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Editor’s note: In November’s column, Dr. Farnesi started a discussion on facial wrinkles and age- or sun-related damage. This month’s column is about treatment options beyond the use of Botox.

Aesthetic medicine is like a pyramid of treatment options.

At the bottom of the pyramid are the more common, more affordable treatments. These treatments, while useful and valid, are usually the least powerful or effective and therefore also carry with them the least amount of discomfort or “downtime” (healing time).

As you move up the pyramid things get pricier, more effective, and require more healing time. And they might be more painful too.

So at the bottom of the pyramid we start with simple cosmeceutical products (creams, lotions, gels, serums). Fine lines and tiny wrinkles sometimes respond well to compounds contained in these products, which stimulate collagen growth in the skin (such as certain peptide products and retinoids), relax smooth muscle found in the skin (such as Argireline), tighten the skin (such as DMAE) or hydrate the skin (such as hyaluronic acid and Estriol).

These compounds are popular in daily facial moisturizers, treatment serums and under-eye creams. There are numerous bio-active compounds like these with varying degrees of efficacy – too many to list here.

The ones listed above are generally the ones that work the best and have the most proven track record. These products generally cost $50 to $200 a three- to six-month supply.

For pigment changes (freckles, “sun spots,” melasma), the main focus is either to peel off the pigmented skin (further up the treatment pyramid in terms of cost and healing) or to suppress the pigment-producing cells.

Over-the-counter compounds that suppress the pigment-producing cells are Retinol, Kojic Acid and Arbutin (available in various gels, creams, lotions, serums). Prescription medications, which are more powerful at suppressing pigment include retinoids (such as Retin-A or Tazorac) and hydroquinone (active ingredient in the popular Tri-Luma – sometimes referred to as “bleaching cream”).

Learn about the use of fillers

For larger folds and hollows of the face, injectable fillers can be used to restore volume under the skin, thereby reducing and softening their appearance. The areas commonly filled include the line between the nose and corner of the mouth (naso-labial fold), smile lines (“commas” at the corners of the mouth), deep frown lines between the eyebrows (some people call these “elevens”), vertical lip lines (sometimes called “smoker’s lines”) or the tear trough (that hollow that can develop underneath the eyes).

Almost anywhere you can put a needle safely can be filled. This can literally take years off someone’s perceived age. The brain is wired to estimate age by gauging the depth of the tear trough and naso-labial folds. The deeper they are, the older someone looks to us when our brain analyzes their face.

Fillers can also be used to add back volume that has been lost in the cheeks, along the jaw line, the eyebrows and the temples. These are some of my favorite areas to fill because the effect is very subtle and yet the result is always noticed by others as a more youthful looking face, without any trace of a procedure being done.

Fillers cost from $300 per syringe for something that lasts six to nine months to more than $1,000 for something that may be permanent. A future column will provide more in-depth information about the various fillers available because each one has unique qualities.

Learn about cosmetic treatments

Finally, at the top of our treatment pyramid are cosmetic procedures, which may tighten the skin, build collagen, reduce pigment and reduce the appearance of fine lines and wrinkles.

These include IPL (Intense Pulsed Light) otherwise known as a “photofacial,” ultrasound, infrared heat, laser resurfacing, microdermabrasion and chemical peels. These all require varying degrees of healing and downtime, as well as cost. For example a chemical peel may cost from $150 to $200 for a simple, light peel, allowing you to go to work the next day. Or you might pay several hundred dollars more for a much more extensive peel, which might require significant after-care and staying home from work for a couple of days.

You have probably heard of these peels: TCA, Glycolic Acid, Salicylic Acid, Jessner’s, Vi-Peel, A-Peel, to name a few. Basically an acid is used to create a controlled burn to the skin, resulting in sloughing of the “old” skin and rejuvenation with new skin growth and the stimulation of collagen and fibrin formation.

The Melanage Peel is the first peel we've had in a very long time that is safe and effective for darker skin types. Up until now there has been very little we could do other than “bleaching creams” and sunscreen to help people with unwanted spots on darker skin. The reason is because darker skin has very active melanocytes, which are stimulated by the sun or by any trauma or inflammation.

If you or someone you know has dark skin, you'll know what I'm talking about. If you pick at a pimple, you usually get a permanent or semi-permanent dark spot that remains for many years after the pimple is completely gone. So what this means is that if WE traumatize the skin at all - either with a laser, a chemical peel or IPL, we are just as likely to worsen the problem as we are to fix it.

The inflammation and trauma caused by laser, IPL or chemical burn can leave a darker-skinned person with even more dark splotches. The Melanage Peel changes all of that. It has such high concentrations of pigment-suppressing medication that it won't worsen the pigment, it will only lighten it. And that's a first!

A microdermabrasion treatment consists of a machine that physically and forcefully exfoliates your skin. This is accomplished with a vibrating abrasive wand, an abrasive brush attached to a vacuum, or by blowing an abrasive compound at the skin with small instrument. A treatment will cost $60 to $120 and you will get the best results with a series of three to five treatments.

A photofacial (IPL) may cost $300 to $500 on average per treatment and usually you can go to work the next day with your face covered in sunscreen. IPL is specifically designed to target red and brown discoloration, and is considered the standard of care for evening the pigmentation of the skin.

Red color can be found in blood – so things like blood vessels and “spider veins” will be blown away. The heat created by the light-based treatment stimulates collagen and fibrin growth in the skin, which can reduce fine lines after a series of treatments. Ultrasound is often combined with IPL, or infrared heat, to increase this deep collagen-stimulating effect and cause skin tightening in other areas of the body such as the neck, arms, hands, belly and thighs. Best results for IPL are again generally with a series of three to five treatments.

Laser resurfacing is probably the most effective treatment for wrinkling and may cost $1,000 to $3,000 on average for the face, potentially more for other larger areas of the body, and may require you to be home from work with aftercare for a whole week. In general, the more downtime and expense, the greater the results.

Most doctors are using fractionated CO2 or fractionated Erbium lasers. The fractionated laser beam is split up into hundreds of tiny columns, leaving intact skin in between. This speeds healing and decreases downtime. However, it also reduces results and so these treatments can be done in a series as well.

All of the light-based treatments (IPL, laser) can be used on other parts of the body besides the face. Many women have their necks and décolleté (upper chest area) treated, due to years of sun damage caused by wearing typical low-cut clothing that exposes the upper chest and neck. Other popular areas are the hands and arms.

Fillers can also be used to add volume to the back of bony hands so they don’t look so old. Yes, even in cosmetic dermatology we can make other areas of the body (besides the face) look better naked too! Stay tuned next month for more in-depth information on some of these procedures along with some before and after photos.

Darren A. Farnesi, M.D., APC, offers his sound advice and personal knowledge of the industry as a successful doctor with Medical Age Management Inc. He can be reached at (619) 299-0700 or online HERE.