More than any other area of Plastic Surgery the treatment of skin texture, tone and health has changed dramatically over the last 5-10 years. A plethora of new techniques and materials are available to help control facial aging and the visible effects of this. As we age, the sun, weather and time all affect the skin in different ways and as gravity stretches and loosens the skin its texture also changes. A large number of systems are now available for skin care to maintain the moisture, texture and tone of healthy young skin. There are also a number of treatments available for irregularities of pigmentation and color. The other area often of concern to people as they age is the appearance of wrinkles and creases in the skin and there has been a veritable explosion of new fillers to help with this problem. One of the oldest available fillers is collagen, which can be used in a superficial or deep manner. This quickly gave way to hyaluronic acid fillers. Hyaluronic acid is a naturally occurring body fluid and your body also has enzymes to dissolve them over time. They tend to sting when injected and we recommend nerve block when injecting sensitive areas like the lips.. Restylane, Juviderm and Belotero are all hyaluronic acid fillers, and there are many more with slightly differing characteristics(hyalaform, Perlane just to name two others we have injected in our office in the past). Another type of dermal filler uses nanoparticles such as Radiesse and ArteFill . Aside from wrinkles, aging also effects the fullness or volume of the cheeks and eye hollows. Volume loss is treated with subdermal fillers like sculptra or autologous fat. Another strategy for beating the wrinkles is used with botulinum toxin (Botox) which can paralyze muscles which cause facial wrinkles. Beyond these injectable strategies are techniques for resurfacing the skin and face from a very gentle microdermabrasion through various acid peels up to the more surgical deeper phenol peels or laser skin resurfacing or dermabrasion type techniques.
One of the newest fillers is belotero. It is a hyaluronic acid like restylane but with a big difference. Belotero is advertised as gentler. What they mean is the substance is less stiff. In our practice, we use different fillers for different purposes and this one will have a special niche for very thin skin. For those few women who really liked old fashioned collagen and the subtle change it could make to those fine wrinkles in porcelain skin, this stuff was made for you. A popular but “off label” use of fillers is for filling “tear trough “circles under eyes. This is a very thin skin area and other fillers will almost certainly leave a visible ridge where the filler is placed. This may be another niche for carefully applied Belotero in select patients. The downside of Belotero is that some patients report that it doesn’t last as long as other fillers (you’d expect this of a softer more subtle filler).
Juvederm is like momma bear. Not as stiff as restylane, not as soft as Belotero. It is FDA approved for nasolabial folds but in our practice we just as often use restylane for this. It will totally depend on your skin type and the problem we are trying to solve. For some women their skin is thin enough that juvederm can fill out their lines where restylane might leave a visible ridge or blue line. We often use juvederm in areas where a “blurry line” is desired, like that shadow just above your lip line . Another common use for juvederm is in the vermillion (pink part) of the lip. Juvederm is also a hyaluronic acid and is broken down by your own body enzymes over time. The duration of action in any given area is related to the amount of hyaluronidase in the skin there and the amount of movement that area is subjected to (it last longer in nasolabial folds than it does in lips)
Restylane is the hyaluronic acid that started it all and is still the gold standard for white roll lip lines. It is the stiffest of the hyaluronic fillers It must be placed slightly deeper in the dermis than the other HA’s or it will leave a blue line. For women or men with thicker stiffer skin and deeply set in lines, Restylane will have more chance of supporting the skin against the fold. The analogy I have often used for describing the HA fillers (which are all the same substance but with different crosslinking and therefore different stiffness) is that of a milkyway candybar. Restylane is a milkyway in the refrigerator, while juviderm is at room temperature on the countertop, and belotero is outside in the hot sun on the sidewalk. Expect some redness at the injection site for one or two hours after injection, and if the lips are injected expect some swelling that may last 2 to 3 days (it will look overcorrected so don’t have a dinner party that night). We recommend an ice pack and elevation for an hour or two after injection if you can to reduce the risk of bruising, otherwise expect this to be an office correction with very little down time.
Radiesse uses a different strategy to stiffen the skin. It is small nanobeads of hydroxylappatite the same substance that bone or coral is made from. Like the pearl is made from sand irritating the lining of a clamshell, radiesse stimulates you body to surround it and lay down swirls of collagen.It comes with its own collagen out of the tube, but body quickly disposes of this foreign substance all the while laying down its own. When your body finally swallows the little particle and carries it off, the collagen reaction settles down and the stiffness goes away. To my way of thinking, Radiesse needs to be placed even deeper in the dermis to prevent palpability. Your injector also has to be very careful to avoid clumping when placing the radiessse,and will likely to suggest to you that you massage the area for the first few days after injection (I do). It lasts at least as long as the HA’s but as with all of them it depends on the area they’re placed. Deep immobile tissue like the dorsum of the nose may last longer than 2yrs whereas the nasolabial fold in some people may see some resorbtion even at 6months.
Artefill also uses microspheres, but the polymethyl methacrylate is not reabsorbable and the filler is considered permanent. Since the microspheres are dependent on your body to generate the collagen, and since there is a possibility of aggregation (clumping) of the small particles, injection into deeper planes of the dermis is recommended. This is going to be best used in thick skin areas like the glabellar creases, nasolabial folds or dorsum of the nose.
Sculptra is a whole different animal. It is more of a volume filler and goes beneath the skin (subdermal space). It is made from the same substance that some dissolving stiches are made of and will last 2 or more years. Unlike the dermal fillers, you will not see an immediate result, and there may need to be several injection treatments to get the degree of filling you desire. Most of the injected substance is fluid and will go away very quickly (approx. 1 day) When we inject it, it is diluted with saline and the effect we get “on table” right after injection is the approximate result we would expect after three treatments. The polylactic acid in the sculptra will induce your body to “grow” collagen sort of like grass seed, but this takes 6-8 weeks of gradual accumulation. This is a nice stealth treatment, because the result sneaks up on people so they can never see when you’ve “had it done”, like the more immediate treatments. It is good especially for the cheek hollows and nasojugal grooves that you see as aging steals away your normal subcutaneous fat carpet pad from your skin.
Fat transfer can be used almost anywhere on the body, but in the face it is most common to use this in the deep fat compartments of the cheeks, or more superficially in the cheek hollows or even in the hollows above the eyes. It requires a fat donor site elsewhere on the body and is usually harvested by liposuction in the office under local anesthesia unless combined with a larger procedure requiring general anesthesia. There is often initial swelling and overcorrection which resolves in 2 to 3 days, then a period of milder swelling as the fat graft incorporates to your body. There is a variable amount of resorbtion (in our patients, when injected into the face this is a very small amount , but some offices expect up to 1/3 of the amount injected to waste away) and then by 6 weeks , the result should stable. Unlike many otf the fillers, this tissue is a living graft of your own tissue and should last just like any other fat in your body, subject to diet and weight loss.
Botulinum toxin A is one of the most potent poisons on earth, but carefully purified and assayed, it can be used to selectively paralyze muscles in a very predictable way. Like any tool, this substance may be used more artfully by some than by others. It comes in “units” and different amounts are necessary to weaken different muscle groups. Big thick beefy male corrugator muscles may need 30 or more units to treat a man’s vertical glabellar creases ( his “11”frown lines) while it might take only 1-5 units to make a change in a fluttering eyelid. Botox will set in quicker if its fresh and will last longer, but typically you see ful results within three days and will last at least 3 months and often still has some effect as long as 6months.
Its one of those too good to be true things. Latisse is a painless, simple, neat, and effective way to grow your own eyelashes. The only potential side effect (aside from an allergy to the stuff) is the potential to turn blue eyes brown with continued application (usually IN the eyes when used for glaucoma).Although not skin care, eyelash care fits in with the nonsurgical facial therapies many women enjoy. A daily application of the solution will over 6 wks of time show noticeable increase in the length and thickness of the lashes. Unfortunately when you stop using it the effect will also gradually wear off returning your lashes to the way they were. Ask about it during your visit.
Of the many available skin care routines we have chosen Obagi Nu-Derm to be our primary skin care regimen. The Retin-A in this produces not only changes that you can notice in your skin but also the biology to a healthier skin type. It can help improve skin wrinkles, large pores and, in general, improves the skin tone. There also are the hydroquinone components of the Obagi Nu-Derm System which can help smooth irregularities of pigmentation, making melasma or lentigines much less noticeable. These active ingredients are also combined with skin exfoliants and moisturizers to help enhance their effectiveness and make the system an easy daily use routine. The Obagi Nu-Derm System is primarily designed for use on the face but is very versatile and can be used over the neck, chest and hand areas if desired. ( www.obagi.com )
To compliment the skin care routines, we also carry a full line of the Gerda Spillman makeup to enhance the quality of your skin. ( www.gerdaspillmann.com )
Microdermabrasion: Microdermabrasion is a technique whereby the very outer layers of skin can be removed. Typically this is a spa type treatment and there are many methods of performing this surgery. Our office uses a diamondtome to gently abrade the outer layers of skin. This results in a smoother feel and modest tightening of the skin. This provides temporary relief of very superficial rhytids and is not intended to be a permanent result. Typically this is done in a pleasant, painless procedure and one can return immediately to all normal activities upon leaving the office.
Glycolic Peels: Many degrees of superficial skin peeling also exist to perform slightly more durable results than the microdermabrasion and these are very easily and painlessly administered in the office with very little risk of side effects. Some of the very superficial peels that we perform here in the office are a mandelic/lactic acid mixture, Dermik Aesthetics, company trade name.
TCA: A trichloroacetic acid peel is the next deeper type of peel. This helps improve sun wrinkles, large pores, melasma and keratoses. This is most often performed after a six to eight week interval of Obagi Nu-Derm or other Retin-A treatment with hydroquinone to precondition the skin to minimize any unwanted change in pigmentation and to maximize the benefits of the peel. We advocate the Obagi Blue Peel for its safety and predictability. It can be varied from a very light peel to a significant deep peel with some permanent effects. Generally there will be some skin shedding over the 5th to 7th days after the peel, hence, the name. Usually our patients continue all their daily activities during this period and it is unusual to miss any time from work. There may be more frequent face washing or makeup application during this time period but generally this is tolerated very well. The Blue Peel can also be used on the neck, chest and hands and results can vary from being very modest in a light peel to very impressive with deeper layers of peeling.
Phenol Peels, Laser Peels and Dermabrasion: Phenol peels, laser skin resurfacing and dermabrasion are all deeper layers of skin resurfacing and here we really do cross the line from nonsurgical to surgical treatments. There are risks with these deeper techniques of permanent scarring or permanent skin color change and need to be very carefully considered in a long discussion with one of our physicians prior to deciding on this goal of treatment. It is excellent for people with significantly weathered or sun damaged skin. There is usually a two-week time period with significant exfoliation of skin off and requiring 7-10 days for re-epithelialization which leads to a burning discomfort and raw appearance to the skin much like a newly opened blister. When properly performed very dramatic results can be achieved.
For further information on these procedures, our experienced staff would be happy to discuss any further questions.