Skin Rejuvenation Tutorial


Our skin is the largest organ in the body, and unhealthy skin can make us appear older and unhealthier than we would want to look. Having great skin is not something that you do just once and then you are done with it. Unfortunately, our skin is in a constant state of renewal and therefore requires constant attention and care. This tutorial is divided into three major sections for your ease of understanding. The first section on intervention discusses how to reverse the aging process and existing sun damage with state-of-the-art technology. Prevention is the next phase so that after cleaning up 20 or 30 years of accumulated sun damage, you can then protect your investment. The most important treatment to limit ongoing aging is BOTOX ® (as well as sun and smoking avoidance). Finally, skin-care maintenance involves great daily skin care and ongoing lighter laser therapies


If you are relatively younger in your 20s and 30s without much accumulated sun damage, then you will most likely not need to read this section. This section on intervention is intended to help someone understand how to reverse the accumulated sun damage through state-of-the-art technologies with a variable amount of downtime.
Excessive exposure to the sun is the leading cause of skin aging and can lead to premature and profound aging, especially in fairer skinned individuals who do not have much melanin protection. Unfortunately, the appearance of one’s skin can be directly related to the amount of sun damage you received prior to the age of twenty even if you have not been in the sun since that time. Also, your overall risk of skin cancer is directly proportional to that early exposure.
If you already have fine to coarse wrinkles even without smiling or frowning, uneven texture and tone to the skin, and some skin laxity, then BOTOX ® and skin-care products may be insufficient to provide you with the optimal level of rejuvenation. Instead, the skin may need to undergo some kind of therapeutic intervention to remove the outer layer of sun damage to essentially “start over” again.

If you have a mild to moderate amount of existing sun damage to your skin and you only have limited downtime (1 to 3 days off from work or a weekend to recover), then PIXEL treatments may be ideal for you. The PIXEL does not remove the outer layer of skin. Instead, an Erbium laser beam is emitted that penetrates the skin down to the dermal layer (where collagen resides) to effect collagen remodeling.

A computer controls the emission of the Erbium laser and creates a precise grid of micropunctures through the skin that is barely perceptible to the human eye. These micropunctures create deep dermal rejuvenation that also improves the outer skin texture and tone. Although PIXEL therapy helps with uneven brown skin blotches as well, it does not successfully improve any red discolorations. (See below for information regarding photofacial and KTP laser for improvement in red discolorations and broken capillaries.)

PIXEL treatment requires a series of 3 to 7 sessions spaced 3 to 4 weeks apart to attain optimal results.
Rhytec Portrait plasma skin resurfacing requires about a week of downtime and provides profound rejuvenation for the individual with more significant sun damage to the skin. Plasma works entirely differently than laser and light devices. Using nitrogen gas that becomes excited, the old skin is rejuvenated by virtue of two processes: deep collagen remodeling that occurs over a period of weeks to months and removal of the old damaged outer skin layer.

The old “gold standard” that provided comparable rejuvenation to plasma resurfacing was the carbon-dioxide (CO2) laser. However the CO2 laser had many downsides. First of all, an individual was subjected to an extremely long and uncomfortable recovery time that could leave someone red for many months. Second, the thermal damage imparted by the CO2 laser left people progressively whiter over time so that you could often see a line of demarcation along the jawline where the laser treatment stopped. Further, the individual could often not go outside in the sun for fear of burning. Well, those days are over. Plasma resurfacing has a recovery much closer to a physician-strength peel of about a week but results that compare to the deeper CO2 laser. Moreover, you do not experience all of the downsides explained above for CO2 laser.

Photofacial treatments have truly come a long way today. However, many individuals have been disappointed with photofacial treatments because they were promised that a photofacial would improve texture and tone of the skin along with wrinkles. This is simply not the case. Photofacial treatments are intended to manage problems with color in the skin. Unlike other treatment methods, there really is no downtime. Using state-of-the-art Advanced Flourescence Technology, Dr. Lam is able to provide one of the best and safest methods of skin treatment. The KTP laser is a separate laser that Dr. Lam uses to treat broken blood vessels and rosacea without the bruising and recovery of the pulsed-dye laser.

Prevention: BOTOX ®

BOTOX ® is thought of as a luxury item just to make you look better before a major social or professional event or whenever you can splurge on this treatment. The many uses of BOTOX ® are discussed in the separate BOTOX ® Tutorial. However, in this Skin Rejuvenation Tutorial, we are focused entirely on the long-term benefits that BOTOX ® imparts to your skin.

The analogy of a shirt has been used in the BOTOX ® Tutorial and elsewhere on this website to explain the role of BOTOX ®. However, it is worth repeating again to explain the role that BOTOX ® has in long-term benefits for your skin as a preventative for wrinkles.

Your skin can be thought of as a shirt that you wear every day. If you continue to wear that shirt, you will also continue to create wrinkles and creases in it. That is what happens to your skin over time. Fine lines and wrinkles that may only be apparent when you smile or frown become progressively deeper etched in lines even when you do not move your face.

Taking your shirt and putting it on a hanger is like the effect that BOTOX ® has on your skin. Even though the creases and wrinkles are still there, over time the wrinkles continue to fade. At the very least, the wrinkles do not get worse over time if you keep the shirt hanging on the hanger. Early lines that are not so deep can actually begin to fade entirely away with consistent use of BOTOX ®.

The 42-year-old gentleman shown has been on consistent use of BOTOX ® for 2 years only without any further skin treatments and his lines have entirely faded away just from BOTOX ®

For deeper lines, the only way to get rid of them is to iron the shirt out. Ironing the shirt would by analogous to plasma or PIXEL treatments. However, after the shirt is ironed, if you wear the shirt again, you will begin to create new wrinkles. Therefore, even after interventional skin therapy, you must be maintained on BOTOX ® (like hanging the shirt on the hanger) to keep the lines from coming back over time. BOTOX ® is an essential element for prevention of skin aging.

As important, if not more so, is good skin hygiene, including proper diet, drinking plenty of water, rest, exercise, avoiding carcinogens like smoking, and even more important sun avoidance and wearing sun protection. Sun avoidance and sun protection tactics are discussed below in the following section.

Maintenance: Skin Care

Daily skin care with medical-grade skin care products is the cornerstone to a successful program of skin maintenance. If you have enough sun damage already to necessitate one of the interventional therapies described above, you should also consider extending that investment as long as possible with BOTOX ® as a preventative measure and good daily skin care as a maintenance regimen.


Cleansers are the first step toward healthy skin. Unfortunately, most individuals are accustomed to harsh, drying soaps that are counterproductive to good skin care, especially for the post-resurfaced skin. Traditional soaps are alkaline by nature and strip essential oils and protective lipids from the skin, leaving it dry and raw. The “antibacterial” soaps may be safely used on the body but are too astringent and alkaline on the more sensitive facial skin and furthermore unnecessary for proper cleaning. Abrasive components, like pumice, only serve to irritate the skin and may exacerbate conditions such as acne or otherwise sensitive skin. Unlike conventional soaps (pH 8-9), cleansers are pH balanced to the skin (pH 5.5) and maintain the acid mantle, which is particularly critical for oilier skin types. Alkaline soaps will excessively remove oil and stimulate increased oil production, leaving the skin even oilier.

Cleansers may be divided into two principal types: creamy and foaming. The former type is particularly suited for dry skin, as it maintains greater moisture than the foaming type. Creamy cleansers work well with the post-resurfaced skin or in older patients who tend to have more desiccated skin. In addition, creamy cleansers are better at removal of cosmetics than foaming cleansers. However, foaming cleansers offer the patient the visual appeal of lather like traditional soap products and may more effectively clean oilier skin than cream-based cleansers are capable.

Cleansers should really only be used once to twice daily. After the face is rinsed, a washcloth may be used to pat dry the skin. If the skin should require additional cleansing during the day, water alone will suffice unless an unusual amount of dirt or debris is accumulated.


Toners are designed to balance the pH (if an alkaline cleanser is used) and remove any residual debris (e.g., lingering make-up) after use of a cleanser. Toners that contain salicylic acid may benefit the acne-prone skin but may at times promote acne flare-up. However, quality, pH-balanced cleansers have effectively made toners in most cases superfluous. If a toner is used, one should avoid a product that contains alcohol or acetone, both of which are detrimental to the skin due to the caustic nature of these agents.


After any kind of cleansing (and/or toning) of the skin, no matter how gentle, the skin is left somewhat dehydrated and requires effective moisturization. Even oily skin that appears to need no moisturization benefits from a good moisturizer. In fact, a moisturizer will assist in keeping the oil production in check, especially after a cleanser has stripped some of the native oils away.

In general, moisturizers may be either water- or oil-based. The former is better for acne-prone or oily skin, whereas the latter is better designed for drier skin types. Combination skin (oily skin distributed along the central T zone of the face) should be treated with a water-based product. However, during the winter months when the air may be quite dry, then a water-based product may be used in combination with an oil-based product for areas that remain dry despite water-based moisturization.

A moisturizer should be used once in the morning and once at night. The morning moisturizer may contain an SPF (Sun Protection Factor), which is a critical element to healthy skin. The lip should also be protected with a moisturizing balm that contains an effective SPF. Prolonged, direct sun exposure, particularly between 10 am and 4 pm during the height of direct rays, should be avoided as much as possible. Sun protection may consist of a physical blocking agent, e.g., titanium dioxide or zinc oxide, or a chemical block, e.g., octyl methoxycinnamate. A combination of a physical and a chemical block will work together synergistically to achieve the best protection, while minimizing the chemical load that would be imparted by a pure chemical blocking agent. Generally speaking, an SPF 30 is optimal for indirect, daily sun exposure with only a nominal gain with higher SPF strengths. Beyond an SPF 30, the face may have a reaction to the product if used on a daily basis. Conversely, the body can tolerate much higher chemical and physical blocks than can the face. All patients that have undergone interventional skin resurfacing should avoid any product with a chemical block for the first 30 days to reduce the likelihood of irritation and dermatitis.

A different moisturizer should be used at night that contains no SPF but instead has a higher lipid content, which acts to nourish and replenish the skin. The skin undergoes its maximal replenishment during the nighttime hours of rest, and therefore nightly moisturization with proper lipid-based ingredients is critical to ensuring healthy skin. As part of any moisturizing program, the patient should drink plenty of water during the day. Water spray mists to the face add little benefit but may instead dry the skin further when evaporated.

In addition to a strict daily regimen of skin care, certain topical agents may serve a medicinal purpose to rejuvenate aging skin. The two types that will be discussed are alpha hydroxy acids and vitamin A derivatives.

Alpha hydroxy acids

Alpha hydroxy acids (AHA) are antioxidants that also act to reduce the signs of aging by gently peeling the outer part of the epidermis. Glycolic acid is a type of AHA derived from sugarcane, whereas lactic acid represents another AHA, which is a constituent of milk. AHAs may come packaged in high-end moisturizers or anti-aging creams, or alternatively as a separate product. Usually 8-12% AHA may act as an effective exfoliant and may be used up to twice daily after cleansing and before application of a moisturizer. Higher strengths of AHAs exist (70%) that act as a physician-strength chemical peel, which violates the full expanse of the epidermis. However, TCA peels may offer the physician more control and efficacy than these higher potency AHA solutions. AHAs are particularly useful for the younger face, which exhibits early signs of aging, or may be used as an alternative to the more irritating vitamin-A derivatives, e.g., tretinoin (Retin-A, Renova). Alternatively, AHAs may be used for a couple of months, as a transition before engaging in a full program of tretinoin in order to prime the skin and minimize unwanted irritation.

Vitamin-A Derivatives

Tretinoin, which is a vitamin-A derivative, comes in different forms, e.g., Retin-A, Retin-A Micro, and Renova. The effect that these agents have on ridding the face of the stigmata of aging is much more pronounced than that of AHAs. However, tretinoin products are quite harsh and drying on most types of skin. Actually, some red irritation is desired as an endpoint, which signals that the skin is responding appropriately to the product. Retin-A comes in different strengths (0.025%, 0.05%, 0.1%) with the latter two concentrations more suited to facial rejuvenation as well as different formulations (cream and gel) with the former better for facial rejuvenation and the latter appropriate for oily, acne-prone skin. Retin-A Micro reportedly offers a more sustained release of the active ingredient over the 24-hour period and may be used instead. Renova has had great success as an alternative to Retin-A and has been considered less irritating to the skin, as the creamier base relieves the drying effect engendered by the medicine.

The method of application is as critical to success as compliance and may considerably influence the level of compliance if done properly. We recommend that patients start slowly on tretinoin-based products, perhaps every third day and advancing to every other day and finally to every day as the skin tolerates it. Retin-A or Renova is applied only at night after the face is gently cleansed. At least 10 minutes (preferably 30 minutes) are allowed to transpire before application of the medicine because a moist skin may accelerate the absorption leading to undesired sensitivity. Only a pea size of the cream is placed on the index finger and equally distributed at four points on the face: the central forehead, each cheek, and the chin. Then this modest aliquot is spread evenly over those four quadrants. A night moisturizer may then be immediately applied. It is very important that you remain out of direct sunlight during use of the product, as it causes photosensitivity. Therefore, a good sunblock should always be used in conjunction with Retin-A or Renova. Also, you will only observe the benefit of the medicine after several weeks to months of consistent usage. Unfortunately, the beneficial effects may be erased if the product is discontinued. Rather than using the harsher medicinal products like Retin-A, gentler retinol-containing products can be used that impart less skin irritation and dryness.

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