Daily Skin Fix

How To Use Retinoids Without Your Face Peeling Off

As many of you know, I am a strong advocate of daily retinoid use for most patients to prevent aging and correct existing damage. There is so much proven scientific data behind them that they are still the gold standard in topical anti-aging treatment. I have been using prescription retinoids and daily sunscreen for 25 years. If you come to see me as a patient, I will likely recommend that you start one of them as part of your anti-aging skin care program. And, of course, if I recommend it, you will do it.

Retinoids are vitamin A derivatives and include over-the-counter retinol, prescription Retin-A, Renova, Refissa, Tazorac, and Differin. Originally developed for acne, they were found to also increase collagen and elastic fiber production, diminish wrinkling, improve brown discoloration, and reduce both roughness and pore size. Retinoids can be applied to the face, neck, back of hands and forearms as these areas also show aging changes from chronic sun exposure.  Apply a pea size amount to each area on completely dry skin in the evening. Most people can only apply it to skin that is off the face every other night because of irritation.

The biggest drawback, and the reason people discontinue retinoids, is that early on they cause peeling and some redness, a process called retinization. The key to success is to use the right form and to use it correctly on a regular basis, not intermittently. Most people do it this way: they use the retinoid; they get dry and peel so they stop until it gets better and then start again. In the meantime the top layer of skin builds up, just in time to peel again when you restart treatment. That is the wrong way to do it. If you do it that way your skin never adjusts and you will keep peeling every time you start treatment again. If you use it regularly without starting and stopping, after about 2 months your skin will stop peeling. You may have occasional episodes of peeling after an environmental insult to the skin, but much of that can be prevented.

Most, but not all, people who have had problems using a retinoid are able to use it successfully if they do it the right way. I often start patients off every other or every third night and work up to every night, but consistently. You can start with the least irritating retinoid and move up to the more irritating product. Gels are more drying and irritating than creams. Refissa and Renova are the least irritating, then Differin, then Retin A, and finally Tazorac is the most irritating. On the other hand, Tazorac gives the most improvement in pore size and acne scars. Another strategy when you are starting treatment is to mix them with moisturizer to dilute them, apply moisturizer before application (if you are having redness, itching or irritation), or after (if you are just dry). And if you have an episode of dryness and peeling later in treatment, you can always dilute them again for a few days. Our Antioxidant Enzyme Peel is great for removing the peeling skin without abrasion.

Mild stinging, redness, peeling and flaking may occur during the first several months and on occasion. This is normal, soreness and irritation are not. Anything that you use on your skin that abrades the skin will cause more redness and peeling. The most common culprits are washcloths, synthetic cotton balls, makeup brushes, or a granular exfoliant. The infomercial technique of applying mineral powder in a circular scrubbing motion with a special brush is the most common cause retinoid intolerance in my clinic.

Discontinue retinoids 5-7 days before waxing, bleaching, peels, microdermabrasion, acne surgery, hair removal, and laser treatments or you will be sorry. If you wax an area that has been treated with a retinoid, strips of skin will come off with the wax when it is ripped off. Other procedures may burn the skin if you don’t stop retinoid use prior to the procedure. That is why the instructions we give with the prescription goes over this. If you didn’t read your instructions, and have an “unfortunate accident” start with a non-fragranced moisturizer and apply it 3-4 times a day to the area where the skin was ripped off.  I like Aquaphor, or Cetaphil cream. Don’t put any toner or active skin care products (glycolic acid, salicylic acid etc.) on it until it has healed. Don’t scrub or pick. As soon as the skin has healed, (pink, not open, crusted or oozing) wear broad spectrum UVA/UVB sunscreen with an SPF of 20 or higher every single day, whether you normally do or not. Avoid sun exposure over the next several months to help keep the area from darkening over time.

Retinoids do make you more sensitive to the sun and you should use sunscreen every day, year round or you are just undoing what you are trying to do. We used to tell patients that they could not use retinoids if they were in the sun, but now we know that, within reason, you may use them if you use sun protection. Of course, I know you are already wearing your sunscreen every day, because you know that it is an essential part of an anti-aging skin care program.  If you are going to the beach, lake, or skiing, discontinue retinoids for a few days before exposure.

To recap:

How to reduce peeling and irritation with Refissa, Retin A, Differin, Tazorac and retinol

• Use it on a consistent schedule—every day, every other day, every third day, not on and off. Work up to every day.

• Choose a cream not a gel.

• Start with Refissa unless you have oily skin and acne. Refissa is in a moisturizing base, is stronger than Renova, and usually the easiest to tolerate. I use Refissa.

• Apply moisturizer underneath to reduce redness and irritation.

• Apply moisturizer over retinoids to reduce dryness.

• Don’t use mineral powder with a brush, use a sponge.

• Don’t use a washcloth or granular exfoliant.

• Stop retinoids 5-7 days before waxing or laser hair removal, chemical peels.

• Wear sunscreen.

Retinoids are very effective as part of your anti-aging skin rejuvenation program. It is worth working with them to be able to use them successfully.

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How to Get Rid of Brown Spots on the Face

“Out, damn’d spot! Out, I say!”  Macbeth Act 5, scene 1

There are things that frustrate you. There are things that frustrate me. And then there is hyperpigmentation, the medical term for increased skin pigment. I can’t tell you the number of times patients have asked me in frustration–“Why can’t I get rid of these brown spots, I hate them! It can’t be so hard can it?”

Unfortunately, yes.

Melanin is the skin’s natural pigment that darkens to protect us from the sun’s skin cancer causing rays. Once sun exposure stops, skin lightens back to its natural color. At least, that’s what is supposed to happen. Damaged or abnormally functioning cells produce discoloration that does not fade. To some degree, the tendency to make abnormal pigment has a genetic basis tied to ethnic background. People with more natural pigment, such as Hispanic, Asian, American Indian, etc., respond to anything that injures or inflames the skin with increased pigmentation.

There are five triggers for abnormal pigmentation—sun exposure, inflammation, injury, hormones and aging. Each of the triggers results in a specific type of pigmentation, and each is more common among different types of patients. In medicine it’s always a good idea to start with an accurate diagnosis, before deciding on treatment and prognosis.  First, look in the mirror and see exactly what kind of pigment you want to improve.

From easiest to most difficult:

In the mirror: Scattered pin-head to quarter size flat brown spots on face, neck, chest, forearms, and hands.

• Diagnosis: Actinic damage from past sun exposure, most commonly in lighter skinned people.
• Treatment: Home skin care, prescription retinoid creams such as Retin A or Refissa, daily sun protection, Intense Pulsed Light (IPL),  GentleWaves, Fraxel Laser.
• Ease of treatment: Moderate.

In the mirror: Tan to dark brown flat or raised growths.

• Diagnosis: Seborrehic Keratosis (age spots), often familial, and more common with age.
• Treatment: First–physician evaluation to be sure they are benign, then destruction with liquid nitrogen, electric needle or Fraxel Laser.
• Ease of treatment: Moderate.

In the mirror: Brown or red-brown discoloration of areas with past acne or injury.

• Diagnosis: Post inflammatory hyperpigmentation (PIHP), most commonly occurring patients with more natural pigment.
• Treatment: Prevention by treatment of acne, not picking, and caution with procedures that can cause pigment such as chemical peels and laser hair removal. Treatment with home skin care, prescription skin bleach, prescription retinoid creams, and for some patients the very cautious use of chemical peels or microdermabrasion.
• Ease of treatment: Moderate—difficult.

In the mirror:  Large dark flat patches of discoloration, usually symmetrical, over cheeks, jawline, forehead and/or above upper lip. It is often more obvious in low light settings, such as at sunset.

• Diagnosis: Melasma or “mask of pregnancy,” is caused by a combination of hormones, predominantly estrogen from pregnancy or birth control, and sun exposure. Once it starts, melasma tends to reoccur very easily with minimal amounts of sun exposure, even if the hormonal trigger is removed.
• I divide melasma into two types: “relatively easy” and “hard.” The difference is dependent on how deep in the skin the pigmentation is found, and whether both the hormonal stimulation and sun exposure can be reduced. Deeper pigment is harder to improve.
• Treatment: Involves both removing the triggers, and using creams and procedures to reduce existing pigment. Daily, year round, broad spectrum sun protection and avoidance of sun exposure is absolutely essential. Reducing hormonal triggers is often a challenge as pregnancy eventually ends, but often the need for birth control continues. Even if the hormonal trigger is removed, the melasma remains “turned on” and even tiny amounts of sunlight cause it to reoccur. Treatment at home with skin lighteners, prescription skin bleaches, retinoid creams, and sunscreen, combined with in-office chemical peels or SilkPeel are tried first.  “Easy” melasma usually responds fairly well to this treatment. For more resistant cases, Intense Pulsed Light, laser, and deeper chemical peels under the supervision of a dermatologist experienced in treatment of pigment, are considered. Results are varied, and these procedures may actually make pigment worse.
• Ease of treatment: Difficult-very difficult.

Overall abnormal pigment, especially melasma, is one of the hardest and most frustrating skin problems that cosmetic dermatologists and their patients deal with. I know, since I have had it myself.

Though Lady Macbeth and I earned our spots in different ways, the frustration is the same.

Next: Let’s dive into the pigment pool in more depth

Do you have a license for that thing?

I was recently talking with a patient whose face had markedly improved since her last visit. When I asked her what had changed she said, “You were right, and I finally took your advice. That made all the difference.” Gratified that my clinical skills had once again been validated, I asked her which specific and wonderful piece of advice she had taken, since I give quite a bit of wonderful advice.

“I had my husband hide my magnifying mirror.”

So here we are at yet another of my pet peeves—magnifying mirrors.  Specifically, magnifying mirrors that are owned and operated by women who also own several pair of devilishly sharp tweezers, assorted safety and straight pins (cleaned with alcohol of course!), and their very own monogrammed comedome extractor  (pimple popper) complete  with loop on one end and scalpel  blade on the other.

Before my gentlemen readers get too smug, at least the women don’t tell me “I didn’t know what that growth on my arm was, but it was bugging me, so I just took out my pocket knife and cut it off. See this scab right here? What do you think it was doc? You don’t think it was something serious do you?” To which I answer “I don’t have a clue.”

When women have a magnifying mirror, at-home surgical instruments, and the stubbornness of a mule, bad things can happen.  

For instance:

• Eyebrow shape becomes very peculiar, with the eyebrow starting centrally too far apart over the pupil, and the natural arch obliterated.
• Milia, those small white balls under the surface of the skin that the nurses and I remove through tiny pricks in the skin with sterile instruments, are excavated through incisions in the skin that most doctors would close with stitches.
• Hair on the chin is plucked, in-grows, is dug out with tweezers and needle, tweezed, in-grows again.  The cycle is repeated until permanent brown and red pigmentation, and scarring occur. And then the hair, ingrown skin, red and brown discoloration, and scar are picked again. Repeat.
• Pimples are popped and picked at before they are ready. Even when the picker knows they are not ready. Because they are there, and they are gross.  So they must be picked, mustn’t they? Of course if one squeeze doesn’t remove the pimple and all signs of its existence, then 200 squeezes must be applied. Because that will make it disappear without a trace. By morning.
• Scabs, flakes of skin, acne pimples that are trying valiantly to heal, are picked off every morning because the dry flaky top looks unsightly with makeup accentuating it. Unfortunately, the trauma of picking at it causes the lesion to make more protective flakey skin and scab, to thicken and pigment. It is in effect saying “please stop so I can heal.” Usually no one listens, and the cycle can literally go on for years.

Sarcasm aside, I commonly see women (and I hate to be sexist, but it is almost exclusively women, unless meth is involved) who have caused permanent and unnecessary scars to themselves by picking.

Am I any better? No. As my husband once said to me “I think you went into dermatology just so you could pick legally.” Partially true.  But be that as it may, I am a licensed and trained professional who knows what the lesion is, how to remove it, how much I can destroy without a permanent scar, and when to stop. Even if I don’t always do it.

Magnifying mirrors should be available by prescription only.  Or at least any magnifying mirror over 3x power. If I can’t see a lesion on exam with my 3x power magnifying glasses, it is not there. Instead, be like my patients who have had cataract surgery, except in reverse. They say “I never had all of these spots on my face until I had cataract surgery.  It gave me spots. “I tell them, gently of course, “No you did, and I have seen them on your face for the last 10 years.  It is just after your cataract surgery, you can see them too.” If you are prevented from seeing it in your 10x magnifying mirror, it will magically disappear.

So step away from the magnifying mirror ma’am, before someone gets hurt.

Next: if you must pick, do it like a dermatologist. Even though my lawyer is sitting at my shoulder trying to shake some sense into me.

Your skin can’t take a joke–so don’t tell it one

Hair and nails forgive and forget. But skin is something else again. It doesn’t forgive and it doesn’t forget. So, I do take care of my skin, and pretty well too. And I have for a long time. That is because skin holds a grudge. If you don’t take care of it , it goes bad on you, and at least some of the damage is irreversible. You can fry your hair, color it blue, lose it from going off birth control pills or after pregnancy and it recovers. Hair just says “whatever, and it grows out just fine. And the kind of hair problems that are really frustrating are not from anything that you do, they just happen, like alopecia areata, and the scarring hair loss diseases.  You can have chipped and damaged nails from working in the garden, you can abuse your nails from wearing acrylics and, within reason, they can recover. Unless you damage the matrix or the nail bed, then you gotta pay. But your skin remembers every unkind thing you ever said about it, did to it, or didn’t do to it (like protect it from sun damage). It really can’t take a joke.

So here is what I do. And I do it every day and every night, without fail. And yes, I use my own line of skin care products, Dr Elaine’s Advanced Skin Treatment, almost exclusively. After all, I developed them, and they are full of both high quality botanicals, marine actives, other natural actives with specific purpose, and various cosmeceuticals including alpha and beta hydroxy-acids, peptides, antioxidants, and vitamins. Since I developed them exactly the way I wanted them, this should  be no surprise to anyone.

My morning routine–First I get up, reluctantly, then:

1. Three days a week I use Dr Elaine’s Antioxidant Enzyme Peel (1 oz 38.99). You have to use it when your skin is completely dry. So I do it the very first thing, I don’t wash my hands or face, and I apply it in a very thin layer. Key word is “very thin” and then I let it sit 30 seconds with my hands in the air, without rinsing them, until the peel liquefies. Next I rub in a circular motion and exfoliate the dead skin. Then I rinse with clear water. I love this product because the papaya, grape seed, and willow extracts in it gently exfoliate without granular particles with the end result that my face reflects light well and glows, but it still allows me to use the retinoid Refissa without the increased irritation of a granular exfoliant.
2. Since I have normal-dry skin, I wash with our Facial Cleansing Lotion (6.7 oz $26.99), using my fingers only, never a washcloth. I love this cleanser–it has glycolic acid to exfoliate, it cleanses well, removes make up and the combined group of natural botanical oils leaves my skin soft and smooth rather than uncomfortably tight.
3. Then I follow with our Gentle Toner (6.7 oz $26.99) applied with a 100% cotton ball. Since I have a tendency to get eczema, and use a fairly potent retinoid every night, I need to reduce the tiny microscopic abrasions that I would get from a synthetic “cotton” pad. I don’t need a drying type of toner, so I use this one that is not drying.
4. Then Dr Elaine’s Correcting Serum (1 oz  $59.99) 2-3 pumps for my entire face and neck. The two things that I feel should be used every day as a basic program, other than sunscreen, is either an alpha hydroxy acid or fruit acid, and a retinoid. Our Correcting Serum has both 8% glycolic acid and a multiple fruit acid complex to exfoliate and promote collagen production, and hyaluronic acid to plump wrinkles and balance moisture.
5. Next I apply Dr Elaine’s Line Diminisher (1 oz $89.99). The peptides Acetyl Hexapeptide-3 and Palmitoyl-Pentapeptide 3 combined with hyaluronic acid help minimize fine lines, and antioxidant green tea calms irritation.
6. Then our Facial Moisturizing Cream ($41.99) in the winter or when I am extra dry or my skin is irritated, or our Hydrating Cream ($39.99) if it is summer or less dry weather. Moisturizers like the Facial Moisturizing Cream that are fragrance free are best if your skin has a tendency to irritation and you are using retinoids like Refissa.
7. Then I apply our Total Eye Renewal (0.5 oz $65.99) to my entire face. Yes, I know it says eyes, and I do use it on eyes,  but also on my face,  because the 3 peptides are very good, it has active Vitamin C, bunches of active botanical antioxidants and I really like the silky smooth effect from the shea butter and silicone base.
8. Then I apply DCL Super Sheer Sunscreen SPF 50 (2.5 oz $24.99) to  my face, neck, chest, forearms and backs of my hands every single day, year round, without fail. I really like this sunscreen because it covers a really broad spectrum of UV, and it is so light weight you don’t even know you have it on.

At  night, no matter how tired I am:

1. Dr Elaine’s Facial Cleansing Lotion
2. Refissa (by prescription $145) to face, neck, upper chest. I apply Refissa to back of hands and forearms every other or every third night.
3. Dr Elaine’s Total Eye Renewal ($65.99) around my eyes after Refissa.
4. Brush on Latisse to the base of the eyelashes (by Allergan–prescription $120 a 3 ml bottle) to grow eyelashes and make them darker–but I only apply it every other night or the lashes get too long and thick. That also cuts the cost, as a bottle will then go 2-3 months.
5. Dr Elaine’s Lip Therapy ($5.99) right before bed so my lips don’t get too dried out.

For Body:

1. Dr Elaine’s Calming Body Wash (12 oz $15.99) in shower which helps my dry skin.
2. Dr Elaine’s Smoothing Body Moisturizer (12 oz $37.99) every night. I am atopic, so my skin is sensitive and rashes easily. That means if I don’t apply moisturizer to my entire body I will itch all night and since I don’t want to do that I just go ahead and use body moisturizer every night. I love the scent, and also the powdery smooth feeling.
3. Then I put our Perfecting Hand and Body Moisturizer (12 oz $36.99) on my feet and heels right before bed. The glycolic acid and fruit oils, soften and repair thickened skin and cracks, and the Evening Primrose oil reduces irritation.
4. If I have been lazy and my heels are really bad I will use Ureacin-20 (4 oz $26.99)on them for a couple of nights. It works really well for thickened calloused heels, but leaves a thin white film on them, so I don’t do it in the daytime.
5. For a little color, in the summer or if I am going on vacation I will use Jergen’s Sunless Tanner ($7.99) for medium to tan skin (just means it has more DHA in it and I get color quicker) or Clarins Self Tanning Instant Gel (4.4 oz)

And that’s how I do my own skin care. I take care of my skin, and I don’t tell it any jokes.

Next: how I do cosmetics

How girl dermatologists do skin care

Female dermatologists are often thought of as the experts on effective, scientific skin care. And that’s because we are. So how does this girl dermatologist, and I use the word “girl” loosely, do skin care? I want to be the best I can realistically be, and that includes my skin. The key to doing the best you can with what you’ve got, it to know what you’ve got. To some degree, you inherit the skin you’ve got. But skin you’ve got is also the result of what you have done, and what you are doing.

Before I became a dermatologist, I always just took my skin for granted and didn’t think much about it. I have moderately sensitive skin, and am “atopic.” Atopic tendencies are genetic, and people who are atopic have skin that is more sensitive than others, gets rashes easier, itches at things others don’t, have little bumps on the upper arms, and often have a family history of asthma or hay fever. If you cut the tags out of all of your clothing, been told you were “allergic” to grass, or wool, or whatever, you are atopic.

Very luckily for me, as a child, adolescent and young woman, I didn’t ruin my skin in the sun. Although I would have loved growing up on the beach, I didn’t.  In Oklahoma City, beaches are hard to find. I wasn’t on the swim or tennis team. We didn’t belong to the country club. Many of my friends would lay out in the backyard and tan. However, sticking to the webbed straps of a wobbly chaise lounge, sweating in the hot humid air, swatting the flies that would continually swarm around was not my idea of fun. So I didn’t do it. Later I was too busy with pre-med and medical school to have any fun outside. So I escaped the early sun exposure that shows up as damage twenty or thirty years later.

I never really had acne as a teen or young woman. Only in middle age, which is not fair and I plan to sue someone, as soon as I figure out who to sue. I pigment moderately easily, and had a decade or so dealing with melasma. Caused by a combination of hormones, either birth control pills or devices, pregnancy or just the hormones made by the body, melasma is a brown pigmentation on the face, especially cheeks and above the upper lip. It is often in a pattern, and I had a delightful set of horns above my eyebrows and a brown pigment moustache.  Melasma drives women crazy, and is incredibly frustrating. I was no exception. Usually it finally burns out, and mine did.

I always ask patients “where is your family from, the old country?” It not because I am just nosy, it is because it makes a difference. The tendency to make abnormal pigment, to get wrinkling with sun damage, to get broken blood vessels and redness, to have sensitive skin all have a genetic basis and that genetic basis is tied to ethnic background. People who have ancestors that had more natural pigment, Hispanic, Asian, American Indian, Black, Middle Eastern etc, respond to anything that happens to the skin, such as pimples, rashes, procedures, treatments, with increased pigmentation. It is hard to fix, so you want to avoid it. If you have light skin, like most Northern Europeans, especially Irish and Scots, and you get a lot of sun exposure over the years, your skin will get thickened bumpy elastosis, wrinkling, loss of elasticity and skin cancer, and you won’t like that either. The list goes on. My family background is German, Dutch, and a little American Indian, so I don’t get sun damage easily, but can make abnormal pigment.

There are 3 components to coming up with your own skin care plan–quiz–soul searching–reality. Kind of like coming up with a life plan.

1. Quiz–What kind of skin do I have?
2. Soul searching–What kind of results do I want?
3. Reality–How much time and money am I willing to spend?

Dr E takes the Dr E  Skin Care Quiz:

• Is your skin very dry, dry, combination, normal, oily, very oily?–Dry
• Do you get breakouts?–Yes, 3-4 per month, painful medium sized pustules and small cysts, and I don’t like it one bit.
• Is your skin sensitive?–get rashy or itchy easily? Yes, didn’t I just say I was atopic?
• If you are out in mid-day sun without sunscreen do you get some immediate darkening of your skin? Yes, a moderate amount
• How much sun do you get daily? Noooooooooooooooooooooooo
• Do you wear sunscreen every day? Duh, yea
• Are you a “soap and water and nothing else”, “I will do 3-4 steps in the morning and same in the evening”, or “as much as it takes” kind of woman? I am a “as much as it takes kind of woman.”
• Are you using any prescription surface treatments like Retin-A, Refissa or for Rosacea? Yes, I have used retinoids in one form or another continuously for the past 30 years.
• Which of the following are a problem–
  • Brown spots–No, see 5 and 6
  • Broken blood vessels–Yes
  • Fine wrinkles–No, see 5 and 6
  • Deeper wrinkles—No, see 5 and 6
  • White “beads” under the skin–Yes, a few
  • Flaking or peeling–Occasionally, from retinoids

Dr E does some soul searching

• What kind of results do I want? Here is what I want–I want have the very best skin I can have.

• I want smooth, uniformly pigmented skin with small pores, minimal wrinkles, no broken blood vessels, no gross brown crusty things, no pimples, and no reddish brown spots after pimples have gone. I want my skin to be approximately in the same place on my face that it was twenty years ago. When I stretch it, I want it to bounce back in less than 10 seconds. And it should not be oily, not be dry, but just right, like Goldilocks porridge.

What am I willing to do to get it?

• No, I am not willing to do a great deal for hair care and nail care. But I am for skin care. Why you ask? All three are visible to the world. All three can make you look worse, or hopefully, better. But, a very important difference. Taking care of your hair and nails make them look better today, but in general don’t influence the appearance tomorrow. I can fry my hair with bleach, color it blue, get split ends and it will still grow it out fine. I can get fungus under my nails, warts around the cuticles, and significant deformity of the nails after acrylics, etc  Although treatment of warts and fungus is difficult and often recurrent, to at least some degree they can be prevented or treated. Preventing nail damage is basically avoiding sharing nail care instruments, whirlpool tubs etc that are contaminated by other customers in nail salons, and not wearing fake nails continuously.
• But skin care is a different story. I can prevent undesirable skin changes, I can improve the ones that are there, and I can change the nature of my skin. In contrast to hair and nails, which are completely replaced when they grow out, skin cells are turned over on the very surface, with lesser turnover under the top layers. That’s why destroyed collagen and elastic fibers, elastosis, scars, pre-cancer, and skin cancer, pigment, broken blood vessels, and brown growths are permanent and don’t “grow out”. Taking care of your skin today makes it look better today and tomorrow. If I don’t take care of it today, it will look worse tomorrow, and some of those changes aren’t fixable.

We all make mistakes in life. It’s just that the consequences of some are worse than others, and some are easier to fix. So the answer to the question “How much time and money am I willing to spend?” Whatever it takes.

Next: what it takes for this dermatologist, every day, to take care of her skin

RIP Liz:
10 Reasons Elizabeth Taylor was beautiful

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

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

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

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

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

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

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

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

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

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

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

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

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

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

RIP Liz

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