How can I rejuvenate my skin without surgery?

When you look in the mirror, your skin appears wrinkled and sun-damaged - and you want to do something about it.

How do you select the best treatment for aging skin? Do you need expensive surgery, or are less-invasive, more cost-effective and safer alternatives available?

First, prioritize what bothers you -is it sagging skin around the neck, furrows above your brow, crow's feet around the eyes or some skin discoloration? Next, decide how much you're willing and able to spend, because cosmetic procedures are not covered by insurance. Finally, make sure you're willing to follow through with a daily regimen of skin care and a healthy lifestyle - including a good diet, sun avoidance and smoking cessation - to maintain the investment in your rejuvenated skin.

Once you've decided what you want to improve or change, the hardest part may be determining whether to visit a med spa or make an appointment with a dermatologist or cosmetic surgeon. Skill and expertise vary widely depending upon the training, credentialing and experience of the professional. When selecting a physician, start by looking for board certification in a skin-related specialty, such as dermatology, plastic surgery, facial plastic surgery, opthalmoplastic surgery, etc. Keep in mind that the market is flooded with new skin "experts," so educate yourself, validate credentials, and don't be fooled by a flashy Web site or advertisements.

I generally recommend that a cosmetic surgeon remove sagging, excess skin. If your skin's looseness is more modest and wrinkles, skin texture and discoloration are your primary concern, you may be a candidate for many of the nonsurgical options provided by dermatologists. Botox injections relax muscles of expression, allowing skin on top to lie smooth. Newer fillers, including hyaluronic acid and other synthetic compounds, soften deep wrinkles and restore lost volume. Laser resurfacing and intense pulsed light tighten and brighten sun-damaged skin and improve texture.

When skin changes are very minor - some discoloration and fine lines around the eyes, mouth and cheeks - all that may be needed is prescription-strength topical agents, such as Retin A and alpha hydroxy acids. Procedures such as superficial chemical peels (chemexfoliation) and microdermabrasion, a gentle "sandblasting" procedure that removes the excess dead skin cells, may also help.

For more severe complexion problems, intense pulsed light therapy painlessly uses multiple wavelengths of white light to reduce the redness and brown age spots. Distinct blood vessels or broken veins and capillaries generally need to be destroyed with specially-designed lasers. Enlarged pores can be minimized and skin texture refined by heating the skin with lasers to stimulate new collagen growth. New "fractional" laser technologies that deliver columns of energy to the deep layers of the skin dramatically reduce wrinkles and pebbly skin. Some are non-ablative (no visible tissue injury and minimal post-treatment pain and care), but require many treatments with only modest improvement.

The newest lasers now use fractional technology for ablative resurfacing. While traditional ablative lasers remove the entire outer skin layer and portions of the middle layer, the fractional lasers vaporize discrete columns of tissue, leaving small islands of healthy skin surrounding the treated tissue. The new CO2 fractional lasers have the added benefit of shrinking the skin, resulting in tighter skin. The risk of scarring is significantly less and healing occurs much faster, with downtime of only four to five days rather than two to three weeks.

Consult a professional to help determine the best approach for you - and maintain realistic expectations. We can drop the clock back a few years, but we can't make you look 20 again.