Big Pores and Oily Skin

There are certain complaints and requests that are frequently mentioned by patients, but are problems for which we don't have good treatments. High on this list is the complaint about large pores. A cosmetic specialists we want to please our patients and give them outstanding results. It is frustrating to both physician and patient when we're forced to say that we don't have a decent treatment for a problem.

That's not to say that there have not been claims advanced by many device makers that their machine will reduce pore size, and there are a many providers out there offering these treatments. However, there is a long tradition of treatments that have been marketed and then fallen into disuse when it became clear that they produced no significant results. The placebo effect is significant, and it is not difficult to persuade patients that they have improvement, when little is visible.

We try to avoid such situations since we build long term relationships with our patients, and failing to deliver on our promises destroys the trust that is necessary for these relationships to develop.

In the March 2013 issue of the Dermatologic Surgery Journal there was a report of using intradermal injections of botulinum toxin to reduce the oiliness of the skin (sebum production) producing a high degree of patient satisfaction. Similar studies have suggested that pore size is also reduced by these treatments. If these observations hold up we will have the first effective and practical method for reducing pore size.

It should be noted that in this technique the depth of product placement is critical. Too superficial placement can fail to produce results and too deep placement can result in undesireable weakening of some muscles of facial expression. This procedure should be performed by an experienced and highly trained injector, not a family practitioner, gynecologist or nurse practitioner. Dermatologists developed and perform the largest number of these noninvasive procedures and, in general, have the greatest expertise in dealing with problems that may arise. 

Too often we see patients who have been treated by ancillary providers who are told, when a problem develops "You need to find someone who can help you". When you choose someone to provide cosmetic services, one of the things you should evaluate is how well they will be able to deal with a problem, if one develops.

Gerald N. Bock MD

California Skin & Laser Center

Stockon & Lodi, CA

Serving Galt, Valley Springs, Manteca, Modesto, Sacramento, Davis, Rio Vista, San Francisco, Fairfield, Concord and other Northern California communities

Big Advances in Skin Tightening

The non-surgical skin tightening has been a goal that has been sought after for many years. It as been well demonstrated that adding energy to the skin results in collagen regeneration and tissue remodelling. However, the devil has been in the details. The problem has been to get adequate energy input without causing damage and hopefully get noticeable results without producing significant pain.

Perhaps the most well known of these devices is the Thermage, which uses a radiofrequency current to cause the skin molecules to vibrate, heating the skin. The Thermage was first released in 2002, and was quite painful and produced results that frequently were difficult to appreciate. Over the years, the Thermage has been gradually refined, so it is somewhat less painful although it still hurts. The results are a bit better, but still variable. We have a Thermage unit in our office, and we found that the results were better off the face than on the face. We ended up using it on the arms and body but did not recommended it for the face and neck, because we did not feel comfortable recommending a procedure with a high failure rate.

Lasers and light sources have also been used in an attempt to achieve skin tightening. There have been units such as the Titan & SkinTyte which did not produce noticeably better results than Thermage.  The more recent entry into the field is the ultrasound devices, most notably Ulthera. Ulthera is able to focus the energy deeper in the skin, but appears to be more painful even than Thermage without producing, in my opinion, significantly better results.

The Women with Blue Eyelids

As the use of fillers becomes more widespread and sophisticated, more physicians, and some non-physicians are trying their hands at it. Originally collagen was used as a wrinkle filler and, while there were occasional side effects, for the most part they were limited to some assymetry with the more serious problem of interference of the circulation to the lower mid forehead skin occurring only rarely.

Now the collagen fillers have been replaced by new families of fillers that bring with them new potential problems. The most commonly used fillers are the hyaluronic acid fillers, such as Restylane or Juvederm that, when placed beneith thin skin, can produce a bluish discoloration.

The change in the use of fillers from wrinkle improvers to facial sculptors, replacing facial volume lost with aging, has resulted in the need for more skilled injectors and increased the variety and risks of complications.

Sculptra: An Old Filler Resurrected

 Sculptra is a unique filler that was first approved in the US in 2004, for treating facial lipoatrophy (fat loss) in AIDS patients. It consists of a suspension of particles of poly-L-lactic acid, a material that has long been used in the skin as an ingredient in absorbable sutures. Although it was legally used for cosmetic purposes immediately after its initial approval, it received official FDA approval for this indication in July 2009.

Zerona: Do You Believe in Magic?

Zerona is a FDA approved device using "low-level" laser light to "contour" the body. Before getting further into this discussion, to avoid interactions with the company's  lawyers, I should make two things clear. First, what I am writing represents my own personal opinion about this device, based on what I've learned in discussions with representatives of the company as well as information on their web site and information presented by speakers at medical meetings. Also, I own a competing device, the Zeltiq, which actually does much of what Zerona purports to do.

There is a long history of medical quackery claiming fat reduction without dieting or discomfort. Zerona, in my opinion, is the latest example of this. Zerona plays on the public's fascination with lasers as well as the almost universal desire to be thinner. While getting treated with the Zerona you lie on a table while 4 low-level lasers rotate above your body. There is no discomfort because, I believe, nothing is happening, though the company, Erchonia", would dispute that.

People Who Don't Get The Message

Today I received an email asking if we have a specific brand of CO2 laser. People who ask this kind of question have absolutely no idea what they're doing, and are at great risk of getting into trouble. In this Wild West world of cosmetic surgery, people get the idea that there is a magic machine or a magic procedure that will take care of their problems. That's absolute nonsense. Let's say there were such a magic machine, but it was operated by a moron who was also a crook, and had no previous experience with the machine. Would this be a good choice?

Hand Rejuvenation: An Underappreciated Treatment

"All the perfumes of Arabia will not sweeten this little hand." William Shakespeare, MacBeth

Fortunately, since Shakespearean times, we have become much better at improving the appearance of hands, although perhaps not much better at washing away their sins.

If you look at the hands of children, the skin is smooth and of uniform color. No bones or veins are visible. With time the hand skin becomes sun damaged and irregular discolorations and rough spots appear. As in other areas, the deeper tissues are lost, and bones and veins become more visible. Many people put up with this because they are not aware that treatments are available. We had a patient in this week who is very attractive with clear facial skin. She regularly gets Dysport and filler. Her hands look like the hands of an 80 yer old. When I mentioned her hands, she said that she feels like she should wear gloves all the time. We discussed other options.

Zeltiq: Cool Device or Flash in the Pan?

Zeltiq is a device currently available in the US, with an indication for skin cooling. However, the real purpose of this device is to reduce body fat through cooling. The company says that the device is in the late stages of FDA approval. When the FDA approves a device, it does not vouch for the effectiveness of the device, only its safety.

At a recent meeting I had the opportunity to view the machine and talk to the company representatives. The working end of the machine is a rectangular device about the size of a hand forming the letter "C". It is long enough to enclose about 1/2 of an abdominal roll of fat. The Zeltiq only treats the skin that can be inserted into the machine. Thus it cannot be used on the thighs or buttocks. It is primarily for the folds on the lower abdomen and "love handles", although it has had some success with folds on the back. It has also been tried on other areas, such as the arms, but there is not a lot of information about its effectiveness in these other areas.

The "Wow" Effect

There are precious few procedures that we perform where, immediately after the procedure, we can hand the patient a mirror and their typical response is "wow". The injection of filler is the outstanding example of this phenomenon. The results are immediate and frequently very impressive. The final result, however, is more of an art, rather than a science. This is especially true now that filling has evolved from plumping up a specific groove to re-contouring the face, producing a more youthful facial structure. This is very operator dependent and it is unusual to see physicians who are not members of "core" cosmetic specialties (dermatology and plastic surgery) venture into this arena.

"I love you, Dr. Bock"

That is how I was greeted last week by a long time patient. She had undergone a number of noninvasive procedures in the past few years, but two weeks before I saw her I had, for the first time, injected filler in her cheeks. The aging of the mid-face has, with the development of better and linger fillers, become recognized as one of the primary events that makes a person look aged. The young face is full, with smooth, convex surfaces, while the aging face becomes concave, with the loss of deep tissue and other structures. This produces depressions such as the "tear trough", a groove that extends downward and sideways from the inner (medial) part of the eye. It was this area that was filled in my patient. She was smiling as she reported that even her teenage son, without knowing that anything had been done, told her that she looked good.