Daily Skin Fix

RIP Liz:
10 Reasons Elizabeth Taylor was beautiful

Beautiful, witty, talented and compassionate Elizabeth Taylor died yesterday. One of our greatest film stars, worldwide celebrity and AIDS activist, she lived a fascinating, colorful, and public life from her early days as a child star until her last day on earth.

I have always thought that Liz was stunningly beautiful, and here’s why:

1. Her gorgeous, almond shaped, violet eyes, with a dark luxurious fringe of eyelashes were her most memorable feature. The contrast of the dark lashes increased the intensity of her unusual eye color. The darkening of irises at the outside rim, visually increased the whiteness surrounding them. The eyes are our most expressively human trait, and as humans we are instinctively drawn to them.

2. Dark thick eyebrows, not over-plucked, they start and stop where they are supposed to, with a beautiful arch in exactly the right spot. Here’s a woman who knew how to shape them right.

3. Classic oval facial shape, with great bone structure. Elizabeth’s high, round cheekbones were the widest part of her face, giving her the “triangle of youth”. Although I thought she had a little too much plastic surgery in her later years, as a young woman, she was perfect.

4. Facial symmetry is the hallmark of youth, and Liz had marked facial symmetry with the ideal proportions.

5. Hair that is a dark, jet black naturally turns a beautiful silver gray or white with aging, as did hers. Those of us with brown hair just go drab.

6. In her youth, her naturally pale porcelain skin gave a striking contrast with her jet black hair, eyebrows and lashes, and also with her luminous eye color, enhancing the effect of each. If I had been her dermatologist, I would have warned her not to overdo the sun during the late 60′s and 70′s because you could see the effects in her later years.

7. In her heyday, Liz’s measurements were reported, and I believe it, as 36C-21-36, or a waist to hip ratio of 0.58. Studies show that the waist-hip ratio of women is very strongly correlated to the perception of attractiveness across all cultures. Although there are some cultural differences, women with a 0.7 waist-hip ratio are invariably rated as more attractive by men, regardless of their culture. This ratio has a very high correlation to female fertility, and unknowingly guide men’s evolutionary choices. And yes, men are usually guided unknowingly by their evolutionary choices. And at that time she was even better than the ideal and she was not surgically enhanced. Unfair.

8. A naturally graceful, sensual way of carrying herself, combined with that body–look out.

9. Elizabeth was a serious actress with a varied range, combining a knockout punch of classic beauty and amazing talent.

10. She actively came out in support of AIDS research and treatment in the early frightening days before it was socially acceptable to mention the disease or associate with AIDS patients. I remember the media frenzy and her pubic support of Rock Hudson, her co-star in Giant, when he publicly revealed his approaching death from AIDS and his homosexuality.  She organized “A Commitment to Life”, a celebrity event to benefit AIDS research and then helped organize the very influential worldwide AIDS organization AMFAR.

Eight marriages, 4 children, 9 grandchildren, 70 film credits, 3 Oscar nominations, 2 Oscar wins, multiple medical crises, 3 hip replacements, benign brain tumor, tracheotomy, congestive heart failure, struggles with her weight, religious conversion, addiction, recovery, tireless philanthropist, charity organizer and supporter, and owner of some of the world’s most magnificent jewelry. And she found time to start her hugely successful fragrance line. An amazing life, and all lived in the public eye.

Though it all Elizabeth Rosemond Taylor didn’t take herself too seriously, she just put one foot in front of the other. When she fell, she got up again. Through good choices, bad choices, scandals, failings, successes, happiness and heartbreak, she kept on going. There is a lesson in that.

RIP Liz

Skin Tightening:
Prevent, slow down and reverse early changes

What to do now so you won’t regret it later

There is really quite a bit that you can do to slow down and prevent sagging of the skin, and the earlier you start the better results you will get. However–and what a bummer– there is a genetic factor to sagging and early wrinkling of skin, especially in women. If the older women in your family, especially your mother, had early sagging and wrinkling, then it is even more important that you start early.

The best way to slow down this progression is prevention: don’t tan, consistent daily sun protection with sun block every day; avoidance of weight fluctuations, toxins and smoking; eating a healthy non-glycemic diet; daily use of topical retinoids, antioxidants, peptides, growth factors, fruit acids. Dealing with estrogen loss helps too.

Of these the most important are to avoid weight fluctuations, don’t tan, and don’t smoke. When you gain weight the skin stretches to accommodate the increased volume. If it didn’t you would get stretch marks. Then you lose it and there is less volume inside the “sack” and it sags. The younger you are when this happens, the better the skin can bounce back because the natural elasticity is still good. The older you are–not so much. Chronic sun exposure and tanning destroy the collagen and elastic fibers and turn them into this gunk called elastosis–the yellowish bumpy stuff you see under the skin when you stretch it early on, and is visible to the naked eye later. Smoking puts carbon monoxide and other toxins in the skin through the blood vessels reducing the amount and health of the nutrient bringing blood flow to the skin and killing collagen and elastic fibers.

If you smoke, you get damage, if you tan–you get damage. If you smoke and tan (or just get a lot of unprotected sun)–you get more than double the damage of either one alone–more like four times the damage. Somehow they make each other much worse. And then, especially with weight gain, you stretch this skin that is damaged with grungy elastic and collagen fibers and the skin can’t recover. Just like that bra you washed and dried too many times, the elastic crumbles and there is no bounce back at all. The non-invasive and invasive procedures we will discuss later work a lot better on skin that has some natural elasticity and tone.

A glycemic diet can also damage the collagen and elastic fibers, making the skin more stiff and reducing elasticity. And it often leads to weight gain. But I have to admit that I have a very hard time following my own advice on this–unfortunately I love sugar and carbs.

When estrogen naturally decreases around menopause, many women see thinning and wrinkling of the skin–often within a year. As everyone knows, estrogen supplementation is a controversial and individual medical decision that depends on symptoms, the general risk/benefit ratio, and the risk/benefit ratio to an individual based on their own health history. You and your doctor will decide what is right for you. I will say this–estrogen helps reduce wrinkling, sagging and thinning of skin.

We covered home treatment with daily use of topical retinoids, antioxidants, peptides, growth factors, fruit acids in the post Skin Resurfacing the Easy Way. Read it. Do it.

All these lifestyle and home treatments help prevent and reduce the development of wrinkles, keeping the skin smooth and lessening the need for skin resurfacing. They also help prevent and reduce sagging, lessening the need for more invasive skin tightening. Are they going to significantly tighten skin–no. Are they doing to slow things down–yes. Are they going to help prevent things from getting worse–yes. Are they relatively easy to do–yes. Will they help your overall health–yes. Are they really expensive–no. Is there a reason you should not do these things–no.

Do any of the devices sold on late night cable to tighten skin work? You know the muscle exercisers, the electric stimulators, the light treatments? I have never seen any evidence that they do with the exception of the LED (light emitting diode) treatments. There is some evidence that the home LED devices may provide some minimal amount of collagen stimulation. The problem is that they are so much less powerful than the ones we use in the office, they have to be used for a long time each day (30-60 minutes) and you really don’t have any way of knowing whether the one you use works or doesn’t as there are multiple ones out there, knock offs and counterfeits. Do I use them–no.

Next: How to fix sagging skin without surgery

So now we are on the last of the 5 R’s of treatments in a cosmetic dermatologist’s anti-aging aesthetic plan: Repair, Relax, Restore, Resurface, Redrape

• Repair Sun Damage–Reduce Lines, Wrinkles, Spots, Sagging
• Relax Muscle Action–Reduce Lines
• Restore Volume–Reduce Lines, Restore Fullness and Lift Sagging Skin
• Resurface Skin Texture–Reduce Lines, Wrinkles, Pore Size, Scars
• Redrape Sagging Skin–Lift and Firm Sagging Skin

On to Anti-Aging Skin Rejuvenation Plan Step #5–Redrape Sagging Skin

It is an unfortunate fact of life–gravity will win. But we can put up the good fight in the meantime.

Young skin is tight skin. It has a natural elasticity that causes it to rebound to its original position quickly when it is stretched. It holds everything up where it is supposed to be. The natural fat pads are held up under the eyebrow, up tight under the eye, and up high on the cheek. Skin feels firm. Eyelids are smooth and tight. The jaw line is tight, with the skin up against the bone. The operative word here is “up”.

With aging, collagen and elastic fibers are broken down and the skin looses elasticity as a result of repeated exposures due to damaging effects of the sun, gravity, smoking, environmental toxins, glycemic diet, weight fluctuations, and hormonal changes. Skin feels too loose. Everything starts to sag. Patients say “my face, and everything else, is falling”. The fat pads end up dragging the eyebrows down, as bags under the eyes, and the cheeks end up at the lower face as jowls. Neck is flabby. And let’s not even go below the neck.

Adding to the loss of elasticity is the loss of volume in the face. With aging, loss of fat, collagen and bone structure cause the skin to be too loose around too little volume. When this happens, gravity takes over and the skin sags. When this occurs, the skin needs to be tightened and everything needs to be lifted–it needs to be redraped. Sometimes volume needs to be replaced in the areas where it has been lost. Tightening, lifting,  and redraping restores tighter more youthful skin.

Lifting and tightening skin can be divided into: methods to prevent or slow down sagging, treatments to give modest tightening, and  procedures that are required when sagging is more pronounced.

Next: the best ways to prevent or slow down sagging skin

Skin Resurfacing
Prevent and Correct Early or Moderate Changes
With Dermatology Office Treatments

When you are starting to see changes that you don’t want to see, it’s time to start with some of the lower intensity in-office resurfacing procedures. You are in this category of early to middle changes if you are seeing loss of glow, dullness, clogged pores, fine lines and the beginning of brown spots.

Options are light to mid-depth chemical peels and medical microdermabrasion.

Chemical Peels

Although chemical peels have been around for awhile, they are still very helpful. Chemical peels use surface agents to exfoliate and regenerate tissue by destroying layers of the epidermis. They can be divided into 3 levels corresponding to the depth of penetration in the skin. How deep they penetrate is directly responsible for what kinds of problems they can treat, the recovery time and the risk of side effects. Superficial peels include the alpha hydroxy acid peels (Glycolic Acid), beta hydroxy acid peels (Salicylic Acid). Mid level chemical peels include low strength Trichloroacetic Acid (TCA). Deep chemical peels include high strength TCA and Phenol.

With the advent of lasers, we, and many dermatologists are no longer performing mid or deep level chemical peels because of the increase in complications and reduced predictability compared to laser resurfacing.

Superficial chemical peels are used to sun damage (photoaging), acne, melasma, brown spots, texture and dullness. They may improve fine lines over time. These peels usually require a series of treatments at an of 6 treatments at 2-4 week intervals. They may be combined with acne surgery, which is the gentle removal of blackheads and pimples with sterile instruments.

Usually your face is red for a few hours and has small crusts if blackheads or pimples were removed. The skin feels tight for a day or two and then lightly peels at day 5. Patients who are treated for anti-aging return to normal activities immediately.

SilkPeel Particle Free Precision Microdermabrasion With Dermal Infusion

Microdermabrasion involves a controlled stream of particles to exfoliate the skin. SilkPeel particle-free microdermabrasion treatments use a refined diamond tip to precisely exfoliate and infuse the skin with topical dermaceuticals at a controlled intensity that improve results. There are specific dermaceutical solutions for bleaching, acne and anti-aging.

SilkPeel Dermalinfusion is used in anti-aging treatment to exfoliate dull dead skin, increase smoothness and glow, treat melasma, some brown spots and give your skin an overall healthy appearance. Treatments may improve fine lines over time. SilkPeel treatment usually requires a series of treatments at an average of 8 treatments at 2-4 week intervals.

After SilkPeel treatment your skin may be flushed for an hour. Otherwise it usually has no flaking, tightness or peeling. Patients return to activities immediately with no down time. It is especially popular before a big event, like a wedding, reunion or holiday.

Both Chemical Peels and SilkPeel are great skin resurfacing options for early to moderate aging changes.

But sometimes you need more than a tune up.

Next: Skin Resurfacing–when you need an overhaul.

The easy way–preventative maintenance with at home treatment

Preventive maintenance, ideally beginning in your early twenties, is the easy way to resurface your skin–before you even need it. At home treatment on a daily basis can prevent many of the changes that would require more aggressive treatment later. Even if you start later, either because the options weren’t around earlier, or because you just didn’t get around to it, you can get a good amount of improvement from relatively simple home treatment.

The key to success with this option is consistent and daily treatment with anti-aging cosmeceuticals, botanicals, exfoliants, retinoids and sunscreen. I see patients who start and stop programs, don’t stick with it, and blow off many days of treatment because they are too rushed to stick to a routine or who only wear sunscreen “when I am going to get a lot of sun”. There really is no reason not to get on a program and stick with it. It will pay off in the long run.

The 5 key components are:

• Cosmeceuticals
• Botanicals
• Exfoliants
• Retinoids
• Sunscreen

Cosmeceuticals are cosmetics that have effects on the skin. The main groups are the peptides, antioxidants, growth factors, and vitamins. They improve fine lines, roughness, blotchy pigment, loss of elasticity, dullness, acne, and stimulate collagen production.

Botanicals are plant derived compounds that are used for their antioxidant, anti-inflammatory, exfoliant, moisture balancing, and collagen stimulating properties.

I will talk about skin care, cosmeceuticals, and botanicals more in a future column with specific information about the individual compounds. In the meantime, there is a complete listing of cosmeceuticals and botanicals with their historical use; scientific, botanical, and trade names; and the scientific evidence of activity on the website in our Education Center.

Retinoids include over-the-counter retinol, and the prescription synthetic vitamin A derivatives tretinoin (Retin-A, Renova, Refissa), tazarotene (Tazorac), and adapalene (Differin).

Retinoids enhance collagen and elastin production thereby diminishing wrinkling, improve discoloration and roughness, and reduce pore size.

Retinoids do make you more sensitive to the sun, and should be used with daily sunscreen. We used to tell patients not to use them if they were going to get sun exposure but now we know that, within reason, you may use them as long as you use good sun protection. If you are going to the beach, lake, or skiing discontinue them for a few days before exposure.

They shouldn’t be used by pregnant or nursing mothers.

The current cost of Refissa (1 tube, 40 gm) $146.00; for Tazorac (1 tube, 30 gm) $170.00-180.00; Differin (1 tube, 45 gm) $260.00. One tube of either of these should last you about 4 months or more.

The biggest drawback, and the reason people discontinue them, is that they are irritating to the skin. I often start patients off on every other or every third night use and work up to every night. Another option is to start with the least irritating, Differin, and move up to the more irritating Refissa (for normal-dry skin) or Tazorac (for oily or acne prone skin). In addition you can either mix moisturizer half and half with them or apply moisturizer before (if you are having redness, itching or irritation) or after (if you are just dry) you apply them at night.

You should apply a pea size amount to the face after cleansing and toning in the evening. The skin should be completely dry before application. You should also apply it to the neck, back of the hands and forearms although most people can only apply it there every other night because of irritation. Those areas get aged from sun exposure just like your face. You don’t want to be one of those women who say “I hate the spots on my hands”. And while you are at it remember the sunscreen to neck, forearms and backs of hands. You need both.

Mild stinging, mild redness and mild peeling and flaking may occur during the first several weeks and on occasion when using Refissa, Renova, Retin-A, Differin or Tazorac.  This is normal.  Flaking is normal, soreness and irritation are not. To help reduce irritation, do not use washcloth, facial brushes, mesh scrubs, daily facial cloths, mineral powder brush or granular exfoliants on the face.

Discontinue these products to affected area 1 week before waxing or bleaching, or before other procedures (peels, microdermabrasion, facial, acne surgery, hair removal, laser treatments as directed.) You don’t want to end up like the bride who waxed three days before the wedding and disaster ensued.

I am a strong advocate of daily retinoid use, I feel that almost every patient desiring to prevent aging, or correct existing damage should use them. There is so much proven scientific data behind them they are still considered the gold standard in topical anti-aging treatment.

Daily, year round, sunscreen use is essential or you are just undoing what you are trying to do. Once again I refer you to my post “Quit complaining and wear your damn sunscreen”. Just do it.

If you start early on a home preventative anti-aging program you will have to do less later on and you will look better both today and tomorrow. It is never too late to start, you will see improvement. Stick with it. It is really a no-brainer.

Next: A tune up: In office treatment for early  or moderate changes

Cosmetic dermatologists achieve a youthful, aesthetically pleasing, attractive face by following the 5 R’s of anti-aging treatments: Repair, Relax, Restore, Resurface, Re-drape.

• Repair Sun Damage–Reduce Lines, Wrinkles, Spots, Sagging
• Relax Muscle Action–Reduce Lines
• Restore Volume–Reduce Lines, Give Youthful Fullness and Lift Sagging Skin
• Resurface Skin Texture–Reduce Lines, Wrinkles, Pore Size, Scars
• Re-drape Sagging Skin–Lift and Firm

Let’s go on to Anti-Aging Skin Rejuvenation Plan— –Step #3–Restore Volume

One of the most aging changes that happens over time is the loss of volume in the face. With age there is a loss of  fat, muscle and bone causing an aged, hollowed out, haggard appearance. In youth fat is under the eyeballs, in the cheeks, the temples, and the eyebrows. Over time this is reduced and drops which causes a “flat” face. This can be seen most dramatically in profile. Patients tell me “my face is melting.”

In youth the widest part of the face is the cheekbones, narrowing to the chin; called the “triangle of youth.”  With aging, volume is lost under the eyes leading to under eye bags,  hollows, and dark circles. The eyebrows fall when fat is lost, causing hooding of the eyelids. The high apple of the cheek falls. As the cheeks descend they cause deep lines from the side of the nose down past the corners of the mouth. These lines are like an arrow pointing downward, and appear to drag the face and neck downward.  The temples are hollowed, often with visible veins. The jaw line widens and the upper face narrows. The “triangle of youth” becomes the “pyramid of age.”  The skin’s “envelope” becomes loose over too little underlying structure leading to sagging, a flat and aged appearance and with jowls.

Adding to this is loss of volume in the lips as they become thinner and roll inward. Loss of bone around the mouth compounds the collapse of the mouth. Both cause a pinched and wrinkled mouth with radiating lines.

So basically, everything is falling. Cosmetic dermatologists call this deflation and descent.

And let’s not even talk about anything below the neck.

In the past, the looseness of the skin and the sagging was treated with a face lift alone, But that often lead to a gaunt, skeletonized, “caught in a wind-tunnel” look. The loss of volume needs to be corrected for a natural, rejuvenated appearance.

In any individual patient, either the volume loss or the looseness may predominate. But often it is a combination of both. If so, the problem of loss of volume and loose skin both need to be corrected. Although some patients certainly require a surgical face lift, we see many patients who successfully receive volume replacement only, or volume replacement combined with non-surgical tissue tightening with Thermage, sometimes called Therma-Fill. We will talk about this aesthetic option later.

Volume loss changes occur over time in us all, but may occur earlier in some than others. Of course, smoking or sun damage to collagen and elastic fibers cause the face to fall quicker and increases severity of facial lines. Individuals who have lost a great deal of weight, runners, and very thin individuals often show these changes earlier than others. I have a saying, “At a certain age, you have to choose between your face and your butt.” But actually you don’t– if you are willing to restore the lost fullness to your face.

So what on earth are we going to do?

Next: What we are going to do.

So now we move on to the next step of a cosmetic dermatologist’s anti-aging skin rejuvenation plan of Repair, Relax, Restore, Resurface, Re-drape.

Relax Muscle Action–Reduce Lines

We all have characteristic facial expressions which often run in families. Many patients tell me “my mom (or dad or grandmother) have horrible frown lines.  I am starting to get them too and I am afraid mine will be just as bad–help!” Characteristic facial expressions are set early in life, usually by 5 or 6 years old and sometimes even earlier. Once set in childhood they are very difficult if not impossible to change.

Frowns are often not due to anger as is commonly supposed but rather concentration. Unfortunately others subconsciously perceive the frowner as being angry. Patients say “I am so tired of people asking me why am I mad–it makes me mad”. Many people have what are called “hyperexpressive faces” and have a lot of frown activity, forehead expression and even crunch their noses up during animation (called bunny crunch or wolf lines). This gives horizontal forehead lines, frown lines and lines leading down from the bridge of the nose onto the cheeks.  Smiling or squinting leads to crow’s feet at the corners of the eyes. At first these lines appear only during expression. Over the years they become permanent, occur at rest and get deeper and deeper.

Now we are able to relax the muscles that cause these lines and reduce the angry, stressed or tired appearance. Injections of pharmaceutically prepared  botulinum toxin (Botox or Dysport) are used to treat the specific lines on the upper face that muscle related such as frown lines, forehead lines, and crow’s feet.  A “Botox brow lift” will lift the eyebows opening up the upper eyelid and reduce hooding. Some lines under the eyes can be improved. You look more rested and less stressed or angry.

In the lower face and neck Botox or Dysport are also used for anti-aging. Injections in the chin reduce muscle activity that leads to dimpling and to reduce the turn down of the corners of the mouth that occurs with age. They are also used to treat a “gummy smile” where the upper lip rises up too far with smiling showing more of the upper gum than is desirable. The muscles at the outside of the jaw which enlarge with teeth grinding can be slimmed. Bands of muscle in the neck can be softened reducing “cords” and improving the jowls.

• All in all Botox and Dysport have been great additions to our anti-aging treatments, allowing both reversal of signs of aging and prevention of progression. And contrary to the ads, nothings “better than Botox”.

Next–questions and answers about Botox and Dysport.

As promised here are my top three anti-aging choices for repairing sun damage:

1. Daily sunscreen, year round. I have been doing it every single day for 27 years. Do I need to refer you again to the previous post “Quit complaining and wear your damn sunscreen“?
2. Daily retinoid (tretinoin 0.05% cream) use. Again I have done this every single night for 27 years.
3. A series of IPL photorejuvenation treatments–usually 3-5. Gives a creamy complexion and is very effective in reducing the signs of aging sun damage.

An often overlooked area in sun damage protection and  treatment–the backs of hands, backs of forearms and the neck. Look at the sun exposed back of your forearm. Now flip it over and look at the sun protected inside. Do I need to say more?

So here is your bonus secret–Just treat the skin on the back of your forearms and hands and your neck exactly the same as your face, especially sunscreen every single day. Many people can only tolerate retinoids to these areas every other night because of dryness and irritation. So alternate tretinoin 0.05% cream (Refissa) one night and a peptide cream or lotion on the other nights. I use our fabulous peptide and antioxidant serum Line Diminisher every other night alternating with Refissa.

When I see a patient for an anti-aging skin rejuvenation evaluation, the first thing I look at is the quality of the skin. Spots, broken blood vessels, large pores, roughness, growths, milia cysts, brown discoloration, scars, acne scars, crépiness, elastosis, fine lines, wrinkles, loss of elasticity, and dullness all decrease the quality of the skin.  Most but not all of these are from chronic  sun damage.

Young skin is smooth, without blemishes, growths, cysts, brown spots, broken blood vessels, and elastosis. It has good elasticity and reflects light well giving it a luminosity. Interestingly studies have shown that people’s impression of the age of another person is primarily determined by the absence of spots, growths and the presence of luminosity. In other words a person with spots and growths but minimal wrinkles looks older than a person with few spots and more wrinkles.

That’s why it’s important in anti aging treatment to “clear the canvas and start over”.So we start with Step #1–Repair Sun Damage. Options to repair sun damage to look younger are:

At home topical surface treatments

• Cosmeceuticals and Skin Care
• Retinoids

In office aesthetic procedures:

• LED Photomodulation
• Particle Free Precision Microdermabrasion/Dermal Infusion
• Chemical Peels
• Intense Pulsed Light (IPL®)
• Fraxel® Laser Treatment

Treatments You Can Do At Home

• Cosmeceuticals and Skin Care

Antioxidants (like Green Tea, Grape Seed, Soy) help prevent and repair the damage from free radicals released by sun exposure. Hydroxy acids (glycolic and multi-fruit) exfoliate dullness and pigment, stimulate collagen production, increase elasticity. Anti-aging peptides (like  Matrixyl™ (pal-KTTKS) and Matrixyl™3000 ) reduce fine lines and increase collagen and elasticity. Stabilized vitamin C (Magnesium Ascorbyl Phosphate) reduces collagen breakdown and protects against UVB damage. To find out more about the science behind cosmeceuticals and the history and science of botanical ingredients in skin care check out our web site. And most important–Daily use of a broad spectrum sunscreen with a SPF of 30 or more is absolutely essential.

• Retinoids

Retinoids are prescription vitamin A derivatives that reverse the effects of photo aging. Over time daily use will improve fine lines, brown spots, dullness, roughness and will give some degree of improvement in pore size. There are several forms of retinoids, I find that for most adults Refissa, a 0.05 percent branded generic tretinoin formulation is the best choice. It is the same as the older 0.05 percent Renova which was discontinued when the patent ran out and replaced with a lower strength and a pump version.

Next: anti aging sun damage treatment procedures.