What's the best treatment for deep wrinkles?

There are many different ways to treat deep wrinkles. It depends on their location and cause.

• BOTOX Cosmetic may be used to prevent a wrinkle caused by repetitive muscle movement from getting deeper
• Injectable filler materials (e.g., Restylane, Juvederm, Radiesse) may be used to temporarily fill the wrinkle
• Lasers (e.g., carbon dioxide, erbium:YAG) may be used to resurface the skin
• Chemical peels and dermabrasion may also be used to resurface the skin

An evaluation by a physician is necessary to determine which treatments are best for a given patient. Minimizing sun exposure and using sunblock are also important to reduce the development of wrinkles and the risk of developing skin cancer.

The latest technology in cosmetic laser resurfacing and deep wrinkle treatment are lasers called Active FX for the facial surface areas and Deep FX for deep lines and wrinkles. It reduces wrinkles, particularly around the eyes and mouth, it tightens and firms up the skin, including the neck, and it eliminates dark or discolored areas.

This is a fractionated laser, much superior to Fraxel. I have not heard of a patient who has had Fraxel who didn't think this was much, much better.

There is about 3-4 days of downtime, and typically afterwards you look like you have been in the sun too long. By the 4th day, the skin has peeled off and you are left with a beautiful result! There is no bruising and no scabbing. When done along with Botox and injectable fillers, this gives you an amazing, amazing result!

There are several options for treatment of deep wrinkles depending on severity of wrinkles, downtime, general health, cost etc.

Assuming there are no health problems, surgery is one option which works by stretching the skin and smoothing out wrinkles. Surgery does not improve actual skin thickness, tone or texture.

Botox combined with tissue fillers is an excellent option with little downtime and quick results. This type of treatment is temporary and has to be repeated every few months. This treatment improves skin appearance by realxing the muscles and filling in the deep wrinkles without actually changing skin thickness, tone, texture or elasticity.

Rhytec Plasma skin regeneration is an excellent option for moderately deep wrinkles, mild to moderate loss of facial tone, jowls, poor skin texture and brown sun spots. This treatment works by using plasma energy to evenly heat superficial and deeper layers of skin. Unlike ablative lasers, superficial skin remains intact and acts as a natural dressing to promote faster healing of deep layers. The skin peels off over a period of 5 to 7 days, removing sun spots, fine lines and rough texture. Deep skin continues to regenerate and over a period of 3 to 6 months gets thicker with significant improvement in deep wrinkles, skin tone and elasticity. The treatment has downtime of about 1 week, which is worth the dramatic improvement.

For those patients that are not candidates or are looking for an alternative to surgery, using cosmetic dermal fillers that are designed for deeper creases, folds, and wrinkles are a good place to start and are usually safe for most patients.

In our practice, we have chosen Perlane, which is in the family of hyaluronic acids (fillers) but is designed more for adding volume to areas that require a deeper volumizing effect. Using more than one syringe will also help achieve full correction. Although this can be quite costly, the payoff usually is a higher satisfaction rate and longer longevity.

Again, as is the case with most cosmetic rejuvenation questions, there is no 'best' answer. Each patient is different and each solution should be tailored to the patient's individual needs.

Another thing to consider with deep wrinkles is the location - what works for nasolabial folds may not work for forehead. As such, all permutations would be almost impossible to include.

Instead, I will focus on some of the options for dealing with deep wrinkles. Keep in mind that wrinkles can be due to action of the underlying muscle or from tethering of the skin to deeper structures.

1. Botox. Botox Cosmetic is indicated for 'temporary treatment of moderate to severe frown lines between the brows in people 18 to 65 years of age.' Botox works by paralyzing the muscle and as such is good for lines created with motion of muscle. It is not good for lines present at rest.
2. Fillers. Dermal fillers such as hyaluronic acid (Restylane, Juvederm, Perlane to name a few), collagen, Radiesse, and others aim to erase lines by filling in the underlying structures. These are temporary and at times cannot address deep wrinkles because it does not release the tethering that is creating the wrinkle.
3. Ablative Lasers - CO2 and erbium. These work on several levels. By taking off the outer layer of skin and promoting collagen tightening, ablative lasers can erase wrinkles and produce a more youthful, even skin texture. The down side to these is the intensive after care.
4. Undermining techniques. New techniques, such as the Surgiwire, aim to release the attachments of the skin to deeper structures which create the deep lines. This can be especially effective when combined with a filler or other substance from somewhere else on the body to prevent the lines from reforming.
5. Hydration and skin care. By providing hydration to the skin, some finer wrinkles can be erased. Similar to inflating a balloon, when skin is hydrated the cracks and crevices are obliterated.

Well, that depends on what "deep" means.

I agree with Dr. Clinton in that Deep Fx is a good treatment for wrinkles, but I would hesitate about including deep wrinkles in that category. Laser treatment is certainly a good idea to treat some wrinkles and make the deeper ones more shallow, but you are most likely going to have to have filler or Botox injected. Sometimes you can get a combination of the two. The glabellar area between the eyebrows is a great example of someplace where the combination of Botox and filler works great.

For deep nasolabial, marionette and glabellar folds, I have had good results with Juvederm Ultra Plus and Radiesse. Radiesse bruises more and it hurts more, so I prefer Juvederm. Juvederm is also smoother.

So, to answer the question, surgery is the only option only if you have extensive loose skin and need an overall facelift. Most deep wrinkles should really be addressed non-surgically if at all possible. Speak to an experienced physician and he or she can give you all of the options appropriate to your individual situation. If your doctor tells you that surgery is your only option, that may be the case, but get a few opinions. It never hurts.

There is no one treatment that will give you the home run. I generally combine a CO2 or an erbium resurfacing treatment, with plasma couple of months down the road and with fillers as needed. My choices depend on the patient's skin type and their ability to put up with down time.

Every patient is unique and the optimal treatment plan will vary according to each patient's situation.

As a general matter, however, the TotalFX procedure is the most effective stand-alone procedure that I have used. Total FX, which uses a fractional CO2 laser by Lumenis, addresses deep wrinkles with a treatment called DeepFX, followed immediately by a fairly aggressive ActiveFX treatment that addresses more superficial issues.

DeepFX uses a narrower laser beam to go much deeper than ActiveFX. In other ways, DeepFX and ActiveFX are substantially similar, utilizing fractional laser technology that facilitates the healing process by leaving bridges of untouched skin between the treated skin. The healing benefits of these untouched bridges of skin allow us to be more aggressive with the TotalFX treatment and achieve better results than any other stand-alone option. The results we have experienced from TotalFX have been phenomenal. NO OTHER REJUVENATION PROCEDURE WE HAVE EVER TRIED HAS COME CLOSE!

Other ways to address deep wrinkles include:

• Botox, which is used where muscles have contributed to the problem
• Fillers, which are preferred when volume has been lost
• Thermage, which addresses loose or sagging skin

Although TotalFX is preferred to address deep wrinkles as a stand-alone procedure, we often combine it with any number of the above treatments to achieve optimal results.

Regardless of the specific treatment utilized, any effective anti-aging strategy must address each of the "Three Ds of Aging":

1. Deterioration - damaged skin (TotalFX, ActiveFX, DeepFX, microdermabrasion, chemical peels)
2. Descent - sagging skin (Thermage, TotalFX, facelift, mini lift, threadlift)
3. Deflation - sunken youthful contours (fat transfer, Restylane, Juvederm, etc . . .)

A comprehensive treatment plan that addresses each of the "Three Ds of Aging" will achieve longer-lasting and better-looking results than a treatment that merely attacks the "deep wrinkles."