By 2g1c2 girls 1 cup

Dmystified- should I be taking a vitamin D supplement?

 

The simplest way to boost levels is by soaking up ultraviolet rays, prompting the skin to manufacture D, but in gray northern climates the sun is too weak from November through February to trigger the viatamin’s synthesis.  Even in sunnier environments like Arizona or California, deficiency is common because most people are sun-phobic.  A sunscreen as weak as SPF 8 can inhibit the vitamin’s production, and SPF 50 (mine) can shut down the production entirely.  Experts have long known that D, along with calcium, boosts bone strength.  And new research shows that the vitamin may help prevent breast cancer by decreasing cell proliferation, and that D levels are low in those with MS.  So what is a girl to do?

To D or not to D- that's not the question, what a funny tanline she'll have!

To D or not to D- that's not the question, what a funny tanline she'll have!

Despite its nickname “the Sunshine Vitamin” people are still afraid to throw aside the risks of sunbathing [i.e.wrinkles, agespots, and skin cancer] for the benefits of nature’s best production source of Vitamin D, a vitamin that is currently claimed to prevent stress fractures in bone, ward off breast cancer, protect against multiple sclerosis, and even boost immunity against the flu [I wish that I had known that LAST week]!  The confusion is actually the fault of physicians, for we in the medical community have been saying for years to wear your sunscreen!  All the time!  Now that people are becoming more and more aware of the bad side-effects of the sun, we have pulled a complete 180 turnaround and now many of my clients in Manhattan wear sunscreen even when they are indoors because they are afraid that too much sunlight is streaming through their office windows.  Most people know that Vitamin D is good for you, but for the most part, sun exposure is bad for you, and the studies up to this point have been inconclusive as to which type of Vitamin D to take if you did want to add it to your supplement regimen.  According to Anthony W Norman, Ph.D., a long-time D researcher and professor of Biochemistry at the University of California at Riverside vitamin D is crucial for good health.  The catch is getting enough; according to the latest estimates, half of us fall short because we are sun deprived.  

  1. Take a supplement- 1,000 to 2,000 I.U.’s of D3 per day.
  2. Eat a D rich diet- salmon, tuna, sardines, milk, and eggs.
  3. Soak up (a little of) the sun- just 10 to 15 minutes a few times a week on sunscreen-free arms  and legs will provide all of the D that you need.

So, getting the appropriate amount of Vitamin D is as easy as 1,2,3!

 

Have a Beautiful Day!

Dr. Lisa

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Posted in Anti-Aging | Comments closed

Botox- are you a man or a mouse?

 

Oh Boy, Botox makes me JUMP for joy!

Oh Boy, Botox makes me JUMP for joy!

 A controversial study raises the concern that the popular anti-wrinkle treatment Botox may travel from its injection site into the brain.  For the study, published in April 2008 in the Journal of Neuroscience, researchers injected botulinum toxin--the active ingredient in Botox- into the whisker muscles of rats.  Researchers then looked at the connected brain areas for signs of the toxin.  Within three days of the injection, they found remnants of a protein broken down by the toxin in an area of the brainstem.  The toxin also moved from one hippocampus, which controls long-term memory and spatial navigation, to the hippocampus on the oppossite side of the brain, and from the superior colliculus, the part of the brain associated with eye-head coordination, back to the eye.  The study found that brain cell activity was disrupted both where botulinum neurotoxin was injected and in some of the distant-but-connected sites. 

But, the dose injected into the rat's whisker pad was about 150-fold higher than the dose typically used for facial twitching.  The Italian scientists also injected the neurotoxin into the hippocampus and the superior colliculus, the brain region that receives signals from the eye.

Joseph Jankovic, MD, professor of neurology and director of the Parkinson's Disease Center and Movement Disorders clinic at Baylor College of Medicine in Texas conducted the first double blind, placebo-controlled study of botulinum neurotoxin A in the early 1980's.  Dr. Jankovic  said that he has treated thousands of patients with botulinum toxin and has never observed side effects related to adverse activity of Botox in the brain or spinal cord.  He added that no such CNS effects have been described, even in patients injected therapeutically or inadvertently with very high doses of botulinum toxin.

Dr. Jankovic said that Botox is safe when used appropriately and by trained physicians.  First approved by the FDA in 1989 for blepharospasm, further studies on strabismus, facial spasm, cervical dystonia, hyperhidrosis, and cosmetic indications subsequently led to the federal green light.  A list of reported side effects for each of these conditions is provided on the FDA website and on the labeling.

But, Dr. Jankovic said that toxic spread into the brain would have resulted in cognitive, spinal, and other neurological problems that have not been documented in any of the millions of patients treated with Botox worldwide and thousands of articles published on its clinical use.

So, what to make of all of this data?  The bottom line is that Botox can be found in the brains of rats, when it is INJECTED into the brains of rats--DUH!  So, despite popular belief, it IS possible to have both Beauty and Brains!

To see my interview with Fox 5 News NYC on this very topic, go to my official website www.lisazmd.com and click on the news section!

Have a Beautiful Day!

Dr. Lisa

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Posted in Botox, DOCTOR TALK- Scientific Journal Update | Tagged | Comments closed

Tighty-whities are back in, better tighten your skin!

See how loose the measuring tape gets after Thermage?

See how loose the measuring tape gets after Thermage?

Thanks to evolving technologies in laser and light source medicine more and more men and women are choosing to postpone having a surgical facelift well until their early to late 60’s if at all.  Most patients who opt for a nonsurgical approach to rejuvenation site several reasons including fear of an overly- pulled and unnatural look , fear of the risks from general anesthesia,  fear of the surgical procedure itself, and an un-willingness to suffer through the necessary downtime to allow for the healing to take place.  As an oculoplastic surgeon, it is a given that I like to operate.  Surgical procedures do have their place, and in my years of taking care of patients I have developed a keen sense of what people are looking for as far as a result is concerned, and sometimes that means a face-lift (rhytidectomy), or a neck-lift (platysmaplasty), or both.  Generally, the conversation begins when I ask my patient to “show me with your hands what you want to achieve…”  [every woman knows  this maneuver because we do it all of the time in front of the mirror at home when no one is looking]!  If the patient shows me a dramatic difference with his or her fingertips, I say, “that’s a face-lift.”  This usually elicits a wide-eyed look of shock and the statement, “but, I don’t want surgery.”  That’s when we can enter into a realistic results- oriented discussion of what non-surgical skin-tightening treatments like Thermage can deliver.


Before I begin to explain to you what Thermage is and how the procedure is performed, you should know a little bit about me.  I am on oculoplastic surgeon (a doctor that specializes in eyelid surgery) and a laser skincare specialist.  My fellowship training in minimally invasive techniques of facial rejuvenation was a private fellowship with a surgeon who maintained practices in New York City and Rio De Janeiro, Brazil.  I am a member of the American Society of Lasers in Medicine and Surgery and have extensive experience with laser and light source technologies in the field of aesthetic medicine.  I have the pleasure of treating an international clientele who visit me from all corners of the globe.  This compels me to stay in step with the global community by participating in international meetings, most recently  the 2008 World Congress on Aesthetic and Anti-Aging Medicine in Paris, France. In brief, I am constantly searching for the best technologies available to offer my elite clientele.  I have been using Thermage since its inception and I have seen the technology evolve up until the present day.  In my opinion, Thermage is the best skin-tightening technology available and I have performed literally hundreds of procedures in my practice.  I have trained countless physicians how to perform this procedure safely and effectively and I am proud to have received the Thermage Pinnacle award two years in a row.  You could say that I am considered something of an expert in Thermage.     

What is Thermage and how does it work?
 

Thermage is a nonsurgical skin tightening procedure that is performed in the doctor’s office. Thermage uses radiofrequency energy (radiowaves) to lift and tighten the skin. Here is how it works.  Our skin is comprised of several layers, the surface layer of the skin is called the epidermis.  This is the skin layer that burns or freckles when we are in the sun.  Below the epidermis is the dermal layer, which consists of many proteins that give our skin structural support.  The two main proteins are collagen which provides tensile strength, and elastin which lets the skin “bounce back” by giving it elastic pull [hence the name].  Below the dermal layer is the layer containing fat, blood vessels, and sensory nerves. When we are younger, the collagen in our skin is abundant and in a tight rope-like meshwork. As we age, sun exposure, genetics, smoking, and gravity makes the collagen less abundant and it loses its organized network, and the rope begins to fray. This is what causes our skin and the supporting soft tissues in the face to sag.  Thermage works like a shrink wrap if you will. The Thermage tips have pre-programmed computer chips with a pre-set number of heat pulses.  Each burst of radiofrequency energy is sandwiched between a cooling burst of cryogen. So, I tell my patients that they will feel cool, then a little pinch of heat, then cool again.  What happens is that the pre-cooling phase protects the epidermal layer of the skin and safely transmits the RF energy directly to the precise dermal level where the collagen resides. The post-cooling phase locks the nurturing heat into the dermal layer for added effect and patient comfort.   Each little burst of heat causes the existing collagen in the skin to contract like a shrink wrap.  Patients see an immediate, subtle effect from the initial contraction of the collagen that already exists in their skin at that moment in time.  Then, about 3 months later, as a result of the skin having been heated by the Thermage procedure, the fibroblast cells (whose job it is to make more collagen) migrate to the area, lay down more collagen, and more dramatic lifting occurs gradually over time as this new matrix of collagen is spun. This is a good thing, considering that after the age of 30 years our innate collagen production decreases by 1% per year and the level of collagenase (the collagen eraser) increases.  Essentially, we are fighting a losing battle in our skin and we are our own worst enemy! 
How do I know if I am a candidate for the Thermage Procedure?
Now that you understand how Thermage works it is easy for you to understand how we determine who will be a good candidate for the Thermage procedure. The results that one can expect from Thermage depend entirely upon how much collagen exists in the skin at the time that the candidate is being considered.  The more collagen that you have, the better your initial result will be, and you can expect more profound results once the collagen remodeling begins [3 months post-procedure].  If there is not a lot of collagen left in the skin (excessive sun damage, thin, fragile, crepe-like skin) then the result will not be as dramatic because there is not a lot of collagen left to contract.  Now you can understand why I have 28 year old models coming to my office seeking Thermage as a “preventative treatment.”   Aside from the collagen level in the skin (analyzed clinically), Thermage patients should be within about 15 pounds of their ideal weight (otherwise gravity works against me) and have a solid bone structure. That’s it!
Does Thermage Hurt?
The procedure itself is not painful.  I know that there are a lot of blog sites out there, and everybody has a friend of a friend who said that Thermage hurts. Believe me, 99% of my patients have the procedure performed without the need for pain medication.  The only time I may advise the patient to take a medication is when I am treating the neck [which can be a bit uncomfortable], but nothing that one little pain pill 15 minutes prior to the procedure can’t cure.  When Thermage first came out the procedure was painful,  I’m not going to lie to you. That was during a time when physicians were still figuring out how to best use the technology and the powers were turned up higher.  Patients would require a pain-killer and an anti-anxiety medication and they were still flying out of their chairs.  Some people even requested to be “put asleep” under general anesthesia. Those days are gone.  What we have learned is that it doesn’t matter how hot the skin is, but how long the minimum temperature is maintained.  Multiple passes over the area at lower powers actually yield the best results. 

What is the difference between the old and the new Thermage NXT machine?

Another major advancement was the introduction of the Thermage NXT device in January 2007.  I was the first physician in New York City to purchase the Thermage NXT and it has made a big difference for my patient’s and my own comfort level.  The new NXT machine, coupled with the new tips, has increased the efficiency of the procedure by 30% so that my patients enjoy more dramatic, immediate effects with less discomfort.  Sometimes I have patients who have had Thermage in the past with the old technology, who claim that “nothing ever happened.” These are the hardest patients to win over, but I tell them that with the new machine and the new tips, they will look in the mirror afterwards and see results.   Another question that I get asked frequently is, “have you ever treated anybody and not seen a result?” The answer to this question is “no.”  If I don’t feel that a patient is a good candidate for Thermage, I offer another collagen boosting procedure such as facial resurfacing –[everybody leaves my office on a positive note].
What parts of the body can be treated with Thermage? 
Thermage is FDA-approved for treatment on the face, eyelids, lips, neck, hands, arms, legs, and buttocks.  In May 2008, I was the first physician in New York City to debut the new Cellulite treatment tip.
What is a Thermage Tip?
There are a variety of Thermage treatment tips available, and I have all of them in my office.  The tips are one use per patient only.  With the exception of the eyelid tip the Thermage tips measure 3.0 cm2.  The Thermage STC tip is for the face.  The eyelid tip is smaller and the heat penetrates less deeply taking into consideration that the eyelid skin is the thinnest skin on the body.  The hands also have a special tip that penetrates less deeply because the hands have little subcutaneous fat.  The Thermage DC tip is for treating the body and heats a little more deeply.  Finally, the Thermage CL is the exclusive cellulite tip that has undergone some adjustments  in its cooling parameters to address some of the factors that give rise to cellulite formation including increasing the bloodflow to the area and repairing the damaged collagen that allows for the fat to dimple beneath the skin. 

What can I expect during the procedure? 

I tell all of my patients that I know exactly what all of my procedures feel like because the first patient that gets treated with any new technology is me!  I have performed Thermage on my face twice and on my eyelids twice.  First, the patient washes his or her face, signs a consent form, and then I take pre-treatment photographs.  Pain medication as needed is provided after the consent is signed.  A sticky patch is placed either on your back, your upper arm, your stomach, or your thigh (depending upon which area is to be treated) and you are then connected to the machine. This is the grounding pad that captures any stray radiowaves circulating in the skin near the treatment area.  The first pulse that you feel from the machine will be cool only (no heat) as the machine takes a pre-treatment skin measurement of your skin’s resistance.   I start by selecting a setting that I know will be cool, then a little warm, then cool again.  This allows you to get used to the whole sensation. Then, I increase the heat in a step-wise fashion and advise you that my goal is on a scale of zero to four, zero being “I didn’t feel that at all” to four being “don’t ever do that again,” I want you to be at about a 2 or 2.5.  In other words, I want you to feel some heat, but not so much that you pull away from me. That’s it!  Once we find your comfort level, I tell you that there will be no more surprises and then we can have a nice time chatting away until the procedure is completed.
How long does the procedure take?
These are estimates only - the actual amount of time depends upon the number of pulses and tips required to achieve the desired effect.
Face = 50 minutes
Face & Neck = 1 hour and 15 minutes
Eyelids = 20-40 minutes
Abdomen = 90 minutes to 1 hour and 15 minutes
Front of legs = 1 hour and 15 minutes
Back of legs = 1 hour and 15 minutes to 2 hours
Buttocks = 1 hour and 15 minutes
Arms = 1 hour and 15 minutes
Hands = 40 minutes
Again, these are approximations and the actual time required depends upon individual circumstances.

What can I expect after the procedure?

Immediate, natural looking results!  The skin may appear to be a little flushed [like you just got off of the treadmill], but this goes away in about 5 or 10 minutes, that’s it!  There is no downtime and no restrictions are imposed upon your activities after the procedure.  You can immediately apply make-up (or not) and go about your day.  The epidermal layer of the skin is left intact; all of the important changes have occurred beneath the skin surface and will continue to occur over the next three to six months.  You can go into the sun if you like [but, please don’t!  We just spent all of this time building more collagen and sun exposure is the number one collagen destroyer].

When will I see additional skin tightening?

This is where you have to have faith.  Collagen remodeling takes at least three months to occur.  There are no exceptions to this rule for the human species.  Your body needs this minimum amount of time for this important change to occur.  However, from my experience, this is what you can expect-- The initial result will be very good.  Then in about 6 weeks, there will be the beginning of an exponential improvement in the tightness of the skin that reaches its peak at about three months and then continues to improve at a more gradual rate up until six months. 
How long do the results last?
Technically, the results last about 2-3 years.  However, we continue to get older every year on our birthday, so the aging process continues.  In practice, most of my patients like the procedure so much that they usually want to have it performed about every year and a half to two years for maintenance purposes.
How many times do I have to come back for the Thermage procedure?
Thermage is a one-time procedure.  The radiofrequency energy penetrates more deeply into the dermis than some of the other devices that rely in infrared technology.  Infrared doesn’t penetrate very well  into the skin and that is why it is always being combined with something weird like suction or laser light.  That is also why you have to go back 4 to 5 times to see the same results with infrared versus the one time treatment of Thermage. 

Who is absolutely prohibited from having the Thermage Procedure?

Those with a pacemaker or implantable defibrillator
Those with large pieces of metal in the body (if you can have an MRI, you can have Thermage)
Pregnant women
Are there any risks to the procedure?
Thermage is safely performed on people of all skin-tones.  In the past, there were reports of some people sustaining burns or fat melting, but this is typically no longer the case.  With the new multi-pass protocol using lower energies the reports of burns are rare.  Fat melting nowadays usually only occurs on purpose when the operator “stacks” the pulses [delivers 4 to 5 bursts of energy in rapid succession to a small pre-determined area].  I  encourage my patients during these “power-sets” that usually occur below the chin or on the abdomen because to quote the personal trainers, “the results are worth it!”  
Can I have Thermage if I have fillers in my face?
Yes.  Thermage has been shown to not affect the integrity of any of the hyaluronic acid fillers [Restylane, Perlane, or Juvederm], Sculptra, Radiesse, or surgically placed fat fillers.  In fact, having the Thermage procedure could potentially eliminate or diminish your needs for these fillers in the future because the nasolabial grooves are improved by the Thermage technique. 
Would you recommend the Thermage procedure?
I’ve done the procedure on myself and my mother…twice!

Have a Beautiful Day!

Dr. Lisa

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Posted in Anti-Aging, NonSurgical Body Sculpting, Thermage | Tagged , | Comments closed

Eyelid Surgery- From the eye of the beholder…

Here's looking at you kid (with my natural haircolor)!

Here's looking at you kid (with my natural haircolor)!

 

 

 

The first thing that I notice about a person is their eyes.  Many people do not know that there are oculoplastic surgeons such as myself who are trained specifically to perform cosmetic surgeries on the delicate eyelid structures.  Unlike many surgeons, when I operate on the eyelids I do not use a scalpel, but a precision Ellman Surgitron Radiosurgical device that emits radiowaves to make my incisions and to minimize recovery time and complications.  As a surgeon, I like to operate, but surgery is not the only means to recapture the look of youth.  In fact, the majority of my patients want to improve their appearance without the downtime associated with surgery.  For these patients, I have designed a regimen of nonsurgical therapies using injectable treatments, lasers and light sources, and Thermage skin tightening to improve the quality, texture, and resilience of their skin.  When used in proper combinations these treatments not only postpone the need for surgery, but actually improve the surgical result when the time comes for a procedure in the future.  But, for those who do need a little help from a surgical procedure, these are the things that I look at from a surgeon’s perspective:

 

 

PREOPERATIVE MEASUREMENTS AND OBSERVATIONS

 

Vertical Palpebral Aperture [distance between the upper & lower eyelids]

Twiggy versus mere mortals:

This is what makes the difference between having wide-open, “doe-eyed” appearance of supermodels (Twiggy), versus us mere mortals.  I once had an oculoplastic surgeon tell me that he knew that I was Czech by my “narrow vertical aperture”- I wonder how many times THAT pickup line worked?  Measuring the distance between the upper and lower lid margins will reveal the presence of a true drooping eyelid [ptosis].  The average vertical palpebral aperture is 10 mm, with the upper lid margin 1 to 2 mm below the superior limbus [“limbus” - point where the white part of the eye (sclera) and the colored part of the eye (iris) meets] and the lower lid margin at the level of the inferior limbus. 

 

Horizontal Palpebral Aperture [distance between the temporal eyelid and the nose]

Kate Moss

Ever do the trick to determine whether your eyes are too far apart or not?  You know, the one in all of the beauty magazines that say to measure one eye between your thumb and forefinger, then shift it to on top of your nose- if this is equidistant to the other eye then you are perfect- no?  Guess you didn’t grow up in the 80’s then (count your blessings). The average horizontal palpebral aperture is 30 to 34 mm. Kate Moss has a broad horizontal palpebral apeture, but a narrow vertical palpebral aperture, and the last that  I checked in, she was doing just fine.

 

Inferior Scleral Show [too much white showing when looking straight ahead]

Marty Feldman

The idealized lower lid rests at the level of the inferior limbus.  Inferior scleral show is the distance from the inferior limbus to the lower lid margin.  It may occur normally as an anatomic variant (large eyeballs from severe nearsightedness, shallow orbits) or as the result of underlying medical problems (overactive thyroid- Marty Feldman).  These patients require specialized reconstructive techniques for the best outcome.  [Don’t worry, we are pretty clever as surgeons…]. 

 

Superior Sulcus (New York versus “so L.A.”)

Nancy Pelosi

Below the eyebrow, the superior sulcus is tucked directly underneath the brow-bone. In young patients, the superior sulcus is a flat or concave surface.  Recontouring the superior sulcus is often the primary objective of eyelid surgery (blepharoplasty).  It’s funny, but in this era of economic crisis, I have had a lot of people hold up their hands to me and say “whatever you do, don’t make me look like Nancy Pelosi!...what did she have done anyway?”   (The answer is that too much fat was removed from the upper eyebrow region. I don’t do that look- it’s old school). The superior sulcus in men should be treated differently than women!  The male superior sulcus which is full, has a flat contour and a low flat lid fold with minimal central arching (Brad Pitt- just right, don’t touch it)! The female superior sulcus exhibits a high, arched lid crease and a delicate lid fold (Sophia Loren- gorgeous).  Oversculpting of the male superior sulcus can give a feminized appearance (Burt Reynolds- too much)!  Patients with droopy eyelids because of a slipped eyelid muscle [levator aponeurotic disinsertion] may have deep, flat superior sulci (Forrest Whitaker- on the right eyelid but still an awesome actor). They might find their droopy eyelid objectionable, but like their superior sulcus contours. These cases require special techniques. Fixing the droopy eyelid will change their superior sulcus contour, usually to their dissatisfaction.       

 

Lateral Canthal Angle [where the eyelid attaches to the temple]

Johhny Depp

I always liked guys with “tilt-tipped eyes.”  For some reason, a slightly upward sweep of the lower eyelid on a man seemed attractive to me.  This is determined by the lateral canthal angle (the point where the tendon holding the lower eyelid inserts onto the temporal bone) The lateral canthus is normally 2 mm higher than the medial canthus [where the eyelid meets the nose- “hello nose”].  In general, the lateral canthal angle is more angular than the medial canthal angle which is round.  Any rounding or inferior displacement of the lateral canthus will be cosmetically significant.  Bilaterally rounded lateral canthi alerts the surgeon (me) that previous cosmetic surgery may have been performed. 

 

Hypertrophic Orbicularis Muscle (bunched up lower lid when smiling)

Jackie Chan

The pretarsal orbicularis muscle holds the lower eyelid in place.  In some people, this bunches up into a little sausage when they smile.  This doesn’t bother me, but it seems to bother half of Hollywood and Broadway.  It’s caused by a strong pretarsal orbicularis muscle (I don’t know if Jackie Chan works this one out- but he does kick some serious butt and is constantly smiling- he truly enjoys his work, as do I).  Personally, I think it gives a cute look of character, but if it really bothers somebody, it can be softened with a little Botox injection to the lower eyelid (but leave it alone, please)!

 

 

Inferior Orbital Rim (Lower eyelid region)

Walter Matthau looks great now!

Correcting “bags” beneath the lower eyelids is the number one surgery requested in the eyelid region.  When you look at a human skull, there are dark sockets where the eyes used to be.  The eyes don’t just sit in empty space, if they did, the eyeball itself would be injured every time that we shook our heads “yes” or “no.” Instead, the eyeballs are protected by a surrounding cushion of fat inside the eye socket.  This cushion of fat is held back by a “girdle-like” tissue called the orbital septum.  In some people (through no fault of their own) this girdle becomes a little stretched, and the fat herniates forwards, giving the appearance of baggy lower eyelids.  No big deal.  We go into the operating room, you get a little intravenous sedation (Pina Colada cocktail), I make a small incision on the inside of the eyelid, the fat pops up, I skillfully sculpt it, and you are on the road to recovery, which takes about a week.

 

Lid Margin and Punctal Malpositions, Canthal Tendon Laxity

Basset Hounds and Blood Hounds

Ever notice how the lower eyelids of Basset Hounds and Blood Hounds just don’t seem right?  That’s because they aren’t.  The lower eyelids are not firmly attached to the skull, the tendons have been stretched, and some of the lower eyelid is folded outwards looking all red and irritated.  It’s just an aspect of the breed.  Well, this happens to people too, only usually not to that extent.  That’s okay; I can fix this as well. I’m like the McGuiver of eyelid surgery… lid margin laxity is determined by grasping the eyelid and pulling it away from the eyeball (globe).  If it can be retracted 6 mm or more from the globe, it is deemed to be lax (distraction test).   Lower lid laxity left unaddressed during blepharoplasty may predispose the lid to turning outwards like a blood hound (cute on a Hush Puppy, but not on you)!    

 

 

So, that’s it.  I know that this was a very technical subject, but I hope that I made it fun by throwing in some celebrity examples to demonstrate the ideals and extremes of what I am looking for during a surgical consultation in my office.

 

Have a Beautiful Day!

Dr. Lisa

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Scarless mole removal- shaken, not stirred!

Some moles ain't so bad lookin...

Some moles ain't so bad lookin...

One of the most popular procedures that I perform in my office is the scarless mole-removal.  It used to be that the only way to remove an unsightly mole was to have it surgically removed (excised), or sometimes the physician would just touch it with liquid nitorgen and then scrape it off with a scalpel.   Well, those days have gone the way of blood-letting and leeching (althought there is still some medical indication for leeches, beyond the scope of this entryl.. Enter the world of scarless mole removal.  The technique makes use of radiowaves that replace the scalpel.  I use the Ellman Surgitron device, the only device approved for use in surgical procedures, to gently shave away the mole layer by layer until we reach the smooth skin hiding beneath the surface.  Not all moles are candidates for this technique.  The moles must be slightly elevated, otherwise a different procedure is required.  The healing time is pretty simple.  First, I apply a numbing cream and let it sit for about 15 minutes.  Then, a tiny little injection (that you won't feel because of the numbing cream- aren't I nice?).  Then, I gently shave the mole flat.  The skin will appear a little yellower than the surrounding skin when you leave because this is the color of normal dermis.  In about 4 days a scab will form that drops off after 10-14 days.  Then, the skin is a little pinker than the surrounding skin for roughly 4-8 weeks (but you can use a concealer once the scab falls off).  That's it!  So, to repeat- day 1 the skin is yellow, day 4 the scab forms, 2 weeks the scab falls off, then 2 months all ais back to normal!  The only favor that I ask is that during the healing phase the area is potected from heavy sunlight or ocean water, so save your mole removals for after your trip to Monte Carlo!

 

Have a Beautiful Day!

-Dr. Lisa

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Out, out damned spot!- IPL for Sunspots.

A leapord CAN change it's spots, but why would it want to??
A leapord CAN change it's spots, but why would it want to??

I can always tell a golfer or a bicyclist by their hands, and a sailor by his or her ears.  I know, I know, it’s a cool party trick, but by mere virtue of the areas exposed to the sun I can guess a person’s hobby pretty quickly.  Golfers tend to have age spots on one hand only, whereas bicyclists have both hands equally exposed.  People who sail tend to have increased redness to the tops or their ears.  That being said, I’m kind of like the mechanic in that the same adage applies, “you can pay me now, or you can pay me later…” when it comes to undoing the sun damage.  Never fear, Intense Pulsed light is here!

 

Intense pulsed light [IPL] is a nonlaser light source that emits a broad, continuous spectrum of light energy.  Depending on the filter used, I can target the melanin pigment in the brown spots, or the red pigment in the red blood cells of the broken capillaries.  Normally pigmented skin is left unharmed.  You come into the office, and the area to be treated is covered in ice-cold ultrasound gel.  Then, we give you a cool pair of swim-goggles to wear so that you won’t be tempted to look at the very bright light (I need to see what I’m doing, but you can sit back and relax- no backseat drivers).  The procedure doesn’t hurt; it feels like a little rubber-band snap on the skin for a second.  A few little rubber-band snaps, then badda-bing, badda-boom, you’re done!  The spots will appear a little darker for about two days, but then they will eventually fade to being better than what they were before (the storm before the calm).  A few sessions might be required, but hey- it took a lifetime for the spots to form, yea?

 

IPL is also fantastic for treating rosacea (dilated capillaries and pores, especially around the nose), and melasma (dark spots on the face, usually from pregnancy- God love the little toddlers)!  Recent studies have shown that IPL also builds dermal collagen, so it tightens the skin as well (something that my assistant has been asserting for years- always trust a Brazilian when it comes to these things)!

 

So if the dark spots have got you down, just hop in, get some IPL and get back on the good foot— it can only make you younger again!!

 

Have a Beautiful Day!

 

Dr. Lisa

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Posted in Anti-Aging, Dark spots (Age Spots), Intense Pulsed Light (IPL) Photofacial, Melasma, Rosacea | Tagged | Comments closed

Dreaming of Baby-Smooth Skin? Lasers to the Rescue!

Not a worry line in the world...
Not a worry line in the world...

Warning- this is a long post, but very worth a read…

There has always been interest in looking younger, but with the introduction of the carbon dioxide (CO2) laser for the treatment of photoaged skin increasing numbers of patients are being lured to the plastic surgeon’s office who were not yet ready for a “cold-steel” surgical solution for dynamic and static rhytids.  The ablative effect of the CO2 laser on the epidermal skin surface combined with the thermally induced collagen remodeling of the underlying dermis gave rise to a solution for both the pigmentary and structural changes associated with photoaged skin.  The impressive early treatment results using the CO2 laser gave rise to non-ablative technologies seeking to minimize epithelial damage while retaining the beneficial property of subsurface collagen remodeling.   Consumer and physician interest in “minimal-downtime” techniques of facial rejuvenation has driven the development of numerous laser and non-laser light sources that reverse the process of photoaging.  Since non-ablative photorejuvination leaves the epidermis intact, patients can return to their normal lifestyles almost immediately after treatment and the complications associated with ablative techniques (infection, post-procedural swelling, persistent redness and long-term discolorationare avoided; however, clinical improvement is limited when used as a solitary treatment method.   Both the patient and physician satisfaction is high with these non-ablative techniques and when combined with Botox, Fillers, and home skin care, results can approach those of the more invasive ablative CO2 laser therapies.  This post seeks to describe the currently available non-ablative technologies with respect toward their mechanism of action and their clinical use. 

 

 HOW ULTRAVIOLET LIGHT CAUSES SKIN DAMAGE

 

The typical changes associated with aging skin can be attributed to both intrinsic (genetic) and extrinsic (environmental) factors.  Cumulative exposure to sun remains the largest factor in aging skin and is responsible for most of the unwanted aesthetic effects.  Photoaged skin is characterized by wrinkles, loose skin, uneven pigmentation, sun-spots, sallow color, dilated blood vessels, increased pore size, and a leathery appearance.  In contrast, chronologically aged skin that has been protected from the sun is thin and has reduced elasticity but is otherwise smooth and unblemished.   Dermal damage induced by ultraviolet irradiation is can be seen microscopically as disorganized collagen fiber and the accumulation of elastin containing material (solar elastoses).  The collagen fibers are replaced by scar.  The amount of fiber breakdown is probably responsible for the fine wrinkle formation associated with sun-damaged skin.  Laboratory studies of sun-damaged skin reveals sustained elevation of matrix metalloproteinases.   Matrix metalloproteinases destroy collagen and elastin and are believed to initiate the molecular pathway underlying the physical changes seen in sun-damaged skin.

 

PHOTOREJUVINATION AND THE REVERSAL OF PHOTOAGING EFFECTS

 

Nonablative photorejuvenation of human skin is a procedure designed to confine selectively, without any epidermal damage, thermal injury to the papillary, and upper reticular dermis leading to fibroblast activation and synthesis of new collagen and extracellular matrix material (neocollagenesis).  The skin surface is not removed or modified.  Instead, dermal “remodeling” or “toning” as a wound healing response is initiated to regenerate subsurface collagen.  Photorejuvenation can span a broad range of wavelengths, light sources, and target chromophores, but may be generally divided into thermal and nonthermal mechanisms.  In general, photorejuvenation uses light energy to cause a thermal injury in target tissues.  Selective heating is achieved due to light energy being taken up by specific absorption molecules [chromophores] such as water, melanin [brown pigment], and hemoglobin [red pigment in blood vessels].  The laser energy absorbed by the target chromophore is then diffused in the form of heat to damage deeper surrounding tissues thus inducing the wound healing response.  Hemoglobin has significant light absorption in the violet, blue/green, and yellow portions of the spectrum.  The wavelengths suitable for targeting hemoglobin are in the absorption bands of 577-595 nm.  Epidermal melanin is the dominant chromophore in human skin.  Melanin is particularly concentrated in the basal layer typically 50-100 µm below the skin surface.  Melanin absorption is highest in the ultraviolet portion of the spectrum, but also significantly absorbs the visible and near-infrared wavelengths.  Subsequent heat conduction to adjacent dermal collagen may give rise to the observed histological changes necessary for nonablative photorejuvination. Laser-induced thermal injury should be confined to a zone 100 to 500 µm below the skin surface where the majority of solar elastoses in sun-damaged skin occur.  More superficial injury may be ineffective for wrinkle reduction; deeper injury may result in scarring.  

 

Photomodulation [LED therapy] is the term used to describe another form of non-ablative technology which uses low level light energy to directly stimulate fibroblast cells to make more collagen.  No heat is conducted to the deeper dermal layers.  The proposed mechanism is that the light molecules [photons] are absorbed directly by the fibroblast mitochondria [cell engines], thus increasing cell activity and the production of collagen. 

 

PATIENT SELECTION AND INDICATIONS

 

Matching the patient to the appropriate photorejuvinative modality is the key to success in rejuvenation of photodamaged skin.  Many methods of patient assessment are available, but the most useful include the Fitzpatrick skin type classification and the Glogau photoaging scale. Although these parameters become more important when the doctor is considering laser skin resurfacing, an understanding of these criteria is important when discussing the expectations and limitations of nonablative techniques with the patient.   The Fitzpatrick Sun-Reactive Skin Type gives a very good indication of potential skin color changes following treatment.  In general, patients with non-tanned skin color tolerate resurfacing procedures with minimal risk of color change.  Resurfacing should be undertaken cautiously in patients with tanned or darker skin color.  The Glogau photoaging scale categorizes photodamage based upon wrinkle depth to help the doctor to select the appropriate resurfacing procedure on the basis of lines and wrinkles that one wishes to correct.  Glogau classifies photoaging types as: type I, “no wrinkles”; type II, “wrinkles in motion”; type III, “wrinkles at rest”; and type IV, “only wrinkles.”    Patients with photoaging type I are not suitable candidates for aggressive interventions, nor are patients with photoaging type IV well served by superficial techniques. 

 

CLASSIFICATION OF LASERS/LIGHT SOURCES

 

Numerous non-invasive techniques exist for rejuvenating facial skin.  These technologies can be separated into 3 categories:  1). Those that improve skin texture and pigmentation- Intense Pulsed Light [IPL], Light-emitting diodes [LED], Non-ablative Neodynium:YAG lasers [Nd-YAG], 1540 nm Er:Glass laser, Pulsed Dye Lasers [PDL], and Fractionated Resurfacing [Fraxel/Pixel]  2). Wrinkle Removal- CO2 laser, Fraxel/Pixel Laser; and 3). Skin Tightening [Thermage, Titan]. 

 

CLINICAL APPLICATIONS AND USES OF LASERS/LIGHT SOURCES FOR PHOTOREJUVINATION

 

1320-nm  Neodynmium:Yttrium-aluminum-garnet (Nd:YAG)

 

The 1320-nm Nd:YAG laser was the first commercially available system designed exclusively for selective dermal heating.

 

Manufacturers

(Cool Touch I, II, & III, New Star Lasers, Roseville, CA)

 

Mechanism of Action

Nd:YAG 1320 nm irradiation is nonspecifically absorbed in the human dermis.  This wavelength is unique for its horizontal scattering.  Such a wavelength when delivered at fairly high fluences can cause significant dermal damage.  Such an approach can also create the potential for significant epidermal blistering.  However, when 1320 nm Nd:YAG laser irradiation is coupled with cryogen cooling of the epidermis, a dermal wound can be created with little risk of epidermal damage.   The laser utilizes a non-contact dynamic cooling agent (tetrafluoroethane) which is sprayed onto the skin for 30 msec, with a delay of 40 msec before each laser pulse (pre-cooling modality).  This protects the superficial 50 to 100 µm of epidermis, and allows adequate heating of the sub-surface layers to create new fibroblasts, which will create new collagen.  A thermal sensor within the laser hand-piece monitors pre-treatment skin temperatures as well as peak therapeutic temperatures.  The significant difference between Cool Touch I and Cool Touch II is the addition of a post-cooling modality.  In the post-cooling modality, the cryogen is sprayed immediately after the laser pulse.  It is thought that this will allow deeper penetration, yet will still protect the superficial epidermis.  Peak temperatures of 37-39º C are desired.  There is a built in safety mechanism in this device.  If the temperature of the skin surface is 40º C or higher, the unit will not fire.   The Cool Touch III device has a system upgrade that allows for pre-, during, and post- treatment cooling modalities for added patient safety and comfort.

 

Clinical indications

Mild crow’s feet and lines around the mouth. 

 

Advantages of therapy

Overall patient satisfaction in subjective improvement of skin texture.  Histologic increases in collagen concentration in 50% of subjects that does not necessarily correlate with clinical improvement.  Slight but statistically significant improvement for Fitzpatrick skin types I or II and mild, moderate, or severe wrinkles.

 

Disadvantages of therapy

Not meant for those with extensive sunspots.  Those patients are best treated with either an ablative laser or a specific pigmented-lesion laser [IPL]. Using a laser without a post-cooling modality increases the risk of blistering, hyperpigmentation, and pitted scarring if the skin surface temperature is allowed to exceed 50º C.  Mild post-treatment swelling and redness lasting 1 to 3 days can occur when using a laser without a post-cooling modality, whereas skin redness associated with lasers having a post-cooling modality generally subsides in about 20-30 minutes.

 

Contraindications to therapy

History of photosensitivity, inflammatory skin disease, or use of oral retinoids within one year prior to proposed treatment.

 

Patient preparation

The patient’s skin is cleansed with a gentle cleanser and then degreased with toner or acetone. A topical anesthetic paste (Photocaine, University Pharmacy, Salt Lake City) is applied for 30 minutes. 

 

Anticipated results

 

Mild redness as noted above.  Variable improvement in facial wrinkles, with maximal improvement noted in more severe lines.

 

1064-nm Q-switched Neodynmium:Yttrium-aluminum-garnet (Nd:YAG)

 

The Q-switched Nd:YAG laser was the first laser used as a nonablative tool for skin rejuvenation.

 

Manufacturers

 

(Medlite IV; HOYA Conbio, Santa Clara, CA; and QYAG-5; Palomar, Burlington, MA)

 

Mechanism of action

 

The chromophores for 1064-nm radiation are, in decreasing order are melanin [brown], hemoglobin [red], and water.  Water weakly absorbs laser energy at this wavelength and is gently heated over the optical penetration depth of the beam (about 5-10 mm); however, severe heating remains localized to the red and brown pigments.  It is believed that the absorbed laser energy causes the localized rupture of capillaries and melanosomes, giving rise to a partially injured epidermis and subsequent skin repair. 

 

 

Clinical indications

 

Facial telangiectasias (spider veins), acne rosacea, mild sun damaged skin.

 

 Advantages of therapy

 

Mild improvement in 97% of mild wrinkles, 68% improvement in moderate wrinkles, 20% improvement in brown and red pigment changes in fair to slightly tanned skin,  35% improvement in pigmentary changes of skin types darker than tanned skin. 

 

Disadvantages of therapy

 

Mild redness lasting 1 to 2 hours (all patients), and bruising.  Post-treatment skin color changes either lighter or darker in tanned or darker skin.  

 

Contraindications to therapy

 

None, however lower fluences should be used in patients with darker skin tones to avoid temporary skin lightening.

 

Patient preparation

 

The patient’s skin is cleansed thoroughly and jewelry is removed.

 

Anticipated results

 

Mild redness persisting for 1 to 2 hours, wrinkle reduction and pigmentary improvement as specified above.

 

Fractional Skin Resurfacing

 

To date there have been two categories of laser skin rejuvenation—ablative and non-ablative, and both have significant disadvantages.  Ablative techniques resurface broad areas of the skin, but carry a high-risk profile.  Non-ablative techniques, carry fewer risks, but produce limited clinical improvement.  FractionalTM Photothermolysis is a new technology that promises to deliver the benefits formerly only realized using ablative techniques with the minimal downtime enjoyed by patients treated with non-ablative technologies.

 

Manufacturer

 

FraxelTM SR (Reliant Technologies, Inc., San Diego, CA), Pixel (Alma Lasers)

 

Mechanism of action

 

Fractional  Laser Treatment (FLT) produces thousands of tiny treatment zones on skin, known as “microthermal treatment zones” (MTZs). The target chromophore for FLT is water, however, only a very small fraction of the skin is treated at one sitting.  Each wound field is composed of thousands of microthermal zones and surrounding spared tissue units that comprise “nodes” of skin repair.  The wound healing response differs from previous techniques because viable cells exist between treatment zones, including epidermal stem cells and transient amplifying cell populations.  Each laser hit produces a 30-70 micron plug of Microscopic Epidermal Necrotic Debris (MENDs) that naturally exfoliate in approximately 14 days.  During this time period, the skin takes on a bronzed appearance. The most superficial layer of the skin contains very little water, therefore it remains intact after FLT, preventing water loss and reducing the risk of infection. The Fraxel laser energy passes through the most superficial layer of the skin and into the deeper dermal collagen.

   

Clinical indications

 

All epidermal and dermal changes associated with photoaging.

 

Advantages of therapy

 

Pain levels very well tolerated by patients.  Minimal downtime.  Ease of physician use.  Decreased risk profile secondary to intact barrier function of the superficial skin surface.  

 

Disadvantages of therapy

 

Sunburn like sensation for 1 hour after treatment.  Post-treatment redness lasting 5 to 7 days.  Bronzed appearance lasting 3 to 14 days. Gradual treatment results with full tightening effect apparent after approximately three months.

 

 Contraindications to therapy

 

Any patient with a known lidocaine allergy should not undergo Fraxel laser treatment.  Patients currently using Accutane, or those who are immunocompromised or have a history of keloid scarring should be excluded from treatment as well.  Like most other laser treatments that cause some removal of the epidermal protective layer, the Fraxel laser treatment could induce a herpetic [cold sore] outbreak in susceptible individuals.  Most physicians institute anti-viral prophylaxis prior to laser treatment.

 

Patient preparation

 

The treatment area is thoroughly cleansed prior to the procedure using a mild, gently abrasive skin cleanser.  OptiGuideTM Blue, a water-soluble tint, is applied to highlight the contours of the skin, and to allow the laser’s tracking system to adjust the treatment pattern with respect to hand piece velocity.  A lipid based topical anesthetic ointment is applied to the skin for about 45 minutes, after which the treatment may be applied directly through the anesthetic ointment. 

 

Suggested treatment parameters

 

A series of 3 to 5 treatments, spaced four to seven days apart has been found to be effective.  A complete procedure consists of a series of horizontal and vertical passes with the laser.  Each pass consists of overlapping strokes.  Each treatment session addresses approximately 20 % of the skin surface.

 

Anticipated results

 

There is a mild sunburn sensation for about an hour then virtually no discomfort.  The skin will have a pinkish tone for 5-7 days with minimal swelling. Patients may apply cosmetics immediately after the procedure if desired.  The skin is completely re-epithelialized within 24 hours.  The bronze appearance created by the MENDs lasts for 3 to 14 days.  Treatment results are gradual, with a stepwise improvement in surface appearance and texture.  It takes about three months to achieve the full tightening effect.

 

 

1540-nm Erbium:glass Laser

 

Manufacturers

 

(Aramis, Quantel Medical, Les Ulis Cedex, France)

 

Mechanism of action

 

The Er:glass 1540 nm Aramis-Quantel laser emits a wavelength of particular interest due to its high water absorption which deposits the laser energy primarily in the dermis.  The skin is cooled using the Constans Handpiece (Quantel Medical, Clermont-Ferrand, France).  This is a cryo-sapphire-tipped handpiece in direct contact with the skin with purified tetrafluoroethane cryogen circulating inside.  The handpiece has a real-time temperature monitor at the sapphire for immediate feedback. 

 

Clinical indications

 

Crow’s feet and fine lines around the mouth.

 

Advantages of therapy

 

Lack of pain, discomfort, or downtime.  Collagen production was evaluated with silicone molds and ultrasound measurement. Ultrasound revealed a 17% increase in dermal thickness.  Silicone imprints were analyzed and showed a 40% improvement in dermal collagen as noted by the reduction in anisotropy.  Ultrasound imaging demonstrated an increase of the dermis thickness as a function of time.  Biopsy specimens show the reduction of solar elastotic fibers beginning 7 days after a single treatment, more markedly after 3 weeks, and very few of them left 2 months after one treatment.  Superficial collagen bands in the upper dermis thickened and the new collagen fibers seemed to be arranged more horizontally.  Six weeks after the fourth treatment, 62% of the patients were satisfied with their results.

 

 Disadvantages of therapy

 

Some patients may have greater expectations and be disappointed with their results.  Improvement is slow (in months), and mild, with most patients appreciating more elastic and firmer skin.

 

 Contraindications to therapy

 

Photosensitivity, use of oral retinoids within one year of proposed treatment.

 

Patient preparation

 

Before treatment the area to be treated is prepared with a skin cleanser only.  The treatment can be performed without any kind of anesthesia.

 

585- nm Pulsed Dye Laser

 

Manufacturers

 

(VBeam; Godelz, Wayland, MA; and VStar;Cynosure, Helmsford, MA)

 

Mechanism of action

Pulsed dye (PDL) lasers emit yellow light (585 nm).  This wavelength of laser light allows for 50% dermal penetration to a depth of approximately 400 microns and is specifically absorbed in the blood vessels of the upper dermal vascular plexus, after passing through the epidermis with minimal interaction.  The light energy that reaches the vascular plexus is of insufficient energy to cause vessel rupture or coagulation, yet is of sufficient intensity to induce a low grade inflammatory response.  Endothelial cells within the injured vessel walls release inflammatory mediators that stimulates fibroblast activity.  The fibroblasts give rise to new collagen production.  

 

Clinical indications

Crows’ feet, port wine stains, cherry-red spots, broken blood capillaries.

 

Advantages of therapy

 

After six months, 90% of patients with mild wrinkling demonstrated 50% or more clinical improvement.  Deeper wrinkles demonstrated greater improvement than shallowwrinkles.  Enhanced collagen production by an average of 84% measured 72 hours after a single laser treatment. 

 

 Disadvantages of therapy

 

Bruising and swelling in all patients (lasting 1-2 weeks).

Contraindications to therapy

None.

Patient preparation

No preparation or application of topical or general anesthesia is required.

 

Intense Pulsed Light (IPL)

 

Manufacturers

Quantum SR; Lumenis, Canta Clara, CA; Estelux; Palomar, Burlington, MA; Prolite; Alderm, Irvine, CA; and Aurora; Syneron, Yokneam, Israel, Alma Lasers)

 

Mechanism of action

 

The intense pulsed light is a nonlaser light source that emits a broad, continuous spectrum of light energy ranging from 500 to 1200 nm.  With cutoff filters, shorter wavelength portions of the spectrum can be blocked.  Depending on the filter used, the longer portion of the transmitted spectrum targets hemoglobin [red], melanin [brown], and water to varying degrees (shorter filters favor hemoglobin and melanin heating).  The effect on dermal collagen is presumably caused by heat diffusion from the blood vessels and by the secretion of inflammatory mediators induced by direct vessel heating.  Tissue water is also directly heated to a smaller degree.  The Quantum SR has a thermoelectrically chilled delivery system, and when used with an ice-cold coupling gel, minimizes discomfort and the potential for epithelial burning.

 

Clinical indications

 

The Quantum SR is effective in the treatment of vascular and pigmentary lesions of the skin in the face, neck, chest, and hands.  Vascular lesions such as rosacea, erythema, flushing, broken capillaries, and post-laser redness respond well to intense pulsed light therapy.  Pigmentary changes such as hyperpigmentation, melasma, and lines of demarcation after laser or chemical peels also are treatable with intense pulsed light therapy.  The device is also useful in the treatment of mild to moderate facial wrinkles.

 

 Advantages of therapy

 

The advantages of IPL when compared to other nonablative technologies include minimal risk of eye  injury, the ability to treat larger areas of nonfacial skin, rapid visualization of improvement in treated areas, and minimal patient discomfort.     

 

Disadvantages of therapy

 

Treatment results in an immediate darkening of already hyperpigmented lesions, a reaction which should be explained to patients prior to treatment.  Within 24 to 48 hours following treatment, dark spots will take on a darker and crusty “peppery” appearance.  These will  spontaneously peel away over five to six days post-treatment.

 

Contraindications to therapy

 

There are four relative and unproven contraindications to performing IPL photorejuvination.  These include patients who have a history of photosensitivity reaction, those taking photosensitizing medications, or the use of Accutane within 6 months prior to intended treatment.

 

Patient preparation

 

Topical anesthesia is not required for every patient.  The anesthetic is applied to the skin surface and occluded with plastic wrap for 1 to 1-1/2 hours prior to treatment.  Before treatment the skin is thoroughly cleansed and a thin layer of ice-cold coupling gel is applied to the areas to be treated.

 

Suggested treatment parameters

 

Guidelines when using IPL technology are to be conservative during the initial treatment session using lower fluences and subsequently watching for tissue response. Begin treatments in a nonvisual zone (i.e. postauricular), examine results of a test spot and adjust parameters accordingly, the endpoint of therapy is mild swelling and redness.  On subsequent visits the patient should be asked about and bruising, blisters, or swelling in response to the prior treatment.   Treatments were spaced 3 weeks apart.

 

Anticipated results

 

Other than mild, transient redness, there are no other immediate visible signs of treatment, and patients may resume normal activities immediately.  Ninety percent of patients achieve greater than 75% improvement in rosacea, 84% improvement in fine wrinkles, 78% improvement in skin coarseness, and 49% improvement in pore size.  Microscopic analysis reveals early signs of new collagen formation, diminished brown pigment granules, and reduced pore size. 

 

 

Light Emitting Diodes (LED)

 

Manufacturers

 

GentleWaves (Light Bioscience, Virgina Beach, VA).

 

Mechanism of action

 

Light emitting diode [LED] photomodulation uses coded pulses of low energy, non-laser, non-thermal, light energy to stimulate mitochondrial activity, increase collagen and fibroblast production and to decrease collagenase (metalloproteinase-MMP 1).   Light emitting diodes are narrow band emitters of a broad range of light energy ranging from ultraviolet to visible to infrared.  LEDs typically emit visible yellow light. It is possible that this narrow band wavelength profile contributes to the unique characteristics of LED photomodulation. [3].  

 

Clinical indications

 

GentleWaves LED photomodulation reduces the appearance of fine lines and wrinkles, as well as improves the appearance of photodamage induced dyspigmentation and increased pore size. 

 

 Advantages of therapy

 

No side effects, downtime, or pain.  Safe for all skin types.  Fast and convenient.  A multicenter clinical trial conducted on 90 photoaged women revealed improvement in the crow’s feet appearance in 62%, and 36% improvement in the upper lip appearance.  Other observations included a 27% reduction in skin roughness, 14% improvement in pore size, and 25% reduction in redness.  Microscopic analysis showed an increase in extracellular matrix proteins associated with clinical improvement in wrinkles.

 

Disadvantages of therapy

None.

Contraindications to therapy

None.

Patient preparation

Skin cleansing prior to treatment.

Suggested treatment parameters

 The currently recommended regimen is 50 seconds weekly for 8 weeks.

Anticipated results

As above.

 

Radiofrequency Device: Thermalifting

 

Manufacturers

Thermage (Thermage, Hayward, CA).

 

Mechanism of action

This device delivers volumetric and uniform heating to the deep dermis via a unique form of radiofrequency (RF) energy.   Unlike lasers, which target specific chromophores on the principle of selective photothermolysis, radiofrequency causes movement of charged particles within the skin, and the resultant molecular motion generates heat.  The heat in turn causes collagen shrinkage and new collagen deposition.  The treatment tip delivers the RF energy to the skin with simultaneous surface cooling.  A coupling fluid is used to ensure proper contact with the skin.  Surface cooling is maintained throughout treatment cycle (pre-, during, and post- treatment) as cryogen is sprayed onto the cooling membrane in the treatment tip. 

 

Clinical indications

 

Thermage is FDA approved for the skin tightening of the eyelids, face, neck, arms, stomach, hands, buttocks, and legs.

 

Advantages of therapy

 

No downtime.  High patient satisfaction levels.  Patients frequently commented that the treated area felt tighter and that family members and friends noticed a difference in their appearance.  Changes in appearance were corroborated microscopically with findings of a thickened epidermis and increased density of dermal collagen post-treatment. 

 

Disadvantages of therapy

 

Some patients relay moderate discomfort levels during the procedure. 

 

Contraindications to therapy

Metallic implants in the body (artificial knee, artificial hip, metal rods for spinal stabilization), pacemakers, and pregnancy.

 

Patient preparation

 

Before treatment the skin is thoroughly cleansed and all topical anesthetic cream, make up, and jewelry are removed.  A thin layer of conductive fluid is applied to the areas to be treated.

 

 

Anticipated results

 

All patients experience mild redness and swelling in the treatment areas that resolves completely within one hour post-treatment.  All patients see an immediate response, with more rapid improvement at 6 weeks culminating at 6 months after a single treatment.  Younger patients (average age 51) tend to respond better and that higher dial settings and corresponding higher energy per pulse correlated with better response.  Those who had the entire surface area of the face and neck treated tend to do better than those with partial treatment.  More favorable results are derived from more frequent passes of the device using lower energy settings.

 

Titan  1100-1800 nm Infrared Laser

 

Manufacturers

Cutera, Brisbane, CA.

 

Mechanism of action

The Titan laser was developed as a “light based” response to radio frequency skin tightening devices.  The Titan laser operates between 1100 nm and 1800 nm targeting water, resulting in heating depths from 1-3 mm.  The epidermal temperature is kept at or below 40º C by pre-, during, and post-cooling of the epidermis by a sapphire tip. 

 

Clinical indications

The Titan is cleared for the treatment of wrinkles in Europe, and for general dermatologic use in Canada.  In the United States, the Titan is cleared for superficial heating, for the purpose of elevating tissue temperature for temporary increase in local circulation where applied.  The primary function is the tightening of skin laxity in all parts of the body such as the area beneath the chin,  jowls, abdomen, arms, and other areas.  It may not be indicated for the deep creases that extend from the nostril to the lip (nasolabial fold).

 

 

 

Advantages of therapy

Manufacturer claims increased safety profile compared to standard radio frequency devices, increased predictability of energy application prevents side effects of tissue overheating and subsequent fat atrophy.  Superior epidermal cooling method and scalable platform with a variety of handpieces, including 2 IPL handpieces to treat for hair removal and vascular lesions

 

 Disadvantages of therapy

 Does not penetrate as deeply as Thermage, therefore multiple treatment sessions are required.

 

 Contraindications to therapy

None.

 

Patient preparation

Skin is cleansed prior to procedure.  No anesthesia is required.  At higher energy levels used to treat larger areas of the body such as the abdomen, providing patient with oral narcotic and anxiety medication increases treatment tolerance

 

Anticipated results

Immediate improvement in skin laxity followed by gradual improvement over a three to six month period as new collagen is formed and the skin tightens. 

 

IN SUMMARY

 

With the expanding variety of therapies available for patients seeking facial skin rejuvenation, the physician must appreciate the indications, complications, benefits, and limitations of each.  Nonablative photorejuvenation offers a new approach in treating photodamaged skin.  Practitioners of nonablative skin remodeling have advocated serial treatments to achieve gradual, cumulative improvement.  Collagen deposition occurs over a period of several months, so the final cosmetic appearance is not immediately evident.  Patients often describe an improvement in skin tone after nonablative laser treatment.  Despite these findings, the ease of treatment, minimal discomfort, and limited side-effect profile makes nonablative laser remodeling an appealing addition to the cosmetic surgeon’s treatment modalities.  The drawback of these positive features is mild cosmetic improvement.  Subtle enhancements may be acceptable to some patients.  Nonablative laser resurfacing is an excellent option for patients unwilling to risk the side effects, pay for the more expensive procedures, or take time off for a lengthy recovery as from ablative resurfacing techniques.  Proper patient evaluation and counseling will provide for optimal patient satisfaction.  With the continued focus on facial skin rejuvenation, nonablative techniques will continue to evolve and further meet with the demands of our ever-growing, sophisticated patient population’s needs.    

 

Have a Beautiful Day!

 

Dr. Lisa

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Posted in Acne, Anti-Aging, Dark spots (Age Spots), Fractionated Skin Resurfacing (Fraxel/Pixel), Intense Pulsed Light (IPL) Photofacial, Laser Skin Resurfacing, LED Therapy, Melasma, NonSurgical Body Sculpting, Pulsed Dye Lasers [PDL], Rosacea, Skin Tightening | Tagged | Comments closed

Never too rich, too thin, or too much filler in your face!

Come'on Doc, there's room for one or two more drops!!

Come'on Doc, there's room for one or two more drops!!

 

 

Since the introduction of injectable collagen for improving or eliminating facial wrinkles, many new agents have been introduced with safer and more effective properties.  Techniques of injection have evolved to less invasive ones, and their combination with other minimally invasive therapies for the skin, such as microdermabrasion, chemical peels, and radiofrequency-based and light-based treatments, has increased the degree of esthetic results and the level of satisfaction for patients and physicians.  There have been many discussions theorizing the attributes of the perfect filling agent.  We want a product that can be administered safely, conveniently, rapidly, and painlessly and without leaving any traces that it has been applied.  We want a product that does not result in any complications and that lasts a long time. The ideal substance should be “biocompatible, nonimmunogenic, nonresorbable, nonpyogenic, noncarcinogenic, inexpensive, and nonmigratory, with the ability to be stored, shaped, removed, and sterilized easily”.  We have not yet achieved this level of perfection, but the nonanimal-derived, stabilized hyaluronic acid products are the current state of the art, fulfilling much of our desired criteria. 

 

HISTORICAL  PERSPECTIVE

 

The history of modern soft-tissue augmentation dates to the late 1800s, when injectable fat was first used for tissue augmentation.   Since then, many substances and devices have been marketed for the purpose of cosmetically improving soft-tissue defects and wrinkles.   Liquid injectable silicone has been used since the 1940’s as a soft tissue filler.  In the 1940s, Dow Corning (Midland, MI) produced DC-4, its first silicone containing product used as a lubricant in military bombers.  The 1940’s also witnessed the first use of silicone in humans for cosmetic improvement.  By the 1960’s misuse was rampant, with large volumes of pure and adulterated forms of silicone being injected with subsequent complications.  In 1974, Dow trademarked a refined liquid silicone with established safety and efficacy.  Nevertheless, the controversy that swirled around silicone breast implants led to the demonization of injectable silicone as well.  The American Society of Dermatologic Surgery responded in 1993 by concluding that the use of liquid injectable silicone by the microdroplet technique is an efficient and safe procedure for many individuals1.   Two U.S. Food and Drug Administration (FDA)-approved medical grade liquid injectable silicones are available today.  Adatosil (Escalon Medical Corp., Chicago, Illinois) and Silikon (Alcon Laboratories, Fort Worth, Texas) are approved for the tamponade of retinal detachments and their off-label use for soft tissue augmentation is permitted by the FDA’s Modernization act. 

 

For the last 2 decades, the most widely available and widely used substance for filling in facial wrinkles has been collagen.  Approximately 25% of the protein in the human body and 75% in the skin is collagen.  Investigators in the early 1970’s developed  a purified human and bovine [cow] collagen that underwent successful clinical trials in human patients.  Subsequent to these results, Zyderm I was developed by the Collagen Corp. and tested by 14 investigators from 1977 to 1978.  In 1981, after 6.5 years of development and clinical trials, Zyderm I received FDA approval for soft tissue augmentation.   Injectable bovine collagen has been used for facial rejuvenation since the 1980’s.  It requires skin testing before it can be used as a filler.  The second generation, derived from human fibroblast cell culture does not require prior skin testing.  The average longevity of correction with these products is about 3 months.  Collagen fillers produced from bovine sources have a risk of inducing allergic reactions.  Sensitivity skin tests prior to treatment are recommended for bovine derived collagen but not for human-derived fibroblast collagen products.

 

In the last decade, hyaluronic acid (hyaluronan) has been shown to possess many properties that suggest its value in soft-tissue augmentation.  Hyaluronic acid is a polysaccharide found in the extracellular matrix of all tissues of all vertebrates and comprises 56% of the extracellular matrix of human skin.  It is composed of a water-loving sugar similar to clear gelatin.   Hyaluronic Acid Products produce longer lasting results and fewer hypersensitivity reactions than collagen products: 

 

Restylane (Medicis, Scottsdale, Arizona), FDA approved December 12, 2002, has  20 mg/mL of hyaluronic acid with a gel bead size of 250 µm and 100,000 units per mL.

 

Perlane (Q-Med, Uppsala, Sweden),  approved in the United States, has 20 mg/mL of hyaluronic acid with a gel bead size of 1000 µm and 10,000 units per mL.

 

Restylane Fine Lines (Q-Med, Uppsala, Sweden), not approved in the United States, has 20 mg/mL of hyaluronic acid with a gel bead size of 100 µm and 250,000 units per mL.

 

Restylane, Perlane, and Restylane Fine Lines are NASHA products, biosynthesized from a nonanimal source.  Restylane is used for the filling of fine lines and moderate wrinkles and lasts an average of 9 months.

 

Perlane is used for the filling of deeper furrows and contour irregularities.  Because it is thicker, it can allow for more effective filling and lasts longer than Restylane.  Restylane can be layered over Perlane for correction of residual superficial irregularities.  Restylane Fine Lines (not available in the United States) is used for the correction of delicate upper lip wrinkles.

 

Sculptra (Polylactic Acid)

 

Sculptra (Dermik Laboratories, Berwyn, Pennsylvania) is synthetic polylactic acid powder (0.15 g per bottle)  that has to be mixed and put into suspension in four to five mL of diluents (half sterile water and half lidocaine) immediately prior to injection to avoid clogging of the 26 gauge needle (supplied with product).  This product works well to fill in broad irregular areas.  It must be injected subdermally.  Because the amount of correction improves with time, a gradual filling in the contour defect is recommended.  Rather than aiming for complete correction in one session, partial correction is augmented in 3- to 4- month intervals3.

 

 

 

Artefill [Polymethylmethacrylate (PMMA)]

 

Artefill (Artes Medical, San Diego, California) is composed of uniform polymethylmethacrylate (PMMA) beads (30-42 µm in diameter) suspended in collagen.  The collagen acts as a temporary filler, and the microspheres create an inflammatory response with secondary collagen production and a longer lasting effect.  Because it contains bovine collagen, it requires skin testing before use3.

 

 

Matridex (Hypromellose, dextanomer  DEAE)

 

Matridex (BioPolymer GmbH, Germany) is hypromellose, dextranomer DEAE suspended in hyaluronic acid and cross-linked hyaluronic acid.  The hyaluronic acid provides temporary filling without the need for pretreatment skin testing and the hypromellose and dextanomer DEAE (positively charged microparticles) promote fibroblast formation and collagen neogenesis, inducing a longer lasting effect.  It is not approved in the United States.

 

Alloderm (Acellular Cadaveric Dermis)

 

Alloderm (Lifecell Corporation, Branchburg, New Jersey) is a solid acellular biological implant that is useful in eyelid and lip reconstruction and for repairing large facial contour deformities.  Human dermal tissue is harvested from cadavers.  The cells, which are targets for the immune response, are removed without altering the collagen and extracellular matrix of the dermis.  This immunologically inert tissue then serves as a framework to support revascularization and cellular repopulation.  Cymetra (Lifecell Corporation) is its micronized, injectable form.  It is supplied as a cryofractured, dried, acellular, particulate dermal matrix.  When refrigerated, it has a shelf life of 2 years.  We have found that when it is injected for lip augmentation considerable swelling and rapid resorption are the rule. 

 

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Posted in Artefill, Collagen, Facial Fillers, Juvederm, Radiesse (Radiance), Restylane & Perlane, Sculptra | Tagged | Comments closed

SwanSong for Boring Old Microdermabrasion!

No extreme makeover needed, SilkPeel will smooth those ruffled feathers!

No extreme makeover needed, SilkPeel will smooth those ruffled feathers!

 

 

 

SilkPeel Dermalinfusion is the most advanced skin treatment available today.  Offered exclusively to physicians, SilkPeel provides simultaneous diamond exfoliation of the skin and infusion of specialized treatment serums deep into the skin where they are the most effective.   SilkPeel’s unique diamond-tipped heads set SilkPeel apart from other microdermabrasion procedures that rely upon abrasive particles that unevenly exfoliate the skin.  As spinning medical grade diamonds buff the skin, one of four solutions is delivered:  clarifying solution for acne-prone skin, hydrating solution for dry skin, brightening solution for discolored skin, or antioxidant solution for damaged skin. The solutions do not just sit on top of the skin like a lotion or cream would, instead the patented SilkPeel handpiece deeply delivers the vitamins, antioxidants and other therapeutic ingredients that your skin needs most.  Dermalinfusion optimizes the benefits of exfoliation without the often uncomfortable and painful effects that people experience with most peels.   Clinical studies have shown that SilkPeel provides even abrasion across the treatment area and rapid hydration to the underlying cells.  The current family of solutions includes:

Clarifying Formula- This anti-microbial and anti-inflammatory solution promotes clear skin for patients with pustular or cystic acne using Salicylic Acid.  The added aloe extract soothes even the most sensitive skin.

Hydrating Formula-Hyaluronic acid plus Allantoin and Glycerin combine to deliver rich, nourishing moisture to very dry skin, improving overall skin texture and reducing the appearance of fine lines and wrinkles.  

Brightening Formula- Utilizing a trio of natural brightening agents- Kojic Acid, Arbutin, and Mulberry- this solution neutralizes active melanocytes while calming the skin with Aloe and Glycerin. Great for Melasma and Age Spots.

Antioxidant Formula- A proprietary blend of antioxidants including the power of Vitamin C neutralizes free radical formation and stimulates collagen production for younger looking skin.

The SilkPeel is the only system of its kind capable of running a disinfection cycle, making it the safest and most hygienic system on the market.

The procedure can be performed in a twenty minute office appointment with none of the residual “grittiness” of traditional microdermabrasion. 

A note from Dr. Zdinak:  “I first encountered the SilkPeel device while at the 2008 World Congress on Antiaging and Aesthetic Medicine in Paris, France.   We tested the SilkPeelTM device in my Manhattan office on individuals who had previous, ongoing experience with traditional microdermabrasion and everyone preferred the SilkPeel treatment (including my friend from Beverly Hills).  My pores were cleaner than after any other cosmetic therapy that I have tried, and my skin was porcelain smooth and glowing for the following week.   A unanimous decision was made to purchase the SilkPeel device that very day, and we haven’t used standard microdermabrasion since!”  

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Posted in Acne, Anti-Aging, Dark spots (Age Spots), Melasma, Nutrition for the Skin, Rosacea, SilkPeel Diamond Microdermabrasion, Skin Care 101, Uncategorized | Tagged | Comments closed

What causes cellulite?

French food gives you cellulite! (But, I love it).

French food gives you cellulite! (But, I love it).

 

 

Cellulite refers to the lumpy fat bulges on the thighs and buttocks of over 95% of the normal female population.  Women have three layers of fat beneath the skin.  The top layer is called the subcutaneous layer and this is where cellulite occurs.  The bottom two layers are the fat reserves where excess calories are stored.  Cellulite does not occur in these deeper layers.  Directly beneath the subcutaneous fat layer there is a layer of connective tissue comprised of collagen called the “fibrous septae.”   This septae separates the fat cells into compartments to provide structural support for the skin and to conserve heat within the body.  When the fibrous septae becomes damaged, the subcutaneous fat cells are pushed through the damaged regions and are squeezed into small bulges that give the overlying skin the “puckered” or “dimpled” appearance that we call cellulite.

There are many reasons why most women are predisposed to cellulite whereas the condition is much rarer in men.  To begin with, the underlying structure of the skin is different in males verses females.  Male skin tends to be thicker and the fibrous septae has strong cross-linking of the connective tissue.  Females have thinner skin and no cross-linking of the underlying septae.  Women have more fat layers than men, and the subcutaneous fat layer in women is regulated by hormones and does not respond to diet and exercise.  The female hormone estrogen causes these fat cells to store fat, whereas the male hormone testosterone stimulates the fat cells to break down fat.  So, women are genetically superior at storing energy in the form of fat to provide energy during pregnancy.  Women also have a higher percentage of body fat in the areas of the thighs, hips, and abdomen, and these fat cells are resistant to diet and exercise. 

Several factors can contribute to the decreased circulation and fluid retention that gives rise to cellulite.

Genetics- Cellulite does seem to run in families and the weak veins and poor lymphatic drainage seems to be genetically inherited.

Smoking- Cigarette smoke contains free radicals that damage the blood vessel walls, leading to inflammation and leakage.  In addition, the nicotine in cigarettes constricts the blood vessels, further reducing the microcirculation to the area.  It has been shown that the blood perfusion to the skin in a smoker is 65% less than in that in a non-smoking individual. 

Estrogen and Progesterone- Estrogen determines the number of fat cells in the body and promotes the accumulation of these cells in the buttocks, legs, and thighs.  Progesterone can lead to weight-gain, fluid retention, and leaky blood vessels.

Pregnancy- Aside from the increased hormone fluctuations in pregnancy, the expanding womb exerts increased pressure on the veins and lymphatic vessels in the lower body, predisposing cellulite formation.

Diet- There is no direct link to diet and cellulite reduction.  Once cellulite is formed, the fat cells have enlarged and the fibrous septae has been damaged.  Diet and exercise can shrink the size of the fat cells, but if the weight is regained the cellulite will return.  There has been some suggestion that following an organic diet results in less toxin accumulation in the fat cells and can in some instances prevent the formation of cellulite.

Cellulite is a progressive disease that develops in phases:

Phase One- Blood circulation and lymphatic drainage to the subcutaneous layer are impaired.  This leads to fluid retention and the accumulation of toxins that damages the connective tissues making them more fibrous.  This stage is primarily asymptomatic and no cellulite is visible to the naked eye. 

Phase Two- Decreased circulation damages the capillaries and veins and the blood vessels become more “leaky” increasing the pressure in the tissues and further restricting circulation and fluid drainage.  Cellulite bumps have still not appeared at this stage.

Phase Three- After a few months of lymphatic fluid  accumulation the fat cells become swollen and begin to push up against the skin.  At this stage, the first “lumps and bumps” of cellulite appear.

Phase Four- The accumulated lymphatic fluid causes the fibrous septae to further thicken, trapping and squeezing the fat cells, thus further reducing circulation to the area.

Phase Five- The presence of this high pressure system shunts bloodflow away from the affected area and the fibers thicken more, trap more fat cells, and form a huge honeycomb-like structure that gives rise to the hallmark appearance of cellulite.

The most common sites for cellulite formation are the thighs and buttocks.  However, cellulite can form on the lower abdomen, and is sometimes associated with digestive disorders.  Cellulite can also form on the upper arms in response to poor bloodflow to the region.

Liposuction does not cure cellulite, and in fact can make it worse.  As mentioned above, women have three layers of fat stores, the subcutaneous fat layer that resides just below the skin surface, the superficial reserve fat layer, and the deep fat reserve layer.  The subcutaneous fat layer is controlled by hormones, and liposuction in this layer actually worsens the appearance of cellulite.  The superficial reserve fat layer and the deep reserve fat layers in females are the prime targets that can be reduced by liposuction. 

In order to consider a particular therapy a cellulite “treatment” that therapy must address some component of the underlying physiological problems that leads to the formation of cellulite, namely, decreased microcirculation, fibrous septae damage, and the accumulation of fat in engorged fat cells.  Creams and lotions that do not penetrate the skin or deep tissue massage only act to temporarily improve the appearance of cellulite by causing localized tissue swelling that hides the dimples of cellulite.  Effective cellulite therapies include carboxytherapy, Thermage, and mesotherapy.

Have a Beautiful Day!

Dr. Lisa

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Posted in Carboxytherapy, Cellulite, Thermage | Tagged | Comments closed