Enhancing your appearance with skin rejuvenation and resurfacing

Skin rejuvenation is a treatment to resurface your skin, or to improve the texture, clarity and overall appearance of your skin. Skin resurfacing procedures can produce a marked improvement in skin conditions and your overall appearance.
The technologies and treatments available are advancing rapidly and you may be surprised at the improvement that can be achieved by relatively simple procedures.

Conditions that can be treated include:

• Static wrinkles: These wrinkles are visible at all times and do not change in appearance with facial movements.
• Dynamic wrinkles: These are expression lines that may appear as folds when the skin is not moving, and deepen with facial movements or expressions.
• Pigmentation: Freckles, sunspots, melasma, or other darkened patches of skin result mainly from sun exposure.
• Scars: As the result of acne or injury to the skin, scars may be rolling (a wavy appearance to the skin), pitted, discolored, or have raised borders.
• Vascular conditions: Blood vessels visible on the surface of the skin, vascular lesions that appear as tiny blood filled blisters or even a constant flush of facial redness.
• Loss of skin tone: Weakening of the supportive skin structure (collagen and elastin fibers) that results in a loss of skin firmness, or the development of cellulite.

What are the different types of facial resurfacing?
Facial resurfacing, or peels, can be separated into three categories:

• Chemical Peels
• Dermabrasion, or sanding
• Laser Resurfacing

Dr. Alexander performs all three procedures, selecting one or a combination of procedures to suit the individual patient and the problem. What these three techniques share is the ability to remove a shallow layer of skin. Once the skin heals, it is smoother and more even. The result is a smoother, clearer and more youthful appearance to your skin.

Effective chemical peels have been around for over a hundred years. Chemical peels use a chemical solution to improve and smooth the texture of the facial skin by removing its damaged outer layers. It is helpful for individuals with facial blemishes, wrinkles and uneven skin pigmentation. Phenol, trichloroacetic acid (TCA) and alphahydroxy acids (AHAs) are used for this purpose. The precise formula used may be adjusted to meet each patient's needs.

Although chemical peels may be performed in conjunction with a facelift, it is not a substitute for such surgery, nor will it prevent or slow the aging process.

Alphahydroxy acids (AHAs), such as glycolic, lactic, or fruit acids are the mildest of the peel formulas and produce light peels. These types of peels can provide smoother, brighter-looking skin for people who can't spare the time to recover from a phenol or TCA peel. AHA peels may be used to treat fine wrinkling, areas of dryness, uneven pigmentation and acne. Various concentrations of an AHA may be applied weekly or at longer intervals to obtain the best result. These peels can be safely performed on the neck, chest, and hands.

AHA peels may cause stinging, redness, irritation and crusting. However, as the skin adjusts to the treatment regimen, these problems will subside.

Uses:

• Smooths rough, dry skin
• Improves texture of sun-damaged skin
• Aids in control of acne
• Can be mixed with bleaching agent to correct pigment problems
• Can be used as TCA pre-treatment

Considerations:

• A series of peels may be needed
• As with most peel treatments, sunblock use is recommended

Trichloroacetic acid (TCA) can be used in many concentrations, but it is most commonly used for medium-depth peeling. Fine surface wrinkles, superficial blemishes and pigment problems are commonly treated with TCA. The results of TCA peel are usually less dramatic than and not as long-lasting as those of a phenol peel. In fact, more than one TCA peel may be needed to achieve the desired result. The recovery from a TCA peel is usually shorter than with a phenol peel.

With a TCA peel, your healed skin will be able to produce pigment as always; the peel will not bleach the skin. However, TCA-peel patients are advised to avoid sun exposure for several months after treatment to protect the newly formed layers of skin. Even though TCA is considered by most doctors to be milder than phenol, it may also produce some unintended color changes in the skin, and has been associated with scarring.

Uses:

• Smooths out fine surface wrinkles
• Removes superficial blemishes
• Corrects pigment problems

Considerations:

• Can be used on neck or other body areas
• May require pre-treatment with Retin-A or AHA creams
• Treatment takes only 10-15 minutes
• Preferred for darker-skinned patients
• Peel depth can be adjusted
• Healing is usually quick, much quicker than with a phenol peel
• Repeat treatment may be needed to maintain results
• Sunblock must be used for several months

Phenol is the strongest of the chemical solutions and produces a deep peel. However, the depth can be controlled by the concentration, making it possible to perform light, medium, and deep peels. An important ingredient in the phenol solution is croton oil, and it is the concentration of this component that determines how powerful the solution is.

It is used mainly to treat patients with coarse facial wrinkles, areas of blotchy or damaged skin caused by sun exposure, or pre-cancerous growths. Since very deep phenol peels sometimes lighten the treated areas, your skin pigmentation may be a determining factor as to whether or not this is an appropriate treatment for you. Phenol is primarily used on the face. However, light phenol can be used on the neck and chest if performed with experience.

Uses:

• Corrects blotches caused by: sun exposure, birth-control pills, aging
• Smooths out coarse wrinkles
• Removes pre-cancerous growths

Considerations:

• Used on the face only, unless croton oil is removed from solution
• Not recommended for dark-skinned individuals
• Procedure may pose risk for patients with heart problems
• Full-face treatment may take one hour
• Recovery may be slow - Complete healing may take several months
• May permanently remove facial freckles
• Permanent skin lightening and lines of demarcation may occur
• Sun protection, including sunblock, should be used
• Results are dramatic and long-lasting

Dermabrasion has been performed for many decades, and helps to "refinish" the skin's top layers through a method of controlled surgical scraping. The treatments soften the sharp edges of surface irregularities, giving the skin a smoother appearance.

Dermabrasion is most often used to improve the look of facial skin left scarred by accidents or previous surgery, or to smooth out fine facial wrinkles, such as those around the mouth. It is commonly used to treat deep acne scars. It can be performed on small areas of skin or on the entire face. Dermabrasion can be done alone, or in conjunction with other procedures such as facelift, scar removal or revision, or chemical peel.

Men and women of all ages, from young people to older adults, can benefit from dermabrasion. Important factors are your skin type, coloring, and medical history. For example, black skin, Asian skin, and other dark complexions may become permanently discolored or blotchy after a skin-refinishing treatment. In addition, dermabrasion can’t be performed during the active stages of acne because of a greater risk of infection. The same may be true if you've had radiation treatments, a bad skin burn, or a previous chemical peel.

Laser resurfacing, developed in the mid 90s, continues to evolve. New technological developments arrive on a regular basis, but not every new technology can deliver what the manufacturers promise.

Laser resurfacing can improve the appearance of fine lines and wrinkles of the entire face, or those that develop in specific regions of the face, such as the upper lip and around the eyes. Several lasers can be used, all of which precisely remove the top layer of skin, allowing a new, smooth layer to heal and resurface the skin.

CO2 (Carbon Dioxide) Laser (1st Generation)
This is an effective laser that is still in use. It is considered “hotter” than newer lasers. Deep peels performed with this laser were found to leave sharp lines of demarcation along the jaw line, making it obvious where the treatment had been stopped. This problem does not tend to appear until approximately 18 months after the procedure. We do not use this laser in our practice.

Erbium Laser (2nd Generation)
The Erbium Laser also removes the top layer of skin but is "cooler" then the CO2 laser. This prevents the problems with light hypopigmentation associated with the CO2 laser. However, because this laser is "cooler," there is more pinpoint bleeding with treatment. This bleeding prevents the surgeon from treating deeper wrinkles because the bleeding impedes the laser energy. We do not use this laser in our practice.

Dual Mode Erbium Laser ((3rd Generation)
This laser actually has two separate Erbium lasers. The first laser works exactly like the Erbium laser described above. This allows resurfacing to be performed in a conservative manner to provide quick healing. The second laser has been modified so that even though it uses a cooler laser, the length of time that the laser energy remains on the skin has been increased, helping coagulate pinpoint bleeding. This simulates the effect of the CO2 laser without the pigmentation complications. Each of the two lasers can be adjusted so they can be used individually or simultaneously to provide the desired result. It is highly versatile. This is the only resurfacing laser we currently use in our practice.

Fraxel®
This is a fractionated laser which uses the same technology as the resurfacing lasers described above. However, the software has been changed so that the energy delivered to the face is different.

With resurfacing lasers described above, energy is delivered to the face at a very shallow depth but over the entire face, thus creating a shallow burn wound. The Fraxel® laser delivers the energy in small pinpoints but at a deeper depth. This allows the laser energy to be delivered deep into the skin without creating an open wound.

The Fraxel® is also highly versatile. When it is set to deliver energy at a shallow depth with very scattered patterns, healing is extremely quick. However, long-term results can be disappointing. When the settings are deeper and the pattern is tighter, results are much more effective but healing times can be similar to conventional resurfacing. In general, as with other peels, long-term results are highly correlated to the amount of downtime required. Regardless of the treatment type, if healing is extremely rapid then long-term results may not be satisfactory.

Fraxel® laser is effective in treating the skin of the neck, chest, and hands.

Non-invasive (non-ablative) Lasers and Light Treatments
Fotofacial® Rejuvenation (IPL)
Breakthrough laser technology uses Intense Pulse Light (IPL) to correct a variety of skin imperfections and signs of aging, including brown spots, broken capillaries, blemishes and fine lines, all with minimal downtime. This procedure is performed by our Physician Assistant in our Medical Spa.

There are several important factors to choosing a surgeon, including recommendations from friends, personality, physician training and board certification, and experience. Based on his extensive experience in these procedures, Dr. Alexander II was selected to author Facial Resurfacing in Plastic Surgery, an 8-volume textbook considered to be a primary source of plastic surgery information for practicing and training surgeons.

Referral from Friends: Many prospective patients find confidence if they have a close friend or other trusted individual who has already undergone a successful procedure. This is often a good first step in making a decision. However, not all patients know someone who has had surgery. Most of our new patients are referred by their friends who are satisfied patients.

Personality: It is important to develop a good relationship with a surgeon, where communication is easy and trust can be developed. A patient needs to completely comfortable and intuitively conclude that they are in good hands. Bedside manner is important in creating a trusting relationship.

Training and Certification: In years past, only plastic surgeons performed cosmetic surgery. However, in recent years doctors from many different specialties are more commonly performing cosmetic surgery procedures, including Ear, Nose, and Throat doctors (also known as otolaryngologists and facial plastic surgeons), Dermatologists, Ophthalmologists, and Gynecologists. Only a surgeon who has completed residency training in an accredited training program can become certified by the American Board of Plastic Surgery. There are many Boards, and it is easy for patients to become confused, or assume that when a doctor says they are “Board Certified” it all means the same thing. BE CAREFUL! Learn more about the significance of Board Certification here.

Experience: Finally, consider the physician's experience, the most important factor in making a decision. As with all professions, expertise is directly proportional to experience, meaning the total number of procedures performed. Medical literature illustrates that biggest predictor of success in surgery is volume, in other words, the number of times that a doctor has performed a procedure.

If the doctor is recommending a specific procedure, how many has he performed? How often does the surgeon perform this procedure?

While board certifications and training are important, a surgeon's experience with the procedure itself is more important. Don't hesitate to ask pointed questions about recommended procedures.

Are You a Candidate for Facial Resurfacing?
We believe that most patients are pretty satisfied with how they look, they’re just not happy with the changes of age. Patients don’t want to look different, or changed, just fresher and younger. Most just want to turn back the clock several years. Many patients comment that they look older than they feel, but are wary of cosmetic surgery, especially if they've seen poor outcomes in others. When patients are considering a peel we often hear, “I don’t want to have white, waxy unnatural looking skin.” An experienced surgeon can prevent these types of problems.

If you have surface changes of the skin, such as wrinkles or pigment changes, that are making you look older, you might be a good candidate for facial resurfacing or a facial peel. While not as involved as surgical cosmetic procedures, skin rejuvenation is a medical procedure. Even though it is less invasive, some resurfacing and peels can require a longer recovery time than surgery.

Skin rejuvenation is an option for you if:

• You are physically healthy
• You don't smoke
• You are not taking Accutane®, or have not taken it within the last 6 months
• You have a positive outlook and specific, but realistic goals in mind for the improvement of your appearance.

To ensure the most natural looking results, it's imperative for a surgeon to recommend the procedure that most appropriately matches your needs and to offer realistic expectations for post-surgery outcomes. When you meet with a surgeon, you should expect a full discussion of the surgically appropriate options for your face, which is uniquely yours.

A good surgeon goes through a series of examinations and observations that are individual and dependent upon your specific situation and goals, but also factor in the surgeon's expertise, training and experience. If a cosmetic surgeon does not offer all types of facial plastic surgery, it may be that they are not a plastic surgeon. For example, if the “cosmetic surgeon” is a dermatologist who does not perform facelifts, he may be inclined to recommend resurfacing when a surgical procedure is more appropriate. Be wary of the “one-size-fits-all” approach.

This is particularly important because as medicine has advanced, patients have more options available. The availability and affordability of options in facial rejuvenation has made it possible for more patients to benefit from these advances.

How is it determined which technique to use?
The procedure is selected based on:

• skin type
• skin problem
• area to be treated
• whether or not other surgical procedures are being done
• anesthesia preferences
• available down time

Often, more than one of the three techniques will be equally successful in solving your problem.

Dermabrasion, while effective, causes the most discomfort and has been widely replaced by chemical peels and laser resurfacing. Dermabrasion is done to smooth scars, deep lines on the tip of the nose, and irregular acne scarring. This technique requires a great deal of experience.

Chemical peels can be done with many different types and strengths of solutions. Chemical peels are considered the “gold standard” for facial resurfacing, because of their ability to smooth the deepest wrinkles and permanently lighten brown spots, especially those associated with pregnancy. When lasers became available, chemical peels were temporarily abandoned because they had been associated with permanent hypopigmentation, or lightening of the skin, especially in patients with darker skin. New formulations allow us to achieve exceptional results without pigment problems, even in patients with darker complexions. This procedure also requires a great deal of experience by the surgeon.

Laser resurfacing is also very effective at reducing wrinkles. This procedure is performed by using a high tech laser. Settings control the depth of the treatment. Surgical experience is essential, but the laser technology lessens the need for experience.

The success of your procedure depends very much on your complete candidness during your consultation. We will ask you questions about your health, desires and lifestyle.

Be prepared to discuss:

• Why you want the procedure, your expectations and desired outcome
• The options available to you for facial rejuvenation
• Medical conditions, drug allergies and medical treatments
• Use of current medications, vitamins, herbal supplements, alcohol, tobacco and drugs
• Past cosmetic treatments

We may also:

• Evaluate your general health status and any pre-existing health conditions or risk factors
• Discuss the options available to you for facial rejuvenation
• Examine your face
• Take digital photographs for computer imaging
• Discuss likely outcomes of a skin rejuvenation and any risks or potential complications
• Discuss the anesthesia options available

Other procedures can further enhance the outcome of facial resurfacing. They include:

• Soft tissue augmentation to recontour the facial structure
• Fat transfers to fill lines or plump up soft tissue
• Wrinkle reduction by injection

Prior to surgery, we will have you:

• Begin taking preventive antibiotics (24 hours before) or adjust your current medications
• Possibly begin pretreatment with Retin-A and/or bleaching creams
• Stop smoking well in advance of surgery

During a Pre Operative appointment, usually 1-2 weeks before surgery, we will:

• Get lab testing or a medical evaluation
• Tell you what to do on the night before and morning of surgery
• Discuss the use of anesthesia during your procedure
• Explain post-operative care and follow-up, and what help you will need after the procedure

Anesthesia requirements vary depending on the procedure.

Chemical Peels:
No anesthesia (area burns until solution removed)
Topical anesthesia (cream to numb surface of skin)
Local anesthesia (area numbed up with injection)
IV sedation (medications through an IV)
General anesthesia (patient lightly sleeping)

Dermabrasion:
Local anesthesia (area numbed up with injection)
IV sedation (medications through an IV)
General anesthesia (patient lightly sleeping)

Laser Resurfacing:
Topical anesthesia (cream to numb surface of skin)
Local anesthesia (area numbed up with injection)
IV sedation (medications through an IV)
General anesthesia (patient lightly sleeping)

These procedures take between 5-60 minutes, depending on the technique and the number of areas being treated.

Step 1 – Marking
Areas to be treated are marked

Step 2 – Cleansing
The face is cleansed with ether, a liquid that thoroughly removes all dirt, facial oils, and makeup

Step 3 – Resurfacing
Chemical peel: The solution is applied to the skin with moist Q-tips. It is left on the skin for a few seconds until the skin looks white (“frosts”). The solution is then wiped off. With peels using a weaker solution (eg Glycolic AHA), the solution may be left in place several minutes.

Dermabrasion: We use a motorized drill with a fine wire brush to gently abrade, or sand, the skin. As the skin is sanded, it is easy to see when the rough or high areas have been lowered adequately to create a smooth surface.

Laser Resurfacing:

Step 4 – Dressing
Chemical peel: No dressing is needed.

Dermabrasion: A gauze dressing is applied that will dry and create a scab over the treated area.

Laser Resurfacing: A fine mesh dressing is applied, over which Vaseline is placed.

Pain
Pain from facial resurfacing is usually minimal. Dermabrasion causes the most discomfort. Patients usually experience heat or burning over the treated areas for the first 24 hours. Pain pills are provided, but are usually not required after a couple of days.

Important facts about the safety and risks of facial resurfacing
The decision to have a skin rejuvenation treatment is extremely personal and you’ll have to decide if the benefits will achieve your goals and if the risks and potential complications are acceptable.

We will explain in detail the risks associated with the procedure. You will be asked to sign consent forms to ensure that you fully understand the procedure you will undergo and any risks and potential complications.

The risks include:

• Infection
• Pigmentation irregularities
• Textural changes
• Skin surface irregularities
• Burns and scarring
• The need for additional treatments

Be sure to ask questions: It’s very important to ask your surgeon questions about your procedure. It’s natural to feel some anxiety, whether it’s excitement for your anticipated new look or a bit of preoperative stress. Don’t be shy about discussing these feelings with us.

When you go home

It is normal for the face to feel tight and for the skin to burn. If you experience shortness of breath, chest pains, or unusual heartbeats, call the office immediately.

You will be given specific instructions that includes:

• How to care for the peeled site
• Medications to apply or take orally to aid healing and reduce the potential for infection
• Specific concerns to look for at the surgical site or in overall health
• When to return to the office

We will see you the day after procedure, then on the 4th or 5th day check your progress. At one week you can resume normal activities. At two weeks you can begin light exercise, and at four weeks there are no restrictions.

Chemical peel: The skin will look fairly normal for 12 hours. If one area is treated, swelling can be minimal. If the entire face is treated, swelling can be significant for 24-48 hours. After the first 24 hours, the skin will begin to ooze serum. Patient should keep the skin coated with a thin layer of Vaseline or antibiotic ointment. It is safe to get the face completely wet in the shower. The face will look the worst at 3-5 days. At that point, the dead skin will begin to flake off, revealing new, soft, pink skin below. Once the skin is healed, no more ointment is required.

Dermabrasion: A gauze dressing is applied that will dry and create a scab over the treated area. Right after the procedure, your skin will be quite red and swollen, and eating and talking may be difficult. You'll probably feel some tingling, burning, or aching; any pain you feel can be controlled with medications. It is safe to get the face completely wet in the shower. The swelling will begin to subside in a few days to a week.

If you remember the scrapes you got when you fell down as a child, you'll have an idea of what to expect from this type of surgery. A scab or crust will form over the treated area as it begins to heal. This will fall off as a new layer of tight, pink skin forms underneath. Your face may itch as new skin starts to grow.

Laser Resurfacing: A fine mesh dressing is applied, over which Vaseline is placed. Patients should keep a light coat of Vaseline over the gauze at all times. Cold compresses can also be used and should be left in place for 10-15 minutes at a time, and when removed will lift off much of the dried yellow serum. It is safe to get the face completely wet in the shower. Once the skin is healed, the gauze can be removed. If the gauze falls off it can be replaced or left off. Ointment can be applied directly to the skin.

Getting Back to Normal

Your new skin will be a bit swollen, sensitive, and bright pink for a few weeks. During this time, you can begin gradually resuming your normal activities. You can expect to be back at work in about 10-14 days weeks. Redness gradually fades over several weeks to months, depending on the depth of the treatment. Makeup can be used to cover the redness once the skin is healed.

When your new skin is fully repigmented, the color should closely match the surrounding skin, making the procedure virtually undetectable.

A special note about sun exposure: Absolute sun protection is essential for the several months after any of these resurfacing treatments to prevent irregular pigmentation. Diligent sun protection for life will help to maintain your new, younger, smoother skin.

Be careful

Following your doctor's instructions regarding medications and other post-operative measures is key to a quick recovery. Herbal medications are available to reduce swelling, bruising, and to speed your recovery.

It is important that the skin is not subjected to excessive force, abrasion, or motion during the time of healing. Avoid wearing any clothing that must go over your head. We will give you specific instructions on how to care for yourself.

Resurfacing treatments can offer dramatic improvements in the surface of your skin, but it will take some time before you see the final results. A series of treatments may be required to achieve improvement in skin texture and clarity and a good skin care program is essential to maintain your results.

Following your treatment, whether skin resurfacing or rejuvenation, your skin will continue to age naturally and you may develop similar conditions to those that have been treated, or other skin conditions. Facial resurfacing doesn't stop the aging process, but turns back the clock on your face and age. Once healed, the face continues to age at a normal pace. If you look five years younger after resurfacing, it will take about five years or more for your face to age back to the preoperative condition.

It's natural to feel impatient about seeing the “new” you, but you'll need to be patient as your face heals from the procedure. The visible improvements appear as swelling subsides. Occasionally, wrinkles may temporarily appear deeper at about 4 weeks, because the swelling leaves the wrinkle sooner than the nearby skin.

After a few months pass it is not uncommon for patients to become so used to their new appearances that they barely notice the change. This is similar to when you get a new haircut and can't help but notice your reflection every time you pass a mirror. After a few months, your self-image resets, and you may not recall how drastic the change is until you happen upon an old photograph.

The same phenomenon occurs with facial rejuvenation, and is one of the main reasons we take “before” pictures. Patients quickly forget how they used to look! Wrinkles are usually not completely gone, but significantly reduced.

Continuing a Skin Care program can help maintain your result and help keep your skin young and healthy. We offer a complimentary facial after your procedure to introduce you to our Aesthetician, Leanne, and our Physician Assistant, Joanna, in our excellent Skin Care Clinic.

Life-long sun protection will help to maintain your rejuvenated appearance by minimizing photo-aging or sun damage. In addition, a healthy lifestyle will also help extend the results of your rejuvenated, more youthful appearance.

After your consult with Dr. Alexander, Julie, our patient coordinator, will provide you with a quote. Cost is always a consideration in elective surgery. We offer patient financing plans, so be sure to ask.

Costs include:

• Surgeon’s fee
• Operating Room and Supplies
• Prescriptions for medication
• Medical tests
• Anesthesia fees

• Anesthesia—General: The patient is asleep, requiring that the airway be protected, either by a standard breathing tube, or by a laryngeal mask (LMA), an inflatable mask that goes in the back of the throat but doesn’t go down the trachea. Through the airway, an anesthesiologist gives gases to put the patient asleep. Drugs may also be given through the iv.


• Anesthesia—Local: The surgical area is numbed up with an injection, but the patient is awake. Sometimes a patient will be given an oral medication, like Valium, to help with relaxation.


• Anesthesia— Sedation (Twilight): The patient is made sleepy with medications given through an iv. The level of sedation can be adjusted, from barely sleepy to very sleepy. Sometimes sedation is given by the surgeon, but most of the time it is administered by an M.D. Anesthesiologist.


• Ablative: Resurfacing treatments that remove the uppermost layers of the skin (epidermis and dermis) to varying degrees.


• Dynamic wrinkles: Expression lines that may appear as folds when the skin is not moving, and deepen with facial movements or expressions.


• Hypertrophic scar: a hyperactive, usually temporary scarring process that makes a scar raised and red, sometimes called a “baby keloid.” More common in patients with pigmented complexion and more common on the chest, trunk, and shoulders. Very uncommon on the face and neck.


• Laser and energy therapies: Ranging from ablative to non-ablative, these treatments use laser energy, light energy, radio waves, ultrasonic energy, or plasma energy to treat the skin.


• Loss of skin tone: Weakening of the supportive skin structure that results in a loss of skin firmness, or the development of cellulite.


• Mesolabial fold (marionette lines): The crease that extends from the corner of the mouth down the side of the chin.


• Nasolabial fold: The crease that extends from the side of the nose to the corner of the mouth.


• Non-ablative therapy: Treatments that do not remove any skin but rather penetrate the skin or treat the skin superficially (only on the surface).


• Pigmentation: Freckles, sun spots, melasma, or other darkened patches of skin result mainly from sun exposure.


• Scars As the result of acne or injury to the skin, scars may be rolling (a wavy appearance to the skin), pitted, discolored, or have raised borders.


• Static wrinkles: Wrinkles that are visible at all times.


• Tear trough: A groove below the lower eyelids extending from the nose across the upper cheek.


• Vascular conditions: Blood vessels visible on the surface of the skin, vascular lesions that appear as tiny blood filled blisters or even a constant flush of facial redness.