Daily Skin Fix

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

The rest of my top 10 anti-aging cosmetic skin filler tips to Restore Volume–Reduce Lines, Give Youthful Fullness and Lift Sagging Skin.

The second 5:

6) Face lift without filler = caught in a wind tunnel look

There are some people who don’t need filler after a face lift and do look good with a face lift alone. But many people, thin women especially, and most women in general, really benefit from either targeted Juvederm or Restylane, or overall increased fullness from Sculptra. In fact, the volume replacement alone is often called liquid lift or liquid face lift. Some women get enough tightening and lifting from volume replacement alone or volume replacement + Thermage, called Thema-Fill. Some don’t and need a surgical face-lift.

Just as full and loose isn’t a good look, neither is tight and pulled.

7) If you don’t like it–reverse it

I am always amazed at the number of patients who come in and tell me that they got filler elsewhere, didn’t like it because of a bump, or weirdly done lips or something else, but put up with it for a year. The hyaluronic acid fillers Juvederm, Juvederm Plus, Restylane and Perlane (with or without anesthetic) can be reversed with an injection of hyaluronidase.

If only life would let us reverse our mistakes so easily.

8) Don’t use fillers not approved by the FDA for use in the U.S.

There are a lot of fillers approved or used in other countries. Some are safe. Some are not. There are plenty of filler options that have been approved by the FDA for use in the U.S. Stick with them.

Why risk it?

9) Don’t be stupid and order fillers off the internet and do it yourself in your bathroom

Because, of course, you can trust everything on the internet. They really care. And you could end up looking like this do it yourself filler injection.

We have already talked about this.

10) Hang on to your teeth

While not strictly related to aesthetic filler issues, if I can give one bit of non-sunscreen related advice–hang on to your teeth. When teeth are pulled and dentures placed, the age related loss of bone in the upper and lower jaw is greatly accelerated. Just like astronauts lose bone mass in low gravity conditions, bone needs pressure placed on it to avoid de-mineralization. The pressure transmitted through the teeth with chewing keeps the bone strong. With dentures the pressure is not transmitted to the bone and bone in the jaw is lost. As the bone is reabsorbed, the mouth collapses inward and the cheeks hollow. Not  uncommonly, the chin muscle becomes hyperactive in an effort to hold the dentures in the mouth, further pushing the mouth inward. Take care of your teeth. You need them.

Make friends with your cosmetic dentist. Or marry one.

Next: Step #4 in a cosmetic dermatologist’s anti-aging rejuvenation plan:

Resurface Skin Texture–Reduce Lines, Wrinkles, Pore Size, Scars

Let’s finish Restore Volume–Reduce Lines, Give Youthful Fullness and Lift Sagging Skin with my top 10 anti-aging cosmetic skin filler tips.

The first 5:

1) If you can only afford one anti-aging treatment–do cosmetic filler injections

Doing aesthetic filler injections is one of my very favorite procedures because it makes such an improvement in giving a healthy, youthful appearance. But you do have to be realistic about how many syringes you need, and the results that you can achieve with the number of syringes you can afford. It takes a certain volume to get a certain result. It is fine to do it a little at a time as you can afford it, but to say that “filler didn’t work” when you needed three syringes but only did one is not a fair test.

I always try to stay grounded in reality.

2) Don’t expect filler injections to remove etched lines

The hyaluronic acid fillers Juvederm and Restylane plump up wrinkles from below and provide lost fullness. But if the line is etched from being folded ten million times, you will need skin resurfacing to really smooth the sharp line. If you stretch the skin and the wrinkle totally disappears, usually filler is all you need. If there is still a surface crease, you will need resurfacing. But either way the line will look a lot better after filler.

It’s always better to see the glass half full.

3) Treat eyebrows and temples

Yes, the lips, the corners of the mouth, and the smile lines are the first priority; cheeks next. But don’t forget the eyebrows and temples. With age, the eyebrows thin and begin to droop, especially at the outer comers. The fat that sits on the brow bone begins to descend, taking the brows down with it. A relatively small amount of Juvederm or Restylane in the outside wing of the eyebrow gives 3 dimensional structure and helps reduce hooding of the upper eyelid. Sunken temples give you a skeletal look and are aging.

Halloween was last night.

4) Treat corners of the mouth

Turned down corners of the mouth make you look unhappy and older. Juvederm or Restylane is injected below and to the side of the corner to turn it up. It breaks up the line from the corner down to the chin. You look happy.

Even when you’re not.

5) With age, thin faces need volume

They do.

Believe me.

Next: Part 2 of  Top 10 Anti-Aging Cosmetic Filler Tips

While cosmetic skin fillers have the potential to give you a big bang for the buck in a positive way; if not done properly they can also give you a bang for the buck in a negative way–an explosion, if you will. Bad cosmetic skin fillers decisions are not uncommon.

The most common filler nightmare causing an unattractive look are either bad lip injections, or too much filler in and around the mouth and smile lines ignoring the cheeks, and temples. Or both. This leads to the dreaded “trout pout” or a “horsey” look. That is why your doctor needs to do an comprehensive filler evaluation and give you a plan.

In some parts of the country–I’m looking at you SoCal in general and Hollywood in particular–this look is more prominent, and sometimes even desired by patients who are used to seeing other women with similar filler distribution. As we discussed previously, these are women who are often very thin and have lost a lot of facial fat. Filling the central lower face only causes an abnormally large lower face, and lacks the youthful upper cheek fullness. Many times, if the physician tries to discuss cheek and temple filling, the patient thinks it will make her look fat, and resists.

And then there are the disasters. I see these images of cosmetic skin filler disasters and wonder what they were thinking.  I bet you have seen them too. Interestingly, often these people think they look good because they are focusing on a particular problem, lip wrinkles for instance, and not looking at the whole picture.

Look at the whole picture.

Next: A word about lips

One of the hallmarks of youth and beauty is symmetry, i.e., one half is the mirror image of the other. When one eyebrow is up or down, when one eyelid droops and the other doesn’t, when one cheek is falling more than the other, the symmetry is marred and to our subconscious mind, the person is less attractive.

Classically, aesthetic facial beauty is characterized by the ‘rule of thirds’  in which the face is divided by three horizontal lines. The top third is from the hairline to between the inside ends of the eyebrow;  the middle third is from the inside ends of the eyebrows to immediately under end of the nose; and the lower third is from immediately  under the end of the nose to the tip of the chin.

Each third should be equal in vertical dimension, and each should appear equally dominant. When they are not, as demonstrated by someone with a very large forehead, large nose, or weak chin, again we subconsciously see that person as less attractive.

It’s my job as a cosmetic dermatologist to try to improve a patient’s symmetry and balance the thirds of their face.

Unfortunately, one of the things that I sometimes see are patients who either have had treatment elsewhere,  are Hollywood or Reality TV stars, or just people on the street, in whom the basic rules have not been applied. You have probably seen them too. Sometimes you just know that they are “off” but not entirely sure why.

The most common of these mistakes are augmenting the lips, smile lines, and corners of the mouth, without considering the cheeks, and temples. This is especially noticeable  on a thin individual with fat wasting of the cheeks and temples. They develop a “horsey” look with a prominent lower face, sunken cheeks and temples. The epitome of this look is the very diet conscious, compulsive exerciser, on Adderall and HCG, with a bunch of filler in her lips and smile lines in an attempt to compensate for her falling cheeks. Good thing that doesn’t describe me.

That’s why it is important to develop a plan with your cosmetic dermatologist, that addresses all of the areas of volume loss, to restore youthful symmetry and balance.

Then you won’t end up on TMZ as a “Don’t” with strangers commenting on your looks.

Next: Now the fine print

• Marionette lines and corners of the mouth—Juvederm Ultra XC or Juvederm Ultra Plus XC--1-2 syringes split both sides
• Lips–Juvederm Ultra XC-1 syringe
• Nasolabial folds (smile lines)—Juvederm Ultra XC or Juvederm Ultra Plus XC
• –1-2 syringes split both sides
• Under eye hollows–Restylane-L —1 syringe split both sides
• Cheeks–Juvederm Ultra Plus XC—2 syringes, one for each side.
• Temples–Juvederm Ultra Plus XC—1 syringe or Sculptra
• If doing overall “re-volumizing”-– Sculptra 2 vials per treatment, 3 treatments, (total 6 vials)

What do cosmetic skin fillers cost?

These are our current prices per syringe or vial for cosmetic skin fillers.

Of course they may change as our filler costs change.  We also have a lot of package discounts and intermittent specials on fillers. And the manufacturers offer rebates and discounts which help you out too.

Juvederm Ultra XC– $599

• Two or more syringes are $562.50
• Plus you get 5 units of Botox for chin free. This helps the turn down of the mouth and jowls.

Juvederm Ultra Plus XC– $625

• Two or more syringes are $587.50
• Plus you get 5 units of Botox for chin free. This helps the turn down of the mouth and jowls.

Sculptra Aesthetic– $899 per vial

• For a 3 treatment series, of 2 vials per treatment (total 6 vials)– $4999

When Juvederm Ultra XC and Juvederm Ultra Plus XC came out with anesthetic, our costs went up a substantial amount but we decided not to increase our prices for cosmetic filler. We thought it was important to hold costs down for our patients in this economy.

Are fillers expensive? I think that they are well worth the costs, because you really get a bang for the buck. When budget is an issue, our patients often start with one or two syringes and then add more later. And many patients only need one or two syringes to get the improvement they want. Also, at the time of retreatment, it is not unusual to not need as much treatment, as some of the results are lasting.

For more information on our current cosmetic procedures on sale and discounts check our web site.

Next: Don’t ignore the obvious

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.