Daily Skin Fix

Just out–our Summer 2011 Cosmetic Dermatology Newsletter

Hot off the presses, the Summer 2011 edition of our famed SkinTreatment.com Cosmetic Dermatology Newsletter. This time we discuss CoolSculpting, Thermage, Botox price shopping, what’s new at ASTC, our social media, and the ever-popular Thoughts from Dr Elaine.

Also gives information about our upcoming Patient Appreciation Week Sale. During week of July 11-15 get 20% Off Botox, Juvederm, Thermage, CoolSculpting, and all Dr Elaine’s Skin Care. Online skin care sale runs July 11-17 on SkinTreatment.com

Click the text link below for the newsletter
Summer 2011 Newsletter.pdf

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.

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.

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

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

Elaine Cook MD

Welcome to the SkinTreatment.com blog, opinions and observations of board certified cosmetic dermatologist and creator of  Dr Elaine’s Advanced Skin Treatment skin care line, Elaine Cook M.D.  I’ve been specializing in Dermatology for 27 years, the last 15 of which have been devoted to the practice of cosmetic dermatology, the development of my own skin care  line, and running SkinTreatment.com. This blog represents the summation of the knowledge and experience I have gathered over the years seeing countless patients and developing multiple prototypes for our skin care products. Some of the medical stories happen over and over again, some are more unusual. Some are purely cosmetic. Some are symptoms of underlying medical disease. All are important. All affect peoples lives.

I plan on discussing a variety of topics. Among them: the so-called “cosmetic” skin problems–acne, melasma, rosacea, aging skin, wrinkles, spider veins, cellulite, stretch marks, hair loss, age spots, sun spots, discoloration and more. I will also discuss the cosmetic procedures used to remedy these problems: Botox, Juvederm, Restylane, Sculptra, Laser, Fraxel  Laser, Intense Pulse Light Photorejuvenation (IPL), Thermage, Therma-Frax (also called Fraxage), Sclerotherapy, Chemical
Peels and the various other light-based treatments such as LED and blue light. Finally, I will be using my understanding of the skin in health and disease and my experience developing my own skin care line as a basis to discuss anything and everything about skin care products.

Basically, I will be discussing whatever I want on any given day.