reason for considering the need in the first place.

Cosmetic procedures

The treatments for wrinkles are cosmetic procedures. Cosmetic procedures are those that do not produce a functional improvement in the patient's condition but they may produce an enhancement in a sense of well-being. They are generally not covered by most insurance plans.

Cosmetic procedures for wrinkles can be grouped into four groups:

1. Paralysis of superficial facial muscles
2. Filling depressions so that they are elevated
3. Changing the nature of collagen either by medical means or by an invasive destructive procedure
4. Surgical removal of excess skin

Some of these procedures are as simple as the application of a topical cream while others are surgical procedures that require general anesthesia and an operating room environment. The determination of which procedure is best is often difficult and requires an individual with expertise in multiple approaches.

This is a relatively recent innovative use of a toxin produced by a bacteria, Clostridium botulinum. This protein was responsible for a number of human deaths from eating contaminated, inappropriately canned foods. Patients died because of the loss of muscle control of respiration. Enterprising scientists refined and diluted this material so that it could be injected into spastic muscles and superficial facial muscles producing a paralysis that lasts two or three months at a time. The result was the disappearance for a time of wrinkles induced by these muscles. Currently, there are two brand-name medications that have FDA indications for injection, onabotulinumtoxinA (Botox Cosmetic) and abobotulinumtoxinA (Dysport), that can be injected into the muscles of the face to ameliorate wrinkles by paralysis of the tiny muscles involved. Other brands of this chemical, although not officially indicated for facial injection, may work as well.

They are incobotulinumtoxinA (Xeomin) and rimabotulinumtoxin B (Myobloc). Injections usually have to be repeated at regular intervals to maintain the desired result. Side effects are generally caused by the injection of too much toxin in the wrong anatomical site. Luckily, the effect of the toxin is self-limited. Currently, there is ongoing research into a topical preparation that potentially could be applied to the skin at home.

There are a variety of substances that have been used to elevate the furrows of depressed wrinkles. There are many FDA-approved fillers that include

• the patient's own fat cells (autologous fat grafting),
• collagen (Evolence, CosmoDerm, Fibrel, Zyplast[R], and Zyderm),
• hyaluronic acid (Belotero Balance, Restylane Injectable Gel, Prevelle Silk, Elevess, Juvéderm 24HV, Juvéderm 3 Hylaform, and Captique),
• lactic acid (Sculptra), and
• hydroxylapatite (Radiesse) and a combination of polymethylmethacrylate beads and collagen (Artefill).

There are also a variety of unapproved fillers such as silicone and mineral oil, which are potentially dangerous and should be avoided. Which brand of filler to be used on which wrinkle in a particular anatomic site is part of the art of cosmetic dermatology and requires special expertise. Most of these substances require reinjection at various intervals and all have occasional side effects.

Certain vitamin A analogs have been shown to induce the remodeling of the upper dermis by inducing fibroblasts to synthesize new collagen when applied topically over a long period of time. Of these "retinoids," tretinoin (Retin-A, Renova, Atralin, Retin A Micro, Avita) is easily available and has been shown to produce subtle but discernable changes in appearance of fine wrinkles induced by ultraviolet exposure. This outward transformation is accompanied by an alteration in the microscopic appearance of the upper dermis.

• Topical retinoid use needs to be accompanied by the compulsive avoidance of sun exposure to be most effective.
• Tretinoin or tazarotene use is associated with a side effect termed retinoid dermatitis, the so-called rosy glow, which in many patients seems to be cosmetically desirable. Tretinoin or tazarotene (Avage, Tazorac) is available in a number of different brands which are prescription only.

Invasive procedures

There are a variety of invasive procedures that can change the appearance of collagen in the dermis which hopefully result in a global cosmetic improvement to the treated skin. These include

• the use of lasers,
• dermabrasion, and
• chemical peeling.

As a group, these technologies damage the dermis just enough to induce the scar-forming cells (fibroblasts) to reconfigure the photo-damaged collagen sufficiently to reduce fine wrinkling and yet produce no unsightly scarring. This is a fine line that only those healthcare professionals with sufficient expertise dare tread. No matter who performs such a procedure, the prudent patient ought to seek to confirm the accuracy of any claims with a number of previous patients.

Low-power radio frequency and ultrasound devices

Recently, low-power radio frequency (Polaris WR and Thermage) and ultrasound devices (Ulthera System) have been touted as potentially useful in reducing fine wrinkling. These devices presumably work by producing heating of the collagen sufficiently so there is protein denaturation and shrinking. This so-called "skin tightening" seems to produce some cosmetic benefits. If heating of collagen is a necessary requirement, special care should be taken to ensure no burn injuries occur. The efficacy and safety of these devices remain to be demonstrated.

Microdermabrasion

Microdermabrasion is a technique in which air propels sand particles at the skin. The result is a transient diminution in the degree of fine wrinkling. This technology will not produce significant damage to the skin so collagen remodeling is unlikely. It seems reasonably safe and may work by producing mild temporary swelling (edema) in the treated skin. This procedure must be repeated at regular and frequent intervals to maintain improvement.

There don't seem to be any home remedies that have any beneficial effects on wrinkles.

The removal of excess, loose skin by surgical means was the original technique used to remove wrinkles. This procedure is generally performed in an operating room under general anesthesia. The result when performed by a master can be quite impressive.

• Cellulite treatment is a special problem that is as yet unsolved.
• Liposuction, which removes subcutaneous fat, does not seem to be the perfect modality to approach fat deposition of fat in the lower dermis, the presumed cause of cellulite.
• Certain chemicals which lyse fat cells could be deposited in the appropriate anatomical site to diminish cellulite. As yet, this technology is not perfected.

There is very little that can be done to affect intrinsic wrinkling other than attempting to limit normal muscular movement, a suggestion that is obviously ludicrous. One has to accept one's genetic inheritance.

On the other hand, extrinsic aging can be controlled to a great extent by limiting exposure to ultraviolet light and by not smoking. When the skin darkens in response to exposure to light, this is a sign that damage has occurred to the collagen in the deeper layers of the skin. This damage is cumulative so it is never too late to change one's behavior.

The major wavelengths of light responsible for this damage are in the ultraviolet range and have been labeled "A" and "B." Sunlight is the major source of this type of radiation, but tanning parlors have light bulbs that produce wavelengths in this range. Ultimately, there is no such thing as a safe tan!

Sunlight avoidance by wearing appropriate clothing, staying in the shade, and wearing a durable, effective sunscreen over exposed areas is a good strategy.

Any health benefit produced by the synthesis of vitamin D by the skin is overshadowed by the negative aspects of ultraviolet light exposure. Vitamin D requirements can be satisfied by taking almost any commercially available multivitamin (1,000 IU/day).

Since the longer wavelengths of ultraviolet light can penetrate window glass, it might be reasonable for especially compulsive individuals to coat suitable windows with a transparent plastic film that absorbs those wavelengths.

Summary

Whichever combination of techniques is used to reduce the appearance of wrinkles, the healthcare professional and their team are the most important variable in obtaining the most desirable result.