Laser energy, radio frequency, and ultrasound all work by creating a controlled injury to the skin that sets a wound-healing response into high gear. This spurs collagen formation and cell regeneration, and firms and plumps the skin.
BEGINNER: EVEN YOUR SKIN TONE: Intense Pulsed Light (IPL) treats discoloration like freckles and rosacea, and uses a wide spectrum of light wavelengths in high-intensity pulses.
The Pros: "It smooths the complexion with no Downtime or discomfort," says Miami dermatologist Dr. Leslie Baumann, who favors the treatment for her own fair, freckle-prone complexion.
The Cons: Because IPL zones in on pigment, it can be risky to use on dark skin, as it has the potential to create uneven results. It's also not ideal for random brown spots (go with a pigment-targeting laser, such as the "Q-switched Nd:Yag," which zaps them one by one) or larger broken blood vessels (for those, a Vbeam pulsed dye laser works best).
When to Start: 20s+ Downtime: None. Cost: About $477 per session. Maintenance: A three- to five-treatment series to start; three times a year after.
INTERMEDIATE: REPAIR SUN DAMAGE: Fraxel Re:Store is one brand name for nonablative fractional laser resurfacing, laser energy that delivers heat deep into skin by drilling microscopic holes in the skin with hundreds of fractionated laser beams. This way the surface of the skin isn't completely scorched, since there are minute untouched spaces interspersed amid the lasered pinholes.
The Pros: "To minimize wrinkles, firm sagging skin, build collagen, and fix sun damage, this is your go-to laser," says Dr. Ellen Marmur, chief of dermatologic and cosmetic surgery at NYC's Mount Sinai Medical Center. "It also protects against skin cancers because it physically removes damaged cells in the dermis."
The Cons: While a numbing cream is applied beforehand, the pain factor can still be significant. It can cause hyper- or hypopigmentation (dark and light spots) on Asian and dark skin tones.
When to Start: 35+ Downtime: Two to three days max. Cost: $1,337 per treatment Maintenance: A series of three treatments (one per month) for best results.
ADVANCED: FIRM AND MINIMIZE DEEP WRINKLES: Cosmetic surgeons and derms across the country can't seem to rave enough about the latest ablative fractional C02 laser resurfacing innovations (brand names are Fraxel Re:Pair and Pearl). "While nonablative fractionated lasers treat skin tone, texture, pigmentation, and fine lines, the ablative version takes resurfacing quite a few steps further to significantly minimize deep wrinkles and create enough thermal damage to stimulate collagen formation and firm the skin," enthuses New York dermatologist Dr. Patricia Wexler.
The Pros: Because it's fractionated, these carbon-dioxide-powered devices aren't as destructive as the original C02 lasers, and you usually need only one treatment.
The Cons: You'll require at least a week or two of recovery for the post-procedure swelling, redness, and peeling. "Whenever intense laser energy is used on the skin, there's a risk of post-inflammatory hyperpigmentation," says Wexler.
When to Start: 40+ Downtime: One to 10 days. Cost: $2,424 per treatment. Maintenance: None.
EXTRA CREDIT COMBINATION THERAPY: Many dermatologists enhance the benefits of fractionated lasers by applying therapeutic chemicals to the skin immediately afterward. "Fraxel allows the skin's pores to be wide open so actives like hydroquinone, retinoic acid, or amino levulonic acid [to treat pre — skin cancers] penetrate deeper," says Marmur. She adds (as if reading our minds): "Your face is still numb from the first procedure, so you often don't feel the second one."
KNIFE-FREE FIRMING: RADIO FREQUENCY AND ULTRASOUND
Thermage (electromagnetic radiation) and the newer Ulthera (ultrasound) devices firm sagging skin on the face, neck, eyelids, and brows sans a surgical lift by delivering heat to tighten tissue and stimulate collagen deep in the skin without injuring the epidermis. Thermage is time-tested, but some derms prefer the newer Ulthera. "It contracts the connective tissue covering the muscle, so you're able to sculpt the face," says Wexler. Doctors can also see the tissue they're aiming for on a screen. Baumann agrees: "I can target the heat exactly where I need to."
The Pros: You generally need only one treatment, and can see dramatic results in three to six months.
The Cons: Pain. One Thermage patient describes it as "someone plunging a sharp object into your muscle and bone." And she was on Demerol.
When to Start: 40+ Downtime: None. Cost: $1,500 to $3,000 per treatment. Maintenance: Thermage: One to two treatments. Ulthera: None.
EXTRA CREDIT TIGHTEN UP: The latest tightening technology to win FDA approval is ePrime, a "minimally invasive" procedure that delivers radio frequency energy into the dermis by way of micro-needle electrodes that puncture the skin. The jury's still out on the long-term benefits.
FREEZE FACIAL LINES: NEUROMODULATORS, aka BOTOX
From Botox and Dysport to the new Xeomin, purified, diluted botulinum toxin type A injected into specific muscles of the face can temporarily erase wrinkles on the forehead, frown lines between the brows, crow's-feet, and even the vertical platysmal bands ("turkey neck" folds) on the neck.
The Pros: Serious — and, in the hands of the right doctor, artful — results. "A neuromodulator works with the yin and yang of elevator and depressor muscles to create better symmetry and open up certain areas of the face," says Santa Monica derm Dr. Ava Shamban, author of Heal Your Skin. "If you inject a lifting muscle, you get a drop, and if you inject a constricting muscle, you get a lift. Injecting the corners of a downturned mouth can lift up those corners slightly and refresh the whole face."
The Cons: "Too much Botox can extinguish facial movement and expression," warns Wexler. "It can take away the arch of the brows, and injecting every crow's-foot will prevent your cheeks from elevating when you smile."
When to Start: 30+ or when wrinkles start to bother you. Downtime: None, although bruising can occur at injection sites. Cost: $397 per treatment; varies with dosage. Maintenance: Results wear off in three to eight months.
PLUMP SAGGING SKIN: INJECTABLE FILLERS
Whether or not you fear needles, temporary facial implants "can re-establish the youthful shape of the face," Marmur explains. "Fillers can strengthen the cheekbones and temples, elongate the chin, and redefine the jaw." There are synthetic fillers, such as Radiesse (a durable substance often used for the jawline) and Sculptra (a watery solution for volumizing large areas like chins). Hyaluronic acid fillers (like Restylane and Juvederm) are made of the same water-binding substance found in our bodies and are used for smoothing lines around the thin-skinned eye and lip areas.
The Pros: Fillers like Sculptra and Restylane gradually stimulate collagen formation in the dermis, so it's likely you will need less and less filler for touch-ups.
The Cons: Results can last six months or more, but if you're not happy with the effects, hyaluronic acid fillers are reversible with a hyaluronidase injection, which dissolves the substance. And be warned: Too much filling and you could start looking like a puffed-up blowfish.
When to Start: 40+ Downtime: None. Cost: $562 per treatment. Maintenance: Twice a year.
EXTRA CREDIT DEEP DIVE: "By injecting filler deeper, underneath the muscle and right above the bone, you can lift certain areas and give shape to the face," says Wexler of the scaffolding-like effect. For example, instead of inflating nasolabial folds superficially, the idea is to make laugh lines disappear by using filler to lift the peripheral muscle of the cheek with volume.
WHAT'S UP WITH CHEMICAL PEELS?
Sure, the traditional peel may sound old school, but don't discount it, especially if budget is an issue. The application of various acids — salicylic, glycolic, lactic, kojic, retinoic, alpha hydroxy (AHA), or trichloroacetic (TCA) — onto the face resurfaces the skin by aggressively sloughing off dead skin cells from the top layer. Each acid interacts differently on the skin, so a derm usually combines a few to achieve the desired result. Peels can be used to get rid of brown spots, dull texture, and fine lines resulting from sun exposure.
The Pros: Did we mention peels are more reasonably priced? They are also an extremely effective option for darker skin tones, since using light and laser treatments can potentially discolor and scar skin with more melanin.
The Cons: Superficial peels don't go as deep into the skin (to affect collagen-building change) as a laser can, and the results of stronger peels can be unpredictable. "You can't control a chemical peel the way you can control the parameters and pulse duration of a laser," says Marmur, who explains that peels can lead to burns or post-inflammatory hyperpigmentation. "Lasers are a much more sophisticated way of treating the skin on a deeper level."
When to Start: 20s+ Downtime: For light peels, two or three days of redness and peeling. Medium peels (such as a 30 percent trichloroacetic acid) require up to a week of social lockdown. Cost: $150 to $719 per treatment. Maintenance: Light peels, once per month for a series of three. Deeper peels, once every three months for a year.
BREAKTHROUGH TECHNOLOGY: INJECTABLE CELL THERAPIES
The future of fillers focuses on their potential to trigger your body to make more of its own collagen, elastin, and new skin cells.
FAT STEM CELLS: Harvesting fat from one area through liposuction, then purifying it and transferring it into your face acts as a natural and permanent filler. Fat contains lots of stem cells, and Baumann says that "stem cells have the potential to become fibroblasts [the cells that produce collagen] or other skin cells, so the idea is that they will cause the skin to regenerate itself faster." But she adds this caveat: "Stem cells can turn into any kind of cell, so what if they turn into skin cancer cells?"
ETA: Fat injections have been around for years, but they're not FDA-approved, and there's no hard data to suggest that the stem cells in fat will turn into collagen-making fibroblasts or healthy new skin cells when transplanted into the face.
BLOOD GROWTH FACTORS: Provocative in a True Blood kind of way, but not yet FDA-approved for facial rejuvenation, is PRP, or platelet-rich plasma, known as "vampire filler." The procedure involves drawing your blood, separating the platelets in a centrifuge, and then injecting that plasma — rich with growth factors — into your face where it will theoretically help to generate collagen and fresh skin cells. As creepy and out there as it sounds, PRP has solid roots in orthopedic medicine, where it's used to facilitate the repair of injured tissue. "While the scientific evidence on PRP is limited," says Shamban, "the concept edges closer to what will be coming in the near future: extracting our own cells, culturing them, and reinjecting them into the skin to tell it to make more collagen."
ETA: While some dermatologists offer PRP treatments off-label (i.e., for another purpose than what was approved by the FDA), the treatment is neither undergoing clinical trials nor seeking FDA clearance for cosmetic use.
SKIN FIBROBLASTS: The fibroblast filler LaViv just won FDA approval for smile lines, and it may be a game-changer. "The science is very convincing, and fibroblasts are better than stem cells because we know they make col-
lagen," says Baumann. Sample skin tissue is removed from behind the ear and sent to a lab where the fibroblast cells are multiplied into millions of new collagen-producing cells, then frozen until the defrosted formulation is injected into the patient's face in a series of three treatments over three months. Shamban, who was involved in clinical trials for LaViv, says: "It's the first biological cell therapy that's been approved to treat lines and wrinkles. Recent studies also show that old fibroblast cells can be revived in the lab to act like younger cells. This may mean that when you're 70, we could potentially make your fibroblasts act like they're 25." Talk about turning back time.
ETA: Expect to see it roll out to derm offices over the next year.