I have been considering laser treatment to get rid of a few lines around my mouth. My plastic surgeon would not recommend peeling, but described laser treatment as safe and gave me the name of a colleague who does it. But I would first like to read unbiased research about potential problems and the long term effects. H D, Dorset………

Laser treatment with a pulsed CO2 laser can be used for facial wrinkles, acne and scars. In theory it simply burns away the top layers of skin, and new, younger skin grows in its place. But laser treatment has many drawbacks, among which is the number of drugs and chemicals you will require in the course of the treatment.

In preparation, you need a topical solution of Retin-A or glycolic acid, sunscreen, moisturiser and a bleaching agent to suppress the production of melanin (to lower the risk of irregular skin coloration caused by the procedure).

The operation takes one to two hours. You will most likely be given a general anaesthetic (which carries its own risks). With the first pass of the laser, one layer of skin is vapourised. The number of subsequent passes depends on the depth of the wrinkles or skin damage and on the surgeon. Each pass shrinks and tightens the collagen in the underlying tissue (Arch Dermatol, 1996; 132: 395-402).

Afterwards, you will be given antibiotics, as your skin will leak fluid and is vulnerable to infection. According to one study, half the treated patients developed dermatitis, which lasted over two months (J Am Acad Derm, 1997; 37: 709-18). In this case, more topical ointments and medication are prescribed. You will also need pain killers.

Your skin will be pink for about three months, during which time you can wear a greenish base to hide the discoloration. Some patients experience permanently lightened skin; others experience darkening particularly after exposure to sunlight. For this reason laser treatment is usually recommended for those with a fair complexion.

Be cynical about the claim that lasers don’t damage the skin. The whole point is to damage, indeed obliterate, the outer layer of skin, and there is insufficient research on what the long term effects of this are. One review concludes that “isolated case reports and anecdotal stories suggest that the potential for scarring from deep thermal injury [treatment] remains significant” (Plast Reconstr Surg, 1997; 100: 1531-4). It also found that while more passes can smooth out wrinkles more effectively, it also increases the risk of scarring, with no evidence that the final outcome is significantly better.

Perhaps the most depressing part is that the effects may only last for a year or two.

Other conventional approaches to wrinkles are just as aggressive and unproven in the longer term. These include facial peels, dermabrasion, topical creams and even deadly poisons. Facial peels are actually chemical burns: a weak acid solution is used to burn the top layers of skin off. The chemical is usually an alpha hydroxy acid (AHA) or glycolic acid. Dermabrasion removes the outer layers with a rotating disc or wire brush.

A topical retinoid, tretinoin (Retin-A, Retinova), has shown some success. In one trial, 40 patients, randomised into either treatment or placebo groups, had cream applied to the face and forearms, and were monitored for 48 weeks. Those in the tretinoin group did experience a reduction in wrinkles and a softening of the skin. But dermatitis on the forearms, facial dryness, acne and peeling were all common side effects (Cleve Clin J Med, 1993; 60: 49-55). The results last only as long as the cream is used, and it is not understood exactly how the compound works (J Am Acad Dermatol, 1997; 36: S27-36; Drugs Ageing, 1995; 6: 479-96).

Some people are now using Botox injections to eliminate crow’s feet. Made from a diluted form of the botulism bacteria, Clostridium botulinum, the treatment is called “pretty poison” by the profession. It relaxes the muscles around the eyes, thus appearing to reduce wrinkles.

The potential complications are often overlooked. No one has researched its effects on the immune system. If the wrong muscle is injected, the patient will have a droopy eye for several months. The FDA has gone on record as being unhappy about this rather frivolous use of Botox (it is usually used to treat crossed eyes and facial tics), but have not banned its use for this purpose. The injections only last three to six months (Ann Plast Surg, 1997; 39: 447-53) and are costly.

The skin care regimen which surgeons recommend to keep your “new”, treated skin healthy is the kind of commonsense advice which would have maintained its health in the first place, such as not smoking and tanning excessively. They also recommend multi vitamins. Antioxidant supplements help eliminate toxins and synthesise collagen, and, to counter stress, the full range of B vitamins is a must.

An unhealthy lifestyle will be reflected in the condition of your skin, which means your skin will continue to age (perhaps even more quickly) after surgery. Unhealthy or prematurely ageing skin is often mirroring the body’s inefficiency in eliminating toxins and waste products. Address the source of the problem before you opt to treat it topically. Follow a diet that is high in whole grains, fresh fruits and vegetables. Herbs which help eliminate toxins include Oregon Grape root (Mahonia aquifolia), dandelion root (Taraxacum officinale), and burdock (Arctium lappa).

Many anti wrinkle creams advertise magic ingredients such as alpha hydroxy acids, glycolic, hydroxy caprylic or lactic acid, passion flower or citrus extract. These fruit acids irritate the skin, causing peeling (thus their use, in higher concentrations, in chemical peels) and slight puffiness. The “results” may actually be the damage done, with the puffy, inflamed skin appearing to have less wrinkles. The higher the AHA concentration, the greater the risk of allergic reactions with no long lasting benefit to the skin. In a recent consumer report, women found anti wrinkle creams most likely to cause skin irritation. The greatest benefit was attributed to straightforward moisturisers (Which?, January 1998: 20-23).

Avoid abrasive cleansers. The more you exfoliate, the more cell divisions occur in the lower skin layers. But the skin cannot divide indefinitely: it eventually reaches a point, known as the Hayflick limit, where it no longer responds. Then the skin cells become sluggish and inefficient. Rather, try regular, gentle facial massage with a simple moisturiser or facial oil. If the facial muscles are toned and relaxed the skin will also appear toned and relaxed.

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Written by What Doctors Don't Tell You

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