Daily Skin Fix

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.

The fine print about skin resurfacing–risks, side effects, and other unpleasant things

So here is the fine print on risks and side effects of the skin resurfacing procedures we talked about. The risks and side effects are similar with all resurfacing procedures: infection, scarring, pigment problems and redness. This differs from the expected post treatment course such as crusting, flaking etc that we discussed previously, because the risks and side effects are things that, thankfully, don’t usually happen, and ones we don’t want to happen.  The incidence and severity of these reactions vary among with the procedure, with the patient, and with the physician.

Infection: Infection risk can be viral, bacterial or yeast. Viral risk is from the cold sore virus with a post procedure outbreak occurring in someone with a history of frequent cold sores. The virus can then spread into the treated area causing scarring. It can occur with any of the procedures but is more common after the more aggressive procedures. Anyone with a history of cold sore infections should receive preventative treatment with Valtrex. Bacterial infection can occur after picking with any of the procedures. Without picking it is very rare in the less aggressive procedures, more common but still unusual in the more aggressive procedures. Fungal infection, usually with Candida yeast only occurs after the more aggressive procedures.

Scarring: Can occur with any of the procedures, but in the absence of picking, or infection, should not occur in the less aggressive procedures. Much more common after deep chemical peels and traditional dermabrasion.

Pigment problems: Patients with any degree of natural pigment are at increased risk for permanent pigment change, usually darker but sometimes lighter skin, after all resurfacing procedures. The risk rises rather steeply as you move from the less aggressive to more aggressive procedures. At risk skin types include: Hispanic, Asian, American Indian, Middle Eastern, East Indian, Black, including those with these skin types in their genetic makeup several generations back. Caucasians who tan easily and those who get sun exposure are also at risk.  Careful patient selection, not treating irritated skin and reducing post treatment sun exposure are important.

So here are my assessments of the degree of risk for each procedure:

Light Chemical Peels

• Infection: Occasional viral infection if not pretreated.
• Scarring: Very rare unless picking.
• Pigment problems: Uncommon if proper patient selection and patient follows sun exposure precautions. More common if they don’t.

SilkPeel (medical microdermabrasion)

• Infection: Very rare viral infection, unless pretreated.
• Scarring: Very rare
• Pigment problems: Rare

Deep Chemical Peels

• Infection: Moderately common, less if pretreated
• Scarring: Moderately common
• Pigment problems: Uncommon if very fair skin, moderately common if darker skin

Traditional Dermabrasion

• Infection: Moderately common
• Scarring: Common
• Pigment problems: Uncommon if very fair skin, moderately common if darker skin

Non-Ablative Fractional (Fraxel re:store)  Laser Resurfacing

• Infection: Uncommon viral infection, unless pretreated. Very rare bacterial or fungal
• Scarring: Uncommon
• Pigment problems: Uncommon if fair skin, moderately common if darker skin

Ablative Fractional CO2 (Fraxel re:pair and others) Laser Resurfacing

• Infection: Uncommon viral infection, unless pretreated. Rare bacterial or fungal
• Scarring: Relatively uncommon on the face, occasional on neck, chest, arms
• Pigment problems: Uncommon if fair skin, moderately common if darker skin

Who are the highest risk patients?: Patients with a fair amount of natural pigment (darker skin types, or those with darker skin types in their genetic background), smokers, pickers, thin skin, those with tendency to form scars, those with undisclosed recurrent cold sores, and those who don’t take the sun precautions seriously.
Disclose all medical information, follow instructions–what a concept

Who are the highest risk physicians?: Physicians without an in depth, formal training in the skin in health and disease, those who aren’t willing to not treat inappropriate patients because of a profit motive, those who aren’t willing to take the time to be sure the patient understands and follows instructions.
Training, experience and ethical standards–what a concept

What are the highest risk procedures?: From highest to lowest–Traditional dermabrasion and deep chemical peels, then fractional ablative laser resurfacing, fractional non-ablative laser resurfacing, light chemical peels, SilkPeel.
Deep chemical peels, and traditional dermabrasion are the most risky procedures. If you are going to proceed with these, be sure the physician is trained, experienced and does a lot of them.

Remember, these are my opinions and what I tell my patients. Your doctor may feel differently. Don’t make your decision regarding procedures on what I tell you, unless you are my patient. Make your decision based on what your doctor tells you.

Next: Aesthetic skin resurfacing tips

Aesthetic Skin Resurfacing Treatments

• Costs
• Number of Treatments
• Recovery Time

As with any aesthetic skin procedure, you need to weigh the benefits of skin resurfacing procedures against the cost, number of treatments needed and recovery time. Of course, these vary by patient, by the severity of the problem that we are treating, and by physician.

The following are averages, your problem may require more or less treatments, your recovery time may be longer or shorter, and the cost may be greater or less than average. Many cosmetic practices offer discounts for packages of a series of treatments, or for multiple procedures performed together or on the same day. So the following are averages, your doctor may charge more or less:

Light Chemical Peels (Glycolic Acid 50-70%)

• Cost: $75/peel or package of 6 for $375
• Number treatments needed: 6
• Recovery time: 1 day of crusted pimples, mild flaking 3-4 days

Medical Microdermabrasion (SilkPeel)

• Cost: $165/treatment or package of 6 for $825
• Number treatments needed: 6
• Recovery time: none

GentleWaves LED

• Cost: $ 140-185/treatment
• Number treatments needed: 6
• Recovery time: none

Intense Pulsed Light (IPL)

• Cost: $500-700 face/treatment
• Number treatments needed: 2-3
• Recovery time: Redness for 1 day, brown spots turn darker and peel off day 5

IPL/PDT

• Cost: $1000/treatment
• Number treatments needed: 1-2
• Recovery time: Redness and light sensitivity for 3 days, crusting of pre-cancerous areas for 1-3 weeks depending on severity

Laser resurfacing results, recovery time, need for anesthesia and costs vary based on the procedure. For example Fraxel now has 3 different versions of the original Fraxel, all named Fraxel (which leads to confusion when patients don’t know which version is which–bad idea I think but no one asked me): Fraxel re:fine (used by aestheticians), Fraxel re:store (the original Fraxel) and Fraxel re:pair (fractional ablative CO2). As you go up the scale, the cost and recovery time increases and the number of treatments decrease. Fraxel re:pair may require IV anesthesia in a surgery center.

Fraxel re:fine laser resurfacing

• Cost: $750-$1000/treatment
• Number treatments needed: 4-6
• Recovery time: 1 day redness, mild flaking 3-4 days later

Fraxel re:store laser resurfacing

• Cost: $1000-$1500/treatment
• Number treatments needed: 3-5
• Recovery time: 1 day redness and swelling, 5 days bronzing skin, fine flaking day 6-7

Fraxel re:pair laser resurfacing

• Cost: $3000-$5000/treatment + possible anesthesia and facility costs
• Number treatments needed: 1-2
• Recovery time: Pinpoint bleeding  and oozing for up to 48 hours. Swelling and crusting for 1 week, redness for 1 month

Laser resurfacing results, recovery time, need for anesthesia and costs vary based on the procedure. For example Fraxel now has 3 different versions of the original Fraxel, all named Fraxel (leads to confusion when patients don’t know which version is which–bad idea I think but no one asked me): Fraxel re:fine (used by aestheticians), Fraxel re:store (the original Fraxel) and Fraxel re:pair (fractional ablative CO2). As you go up the scale, the cost and recovery time increases and the number of treatments decrease. Fractional ablative CO2 resurfacing technology may require IV sedation and ambulatory surgical facility which may increase costs.

So there you have it, as always in life, there are tradeoff’s and you just have to decide what you want, what you need, and what you are willing to do to get it.

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

How do you know which aesthetic skin resurfacing treatment is right for you?

I am often asked this question and my answer is “what do you want to accomplish, how much improvement do you want, and how much time and money do you want to devote to it?” You can start at either end–want do you want or what are you willing to do to get it, but you have to start somewhere. Cosmetic skin resurfacing procedures that are more aggressive give more results. They cost more, usually because of the technology involved.

If you expect a lot of improvement, but don’t have the time or money to get there, you are going to be disappointed. Sometimes this is a hard pill for patients to swallow. They want the kind of results that the procedures that they can afford won’t give them. I try to be honest and explain the real world results that they can expect, and then the choice is to do the less expensive, less aggressive treatments and get some improvement, do financing and pay it off over time, or save up until you can afford what you need. On the other hand, if you don’t need or want more aggressive results, then the less aggressive procedures are right for you. That’s why the prevention strategies we discussed previously are so important. But if the horse is already out of the barn, you have to do what it takes to get him back in.

Remember if you are not my patient don’t pay attention to what I tell you. Pay attention to what your doctor tells you.

If you have these changes, then these are your options:

Dull skin:

• Home treatment: exfoliants, glycolic, salicylic or multi-fruit acids, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: light chemical peels, microdermabrasion (SilkPeel), LED (GentleWaves)
• More aggressive office treatment: not needed

Flat brown spots:

• Home treatment: some improvement if mild*–exfoliants, glycolic or multi-fruit acids, tretinoin (Retin-A, Renova, Refissa), skin bleach
• Less aggressive office treatment: light chemical peels, microdermabrasion, LED (GentleWaves)
• More aggressive office treatment: Intense Pulsed Light (IPL)

Raised brown spots:

• Home treatment: won’t work
• Less aggressive office treatment: lesions destruction with liquid nitrogen or electocautery
• More aggressive office treatment: lesion destruction + laser resurfacing

Fine lines

• Home treatment: glycolic, multi-fruit acids, peptides, growth factors, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: LED (GentleWaves), Botox, light chemical peels, microdermabrasion (SilkPeel)
• More aggressive office treatment: laser resurfacing

Skin colored bumps (milia cysts, moles, syringomas, fibromas, etc)

• Home treatment: milia only–exfoliants, glycolic, salicylic or multi-fruit acids, tretinoin
• Less aggressive office treatment: milia only–light chemical peels. All others–lesion destruction with shaving, electrocautery
• More aggressive office treatment: laser resurfacing

Broken blood vessels

• Home treatment: won’t work
• Less aggressive office treatment: electrocautery to isolated veins
• More aggressive office treatment: Intense Pulsed Light (IPL)

Non-etched wrinkles (go away when you stretch the skin)

• Home treatment: some improvement if mild*– glycolic, multi-fruit acids, peptides, growth factors, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: dermal fillers (Juvederm, Restylane etc), Botox
• More aggressive office treatment: laser resurfacing,dermal fillers and/or Botox + laser resurfacing

Etched wrinkles (don’t go away when you stretch the skin)

• Home treatment: some improvement if mild*– tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: dermal fillers (Juvederm, Restylane etc), Botox
• More aggressive office treatment: laser resurfacing, dermal fillers and/or Botox + laser resurfacing

Rough spots (pre-cancerous actinic keratosis)

• Home treatment: some improvement if mild*– tretinoin, more improvement with– prescription topical fluorouracil, imiquimod, diclofenac
• Less aggressive office treatment: liquid nitrogen
• More aggressive office treatment: photodynamic therapy (IPL/PDT)

Enlarged pores

• Home treatment: if plugged only–exfoliants, glycolic, salicylic or multi-fruit acids, tretinoin (Retin-A, Renova, Refissa), tazarotene (Tazorac), and adapalene (Differin)
• Less aggressive office treatment: if plugged only–light chemical peels, microdermabrasion.
• More aggressive office treatment: if permanently enlarged–laser resurfacing

Scars

• Home treatment: some improvement in acne scars if mild*– tazarotene (Tazorac)
• Less aggressive office treatment: some improvement in acne scars if mild*–light chemical peels, microdermabrasion, dermal fillers (Juvederm, Restylane etc)
• More aggressive office treatment: laser resurfacing, surgical removal

Loss of elasticity

• Home treatment: some improvement if mild*–glycolic, multi-fruit acids, peptides, growth factors, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: some improvement if mild*–light chemical peels, microdermabrasion.
• More aggressive office treatment: laser resurfacing

Elastosis (yellowish, stiff, bumpy, permanently creased or cross-hatched change from long term sun damage)

• Home treatment: won’t work
• Less aggressive office treatment: won’t work
• More aggressive office treatment: laser resurfacing

Note: “some improvement if mild*”–your definition and my definition of mild may not be the same.

Next: What’s it gonna take?

Skin Resurfacing–the Overhaul
Prevent and Correct Moderate or Advanced Changes
With Dermatology Office Treatments

When you are seeing more advanced changes and look in the mirror and think “I really don’t care for these changes,” it’s time to move on to some of the moderate to advanced dermatology in-office resurfacing procedures. You are in this category of moderate to advanced changes if you are seeing one or more of the following changes: etched lines(lines that don’t totally go away when you stretch the skin), enlarged pores, loss of elasticity, the irregular bumpy slightly yellowish sallow surface that dermatologists call elastosis, and more pronounced brown spots, and worsening of old acne scars.

Options are:
Deep Chemical Peels
Traditional Dermabrasion
and Laser Resurfacing

Deep Chemical Peels

Deep chemical peels have been around for a long time. They include high strength Trichloroacetic Acid (TCA, and Phenol peels. Both will penetrate deep enough into the skin to treat at the level at which deep etched wrinkles and acne scars reside, and that is how they treat deep etched lines and acne scars. The problem that is also the drawback, that they penetrate deep enough into the skin to cause scarring. Because they are applied by hand, by a physician, they are dependent on the thickness of the skin, the preparation of the skin before the procedure and the amount of acid applied. And even in the hands of a skilled physician who has performed many deep chemical peels, there is an inherent unpredictability with the depth that the acid will penetrate. Because of this, the risk of side effects such as permanent pigmentation changes, and scarring are greater than with laser resurfacing. Also sometimes they actually cause enlarged pores. Phenol peels always cause permanent loss of pigment so that the skin turns snow white. This is acceptable if your skin type is extremely fair, but not if you have any significant natural pigment. Both require general anesthesia.

I did a fair amount of deep chemical peels under anesthesia early in my career, but have abandoned them in favor of laser resurfacing. I will say that Phenol peels remove etched lines above the upper lip more completely than any other treatment, by replacing the skin and wrinkles with what is essentially a sheet of white scar. But this requires a patient with very fair skin, and the patient will be required to wear makeup every day forever to cover the fairly marked difference in color between treated and untreated skin.

Traditional Dermabrasion

Traditional dermabrasion (not to be confused with microdermabrasion), involves using an electric medical sanding tool to sand off the skin. It is used most often for deep acne scars. The problem again is that the depth of the treatment is dependent on the skin thickness, and the skill of the physician doing the procedure. Deep acne scars are from acne cysts that occur deep enough in the skin to cause a scar. Traditional dermabrasion is performed at the level of skin where scars form. That is why traditional dermabrasion replaces acne scars with a sheet of new scar. The skin never really looks or feels normal.

Laser Resurfacing

Laser resurfacing is divided into ablative and non ablative depending on whether the surface layer of the skin is removed with treatment (ablative) or not (non-ablative). It is also divided into fractional and non-fractional.

The first skin resurfacing lasers in the 90′s were ablative and non-fractional CO2 lasers. Non-fractional ablative lasers only required one treatment but usually required general anesthesia. Patients looked like they belonged in a burn unit for 2-3 weeks, were red and sensitive for months. Although not known in the first few years of use, some patients developed permanent loss of pigment in the treated skin several years after treatment. Additionally the risk of scarring, though less than deep chemical peels and traditional dermabrasion was unacceptably high. I also did many ablative non-fractional CO2 laser treatments in the 90′s but like most physicians switched to fractional laser resurfacing when it became available.

Fractional laser resurfacing was developed to address some of these problems. Fractional means that only a fraction of the skin is treated at a time by creating thousands of tiny treated channels in the skin surrounded by untreated skin. This allows safer treatment with much less risk of scarring and permanent pigment change, but requires more than one treatment to achieve best results. Fractional lasers are either ablative (destroys the top layer of skin) or non-ablative (does not). Fraxel was the first laser to utilize the fractional technology. Fractional laser resurfacing creates microscopic “wounds” within targeted areas beneath the outer layer of skin. The natural healing process produces collagen and healthy skin cells.

The original fractional laser resurfacing treatment Fraxel, is now Fraxel:restore, and is non-ablative. Fraxel:repair is a more recent development and is ablative. Ablative lasers require less treatments, but each treatment has a longer recovery time. Ablative lasers also may require general anesthesia. Non-ablative lasers may be safely used on the neck, chest, forearms and hands. Ablative lasers carry a risk of scarring in these areas.

We use Fraxel:restore as our patients prefer more treatments with less downtime and less discomfort with each treatment. They also don’t want general anesthesia which ablative procedures may require. In the last few years, many new resurfacing lasers have emerged. All have their pros and cons, but there are now multiple choices, and each physician usually has a personal preference.

Laser resurfacing treats mild to moderate wrinkles, surface irregularities, blotchy pigment, acne scarring, large pores, and stretch marks. Skin is smoother, less wrinkled and more refined with smaller pore size.

Photos of before and after Fraxel eyelid treatment
Photos of before and after Fraxel facial treatment

Next: How to know which skin resurfacing treatment is right for you.

The easy way–preventative maintenance with at home treatment

Preventive maintenance, ideally beginning in your early twenties, is the easy way to resurface your skin–before you even need it. At home treatment on a daily basis can prevent many of the changes that would require more aggressive treatment later. Even if you start later, either because the options weren’t around earlier, or because you just didn’t get around to it, you can get a good amount of improvement from relatively simple home treatment.

The key to success with this option is consistent and daily treatment with anti-aging cosmeceuticals, botanicals, exfoliants, retinoids and sunscreen. I see patients who start and stop programs, don’t stick with it, and blow off many days of treatment because they are too rushed to stick to a routine or who only wear sunscreen “when I am going to get a lot of sun”. There really is no reason not to get on a program and stick with it. It will pay off in the long run.

The 5 key components are:

• Cosmeceuticals
• Botanicals
• Exfoliants
• Retinoids
• Sunscreen

Cosmeceuticals are cosmetics that have effects on the skin. The main groups are the peptides, antioxidants, growth factors, and vitamins. They improve fine lines, roughness, blotchy pigment, loss of elasticity, dullness, acne, and stimulate collagen production.

Botanicals are plant derived compounds that are used for their antioxidant, anti-inflammatory, exfoliant, moisture balancing, and collagen stimulating properties.

I will talk about skin care, cosmeceuticals, and botanicals more in a future column with specific information about the individual compounds. In the meantime, there is a complete listing of cosmeceuticals and botanicals with their historical use; scientific, botanical, and trade names; and the scientific evidence of activity on the website in our Education Center.

Retinoids include over-the-counter retinol, and the prescription synthetic vitamin A derivatives tretinoin (Retin-A, Renova, Refissa), tazarotene (Tazorac), and adapalene (Differin).

Retinoids enhance collagen and elastin production thereby diminishing wrinkling, improve discoloration and roughness, and reduce pore size.

Retinoids do make you more sensitive to the sun, and should be used with daily sunscreen. We used to tell patients not to use them if they were going to get sun exposure but now we know that, within reason, you may use them as long as you use good sun protection. If you are going to the beach, lake, or skiing discontinue them for a few days before exposure.

They shouldn’t be used by pregnant or nursing mothers.

The current cost of Refissa (1 tube, 40 gm) $146.00; for Tazorac (1 tube, 30 gm) $170.00-180.00; Differin (1 tube, 45 gm) $260.00. One tube of either of these should last you about 4 months or more.

The biggest drawback, and the reason people discontinue them, is that they are irritating to the skin. I often start patients off on every other or every third night use and work up to every night. Another option is to start with the least irritating, Differin, and move up to the more irritating Refissa (for normal-dry skin) or Tazorac (for oily or acne prone skin). In addition you can either mix moisturizer half and half with them or apply moisturizer before (if you are having redness, itching or irritation) or after (if you are just dry) you apply them at night.

You should apply a pea size amount to the face after cleansing and toning in the evening. The skin should be completely dry before application. You should also apply it to the neck, back of the hands and forearms although most people can only apply it there every other night because of irritation. Those areas get aged from sun exposure just like your face. You don’t want to be one of those women who say “I hate the spots on my hands”. And while you are at it remember the sunscreen to neck, forearms and backs of hands. You need both.

Mild stinging, mild redness and mild peeling and flaking may occur during the first several weeks and on occasion when using Refissa, Renova, Retin-A, Differin or Tazorac.  This is normal.  Flaking is normal, soreness and irritation are not. To help reduce irritation, do not use washcloth, facial brushes, mesh scrubs, daily facial cloths, mineral powder brush or granular exfoliants on the face.

Discontinue these products to affected area 1 week before waxing or bleaching, or before other procedures (peels, microdermabrasion, facial, acne surgery, hair removal, laser treatments as directed.) You don’t want to end up like the bride who waxed three days before the wedding and disaster ensued.

I am a strong advocate of daily retinoid use, I feel that almost every patient desiring to prevent aging, or correct existing damage should use them. There is so much proven scientific data behind them they are still considered the gold standard in topical anti-aging treatment.

Daily, year round, sunscreen use is essential or you are just undoing what you are trying to do. Once again I refer you to my post “Quit complaining and wear your damn sunscreen”. Just do it.

If you start early on a home preventative anti-aging program you will have to do less later on and you will look better both today and tomorrow. It is never too late to start, you will see improvement. Stick with it. It is really a no-brainer.

Next: A tune up: In office treatment for early  or moderate changes

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

One of the most common complaints I hear are about lipstick lines that radiate around the lips. This is usually followed by “and I never even smoked!” The causes of lipstick lines and loss of lip volume are several: loss of soft tissue and bone with chronologic aging, sun damage causing breakdown of elastic and collagen fibers, and repetitive muscle action. And, of course, smoking worsens all of these by both the direct toxin effect on the tissue and the habitual pursing of the lips.

The deeper the lines are around the mouth and the more the mouth sinks inward, the more aged you look. Additionally the muscle in the chin often becomes hyperactive and pushes the center of the lower lip upward and the corners downward. You see this most prominently in women with dentures but it occurs with most people as they age. Botox treats this very effectively with as little as 5 units per treatment.

Filler treatment of the lips can be very effective, but it is also the area where improperly done treatment has the potential to make you look worse. I used to get “don’t make me look like Goldie Hawn in First Wives Club”, then “don’t make me look like Angelina Jolie”, now “make me look like Angelina Jolie.” News flash–there is not enough filler on the planet to make you (or me) look like Angelina Jolie.

But there are some basic rules that should be followed. Remember these are IMHO, your doctor may feel differently:

• Lip augmentation should look as natural as possible. You are not a duck or a trout. You are not Angelina Jolie. You want your lips to look like they belong on your face, only a little fuller and with less lipstick lines.
• The outer corners of the lip should be filled to keep a youthful wide mouth. Don’t just fill the center and the lipstick lines.
• Turned down outer corners of the lips should be buttressed with filler so that they are either in neutral position or turn up.
• Most lipstick lines are best treated with filler in the red part of the lips themselves and in the junction of the red and skin, not just treated with filler in the skin above the lips. Sometimes a combination works best.
• Permanent implants in the lips are a bad idea. There may be some out there that don’t look bizarre but I have never seen them.
• The best fillers for lips are the hyaluronic acid fillers, Juvederm or Restylane. I usually use Juvederm Ultra  XC, as I think it looks and feels more natural and smooth. Thicker and more permanent fillers such as Sculptra, Artefill, Radiesse are not meant for use in the lips and may give lumps and stiffness.
• Your lips may feel stiff for 3-5 days after treatment with hyaluronic acid. This resolves.
• The ratio of the vertical dimension of the upper to lower lip should be 1:1.6. Your bottom lip should be more full than the upper lip. I often have requests to treat the upper lip lines and to not treat the lower lip because the patient would prefer to use the rest of the filler on the smile lines or elsewhere. Don’t do it if the upper lip becomes as large as or larger than the lower lip. You will look weird, especially in profile. Spring for another syringe if you need it.
• I don’t inject fat in lips because I don’t think it is as controllable and it is less predictable in terms of how much will last and how much will reabsorb. If you have fat injected into your lips, be prepared for significant swelling lasting at least 3 weeks, regardless of what you are told. Better to be pleasantly surprised than upset.

The best lip augmentations are those that no one knows you’ve had. It can be done. It does take an experienced physician injector, an aesthetic sensibility and the ability to know when to stop. Do it right or don’t do it at all.

Next: Cosmetic skin 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