Chemical Peels
Chemical peels are used in the treatment of skin laxity through a process similar to ablative lasers. Unlike other methods described in this article, this type of treatment is only reserved for the facial areas. The peel must penetrate to the lower papillary dermis or deeper to allow for adequate collagen synthesis.55 As such, medium to deep peeling agents should be used.56 Peels cause coagulation of membrane proteins and necrosis of the epidermis and dermis, thereby stimulating collagen synthesis and keratinocyte regeneration. Additionally, there is an increase in the deposition of glycosaminoglycans, which play a major role in providing hydration for the skin because of their water-binding capacity.56 Deep peels have the added effect of restoring dermal architecture to its native state. Medium-depth peels work up to the layer of the epidermis and dermis.57 Trichloroacetic acid (TCA) 35% is the main ingredient used in these types of peels. Some examples include Monet combination (Jessner solution with 35% TCA), Brody combination (solid CO2 plus 35% TCA), and Coleman combination (70% glycolic acid and 35% TCA). Deep peels penetrate to the levels of the reticular dermis.58 The formulation of these peels contain croton oil and phenols in various concentrations.57,58 A study by Brody59 noted clinical improvement of skin laxity–attributed histologic depth achieved by medium-depth peels. The results of the study demonstrated that the depth of wounding from 3 consecutive applications of TCA led to greater epidermal hyperplasia and a more dense formation of dermal elastic fiber formation on histologic examination. Side effects noted in the study included transient erythema, edema, and erosions that resolved without scar formation at 30-day follow-up.59 Another study performed by Oresajo et al60 demonstrated that patients treated with either a chemical peel of 41% capryloyl salicylic acid or 30% glycolic acid led to notable reduction of fine lines/wrinkles vs baseline. Side effects noted included pruritus, erythema, increased skin sensitivity, epidermolysis, allergic and irritant contact dermatitis, and postinflammatory hyperpigmentation.60
Skin Care
Skin care products have been developed over the years and marketed to aid in the treatment of skin laxity. Some studied methods include photoprotection products, antioxidant-based products, and vitamin A products. Photoprotection plays a crucial role in the prevention of skin laxity. Unprotected sun exposure can induce damage to previously treated skin, leading to minimized or cancelled rejuvenation measures.61
Oxidation is a major contributor in the development of skin laxity. The skin naturally possesses endogenous antioxidant defense mechanisms that protect its cells from free radical damage. However, these mechanisms are reduced as skin ages and are further diminished with photodamage. Ascorbic acid is a collagen stimulator that is known to have antioxidant properties. In the appropriate formulations, topical vitamin C directly supplements the skin’s antioxidant reservoir.61
The use of vitamin A, a retinoic acid, for treatment of skin laxity is based on its ability to improve the production of procollagen and elastic fiber components, resulting in the restoration of dermal matrix proteins.61-65 Vitamin A in the skin plays a key role in the regulation and control of proliferation and differentiation of all major cell types found in the epidermis and dermis.61 Studies have shown that the long-term use of topical vitamin A improves fine and coarse wrinkling.65
Final Thoughts
Various technologies have been developed to provide clinically significant skin laxity reversal. Laser, RF, ultrasound, IPL, and topical therapies provide numerous options at our disposal. Although many devices are available, it is important to consider the desired outcome, cost, and adverse events when discussing therapeutic options for treating skin laxity (eTable). Patients should be advised that multiple treatment sessions over the course of months will likely be necessary. With the development of numerous technologies, we now have many options to offer our patients who desire minimally or noninvasive skin tightening.