Skin rejuvenation can be confusing to even the most informed patients, and understanding how directed and combination therapies act to deliver results, is crucial. In general, the degree of effect is directly related to the depth of penetration in the skin. Skin can be divided into three layers, the epidermis, constituting the outer layer, and the dermis, the inner two layers. Therapies are classified as superficial, medium, or deep based on their depth of penetration. The three most common treatment modalities used for skin rejuvenation are chemical peels, mechanical dermabrasion, and lasers. All three modalities can be used for superficial, medium, or deep rejuvenation.

Medical grade skin care products act to hydrate skin, increase exfoliation, build collagen, and treat skin discolorations and blemishes. Topical vitamin therapy is a common, minimally invasive therapy, of which, the most relevant to skin rejuvenation is tretinoin, a vitamin A derivative. It acts to rejuvenate, by thickening the epidermis and decreasing photoaging, including: dyschromias and brown spots, in the short term and increasing collagen production with a decrease in fine wrinkles with longer courses. Hydroquinone and Kojic acid are topical bleaching agents that inhibit melanin production: lightening age spots, imporoving melasma, as well as other causes of hyperpigmented blemishes.

Superficial rejuvenation primarily includes glycolic acid and jessner chemical peels and acts on the epidermis, decreasing discolorations and blemishes while allowing the germinal layer of the epidermis to regenerate. Additionally, they also act to increase superficial collagen formation in the dermis, improving fine wrinkles. Lasers can be used to perform "micropeels," acting on the epidermis only, with benefits similar to the other superficial rejuvenation procedures.

Medium or deep rejuvenations act to the level of the dermis and are used to treat deeper photoaging and wrinkles. By increasing the depth of penetration, the overall effect is increased due to improved recruiting of fibroblast activity and collagen deposition. Consequently, there is also an increased risk of complications with deeper rejuvenations, which can include hypopigmentation and scarring, along with prolonged healing times. Medium and deep chemical peels include jessner/TCA peels and phenol peels, respectively. Dermabrasion is an effective resurfacing technique that uses mechanical abrasion to remove skin, layer by layer. Today, it is largely used for scar resurfacing/revision and the treatment of well formed wrinkles around the mouth. The depth of treatment with conventional lasers is primarily controlled by the type of laser used, the power settings, and the number of passes performed. In general, less aggressive settings and a decreased number of passes, result in less down time, a more superficial treatment, and subsequently less impressive results. In addition to the superficial rejuvenation benefits, the deeper rejuvenation procedures improve photoaging in the dermis along with deeper, more robust collagen deposition with more significant wrinkle reduction.

Fractionated laser therapy has been introduced to deliver results comparable with traditional laser therapy, but with decreased healing time. Fractional lasers work by treating a percentage of the skin surface area, usually between 5-30%, with spaced, deep penetrating, laser microcolumns that leave intact bridges of skin between the treated areas, thereby, decreasing the risk of complications associated with conventional full skin resurfacing techniques, while maintaining the deeper benefits. Thermal energy is delivered to the deeper dermal elements to trigger collagen formation, while treating the deeper photoaging dyschromias and brown spots, and allowing for faster recovery due to the intact bridging of skin. Today, the state of the art in laser resurfacing techniques combines conventional full skin resurfacing to remove the epidermis, improving the epidermal elements, followed by fractionated therapy to treat deeper photoaging and stimulate deeper collagen formation and wrinkle reduction.

Skin rejuvenation therapy must be tailored by the patients, not the physician’s goals. Aggressive therapy can lengthen healing times and increase the risk of complications, but also have the best results. Maintenance therapy with medical grade skin care products and superficial rejuvenation agents, with interval medium to deep rejuvenation therapy is ideal for optimal outcomes. Skin resurfacing/rejuvenation should be viewed as complimentary, not a substitute for face lift surgery. The choice of resurfacing agents used to achieve the patient’s goal is collaborative and based on the comfort of the patient with the rejuvenation agent and the experience of the physician.