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Skin is a living dynamic organ - the single largest organ of our body. It is a protective shield against the harshness of the outside world in which we live. The skin presents a barrier to moisture and prevents us from drying out. Our body is largely composed of water and without healthy skin we would rapidly evaporate our precious water into the atmosphere about us. Skin is a tough, elastic material which protects us from the puncture and tearing injury of minor scrapes and blows and the invasion of bacteria, fungus and viruses that we come in contact with daily.

Skin varies greatly in texture, thickness, types and numbers of glands, hair follicles, and the circulation of blood in different areas of the body. Eyelid skin is thin, hairless, and has a rich supply of blood vessels while the skin on the back is very thick, has many sweat and oil glands and variable pattern of hair growth.

The skin serves as an instrument in the regulation of body temperature, both preserving and dissipating body heat. Tiny blood vessels just beneath the skin dilate, allowing the warm blood to radiate heat to the surface of the skin, letting the body cool. The skin also produces sweat which evaporates fro its surface to further cool the body. In an atmosphere of cold, the skin preserves body heat by constriction of the small blood vessels under the skin to reduce the transportation of body heat to the surface. There is a layer of fat beneath the skin which also provides thermal insulation and a cushion around the deeper structures of bone and muscle.

The skin is made up of layers of living cells and collagen. The upper layer of skin, called the epidermis, contains rapidly dividing cells organized into very uniform layers which rise to the surface where they die and slough off, making room for new cells. This continuous process provides a dynamic waterproof seal which neither absorbs moisture nor gives up body water. The deeper layer, called the dermis, is made up of blood vessels, hair follicles sweat glands and oil glands in a bed of collagen. Sweat glands deliver sweat to the skin's surface regulating body temperature and providing each person with an individual scent. Oil glands produce lubricating oils that smooth the skin, aiding in retention of natural moisture. Hair follicles seated within the dermis produce hair that further covers and protects the skin. Deep in the dermis is a layer of elastic tissue which provides resilience and tone to the skin.

Blemishes are defects in the uniformity of skin texture and color which develop with injury from burns, cuts and scrapes, damage caused by sun and weather, the development of moles and tumors, and inherited areas of increased skin pigmentation. Skin color is determined by the number and distribution of melanocytes, or pigment cells, in the skin and the amount of pigments that they contain. Normally, melanine pigment is present in all skin. Freckles are localized areas of increased melanine deposits. Age spots (areas of raised red or brown skin) result from sun exposure.

Sun damage to the skin is cumulative - the sunburns of childhood and weekend sunbathing in adults produce skin damage that increases the chance of skin cancer formation. In sun-damaged skin there is a disruption of the normal cell layers of the epidermis. The skin becomes dryer, loses elasticity and exhibits early wrinkling; solar keratosis and skin cancers result. The effects of unprotected sun exposure are now considered to contribute to perhaps 90% of all skin cancers.

Sunscreen and sun blocking agents are now available which significantly protect the skin from the damaging effects of the sun's rays. The use of these agents is currently the most valuable method of forestalling wrinkles and blemishes.

There are also numerous, sometimes costly cosmetic products which claim by secret formula or strict regimen to restore youthful, beautiful skin. These claim to work by virtue of their ingredients of collagen, hormones, proteins, amino acids, rare oils, plant extracts, and vitamins. None, however, seem to have any measurable documented effect of restoring youthfulness to the skin.

As we age, the skin gradually loses elasticity and the underlying fat cushion shrinks, creating small folds and wrinkles. Oil glands decrease their production of lubricating oils allowing the skin to become dry. These changes are first apparent in areas of repeated sun exposure such as the backs of hands and the face and neck.

Lines are the deeper wrinkles in the surface of the skin that eventually form in areas of repeated folding from the movement of underlying muscles. The muscles of facial expression contract and relax during smiling, frowning, talking and yawning, pulling the overlying skin into folds that eventually become permanent creases. Forehead frown lines, crow's feet wrinkles at the corners of the eyes, and vertical lines of the upper and lower lips are all produced in this manner.

Cigarette smoking probably accelerates the formation of skin wrinkles as well; smokers tend to exhibit earlier wrinkling around the eyes and lines and creases of the upper and lower lips. This is due not only to squinting and the pursing of lips around a cigarette, but probably also to nicotine's constriction effect on the skin's blood supply.

Retin-A is a medication which does seem to show a positive effect on the reversal of some of the changes seen in the aging of skin. Retin-A is a Vitamin A product which is applied to the skin as a cream, gel or liquid. It was first used for acne to clean out the obstructed oil glands of the skin.

There has been continued interest in the wrinkle removing effects of Retin-A. The anti-aging effects from Retin-A require continuous long-term use. After a few weeks to months, there is a plumping of the dermis of the skin which produces a reduction in the depth of wrinkle lines of aging skin. This activity produces a shiny, almost waxy look to the skin. Long term use of Retin-A also produces bleaching to the skin through the concentration of melanine pigment in the melanocytes, resulting in a general lightening of the skin. There also seems to be a partial reversal of the effects of sun damage to the skin with some fading of keratosis or age spots in some people.

Retin-A also seems to improve the healing of cuts and other wounds in areas which have been under treatment with this product for at least a few weeks before the injury. While useful, Retin-A has an effect of increasing the skin's sensitivity to the sun resulting in the need for sun protection during its use. It also causes areas of scaling patches of redness and irritation of the skin under treatment. These adverse effects often diminish after a few weeks of use.

There are several medications which are effective in bleaching the skin to reduce blotchy skin pigment irregularities. They are somewhat effective in bleaching the increased pigmentation from skin damage and scarring. Creams containing Hydroquinone cause a gradual bleaching of freckles and age spots by interfering with the formation of melanine pigments by melanocytes. If the areas which have been bleached by these creams are not protected from sun exposure with sun blocking or sunscreens, the pigment will return. A related cream containing Monobenzone is much stronger and will often completely
bleach a skin area of its color. This is used in very few instances to uniformly fade the skin to a more uniform whiteness when there are blotchy areas of completely depigmented skin already present.

There is a tablet containing Trioxsalen which seems to stimulate the production of melanine pigment with exposure to the sun. This medication is used to help very fair-skinned people tan or darken their skin to aid in increasing Trioxsalen which seems to stimulate the production of melanine pigment with exposure to the sun. This medication is used to help very fair-skinned people tan or darken their skin to aid in increasing resistance to solar damage and sunburn. It will even help people who have no melanocytes to increase their tolerance to sunlight even though they area unable to produce melanine.

Not everyone passes through youth with clear, unblemished skin -just ask anyone bearing the pitted, bumpy scars left from acne. These scars are the result of infected oil glands that form tiny abscesses and heal with dense scar bands, pulling the skin inward producing dents and ridges. These skin blemishes can range from a few shallow irregularities across the cheeks, forehead or chin, to large, deep pits over the face, chest, shoulders and back.

All injuries to the skin which extend into the deep layer of the dermis heal by scar formation. A scar is the normal process by which the body repairs an injury by pulling uninjured surrounding tissues into the wound to fill the defect. Scars of the skin differ in color, texture and elasticity from the normal surrounding skin. Wide scars, appearing white or discolored, lack normal skin pigmentation and cannot darken normally from exposure to sun. Thinner scars and scars from more superficial injury may form increased melanine deposits remaining permanently darker than the undamaged skin. Thick scars shrink and may cause deformity of the surrounding tissues when the wound is wide or deep. Scars which produce a line across normal creases of the face are more noticeable because they eye is attracted to the unusual configuration created by the abnormal line.

As scars vary in width and thickness in different areas of the body, the formation of scarring varies with each individual. A surgeon's fine incision may heal virtually unnoticeable in the eyelid while scars on the shoulder, back, knees and mid-chest are, by nature, apt to spread despite the skill of the surgeon or the care of the wound. Infection, poor blood supply and type of treatment will all have an effect on the final healing. Location on the body still remains one of the biggest factors in scar formation.

Scars can never be completely removed by the plastic surgeon, only exchanged for a less noticeable one.

Linear scars across the face are made less noticeable by breaking them up into zig-zag patterns, re-directing portions of the scar to more closely follow the normal skin lines. This makes it harder for the eye to follow the line of the scar, therefore making it less noticeable.

Deep scar deformities can be improved by removing scar tissue and bringing the underlying tissue back to a more normal position. Raised scars can be sanded, shaved, or cut out to make the skin smoother. Depressed and pitted scars can be temporarily filled out with injection of collagen, a natural substance in the dermis or all mammals. The rough cobblestone surface of acne scars are often sanded down in a procedure called dermabrasion. Some scars may require a series of surgery for best results.

The hypertrophic scar is thick, raised, and pink, seen following injuries from burns, cuts and scrapes. Keloid scars grow beyond the boundaries of the original wound, forming tumor-like growths on the surface of the skin that can often interfere with the body function, particularly if in an area of extensive movement such as the shoulder, elbow, neck, etc.

Hypertrophic and keloid scars may be treated with steroid injections and pressure garments that keep continuous pressure on the scar. Large hypertrophic scars may be surgically removed and replaced with skin grafts or skin that has been expanded with tissue expanders (a tissue expander is a special balloon-line sack placed under the skin and gradually filled to increase volume that causes the overlying skin to stretch, thus providing more skin area).

Scars take months - up to a year or more, to completely heal and mature. The red, raised and shiny scar that is three weeks old may heal to a flat, almost unnoticeable scar several months later. Protecting the healing scar from sun exposure or further tissue damage will  aid in the final outcome.

Laser skin resurfacing is an extremely unique and effective method to reduce and improve the appearance of scars and other skin defects. Resurfacing can also remove wrinkles and other signs of aging.

A board certified plastic surgeon is specially trained and experienced in the treatment of wounds and scars and should be consulted for the use of sunscreens and the appropriate time and type of scar revision suitable for each individual. Many scar revision procedures in both adults and children can be done under a local anesthesia as an outpatient, with the patient able to go home following surgery.

Fred Suess, M.D.
San Francisco, California


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