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Medical Author:

Gary W. Cole, MD, FAAD

Gary W. Cole, MD, FAAD

Dr. Cole is board certified in dermatology. He obtained his BA degree in bacteriology, his MA degree in microbiology, and his MD at the University of California, Los Angeles. He trained in dermatology at the University of Oregon, where he completed his residency.

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Medical Editor:

William C. Shiel Jr., MD, FACP, FACR

William C. Shiel Jr., MD, FACP, FACR

Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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The treatments for wrinkles are cosmetic procedures. Cosmetic procedures are those that do not produce a functional improvement in the patient condition but they produce an enhancement in a sense of well-being. They are generally not covered by most insurance plans.

Cosmetic procedures for wrinkles can be grouped into four groups:

1. Paralysis of superficial fascial muscles
2. Filling depressions so that they are elevated
3. Changing the nature of collagen either by medical means or by an invasive destructive procedure
4. Surgical removal of excess skin

Some of these procedures are as simple as the application of a topical cream while others are surgical procedures that require general anesthesia and an operating-room environment. The determination of which procedure is best is often difficult and requires an individual with expertise in multiple approaches.

This is a relatively recent innovative use of a toxin produced by a bacteria, Clostridium botulinum. This protein was responsible for a number of human death from eating contaminated, inappropriately canned foods. Patients died because of the loss of the muscle control of respiration. Enterprising scientists refined and diluted this material so that it could be injected into spastic muscles and superficial facial muscles producing a paralysis that lasts two or three months at a time. The result was the disappearance for a time of wrinkles induced by these muscles. Currently, there are two brand name medications FDA indications for injection, onabotulinumtoxinA (Botox Cosmetic) and abobotulinumtoxinA (Dysport), that can be injected into the muscles of the face to ameliorate wrinkles by paralysis of the tiny muscles involved. Other brands of this chemical, although not officially indicated for facial injection, may work as well. They are incobotulinumtoxinA (Xeomin) and rimabotulinumtoxin B (Myobloc). Injections usually have to be repeated at regular intervals as needed to maintain the desired result. Side effects are generally caused by the injection of too much toxin in the wrong anatomical site. Luckily, the effect of the toxin is self-limited. Currently, there is ongoing research into a topical preparation that potentially could be applied to the skin at home.

There are a variety of substances that have been used to elevate the furrows of depressed wrinkles. There are many FDA-approved fillers that include the patient's own fat cells (autolagous fat grafting), collagen (Evolence, CosmoDerm, Fibrel, Zyplast[R], and Zyderm), hyaluronic acid (Belotero Balance, Restylane Injectable Gel, Prevelle Silk, Elevess, Juvéderm 24HV, Juvéderm 3 Hylaform, and Captique), lactic acid (Sculptra), and hydroxylapatite (Radiesse) and a combination of polymethylmethacrylate beads and collagen (Artefill) There are also a variety of unapproved fillers such as silicone and mineral oil which are potentially dangerous and should be avoided. Which brand of filler to be used on which wrinkle in a particular anatomic site is part of the art of cosmetic dermatology and requires special expertise. Most of these substances require reinjection at various intervals and all have occasional side effects.

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