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.

Lip Lines: Reversing Tissue Loss

We now understand that many of the aging changes are due to loss of deeper tissue. One of the most frustrating forms of this, especially for women, is loss of tissue in the lip. This is something that is visible every time one looks in the mirror, and is often noticed by friends and acquaintances. The fine lip lines form chanels encouraging the migration of lipstick.

Previously we did not have a satisfactory answer for this. Laser resurfacing would eliminate the lines but was associated with considerable down time and considerable risk of permanent color change. Injecting filler into the lines was only a partial solution and not infrequently replaced the line with an elevated ridge.

Now we have thinner fillers available to us. These enable us to spread a thin layer of filler across the entire lip, replacing some of the lost tissue and reducing the lines. Furthermore, the filler also induces the skin to make new collagen, so after one or two treatments the results become longer lasting.

The photo above is before filler was added.

This photo is several weeks after filler was added.

This photo is before filler was added.

This photo was taken several weeks after filler was added. With time the body will create new collagen that will make this result semi-permanent. Furthermore, this approach can be used to repair the skin on other parts of the face where the skin is crepey.

 

Gerald N. Bock MD

California Skin & Laser Center

Stockton & Lodi, CA

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.

Topical Botulinum Toxin is Coming!

Botulinum toxin first came into clinical use in the early 1990s. Since then it has become very widely used, and is a billion dollar business. It acts by blocking the transmission of the signal from the nerve to the muscle, so the muscle is not stimulated and does not contract. Fortunately, the product is specific for the motor nerves and it does not affect the sensory nerves. Thus there is no localized loss of sensation or numbness associated with the use of botulinum toxin.

From the onset, the product has been injected into the target muscles. The toxin molecule is large, and it is difficult to get large molecules through the skin intact. Furthermore, in many areas the product must be placed precisely, so as not to affect muscles that would give an undesireable effect. Droopy upper lids or an assymetrical smile are examples of unwanted botulinum toxin effects.

Microlaserpeel + Broad Band Light: 1+1=3

Although patients commonly come in requesting a single procedure, very frequently they will get significantly better results if two or more procedures are combined. That is true of the MACS-lift (short scar facelift) combined with neck liposuction. It is also true of the microlaserpeel combined with the BBL (broad band light)

 

Fractional CO2 Resurfacing: Does The Emperor Have Any Clothes?

In an article published in the October 2010 issue of Lasers in Surgery and Medicine, the authors examined the results of fractional ablative CO2 resurfacing in 9 Chinese patients. The patients were being treated for skin rejuvenation and acne scars. Overall, the vast majority of the patients were pleased with their results, and there was mild to moderate improvement. However, there were significant problems with post treatment increase in skin color, and the authors raise the question of whether the results were enough to justify the treatment.

Topical Botulinum Toxin?

Revance Therapeutics, a start up company, has been working to develop a topical form of botulinum toxin. This would be an advantage for people who are adverse to needles. Botulinum toxin is a relatively large molecule, and conventional wisdom would suggest that it would be difficult or impossible to get such a large molecule through intact skin. The molecule would have to be in good enough shape to be functional.

Apparently Revance has overcome this obstacle and it is working on getting approval for its product for at least 2 different applications. The first of these is for the treatment of the wrinkles by the corner of the eyes, the "crow's feet". If the product is going to work at all, this should be a prime location. The skin in this area is thin, and the placement of the toxin does not have to be very exact. The product will be applied in the physician's office and the patient will have to wait while it is occluded for 20 minutes. How it will compare in price to the injectable toxin is unknown.

Resurfacing, the Big Gun

Skin resurfacing has been around for a long time. The earliest procedures were performed over 100 years ago, using a variety of acids. Eventually the procedures became somewhat standardized, with the phenol peel becoming recognized as the most effective of the peels. It has fallen from favor because, in the long term, it reliably produced significant loss of pigment (hypopigmentation). The weaker peels, some of which such as the glycolic and trichloroacetic peels, produced less problems but also were less effective and somewhat erratic in their outcomes.

Fraxel re:pair (CO2)

This past weekend I went to a Fraxel re:pair seminar at Reliant Technologies. The re:pair is a CO2 laser that uses Reliant's patented scanning technology to lay down a precise pattern of laser  pulses on the skin. There us no doubt, in my view, that Fraxel has the most sophisticated technology in the field. The scanner is fast and precise, and the relatively high power of the laser allows deeper penetration than competing lasers.

Fraxel Re:pair (CO2)

It was with some trepidation today that I signed the contract to purchase the new Fraxel Re:pair laser. The laser is quite expensive, but it appears likely to revolutionize the treatment of aging, wrinkled and scarred skin.