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.

Laser Fat Destruction & Eyelid Burns

Although many cosmetic surgeons now recognize that lower eyelid bags are more commonly due to tissue loss rather than true fat protrusion, there are many who are still excising lower eyelid fat. Apparently a very small subset of these is attempting to remove this fat by making a small incision in the lateral lower lids, inserting a fiber from the "LaserTight" device and attempting to melt the fat and tighten the skin. This is a procedure that is new to me, and on the surface appears fraught with hazard. There are muscles near the fat that, if injured, could make it difficult for both eyes to move in a coordinated fashion. Furthermore, bleeding from eyelid surgery can rarely result in loss of vision, and this procedure is performed without direct visualization.

Latisse: Something Really New

It is rare that a product or procedure is introduced that opens up a new area of cosmetic enhancement, or redefines an old one. The introduction of collagen filler injections was one, as was the introduction of Botox. The use of lasers to resurface the skin and destroy blood vessels was also a paradigm changer. Now we have the introduction of Latisse, which reliably produces longer, thicker and darker eyelashes in the vast majority of people.

How to Get Your Money's Worth When Times are Tough

Now that the economy appears to be in recession, it is more important than ever to get your money's worth when spending for cosmetic procedures. While it is certainly an option not to have anything done, for many people that may not be the best choice. There are many studies that show that your appearance significantly affects how people react to you. This is always important, but it may be even more so now, when people are feeling stressed. If you appear more relaxed, others around you will likely feel more relaxed as well.

An Ounce of Prevention vs. a Pound of Cures

There are people who espouse the Phyllis Diller approach to cosmetic procedures: wait until things look really bad and then have some things improved, and everyone will notice and comment on your improvement.  Others will take the approach used by many Hollywood actresses: do things early and slowly and you'll continue to look good with little downtime. In my view the second approach is much preferred. However, there's another aspect of this that is rarely emphasized, and that is prevention.

Cosmetic Procedures and the Economy

We feel we are living in tough financial times. Gas, energy and food prices are up, although most other items are not. Unemployment has risen, although it is still low by historical standards. Credit is tight, and housing prices are down, although they are 1/3 higher than they were in 2000. According to an article in the Wall Street Journal, living standards are the highest they have ever been, including for the middle class and poor. Nevertheless, the media tells us that we are living in a time of crisis, and, in our hearts, we feel that this is so. People want to be cautious.

Books for Botox Holiday Reading Initiative

We have begun our Books for Botox holiday reading initiative. If you are anywhere near us, stop by, contribute some books and draw from our stocking for valuable prizes. Everyone is a winner! If you're not near us and wish to send us some books, feel free. If you wish, we can draw an envelope and send it to you. The prizes are transferable so if you know someone in Northern California, you could send the prize to them.
We give thanks to Dr. Corey Maas  of San Francisco  for his help in this project

Gerald N. Bock MD
Stockton, CA
California Skin Laser Center

The Unhappy Patient

I got an e-mail today from a patient seen recently. She had come in for a consultation for leg vein treatment, and I had discussed that, and also mentioned some other things that we do that might benefit her. She felt that by mentioning anything besides her legs, I was trying to make her "feel bad" about herself.
I was quite astounded by her response, since I've never seen anything like it before. I am not one to push things on people, but we do many things that are currently performed by a limited number of physicians, and most patients are unaware that these options exist. When I offer to discuss them, an offer that may be declined, almost all patients are pleased to learn something new. Not infrequently people will say that they were aware of a particular issue, but did not know that anything could be done. This woman had chosen us because we were less expensive than the dermatologist that she usually saw. I guess this is another example of why shopping for procedures by price is not always a good strategy. Clearly we were not a good fit.

Botox Past, Present and Future

The original work on Botulinum toxin was done in the 1970s, but it was not until 1989 that the FDA approved Botox (botulinum toxin A) for treatment of neurologic spasms around the eye. However, in 1987 a Canadian opthalmologist and dermatologist, doctors Alastair and Jean Carruthers began experimenting with the use of Botox to treat frown lines, after a patient who was receiving Botox around the eye area commented on how relaxed it made her look.
In 2000 Botox was approved for the treatment for neck spasm and in 2002 it was finally approved for treatment of the forehead frown lines. Currently Botox is used on the face and neck to treat lines created by skin folding.  Botox acts by preventing the release of acetylcholine  which is the mediator of the  impulse to the muscle.  As a result the muscle  does not receive the  command to contract and stays relaxed.  Sensation is mediated by a different pathway, so there is normal sensation  in areas treated with Botox.
Botox (type A toxin) is one of 8 different botulinum toxins, and type A is the only one that has been  successful comercially.  Type B is available as Myoblock, but  it is not as long lived as  type A  and is not widely used.  Over the years, presumably  due to the lack of competition, the price of Botox has increased rapidly, compared to the  prices of other  cosmetic products  such as fillers.  Currently there is  another type A toxin in the final stages of testing.  This has been available in  Europe  for years under the name Dysport. In the US it will be called Reloxin.  Reloxin is a bit different from Botox. The units are different and  Reloxin  diffuses a  bit  further than Botox.  A head to head study for treatment of frown lines suggested that Botox was more effective, but the dose of Reloxin (Dysport) seems to be below what would be an equivalent dose. A British comparison study using both agents to treat increased palmar sweating (hyperhidrosis) suggested that the agents were equivalent with a trend toward greater effect of the Dysport (Reloxin). Another similar study found no difference.
Patients will benefit from having more than one supplier of Botulinum toxin A on the market. There are other manufacturers that are also submitting similar products for approval.  Hopefully some of these newer products will offer additional advantages over the currently available product.