Dear Paula's Choice Research Team - Aging Skin or Wrinkles

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Category: Wrinkles/Aging Skin

Dear Paula's Choice Research Team,
I've noticed that I am getting some deep wrinkles on my chest, caused by sun damage, and my neck is also getting a little saggy. Are there products you can recommend for these two things? I will never be without sunblock again!

– Jodi, via the Paula's Choice Facebook page

Dear Jodi,
Hindsight really is 20/20, isn’t it? All of us here at Paula’s Choice with similar concerns know how you feel! Although we wish there were products to fix the sagging and deep wrinkles, in truth, these are areas where skin care has limitations. It’s not that good skin care doesn’t make a difference, it’s just that it never works quite as well as we hope.

Don’t be discouraged, though: Along with daily sun protection from a product rated SPF 25 or greater (and be sure to apply liberally), you can improve the deep wrinkles by using an AHA exfoliant and retinol treatment. Paula’s Choice Skin Revealing Body Lotion with 10% AHA is a good place to start, and you can follow with Neutrogena Healthy Skin Anti-Wrinkle Cream, Night.

You can also consider cosmetic corrective procedures, such as Fraxel, Ulthera, or Thermage, all of which are good options for treating the first signs of sagging; however, each of these can be painful if used on the neck, so be sure to ask your dermatologist to numb the areas prior to treatment. A cosmetic dermatologist can also use various lasers to improve the texture of sun-damaged skin on the chest, which also will soften the deeper wrinkles. It’s a combination of great skin care and cosmetic corrective procedures that will make the most beautiful difference.

One more comment: You do NOT need to research or spend money on special creams labeled specifically for the neck or for the chest. These “special” creams are nothing more than facial moisturizers designated for another part of the body. They cannot stop sagging, significantly firm skin, or plump deep wrinkles.


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Category: Wrinkles/Aging Skin

Dear Paula,
I am wondering what you think about Tria Anti-Aging Laser [Age-Defying Laser], which is FDA approved? I currently use your skin-care products in addition to tretinoin 0.025%. I am 42, on a tight budget, and looking for a little extra boost in anti-aging! Do you think it's worth the $500 splurge to obtain results at home that might be better than the results from tretinoin?

– Pamela

Dear Pamela,
Tria’s Age-Defying Laser, an at-home device that retails for $495, is what we believe will be a growing trend in the field of at-home facial rejuvenation products. Despite the high price, the technology behind this device is sound, and the results from consistent use are likely to be impressive for most people, making the investment worth it.

The question of whether or not this works better than tretinoin is difficult to answer, as there are no comparative studies. We suspect that most people who use tretinoin or higher-strength retinol products will want to keep doing so, and use an at-home device as part of a comprehensive anti-aging routine.

What about Tria’s Age-Defying Laser replacing the fractionated laser (such as Fraxel) treatments that a dermatologist offers? No question: The in-office procedure can produce better results from fewer treatments, but it costs more, too. The other point to keep in mind is that a doctor can customize and strengthen the treatment in a way that users of at-home devices cannot, which allows for more targeted results in much less time.

Which way to go? This is a decision you need to make based on how much time and money you’re willing to spend. At $495, the Tria Age-Defying Laser costs less than an in-office Fraxel treatment, but it requires a minimum of 12 weeks of treatments, five days per week. In contrast, you will likely love the results after only 2–3 brief Fraxel treatments, spaced 4–6 weeks apart. Personally, I’ve found Fraxel to be pretty remarkable (though it can be painful).

One more comment: The Tria Age-Defying Laser is “FDA cleared,” not “FDA approved.” What’s the difference? To get a “cleared” rating, Tria had to show that their device was “substantially equivalent” to a device or product already being marketed for the same use (and that device or product must have a demonstrated safety record). To gain “FDA approved” status, Tria would have to show that their specific device is safe and effective.

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Category: Wrinkles/Aging Skin

Dear Paula,
I’m a soon-to-be 58-year-old woman who has been blessed with great genes. My genes, combined with a lifetime avoiding sun exposure, have led to minimal wrinkles or other signs of sun damage.

Lately, however, menopause has caused some upsetting changes in my skin. I've noticed some loss of fat in the hollows of my cheeks and some changes in elasticity in that area as well.

Which of your great products would you recommend as "must haves" for me to start using?

I need to keep an eye on finances, but I’m very interested in finding some effective starter products. I really do view this as an important investment in myself.

– Carla

Dear Carla,
We're nearly the same age, so I absolutely empathize with the changes you’re seeing in your skin. Just when we think we've got this anti-aging thing under control with sunscreen, exfoliants, and the like, menopause and its resulting drop in estrogen levels throws our skin a major curveball.

I want to make one thing very clear: Skin care has limitations. Don't get me wrong—good skin care does a lot to prevent, reduce, and, in some cases, even eliminate many signs of aging—but the loss of facial volume and resulting sagging are two areas where skin care can only do so much on its own.

What’s needed? I know it's not exactly the budget-conscious option, but for impressive results, you'll want to see a cosmetic dermatologist for dermal fillers or non-invasive procedures like Thermage. These procedures can work great ... if they're done when the first signs of sagging are noticed. Dermal fillers (for example, Juvederm) can add lost volume to facial features to compensate for what’s happening underneath—areas where topical skin-care products cannot make a difference.

If cosmetic procedures are not for you, your skin-care starter regimen should include a gentle cleanser, an AHA or BHA exfoliant (go for BHA if you're struggling with breakouts or enlarged pores), daily sun protection, and an anti-aging moisturizer. Beyond this, you can consider an anti-aging serum or specialty treatment product to firm skin, fade brown spots, or treat other skin concerns.

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Category: Wrinkles/Aging Skin

Dear Paula,
I'd like to know how to treat the lines on and around my lips. Is there anything, other than injections, that I can do to reduce their appearance? Thank you for all the great advice that you give!

– Kimberly

Dear Kimberly,
Lines around the lips can be very stubborn. I've dealt with them myself for years; they're one of the reasons I am such a big fan of long-wearing matte lipsticks and anti-feather lip liners!

The cause of lines around the mouth is typically a combination of sun exposure and years of movement. When you think of all the things we use our mouths for–from talking, to eating, smiling, frowning, and other facial expressions–it's easy to see how this small area becomes overworked. And, if you smoke, you will absolutely see lines around the mouth–one more reason to kick that habit!

So what can you do about those lines? On the skin-care front, you can use an AHA or BHA exfoliant to smooth the skin's texture and soften the lines, and an anti-aging serum loaded with antioxidants and skin-repairing ingredients. Plus, it almost goes without saying, protecting this area with a sunscreen rated SPF 15 or greater is of critical importance. For a temporary smoothing effect, you malso might consider spackle-like wrinkle fillers, which you can pat on the lines to temporarily fill them. One of my favorites is Mary Kay TimeWise Age-Fighting Lip Primer.

Although the products mentioned above will help, skin care can make only so much of a difference on lines around the mouth. For the best results, you will need to see a cosmetic dermatologist for dermal fillers. Several years ago I had a semi-permanent filler (Artecoll, now known as Artefill) injected into the lines around my mouth. The results were great, and because the treatment is semi-permanent, they last much longer than fillers that contain hyaluronic acid.

Dermatologist-administered AHA or BHA peels can also help with lines around the mouth, but as I said, you'll see better, longer-lasting results with fillers.

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Category: Wrinkles/Aging Skin

Dear Paula,
Please give me some tips for eyelid care. I've always applied my regular moisturizer to my under eye area, but avoided the eyelids. Recently, when I noticed my eyelids were looking crepey, I tried applying moisturizer directly to my eyelids. The result was swollen eyelids, so I backed off. I tried it again with your Resist serum, thinking maybe I needed something lighter, but had the same result. Am I perhaps using too heavy an application, or the wrong technique? I just want to prevent further dryness and crepiness there.

-Paula

Hello Paula,
Always nice to hear from another Paula! And I understand your concern of skin on the eyelid looking crepey. Like most other parts of our face, the eyelids also change with age and sun damage. Let's talk about what you can do to help!

First, eyelid skin is among the thinnest skin on the body. This fact and its close proximity to the eye itself is why most skin-care products have a precautionary statement about avoiding "direct contact with eyes". The fact is, anything applied to the eyelid stands a good chance of migrating into the eye itself, which results in puffy, red, irritated eyes.

Swollen eyelids from skin-care products can be an issue for some people, yourself included. It's possible the skin on your eyelids is simply too sensitive for what you applied, or you may have blended the product toward (rather than away from) the tear duct, which guarantees the product will get into the eye itself.

Personally, I've found applying my Skin Perfecting 2% BHA Liquid to the eyelids helps a lot in smoothing crepey-looking skin; however, I don't recommend everyone try this because it definitely risks irritation. But, if you're curious, I apply it with a cotton swab, blending away from the tear duct, and I use only a tiny amount.

In your case, at least to combat the dryness, you can try applying a very thin layer of Aquaphor Healing Ointment at night, again being careful to blend away from the tear duct.

Going forward, be sure to protect this area with a gentle mineral-based sunscreen (active ingredients should be titanium dioxide and/or zinc oxide) and invest in a good pair of sunglasses to protect the eyelid skin from further sun (UV) damage, even when it's cloudy.

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Category: Wrinkles/Aging Skin

Dear Paula,
I am 65 years old, have never been a smoker, yet my skin is aging by forming wrinkles around the corner of my mouth and my chin. I have consulted several physicians about this issue, and have received recommendations ranging from CO2 laser resurfacing to Sculptra injections to a lower face-lift with fat implants. Has there been any treatment developed that is more or less effective to treat this area of trouble?? I take the usual precautions with skin care and sunscreen.

-Rita

Dear Rita,
Many women are concerned about lines in this area, so at least you know you're not alone. Dermatologists refer to the vertical lines that run from the corner of the mouth down to the chin as marionette lines, referring to marionette puppets and the "lines" on either side of the lower face that allow the puppeteer to control movement of the puppet's mouth.

Although a smoking habit can contribute to these lines and make them deeper (as can years of sun damage) the chief culprit is the gradual loss of fat that occurs in the lower half of the face as we age. As the fat pads in this area shrink they also begin to sag, creating grooves on either side of the mouth.

As mentioned, sun damage is also a factor and so is bone loss which can begin during menopause and continue into old age, especially if one has low calcium or osteoporosis. If you suspect either issue, consult your doctor.

The treatment advice you were given was good, but vastly different. I'd advise starting with a dermal filler such as Sculptra, Restylane, or Juvederm. If you're not happy with the results of those, you can consider Thermage which may get you some tightening to reduce sagging. A CO2 laser treatment or lower face-lift are options but not as targeted for these lines—and both have significant recovery times, not to mention the expense compared to dermal fillers.

Bottom line: Begin with the non-invasive procedures and go from there based on the results and your comfort level.

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Category: Wrinkles/Aging Skin

Dear Paula,
I'm 34 and am just starting to notice very fine lines and dryness around the eyes. I've been using Paula's Choice Resist Intensive Wrinkle Repair Retinol Serum and Paula's Choice Super Antioxidant Concentrate Serum alternating day and night. I used to use Estee Lauder Perfectionist Anti-Wrinkle Serum. How do I know the products I apply are working? Obviously fine lines and wrinkles won't be erased, and I can only hope that the texture of my skin should improve but how do I now these products are working and that my skin is being protected? I don't see or feel a difference when I apply or don't apply creams or products to my skin. I'm very frustrated.

-Natalie

Dear Natalie,
I understand why this is frustrating yet am also surprised that you're not feeling a difference after using serums with undeniably silky textures (this is true for the Estee Lauder serum, too). This may be because your skin was in better shape than you thought but it may also be because you're not applying enough each time—or perhaps you haven't been using the products long enough.

My other thought is sun protection. If you haven't made that a part of your daily routine (even on cloudy days) then that would explain why you're not seeing much of a difference. Any anti-aging routine needs sun protection to complete the anti-wrinkle, anti-dark spot, and anti-sagging picture. Skin care isn't as simple as one or two serums, though I, for one, wish it were!

Last, even though the Lauder and Paula's Choice serums you've been using are very good, you need to consider the other products you're using and what effects they're having on your skin. For example, do you use bar soap? What about a drying toner or moisturizer with fragrant ingredients? All of these can conspire to keep your skin from looking and feeling its best.

If you're being good about sun protection every day and know that the rest of the products in your routine are not making matters worse, it's possible that for whatever reason your skin isn't showing results from the serums you're using. The next step? Try others we recommend and see if you don't notice a difference.

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Category: Wrinkles/Aging Skin

Dear Paula,
Is there any help for the crepey skin under the eyes? Does Botox or lasers help this area? What about Renova? I moisturize this area but it doesn't really help much.

-Kimberly

Dear Kimberly,
Botox won't help in this area because crepey skin is about sun damage and a loss of elasticity, not muscle movement, which is what Botox acts on.

Laser treatments and dermal fillers can be helpful for this concern, and you may see some benefit from Renova, too—but ideally in-office procedures that encourage tightening will have the best results. Procedures to consider with a cosmetic dermatologist include Fraxel and Thermage, both of which can help smooth and tighten crepey skin around the eyes. These are best done at the first sign of crepey skin rather than waiting until skin appears very crepey.

Turning to skin care, of course daily sun protection is important because sun damage is a big reason why your skin becomes crepey over time. You don't need a special eye cream, and most of them lack sun protection so they're actually a bad idea to apply during daylight hours. Look for a gentle, mineral-based sunscreen to apply around the eyes. Many Paula's Choice customers love applying Resist Cellular Defense Daily Moisturizer SPF 25 around the eyes, because it won't sting and has a brightening effect.

You can also consider applying a BHA exfoliant around the eyes for some tightening. The effect won't be dramatic but since I've had Fraxel and begun doing this with my 2% BHA Liquid, I've noticed a difference (and so has my dermatologist)!

One more comment: Crepey skin around the eyes isn't about skin being dry, so moisturizer alone won't do much. If the skin around your eyes is dry, a crepey texture will be more pronounced, but treating crepey skin must involve more than just moisturizer.

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Category: Wrinkles/Aging Skin

Dear Paula,
As an aging baby boomer (I am 55) I have noticed increasing lines around the lips and eyes. I love your products, but have not seen any significant difference with improvement of the wrinkles on my face. Many advocate the use of coenzyme Q10, but this ingredient is not in any of your products. Can you help guide me in selecting any products specifically for use around eyes and lips (I use the Super Antioxidant Concentrate product you offer now).

Brenda, via email

Dear Brenda,
I can relate, we baby boomers don't want to age, and every line and wrinkle is a reminder that our youth is waning. What truly makes a difference is to not be seduced by claims that there is a miracle product or miracle ingredient that can change what you are seeing in the mirror. Cosmetic anti-aging or antiwrinkle products (no matter who is selling them or what claims are asserted) have serious limitations in terms of being able to improve the appearance of skin. Regrettably, and I mean that with the utmost sincerity, lines and wrinkles around the mouth and eyes cannot be eliminated with cosmetic products. Even the most well-formulated skin-care products (and I do believe mine fit in that category) will net only some visual improvement, especially in cases where the lines are more etched such as those that result from facial expressions. This is the primary reason why noninvasive medical corrective procedures such as Botox, dermal fillers, laser resurfacing, and chemical peels have become so popular—they do for wrinkles what cosmetic products cannot.

I don't know how long you've been using my products, but I sense that your expectations may not be realistic. Using well-formulated skin-care products over wrinkles won't make them go away. However, they will help the skin repair itself, reduce inflammation, restore a protective barrier, and, over time, can make wrinkles and lines less apparent. The results won't make you look 20, 30, or 40 again, but a skin-care routine that includes use of state-of-the-art products (including daily application of sunscreen rated SPF 15 or higher, an exfoliant such as AHAs or BHA, and a moisturizer filled with antioxidants) combined with occasional medical antiwrinkle procedures is the only way to create the results you are looking for.

Regarding coenzyme Q10, there are only a handful of studies showing it to have any effect on wrinkles (Sources: Biofactors, September 1999, pages 371-378, and Zeitschrift für Gerontologie und Geriatrie, April 1999, pages 83-88). However, neither of these studies was a double-blind or placebo-controlled trial, so there is no way to tell whether or not other formulations with different ingredients could net the same results. CoQ10 has received particular attention in the prevention and treatment of various forms of cardiovascular disease, strokes, immune system disorders, and hypertension. "CoQ10 supplements are readily absorbed by the body and no toxic effects have been reported for daily dosages as high as 300 mg though the safety of CoQ10 has not been established in pregnancy and lactation, so caution is advised here until more data becomes available" (Sources: International Journal of Alternative and Complementary Medicine, February 1998, pages 11-12, and www.naturaldatabase.com). Most likely coenzyme Q10's benefit for skin is as an antioxidant, but there are hundreds of potent antioxidants, and so far there is no reason to seek any one in particular.

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Category: Wrinkles/Aging Skin

Dear Paula,
How should I take care of my neck to reduce signs of aging? It seems a woman's neck often belies her true age-or makes her look much older than she really is. I don't want to just use my facial products on my neck because mine are mainly acne-related. I am 36 years old, and want to be proactive about this before my neck skin starts looking like a turkey's!

Gail, via email search

Dear Gail,

You're right! A woman's neck often gives away her true age, even if she has been fastidious about taking care of her facial skin. Aside from all the sun damage the neck gets (we tend to forget to use sunscreen there) the neck is in fairly constant motion (moving every time you turn your head, swallow, or speak), and such movement eventually generates deep lines, much as movement of the forehead can do. The simple answer is that skin anywhere on the body requires the same care as skin on the face. Well-formulated face products can do double duty on the neck and chest. It is rarely necessary to seek out special neck creams, because their ingredients rarely, if ever, differ from those of facial moisturizers, and frequently they aren't as well-formulated.

You are smart to be proactive about this now and a broad-spectrum sunscreen loaded with antioxidants is a must, and it should be applied daily, rain or shine. Several companies offer elegant sunscreen formulations that include sufficient UVA protection. The best of those include Clinique, Dove, Estee Lauder, Neutrogena, Olay, Paula's Choice, or SkinCeuticals. Look for one rated SPF 15 or greater. Beyond sunscreen, you can apply an antioxidant-rich moisturizer in the evening. Look for one in stable packaging (an opaque tube rather than a jar) that is also loaded with ingredients that mimic the structure of skin. All of the companies mentioned above offer such options. A prescription tretinoin product (such as Renova) can be useful for restoring the appearance of sun-damaged skin, but ask for the lowest active concentration because skin on the neck tends to be more sensitive. Don't forget that AHA and BHA peels may be performed on the neck, and discolorations may be treated with skin-lightening products containing 2% hydroquinone (higher concentrations are available by prescription only).

When gravity takes its toll and neck skin begins to sag, you can consider cosmetic surgery, including a neck lift, which serves to remove excess skin and fat while repositioning the platysma muscle. Liposuction is a less invasive but still an effective option to deal with the beginnings of a sagging neck or jaw line. However, with any luck and depending on the rate at which your skin ages and your diligence about using sunscreen, the genuine need for such procedures may be many years away.

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Category: Wrinkles/Aging Skin

Dear Paula,
I have read your books and happen to have a nearly photographic memory. I find myself reminding sales assistants at the cosmetics counters of the myths, fallacies, and unproven results of the products that they sell. I have found that there is always one sales assistant who will persist in stating that the product is going to give me, you, or anyone, perfect, wrinkle-free skin. I have an answer for all of the women out there who are annoyed by the hard sell that many cosmetics companies train their employees to use: (1) Ask the salesperson if they use the antiwrinkle product in question and (2) If they say "yes", they do use the product and they love the effects, ask them why they still have wrinkles! It's guaranteed they will have a wrinkle somewhere on their face.

I have not met a salesperson yet who will continue spouting untruths in the face of that question. You will find that they have no answer for you at all, and that they will go away in search of another customer who doesn't challenge them. You are then free to peruse and compare products (with your book and newsletter in hand) to your heart&s content, without having to listen to their sales pitches. I believe this approach also makes them think about what they say to customers.

Cathleen, via email search

Dear Cathleen,

If only all women were as assertive and informed as you! However, your game plan only works if the salesperson is over the age of 30, when wrinkles start becoming more noticeable. I also believe women aren't really hoping to get rid of all their wrinkles, but rather to improve or reduce the appearance of them. That expectation is what keeps women endlessly looking for and buying the next product claiming to "reduce" wrinkles. The salesperson may have wrinkles, but the sales pitch, or the consumer's underlying belief is, "Just think how much worse it would look if the product wasn't used at all." What might be even more direct is to ask: "What's the best product your line sells for getting rid of wrinkles?" When the salesperson indicates her recommendation you can say, "If that's the best one, why does the line sell all these other products making the same claim?" That could also end the sales pressure right there. I know this one used to work for me all the time when I needed to be left alone at the counters to shop.

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Category: Wrinkles/Aging Skin

Dear Paula,
I've just read about DMAE being an antiaging ingredient and a natural alternative to minor cosmetic surgery, [and] I wanted your opinion on this. I've just bought your books and love them. Since I'm an aesthetician, your facts are just what I've been looking for. Keep up the great work. You do us ladies a great service.

Ann, via e-mail search

Dear Ann,
It's not often that aestheticians compliment my work, so I want to thank you for your kind feedback. DMAE is known chemically as 2-dimethyl-amino-ethanol. DMAE has been known in Europe by the product name Deanol for over three decades. This supplement is popularly known for improving mental alertness, much like Gingko biloba and coenzyme Q10. However, the research about DMAE does not show the same positive results the other two supplements do for cognitive function.

As far as skin is concerned, there is almost no research associating topical application of DMAE with any improvement in skin. Theoretically, it may help protect the skin-cell membrane, but this has not been proven. There is one double-blind split-face study showing topical application of a 3% DMAE solution in comparison to the same solution without DMAE increased skin firmness (Source: Skin Research and Technology, August 2002, page 164). However, the study was done on only 30 subjects, the increase was modest at best, and it did not report whether or not the improvement lasted. Plus, one study is hardly proof positive this ingredient is the answer to your skin care woes.

For the brain, DMAE is similar to choline, which is thought to stimulate production of acetylcholine. Acetylcholine is a brain neurotransmitter, so it's easy to see how it could be associated with brain function. However, studies do not confirm that DMAE serves as a precursor to acetylcholine, and there is little evidence it has any positive impact on brain function.

Studies on DMAE go back to the 1950s. One double-blind, placebo-controlled trial performed with twenty-seven patients with severe Alzheimer's disease did not show any significant benefits (Fisman 1981). Another study on twenty-one patients with memory deficits was also discouraging, since no improvement was found in memory (Caffarra 1980). However, DMAE was found helpful in patients with age-related cognitive decline. This nutrient was given to fourteen older patients in a dosage of up to 600 mg three times a day for four weeks (Ferris 1977). Ten patients improved and four were unchanged. The patients on DMAE had reduced depression, less anxiety, and increased motivation, but they had no improvement in memory. The researchers say, "the results thus suggest that although DMAE may not improve memory, it may produce positive behavioral changes in some senile patients." But this is a stretch, given the incredibly small size of the study and the fact that it was never repeated.

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Category: Wrinkles/Aging Skin

Dear Paula,
Contrary to what some people would lead you to believe, the term "antioxidant," when used in reference to cosmetics does not mean anti-oxygen. In actuality, it means anti-oxidation, to prevent the oxidizing or degeneration (aging) of the skin. Some people would foolishly have you believe that oxygen and its effects on the skin are detrimental. Science has proven that oxygen and its components play a key role in many of the processes of life itself. Molecular oxygen, whether it is being inhaled or applied topically, is basic for overall health, beauty, and healthy looking skin.

Some folks would also lead you to believe that topically applied oxygen-infused products cannot be absorbed by the skin; once again ... incorrect. Cosmetic products that contain time-released oxygen can certainly be absorbed by the skin, and this would indeed explain their effectiveness. Apparently, some people need to study the facts and clinical tests that have been initiated worldwide by professional doctors, dermatologists, and scientists before they start spouting off negatively on this subject. It is apparent to us that some individuals, for whatever reason, cannot seem to wrap their limited intellect around the fact that there are oxygen products on the market today that really work in retarding the aging process.

Some sources are indicating that oxygen itself causes free-radical damage to the skin, but in actuality, the greatest negative effects are from ultraviolet light from the sun and environmental factors such as smog and cigarette smoke. This has also been proven and is completely factual. Anyone who openly admits that oxygen is a free-radical factor in damaging the skin need only go to the public library or surf the Internet to be properly enlightened on this subject. We can only look upon this feeble attempt to derail what has taken years properly to develop, as perhaps some disgruntled plastic surgeon whose business has been faltering.

Valerie Dumont, President of Cosmetic Manufacturers Inc.

Dear Valerie,
Your information about oxygen and free-radical damage does not match any of the research I've seen. Further, your letter did not include any studies supporting your contentions, so there is no way to evaluate how you reached your conclusions [nor have I received any since I sent this letter to Ms. Dumont in March of this year]. Insulting the intelligence of those who recognize the damage oxygen can cause, citing unnamed dermatologists, and referring to unidentified test results does not establish, confirm, prove, or change anything.

Without question, published research on free-radical damage, and the many scientists researching it, confirms that oxygen, along with other factors such as sunlight, pollution, enzyme actions, and hydrogen peroxide, does cause free-radical damage. Oxygen is necessary for life, but so are the processes causing free-radical damage. Many human and plant systems would not work without it. However, oxygen (and other oxidizing agents) left unchecked (without the balance of antioxidants) can be problematic for the body and skin. I can quote from endless sources proving the problematic nature of oxygen; but here are just a few for your consideration.

Reproductive BioMedicine Online, January-February 2003, pages 84-96: "...many aspects of early mammalian development, from fertilization through to differentiation of the principal organ systems, take place in vivo in a low oxygen environment. This may serve to protect the embryo from free radical damage, from exposure of early embryos to ambient oxygen concentrations..."

Mutation Research, December 2002, pages 111-119: "However, it is known that exposure to high concentrations of oxygen may lead to oxidative stress and cause cell and tissue damage. Oxygen toxicity and possible cancer-promoting effects of HBO [hyperbaric oxygen] therapy have been a matter of serious concern."

Journal of Biological Chemistry, November 2002, pages 42563-42571: "...O2 [oxygen] and H2O [water] damage cells in different ways."

Toxicology Letters, July 21, 2002, pages 203-210: "Increased oxygen concentrations can also lead to an increased production of reactive oxygen species (ROS). If antioxidant defenses are not completely efficient, ROS can cause cell injury including DNA damage."

The Reporter, Vanderbilt Medical Center, www.mc.vanderbilt.edu/reporter, February 7, 2003: "...oxygen is not as benign as many believe it is,' said Dr. L. Jackson Roberts II, professor of Pharmacology and Medicine... 'it [is] possible to study the oxygen-induced damage and to evaluate potential therapeutic interventions like antioxidants..."

Life Extension Magazine, September 1998: "Free radicals are highly reactive molecules produced in the body, often derived from oxygen, that carry an unpaired electron on their surface, making them prone to causing damage to other molecules they encounter. The ongoing, damaging effects of free radicals may be involved in aging and degenerative disease."

You can search the Internet and find information that concurs with yours, but none of it is cited or identified, or when the information is sourced, it dates back to the '70s, well before the extensive research on oxidative damage started taking place. Valerie, any current evidence supporting your notion that oxygen does not cause free-radical damage would have been helpful to validate your viewpoint, but I suspect the reason you didn't include any is because there is none to be found.

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Category: Wrinkles/Aging Skin

Dear Paula,
Your article on the Distinction by Leigh Valentine skin-care line deserves at the very least a reply. I first must admit that I have enjoyed your Web site and have loved reading your ingredient dictionary. You have gone to great lengths to educate women and for that you deserve a round of applause.

I would like this letter to convey to you that OneWorldLive (distributor of Leigh Valentine's products) has worked hard to build good faith, customer loyalty, and products with integrity. We work with one of the top labs in the country. They are world-renowned and mentioned on almost every page of the International Cosmetic Ingredient Dictionary and Handbook. They not only formulate the best version of ingredients, they are pioneers in research and have brought numerous "proprietary" ingredients to the cosmetic market.

In your article you stated "...the only thing Ms. Valentine's kit will lift is money from your wallet." While I am sure you were attempting to be clever, you were also implying something that is factually wrong. Please consider the following concerning our Non-Surgical Facelift Kit: Dr. Glen Gillis, a scientist at our lab, said "An enormous amount of time and research were put into the discovery of elastisome, specifically the way to blend and complex these particular herbs so that they can give the maximum benefits. Most cosmetic applications look for short-term results. Elastisome provides a cumulative effect, long term benefits so that the skin is more beautiful, with better structures, healthier and balanced."

An independent laboratory conducted the clinical studies on elastisome. These studies have solid scientific evidence to support our product's success. But I can assure you, we did not take the "clinicals" at face value. We did a photo study ourselves to see the results. I have enclosed photos of three women from this study. As you will see from the photos, this is a product that works on "wrinkles." The Mask is meant to be a temporary fix while Firmalift with elastisome gives the long-term reduction of wrinkles. These results will keep improving for up to six months and then results can be maintained with continued use.

The American Institute for Plastic Surgery's Dr. Peter Raphael, a well-respected plastic surgeon, said the following: "We always approach any product with some skepticism and I think the Non-Surgical Face Lift product is a tremendous product. If people use it on a regular basis they can see a nice improvement in the appearance of their skin and retard the future signs of aging."

One should not be so quick to "judge a book by its cover." You can take almost any popular brand and find a generic equivalent. The ingredient lists are usually identical. Would you then say the products are "identical"? The truth is, a generic rarely measures up to the original brand. I just don't believe that judging a product solely by its ingredient list is a very good or fair standard of evaluation. I do believe that most consumers are sophisticated enough to realize that you are oversimplifying the process.

You mention that our Skin Renewal Booster "...contains arnica, which should never be left on the skin for long periods of time (such as overnight)." It would be more accurate and fair if you stated that you have to consider the percentages when concluding anything about an ingredient. Our lab confirms that arnica is used widely in cosmetics at a low percentage and works with the rest of the formula to promote circulation. In contrast, when used in high concentrations it can be irritating to the skin. It is unfair to assign only "one" response to any ingredient you find in a list. You are totally unaware of the percentages that are used, or the lab's proven intention. All of our products do go through dermatological tests and are proven safe.

We back the complete Distinction line with our "money-back guarantee." Anyone not happy for any reason can receive a complete refund of the purchase price. Here at OneWorldLive we have solid science behind all of our products and stand behind them 100%. We have a great lab, clinicals, and support from the professional community. Our customers are our greatest advocates.

Cheryl Gunter, Director of Business Affairs, OneWorldLive

Dear Cheryl,
I appreciate your comments and concerns regarding my review of Distinction by Leigh Valentine. However, your letter and information do not alter the point of my review. You stated that your company works with "one of the top labs in the country" and that they are "mentioned on almost every page of the International Cosmetic Ingredient Dictionary and Handbook"; which lab is that? I own the last four editions of this book, and there are no ingredient manufacturers or labs listed "on nearly every page". However, even if that were the case, if this unnamed lab is as popular and reputable as you say, then they assuredly must be making products for lots of other companies and not just yours, so they must have a lot of other wonderful products out there.

I'm also not clear what you mean by "generic" equivalents. Is your company making an equivalent of someone else's product, or is everyone just copying your company and yours sets the standard? In actuality, there are few, if any, "generic" cosmetics. Most of the cosmetics industry is made up of companies like yours, selling products making redundant claims, with the possibility they may be using the same lab.

You mention that elastisome took some amount of time and research to create, but you provided none of that documentation. And exactly what is elastisome? It is not found in the International Cosmetic Ingredient Dictionary and Handbook, nor is there any published research or information on it, and it is not on your FDA-regulated ingredient listing. You mentioned independent laboratory studies, but provided none of that data. I can't tell you the number of letters I get from companies insisting they have "independent studies," and though I have requested copies of them I've never received one of them. These mystery studies are better-kept secrets than the U.S. Department of Defense could ever hope to achieve! [I still have not received any documentation from Ms. Gunter.]

The pictures and endorsements you sent are no different from those many cosmetics companies offer as proof of their claims. But pictures are too easily altered by lighting and computer photo-reprocessing. Plus there is no way to ascertain how the pictures you sent were achieved. Without the accompanying study, these are just pictures with no real meaning of what took place. (Was the study done double-blind? Was your product compared with a placebo? How was each side of the face treated? How and by whom were the pictures taken? What other assessment was obtained? And on and on.) Women attest to loving lots of different products, but that does not indicate product efficacy. After all, lots of women like tanning and think their skin looks great after days in the sun, but research clearly shows that this passion is really bad for skin.

In regard to arnica (or any ingredient that may have irritating or sensitizing properties), I have repeatedly written that because cosmetics companies do not have to reveal the amounts of the ingredients they use I can only go by what I know to be true of an ingredient, especially a particularly sensitizing one. Further, because cosmetic products are used repeatedly, day in and day out and often twice a day, even a small amount of a sensitizing ingredient can build up and cause problems.

One final point: The plastic surgeon you quote as saying that Distinction's Nonsurgical Face Lift is a tremendous product is beyond credibility. Suggesting that any product other than a sunscreen can ward off future signs of aging is nothing less than ludicrous and fairytale thinking (or maybe a paid endorsement). Incidentally, the American Institute for Plastic Surgery is not an accredited agency or organization of any kind, but merely the name of Dr. Raphael's business.

I do apologize for sounding strident or flippant in my review of Distinction by Leigh Valentine. The industry often gets to me and I tire of the endlessly shocking, frivolous, and unsubstantiated claims being made. Believe it or not, I did hold myself back. search

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Category: Wrinkles/Aging Skin

Dear Paula,
Have you found some new information about antioxidants that you haven't passed along? According to the latest edition of The Beauty Bible, you don't seem to think that they work or, at best, nothing has been proved. If antioxidants don't work, why have you brought out the Super Antioxidant Concentrate. There are antioxidants in the new formulation of your sunscreen as well.

The May/June 2002 newsletter included an excerpt from your book that stated, "Even if antioxidants did work on the skin to prevent free radical damage ..." (p. 3), which seems to imply that you don't believe that they do work.

On the surface it appears that you are writing one thing, but doing another. Can you please explain this inconsistency?

Christine, via email

Dear Christine,
In regard to my comment above, I was playing devil's advocate rather than making a contradictory statement that antioxidants do not work to prevent free-radical damage. I have not uncovered any new information pertaining to antioxidants, other than the abundance of existing research pointing to the anti-irritant and anti-inflammatory benefits of these topically applied ingredients. There are also a large number of studies showing antioxidants to be beneficial in helping skin heal, mitigating UV damage, and increasing collagen production.

However, I can understand how my comments about antioxidants may seem contradictory in regard to the antioxidant product I added to my line of skin-care products. Actually, there are antioxidants in almost all of my topical, leave-on products, and they've been there from the beginning. What I am really rallying about is that antioxidants are not the answer for wrinkles, nor do they make them disappear. They are also not a substitute for a well-formulated sunscreen, nor are they capable of stopping the skin from aging. Yet that is precisely how many companies whose products contain antioxidants present them—as antiaging miracles. Paula's Choice Super Antioxidant Concentrate makes no such fantastic claims. Rather, it simply hopes to minimize free-radical damage because of the levels and variety of antioxidants it contains.

Minimizing free-radical damage will not change one wrinkle (or lift or tighten the skin), but it can help the skin defend itself from the very things (free radicals) that cause it to become impaired and gradually break down. How much and exactly which antioxidants are needed to accomplish this task is still unclear, as is the issue of whether or not you could ever apply enough antioxidants to truly affect long-term skin damage. Still, I feel strongly that the topical application of antioxidants will likely turn out to be an extremely helpful step for maintaining healthy functioning of the skin, at least that's what the research points to.

Antioxidants have a significant place in skin care for all skin types. There is copious substantiated research showing that topically applied antioxidants have merit and are an important consideration when formulating or shopping for skin-care products, something I have done in my line and many other cosmetics companies are doing as well. In the latest edition of my book Don't Go to the Cosmetics Counter Without Me, one of the most notable changes was the way I rated moisturizers, toners, and other skin-care products. If they didn't contain an impressive assortment or concentration of antioxidants they did not receive a "happy face."

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Category: Wrinkles/Aging Skin

Dear Paula,
I have read your books and have changed my facial and hair-care routines with great results. I think you do a great service to people who are concerned about their skin and their hair. That said, why do you spend so much time telling people they can prevent wrinkles by avoiding the sun, but make no mention of avoiding cigarette smoke, which is probably just as damaging to skin (not to mention heart and lungs, of course!)? Anyone who is serious about keeping his or her skin healthy should not smoke! This is not a morality lecture-it is simply a fact.

Liz, via e-mail

Dear Liz,
You're right! I am remiss in not giving more attention to the impact of smoking on the skin! I will correct this from now on because it is absolutely true that smoking is, at the very least, equal to the sun in the direct damage it causes on the surface of the skin. Smoking is probably even more insidious than sun exposure when it comes to healthy skin. Not only does smoking literally suffocate the skin (reducing oxygen in the blood by replacing it with carbon monoxide) and cause serious free-radical damage, it also creates necrotic (dead) skin tissue that cannot be repaired. Even more unattractive is the breakdown of the elastic fibers of the skin (elastosis) which gives rise to yellow, irregularly thickened skin. (Journal of the American Academy of Dermatology, July 1999, "Cigarette Smoking-Associated Elastotic Changes in the Skin.")

Moreover, smoking causes a progressive cascade of damage internally (restricted blood flow, reduced capacity of the blood to take in oxygen, impairment to the body's immune system) that eventually shows up on the surface of skin, making it look haggard and dull. It also creates serious deep wrinkling around the lips and lip area.

While all of that can make skin look prematurely wrinkled and aged, smoking ends up being unattractive for many other reasons including the permeating smell of smoke on clothing, breath that smells like smoke, and yellow stains on hands, nails, and teeth. Smoking isn't pretty and it can be deadly.

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Category: Wrinkles/Aging Skin

Dear Paula,
During my local PBS [Public Broadcasting System] fund drive, they showcased dermatologist Nicholas Perricone's video and book on The Wrinkle Cure. The PBS host who interviewed Perricone during breaks said she had been using products containing his recommendations (she, apparently, had not been using HIS products before this) and she was amazed and thrilled with the results.

It has occurred to me that were this interview not on PBS, I would have thought it an infomercial. I have purchased every one of your books and just reread your opinion on vitamin C and that it does not live up to its reputation. In fact, you even mention Perricone and his book. I did purchase Cellex-C when it first came out and had to return it to the company because of the extreme burning of my skin.

Please advise me about your latest opinion on Perricone's claims of vitamin C as an anti-inflammatory, and thus using it on the face causes the sagging to firm up. I am in my late 50s and, much to my dismay, my face appears to have dropped an inch since menopause.

Judi, via e-mail

Dear Judi,
I actually don't know where to begin when discussing the nature of Perricone's work. In many ways this embodies some of the worst elements of what is taking place in the world of dermatology (starting with Dr. Murad of infomercial fame), namely using the cloak of medical expertise to promote the sale of skin-care products. The physician allure attributes medical connotations to products that end up not being different in any significant way from other skin-care products being sold from many lines without a doctor's endorsement.

In regard to vitamin C, while it's clear that it is a good anti-inflammatory, it is not the only, nor the best, one to use. What is even more significant is that there is no research showing that vitamin C (or any anti-inflammatory) makes skin stop sagging or lifts it up in any way. In Perricone's book The Wrinkle Cure, he more often than not refers to his own research or his own patients' experience as proof for what he states about a particular antiaging treatment (always his own products, by the way). That may sound convincing, but it's not anyone's definition of science.

Moreover, vitamin C is a substance that still suffers from stability issues. A study in Dermatologic Surgery, February 2001 (pages 137-142) states that "L-ascorbic acid must be formulated at pH levels less than 3.5 to enter the skin." That low a pH can cause skin irritation (which probably explains your irritation when you purchased Cellex-C). Similar conclusions about vitamin C were drawn in an article in the Journal of Pharmaceutical and Biomedical Analysis, March 1997 (pages 795-801), which explained that magnesium ascorbyl phosphate was more stable than ascorbic acid and ascorbyl palmitate, all of which are forms of vitamin C. I won't burden you with all the research on the issue, but this smattering may give you the idea.

It's interesting to note that even Perricone wavers on the issue of what is the "best" skin-care ingredient. His own line has an array of products with ingredients other than vitamin C. These range from tocotrienol (a potent form of vitamin E), to alpha lipoic acid, DMAE, olive oil polyphenols, and glycolic acid. If vitamin C was the best, why bother with these other ingredients? Vitamin C is also not a proprietary ingredient; it is available and used by many cosmetics companies. None of this means that vitamin C can't be helpful for skin, but it is not the miracle that Perricone or others make it out to be.

I too am disappointed that PBS has either inadvertently or blatantly put themselves in the infomercial business, but your letter and others I've received about Perricone's appearance have questioned their judgment on this one.

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Category: Wrinkles/Aging Skin

Dear Paula,
I've recently read that NouriCel, developed by Advanced Tissue Sciences, is the next best thing in the fight against wrinkles. The claims are that skin treated with NouriCel regenerates collagen five times faster than skin treated with Retin-A and that unlike Retin-A, NouriCel doesn't irritate skin but rather it heals skin. I trust your honest and thorough insight--What is the reality of this new cosmetic ingredient?

Erika, via e-mail

Dear Erika,
Any and all information about NouriCel being effective for wrinkles or building collagen is generated by Advanced Tissue Sciences, the company manufacturing and licensing the ingredient to cosmetics companies. The questions I've been receiving about NouriCel primarily correspond with the infomercial debut for a small line of products called RevitaCel, being marketed by Biozhem. RevitaCel contains the showcased ingredient NouriCel. You'll recognize this infomercial as you flip channels when you see actress Lindsay Wagner, who is the hired spokesperson for this line.

According to Advanced Tissue Science, NouriCel is a natural by-product of the company's patented process for engineering human tissue for burn treatment and wound repair. NouriCel is supposed to be a type of human growth factor. It is derived from a nutrient solution that is used to feed and grow engineered cells that ultimately become human tissue. NouriCel, in vitro, helps stimulate the tissue to produce collagen (source: www.advancedtissue.com).

Advanced Tissue Sciences has two studies they feel demonstrate the value of their new miracle ingredient. Of the two studies, one had 14 participants and the other 16. In the first study (not double-blind, peer-reviewed, nor published), 9 of the 14 participants had visible improvements and an average decrease in wrinkle depth of approximately 27% after using the product for 60 days. Their other study showed a 50 to 80% increase in collagen production. If those numbers sound impressive to you then it may be something for you to consider, but the protocol for this study is more fluff than science and hardly sweeping in scope. A more extensive study for NouriCel is reportedly due out shortly but the new study was conducted by SkinMedica, and they are hardly an objective or non-interested party, as they are already selling a product that contains NouriCel.

If NouriCel sounds interesting to you, you can buy RevitaCel Replenishing Complex with NouriCel ($39.99 for 4 ounces). Strangely enough, NouriCel is also available in a product sold by SkinMedica called TNS Recovery Complex ($130 for 0.5 ounce). SkinMedica is a self-styled professional line of products available only from physicians (but clearly their formulations are available from other sources). This sounds exactly like the story for the ingredient Kinetin, which is also an alleged miracle antiwrinkle ingredient. When Kinetin was first launched, in the product called Kinerase that is primarily sold by physicians, it retailed for over $70 for 1 ounce. It is now available from The Body Shop and Almay for less than $20 for 1 ounce.

Advanced Tissue Science is probably banking on the success of their new ingredient, as their company has had significant financial losses. According to Strategic Global Investors Newsletter, June 1, 2001, the company's NASDAQ-traded stock (ATIS) was selling at $3.85, down from a 52-week high of $6.75. That followed a delay in the FDA's approval for Advanced Tissue Science's wound covering made with human cells, called Dermagraft, the first of its kind (source: FDA Consumer Magazine, (July-August 1997). It goes without saying that as a cosmetic ingredient (not a drug) NouriCel is a far easier product to produce, since it doesn't have to overcome the same obstacles or require the costs needed to obtain FDA approval that Advanced Tissue Science's other products do.

For more information about RevitaCel from Biozhem call (800) 463-1952 or visit www.biozhem.com. For more information about SkinMedica call (877) 944-1412 or visit www.skinmedica.com.

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Category: Wrinkles/Aging Skin

Dear Paula,
Your bit about how face exercises don't work is totally wrong. You must be in cahoots with plastic surgeons that are doing everything possible to deny that God-given face muscles can be exercised in a manner that turns back time.

It is said that the only reason that face exercises haven't made it big (from a consumer standpoint) is because there's no money in it. The reason that they have been around for 100 years is because they do work. Nobody would invest time and energy into something that doesn't work!

I have been doing facial exercises for six years. I'm 43 and I still get carded when I go out for drinks with my same-aged friends. There are thousands of us out there - dig a little deeper, listen to your heart, and tell the truth. I plan on publishing my own book. And I will quote you. After you see what's in the book, you are going to feel a little embarrassed.

Chrystella, via e-mail

Dear Chrystella,
I have been accused of a lot of things but I have to admit, your letter just about takes the cake. According to you, I must have my non-exercised head screwed on wrong, and while that may well be the case, "being in cahoots" with plastic surgeons to further my anti-facial exercise cause for financial gain is ridiculous. You've got to be kidding. Think about it: what organization would be funding me and for what earthly reason? Talk about a conspiracy theory! I haven't made a dent in the cosmetics industry sales after all these years—they are growing by leaps and bounds as they do year after year selling more antiwrinkle creams than ever before despite my critical reviews. The few times I've commented on facial exercises couldn't possibly be enough to stop your miracle antiwrinkle treatment from gaining attention if it really worked. There have been facial exercise-themed infomercials and books galore dating back to the early 1900s - clearly, women are not eschewing this system because of me.

In terms of telling the truth, let me mention that your statement "Nobody would invest time and energy into something that doesn't work," is not realistic. Have you never heard of fad diets (the grapefruit diet comes to mind), get-rich-quick schemes (selling swamp land or credit card scams), exercise contraptions like the Abdominizer, cellulite creams, bust enhancing pills and creams, or fat-burning pills that purport to work without exercising (and our country has more obese people than any place else on earth) to name a few! Women also invest a great deal of time and energy into sun tanning, which is extremely dangerous for skin, and also spend billions of dollars on antiaging products, yet plastic surgeons still flourish. Investing time and energy in things that don't work is what the cosmetics industry counts on!

If exercising your facial muscles works for you I would be the last person to tell you not to do it, but there is no science behind it and the research that does exist indicates it is more of a problem than a help. Botox, in particular, demonstrates what happens to skin when you don't repeatedly use your facial muscles—it becomes smooth and flawless without a wrinkle anywhere to be seen.

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Category: Wrinkles/Aging Skin

Dear Paula,
I am writing in response to Charlotte, who was unhappy with deep microdermabrasion treatments she received (Cosmetics Counter Update, Vol. 7, Issue 2). As a board-certified dermatologist who has been performing and receiving microdermabrasion treatments since 1996, I am extremely sympathetic to Charlotte's plight, and agree with you that if a complication occurs in a given individual, then it is definitely a fallacy to deny that it exists.

The consumer press is full of articles about microdermabrasion that do not reflect the entire issue. I would like to clarify some of the murkier issues surrounding the procedure.

It is useful to distinguish between superficial and deep microdermabrasion procedures. Superficial microdermabrasion is the procedure which we commonly call microdermabrasion. It is the procedure performed at spas, as well as physician's offices by aesthetic, paramedical, and medical personnel alike. This involves superficial abrasion of the skin's surface (the nonliving skin cells that occupy the top 3 to 5 layers of skin only). This cell layer has no capillaries and [is] nonpigmented, hence its disruption causes no bleeding, crusting, or skin discoloration. It is known that skin takes on a dull or thick appearance and fine lines seem more apparent because the surface skin cells slough unevenly. Regular superficial microdermabrasion treatments with an appropriate system (I use the MegaPeel Gold series system) can even out and slough skin. It is believed, though histologic confirmation has been difficult to obtain, that the excess uneven skin surface magnifies skin irregularities such as wrinkles and scarring.

Deep microdermabrasion is performed only by physicians and involves disruption of part of or the entire epidermis. The skin cells of the epidermis have capillaries and varying degrees of melanin, therefore their disruption can cause bleeding, crusting, and skin discolorations, particularly in darker-skinned individuals. It was believed, when microdermabrasion technology was newer, that this deeper disruption of the skin, akin to traditional dermabrasion, causes dermal remodeling of collagen and should therefore reduce the appearance of acne scars, pits, and deeper wrinkles. Histologic confirmation of this has yet to be established and clinical correlation remains controversial (Cosmetic Dermatology, March 2001).

It seems that Charlotte suffered the known recovery issues associated with deeper microdermabrasion. It should be stressed that this treatment is very different from superficial microdermabrasion, in which, by definition, these complications should not occur. Superficial microdermabrasion remains a safe, effective, and popular treatment for skin surface irregularities for all skin types.

Lastly, it should be mentioned that superficial microdermabrasion may in fact be safer than some glycolic or salicylic acid chemical peels in darker-skinned individuals, because acid peels may alter pigmented cells in the epidermis.

Thank you for entertaining my response. I have read your books and find your information to be sound scientifically and exceedingly wise.

S. Manjula Jegasothy, M.D., Miami, FL

Dear Dr. Jegasothy,
I appreciate your comments about microdermabrasion. Often what happens between doctor and patient is that too little information is provided, so that the patient is not aware of all the risks or even the type of procedure they are receiving. Indeed, superficial microdermabrasion is a fairly safe procedure with some interesting, though not very dramatic, benefits. It should also be pointed out that the best results are achieved from repeated, ongoing treatments.

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Category: Wrinkles/Aging Skin

Dear Paula,
I just read an article in the Dermatology Times (on-line) that stated that Differin is just as effective for sun-damaged skin as Renova/Retin A and that Differin was less irritating to boot. I have been considering going the Differin route because my health insurance won't pay for anything they consider "cosmetic" and Differin is less expensive than Renova/Retin A. What is your recommendation? Thanks for your help! You are my wallet's and face's best friend!

Diana, via e-mail

Dear Diana,
Differin is not approved for the treatment of sun-damaged skin or wrinkles by the FDA. Nonetheless, many dermatologists feel that Differin (active ingredient adapalene) would have similar if not identical effects on sun-damaged skin as Renova or Retin-A (active ingredient tretinoin). Both adapalene and tretinoin are retinoids and have a similar chemical structure, although Differin has been shown to be less irritating than Renova and Retin-A. If Differin proves to be a better option for you, it is worth trying to see what kind of an effect it will have for you. Plus, like Renova, Differin is now available in a cream base!

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Category: Wrinkles/Aging Skin

Dear Paula,
I have read the section in your book The Beauty Bible on cosmetic surgery very carefully, and have used it as a baseline when reading other books and talking with plastic surgeons. I am seriously considering a mid-face/cheek-lift, and am puzzled about the risks. If you can clarify this for me, it would truly help.

My favorite plastic surgeon (takes lots of time with me and is patient and forthcoming about risks) is recommending an endoscopic cheek-lift. He would take the fat pad of the cheek area, unattach it, and then surgically move it up and reattach it near the temple. This would be done in conjunction with filling fat into the hollow areas under my eyes to make them look less sunken. He would also do a minor endoscopic forehead lift to address heaviness above my eyes. I don't have drooping skin, so I don't seem to need the full facelift. His overall plan makes sense to me.

However, I have heard that mid-cheek-lifts are controversial. Specifically, the book I read last night (Kimberley Henry's The Facelift Sourcebook), which says that an SMAS face-lift "is controversial, mainly because of increased risk to the patient. Some surgeons perform them as a matter of course, others refuse to do that at all out of concern that they could injure the facial nerves and other facial structures. A small percentage of patients experience some temporary facial paralysis, and in a very small percentage the paralysis is permanent." She also says that sometimes facial expressions can look unnatural after this procedure.

This makes sense to me too, and she sounds very skilled. Very few cosmetic surgeons can do the procedures she is recommending!

When I asked my surgeon about this he says he goes in over the area where the risky nerve is located so that there is no risk for this problem. I should note that he said he has done about 50 of these. He does "2 endoscopic forehead lifts a week and about 2 endoscopic cheek-lifts per month."

Lastly, Henry states that "the highest risk of nerve function loss is in the SMAS or subperiosteal face-lift. It is not the deep or superficial plane dissections but the middle plane of dissection that poses potential for nerve injury. If you are really worried about a problem with the SMAS dissection, then ask your surgeon to only perform a superficial face-lift in combination with a deep composite subperiosteal facelift-a safe procedure that keeps you away from the nerves and provides a beautiful appearance to the mid-cheek area."

Confused, via e-mail

Dear Confused,
The world of cosmetic surgery, with all the options now available, is incredibly confusing because understanding surgical procedures along with their pros and cons is like attempting to pass a mini-course in physiology. It's no easy task, which is why most women usually opt for choosing whatever plastic surgeon their friend, or friend of a friend used, and following whatever they say. Your research quest is wonderful and I want to praise you for taking the time to become as familiar as possible with what may be best for you and your risk tolerance.

Let me reassure you about two things. First, all cosmetic procedures have risks. All of them! There are some that have more risk than others, but when put on a scale the general rule of thumb is that the more intrusive the procedure the greater the risk. The second is that you reduce your chances of risk if you see a qualified, accredited plastic surgeon. Without question SMAS is more invasive, yet the preferred outcome may be worth the risk (but that is up to you).

SMAS refers to the Superficial Musculo Aponeurotic System. The skin on the face is comprised of the superficial epidermal-dermal layer (the top layers of skin), the underlying subcutaneous fat (that is the layer under the epidermis and dermis), and, beneath both of those, a gliding membrane composed partly of fibro-elastic connective tissue and partly of muscle. This gliding connective tissue membrane layer is called the Superficial Musculo Aponeurotic System or SMAS. When you cut under the muscle layer you do run the risk of negatively affecting nerve endings. But if you only pull the top layer of skin and fat layer, the muscle layer (which also sags and causes an aged appearance to the face) would not be corrected. Many surgeons feel that not addressing the SMAS layer of skin can create a flat or unnatural appearance to the face.

In regard to endoscopic face-lifts that just replace fat pads and do not alter the position of the muscles, these do not affect the SMAS. (Endoscopic face-lifts refers to teeny incisions that are placed strategically at the temple, forehead, or chin. Through these, via microsurgery-the surgeon watches what is being done under the skin via a television screen-the surgeon sutures the fat pads and/or muscles back where they belong.) Endoscopic face-lifts that realign the muscles can potentially affect nerve endings.

A subperiosteal lift is a relatively new technique for the mid and upper face, an area that is not helped by the typical face-lift (cutting and pasting around the ear area), or by endoscopic brow-lifts. The deep composite subperiosteal-lift is performed through an incision made across the top of the head in the hair (though the hair is not usually shaved). Soft tissue and muscle are completely separated from the orbits of the eyes, the cheekbones and the nasal bones. According to many sources, this cutting and pasting technique is very close to the nerves that control movement of the face and is indeed risky.

It may be interesting for you to know that according to an article in the Journal of Plastic and Reconstructive Surgery, October, 2000, in an article entitled "National Plastic Surgery Survey: Face Lift Techniques and Complications," "...15 percent of [cosmetic] surgeons perform... [superficial] skin-only procedure, and 74 percent said they address the SMAS. Nine percent of surgeons prefer a composite or deep-plane lift. Only 2 percent generally perform a subperiosteal-lift; about half of those use the endoscope.

Endoscopic mid-cheek face-lifts, forehead-lifts, or chin-lifts are definitely options for greatly improving the appearance of skin without the cutting and pasting that takes place in traditional cosmetic surgery lifts. Although if you have a great deal of excess or deeply wrinkled skin endoscopic lifts alone are not going to have much, if any, effect. But with so few surgeons capable of doing microsurgery this is not often presented as option.

The final decision is yours, and I would definitely talk to two other surgeons (who also perform endoscopic procedures) to reevaluate your options. Weighing out which one works for you and your level of risk is a decision I can't make for someone.

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Category: Wrinkles/Aging Skin

Dear Paula,
What do you think of the "skin-care" pill Imedeen? They claim that this pill will make the skin look younger and seem to have done studies that back this up? The pill is made by the Danish company Ferrosan and it contains something they call a "marine complex" derived from fish. The reason I don't just think it is a hoax is that I've found some studies mentioned in the online PubMed database [the National Library of Medicine's resource of published scientific research] that seem to support their claims that the pill has a significant and visible effect on skin. These studies seem OK to me. Still I would like to know for sure that these studies can be relied on.

Tine, via e-mail

Dear Tine,
Imedeen is a dietary supplement containing a few milligrams of zinc, 60 milligrams of Vitamin C, and some unknown marine compound that is supposed to contain some special proteins and fatty acids. As you mentioned, these overhyped little pills ($42 for 60 pills, a one month supply if you follow the recommended dosage of 2 pills per day) are supposed to get rid of wrinkles, and quickly too. Imedeen's proof of their claim is based on scientific research they cite and paraphrase on their Web site. But what the studies are really saying is indeed the issue. A PubMed search returned five articles on Imedeen. What is initially interesting if not compelling is that two of those studies concluded Imedeen has no positive results or caused skin irritation. The other two studies were done on a small group of women (one was a group of 10 women the other a group of 15 women). Because the numbers are so small, they are at best suspect in terms of calling the results conclusive (which the studies did). What most legitimate studies would do is suggest that further research and a larger sampling is considered necessary. Even more startling was that one of those studies actually concluded that the results for Imedeen were not as good as for another oral supplement called Vivid (Imedeen left that bit of information out of their brochure).

The final study, and the one that Imedeen boasts about on their Web site, was published in the Journal of the European Academy of Dermatology and Venereology, September 1998, titled "Imedeen in the treatment of photoaged skin: an efficacy and safety trial over 12 months." While the study concluded that there were significant improvements in skin, what the study didn't state speaks volumes about the accuracy of the results. It turns out this study was paid for by the company that owns Imedeen, and that the primary researcher, Dr. Marianne Kieffer, was also sponsored by Imedeen. Equally significant is the study's failure to disclose that similar and perhaps even more striking results have been obtained in numerous studies involving people taking dietary supplements of vitamin C and vitamin E (a cursory PubMed search brought up more than 20). This is also true for other varying forms of oral antioxidants and supplements for a lot less money then this with a lot less misleading information.

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Category: Wrinkles/Aging Skin

Dear Paula,
Have you heard of Artecoll, a substance that replaces collagen injections? What do you think of it?

Lisa, via e-mail

Dear Lisa,
For cosmetic surgeons and dermatologists, Artecoll is the new kid on the block for medical injection procedures to reduce or eliminate wrinkles. Artecoll is a substance made up of polymethylmethacrylate (called PMMA for short) and collagen (the sort of collagen typically used in cosmetic surgery). It has been used overseas for cosmetic facial recontouring since 1989 and in Canada since 1998. Artecoll is not approved as an implant material in the United States. It has only recently been accepted by the Food and Drug Administration (FDA) for research as an Investigational Medical Device (IDE), which means that only a handful of doctors are approved to use it.

The people who distribute Artecoll have high hopes that it will fast replace the use of collagen and fat injections for facial recountouring. While Artecoll is injected the same way collagen and fat injections are, and despite the fact that Artecoll contains collagen, Artecoll's action in skin is radically different from fat or collagen injections. Artecoll's primary and most significant difference is that it does not decompose, but rather causes a permanent change under the skin (both collagen and fat injections only last for three to nine months, and then must be redone to maintain results). Another major difference is how the change in skin takes place. Both fat and collagen injections initially plump skin and remain that way until they decompose and are absorbed into the body, eventually diminishing their effect. Artecoll produces a similar initial improvement due to the collagen part of its composition, but as the injectable collagen decomposes and the effect "deflates," your own new collagen is building up around the small amount of PMMA material that remains, keeping the wrinkle filled out and less noticeable. The process can take several months and two or more injections may be needed to obtain long-term results.

What is even more impressive is that there have been no known rejections or negative reactions to the PMMA. (Some people may be allergic to the lidocaine or collagen used as part of the injection process, however, so allergy testing must be performed before any treatment is done.)

While Artecoll is relatively new in the treatment of wrinkles, it has been around for the past 50 years and is used in medical procedures to fix hip-joint replacements, repair skull defects, and stand in as a bone substitute; it's also used for artificial lenses and in dentistry, and is known to be exceptionally safe, with minimal to no known rejection complications. This is one to keep a watch on to see whether the final tests here in the U.S. prove its unique action in treating wrinkles to be true.

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Category: Wrinkles/Aging Skin

Dear Paula,
I had some treatments called particle skin resurfacing done this past spring, and I had to stop after nine treatments because of the cost and the time. My doctor led me to believe that there would be no down time, but she was wrong. She does aggressive treatments that leave the skin bleeding, peeling, and scabbing because she said you get better results, but I could not tolerate that and still function on a daily basis at work or socially so I stopped.

I think that not only did my face return to its original condition as far as deep wrinkles go, but now when I smile my face wrinkles up worse than before treatments. Is this normal and would I have to keep these treatments up for the rest of my life in order for my skin to look decent? The doctor denies that anything negative could happen from the particle resurfacing.

Charlotte, via e-mail

Particle resurfacing is a fancy name for what is also called Microdermabrasion, the Lunch Time Peel, the Italian or Paris Peel, and the Derma Peel, among a few other creative labels. All of these procedures use a machine that shoots a jet of small, abrasive crystals (usually a form of aluminum oxide) onto the skin, and then vacuums them back up off of the skin. Depending on the pressure and intensity settings used (which are controlled by the technician), varying problems absolutely can occur. Not only is your doctor misinformed about the risks of microdermabrasion, but I find it galling that when you describe the very problems known to take place with this procedure the doctor retorts, "but that never happens." Obviously it does happen and you're living proof of it.

Just to reassure you that your own experience isn't anecdotal, the following excerpt from an article in Skin & Allergy News, November 1999, states the concerns and potential problems caused from microdermabrasion: "Microdermabrasion's versatility and potentially destructive power was demonstrated in a histologic study [histologic means looking at skin structure under a microscopic] presented at the annual fall meeting of the American Academy of Facial, Plastic, and Reconstructive Surgery... Used conservatively, the system works well in treating basically, anything that's minor... Under the microscope, a low number of passes equated with negligible histologic evidence of meaningful skin changes. But increasing passes resulted in extreme damage down to the dermis. Of note, deep ablation with the microdermabrasion machine produced serum exudate [oozing] and bleeding, and left histologic evidence of aluminum oxide crystals embedded in the dermis...." The study also concluded that microdermbrasion machines are capable of blowing the skin away, producing or leading "to total removal of the epidermis."

That's not to say there can't be impressive results from microdermabrasion. But to suggest it isn't without risk is either deception or ignorance. And it goes without saying that the results are under no circumstances not permanent. (Here, it is important to note that microdermabrasion is unrelated to what laser resurfacing does for the skin. For example, laser resurfacing is done once and the results can last from four to seven years, while microdermabrasion must be done repeatedly to maintain an effect.)

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Category: Wrinkles/Aging Skin

Dear Paula,
This is from ABC News' Web site:

"Scientists Say Anti-Wrinkle Creams May Accelerate Aging

"LONDON, Aug. 9: Anti-wrinkle creams may soon be getting a face-lift. The European Commission, the administrative arm of the European Union, is considering tough new limits on anti-wrinkle creams containing ingredients known as alpha-hydroxy acids, or AHAs, because scientists say the creams may actually cause skin to age more rapidly.

"The commission is deciding whether to impose a formal limit on the amount of AHAs it will permit in skin creams and is considering making it compulsory for any product containing the acids to carry warning labels. Found in many anti-aging products, AHAs, also known as fruit acids, claim to "exfoliate" or rejuvenate skin by peeling off the outer layers to reveal the fresher skin beneath. They promise to smooth fine lines and surface wrinkles, to improve skin texture and tone, to unblock and cleanse pores, to improve oily skin or acne, and to improve skin condition in general.

"But European and U.S. scientists are finding the chemicals may actually cause long-term damage instead. This week, the European Commission's Scientific Committee on Cosmetic Products made available a number of studies, including research from the U.S. Food and Drug Administration, about this issue. Calls to the FDA regarding AHAs in products in the United States were not immediately returned.

"The EC committee found that the chemicals appear to increase the number of skin cells that are damaged, stimulate reddening, blistering and burning and put users at greater risk of ultraviolet damage from the sun. Dr. Nick Lowe, a dermatologist, says the problem stems from consumer misuse or abuse. "Improper use, too frequent use and use by those with sensitive skin, this is where you see the damage," he says. "Products using AHAs should be administered in a clinic."

"Products with AHAs are marketed as a "natural" way to rejuvenate skin. They are called acid peels, fruit peels, anti-aging exfoliates and any number of other names. The commission is welcoming comment from interested parties, such as cosmetics companies and other medical groups, before it makes a decision next month."

What do you think about all this?

Confused, via e-mail

Dear Confused,
Thank you for sending along this "news story." The information in this story is best described as vague. While it mentions "a number of studies made available ... about this issue" it doesn't mention which ones. The only ones I'm aware of are from the FDA in regard to the fact that AHAs can make the skin more sensitive to the sun. (However, that research doesn't take into consideration my long-standing admonition that to remove surface layers of skin and not protect that vulnerable new skin with an effective sunscreen would almost predictably cause more problems in the long run.)

I receive over five dermatologic and two plastic surgery journals (not to mention scouring the research available on the Web), and not one has any study demonstrating that any product either stops or worsens skin aging (except for theoretical models not using sunscreen). The one statement I absolutely agree with and have stated repeatedly is the one by Dr. Nick Lowe, who said, "Improper use, too frequent use and use by those with sensitive skin, this is where you see the damage." Given that many lines sell multiple AHA products or high-concentration AHA products (over 10% has always been a concern of mine), the level of irritation those products may cause can be a problem for skin (irritating and inflamming skin is always a problem). However, when it comes to removing the thickened layers of skin and improving the health of skin (much like removing a callus), AHAs can help. They also make skin feel and look smoother, which is why AHAs and other peels (ranging from BHA to laser resurfacing and microdermbrasion) are so popular: they do make a positive difference in the skin.

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About the Experts

Paula Begoun is the best-selling author of 20 books on skin care and makeup. She is known worldwide as the Cosmetics Cop and creator of Paula's Choice. Paula's expertise has led to hundreds of appearances on national and international television including:

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The Paula's Choice Research Team is dedicated to helping you find the absolute best products for your skin, using research-based criteria to review beauty products from an honest, balanced perspective. Each member of the team was personally trained by Paula herself.

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