Besides chemical peels, there are other methods of reducing what plastic surgeons call "age-related cosmetic depressions", and what you and I call wrinkles.

This chapter deals with these alternative methods, which have applications for those skins that might not take well to a chemical peel, or for those cases of localized creases where a full-face peel may not be called for.

Medically, they are known as proto-fillers, and they are the ultimate in quick fixes for wrinkles. The approach basically is to erase wrinkles by injecting them with a line-filling substance. Down the decades, all kinds of such substances have been tried; many, including liquid paraffin, polyvinyl alcohol and teflon have fallen by the wayside. So has liquid silicone, first used in the 1950s, but rejected worldwide in the '90s because of adverse reactions that it produced, ranging from uneven surface skin to lumps and even siliconomas.

Collagen This is the line-filler that everyone knows best, Collagen, as we've explained in an earlier chapter, is the protein that gives skin its elasticity. Today, synthetic collagen derived from cowhide and therefore known as `bovine collagen' can be injected into creases to 'fill them up', thereby restoring smoothness to the area.

Three types of synthetic collagen (of varying viscosity) are available, depending on which area of the face is to be treated and also on whether superficial lines are to be filled up or deeper furrows. Zyderm I is best suited for lines around the eyes; for other areas, Zyderm II provides better and longer-lasting correction; Zyplast, the most stable form of synthetic collagen, is ideal for deep wrinkles, depressed scars, for smoothing out uneven contours in the region of the nose, and for increasing nipple projection.

Whichever type of collagen is used, a skin test for a potential allergic reaction needs to be carried out four weeks earlier. Those with oily skins or enlarged pores should also be pre-treated for these since porous skin will not retain a sufficient amount of the injected collagen.

When injected, the gel-like collagen warms to body temperature and forms an implant, which enables the substance to stay put at the injected site, giving structural stability to the skin there.

Soon after the injection of collagen, the skin blanches and then becomes slightly raised. This settles down spontaneously. Resist any impulse to massage the area. The exception is when collagen is injected into lines around the eyes where the skin is very fine and where visible lumpiness can persist over a long term unless the area is massaged immediately after the injection and occasionally a few more times over the next 48 hours.

The downside of collagen injections is that they are expensive. Also, the effects are not permanent top-ups are required every four to twelve months. How long their efficacy lasts depends upon skin type, age, sex, metabolism, disease and external stresses operating on the site (e.g. excessive facial movements). Injected collagen is subject to the same physical influences and physiological processes as natural collagen.

  • Auto-Fat Injections

    This is a newer option than synthetic fillers and many doctors consider it a better option since it avoids the rejection problems and other complications that sometimes occur when collagen or silicone are used.

    "Fat re-transplantation", as the technique is sometimes called, simply calls for the surgeon to make a small incision in an area of the body where there's an excess of fat (for instance, the hips or the tummy), remove a tiny amount of fat from this site, and then micro-inject it into facial lines, using a syringe.

    Liposuction patients often have the procedure performed at the same time as they undergo fat removal.

    Auto-fat injections are most frequently used for the area around the lips, for forehead lines and even on the hands. They are not as useful for the meat of the lips: if injected in excess.they can leave lips looking unnaturally puffy, as if they've been stung.

    Normal saline is used to expand the area. The fat is then injected, including about 20% more than is needed in order to ensure there is enough fat to survive the destruction of some cells. Swelling peaks during the first 72 hours, during which valleys and crevices on the face turn into mounds.

    Unlike with collagen, there is a lot of variation in the life of corrections carried out using fat injections. Some particularly those on hands are reported to last for years. What determines how long the effects will last? The source of the fat does not seem to make a difference. Some surgeons claim longer-lasting results after breaking up the fat into smaller pieces; others say this simply allows it to be used for more superficial lines, like crow's feet. What most doctors seem to agree on, however, is that this all-natural filler yields fairly long-lasting results after a series of injections.

  • Dermabrasion

    Also called 'sanding', was first attempted in 1940, using actual sandpaper. It is usually associated with erasing the scars of chicken-pox, small-pox or accidents, but it can also remove some fine wrinkling as well as the brown spots and leathery texture associated with older, sun-damaged skin. Deep forehead furrows and pronounced naso-labial creases do not respond as well. The face is the best candidate for this treatment; areas like the arms and legs heal poorly and scarring is a definite risk in the last.

    In this procedure, the face is sprayed with a freezing solution, and skin is held taut as the doctor, using a diamond-coated instrument, sands off the upper (epidermal) layer of the skin. Today, laser-abrasion offers a greater degree of control in removing skin. It can be done under local anaesthesia combined with sedation when smaller areas are being treated, and under general anaesthesia when the entire face needs to be sanded.

    Dermabrasion does not really alter the underlying scar tissue. But by sanding down unaffected areas of the face to the level of the scars, it creates a more uniform, (trough- less) look. The surgeon needs to exercise care around the area of the eyelids, however, since the skin here is very fine, with a soft base.

    The newly - exposed skin is extremely tender and moist, and an antibiotic cream or powder must be used. Pain-killers are also required. Crusting develops over the treated area in one or two days which is the period you' ll normally be required to stay in hospital. During this time, the dermabraded area is kept dry using an air-blower. The scabs should not be picked but allowed to fall off naturally; picking at them will result in scarring.

    The skin oozing continues for one to two weeks. After this, make-up can be used. Harsh chemicals, should however not be used over the new pink skin.

    The entire process of healing can take eight to 12 weeks, even longer. During this time you'll need to avoid the sun, as well as extremes of temperature. A sun-protection lotion must be used for at least 12 weeks.

    Depending on the original condition of the skin, an improvement ranging from 50 to 90% can be expected. Dermabrasion can, however, be repeated when scars are more pronounced. It can also follow a face-lift. It is superior to a chemical peel when the skin is thick and oily, or wrinkles are deep (though success is still limited in the latter case).

    (It is of course possible to carry out both treatments on the same person; dermabrasion for all except the thin-skin areas, followed by a chemical peel for these areas and for any areas requiring additional refinement.)

    At its best, dermabrasion produces a fresher, smoother, more youthful appearance. The skin's natural fibers, collagen and elastin, are spurred on to new growth, resulting in a tauter look.

    The risks and complications of the procedure include hyperpigmentation; hypopigmentation; excessive inflamation; the formation of white-heads and scarring.