Daily Skin Fix

Skin and Sin

There are sins of omission, sins of commission, and just sin.

Sins of omission, is not doing something. For hair that could be not getting enough iron intake and having hair loss as a result. For nails it might be not keeping the edges filed, and getting splits at the ends. For skin it could be not wearing sunscreen daily and using a targeted anti-aging skin care program so your skin ages faster than it needs to, or having severe acne, but not treating it, and then getting scarring.

Sins of commission are things you do that are just the result of bad decision making, that affect the skin, hair and nails, and badly. For hair it is that really unfortunate hair color, or decision to resurrect your 80’s perm. For nails it is wearing acrylics continuously, rocking the ends and super gluing the loose areas yourself. For skin it is going to the tanning bed 5 times a week.

And just sin is when you do something you know is damaging, and that serves no purpose, but you do it anyway. For hair it could be over plucking the eyebrows until you look like a silent movie star from the 1920’s. For nails it is biting them to the quick and ripping the cuticles off so that you can’t show your hands in a job interview. For skin it could be picking at that pimple 4000 times using your 15 power magnifying mirror, when you know nothing will come out of it, but you can’t stop picking. And then when it is trying to heal, picking at it again.

Of course, there is a lot of overlap, as when you don’t do something, and it is bad decision making, and it really serves no purpose but you do it anyway. Like not wearing sunscreen on your face, neck, forearms and hands every day. Yes, it does take 20 seconds to do. As opposed to the 5 minutes it takes to apply a heavy foundation to cover up the effects of sun damage. Clear cut categories of sin are sometimes in the eye of the beholder. And some of my “skin sins” are really other sins that affect your skin, but as my grandmother used to say to me: “Little missy, don’t try to talk your way out of this one, I am on to you. Just admit you are wrong, say you are sorry, and don’t do it again.” And as usual, she was right. So without further ado, here are my top 10 Skin Sins.

Top 10 Skin Sins

1. Unprotected Sun Exposure. You knew it would be #1. I am not going to go into my usual tirade about the aging and damaging effects of the sun, except to say—daily sun exposure is one of the top 2 most aging things you can do to your skin, and causes skin cancer. It causes discoloration, broken blood vessels, wrinkles, large pores, loss of elasticity and that stiff, yellow cross hatched skin that is characteristic of chronic sun exposure. You know this, so put on your sunscreen every day.
2. Smoking. Do I really have to say this? Smoking reduces blood flow in the skin, exposes you to direct toxin exposure on the skin and in the blood. And, if that’s not bad enough, the facial expressions repeated over and over etch lines in the skin. It is the other sin in the top two most aging things you can do to your skin. Whatever you do– don’t do 1 and 2 together. The effects of chronic sun exposure in smokers are much more damaging than either one alone. The results aren’t pretty.
3. Procrastination. I see this frequently. Young people in their twenties and early thirties are more worried about hair style, eye shadow, and outfit than they are about the health of their skin. That’s because they are young, and by and large have good skin. And then in their thirties and early forties they are raising a family, busy at work. Mornings are too rushed to apply sun screen, and evenings never end so active skin care is not applied. Then all of a sudden at 45, they have an “OMG what has happened to my face” moment. And end up in my office. All of the easy stuff to slow down aging of the skin work best when you do them while your skin is still good. And they are not really complicated—sun screen every day, a retinoid (tretinoin, retinol etc.) every night, a peptide lotion and a combo botanical and fruit acid serum once a day. Add a little Botox when those frown lines start showing and a little dermal filler for smile lines and you are good. Yes, those things help later too, but it is always easier to prevent than try to fix the damage.
4. Following every fad. There are patients who jump from doctor to doctor and back again. They try this new procedure, that new skin care ingredient they read about. Some may be appropriate for them, some are not and some are bogus. But they never stick with anything long enough to see the results they could see if they picked one doctor, committed to a treatment plan and then followed through.
5. Ignoring your teeth. We all lose bone structure in our face as we age. When we do there is less structure to the eyebrows, cheeks, around the mouth and at the jawline. Soft tissues and skin sag when there is less underlying structure. Tooth loss leads to loss of supporting bone structure around the mouth. Teeth wear down and become discolored over time. The result is a collapsed mouth without enough underlying structure to fill out the skin. So take care of your teeth. You need them.
6. Yo-yo weight fluctuations. The weight goes on. The weight comes off. The weight goes back on again. Repeat. Skin is pretty elastic, up to a point, when you are young, but it loses elasticity over time. At any age, too many episodes of weight gain and stretching, or too large of weight gain and skin loses its ability to shrink back. The result is sagging skin on the face, and sagging and stretch marks on the body.
7. Picking, picking, picking. One of my pet peeves. So much so I wrote a whole series on why you should step away from the magnifying mirror before someone gets hurt.
8. Accentuating asymmetry with bad eyebrows. Another of my pet peeves. Eyebrows frame your eyes and balance your face. Symmetry is the hallmark of a young face. We all get more asymmetrical over time but funky eyebrow shape accentuates it. The biggest mistakes are tweezing the brow too thin, tweezing the center margin too far outward and starting the arch too far centrally giving a comma shaped eyebrow. Hold a pencil parallel to the outside corner of your nostril through the inside corner of your eye to your eyebrow. Only tweeze center of this line. Rotate the pencil through the outside corner of your eye to your eyebrow. This is where your eyebrow should end. Rotate through the outside edge of the colored part of the eye to the brow. This is where you arch. Do it right and it will make a big difference.
9. Wearing heavy, mismatched foundation. Heavy foundation actually makes texture abnormalities like large pores, lines and wrinkles look worse. It can cover red discoloration. So lighten up on the foundation. It you want to fill in some of the texture abnormalities like lines and pores, and then use silicon based translucent foundation primer, followed by a lighter liquid foundation or mineral powder applied with a sponge.
10. Rushing around, doing too much and not getting enough sleep. During sleep many of the body’s natural repair mechanisms are more active including those that repair your skin. Sleep deprivation leads to both decreased levels of some beneficial hormones and less time to repair damage. Missing sleep for one night makes you look bad the next day and missing sleep on a routine basis can affect your appearance long term. So let everyone else do some of the work and go to bed.

It takes little or no money to correct these 10 skin sins. Just consistency and a little determination. So follow my grandmother’s “advice”—admit you are wrong, tell your skin you are sorry, and don’t do it again.

How to Get Rid Of Your Past:
Removing Brown Spots From The Sun

In a previous post, Out Damn’d Spot, Out I Say we discussed how to tell what kind of brown spots you have, so you know what needs to be done to get rid of them. They are of very different causes and presentation, and have very different treatments. And it’s always a good idea to know what you have got, before you decide what you need to do. Let’s start with the easiest to treat, relatively speaking, brown discoloration from past sun exposure.

To recap, here is what you see:

• In the mirror: Scattered pin-head to quarter size flat brown or reddish brown spots on face, neck, chest, forearms, and hands. Some may be scaly.
• Diagnosis: Actinic damage from past sun exposure, most commonly in lighter skinned people. Freckles are small, relatively regular in size and distribution, flat and most common in redheads. There are two kinds of actinic, or “sun spots”. Actinic pigmentation are flat brown or reddish brown spots, irregular in size and distribution, but not scaly. Actinic keratoses, or AK’s, are also scaly or crusty.
• Treatment: Daily sun protection with clothing and sunscreen, prescription retinoid creams such as Retin A or Refissa, over the counter Retinol, prescription or over the counter bleaching creams, Intense Pulsed Light (IPL), Chemical Peels, Particle Free Precision Microdermabrasion/Dermal Infusion such as SilkPeel, LED treatments such as GentleWaves, and laser treatments such as Fraxel Laser. For pre-malignant sun damage treatments are liquid nitrogen destruction, prescription medications and photodynamic therapy such as IPL/PDT.
• Ease of treatment: Moderate.

So, now you know how you got where you are—spots, and blotches from sun damage.

• Freckles are small pinhead size brown to red to tan flat spots and are found on any part of the body that’s exposed to the sun, like the face, nose, shoulders and chest. They become darker in the summer and fade in the winter. Freckles can occur on all skin tones, but they’re more common in those with fair skin, red hair and light-colored eyes, and occur from childhood onward. Freckles give character and individuality, and many people with freckles like them and don’t desire removal, but remember the reason for them is overexposure to the sun and are a sign of sun damage.

• Sun spots are isolated discolorations appearing from prolonged sun exposure over extended periods of time. They are random in distribution, vary in size and color from tan to reddish brown, to dark brown, larger than freckles, usually flat. They’re most common on the hands, sides of the face, chest and neck, and any other part of the body that’s regularly exposed to the sun. Most common in lighter skin types, but can occur in anyone who is exposed to sun over a period of time. Sunspots usually tend to show up on the skin later than freckles, but as early as your 20’s and 30’s if you have light skin or have had significant sun exposure. Over time, as they become pre-malignant actinic keratosis they may become scaly, and accompany the crinkly texture changes, broken blood vessels and wrinkles of chronic sun damage.

Home Treatments:

• Daily Sun Protection: Of course, as with much of life, the best offense is a good defense. And the defense is sun protection started at an early age and continued though out life. And it is even more important if you have skin type I or II and live in a sunny climate such as southwestern US, southern US, the tropics or Australia; work or recreate outdoors; or grow up on the beach. I have gone over this before, and I know you don’t want the lecture again. If you do, read my previous post Quit Complaining and Wear Your Damn Sunscreen. The vitamin D issue? Topic for another day.

• Prescription Retinoid creams such as Retin A or Refissa: Retinoids are compounds which are able to penetrate the top layers of skin. Retinol is the naturally occurring form of Vitamin A and is converted to the biologically active form, retinoic acid, in the skin. Prescription retinoids are forms of retinoic acid, and are stronger than retinol. Retinoids have well documented anti-aging, sun damage reversal and acne treatment effects, and are considered the gold standard in both anti-aging and acne treatment. Prescription tretinoin, or the other prescription retinoids  include Retin-A, Retin-A Micro, Refissa, Renova, Differin, Tazorac) that come in creams and gels. I have been using one form or another of prescription tretinoin for 25 years. The key is to use the right form. I use currently use Refissa (it is the old Renova 0.05% now a branded generic), tretinoin 0.05% in an emollient base. It is much easier to tolerate than Retin-A, and even easier to tolerate than Renova 0.02%. Creams are much easier to tolerate than gels. The key is to have your face completely dry before you put it on at night, and use it on a regular basis, not intermittently. When your face is damp you absorb more and it is more irritating. When you use it, get dry and red, stop, get better and start again, your skin peels, reforms just in time to peel again when you restart it. And your skin never gets tolerant of it. You can do it every other night or even every third night to start and work up. Be very careful with exfoliants, which can cause microscopic abrasions which allow the tretinoin to penetrate and cause inflammation. Even using a washcloth or facial cloth, synthetic cotton balls (use 100% cotton), cleansing brushes, or a makeup brush to apply loose mineral powder can cause you to not tolerate it.

• Over the counter Retinol: In general, the strength of pure time-release retinol in medial grade, non-prescription products is 0.1-0.5%. The percentage may increase up to 1.5% if the product is actually a mixture of retinol, retinyl palmitate and retinyl acetate.

• Prescription or over the counter bleaching creams: Prescription hydroquinone, non-prescription hydroquinone and other over the counter bleaching creams are often helpful in addition to the other methods we are discussing. That is a complicated topic, and one which we will discuss in depth when we discuss the bane of pigment problems, melasma, later. So you will just have to stay tuned, and return later.

Office Treatments:

• Intense Pulsed Light (IPL): A series of 3-5 Intense Pulsed Light treatments (called IPL, Photofacial, or Photorejuvenation) reduces broken capillaries, redness, brown pigment, age spots, and freckles. It is ideal for those who have lighter skin, with discolorations and little or no textural problems, because it targets the pigment in cells and broken blood vessels to destroy them, while not disrupting the other, lighter parts of the skin.  Red areas get redder for 24 hours, and dark spots get darker for 5 days, and then peel off.It is absolutely essential that you use daily sunscreen, and avoid sun exposure for 3 weeks before treatment, to reduce the natural pigmentation in the surrounding normal skin. Patients with skin types III and up must be especially careful. If you don’t you are at risk of getting burned. Also it is essential that you are evaluated and treated by a physician who is trained and experienced in the skin. IPL is a great procedure when properly done, but one that takes skill to do right. We see patients who have had treatments by individuals with little training or experience and who then develop burns, more pigment, or who are given many low energy treatments with little results. IPL also can be used to improve the red and brown discoloration on the neck, chest, back of the arms, and hands from sun damage. The healing time is longer and the risk of burns higher if you don’t follow sun protection or if done by an inexperienced or untrained operator.

• Chemical Peels: At-home products with glycolic or fruit acids and a series of in-office light chemical peels can improve discoloration by peeling off the top layer of pigmented skin cells, and allowing better penetration of other surface treatments. They are best when used with home retinoids, prescription hydroquinone or other skin lighteners. Skin may be red, dry and flaky for up to 5 days.

• Particle Free Precision Microdermabrasion/Dermal Infusion such as SilkPeel: Particle-free microdermabrasion uses a treatment tip to exfoliate the skin. SilkPeel Dermal Infusion uses a diamond treatment head to precisely exfoliate accompanied by application of bleaching solutions at controlled intensity. It removes surface pigment, and allows better penetration of prescribed home skin treatments. A plus is that there is no redness or flaking after treatment.

• LED Treatments such as GentleWaves: GentleWaves LED Photomodulation uses a painless light emitting diode treatment to stimulate collagen and elastin production and improve mild brown discoloration over a series of 8 or more treatments. There is no downtime, but should be used with other treatments, and improvement is variable.

• Fractional Laser Treatments Patients who don’t respond well to the treatments above or who also desire improvements in mild to moderate wrinkles, large pores, surface irregularities, or acne scarring are candidates for fractional laser treatments such as Fraxel Laser Treatment or Active FX. Fractional lasers deliver energy deeper into the skin through thousands of deep tiny columns breaking up deeper pigment, resurfacing sun damage, irregular surface changes, wrinkles and scars. There are two main types, ablative requiring less treatments, but have a longer recovery time and discomfort during treatment and non-ablative which require more treatments, have less recovery time and discomfort during treatment.

Top 10 Skin Tightening Tips
From A Cosmetic Dermatologist

1. Take prevention seriously. Start protecting your skin early from daily sun exposure, by wearing sunscreen every day. Don’t tan. Don’t smoke. Use a retinoid, antioxidant, peptides and an alpha hydroxy acid daily. It’s never too late to start.
2. Non-invasive skin tightening procedures like Thermage work best on mild to moderate skin sagging. Start these procedures early and plan to do them intermittently every couple of years to tighten and slow down sagging. Don’t wait until you have pronounced sagging.
3. Dermal fillers like Juvederm and stimulatory fillers like Sculptra not only make you look better today, they actually provide the right environment for your skin to manufacture additional collagen. Don’t put it off when you start to see early loosening of the skin.
4. Take care of your teeth. You need them. Loss of teeth leads to loss of facial bone structure, accelerating sagging. Do everything you can to avoid having teeth pulled and dentures placed.
5. If you are thinking about surgical tightening procedures like a facelift, choose your plastic surgeon carefully. Opt for structured formal training in plastic surgery, certification in Plastic Surgery by the American Board of Medical Specialties, and experience over glossy ads, media coverage, and smooth bedside manner.  Be cautious about internet reviews; some glowing reviews are planted by the physician, and some bad reviews are planted by a competitor. Get recommendations from friends who have used the surgeon, and from trusted physicians and nurses. Be a little careful with taking all referrals at face value, sometimes the physician you ask is a personal friend of the surgeon. Plastic surgeons often give nurses a professional discount, which could cloud their judgment. Ask multiple people. Get second opinions.
6. This goes for cosmetic dermatologists too. They should be certified by the American Board of Medical Specialties in Dermatology. Get personal recommendations from people you trust who have used them.
7. Don’t get set on having a specific procedure based on something you read on the internet or saw on a TV show. If you have done your homework, your cosmetic dermatologist or plastic surgeon is very experienced in evaluating your face, your medical condition and your desires and deciding which particular procedure is best for you. Be specific in what kind of results you want, how much money you can spend, how much recovery time you can afford. Then let the surgeon guide you in which procedure is right for you. If you don’t feel the physician is the right fit, get a second opinion.
8. Follow your plastic surgeons instructions. Be truthful about your medical history. Don’t lie about smoking. Don’t agree to quit, then sneak “just a couple” while you are recovering from a facelift. If you are having problems after surgery, insist on being seen. Good plastic surgeons will want to see you. They don’t like complications either.
9. Aim for a natural, but rejuvenated look. You are never going to be 28 again, or look like the photo you brought in of yourself at 28. Get over it. Be realistic.
10. Know in advance that your definition of “recovery time” after surgery and the surgeons is the same. Ask specifically when you can expect to be there. There is a difference between “most of the bruising and swelling will be gone” and “no one will know I have had surgery”. Ask for a specific time frame. Then double it and plan accordingly.

Bonus Tip: Don’t decide on an invasive surgical procedure based on an infomercial.

The fine print about skin tightening procedures–risks, complications, side effects, poor cosmetic results, and other unpleasantness

If you are thinking about getting one or more procedures for skin tightening, you will want to know about the risk, side effects, and how happy you will be with the results. The problems that occur with all skin tightening procedures generally fall into one of three categories:

• Risk of medical or surgical complications that are a risk to your health or the integrity of your tissues
• Risk that the procedure performed is not the procedure that you really want or need–either too much, too little or the wrong procedure to address your problem
• Risk that the results will be either unnatural looking or obviously operated upon

My lawyer is again reminding me to remind you that you should not rely upon the following discussion of risks as a basis to decide whether or not to have a procedure. If I am not your doctor, I am not your doctor. Rely upon what your doctor tells you.

Risk of complications that are a risk to your health or the integrity of your tissues

All of the surgical procedures have similar sets of risks, although the likelihood that they will occur vary among the procedures, with the skill of the surgeon, and the patient’s individual medical condition. Differentiation has to be made between events that are expected and occur in most, if not all patients, such as swelling and bruising, and complications that only occur in some and can cause permanent damage. Skin tightening surgical procedure risks include excessive bleeding, infection, nerve damage, tissue death, scarring, swelling, and the risks of general anesthesia, if needed.   Bleeding after surgery can be a problem when the blood collection prevents healing or puts pressure on other structures. Infection can cause damage to the tissue. Nerve damage can cause loss of sensation or muscle movement. Death of tissue at the edges of the area that has been lifted in a facelift can cause significant scarring. Scarring can be unsightly or actually affect function, as when eyelids don’t close properly because of scarring and chronic drying then damages the surface of the eyeball.  Additionally eyelid lifts have a risk of loss of vision (luckily extremely rare), changes in vision, double vision, excess or inadequate tearing.

Fortunately, serious, lasting complications from surgical skin tightening procedures are uncommon. But as with all the risks that your physician discusses with you, they do sometimes occur. Otherwise they wouldn’t be talking to you about them. Each of the surgical procedures has its own relative risk of each complication that is specific to that procedure, based on the extent of surgery performed and the characteristics of the tissue that is located on the surgical field. For example, facelift surgery has the greatest risk of “flap necrosis” or death of skin at the edges of the “flap” that is moved because the area of tissue that must be separated from the underlying blood supply is the greatest. Eyelid surgery affects structures surrounding the eyeball, so the risk of damage to the eye, though very low, is specific to that particular surgical procedure.

The non-surgical procedures risks in general are less severe, reflecting the less invasive nature of the procedures. But, they do occur. Radiofrequency tissue tightening with Thermage risks include very rare risk of burns, surface irregularities or fat atrophy which are reported with current technology and current treatment protocols as less than 2 cases per 10,000 patients treated. Liquid lift with skin filling injections may cause bruising or swelling lasting for up to a few weeks. Bumps under the skin may occur and are occasionally visible. Rarely compression of a blood vessel may occur, which if not successfully treated, can cause damage to the tissue from lack of blood flow. Very rarely, a long lasting infection can occur.

Risk that the procedure performed is not the procedure that you really want or need–either too much, too little or the wrong procedure to address your problem

It is not unusual for a patient to request one procedure when another is indicated. A patient may request an eyelid lift, when the real need is for a brow lift, since a sagging brow doesn’t hold the eyelid up well, so it sags.  Another may request Thermage treatment, when their real need is for a face lift. Plastic surgeons and cosmetic dermatologists are trained to evaluate the real nature of the problem and to suggest the proper procedure to address it. Problems occur when the physician does not accurately evaluate the problem, and/or performs the wrong procedure. That is why formal training, experience, judgment, an artistic eye, and our old friend the Hippocratic oath are important.

Risk that the results will be either unnatural looking or obviously operated upon

Many patients worry more about having a bad cosmetic result than they do about the risk of serious complications from skin tightening. We have all seen results that are unfortunate. Sometimes they are very obviously bad, and sometimes it just doesn’t look right. Too tight, too unnatural, too “done”.

Bad results after surgical procedures include the dreaded “wind tunnel” pulled too tight/too much look. Often this is the result of a surgical face lift, brow lift or eyelid lift that has either removed too much skin or fat, or has pulled skin tight over a face that has very little fat to provide normal contour. Too tight face lifts often leave a “skeletonized” appearance to the face. Too tight brow lifts can raise the eyebrows unnaturally. Eyelid lifts that remove too much fat give a hollowing around the eyes.  Facelifts and brow lifts may cause changes in the hairline shape or localized hair loss. Scars may be visible, thick or distort the shape of the surrounding structures. Shape of the structures may change. This is often noticed as a change in the attachment of the ear to the side of the neck, so called “pixie ear”, after a facelift, or rounding of the normal almond shape of the eye after an eyelid lift. Skin may be pulled in an unnatural direction, such as the “sweep” of the cheek looseness that may change from the pre-surgical downward jowls to a horizontal pouch.  Asymmetry may occur, either as accentuation of pre-existing asymmetry or as a new problem, with one side tighter, higher, flatter or more prominent than the other side.

Poor cosmetic results, as abnormal or too tight appearance after non-surgical radiofrequency treatments have not been reported. Surface irregularity, though very rare, is aesthetically unpleasing. Lack of sufficient improvement in skin tightening may give inadequate cosmetic improvement.  Filler treatment may be either too much or too little. Inadequate filler volume gives inadequate results. Excessive filler volume gives an unnatural, bloated appearance. Shape of structures may be changed, most commonly seen in the “trout pout” of some patients after lip injections. Lumps, bumps, puffiness or visibility of the filler through the skin may occur.

Oh my, such unpleasantness. Fortunately, a good cosmetic outcome without complications is common when the physician is trained and skilled, and the patient does their part. So we better discuss that next.

Next: Top 10 aesthetic skin tightening procedure tips

Cosmetic skin tightening procedures–what’s it going to take? Costs, number of procedures, recovery times for surgical and non-surgical treatments.

Now that you have tried to make a realistic estimation of what kind of results you want, and have talked to your cosmetic dermatologist or plastic surgeon about what it is going to take to get there, what are the costs, number of procedures needed, and recovery times?

The number of treatments, and recovery times are fairly standard, although they do vary. They are based on the assumption that you require the average amount of treatment, and that you do not have a complication after the procedure. If you have a complication, the recovery times can be significantly longer. And especially with the surgical procedures like a face lift, the extensiveness of the procedure varies, depending on what your surgeon feels you need for best results. More extensive procedures, in general, require more recovery time.

The other thing about recovery time is that your definition of “recovery time” and your surgeon’s may be different. Do you mean until you don’t scare people or do you mean you can go to work or an event and no one will know you have had surgery? Will you need to wear your hair down to cover the scars? Until the scars fade (they never go 100% away)? Until all swelling is gone? I have found that it is not uncommon for the “recovery time” by the patient’s definition to be longer than they expected from their discussion with the surgeon. A good rule of thumb, although my surgical colleagues may not agree with me, is to take the estimation of “recovery time” that your surgeon gives you and double it. It is much better to be pleasantly surprised than to plan to be looking good when you see your ex at your son’s wedding and be disappointed. Final resolution of swelling and restoration of normal contours may take months.  The important thing is to have a frank discussion with your surgeon and let him or her know what you think is recovery time, and go from there.

Costs vary quite a bit, based on the amount of treatment you need, your location and the physician performing the procedure. Sometimes other procedures are bundled into the price. All costs given are an average and based on data around the country.

My lawyer wants me to remind you that this is what I tell my patients. If you are not my patient, don’t rely on what I tell you, rely on what your doctor tells you.

So here goes:

• Procedure: Full Face-lift
• Average cost: $11,000-20,000
• Number of treatments: One
• Recovery time: Bruising for up to 3 weeks. Most swelling resolved by one month, but may have some residual swelling for several months. Scars fade in 6-12 months.
• Probable need for complimentary treatments: May require fat transfer or other filler to re-volumize. Fat transfer has pluses and minuses and is very technique and patient dependent. Results vary.

• Procedure: Lower Face Lift (a real one by a real Board Certified Plastic Surgeon)
• Average cost: $6000-11,000
• Number of treatments: One
• Recovery time: Bruising for 1-3 weeks. Most of the swelling is resolved by 3 weeks, but may have some residual swelling for several months.
• Probable need for complimentary treatments: May require filler to re-volumize.

• Procedure: Eyelid Lift
• Average cost: $2800-$4100 upper eyelids, $2800-$4100 lower eyelids
• Number of treatments: One
• Recovery time: Swelling and bruising for 1-3 weeks.
• Probable need for complimentary treatments: Usually none

• Procedure: Brow Lift
• Average cost: $3200-7200
• Number of treatments: One
• Recovery time: Varies depending on the patient and whether it was an open or endoscopic procedure. Swelling for 1-3 weeks and bruising for up to 3 weeks. Six months to a year for scars to fade.
• Probable need for complimentary treatments: Usually none

• Procedure: Liposuction Neck
• Average cost: $2500-5000
• Number of treatments: One
• Recovery time: Bruising and swelling for 1-3 weeks. Often advised to wear chin strap 24 hours a day for a week or more, then at night.
• Probable need for complimentary treatments: May need to be performed with a surgical neck lift.

• Procedure: Neck Lift with Liposuction
• Average cost: $5800-8000
• Number of treatments: One
• Recovery time:  Swelling and bruising usually lasting for 1-3 weeks but up to 6 weeks for complete resolution.
• Probable need for complimentary treatments: Usually none

• Procedure: Non-invasive Tissue Tightening (Thermage)
• Average cost: $2200-2800
• Number of treatments: Usually one, may need a second treatment
• Recovery time: None
• Probable need for complimentary treatments: May need re-volumizing with Sculptra or Juvederm.

• Procedure: Liquid Lift with Sculptra
• Average cost: $5000-7000
• Number of treatments: 3 sessions, 2 vials each session for a total of 6 vials
• Recovery time: Swelling for 1-3 days, bruising for 1- 3 weeks. Bruising has been dramatically reduced with newer techniques, with more recent patients having minimal bruising lasting less than a week.
• Probable need for complimentary treatments: May need non-surgical tissue tightening with Thermage

As you can see costs and recovery time vary. You want to do everything that you can to be prepared for your actual recovery time in your situation and to reduce the risks of extending your recovery time or having a complication. I hope I don’t have to say “follow your surgeon’s instructions to the letter”. Good. Do it.

Next: the fine print about skin tightening–risks, side effects, and other unpleasant things

How to know which skin tightening treatment is right for you?

When you are considering which aesthetic skin tightening treatment will work best to reduce sagging skin, how do you decide? I am often asked whether a particular patient will benefit from the non-invasive treatments or will require a surgical face lift. As with most other cosmetic or aesthetic problems, the answer is–”it depends”. There are two components to the question. First, objectively, what does the physical status of the sagging skin require to achieve tightening? What, objectively, can you expect as realistic results for any treatment? Second, what degree and kind of results do you, as the patient, desire. And finally, what are you willing to do to get it? What kind of discomfort, down time, and recovery are you willing to undergo? And what are you willing to pay for it?

At times I see patients who have a mismatch between the first, second and third components of the equation. It is part of my job to try to outline for them what they can realistically expect based on the combination of their choices of desired results, down time, discomfort, risk and cost, on the background of how they as individuals likely will medically respond.

Most commonly this mismatch is seen with patients who need a significant amount of change, but want to do very little to achieve it. These patients have a lot of skin sagging (laxity), very little elasticity, and significant loss of volume where it should be (mid and upper cheeks, under the eyes, around the mouth and in the lips), and too much volume where it shouldn’t (jowls, jaw line and as bags under the eyes).  When asked what kind of results they want, the answer is almost always “I just want this” as they take their hands and pull the skin back tightly several inches from their lower face toward the ears, removing all looseness and giving them a tight jaw line and upper neck. When we discuss that “I just want this” requires a surgical face lift (and often also an eyelid lift and brow lift) and adequate volume replacement they are disappointed that one syringe of filler or one treatment of non-invasive skin tightening with Thermage won’t achieve “this”.  The disappointment stems from the cost involved in a facelift with adequate volume replacement, as well as the risk of surgical complications and recovery time. And of course, some patients just don’t want surgery.

On the other hand, I have many patients, the majority in fact, who say “I don’t like this turn down at the mouth and I would just like my face a little tighter.” They are willing to do a non-invasive Thermage treatment, and plan on repeating it every 2-5 years. Also they are willing to do adequate volume replacement with multiple syringes of Juvederm or several sessions of Sculptra. These patients either have early or moderate changes and only need non-invasive treatment, or they have more advanced sagging but are willing to accept a modest amount of improvement. We see a fair amount of patients who definitely fall in the appropriate for a surgical face lift category, but don’t want one. As long as their expectations are realistic, we are all happy.

For non-invasive skin tightening procedures to be effective, you have to have some elasticity left in your skin, have some underlying volume (or replace it), be of an age where the body will still produce collagen, and be a non-smoker. And it works best on early to moderate changes, not advanced sagging. The reason they work less well on advanced sagging is simply the skin has lost almost all elasticity, there is too much excess skin, and the only thing to do it to remove some of it. Since a surgical face lift involves cutting above, in front, around, and behind the ears and trimming off as much excess skin as needed as well as tightening the muscles underneath, it is no surprise that significant sagging can be corrected.

In a nutshell: If you want “this”–you need a surgical facelift. If you are starting to see some early looseness or “don’t like this turn down at the corner of my mouth and would like my face to be a little tighter”–non-invasive treatments are right for you. But you can’t have “this” with one non-invasive skin tightening procedure. When you face a situation where what you want doesn’t jive with what you want to do to get it, you have two alternatives: alter your objectives or alter your battle plan.

You will, of course, need a cosmetic dermatologist who is experienced enough to be able to predict the results a certain combination of treatments will give you as an individual based on all of the patient related variables that affect results. And most importantly, one who respects you enough to be honest with you about what you can expect, and who won’t treat you if your expectations are out of line with the results you will actually get.

So decide what you want, be realistic about what you need to get there, and discuss it with your cosmetic dermatologist or plastic surgeon.

Next: Cosmetic skin tightening procedures–what’s it going to take? Costs, number of procedures, recovery times.

Sometimes you need a knife–the surgical face-lift

Surgical skin tightening–when you need significant tightening for sagging skin you need a face lift

For patients with significant sagging of the skin, poor elasticity or who want dramatic results, surgical treatment is necessary.  A face lift, or rhytidectomy, surgically rejuvenates the face by tightening the skin, underlying muscles and fat of the face. A face lift is designed to improve signs of aging in the lower face, including the lower cheeks, jaw, and upper neck. A common misconception is that a facelift will dramatically improve the smile lines, lipstick lines, and eyes. They don’t. Surgical treatment of the forehead, brows, and upper eyelids are best treated with a brow/forehead lift or upper eyelid surgery. The middle of the face and lower eyelids are best addressed with a midface lift and/or lower eyelid surgery. There are various incisions, depth and extent of treatment under the skin and surgical techniques used depending on the patients needs and the surgeons preferences.

Commonly, for the best and most natural looking results, the patient will also need other procedures in addition to the face lift. Resurfacing for etched lines and skin texture, especially around the lips, and volume replacement are the two most commonly performed additional facial non-surgical procedures. Liposuction of the fat under the chin may be needed as well.

Natural looking results are achievable. It takes an experienced, and well trained plastic surgeon and it is very technique dependant. You often can recognize a bad facelift. The face is too tight, the classic “wind tunnel” look, the lines have been rearranged from running up and down to being pulled to the side towards the incision line. There has been no volume replacement and the skin is pulled tightly over the skull giving a skeletonized look–and let’s not even get into bad eyelid lifts.  The ear lobes are deformed with the “pixie ear” point instead of the rounded lobe attachment to the side of the face, and the angle of the ears has been changed. There is a visible scar in front of and around the ear and the hairline may be pulled backwards. These patients often end up always having to wear their hair down, covering the sides of the face, and wear big earrings to disguise the ear problems. These are the ones you look at and think “wow–bummer”. You want the one that people don’t know you have had done, they just think you look great for your age.

I have seen a lot of both great and horrible facelift results over the past 30 years. I firmly believe that the most important factor in getting the former rather than the latter is the formal training, skill, experience and aesthetic judgment of the surgeon performing the procedure. These are real surgical procedures, with real risks and recovery time. I always refer my patients to a Board Certified Facial Plastic Surgeon for face lift surgery and would strongly suggest that you stick with these surgical sub-specialists. For eyelid lifts I refer to Board Certified Oculo-Plastic Surgeons.

Do other specialties perform these procedures–yes. Are some good–yes. Do I perform these procedures–no, even though I have a lot of experience in rejuvenation treatments and consider myself to be trained in evaluation and treatment of aging. Are some Board Certified Facial Plastic Surgeons not so good–yes. But it is a place to start. That at least tells you that the surgeon has official structured training in facial plastic surgery and has passed an objective exam by a real organization certified by the American Board of Medical Specialties. Check them out at the “Is your doctor board certified by the American Board of Medical Specialties site –although I just checked myself and they have me under my maiden name that I haven’t used professionally in many years, Elaine Remmers, and an address from 15 years ago.

Are “I have developed an interest in cosmetic surgery”, “I have a lot of experience in doing plastic surgery”, “I am certified by the Board of Who-Knows-What” and all of the other things that physicians who are not Board Certified in Plastic Surgery by the American Board of Medical Specialties say an acceptable substitute–no.

And beyond that you need a referral from someone you trust. This can be a friend who has a face lift that is both natural looking with good results (though if it is a really good result you may not know they have had a facelift). Your cosmetic dermatologist is another good source, because we see a lot of post-facelift patients, and know what makes a good result.

You should talk to a couple of surgeons, and don’t shop for a deal or the lowest price. This is your face we are talking about.

How long does a facelift typically last? Face lifts set the clock back, they don’t stop it. You will continue to age, and results do loosen over time but most people see a good 10 years from a properly performed procedure that tightens the underlying muscle. Skin only procedures (see below) last a much shorter period of time anywhere from 6 months to  a couple of years.

And what about the L******** L*** that is advertised on infomercials and online?

L******** L*** is not an advance in technique, it is a marketing term. It is a form of a mini-facelift. “Mini-lift” on the whole implies a surgical procedure meant to address mild aging changes seen in the lower third of the face. It uses smaller incisions but does tighten the underlying muscle layer and involves removing skin. L******** L*** is performed through a larger incision and may or may not involved tightening the muscle. It is done under local anesthesia. The chain hires physicians, many who are not trained plastic surgeons, but are other specialties to perform the procedure. They always show patients with results months out from the procedure, not long term. They advertise extensively and have been the subject of much controversy involving results, complications and the legitimacy of those who are portrayed as patients and giving glowing testimonials on the internet. Google them.

The patients I have seen who have had L******** L*** are often initially satisfied, although I consider the scars, earlobe changes and results to be unsatisfactory. As I see them over a couple of years, most of the tightening is gone, and they are left with wide and visible scars. Would I ever, in my professional opinion, recommend it for a patient–no.

This is one area where I really believe, do it right or don’t do it at all.

Next: How do you know which aesthetic skin tightening treatment is right for you?

How to tighten sagging skin without surgery

When you need more than prevention

When you are starting to see skin looseness and sagging but it is not pronounced, then it is time to start in-office non-surgical aesthetic skin tightening treatments to prevent and correct early or moderate changes. Non-surgical cosmetic procedures to combat sagging can also be useful in patients who have more pronounced sagging, but who are either not candidates for surgical tightening or who don’t want a surgical procedure and are willing to accept less tightening than they would get with surgery.

There are basically two ways to approach the problem and often the best results are achieved by utilizing both. The first approach are procedures that tighten the skin by increasing collagen and tightening the existing collagen and elastic fibers. The second option is to restore the aging related lost volume with fillers and lift the skin in what has been called a “liquid lift” or “liquid face-lift”.

Current non-invasive aesthetic facial skin tightening procedures employ one of two types of energy–radiofrequency (Thermage, Accent) or infrared light (SkinTyte)–to tighten by heating the area below the surface of the skin. The heat works by two mechanisms, by causing a small injury and inflammation which causes existing collagen to tighten, and as it heals inducing the skin to make new collagen. In any individual patient the amount of tightening may be tilted toward either mechanism, depending on the amount of existing collagen and the ability of the patient to make new collagen.

There are several different branded machines used to tighten skin, and each physician, including me, thinks that the one they use is the best.

The first procedures that were observed to tighten skin were the ablative CO2 lasers, like the original UltraPulse laser we used 13 years ago. Although they were used primarily to treat wrinkles, the heat generated during treatment did give some tightening. But they couldn’t be used on the body, and the prolonged healing, potential pigment changes and redness limited their usefulness and ultimately they were replaced by fractional laser resurfacing. Today the fractional ablative CO2 lasers, Fraxel re:pair and DeepFX, do give some tightening, but have a recovery time, and some risk of scarring and pigment change. They are not used primarily for skin tightening, but for patients who need significant skin resurfacing and who are willing to accept the recovery time.

The original non-surgical treatment developed specifically reduce sagging skin is Thermage, which uses radiofrequency energy to heat the deeper areas of the skin. Because too much heat can damage the skin, before and after each burst of radiofrequency energy a burst of cooling is used to protect the surface of the skin, and the fat below. The heat causes some tightening of existing collagen and production of new collagen over a 6 month period of time. Some patients see immediate results, some see results over time. There is no downtime. I think Thermage, especially the latest generation treatment, works best and most reliably for skin tightening. Your doctor may think differently.

There is definitely variability in results among patients because of patient factors, differences in machine technology, and skin in treatment techniques. I tell patients that because of this variability there is a spectrum of results– on one end are those patients who get really good results, on the other end are those who really don’t see very much change, and in between are those who get some tightening and who are usually satisfied with their results. Patients who are definitely not satisfied are those with moderate or marked looseness who are expecting face-lift like results.

All of the skin tightening treatments work best on patients with some remaining collagen, elasticity and underlying fat; on those who are healthy; non-smokers; those with mild to moderate skin looseness and good underlying muscle tone.  They all work less well on those with very thin skin (lacking collagen and fat), smokers, those who continue to tan, and patients over 65 who have decreased ability to make new collagen. And they are not a substitute for a face-lift, although I have some patients, who really need a face-lift but who don’t want one, get some improvement with Thermage and be happy with the results. Because facelifts only surgically remove skin and pull the remaining skin and underlying fat and muscle into place, they do not by themselves produce more collagen and elasticity. For that reason we also sometimes perform Thermage on patients who have had a facelift in the past but who are getting some loosening and want increased elasticity and tightness to the skin.

As we discussed in in some of the previous posts about restoring volume to skin with fillers such as Juvederm, Restylane, Sculptra or Radiesse in a “liquid face lift” also helps to lift skin and gives a more natural look as well. Initially we worried that treatments like Thermage given to skin that had received filler would cause the filler to go away quicker, but now we have found just the opposite. It actually helps patients get better results because the fillers, especially the hyaluronic acid fillers like Juvederm improve the function of the fibroblast cells that produce new collagen. Many of my patients benefit from doing both together.

Realistic expectations are key to satisfaction with non-surgical skin tightening. Patients can’t expect more than a procedure can deliver. Physicians can’t promise more than the technology and the patient’s condition will permit.

Next: Sometimes you need a knife–surgical skin tightening

Skin Tightening:
Prevent, slow down and reverse early changes

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

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

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

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

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

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

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

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

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

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

Next: How to fix sagging skin without surgery