Daily Skin Fix

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

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

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

So now we are on the last of the 5 R’s of treatments in a cosmetic dermatologist’s anti-aging aesthetic plan: Repair, Relax, Restore, Resurface, Redrape

• Repair Sun Damage–Reduce Lines, Wrinkles, Spots, Sagging
• Relax Muscle Action–Reduce Lines
• Restore Volume–Reduce Lines, Restore Fullness and Lift Sagging Skin
• Resurface Skin Texture–Reduce Lines, Wrinkles, Pore Size, Scars
• Redrape Sagging Skin–Lift and Firm Sagging Skin

On to Anti-Aging Skin Rejuvenation Plan Step #5–Redrape Sagging Skin

It is an unfortunate fact of life–gravity will win. But we can put up the good fight in the meantime.

Young skin is tight skin. It has a natural elasticity that causes it to rebound to its original position quickly when it is stretched. It holds everything up where it is supposed to be. The natural fat pads are held up under the eyebrow, up tight under the eye, and up high on the cheek. Skin feels firm. Eyelids are smooth and tight. The jaw line is tight, with the skin up against the bone. The operative word here is “up”.

With aging, collagen and elastic fibers are broken down and the skin looses elasticity as a result of repeated exposures due to damaging effects of the sun, gravity, smoking, environmental toxins, glycemic diet, weight fluctuations, and hormonal changes. Skin feels too loose. Everything starts to sag. Patients say “my face, and everything else, is falling”. The fat pads end up dragging the eyebrows down, as bags under the eyes, and the cheeks end up at the lower face as jowls. Neck is flabby. And let’s not even go below the neck.

Adding to the loss of elasticity is the loss of volume in the face. With aging, loss of fat, collagen and bone structure cause the skin to be too loose around too little volume. When this happens, gravity takes over and the skin sags. When this occurs, the skin needs to be tightened and everything needs to be lifted–it needs to be redraped. Sometimes volume needs to be replaced in the areas where it has been lost. Tightening, lifting,  and redraping restores tighter more youthful skin.

Lifting and tightening skin can be divided into: methods to prevent or slow down sagging, treatments to give modest tightening, and  procedures that are required when sagging is more pronounced.

Next: the best ways to prevent or slow down sagging skin

Top 10 Aesthetic Skin Resurfacing Tips

Here are my top 10 tips on cosmetic skin resurfacing, in no particular order. My philosophy is to err on the side of safety. You may get away with breaking the rules. You may not.

These are my opinions, your doctor may feel differently.

1. Top home treatment for skin resurfacing–hands down– are prescription retinoids (Refissa, Renova) in a high enough strength (0.05% or higher)

2. Top home treatment for skin resurfacing without a prescription is glycolic acid containing skin care in a high enough strength to do some good (8,10 or 15%)

3. Remember to stop your retinoids and glycolic acid 3-5 days before a light chemical peel, microdermabrasion, or facial waxing unless you like the scabbed up look.

4. Don’t expect more from the less aggressive treatments than you are likely to get. Fresh, glowing skin with reduced acne and some blending of pigment–yes. Removal of wrinkles and acne scars, growths–no.

5. If you are thinking of doing a deep chemical peel and have any degree of natural pigmentation, or any ancestors even 3 generations back that have any degree of natural pigmentation–think twice. And then think again.

6. When a male doctor tells you that “you will be a little crusted for a couple of days” he usually means “you won’t be comfortable going out in public for a week or more”.

7. For any aggressive skin resurfacing procedure, it is almost always better to do your whole face instead of just a segment. That way if you do get any color change it will at least blend somewhat into the other areas.

8. Be very careful with ablative CO2 laser skin resurfacing, even fractional, on the neck and chest as the risk of scarring is higher on those areas. And the scarring can involve the whole area not just a small section.

9. If you have had an ablative laser (CO2) skin resurfacing procedure, fractional or non-fractional, and are having any problems, such as increasing pain, persistent redness or sensitivity, blisters, insist that you are seen and evaluated by the doctor. Early treatment of complications can reduce scarring.

10. Take the bleaching and sun protection instructions seriously. And follow them.