Botox, Fillers, Lasers, and Surgery
Is a Procedure Right for You?
This chapter is an overview and conversation about why cosmetic corrective procedures or surgery for the face might make sense; it is not, and not meant to be, a comprehensive examination of all the various procedures available. We touch on what options are available, and in what combination you may want to consider them, as you plan how to improve your appearance beyond what skincare is capable of providing (more on that in a moment). Before we start sharing details, it’s critical for you to understand that any one procedure never can do it all, just as any one skincare product cannot do it all. Even a face-lift addresses only some of the things that make a face look older—the procedure is not a cure-all for everything that causes skin to change because of time and cumulative damage.
To be clear: Here at Paula’s Choice, we are neither for nor against cosmetic surgery or cosmetic corrective procedures. What we are always for is knowing the facts—both the pros and the cons—rather than relying on the overhyped promises made by some of those less-than-scrupulous cosmetic surgeons and cosmetic dermatologists. (Unfortunately, some physicians and their assistants can hard sell their services and downplay the risks, just like salespersons in other areas.) The only way to ensure you know what you are getting and what you’ll end up with is to have unbiased information and realistic expectations—and that information should be from multiple sources, not only from a physician or a health care provider. You have homework to do, too!
Did She or Didn’t She?
In the world of beauty, nothing stirs up as much controversy as the topics of cosmetic surgery and cosmetic corrective procedures. Everything, from Botox to dermal fillers and face-lifts, are claimed to plump up lines and thinning lips, eliminate forehead wrinkles, remove brown spots, tighten a sagging jaw line, and lift up sagging breasts; and others to cut away a flabby tummy or suck out fat with liposuction, and on and on.
Much of the debate about these procedures and surgeries revolves around celebrities, some of whom have distorted their faces and bodies by having so much “work” done. They have become little more than caricatures of themselves by cutting, pasting, filling, and Botox-ing their faces and bodies to the point of absurdity. Guessing and gossiping about who’s had what done has become a popular pastime for lots of people.
A far more serious aspect of cosmetic corrective procedures and cosmetic surgery are the risks associated with these procedures. Taking such risks, some of which are significant, for the sake of beauty is understandably controversial. And being impulsive or uninformed about the risks of beauty enhancement is as shortsighted as dismissing them with disdainful judgment.
Beauty, and the desire to look young, is hardly novel. And nowadays, that desire to look young is starting at younger and younger ages, with many people in their 30s already undergoing a full menu of procedures. We all think about it to some extent, and probably act on it, at least to one degree or another. For example, even dyeing your hair to get rid of the gray or spending $200 on a wrinkle cream are attempts to look younger. The question that anyone who wants to look younger must answer for themselves is: What am I willing to do, and how much am I willing to spend, to look and feel more beautiful—what makes sense for me? Once you’ve determined how far you’re willing to go, the next step is to be sure you have a thorough understanding of what works and what doesn’t, then what procedures to consider and, finally, in what sequence do you want them—which can come down to your age and your expectations.
When Skincare Isn’t Enough
We here at Paula’s Choice are the last people in the world to suggest that skincare can’t do amazing things for skin, because it can. But it would be disingenuous of us to say that skincare can replace what cosmetic medical procedures or cosmetic surgery can do. Anyone who says otherwise is simply not telling the truth.
Skincare products that claim to work like cosmetic surgery, or Botox, or fillers, or lasers are making ridiculous, unsupportable claims. A comprehensive skincare routine with well-formulated skincare products (it always takes more than one product) can make a huge difference in the appearance of your skin, but it simply cannot come close to what cosmetic medical procedures or cosmetic surgery can do—it just isn’t possible. The effects of aging, sun damage, gravity, genetics, and hormone loss due to menopause or health issues, among many other factors, cannot be erased by skincare products. Believe us, we wish we could say otherwise, but we don’t want to mislead or delude you in any way.
It’s also true that cosmetic corrective procedures and cosmetic surgery have limitations. Just because you’ve had dermal injections, Botox, and a face-lift doesn’t in any way, shape, or form replace what great skincare products can provide going forward in life. You will still age, you will continue to sag and wrinkle, and brown discolorations will return. But, a brilliant skincare routine can slow that process, and help to maintain the results you get from medical procedures!
It’s the combination of a great skincare routine complemented by the procedures that cosmetic dermatologists or cosmetic surgeons can provide that will give you the results many skincare ads allude to. It’s important for everyone to realize the limitations of skincare as well as the limitations of corrective procedures and surgery—and to understand that one cannot replace the other.
Although it might seem as if cosmetic corrective procedures and cosmetic surgery are expensive, they don’t have to be! In fact, if you take all the money you’d normally spend on overpriced skincare products (with rare exceptions, products over $80 are not providing value for the money), and put it in the bank, you may very well have enough money to invest in cosmetic procedures or surgery sooner than you think—and likely be more satisfied with the outcome!
What about Just Aging Gracefully?
On the flipside of those who opt for cosmetic corrective procedures or cosmetic surgery are those who say we should just choose to “age gracefully.” Rather than procedures or skincare products, focus instead on being healthy and don’t bother trying to erase any signs of aging on our faces or bodies.
Without question, being healthy is fundamental to looking and staying beautiful regardless of your age, but whether you’re pro- or anti-cosmetic surgery, the truth is that a combination of great skincare + cosmetic procedures can produce outstanding results. Procedures have their risks, yes, but there’s no denying that they work. It’s a personal choice, but if you decide to actually do something in the realm of medical cosmetic procedures or surgery, don’t feel guilty or embarrassed—feel empowered!
In reality, lasers, Botox, fillers, and cosmetic surgery are the only ways to actually take years off your appearance between the ages of 40 and 70 (or before that, depending on the amount of sun damage you have). Skincare alone won’t cut it (pun intended), and hoping that it would will just be a waste of your money—which could be better spent elsewhere.
As we’ve said, even the best skincare routines and products have limitations, but after a certain amount of time, it’s the combination of a brilliant skincare routine coupled with surgical or corrective procedures that is the most realistic solution to looking younger, longer.
The Fear Factor
Not having some “fear” about cosmetic corrective procedures would be unwise, but being overly afraid is not necessarily wise either. If you’re considering procedures or surgery, we think it’s best to refer to this fear factor as “constructive concern,” which can take some of the fear out of the process.
Having constructive concerns is helpful, and encourages you to be proactive in finding the right surgeon (not just automatically going with the first one you talk to), understanding before you make your appointment what sorts of procedures you’re interested in, and to really know what your budget is or should be. (Note: Looking for a bargain in the realm of surgery or procedures is a really bad idea.)
When you finally do book your appointment, those constructive concerns mean you will be better prepared with questions about the risks of the procedures you’re considering. Asking for the pros and cons and insisting the doctor not downplay the cons is all part of having constructive concerns. The most important thing to remember is that getting answers for your concerns is part of being a great patient and getting the best results.
One way to approach this objectively is to realize how many of these types of procedures are performed each year. Each year, millions of people in the United States alone have chosen to have cosmetic surgery or cosmetic corrective procedures. According to the American Society of Plastic Surgeons, the top five cosmetic surgery procedures in 2014 were: breast augmentation and breast lifts (386,000 procedures); nose reshaping (221,000 procedures); liposuction (200,000 procedures); and face-lifts (133,000 procedures). The top five cosmetic corrective procedures in 2014 were: Botox (6.3 million injections); dermal fillers (2.2 million procedures); and chemical peels (1.2 million procedures). If you’re considering an elective procedure, you’re not alone—many people have gone where you’re thinking of going. The following information should help set you on the right path to getting the information you need to make an informed decision.
Cosmetic Surgeon or Plastic Surgeon?
In the world of surgery, the terms cosmetic surgery and plastic or reconstructive surgery are often used interchangeably, but they are absolutely not the same. Cosmetic surgery is elective; it’s performed to improve the physical cosmetic appearance of the face or body. Plastic or reconstructive surgery is a surgical procedure used to reconstruct facial or body defects due to genetic abnormalities, trauma, burns, or disease.
The training of a board-certified cosmetic surgeon and of a board-certified plastic surgeon differ significantly. A board-certified cosmetic surgeon’s training is all about cosmetic surgery, while a board-certified plastic surgeon’s training is only in part about cosmetic surgery. So, if a board-certified plastic surgeon is also a board-certified cosmetic surgeon, that individual is thoroughly trained in all aspects of the types of surgery that alter and improve the face and body, regardless of the cause or need. That combined training could mean that person has a superlative set of skills. Nonetheless, when considering surgery for your appearance, the most important thing to realize is that a board-certified cosmetic surgeon is the most important credential to look for because that encompasses the extensive specialized training needed for elective cosmetic procedures.
Both cosmetic and plastic surgeons can perform and are trained in an extensive array of procedures, ranging from invasive procedures (meaning surgery) to non-invasive procedures (meaning Botox and dermal fillers). Some would argue that surgeons should stick to invasive surgeries such as face-lifts and eye-lifts (blepharoplasty) and that cosmetic dermatologists should be sought for fillers, Botox, and laser procedures. There’s no right answer to this one. However, what is 1000% true is that if you are having any kind of cosmetic surgery, the doctor you choose must be a board-certified cosmetic surgeon or board-certified plastic surgeon—and it’s even better if he or she has both certifications.
Board-Certified Surgeons—The Gold Standard
The difference between just any physician performing cosmetic or plastic surgery and a board-certified cosmetic or plastic surgeon performing the surgery is night and day! Training and credentials in surgery are the issues. Although a doctor may offer cosmetic, plastic, or aesthetic surgery, he or she may not be board-certified to perform that type of surgery. The person could be a gynecologist, pediatrician, or dermatologist with no training in cosmetic surgery whatsoever. Scary, huh?
Board-certified means the doctor has gone through very specific and extensive training in a specialized field and has passed a difficult examination administered by a board of experts in that field. A cosmetic or plastic surgeon who is not board certified may be self-taught, and may lack formal training in that field.
Why would anyone want cosmetic corrective surgery performed by someone who has never had any formal cosmetic surgery training? The answer is: You don’t! At least not if you want the best possible outcome, which is why opting for a board-certified cosmetic or plastic surgeon is so important. We cannot stress that point enough.
One clear distinction that sets board-certified surgeons apart is that they have privileges to perform surgery at an accredited hospital. Although most cosmetic surgery procedures are performed in a doctor’s office, you want to be assured that your surgeon has a level of skill that’s accepted by an accredited hospital.
It’s completely fair (and not the least bit rude) to ask any doctor you see for a cosmetic surgery consultation whether he or she is board certified, and, if so, which hospitals he or she is affiliated with. But that’s not the end of it! With that information in hand, the onus is on you to check to be sure the hospital is accredited and that the doctor’s certification is current and recognized by the appropriate board. For more information, visit the following websites.
Finding out first if the physician you are considering is board certified significantly reduces the odds of your getting someone who is inexperienced.
Although this section is about cosmetic surgery and board-certified cosmetic or plastic surgeons, it’s important to realize that a board-certified dermatologist, even one trained to perform dermatologic surgery, does not have a certification that qualifies that doctor to perform cosmetic corrective surgery. Finding a board-certified dermatologist is vitally important for any cosmetic corrective procedures you are considering, but it is not enough for cosmetic surgery procedures.
Cosmetic Dermatologist or Medical Dermatologist
Similar to the confusion between a cosmetic surgeon and a plastic surgeon, there is equal confusion between the roles of a cosmetic dermatologist and the role of a medical dermatologist. The term medical dermatologist is the exact same thing as having the title dermatologist, but the term medical dermatologist is often used to make the distinction between the two relatively less confusing.
Unlike cosmetic surgery and plastic surgery, which are different, there is no such delineation between cosmetic dermatology and medical dermatology; they are indistinguishable. Ultimately, what that means is that medical dermatologists can call themselves cosmetic dermatologists, even if they have no special training or qualification, and they may choose their title based on the services they wish to offer. In other words, there is no specified certification that medical dermatologists must have to call themselves cosmetic dermatologists.
In many ways, the only real distinction between a cosmetic dermatologist and a medical dermatologist is financial (which we realize is a controversial statement that no doubt will raise the ire of many dermatologists, but it’s a well-known and ongoing debate within the world of dermatology). Using the title cosmetic dermatologist is simply a way to indicate that a doctor’s practice is mostly about elective procedures, such as Botox, dermal fillers, lasers, peels, light treatments, and the like. It also indicates that their services are primarily pay in advance, which means the doctor has far fewer insurance forms to fill out and there is no wrangling over how much to charge for a procedure.
Medical dermatologists, on the other hand, generally provide traditional therapies to treat skin disease, and then must wait for reimbursement from managed-care plans. This doesn’t mean that medical dermatologists who don’t refer to themselves as cosmetic dermatologists can’t perform cosmetic corrective procedures, because they can and often do. The title medical dermatologist merely indicates the area in which the doctor chooses to focus: skin disease and disorders rather than cosmetic beautification.
So what does that all mean for you? It means it’s a bit harder to determine what to look for when choosing a doctor to perform cosmetic corrective procedures because the only certification on the wall could be dermatology, and maybe some formal-looking “degrees” indicating training in specific procedures. In summary, there is no certification for cosmetic dermatology on the wall because such a certification does not exist.
Our personal recommendation: Find a board-certified dermatologist who describes his or her practice and/or themselves as cosmetic dermatology. That at least gives you some information about what you can expect when making an appointment; the doctor performs cosmetic corrective procedures more often than he or she treats skin disease. If your doctor frequently performs the procedures you want it means the doctor has at least some amount of experience in that area—and in the world of medicine, experience is everything, especially when it comes to beauty.
We also strongly suggest that you never have your dentist or gynecologist perform any cosmetic corrective procedure for you. [224] As shocking as it might seem, many physicians who are not board-certified dermatologists or cosmetic surgeons can also legally perform procedures. Although it might be hard to resist because it seems so convenient, cosmetic corrective procedures require extensive medical education, training, and experience in this very specialized field. Just because a dentist knows what to do when you open your mouth doesn’t mean he or she has the extensive medical education and training needed to perform cosmetic corrective procedures. Do we even need to mention that getting cosmetic corrective procedures from your hairdresser is also a very bad idea?!
When to Do It
In the not-too-distant past, most people waited until they were in their late 50s or 60s, and until their skin had noticeably aged, before they seriously considered cosmetic corrective procedures or surgery. All that has changed with the advent of relatively non-invasive, low-cost procedures such as laser resurfacing, Botox, and dermal fillers, as well as new and more advanced surgical techniques that leave barely noticeable scars.
Having procedures performed at a younger age, before you “need it,” means having healthier, younger-looking skin continually for years, as opposed to having it done after you’ve begun to show signs of aging, which means there will be an abrupt change in your appearance. From our point of view, it doesn’t make sense to wait until your skin is drooping and leathery before you do something about it. Think of it like waiting to quit smoking until your doctor breaks the bad news that you have lung cancer, instead of quitting years ago.
If your friends and family say you don’t need surgery or a procedure yet, but there’s something about how you’re aging that bothers you (and is beyond the reach of a great skincare routine), then it’s better to do something about it sooner rather than later. It’s your face and neck, and your decision! And do you really want to wait until your friends and family begin saying you’re looking old these days and you really should do something about it? Plus, having procedures or cosmetic surgery at a relatively younger age slows the way the skin will age, and when we’re younger our skin is better able to heal. In short, the right time is when you are ready, based on your own feelings and finances.
Despite our strong recommendation that only you can determine when to start having cosmetic corrective procedures or surgery, it’s also important to listen to your family and friends, especially if they start saying that you’re distorting your appearance. You don’t want to ever be a makeover nightmare, especially when it’s a makeover you can’t undo.
Which Procedures Are Right for Me?
Probably the most fundamental question people ask when considering the vast assortment of cosmetic corrective and cosmetic surgery procedures is this: Which procedures are right for me? The number of ways the different procedures can be combined are truly mindboggling, so we understand the confusion. The simple answer: The choices depend on what you want to achieve and on your doctor’s recommendation.
Perhaps the most difficult and discouraging part of all is to realize that no single cosmetic corrective procedure or surgery can do it all. Botox does not replace what dermal fillers can do, lasers do not replace what fillers or Botox can do, and surgery does not replace what fillers, Botox, or lasers can do. There can be some overlap of benefits depending on how much damage you’ve suffered or on how advanced the signs of aging are, but for the most part a little bit of each type of procedure, spaced out over a reasonable amount of time, will achieve the best results without looking overdone. For some people, especially if you are under the age of 40, one procedure may be all you need for a period of time to get the results you want—but nothing lasts forever. Overall, the less you are trying to correct, the fewer procedures you need to consider.
Another complication is that physicians often don’t use the same machines, injections, peels, and surgical techniques available. There are literally hundreds for them to consider, receive training on, and then purchase. Given a doctor’s investment in the equipment and in the training, each has his or her own favorites or the ones where they have the most skill. (Remember: There isn’t time to receive training in or become an expert on everything.)
It’s also important to realize that each physician has his or her own biases and sales pitch for the procedures they offer. That doesn’t have to be bad; it’s just that you need to know that a physician may recommend a specific type of laser or light machine or specific type of dermal filler over another because that’s what he or she has available in the office. It’s unlikely that a physician is going to tell you that there’s a doctor next door or down the block who has a machine or injectable material that’s better for you.
Before you even begin perusing our list of procedures and surgeries or begin your Google search, keep in mind that it isn’t over until it’s over. First, no procedure—surgical, invasive (deep ablative laser resurfacing), or non-invasive (Botox, dermal fillers, non-ablative lasers)—lasts forever. For example, Botox and some dermal fillers last no more than six months or a year. And, just having a procedure, or even several, doesn’t mean you’re going to stop aging. To maintain your results, you must have an ongoing plan of carefully selected procedures over your lifetime. You don’t have to do any of it, but it’s important to know that that is what it will take to keep up appearances and deal with further signs of aging with the passage of time.
Of course, if you don’t use brilliant skincare products, including sunscreen unfailingly to fight off aging from UV light exposure and environmental damage, you will continue to age faster than you need to. Cosmetic corrective procedures of any kind do not in any way replace an exceptional skincare routine and daily, broad-spectrum sun protection.
Overview of Procedures
Following is an overview of what to consider when trying to understand your options for cosmetic corrective procedures and surgery for the face. Hold on to your hats—this is where it gets really complicated! Your doctor will have much to say about what to select to meet your specific needs and desires, but because doctors have only so much time to spend with you and because they often will oversell what they have to offer, you must be prepared with your questions and must do some preliminary research (this book will help).
Please note: In the list of procedures and surgeries below, we do not list specific lasers, intense-pulsed-light (IPL), radiofrequency, or ultrasound machines because there are just too many out there. Adding to the complexity, different types of lasers often are combined into one machine and new machines are being launched all the time. There also are numerous variations of modality, wavelengths, intensity, and brand names, making it impossible for consumers, even if they do extensive research, to follow. Even doctors find it difficult, if not impossible, to keep up, as we’ve been told by many a cosmetic dermatologist!
We start our list with Botox because it’s the most popular cosmetic corrective procedure in the world.
Botox and Dysport are both drugs derived from the botulinum toxin Type A. Both are injected into various points on the face to temporarily paralyze specific facial muscles, which in turn erases lines almost immediately. Although this sounds like a radical procedure, Botox has been in use since 1973 and has a long history of safety and effectiveness. [225,226]
Botox and Dysport, made by different companies, have been found to be equally effective, with very little difference. Both are used to eliminate horizontal lines on the forehead, to reduce or possibly eliminate the “11” lines between the brows (known as glabellar lines), and to reduce crow’s feet by the eyes. [227] Some doctors also use Botox to lift the marionette lines (oral commissures) at the corners of the mouth, on the chin to reduce the “orange peel” look, to reduce puffiness under the eye area, to create an eye-lift appearance by injecting in areas above the brow, to reduce some deeper vertical lines around the mouth, and to soften the banding that can occur on the neck. The effects of Botox and Dysport can last for up to six months or a bit longer, and then begin to wear off.
Many people get both Botox and dermal fillers because the combination can produce a remarkably younger-looking face, but they do so in very different manners. Although both procedures involve injections, Botox is most often injected around the forehead and in wrinkles around the eyes to stop the muscle movements that lead to wrinkles (sometimes referred to as expression lines). Botox and Dysport injections have nothing to do with the plumping, smoothing effect of dermal fillers.
Dermal fillers are various kinds of injectable materials, either naturally derived or synthetic (including brand name fillers like Bellafill, Belotero Balance, Juvéderm, Perlane, Radiesse, Restylane, Sculptra Aesthetic, and Zyderm), that are suitable for and approved to be injected into the skin; some are better for specific needs or for specific areas of the face. [228] Dermal fillers have a very specific function that is unrelated to other medical corrective procedures. Dermal fillers are used to plump up deep creases that run from the nose to the mouth (called nasolabial folds or laugh lines), to plump thin lips and smooth out vertical lines around the edges of the lips, to augment the cheeks to improve their shape, to fill out depressions under the eye area, to fill in depressed scars such as from acne or chicken pox, and to add volume to a gaunt look in the lower cheek or temple area, which most often occurs due to fat pads shifting beneath the surface of skin. Depending on the filler, the effects can last from six months to two years; for semi-permanent or permanent fillers, the effects can last up to five years, and there are reports of even longer-lasting results.
Laser is an acronym for Light Amplification by Stimulated Emission of Radiation. There are many forms of lasers and there is no single best one (wouldn’t it be nice if there were?). Depending on your needs and concerns, you might need more than one laser to achieve the best overall results. The following overview of lasers will highlight the different categories of lasers and what they can do.
Ablative lasers (also called ablative non-fractionated lasers), including the CO2 laser and Er:Yag laser, work in a very precise manner to destroy the entire top layers of skin with intense heat. This results in a deep wound over the treated areas that lead to the formation of relatively thick scabs, which eventually heal, revealing new skin. Ablative lasers are used to deeply resurface skin on the face, neck, or chest, removing sun damage, greatly smoothing skin’s texture, improving skin tone, tightening skin, building collagen, and, to some degree, improving the appearance of wrinkles, scars, and brown discolorations. Of all the laser and light modalities available, ablative lasers produce the most dramatic and immediate results; however, they also have more serious risks. [229]
Ablative fractional lasers have results similar to those of ablative non-fractionated lasers, but work in a different, and relatively less invasive, manner. Where ablative lasers target the entire surface of the area being treated with deep, intense heat, ablative fractional lasers deliver deep, intense heat into the skin via thousands of tiny pixilated dots. The area around the dots remains unwounded, so healing time is considerably less than for ablative lasers, where the entire area of skin being treated is “wounded.” Ablative fractional lasers work well to reduce the appearance of wrinkles and brown skin discolorations, and to produce a smoother skin texture. [230]
Non-ablative lasers (also called non-ablative nonfractionated lasers) can treat many aspects of skin rejuvenation without requiring much, if any, downtime because they do not put out as much heat as ablative lasers and thus rarely wound skin. Overall, depending on the machine and its settings, non-ablative lasers can reduce brown spots, surfaced capillaries, and redness from rosacea or post-acne marks, build collagen, tighten skin, improve skin texture, and, to varying degrees, improve scarring.
Non-ablative fractional lasers are said to combine the best of the relatively more gentle and safer aspects of both ablative and non-ablative laser technologies. [231] Non-ablative fractional lasers deliver a high degree of heat, similar to, but not as strong as, ablative lasers, to the skin in tiny pixelated areas (think of a grid). While hundreds of tiny areas of skin are vaporized, as they are with traditional ablative lasers, there is a difference in that the entire surface of skin is not wounded, which makes recovery much faster. [232] The trade-off is that this type of laser procedure often requires multiple treatments to achieve the desired results. They can work very well for mild skin tightening (think first signs of sagging), some collagen rebuilding, mild to moderate wrinkles, improving sun-damaged skin, some types of scarring, and various skin discolorations. [233]
Intense pulsed light (IPL, also referred to as a photofacial or photorejuvenation) is a type of non-ablative laser that emits multiple wavelengths and intensities of light that can be targeted to “zap” red blood cells in surfaced capillaries or the brown color (melanin) in sun-damaged spots. The results can be relatively immediate, but depending on the number of brown spots or surfaced capillaries and on the degree of redness, three to five treatments may be necessary, and the treated areas may worsen before they improve. When IPLs are used for overall “photorejuvenation” to reduce wrinkles and tighten skin, it definitely requires three to five treatments, usually once every three to six weeks. [234,235] The amount of improvement obtained from IPLs in regard to rejuvenation is considered impressive, although not as dramatic as the improvement from ablative fractional or non-fractionated lasers. [236,237,238]
Radio-frequency (RF) machines work on the same principle as lasers, except that the heat is delivered via RF waves rather than light waves. The two most well-known RF devices are Thermage and Pellevé. RF machines improve some amount of sagging skin, smooth out stretch marks, and tighten other areas of loose skin. Like non-ablative lasers, RF machines can require multiple treatments to achieve optimal results. [239,240,241]
Microfocused ultrasound is performed using a machine called Ultherapy, which works differently from all other forms of lasers and RF devices in that it uses ultrasound energy to generate heat in the skin. The heat from lasers and RF devices targets the surface layers of skin, but Ultherapy bypasses the surface layers and delivers heat to the deepest layers of skin, directly targeting and stimulating collagen production. The primary use of Ultherapy is for skin tightening and for mild to moderate sagging, and the results are considered impressive. Ultherapy is considered one of the more painful non-invasive treatments. You should discuss your pain tolerance levels and medications with your physician before having the procedure. [242,243,244]
Chemical peels are a way to resurface the top to the deeper layers of skin to improve the appearance of wrinkles, make skin smoother, tighten skin, and reduce skin discolorations. Lighter chemical peels have a temporary smoothing effect that can last from a few days to two weeks. Results from deeper peels can last from several months to one or two years. There are various types of peel solutions used in these treatments, including glycolic or lactic acid (AHAs), salicylic acid (BHA), or trichloroacetic acid (TCA).
Superficial peels, often referred to as lunchtime peels, use low concentrations of glycolic, lactic, or salicylic acid and act relatively gently to quickly improve skin texture, minor skin discolorations, and wrinkles. They can minimally tighten skin and improve the appearance of acne scars.
Medium-depth peels use the same acids as superficial peels to exfoliate past the superficial layers of skin into the middle layers of skin for more pronounced results. Medium-depth peels have the same overall impact as superficial peels, but with far more noticeable and longer-lasting results.
Deeper peels almost always involve trichloroacetic acid (TCA), which penetrates into the deeper layers of skin. This enhanced penetration provides far more and longer-lasting improvement than superficial or medium-depth peels. Not surprisingly, the recovery time and risks for deeper peels increases as the penetrating depth of the peel increases.
Face-lift, technically called an upper rhytidectomy, and neck-lift, technically called lower rhytidectomy, are fairly straightforward and are almost always done at the same time. They’re perfect if you have extreme sagging skin at the jaw, neck, under the chin, or middle area of the face, or if you need to improve facial contours. A skilled, board-certified cosmetic or plastic surgeon should perform face-lifts and neck-lifts. The surgeon deftly cuts away just enough excess skin to make the face look younger without over-pulling and removing too much skin, which can create a distorted appearance.
During the surgery, the doctor also tightens the muscles under the skin, repositions or adds to the fat layer of skin, and then stitches everything back together again. Incisions are hidden along the inside of the ear, back of the ear, and along the back of the neck at the hairline. Depending on the amount of sagging, surgery might be the only option that makes sense.
Lasers and other types of machine-oriented or injectable procedures can tighten and restore volume to skin, some rather dramatically, but if you’ve waited too long and have pronounced fallen skin, corrective procedures might be a waste of your money, when a face-lift could produce the desired results in one fell swoop—albeit one with a much longer and more involved recovery time.
Eye-lift or eye tuck, technically blepharoplasty, is a surgical procedure performed either on the upper eyelid or the area under the eye. It’s a perfect procedure for removing excess fatty deposits that appear as puffiness around the eyes, bags under the eyes, drooping lower eyelids, and wrinkles around the eye. It’s the same basic process as a face-lift, but performed as an eye-lift: Excess skin is cut away, muscles are tightened, fat pads are either reduced or repositioned, and then everything is stitched back together.
A skilled surgeon will hide the incision for the lower eye-lift on the inside portion of the lower eyelid or directly along the lash line in such a way that it’s almost imperceptible after healing. For the upper eyelid, the incision is carefully placed in the crease of the eye, and also barely perceptible after healing.
Whether you want to improve the appearance around your eyes or you’re experiencing functional problems (such as reduced vision) with your eyelids, an eye-lift can be a stunning success. If the problems are with the functional aspects of the eye that may require surgery, they are often covered by your health insurance.
Forehead lift or brow lift is surgery performed to minimize or eliminate horizontal forehead lines and wrinkles, raise drooping brows, and open the eye area by lifting sagging skin on the upper eyelids. There are various forehead lift procedures, the different ones involve the surgeon making different length incisions in different locations along the scalp or hairline. A variation of this procedure, known as an endoscopic forehead lift, is intriguing because it’s minimally invasive. This procedure uses an endoscope (a threadlike tube with a tiny camera on the end) along with specialized surgical instruments placed through very small incisions directly at the hairline. By looking at a screen, the endoscopic camera shows the surgeon where to adjust fat pads, reposition skin, and tighten muscles. Now that’s a great surgical assistant!
Another type of forehead lift is a coronal incision forehead lift. This procedure is performed by creating an incision ear to ear across the top of the head about one to two inches behind the hairline. The forehead skin is then lifted and cut away at the incision line, making it possible to adjust muscles or fat pads with everything revealed (unlike the endoscopic technique, which, despite its cool factor, limits the doctor’s overall view of the area).
The resulting scar from a coronal brow lift is well concealed within the hair, and when the hair grows back the scar is not visible, assuming you have enough hair growth to hide the scar. Either type of brow lift is perfect to improve a sagging or furrowed forehead, sagging brows, or upper eyelid, as well as to improve the shape of the forehead.
Chin augmentation, technically genioplasty or mentoplasty, is a surgery that involves inserting an implant into the chin area to improve the structure and appearance of the jaw and chin area. The implant material can be harvested from bone from the patient’s body or from donor bone.
Ear surgery, technically otoplasty, is typically performed to “pin back” naturally protruding ears or to lift sagging ear lobes, which are often caused by years of wearing heavy earrings, although it might be a genetic feature for that individual. While ear surgery is not a popular procedure, it can be performed at the same time as a face-lift to improve the overall appearance and symmetry of the face.
Rhinoplasty, often referred to as a nose job, involves surgery to reshape and restructure the nose. The procedure typically is performed through incisions on the inside of the nose, so the scars won’t be visible after healing. A skilled surgeon then remakes or reshapes the bone and cartilage of the nose by removing the cartilage that is not needed and then adding or rearranging the bone and cartilage to create a newly shaped proboscis (nose).
What Can Go Wrong
In short—everything can go wrong, or nothing can go wrong. Each procedure comes with its own risks and rewards. It turns out that there are far more positive results with any cosmetic corrective procedure or surgery than there are negative outcomes. In fact, negative outcomes are relatively rare, ranging from 1% to 5% depending on what you have done.
The rewards are obvious once recovery is complete; when you look in the mirror, you will look younger and likely see yourself as more beautiful. However, it’s not a good idea to ignore the potential negatives; in the world of cosmetic corrective procedures, ignorance is not bliss!
The risks we describe in the following section sound pretty dire, but keep it in perspective and remember that, statistically, the positives far outpace the negatives, and sometimes there are no negatives. We also don’t want you to base your decision about cosmetic corrective or surgical procedures on headline horror stories, which are all over the Internet and in the media. There are, indeed, rare horrendous outcomes, often due to an unqualified doctor performing the procedure and botching the work. There also are people, fortunately only a small minority, who become addicted to procedures, having things done repeatedly to their face. Unfortunately, their skin and the underlying structures can take only so much, and eventually they start looking plastic, distorted, and peculiar.
Following is a basic list of things to keep in mind when considering the types of medical treatments we discuss throughout this chapter. We do not mean to scare you, but these are the facts and the risks you must consider before booking your appointment.
The overarching risk for all procedures is being disappointed with the results. It might be that it wasn’t worth the cost, that no real improvement was seen, that the pain was overwhelming, that the face seems now to have an uneven or distorted appearance, that skin discoloration or an unwanted texture to the skin appeared, or that the scarring takes too long to heal or heals in a ropey or raised manner— those are all possibilities.
As a general rule, the more invasive the procedure, such as a deep laser treatment or surgery, the higher the risk of complications and pain during recovery. The less invasive the procedure, the lower the risk of problems. However, pain is always a risk, and it varies from person to person and procedure to procedure.
Cosmetic or plastic surgeries—face-lifts, neck-lifts, eye-lifts, forehead lifts, and nose jobs—have a scary list of complications, so brace yourself! This is surgery, and there’s a lot involved when you cut into skin and stitch it back together, no matter how superficial or deep the surgeon goes. Typical problems are scars that don’t heal well, becoming ropey or thick; a numbing sensation that can last for a long period, or that doesn’t ever go away; a feeling of tightness that lingers or doesn’t go away; and pain in the area of the incision or surrounding area, which also can linger or never go away. Scars can be improved with different treatments or procedures, but the numbing and tightness that persists is not easily, if ever, resolved.
For cosmetic or plastic surgeries that require anesthesia or sedation, there are potentially serious risks, involving allergic reactions or breathing problems, and you should thoroughly discuss these with the anesthesiologist well in advance of the procedure—not wait until the day of the operation!
Bruising and blood loss during and after cosmetic surgery is considered normal, but excessive and continuing blood loss, especially once you’re back home, is not normal and requires immediate medical attention. Don’t wait—call the doctor!
There’s also the possibility of infection, which is a risk after any type of surgery. Any sign of infection must be dealt with immediately because if left untreated, it can quickly spread and cause serious complications. If a severe infection does occur, additional procedures or surgery may be needed to remove the dead skin that can build up around or along the area of the incision.
A strange, and fortunately rare, negative outcome of eye-lifts is something called ptosis. This appears as unwanted sagging and drooping of the eyelid post-procedure, and can be corrected with additional surgery.
Depending on the extent of the surgery and the amount of correction needed, the list of potential disappointments can increase considerably. That’s why you should discuss every potential side effect with your surgeon before you agree to have a cosmetic surgical procedure.
For dermal fillers, the most common issues are initial discomfort that lingers or temporary swelling or bruising that lingers. Fillers can also result in cysts, bumps, lumps (called nodules), skin irregularities, and/or inflamed tissue that persist, even with semi-permanent fillers. Allergic reactions can happen, but are rare. If you tend to get cold sores, dermal fillers can trigger a new breakout. Infection also can result, but it’s extremely rare and easily treated. Not surprisingly, the most typical complaints about dermal fillers involve the results of the procedure.
Problems such as poor or inaccurate placement, unevenness, and overfilling the area are not unusual. Skilled doctors can correct some of these complications; for shorter term fillers, you just have to be patient and wait for the filler to dissipate as it is absorbed by your body. If hyaluronic acid–based fillers are used, errors sometimes can be corrected by injecting an enzyme into the affected area, which breaks down the material without causing any further problems.
Botox and Dysport have the most interesting potential downsides because of how they impact the muscles of the face. As mentioned in the previous section, most injections of Botox or Dysport are to treat lines and wrinkles on the forehead, including between the eyebrows. When done right, they definitely get rid of wrinkles, but can also result in what some people think looks like a stiff, immovable, and expressionless appearance. It’s a trade-off that you must decide whether it’s right for you.
The “Spock Effect” occurs when one or both eyebrows become overly arched and elevated, causing a surprised, unnatural appearance. If the doctor or practitioner doing the injections knows what he or she is doing, this is easily correctible with one or two expertly placed injections.
Eyelid or facial ptosis (drooping) occurs only rarely, but there are reported cases, and this is the most serious and obviously undesirable risk—and one more reason you want to ensure that the person doing the injection is well trained and experienced. There are prescription drops that will temporarily help counter the drooping until the effects of the Botox are gone; it takes about three to six months for most people.
In attempting to smooth the entire face, especially around the mouth, doctors and practitioners can get carried away and inject areas of the face that are probably best left alone. This is especially noticeable around the mouth and cheeks, where the procedures can lead to a flat smile as opposed to one that turns up. It can smooth out the wrinkles, but the overall appearance can be a negative for some people.
Developing “bunny lines” on the sides and the top area of the nose is a curious side effect of Botox and Dysport injections. Although these injections prevent muscle movement of the forehead and eyebrows, they don’t stop the face’s natural autonomic response to raise or furrow the forehead or eyebrows. The face responds to these attempted movements by engaging and eventually overusing other muscles, resulting in bunny lines.
Minor discomfort and bruising often occur from the injections, but usually resolve quickly; pain during the procedure is typically minimal and easily avoided by applying a topical numbing cream pre-injection.
Depending on where you have the injections, some extremely rare, but possible, side effects include dizziness, difficulty swallowing, headaches (although Botox also has been used to reduce migraines), eye irritation, reduced blinking, and muscle weakness.
IPLs (intense pulsed light) and non-ablative lasers present the lowest risk of negative side effects, but they also have less dramatic results. The unwanted side effects can be pigment problems, ranging from reddened or purplish discoloration (known as purpura) to lighter patches of skin (hypopigmentation) in people with medium to darker skin tones or when the procedures are done on people who have tans.
Infections from IPL are rare. They occur primarily when the treatment is used around the mouth for hair removal, to reduce redness, or to improve collagen formation because the heat generated by the IPL can stimulate a dormant infection such as the herpes simplex virus.
A few minor transient problems can be a sunburn type of reaction, where the skin either feels hot or looks burnt. Swelling and bruising is possible, but again, almost always resolves quickly. As for pain, the sensation from each pulse (and there will be over a dozen pulses during each treatment) is most often described as similar to snapping a rubber band against your skin—more a discomfort than truly painful.
Ablative lasers have a far more scary list of side effects than IPLs because the depth of the treatment is greater and the manner in which skin is wounded is more serious. The deeper the resurfacing, the more severe the side effects. Immediately after ablative laser resurfacing, one can experience itching, swelling, redness, weeping skin, blisters, redness, acne, rashes, infection, changes in skin color (either lighter or darker than normal), and severe peeling, which can last for several days. Ablative laser resurfacing also poses a risk (although rare) of permanent scarring. If the resurfacing is around the eye area, a condition called ectropion can occur. Ectropion is where the lower eyelid and sometimes the upper eyelid turn outward, leaving the inner eyelid surface exposed, causing a strange look around the eye. Ectropion can be corrected with surgery, but it also can be prevented in the first place if the doctor takes precautions to stitch the back corner in such a way that it prevents it from occurring. (Paula’s surgeon took this precaution when she had her ablative laser resurfacing.)
Finally, if you see any signs of infection, or if any of the other conditions persist, you must see your physician immediately.
Chemical peels have risks that vary with the type of peel. Superficial peels present minor risks, including redness, irritation, flaking, dryness, and, rarely, blistering for one day up to a week. Medium-depth peels have similar risks, but the intensity of the side effects increases and the length of time it takes to heal can be at least a week, possibly two. Because a deep peel literally causes a second-degree burn of the skin, all the side effects for the other types of peels will occur, plus a scabbing over and weeping of the skin. There also is a greater risk of infection and scarring with the deeper peels, and healing can take anywhere from two weeks to two months.
General Tips Before Having Any Procedure
Stop taking medications and supplements that increase bruising, swelling, or bleeding. Definitely talk with your doctor if it’s absolutely necessary for you to continue to take any medications daily. Also ask your doctor if any other supplements or medications you’re currently taking, or habits (such as smoking), could increase the risk of side effects post-procedure. Be 100% honest; tell the doctor about everything you use. The risks to your outcome depend on it, so this is not a time to be coy or embarrassed.
At least one to two weeks prior to your appointment, stop taking aspirin, ibuprofen (Advil), naproxen (Aleve), Ginkgo biloba, St. John’s wort, vitamin E, fish oil (omega-3) pills, ginger, and garlic. All of these are known to increase the risk of bruising and bleeding.
Do not drink alcohol for at least 24 hours prior to the procedure and, depending on what procedure you’re having done, for up to several days (or weeks) afterwards, as alcohol inhibits the body’s ability to heal.
Consider taking arnica. Because arnica has anti-inflammatory properties when taken orally, it may help if you begin taking this supplement up to two weeks before your procedure(s). Check with your physician to get his or her approval and a recommended dosage. Do not apply arnica to wounded skin, as it can be irritating.
It goes without saying, but just in case: DON’T TAN and DON’T SMOKE! This precaution is warranted because many people still tan and smoke, despite the fact that there are mounds of research showing that both of these lifestyle choices have a negative impact on skin. Tanning and smoking contribute significantly to skin discolorations, increase scarring, and delay healing, which is counterproductive to your skin’s ability to heal. Plus, why engage in two such aging behaviors when you’re paying good money for procedures to look younger, longer?
In regard to smoking, a doctor should ask a smoker to stop for at least three weeks before having surgery or an invasive corrective procedure. For many people, some of the more detrimental effects of smoking are greatly reduced after three weeks. Smoking has serious consequences because it introduces carbon monoxide into the body, which reduces the amount of oxygen available to the tissues, greatly inhibiting healing. Nicotine is also an issue because it restricts blood flow within the blood vessels. All this adds up to a greater risk of complications, none of which are pretty.
Skincare Before Having a Corrective Cosmetic Procedure
Generally, when it comes to cosmetic corrective procedures, there are no absolutes or special skincare steps or products you must add to or remove from your existing daily skincare routine. This, of course, assumes you are following our product recommendations and advice for taking brilliant care of your skin. The mantra here is (with very few exceptions) to continue to take great care of your skin! Doing so encourages faster healing and can also make recovery far easier.
Despite the fact that there are no pre-procedure musts for your skincare routine, some physicians do have opinions about your skincare routine and may ask you to change it. You should follow your doctor’s advice on what he or she thinks is best, but, if in doubt, be sure to speak up and ask your physician why he or she is making the recommendation. Even if you don’t agree, it’s still wise to follow your doctor’s advice.
Both before and after the procedure, discuss with your physician the topical prescription medications you use because they may interact with the surgery or procedure you’re having done. For example, topical cortisone creams (over-the-counter or prescription-strength) can impede healing. Doctors also occasionally want their patients to stop using retinoids, such as Renova, Retin-A, or retinol-based products one to two weeks before a procedure because they may increase post-procedure inflammation. They also may tell you to wait a few weeks post-procedure before resuming topical medications.
Many doctors feel as we do and believe it’s best to continue to use retinoids, whether prescription-only or in serum or moisturizers in the form of retinol, because retinoids strengthen the skin in significant ways that can reduce the risk of complications.
No matter what, be sure you’re up front with your physician about any topical medications you use and share the details on any oral medications you take, including supplements bought over-the-counter from health food stores or drugstores. Many oral medications can interfere with recovery from a cosmetic procedure, so, as we mentioned above, it’s critical for your physician to know exactly what you’re taking.
It’s also critically important to protect your skin from the sun, even more so than usual. It’s best to be very afraid of the sun (really) before a cosmetic corrective procedure of any kind, whether invasive or non-invasive. Sun damage, whether you see it on the surface or not, hurts the skin’s ability to heal, increases the risk of inflammation, and can make scarring worse. For some laser or light procedures, tanned skin can be more susceptible to complications than untanned skin.
Ask your doctor whether or not you should continue to use an AHA or BHA up until the procedure, and when you can add them back into your routine afterwards. Some doctors feel you should give up your daily topical exfoliants containing AHAs (glycolic or lactic acid) or BHA (salicylic acid). On the other hand, there are physicians who feel as we do; continuing to use your AHA or BHA exfoliant helps to gently remove the buildup of dead skin cells these procedures cause, and removing the buildup accelerates healing. However, if your physician urges you to skip this step for the time being, follow his or her advice.
Skincare After Having a Corrective Cosmetic Procedure
You’ve had a procedure (or multiple procedures) done. Now what? Here’s what you need to do (or plan for) when you’re recovering from minor or major procedures.
Apply cloth-wrapped ice packs as directed. One of the most important things you can do is to apply ice packs following Botox and dermal filler injections as well as other non-ablative laser- or light-based and intense pulsed light (IPL) treatments. Continue to use ice on and off throughout the day that you had the procedure.
For other procedures, such as chemical peels, ablative laser resurfacing, or cosmetic surgery such as a face-lift, follow your doctor’s instructions precisely for at-home care. Generally speaking, the more involved or extensive the procedure, the more involved the post-care. There’s a big difference between post-care following a Botox treatment and post-care following a face-lift!
Avoid activities that raise body heat. Depending on the procedure, your doctor may advise you to avoid raising your body temperature for the next few days. This means no strenuous exercise, no hot yoga, no soaking in the hot tub or sitting in the sauna, and no extended cooking over a hot stove.
Sleep with your head elevated. After any cosmetic corrective procedure, it can be exceptionally helpful to sleep with your head in an elevated position as much as possible. This reduces swelling and can significantly speed the healing process. If this proves too uncomfortable for you, try propping pillows against your sides so your arms can rest more easily with your head elevated.
Add a rich, emollient moisturizer. Many of these procedures can leave skin scaly and dry for several days, so if your skincare routine doesn’t include a rich moisturizer, it should—even if your skin is usually oily. The moisturizer doesn’t have to be heavy and occlusive like Vaseline, but it does need to be emollient and loaded with skin-healing antioxidants and skin-repairing ingredients. Once skin has healed you can go back to your usual moisturizer that is suitable for your skin type and concerns.
Along with moisturizer, consider using a silicone-based serum. Silicone ingredients, such as cyclopentasiloxane and dimethicone, have a proven ability to help protect and heal skin, and a silicone-based serum loaded with antioxidants and skin-repairing ingredients can be a wonderful addition to your post-procedure skincare. You’ll want to keep using it after your skin has healed, too!
Stop using scrubs or the Clarisonic. Scrubbing your skin is a problem after most cosmetic corrective procedures because it can cause microscopic tears, which slow the healing process, especially after laser resurfacing and chemical peels. You can begin using these again only after your skin is completely healed.
After the initial healing process, you can return to your normal skincare routine, which we hope dovetails with the advice in this book. Once you begin using your AHA or BHA exfoliant again, pay attention to how your skin responds, and adjust the frequency of use accordingly. Discontinue use if you notice any signs of irritation. Many people find that these products enhance healing and lead to an even better outcome, but others do not. Our advice? Experiment to see what works best for you!
It’s Up to You!
There’s no question that having the best skin of your life includes a combination of great skincare, a healthy lifestyle, and, potentially, cosmetic corrective procedures of some kind. We consider it a trifecta that can keep you looking beautiful and young for years and years. Cosmetic corrective procedures are not for everyone, but if you do choose to have something done, what you do to help your skin through the process will make it easier for you to see the results you want faster and more safely.
We’re in a new era where cosmetic surgery and corrective procedures are widely available and getting better every year. Some people are pleased to know their face doesn’t have to reflect their real age, and that they have a choice about what to do about it. As long as the results are impressive (and they often are), most people will want to maintain their youthful appearance via procedures that are relatively low risk and relatively permanent.
Wondering about that word “relatively” above? We use it because cosmetic surgery has duration limitations; that is, having a procedure will not keep your skin age-free forever. That’s neither bad nor good, but many of these procedures, both invasive and non-invasive, are legitimate options for creating the look you want. Plus, it beats wasting money on creams and lotions that might do nothing for the wrinkles or sagging or pouching that bother you the most.
Skincare can do a lot to prevent and repair signs of aging, but any cosmetic surgeon worth getting to know would agree: When it comes to correcting signs of aging, the combination of a brilliant skincare routine (we can’t say this enough) with the right cosmetic surgical (or non-surgical) procedures is what research has shown to be best for reducing and potentially eliminating many of the most bothersome signs of aging.
Micro-Needling
Micro-needling is a general term for a process that involves moving a special device over your skin that has a roller with many tiny needles embedded in it. There are different kinds of micro-needling devices with different product names. One is the manual version of micro-needling called a Dermaroller. There are also motorized devices such as the Dermapen or Dermastamp.
For the most part these micro-needling devices have reasonable science behind them indicating they may help in reducing the appearance of scars, but there is far less support for their ability to address wrinkles or for their ability to help anti-aging ingredients absorb better into skin.
It’s tricky to weigh the pros and cons of such devices because when something sounds possible for one thing, many people often assume it must be good for everything. Another obstacle to obtaining the facts about micro-needling is the skewed information from the people who sell the device or use it in a spa versus having it done as a medical treatment by a physician. The exaggerated and misleading information we’ve seen is over the top!
A serious issue with these devices is you can buy them yourself and cause far more damage than any possible and even remote benefit. We’ll do our best to make it easier for you to distinguish the real possibilities from the foolishness, but, for certain, micro-needling isn’t for everyone, it can damage skin and make things worse not better, and for certain it doesn’t perform miracles.
Dermarollers resemble small paint rollers you would use to get into tight spots, and they act as miniature aerators, like something you’d use on your lawn. They have a round, rotating cylinder with at least 200 tiny needles protruding from it, and a handle for moving it around your face. And that’s exactly what you’re supposed to do with it: You roll this quasi-aerator over your skin with some amount of pressure, puncturing hundreds of tiny holes wherever it goes.
Dermapens look exactly like a pen, with a circular head studded with tiny needles. The head and needles are motorized. The motor-driven needles move in and out of the skin in a stamping motion piercing it with thousands of tiny punctures.
Dermastamps resemble Dermapens but have a larger head with more needles protruding from the device and may be motorized or manual. They work exactly as the name implies: Rather than rolling needles over the skin or being moved over skin by a motor, you stamp the needles into skin. It’s a bit like a tattooing machine, but with many needles puncturing skin all at once rather than a single needle (and obviously minus the ink deposit).
There are three primary uses for micro-needling devices. The first, which has some good research behind it, is to break down the thick collagen that causes some types of scarring. [245,246,247] The other two are more questionable, especially in terms of wrinkles and those are to stimulate collagen production by wounding skin and thereby improving the appearance of wrinkles, and the last is to deliver skincare ingredients into skin.
It seems clear from research that medical treatments using either the Dermastamp or the Dermapen to reduce scarring have the potential to produce good results. Whether or not the Dermaroller produces the same results is unclear because there is almost no published research available, but theoretically it should have the same results. Whether or not micro-needling of any kind can work on cellulite is at best dubious, but given that cellulite occurs on areas such as the thighs and not the face any downside would be far less evident.
In terms of building collagen, the Dermapen and Dermastamp have emerging research about their benefits for wrinkles as an easy procedure that is far less expensive than other devices or treatments. In contrast, the Dermaroller has no such research, though again, theoretically there is logic to the concept.
The Dermaroller is often touted as being better than chemical peels or resurfacing lasers for wrinkles because it doesn’t remove the epidermis, but that it works in the same way to promote collagen production to repair the wounds it causes. However, removing the surface layer of skin is a primary benefit of chemical peels and resurfacing lasers. Resurfacing the skin creates a notably smoother outer layer of skin removing layers of sun damaged skin. Building collagen is only one way to improve wrinkles. Plus there many other types of lasers, light, radiofrequency, and ultrasound machines that don’t resurface skin.
It’s vitally important to keep in mind that if you constantly wound skin on a regular basis, eventually you will experience negative consequences. That’s one of the major concerns about using any repeated treatment that constantly wounds skin, and why we’re not enthusiasts of micro-needling devices for at-home use because of the risk of abuse. We describe the physiology of how this can happen below.
In wound healing and the formation of scar tissue, there’s a change in the relative amounts of type I and type III collagen (for quick reference, there are at least 16 types of collagen in the body; types I and III are most prevalent in skin). [248] When skin is wounded, the amount of type I collagen increases and the amount of type III collagen decreases. When type I and type III are in balance, skin is healthier and looks younger; when they are out of balance, because of injury or aging, especially if the skin is repeatedly being reinjured, then type I is more prevalent. The result? Skin becomes stiffer and looks unhealthy. It’s the balance between type I and type III collagen that comprises young skin. When skin is “wounded” during laser procedures or chemical peels, type I collagen increases as a response to skin’s healing process, but then during the healing process skin starts producing lots of type III collagen to bring it back into a healthy state (skin loves being repaired if we don’t get in its way).
Because it’s the balance between type I and type III collagen that makes skin healthy, look younger, and radiant, continually wounding skin makes it almost impossible to regain or maintain a healthy balance between these two types of collagen. Peels and lasers are performed intermittently, while most needling devices come with instructions to use them daily and it’s just too easy to think if a little is good a lot would be better.
Another claim about the benefit of micro-needling is to enhance the penetration into skin of prescription ingredients or cosmetic ingredients. While there is definitely research showing the potential benefit of micro-needling as a means for delivering prescription drugs into skin this is developing research and is not a standard practice by any means. [249,250,251,252]
In terms of skincare ingredients penetrating “deeper” by using the Dermaroller or similar tools, the benefit is at best dubious and minimally studied. Much of this research uses a small number of people and is often done by people (even doctors) representing the companies selling these machines.
The major issue, as we mentioned, is the risk of constantly re-wounding skin, which eventually damages it. The second issue is in regard to what skincare ingredients are going to be absorbed further into skin—and is that even a good thing?
The claims are usually around improved penetration of everything from hyaluronic acid to retinol, and vitamin C. There are even claims that human or plant stem cells and growth factors can be used at home with these devices to absorb better into the skin. [253] By the way, even if skincare products claiming to contain stem cells or growth factors could work they would have serious risks to the health of your skin, but they can’t work so it’s really more a waste of your time and money than it is a real risk.
Gaining the benefit of toners, moisturizers, or serums with anti-aging ingredients is not just about maximum penetration. Many ingredients, like antioxidants and skin-identical ingredients, must stay in the top layers of skin to have benefit, including defense against environmental free-radical damage (which encounter skin’s surface first). Then there’s the risk of getting unwanted ingredients (like preservatives or problematic plant extracts) deeper into skin, where their negative effects may be worse. Even beneficial ingredients like hyaluronic acid, vitamin C or retinol can be more sensitizing if they penetrate through a wound (i.e., when applied over broken or “punctured” skin), rather than being able to do their work in the uppermost layers of skin or penetrating deeper naturally through intact skin all on their own.
The fine point (sorry, we couldn’t resist) on micro-needling is that in some situations it can have benefit especially for scarring and remotely but possibly cellulite, but there is absolutely not enough research to support a recommendation to use such tools as part of an anti-aging routine or to gain better results from deeper penetration of cosmetic ingredients (and we are all about the research). From what science has shown to be true about the types of collagen in the body and how the types of collagen in skin work in balance, there’s a real risk to frequent use of micro-needling devices, powered or manual, in terms of throwing off the balance of healthy, youthful collagen production.
At-Home Light Devices for Wrinkles or Acne
You may have heard about high-tech light devices for acne and wrinkles advertised for use at home. Alternatively, you can have a procedure in a spa or clinic setting called light-emitting diode (LED) therapy. Also known as photodynamic therapy (PDT), these light-emitting devices have a decent amount of research showing they can be effective for reducing acne and wrinkles. Even more impressive? There doesn’t seem to be any risk associated with these treatments!
As positive as the research for these devices looks (and these aren’t large studies by any means), they shouldn’t be confused with, nor do they work or share strong similarities with, more sophisticated medical devices. LED light devices do not in any way replace medical options, such as ablative lasers, non-ablative lasers, IPL, radiofrequency machines, or ultrasound machines, for treating wrinkles. They also don’t replace the need for a well-formulated skincare routine.
LED devices can be used at a doctor’s office, but it’s not necessary unless you are also being treated with a topical medication that then requires you to sit in front of an LED-emitting device for about 30 minutes to an hour. This treatment and medication, referred to as topical 5-aminolevulinic acid (ALA) with mediated PDT, can be effective for moderate to severe acne. [254] In contrast, at-home LED devices for acne tend to be best for mild or sporadic acne, and do not require concurrent use of a topical medication during treatment.
But, back to the at-home devices: There are mostly pros and only one con to consider, but if your expectations are realistic (these are not a cure for acne and the results for wrinkles are relatively subtle) the research is promising. That means there’s almost no reason not to give these devices a try if you have the patience and the time!
Blue LED treatments for acne use specific wavelengths of blue light to target and kill the Propionibacterium acnes bacteria that play a pivotal role in causing acne for many people. It also can reduce inflammation. Although it sounds strong, this light doesn’t damage healthy skin in any way; in fact, there’s research showing it can reduce oil production. Other research shows that blue LED treatments can be helpful to reduce thickened scars. [255,256,257,258,259]
Not everyone will respond the same way to this kind of treatment; however, because the devices are reasonably priced (at least compared with repeated medical treatments), there’s almost no reason not to see how this treatment works for you. Just keep in mind that blue LED treatments don’t replace a great skincare routine for acne. [260] Plus, this treatment requires a time commitment: You must hold the device to your skin or sit in front of a panel of lights for several minutes once or twice daily, on a regular basis, to obtain results. Important tip: Be sure to protect your eyes from exposure to the light.
Two more points: Blue LED devices without ALA are not considered effective for cystic acne, and they have no impact on blackheads or whiteheads (milia)—one more reason to keep using effective skincare products along with LED treatments.
Red LED devices for wrinkles are identical in practice to the blue LED treatment devices, except that they emit red light. Like blue LED light, you expose your face to red LED light by moving a handheld device over your face or by sitting in front of a panel of lights. Red LED treatments have a relatively extensive amount of research showing they can help heal wounds and reduce wrinkles. Red LED devices are also believed to target the skin’s oil glands to reduce cytokines, a class of pro-inflammatory substances believed to play a role in chronic acne and rosacea. [261,262,263,264,265,266]
The treatments can be performed at home or in a doctor’s office, but there’s no reason not to consider doing this at home given the relative affordability of at-home devices and the fact that when you follow the usage instructions there are no known side effects. If there’s any downside, it’s the fact this requires multiple treatments several minutes once or twice daily on a regular basis. Just like when using blue LED devices, you also must protect your eyes from the light.
What to buy? If you are considering an at-home LED device for anti-aging or clearing acne, we recommend shopping carefully and buying only from reputable manufacturers. Due to concerns over liability issues, many manufacturers of at-home devices limit their intensity, sometimes to a much lower strength than the LED-emitting machines your dermatologist uses. In a sense, that’s good news because, although side effects are nil if used correctly, it’s possible to overdo these treatments and end up damaging your skin, which is never the goal.
Some of the LED devices available to the public actually do have the strength of those used in dermatologists’ offices. If that’s the case, caution is warranted: To get the best results while minimizing, if not eliminating, risk, be sure to read all accompanying instructions and follow the usage directions to the letter!
At-home blue LED devices we recommend for treating acne: Quasar MD BLUE ($595); Quasar Baby Blue ($349); Quasar Clear Rayz for Acne ($249); Tria Acne Clearing Blue Light ($299).
At-home red LED devices we recommend for treating wrinkles: Quasar MD PLUS ($795); Baby Quasar PLUS ($399); Tanda Luxe Skin Rejuvenation Photofacial Device ($195).
Don’t get caught up in making a decision based on the “FDA approved” label for what’s known as a “Class II medical device.” All that means is that the FDA approved the device for safety, not for effectiveness.
At-home diode lasers for wrinkles are very different from the blue or red LED devices discussed above. Products like Tria’s Age-Defying Laser and PaloVia’s Skin Renewing Laser are both at-home diode lasers. They are not LED (light emitting diode) devices, which is what makes them completely different from the blue and red LED treatments we discussed above.
What makes these diode devices unique is their energy output and the wavelength of light they produce. PaloVia’s device has a maximum energy output of 15 megajoules (mJ, a measure of energy) and a wavelength of 1410 nanometers; Tria’s has a maximum energy output of 5–12 mJ/pulse and a wavelength of 1440 nanometers. Technically, this makes them similar to the type of non-ablative laser treatments you can receive in a doctor’s office. These at-home devices have some advantages over the in-office versions: They can provide results similar to those you get from in-office treatments, without the repeated cost (most non-ablative laser treatments require multiple treatments over time). The downside is that similar does not mean the same. The energy output is the major difference and the versions in a doctor’s office are far more powerful and effective, are used by someone who knows what they are doing, and can be calibrated to offer a customized treatment. [267]
The fact that the energy output of the Tria and PaloVia is less than that of the in-office devices doesn’t mean that the diode devices don’t have an impact on wrinkles. The technology behind these devices is sound, and if used following the instructions, if you can put up with the discomfort (it hurts), and if you make the time commitment, you can get reasonable results.
Both the Tria and PaloVia devices, not surprisingly, come with unrealistic claims. The question of whether or not these work better than retinoids, such as prescription tretinoin or over-the-counter retinol, is irrelevant because a laser or light treatment of any kind isn’t skincare. How lasers or light treatments work is completely different from the benefits you get from great skincare products or topical retinoids. Lasers and light treatments remodel and stimulate increased collagen production, but there is much more to taking care of skin than that. Retinoids help skin cells make healthier cells and skincare products formulated with potent antioxidants and skin-repairing ingredients reduce further damage. AHAs and BHA exfoliants also keep the surface of skin smooth, something diodes or LED devices cannot do. And, of course, neither LED nor diode devices can protect skin from UV light, which is the leading cause of all signs of skin aging and a detriment to those struggling with breakouts.
We also wanted to compare stronger types of in-office procedures, such as much stronger lasers, IPL, ultrasound, and radiofrequency treatments to at-home LED and diode devices, but there’s very little published research to be found. That means your guess is as good as ours! However, given that a doctor can customize and strengthen treatments and that users of at-home devices cannot, we suspect in-office procedures, even those that are similar to at-home devices, will retain their edge. Being able to “dial in” these treatments allows for more targeted results in much less time—which is good to know if you’re dealing with more pronounced wrinkles, acne, or sun damage.
Which way to go? This is a decision you need to make based on how much time you have, how much money you’re willing to spend, and the results you’re hoping for. The Tria and PaloVia devices each cost about $500, and they require a minimum of several treatments over a period of weeks. And, most important, don’t expect miracles—modest, incremental improvements after several weeks of use is a realistic expectation that will ensure you don’t end up disappointed.
At-Home Laser Hair Removal
Perhaps no other form of light-emitting at-home device has shown more consistent promise and improvement in the research than laser hair removal devices. Among our favorite brand for this time- and money-saving procedure is Tria.
The Tria Laser 4X is a relatively new incarnation of the 810-nanometer diode laser device you can buy for use at home. As surprising as it sounds, it really is virtually identical to the laser hair removal machines used in doctors’ offices or clinical/spa settings, which means it works to permanently remove hair! With a retail price of $449, the Tria Laser 4X isn’t cheap, but it’s definitely cheaper than repeated treatments for laser hair removal from a physician, especially if you have particularly stubborn hair growth that will require more than the usual number of treatments. Most will find this device worth the investment—at least if you can figure out how to use it! One drawback of the Tria device is that you must follow the instructions exactly or the device won’t produce even minor results. This is not pain-free, but the treatment at the doctor’s office isn’t pain-free either. If you can keep up with the treatments and are patient, you could be pleasantly surprised and end up never having to use a razor again.