When I looked closely at each treatment, it was clear that they all produce a controlled injury to the epidermis and dermis, which in turn stimulates collagen to remodel. This then produces a variable degree of change to the texture and firmness of the skin. The method of injury involved is the main difference between modalities, and there are really just a few basic techniques being used: chemical peels, lasers, light, radiofrequency, ultrasound, needling, and abrasion. I’ll explore each of them here, with a discussion of the most popular treatments. I’ve listed the average cost per treatment around the country, and a “worth-it rating” as determined by the users of RealSelf (www.realself.com). I’ve avoided any discussion of injectables including Botox® and Juvederm™, as these will be addressed in a future blog. In addition, I have not included topical treatments or spa treatments, such as microdermabrasion and laser hair removal. Just a note: I offer chemical peels, microneedling, dermabrasion, and Pellevé® in my office, so I’ve given my own observations about those items based on my experience. Comments about the other treatments are based on what the manufacturer and users of RealSelf have posted online.
A chemical solution is applied to the skin, removing the damaged outer layers. The depth of the peel is determined by the specific chemicals used, which may include phenol, trichloroacetic acid (TCA), or hydroxy acids (salicylic acid, glycolic acid, lactic acid, maleic acid), and by the number of layers applied. Chemical peels may be light, medium, or deep. Light peels produce a subtle difference, and do not require any downtime. Deep chemical peels produce dramatic results, but may require a recovery period of 10-14 days. Chemical peels are excellent for treating acne scars, age spots, fine lines and wrinkles, irregular skin pigmentation, and sun damaged skin. They are not well-suited for the treatment of deeper wrinkles and folds on the face, loose skin, broken capillaries, large pores, and deep scars. Satisfaction with a chemical peel is generally high. In my office, I perform both light and medium depth peels, and have been pleased with the results. The following are some of the most popular chemical peels:
- Salicylic acid: Salicylic acid is used in light chemical peels for the treatment of fine wrinkles and acne. It is also an excellent treatment for blemish-prone skin. During the peel, the chemical is applied to the skin for removal of the epidermis. During treatment, mild stinging only is experienced. The peel is neutralized, and sunscreen is applied. 4-6 treatments are typically necessary to see sustained results. Average cost is $125 and there’s a nice satisfaction rate: 100%!
- Cosmelan®: Cosmelan® is a light chemical peel which specifically targets issues with skin pigmentation, including melasma. The main ingredients include azelaic acid and kojic acid, which are natural skin brightening agents. Cosmelan®MD is a stronger peel which also uses hydroquinone. The manufacturer’s recommended protocol for Cosmelan® involves two in-office masks, one for the full face and then another “touch up” to address areas that still have pigmentation approximately 1 month after the first mask. $600, 88%.
- Jessner: This is a light to medium depth peel which contains salicylic acid, lactic acid, and resorcinol, an agent which is chemically similar to phenol. The primary indications for a Jessner peel include age spots, acne, hyperpigmentation, and freckles. Jessner peels may be applied prior to TCA peels for the treatment of acne scarring. The Jessner solution increases the penetration of TCA and can promote a more even peel. $125, 80%
- Blue Peel: The Obagi® Blue Peel is a medium depth chemical peel which uses TCA mixed with their patented blue base. The bluish tint will last approximately 24 hours, and most patients peel for 4-5 days. Blue Peels are often used to treat blemishes, facial lines, scars, uneven pigmentation, and acne. $675, 87%
- VI peel™: The VI peel™ is a medium depth peel which combines TCA, salicylic acid, retinoic acid, phenol, glycolic acid, and vitamin C. It is indicated for fine wrinkles, age spots, and uneven pigmentation. The peel is applied to the skin, and does not need to be neutralized. It is reportedly painless. Average cost is $275 with a satisfaction rate of 63%.
- Phenol peel: This is the deepest peel available. Phenol penetrates to the deep dermis, and is indicated for the treatment of deeper wrinkles and folds, significant sun damage, scars, and precancerous lesions. Patients require pretreatment with a retinol based cream or gel for 8 weeks. During the treatment, patients should be on a heart monitor, as this chemical can cause cardiac arrhythmias. Sedation is required given the level of pain associated with the peel. After the peel has been applied and neutralized, ointment and dressings are applied. You should expect to have significant peeling, crusting, redness, and discomfort for several days. You will be able to return to work after 10-14 days. Swelling is usually gone in 2 weeks, but the skin may remain red for 3 months. While the results are dramatic, this peel is not for every patient. Average cost is $2800, but the satisfaction rate is high: 88%.
Lasers have traditionally come in two varieties, ablative and non-ablative. Non-ablative lasers stimulate collagen growth and tighten skin by targeting the dermis, while ablative lasers will actually remove thin layers of the epidermis. A non-ablative laser will be associated with less pain and downtime, but may require several treatments to see sustained results. Ablative lasers are associated with more pain and downtime, but will produce more dramatic results. Fractional lasers attempt to bridge the gap between these two modalities, by working on both the epidermal and dermal layers of the skin and targeting the skin in tiny fractions at a time.
Although I don’t offer laser treatments in my practice and can’t comment personally on their efficacy (or the reason for the wide range in price), I thought it would be helpful to review some of the more popular ones on the market. As you can see, there are a lot of them. Keep in mind that some of names of the specific types of lasers have changed over time, and some have been discontinued entirely.
- Fraxel®: Everyone seems to have heard of or tried the Fraxel® laser, which uses fractional photothermolysis. It has both ablative and non-ablative modalities. The Fraxel® DUAL 1550/1927 is a non-ablative laser which combines their 1550 nm laser (previously called Fraxel® re:store) with a 1927 nm laser specifically designed to treat pigment issues including sun damage, freckles, and age spots. $1000, 72%
- Laser Genesis: Laser Genesis is another non-ablative laser which is used to improve skin texture and reduce pores while redness and fine wrinkles. The laser heats the upper dermis to stimulate the regrowth of collagen. $500, 55%
- ResurFX™: ResurFX™ is a fractional, non-ablative laser, commonly used to treat a variety of skin conditions, including acne and surgical scars, skin discoloration, periorbital wrinkles and stretch marks. Again, the tissue is heated in a controlled manner to stimulate the regrowth of collagen. $825, 67%
- Smooth Beam laser: The Smooth Beam laser another non-ablative laser used for the treatment of acne by heating and shrinking the oil glands while cooling and protecting the top layer of the skin. As the oil glands shrink, there is less oil production. Four treatments performed 3-4 weeks apart are recommended. There is mild discomfort associated with the procedure. $450, 57%
- Titan™: This is a non-ablative laser designed by Cutera® which creates heat in the dermis, thereby stimulating skin tightening and collagen growth. There is some swelling but apparently little to no downtime. $1525, 53%
- Fraxel®: Most laser aficionados have heard of the ablative version of the Fraxel® laser, the Fraxel® re:pair SST. This laser uses carbon dioxide (CO2) to vaporize microscopic columns of tissue deep within the skin to treat uneven skin tone and texture, deep frown lines and wrinkles, and skin redness. Patients typically require a topical anesthetic in addition to light sedation. 1-2 treatments are required, and there is a 2-3 day period of recovery. $1625, 72%
- CO2: This was one of the earliest ablative lasers to be developed for resurfacing of the skin. The outer layers of skin to reduce the appearance of deep lines and wrinkles. Topical anesthesia with or without sedation is generally required during the procedure. Expect at least 3-4 days of downtime. $2600, 78%
- Pixel®: This is a fractional, erbium laser which resurfaces the skin, helping to reduce the appearance of fine lines and wrinkles, smooth out acne scars, and improve the overall texture and appearance of the skin. There is mild discomfort during treatment, and redness of the skin for 24-48 hours. 3-5 treatments space 1-4 weeks apart are generally required for sustained results. $650, 70%
- Lumenis FX™: Active FX™ is a one-time procedure which targets fine lines and wrinkles, loose skin, and irregular skin tone. A high-energy laser treatment is applied in a fractionated pattern, leaving areas of untouched skin to promote faster healing. Redness is noticeable for the first day. Deep FX™ targets the deep dermis to produce immediate collagen contraction and long-term remodeling. When both are combined together, the procedure is sometimes referred to as Total FX™. $2075, 91%
- SmartXide DOT™: Another fractional CO2 laser which treats skin discoloration, sun damage, wrinkles, and acne scars, but which targets only small “dots” of skin. Treatments take 30 minutes to perform and are associated with a stinging sensation. Mild redness and swelling is noted for several days. $1400, 72%
- ProFractional™: ProFractional™ ablates narrow-diameter channels in the skin, covering a fraction of the total treatment area. This action initiates the body’s wound healing response, while leaving the surrounding tissue intact for rapid healing. Patients are reportedly more comfortable and note faster healing. It is used to improve skin tone, acne scars, and discoloration. $1075, 63%
- Pearl® and Pearl® Fractional: These ablative lasers can deliver energy in either a superficial or deep fashion for the improvement of brown discoloration, mild to moderate wrinkles, laxity of the eyelids, “smokers lines” on the upper lip, acne and surgical scars, and loose skin along the jawline. Topical anesthesia with or without light sedation is generally required. 1-2 treatments are recommended, and most patients need 4-5 days of downtime. $1450, 50%
- Halo™: Halo™ has been described as a hybrid fractional laser which delivers both ablative and non-ablative wavelengths. The benefit is ablative results with non-ablative downtime. There is an integrated cooling device which keeps patients more comfortable during treatment, but topical anesthetic is usually also administered as well. The amount of ablation applied will determine the length of discomfort and downtime, and quality of results. This device is indicated for the improvement of skin tone, texture, fine lines, and wrinkles. One or more treatments are needed depending upon your skin condition and goals. $1425, 90%
- MiXto: Here’s yet another CO2 fractional laser which treats sun damage, brown spots, skin laxity, and acne scars. Light sedation and topical anesthesia are generally recommended for the one hour treatment. Patients typically note redness and crusting on the face for three days. A single treatment only is required. $1950, 82%
- IPL: IPL, or intense pulsed light, uses a hand-held flashgun to deliver an intense, visible, broad-spectrum pulse of light. Because the light has a spectral range that targets and destroys specific structures and chromophores (such as the melanin in hair), it can be used for various indications include hair removal, skin pigmentation, sun damage, spider veins, and acne. $475, 70%.
- Photodynamic therapy: In photodynamic therapy, a photosensitizing drug is applied to the face, followed by blue light, red light, intense pulsed light, or pulsed dye laser. Patients typically note a burning sensation during treatment. Following treatment, the skin is very light sensitive for 48 hours until the medication has completely metabolized. Hats, scarves, thick sun block with zinc oxide and light avoidance are required to protect the skin during that time. Redness and mild peeling may occur over the first two to three days. The procedure is indicated for the treatment of premalignant lesions and acne. $475, 85%
Radiofrequency (RF) includes any of the electromagnetic wave frequencies that lie in the range extending from around 3 kHz to 300 GHz, which include those frequencies used for communications or radar signals. The goal is to heat the skin to at least 40°C for sustained period, which will induce the production of new collagen.
- Pellevé®: Pellevé® uses radiofrequency to heat the deep layers of the skin, stimulating the production of new collagen in the face, including the skin around the eyes. A series of three monthly treatments is recommended with yearly touch-ups for optimal results. The treatment is comfortable, and there is no downtime. I offer this treatment in the office for patients with mild facial wrinkles and laxity, and have been very pleased with the results. 82%, $750
- Thermage®: Thermage® is another radiofrequency skin therapy which aims to smooth and tighten sagging skin and reduce the appearance of wrinkles by stimulating collagen growth. Treatments take 45 minutes to perform, and there is no downtime. One treatment only is typically recommended. $2425, 38%
- ThermiTight™: ThermiTight™ is a “micro-invasive” procedure in which a small probe is inserted under the skin for the delivery of radio frequency energy to produce immediate shrinkage. Local anesthesia only is required and patients are able to return to normal activities within 24 hours. One treatment only is generally required. It’s primarily used to tighten sagging skin on the face, but it can also be used on the neck, abdomen, and thighs. $3100, 91%
- INFINI: INFINI is a high intensity focused radiofrequency device. Fractional RF is delivered by insulated gold-coated microneedles which are pressed against the skin, sending radiofrequency energy to multiple layers below the surface. It is indicated for the reduction of wrinkles, scarring, and sagging skin. $1525, 94%
- TriPollar Apollo: The Apollo is an RF device cleared by the FDA for treatment of facial wrinkles. It is also used for jaw line contouring, wrinkles and fine lines, and general toning and lifting of the face. A typical facial treatment takes about 30-45 minutes. The company recommends 4-6 treatments, with touch-ups every 3-6 months. $1200, 67%
- eMatrix: Marketed towards patients with darker skin, eMatrix is a “sublative” technique which delivers radiofrequency to the deep dermis by the use of multi-electrode pins. Acne scars, stretchmarks, and facial rejuvenation are targeted in a series of three treatments spaced 4-6 weeks apart. $1275, 75%
- Venus Viva™: Venus Viva™ is a non-invasive radiofrequency treatment which can be customized in intensity. It is indicated for the treatment of visible pores, acne scarring, fine lines, deep folds and wrinkles, irregular skin texture, and lax skin on the neck, jowls, and décolleté. Each treatment session lasts 15 minutes, and 1-4 treatments may be necessary. Patients have mild redness for 1-2 days, and are able to wear makeup the following day. A hand-held device sends energy below the surface of the skin, which heats the cells and stimulates the body’s natural collagen production. $950, 75%
- ReFirme™ is now known as Sublime: Sublime is a combined radiofrequency and laser device which stimulates the production of new collagen. It is indicated for the treatment of loose, sagging and wrinkled skin on the jowls, neck, cheeks, eyelids, and forehead. Redness and mild swelling may be noted for several hours. ReFirme’s rating was 52% with a cost of $525 per treatment.
Ultherapy®: Ultherapy® is the only ultrasound therapy cleared in the US for the non-invasive lifting of the eyebrows, neck, and submental region. It is also cleared for the treatment of lines and wrinkles on the décolletage. The procedure stimulates the production of collagen by delivering focused ultrasound energy to the dermis. Treatment of the face and neck takes one hour and is moderately uncomfortable. Results are seen in 2-3 months. Although I offered this treatment in my office for approximately 18 months, I was unfortunately underwhelmed by the results. For the level of pain involved as well as the high price, better treatments are available. $3500, 65%
The old-fashioned needle is still remarkably effective. A controlled injury is created with a number of micro-punctures, and collagen production is induced. It is effective in the treatment of fine lines, wrinkles, and scars.
- Dermaroller: The DermaRoller is a hand-held roller device in which tiny needles are rolled over the skin to create tiny punctures. The depth of injury is determined by the amount of pressure used. Mild pain is temporarily experienced, and redness may last for several hours. $125, 85%
- Microneedling: Microneedling is an advanced version of dermarolling. Rather than using a roller with variable penetration, microneedling uses a mechanical pen with sterile needles which enter the skin at a specific depth. Depths of up to 2 mm are used for the treatment of deep wrinkles and scars, while depths of 0.5 – 1.5 mm are used for cosmetic rejuvenation of the face. A topical anesthetic is applied to the face for 10-15 minutes, and treatments take only 10 minutes to perform. Mild redness lasting 2-4 hours is noted following treatment. I love microneedling, and have been very impressed by the results when treating not only scars and fine lines, but also uneven skin tone and enlarged pores. For deep wrinkles and scars, most patients will require 4-6 treatments about 4 weeks apart to see optimal results. For facial rejuvenation of fine lines, 2-3 initial treatments followed by an annual treatment are recommended. $500, 82%.
- Acupuncture: Cosmetic acupuncture is a natural skin rejuvenation technique which stimulates the body’s healing energies and increases circulation to reduce wrinkles, fine lines and folds. Tiny acupuncture needles are inserted in regions of the body to unblock one’s “qi”, or vital energy. Multiple sessions are administered over 1 to 2 hour periods. $700, 100%. Sign me up.
Dermabrasion is the process of surgically scraping the skin down to the dermis to help lessen the appearance of scars, wrinkles, and pigmentation. Patients do require at least topical anesthesia, and in some cases sedation, prior to treatment. Expect significant redness and oozing from the skin for 4-5 days. Although there is some downtime, it remains one of the most effective treatments for fine lines around the lips. I still perform dermabrasion, and find it to be very effective. $1075, 78%
In general, I would suggest considering a treatment only if the rating is at least 75-80%. It’s clear that most chemical peels have a good satisfaction rating, although downtime is variable depending upon the depth of the peel. Given the lower price point, I find that they are ideal for routine maintenance and refreshing of the skin. Lasers showed extremely variable ratings, with less enthusiasm by consumers for non-ablative lasers. The ablative and fractional lasers which really seem to stand out are those which require just 1-2 treatments to deliver results; Lumenis FX™ and Halo™ were the most popular with patients in terms of their satisfaction with results. Light therapy is best indicated for acne, and specific recommendations for treatment should be made by a qualified dermatologist. Some of the newer radiofrequency treatments are very promising. While I like the results with Pellevé°, I am impressed by what I’ve learned about some of the “micro-invasive” radiofrequency devices, especially ThermiTight™ and INFINI, which deliver energy in a focused manner by the use of small needles which penetrate the skin. The high satisfaction rating with both of these devices suggests that this may be the wave of the future. To my knowledge, there are limited ultrasound technologies available for non-invasive facial rejuvenation. As I mentioned above, my own experience with the use of ultrasound was disappointing. Needling is a great option given the minimal downtime and relatively low cost. Although I have no experience to date with cosmetic acupuncture, it seems worth exploring. Abrasion is another traditional but still effective treatment, and I often perform this in conjunction with surgical procedures when the patient is already under anesthesia. As with any procedure, be sure that you are under the care of an experience physician who is very familiar with the device being used. It also helps if you can speak to someone in the office, or another patient, who has had the same treatment. Be prepared for some downtime depending upon your treatment, and be patient when evaluating your results. Surgical results are immediate (which is why impatient people like me become surgeons), but non-surgical results take much longer to manifest and may require regular re-treatments. In addition, they will not be as dramatic as what you can expect from surgery, but in some cases, that’s ideal. If you can be realistic with your expectations and recovery, you will likely find something in a large family of non-invasive devices which will successfully rejuvenate your face.[:]