Palm Beach Perfect Skin: The Quest for Ideal Skin Health & Beauty

PALM BEACH PERFECT SKIN The Quest for Ideal Skin Health & Beauty KENNETH BEER, MD, FAAD Palm Beach Perfect FINAL 1 8/...

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PALM BEACH PERFECT SKIN The Quest for Ideal Skin Health & Beauty

KENNETH BEER, MD, FAAD

Palm Beach Perfect FINAL 1

8/16/06 5:38:59 AM

DISCLAIMER The information contained in this book represents the opinions of the author and should by no means be construed as a substitute for the advice of a qualified medical professional.The information contained in this book is for general reference and is intended to offer the user general information of interest.The information is not intended to replace or serve as a substitute for any medical or professional consultation or service. Certain content may represent the opinions of Kenneth Beer, MD, FAAD based on his training, experience, and observations; other physicians may have differing opinions. All information is provided “as is” and “as available” without warranties of any kind, expressed or implied, including: accuracy, timeliness, and completeness. In no instance should a user attempt to diagnose a medical condition or determine appropriate treatment based on the information contained in this book. If you are experiencing any sort of medical problem or are considering cosmetic or reconstructive surgery, you should base any and all decisions only on the advice of your personal physician who examined you and entered into a physician-patient relationship with you. This book is designed to provide information of a general nature about cosmetic procedures.The information is provided with the understanding that the author and publisher are not engaged in rendering any form of medical advice, professional services, or recommendations. Any information contained herein should not be considered a substitute for medical advice provided person-to-person and/or in the context of a professional treatment relationship by qualified physician, surgeon, dentist, and/or other appropriate healthcare professional to address your individual medical needs.Your particular facts and circumstances will determine the treatment that is most appropriate to you. Consult your own physician and/or other appropriate healthcare professional on specific medical questions, including matters requiring diagnosis, treatment, therapy or medical attention. Any use of the information contained within is solely at your own risk. MDPress, Inc. assumes no liability or responsibility for any claims, actions, or damages resulting from information provided in the context contained herein. ISBN: 0-9748997-3-9 Copyright © 2006 by Kenneth Beer, MD, FAAD All Rights Reserved The contents of this book including, but not limited to text, graphics, and icons, are copyrighted property of Kenneth Beer MD, FAAD. Reproduction, redistribution, or modification in any form by any means of the information contained herein for any purpose is strictly prohibited. No part of this book may be reproduced, stored, or introduced into a retrieval system, or transmitted, in any form, or by any means (electronic, mechanical, photocopying, recording, or otherwise), without the prior written permission of both the copyright owner and the publisher of this book. Printed in the United States of America. Book design by StarGraphics Studio

MD PUBLISH.COM


350 Fifth Avenue, Suite 7619 | New York, New York 10118

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Acknowledgements I would like to thank my wife Jennifer, my sons Jacob and Michael, and my daughter Gillian for putting up with me during the writing of this book.You have been a source of inspiration with each passing day, and for this I am eternally grateful.To my patients, thank you for your faith in me and my work. I hope that I may continue to help you, with the very best resources available, in your quest for beauty and skin health. A special thanks to the MDPublish team for their skillful collaboration.


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To my wife, with love, honor, and admiration. To my sons and daughter, with pride in everything you do and everything you will become. To my parents Myrna and Daniel Beer, M.D., for giving me the encouragement to exceed my own dreams. To my colleagues and friends, with gratitude for the lessons you have taught me along the way. To my staff, who as a team have taught me to become a better dermatologist.


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Contents Introduction

Chapter

13

1

The Structure of the Skin & How This Changes with Aging

19

Skin Overview

20

Under the Microscope with Normal Skin

22

Skin Structure

23

How Changes in Skin Structure Lead to Wrinkles Fine (Superficial) Wrinkles Deep Wrinkles Creases Dynamic Wrinkles Static Wrinkles

26 27 27 27 28 28

Skin Through the Ages

29

Chapter

2

The Sun & Your Skin

35

Preventing Sun Damage

38

Sun Protection Factors

40

Selecting an SPF

42

Sun Protection Checklist

43

What to Do If You Get Burned

44


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Chapter

3

Skin Maintenance & Improvement: Damage Control & Repair

45

Advancements in Cosmeceutical Skincare

46

Moisturizers

46

Cosmeceutical Creams

47

Glycolic Acid

48

Vitamin C

48

Growth Factors

49

Antioxidants

49

The Palm Beach Peel® System

50

The Palm Beach Peel® Steps: Exfoliation, Nourishment, Cleansing, Moisturizing & Exfoliation

51

Skin Nourishment

52

An Overview of Cosmeceuticals

54

Chapter

4

A Lifetime of Perfect Skin: Why You Need a Cosmetic Dermatologist

59

What Is a Cosmetic Dermatologist?

60

Know Your Skin Type

62

Fitzpatrick Classification

63

How to Choose an Ideal Skin Regimen

65

Before You Buy

65

The Basics: Six Steps for Ideal Skin

66

Seasonal Skincare

69


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Chapter

5

Maintaining Clear Skin When You Have Acne

71

Understanding Acne

72

Oral Acne Treatments

73

Accutane® and Its Generic Versions

74

Hormonal Therapy

75

Topical Acne Treatments: Prescription, Over-the-Counter Products, Light Based Treatments, and Daily Care for Acne Prone Skin A prescription from a dermatologist Non-prescription options Light based treatments

76 76 76 77

Photodynamic Therapy (PDT)

77

Daily Care for Acne Prone Skin

78

Dr. Beer’s Daily Anti-Acne Regimen

78

Chapter

6

Common Conditions That Interfere with the Perfect Skin Plan: Rosacea, Sensitive Skin, Eczema, Psoriasis

79

Rosacea

80

Daily Care for Rosacea Prone Skin

81

Sensitive Skin

82

Eczema (Atopic Dermatitis)

84

Psoriasis

85


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Chapter

7

Lasers & Light Sources: The New Waves

87

Lasers for Skin Rejuvenation

89

Non-Laser, Light Based Rejuvenation: Intense Pulsed Light, Radiofrequency, Photodynamic Therapy, LED, and Fraxel™

89

Intense Pulsed Light

90

Radiofrequency Waves

91

Syneron ELOS™ System

92

Photodynamic Therapy

92

LED Technology

93

Fractional Resurfacing Including Fraxel™

94

Summary of Lasers, IPL, and LED Devices

94

Combination Treatments That Work in Conjunction with Laser, LED & IPL

95

Chapter

8

All About Botulinum Toxin

97

What Is the Difference Between Botox®, Myobloc®, and Reloxin®?

98

How Botulinum Toxins Work

99

After an Injection

102

How to Avoid Problems with Botox®

103

Limitations of Botox®: Where Fillers Are Needed

103


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Chapter

9

Fillers for Facial Rejuvenation

105

A Brief History of Soft Tissue Augmentation

106

How Fillers Work

107

How Long Do Fillers Last?

108

What Are the Side Effects?

108

How Long Is the Recovery?

109

What Goes Where?

109

Fillers in Detail

110

Hyaluronic Acids Restylane® Hylaform® and Hylaform® Plus Captique™ Juvederm®

110 110 112 112 112

Collagens

112

Zyderm® and Zyplast® Human Collagen

113 113

CosmoDerm®/CosmoPlast®

113

AlloDerm®

114

and

Cymetra®

Products Derived from Your Body Isolagen Volumizers: Long-Term Soft Tissue Augmentation

114 115 115

Sculptra®

115

Facts About Fat Transfer

117


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Semi-Permanent and Permanent Fillers Artefill® Radiesse™ Injectable Liquid Silicone

117 117 118 119

The Spectrum of Dermal Fillers

120

Chapter

10

Holding on by a Thread

121

Contour Threadlift™

122

Who Is a Good Candidate?

122

Who Is Not a Good Candidate?

122

What Areas Can Be Lifted?

123

How Is the Procedure Performed?

123

What to Expect After the Procedure

123

How Long Do the Results Last?

124

Chapter

11

Tumescent Liposuction

125

How Safe Is Liposuction?

127

Who Is the Ideal Candidate?

128

The Liposuction Procedure

130

What to Expect After Liposuction

130

Fat Transplantation

131

The Fat Transfer Procedure

132


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Chapter

12

Eradicating Veins, Unwanted Hair, & Stretch Marks

133

Leg Veins

134

Hair Reduction Strategies

135

Hair Removal Methods

138

Laser Hair Removal

140

The Laser Hair Removal Procedure

141

Improving Stretch Marks

143

Chapter

13

Advances in the Diagnosis & Treatment of Skin Cancers

145

Early Detection

147

Actinic Keratoses Origins of Actinic Keratoses Symptoms of Actinic Keratoses Types of Actinic Keratoses Treatment of Actinic Keratoses

149 149 149 150 150

Basal Cell Carcinoma Origins of Basal Cell Carcinoma Symptoms of Basal Cell Carcinoma Types of Basal Cell Carcinoma Treatment of Basal Cell Carcinoma

151 151 152 152 153


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Squamous Cell Carcinoma Origins of Squamous Cell Carcinoma Symptoms of Squamous Cell Carcinoma Types of Squamous Cell Carcinoma Treatment of Squamous Cell Carcinoma

153 154 154 154 155

Melanoma The Origin of Melanoma Symptoms of Melanoma Four Basic Melanoma Types Treating Melanoma

155 155 156 156 157

Non-Surgical Treatments for Skin Cancer

157

Surgical Approaches to Skin Cancer Excisional Surgery Electrodessication and Curettage Mohs Surgery

158 159 159 160

In Summary

162

Chapter

14

What the Future Holds in the Quest for Perfect Skin

163

Glossary

166

Resources

180

Index

181

About the Author

184

Appendix

185

Order Form

190


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Introduction Perfect skin is a goal that many seek but few attain. Perfect skin must be healthy on the inside as well as on the outside. The outer (epidermal) layers should be blemish-free and radiant, the middle layers resilient, and the inner layers must provide support, structure, and nutrition. Any deficiency in this triad will result in skin with sub-optimal appearance and wellness. Some people are born with perfect skin. Others need help from cosmetic dermatologists and plastic surgeons. This book will help you navigate your path to perfect skin. We will discuss skin treatments and products designed to help you look your best as well as information and some common problems that may be barriers to your goal. The renaissance underway in cosmetic dermatology makes this an ideal time to begin your quest for perfect skin. Presently available techniques, procedures, and products can rejuvenate your skin while avoiding the risks and downtime of invasive surgery. Non-invasive procedures are constantly improving, and we will review what is presently available and glimpse into the near future. We will discuss skin function when it is healthy and present information about common skin diseases and problems. To help you choose the best skincare products for your skin, information about cosmeceuticals and prescription skincare products is presented. If, after reading this book, you can make educated decisions about what is and is not right for your skin and know what questions to ask your dermatologist or plastic surgeon, I will have succeeded in my goal for writing it. In order to provide some background, let me offer a brief biography: I attended medical school at the University of Pennsylvania School of Medicine, and after completing one year of internal medicine I spent four years at the University

Introduction


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of Chicago in a dermatology residency and dermatopathology fellowship. During those four years, I learned most of what I know about the skin. My pathology training taught me about the microscopic structure of the skin and, during my fellowship, I began to wonder about how to create healthier skin at a microscopic level and more youthful appearing skin at a clinical level. I spent years learning how to diagnose and treat melanomas, basal cell carcinomas, and squamous cell carcinomas. The transformation from damaged cell to pre-cancerous cell to cancer fascinated me, and I studied the prevention of this process. As I learned more about skin cancers, I realized that the development of these lesions and the process of aging is closely interrelated and that preventing skin cancers could also help the skin appear more youthful. In my dermatological surgery practice, I specialize in cosmetic dermatology as well as in the diagnosis and treatment of skin cancer ; I enjoy both. I teach at the University of Miami in the Department of Dermatology, and my research interests encompass both areas. The Cosmetic Boot Camp—a course that I direct with Mary Lupo, M.D.— keeps me on the “cutting edge” of the newest products and procedures in cosmetic dermatology. Some background about dermatology in general—and cosmetic dermatology in particular—will help you to understand the information contained in this book. Dermatology is the ONLY branch of medicine dedicated to the skin. Dermatologists are physicians who have completed four years of medical school (if they are medical doctors; there are also osteopathic dermatologists who have not gone to medical school). If they are Board Certified by the American Board of Dermatology, they have completed a year of internal medicine, pediatrics, or surgery prior to spending three years studying the skin at a university hospital where they are supervised by other dermatologists. After this training, they must pass a board certification exam to state that they are “Board Certified by the American Board of Dermatology”. 14 PALM BEACH PERFECT SKIN


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To maintain proficiency, they must recertify at least every ten years if they have completed their training after about 1992 (older dermatologists are exempted from this requirement). Some dermatologists spend additional time completing fellowships in dermatopathology (the study of the skin using a microscope), dermatologic surgery, or pediatric dermatology. Recently, there has been a proliferation of internists, family practice doctors, gynecologists, and a host of other practitioners who call themselves skin specialists, cosmetic surgeons, or even dermatologists without being board certified by the American Board of Dermatology. Unfortunately, this practice is not closely regulated in many states, but patients should be aware that these individuals do not have the training or experience required to take care of your skin. Dermatology experienced a renaissance from the days when it was dominated by acne and warts. Part of this revolution in dermatology was actually brought about by managed care and healthcare reform. As insurance companies moved skin cancer surgery from the hospital to the dermatologists’ offices, the specialty became primarily surgical. Dermatologists became more knowledgeable about skin cancer reconstruction. This experience prompted interest and research into lasers, fillers, liposuction, and other cosmetic procedures that could also be performed in the office. The evolution of surgical dermatology occurred as I was training. During my residency I became interested in research, skin cancer reconstruction, liposuction, lasers, chemical peels, soft tissue augmentation using collagen, fat, and hyaluronic acids. How much the field of dermatology has changed is demonstrated by Medicare statistics which show that the majority of skin cancers treated in the United States are now treated by dermatologists. Surgical dermatologists are represented by the American Society for Dermatologic Surgery (www.asds-net.org), and they are now known as Dermasurgeons. We have our own Introduction


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meetings, research, and journals. Dermatologic surgeons differ from plastic surgeons (who specialize in procedures such as hand reconstruction, facelifts, burns, and breast augmentation) because we focus only on the skin. Cosmetic dermatology has added several major products and procedures in the past few years, including novel uses for botulinum toxins such as Botox®, Myobloc®, and Reloxin®. Until recently, these proteins were used exclusively for frown lines. Now they are used to treat wrinkles of the chin, forehead, lip and to minimize crow’s feet, neck bands and drooping breast skin. These toxins are used to treat excessive sweat, headaches, and medical problems ranging from back spasms to urinary incontinence. Revolutionary fillers such as Restylane®, Restylane® Sub Q, Perlane®, Sculptra®, Hylaform®, Captique™, Hylaform® Plus, Juvederm®, Isolagen, silicone and Radiesse™ have expanded a universe of fillers once limited to collagen. New lasers, intense pulsed lights, and radiofrequency devices including Thermage® and Fraxel™, have opened up new possibilities for non-invasive skin rejuvenation. Dermatologists and plastic surgeons are just beginning to discover the full potential of these devices, products, and procedures, and learning what can be accomplished when they are used together.

“The ‘injected facelift’ is now a foreseeable reality.”

Until recently a facelift was the best way to rejuvenate an aging face. Now, novel techniques including fat transfer, soft tissue fillers, volumizers such as Sculptra®, lasers, and botulinum toxins can reverse the signs of aging without surgery. The “injected facelift” is now a foreseeable reality. Suspension sutures used to directly reposition the skin upward eliminate the need for cutting with some patients. For others, there will never be a substitute for a facelift but those numbers are dwindling. Even for individuals requiring a facelift, the judicious 16 PALM BEACH PERFECT SKIN


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use of lasers, fillers, botulinum toxins, peels, and a good skincare regimen can ensure the best possible results. Throughout the course of this book, I will identify trends, treatments, and products that make sense. Thus, we will discuss the rationale for what is used in cosmetic dermatology. My cosmetic dermatology practice draws upon a palette from which I create an individualized program for each patient based on their goals, tolerance for downtime, and budget. Typical patients rejuvenate the outer layers of skin with intense pulsed light, laser, chemical peels, and/or topical treatments that include prescription and non-prescription products. My patients with wrinkles due to muscle activity (including frown lines and crow’s feet) get treated with botulinum toxins such as Botox®. Wrinkles due to loss of subcutaneous tissue are filled with hyaluronic acids (including Restylane®, Hylaform®, Captique™, Juvederm®, and others), Sculptra®, Radiesse™, collagen and/or fat transfer. I perform body contouring with tumescent liposuction and fat transfer. Lasers and intense pulsed light sources are utilized to treat pigment irregularity, spider veins and unwanted hair as well as to tighten the skin by rejuvenating the collagen and elastic fibers. Two new lasers are able to help successfully treat cellulite. My book will also help readers to understand how the skin functions when it is well and what happens when it is diseased. I will discuss the structure and function of normal skin and then contrast this to skin effected by acne, psoriasis, eczema, rosacea, skin cancer and other common skin ailments. Hopefully, this will provide enough information to enable you to have a meaningful discussion with your dermatologist and to help you take better care of your skin. Skincare products consume significant amounts of time and money. While some products are marketed by unscrupulous means, others result from years of research and development at companies with impeccable reputations and great scientists. Frequently, it is difficult for consumers to tell the Introduction


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difference between these two extremes, and I will provide some pointers in the skin product section. My own product line began with a few glycolic acid products, but expanded as it was embraced by my patients, their friends, and their relatives. As the circle of users has expanded, I have increased my offerings, which now include the Palm Beach Peel® integrated product system. The goal of my skincare system is to provide the type of skincare that was, until recently, only available at a cosmetic dermatology office. With The Palm Beach Peel®, one can customize the frequency and duration needed to peel, exfoliate, cleanse and apply nutrients and vitamins to the skin. I continue to change my products as newer research discovers better ingredients. My ability to do this is one reason that I developed my own line of products. Each patient who walks into a cosmetic dermatologist’s office wants to look his or her best. Whether in my office or in this book, it is my job to provide information about the products and procedures that will help accomplish this goal and to provide information about some of the obstacles that can stand in your way.

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1

CHAPTER

The Structure of the Skin & How This Changes with Aging “In cosmetic dermatology, a little knowledge will help you to have a lifetime of perfect skin.”


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In order to comprehend skincare products, and treatments and the various conditions that affect the skin, it is necessary to understand some basic skin anatomy. While it is not possible to compress three years of dermatology residency and one year of dermatopathology fellowship into one book, it is reasonable to get some insight regarding the basic structure and function of the skin. This will help you understand why a treatment such as a superficial chemical peel, which treats the outer layers of the epidermal layer, will not have any effect on deep wrinkles or creases. To improve blotchy skin associated with sun damage (a frequent sign of aging), it is important to know where the pigment causing the problem resides so that appropriate care can be selected. Any laser, medication, or cosmetic procedure that does not address the part of the skin anatomy causing the problem is destined to be a waste of your time, effort, and money.

Skin Overview

“There is a lot going on inside what appears to be a bland organ system called the skin, which is the body’s shield against a hostile environment.”

The skin is the body’s barrier; it defends against diseases, environmental challenges, and infection. It helps to regulate body temperature and contains a vast array of chemical messengers and hormones used to communicate with various cells in the body. Every square inch of skin contains about 15 feet of blood vessels, 100 oil glands, and two different kinds of sweat glands. As you can already see, there is a great deal of activity within the skin. The best way to appreciate the differences between old skin and new skin is under the microscope.



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(Photo Gallery Page 1, middle) A photomicrograph of new skin demonstrates skin with an organized outer (epidermal) layer as well as collagen and elastic fibers (the thick pink layer) that provide structure and support. When these fibers are young and intact, the skin is elastic and devoid of wrinkles. As the collagen and elastic fibers degenerate, this layer becomes thin and disorganized, and the skin begins to wrinkle and sag. From a microscopic perspective, we can begin to understand how what goes on at a cellular level translates into visible signs of aging and think about logical means of reversing them. If we look at a deeper biopsy, (such as photomicrograph 10 normal skin, no sun damage ) subcutaneous adipose (fat) is visible in the bottom parts of the biopsy. Fat provides a source of energy storage, insulation, and also support for the contour of the skin. As this fat diminishes with age, the skin loses volume, and deep creases will begin to appear. Treatments aimed at restoring volume and replacing fat must address these deep layers of the skin if they are to succeed. Procedures or products designed to treat wrinkles need to replace or replenish the collagen and elastic fibers of the middle layers. Improvements of the canvas (outer layer of the skin) must alter the epidermis in a manner that restores a more youthful structure. A photomicrograph taken from aging skin demonstrates skin that is older and sun damaged. The epidermis is only a few cells thick (two cells in most of this image). It is easy to see that this thin skin is going to be more susceptible to damage such as tears. This thinning of the epidermal layer will leave an aged appearance to the surface of the skin. Beneath this ragged epidermal layer, the collagen is no longer pink and organized but rather bluish and raveled. Deeper still, we see that the adipose layer is thinner than it was when the skin was younger. These changes in the deeper layers and loss of skin elasticity correspond to a



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southward drift of the face. They are also responsible for producing wrinkles and creases around the mouth and jowls. Procedures designed to tighten the skin, replace lost connective tissue, or renovate the surface of the skin must deal with the anatomic changes visualized and discussed here to have a chance of obtaining their objectives. These photomicrographs graphically illustrate what happens to the skin as it ages. Products and procedures used in cosmetic dermatology and plastic surgery promise to restore youthful skin and frequently make claims that they will repair damage due to aging. While these products (such as Retin-A®) will actually cause the collagen and epidermis to rejuvenate (this has been confirmed with biopsies), others simply prey on the quest for youth.

Under the Microscope (Photo Gallery Page 1, top) The skin is only two cells thick in areas, and the epidermal cells are disorganized. In addition, the pink collagen that provides support for the skin is thin. As support structures and epidermis thin, wrinkles and precancerous growths develop. (Photo Gallery Page 1, middle) This is in contrast to the second photograph that demonstrates youthful skin which is thicker and more organized. My dermatopathology training solidified my understanding of the skin in health, in disease and in aging. I have analyzed thousands of skin biopsies, each of which graphically reveals subtle changes that speak to the pathologist. To a dermatopathologist, middle age is a transition between organized and disorganized skin. Depending on the color of the skin and the amount of sun damage that it has sustained, biopsies performed during middle age have small precancerous growths called actinic keratoses.These biopsies show loss of thickness from the dermal layers, which translates into



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visible fine lines around the mouth and eyelids. Increased pigment visible in biopsies at the base of the epidermal layer (basal layer) is seen on the skin as “liver spots.” Clearly, what we learn about the skin under the microscope has repercussions for clinical dermatology in general and cosmetic dermatology in particular. As with other parts of the body, the skin can age at a normal chronological rate (in which case people will appear as old as they are), at an accelerated rate (in which case they appear older than their years), or at a decreased rate (in which case they appear younger than they are). The pace of skin aging is determined by genetics, sun damage, skincare, and many factors that are just now beginning to be understood by dermatologists. I consider these issues when designing a skincare program for my patients, and it is worthwhile to think about them when deciding which products or procedures are worth trying on your skin.

Skin Structure

A rational approach to skincare and skin wellness requires an understanding of the structure of the skin. Beginning at the outer layer, the skin is comprised of: 1. Epidermis 2. Dermis 3. Subcutaneous tissue

The epidermal layer may be further subdivided into four sublayers.The outer layer, called the stratum corneum is comprised of dead skin cells. Basket weave in appearance, this is the body’s shield and first line of defense against dehydration,



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infection, ultraviolet damage, and a host of other environmental insults. Its health is obviously important not only for how your skin appears but also for how it ages and functions. Stratum corneum cells may be polished by microdermabrasion, chemical peels, topical medications, and cosmeceuticals. Proceeding inward from the stratum corneum are three layers of cells: the stratum granulosum, stratum spinosum, and basal layer. Cells in these layers are in a constant state of flux with a 28-day cycle for the bottom cells to reach the top layer. The timing of the cellular cycle governs the frequency of many procedures and treatments used in cosmetic dermatology. For instance, there is no point in trying a skincare product for less than one month if you believe it is going to rejuvenate the entire epidermal layer. Nor does it make sense to have chemical peels several times per week as some overly aggressive practitioners advocate. The stratum spinosum and granulosum are the middle epidermal layers that are the thickest portion of the epidermis. These layers give rise to skin cancers known as squamous cell carcinomas. Deep to these layers is the basal layer of epidermal cells. It is this layer that forms the boundary between the epidermis on the outside of the skin and the dermis on the inside. Basal cells are a frequent source of skin cancers known as basal cell carcinomas, the most common of all skin cancers. Scattered amongst the basal cells at about every eight cells are melanocytes. These cells produce the pigment known as melanin, which is the pigment responsible for the color of your skin and hair (or in some cases where it is responsible only for the color of the roots of the hair). Melanocytes cause the age spots that appear on the face and hands. They also allow the body to tan in an attempt to



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shield itself from ultraviolet (UV) radiation. Melanomas, the most deadly form of skin cancer, result from melanin cells gone awry. Beneath the epidermal layer is the dermal layer (dermis). The dermis contains collagen and elastic fibers that provide strength and support for the skin. Blood vessels and nerves traverse the dermis as they provide the skin with oxygen, nutrition, and sensation. Beneath the dermis and epidermis lies the subcutaneous layer, comprised of fat and other support structures that form the layer between skin and muscle. It is within the dermal and subcutaneous layers that wrinkles and folds form. Treatments for wrinkles and folds are designed to restore collagen, fat, and other support structures that have been lost. Injectable products designed to replenish the dermal and subcutaneous layers include collagen, Isolagen, Restylane®, Perlane®, Restylane® Sub Q, Hylaform®, Hylaform® Plus, Captique™, Juvederm®, silicone, Radiesse™, and Sculptra®. Insight into the structure and function of the skin layers helps to understand just how critical the experience and training of the injecting physician are to successful outcomes. The right products placed at the wrong level may produce either no result or lumps and bumps. Treatments such as Fraxel™ and Thermage® use energy to tighten existing collagen fibers and stimulate the formation of new ones. Treatments and products that address facets of aging at each layer of the skin, allow cosmetic dermatologists to produce dramatic results. The subcutaneous layer also contains hair follicles, sweat glands, and a host of other important structures. Fat cells (adipocytes) found in this layer are a rich source of material used for soft tissue augmentation. Cells may be removed from areas such as the buttocks, thighs, or abdomen and relo-



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cated to the hands or face with dramatic results. Adipoctyes are a rich source for stem cells that may one day provide replacement tissue for any part of the skin that is deficient or diseased. Deep within the subcutaneous tissue are the roots of the hair follicles. These roots (or matrix cells) are the targets for lasers and intense pulsed lights that treat unwanted hair. Wavelengths and energies are constantly being improved to more effectively target the matrix cells (located in a region of the follicle known as the bulge) so that hair removal is safer and more effective. Treatments for hair removal that do not have the energy to reach this deep level have no chance of success.

How Changes in Skin Structure Lead to Wrinkles Changes in the skin structure directly lead to visible changes at the surface of the skin. As muscles frown and scowl, push and pull the skin, wrinkles become etched into the face. Botox®, now the most common cosmetic procedure in America, relaxes these muscles, minimizing the appearance of these wrinkles. Degeneration of collagen, and elastic fibers translates to the appearance of jowls and creases. Changes at the microscopic level that result in alterations at the visible level may be repaired with fillers including Restylane®, Sculptra®, fat, collagen and others presently under development. The best way to understand cosmetic products and procedures is to first understand the skin changes that they are trying to reverse. To help with this understanding, I will first discuss the various types of wrinkles and damage that effects the skin, and then present various ways to reverse the damage.



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Fine (Superficial) Wrinkles

Etched in, superficial lines extend only to the upper dermis. They are typically caused by sun damage and smoking, which accelerate the degeneration of collagen and elastic fibers. The best examples are the little lines around the mouth that cause lipstick to bleed. Treatments directed at fixing superficial wrinkles must target the upper layers of the dermis; if they affect the epidermis or deeper layers, they will not be fruitful. Thus, when you are concerned about these types of lines and someone recommends a superficial chemical peel, you should understand that this most likely will not be productive because it does not address the deficiency at the dermal level. In contrast, appropriately selected fillers, medium strength chemical peels, and a few lasers will act at the correct part of the skin to make a difference. They are worth trying.

Deep Wrinkles

Deep wrinkles extend through the upper dermis into the mid and lower dermis. Repairing these wrinkles requires either a resurfacing procedure that will remove all of the layers above the wrinkle or fillers designed to replace the support structures that have been lost. Fillers appropriate for deep wrinkles might include hyaluronic acids, collagens, fat, Sculptra®, and several others presently undergoing clinical trials. Radiofrequency devices that stimulate fibroblasts to produce more collagen and devices that tighten fibers can repair damage at this level.

Creases

Creases are caused by the loss of deep subcutaneous tissue.They require more substantial replacement of volume. One good



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example of these are deep smile lines. These are caused not only by loss of subcutaneous tissue but also by the laxity of the connective tissue above it. Repairing creases involves replacing lost tissue with thick fillers designed for placement at a deep level. These include autologous fat, Restylane® Sub Q, Juvederm®, Perlane®, or Sculptra®.

Dynamic Wrinkles

Wrinkles caused by muscle movement are entirely different from those caused by loss of connective tissue. Without an understanding of these differences or the tools to treat them differently, attempts to correct them are destined to be a waste of time and money. The best example of dynamic wrinkles is a frown line. Frown lines are the most commonly treated wrinkles and the only FDA approved indication for Botox®. These lines are the result of a series of muscles (known as the corrugator, procerus, and depressor supercilii muscles) that pull on the skin. As the skin moves, wrinkles are formed. It is easy to understand why botulinum toxins, which inhibit muscle activity, are the perfect treatment for these wrinkles. For this type of wrinkle, injecting fillers without a botulinum makes little sense because the muscle activity will simply continue to wrinkle and the frown line will be back in short order. Thus, treatment of dynamic wrinkles should involve Botox®, Reloxin®, or Myobloc®. Frown lines are one example of the fact that the successful treatment of wrinkles frequently requires multiple modalities.

Static Wrinkles

In contrast to wrinkles seen with movement, static wrinkles are evident at rest. These will not be helped by botulinum toxins. They require fillers to replace lost volume, and/or



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treatment with radiofrequency, laser or chemical peels to tighten the connective tissues. Static wrinkles are difficult to treat but when they are correctly addressed, their resolution yields the most rewarding changes in appearance.

Skin Through the Ages The skin changes with age and the skin you had in your childhood is significantly different from the skin of your adult years. Understanding the skin at various points in time will help you to have the best possible skin at each stage of life. Let us look at the skin during various times in life: Childhood, Teens, and 20s—Protection, prevention, and medication are the keys to success in these years. Parents of young children need to be vigilant with sun protection and discuss the risks of sunburns with children. Information regarding protection from the sun may be found at the website for the American Academy of Dermatology (www.aad. org) as well as the Weather Channel (www.weather.com). Teens should be responsible for their sun protection. Gentle coaxing as well as additional information from parents may be helpful (sometimes this must be tied to the car keys) when trying to get teens to prevent skin cancers that are decades away. Damage done during early years is especially significant for aging skin and skin cancers. Early intervention and education can have the most impact on skin wellness in later life. Teenage years are typically the first time that the hormones responsible for acne begin to affect the skin. This may require prescription medications as well as a discussion about skincare and skincare products. A dermatologist can be very helpful during these years. There are many newer



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treatments for acne including laser, IPL, and photo dynamic therapy, in addition to more traditional treatments such as topical and oral medications. The Palm Beach Peel® Exfoliation Pads can help to unclog pores. 30s—The 30s are the branch point in the life of your skin. The early 30s are a continuation of the 20s—basic skincare with some focus on prevention and early treatment. By the age of 35, however, most people hit a dermatologic (and metabolic) wall. The exact age that this transformation occurs is not etched in stone, and it depends on genetics, health, skincare regimen, and external influences such as smoking, sun, and stress. Skin color also plays a role, as darker skin tends to look better at a given age than lighter skin. How do you know when you hit the transition point? When you begin to notice infomercials for age defying diets and skincare programs you have begun middle age for the skin. Once this occurs, the fight against aging begins in earnest. During the 30s good skincare includes visits to the dermatologist for rejuvenation and prevention. This may consist of chemical peels or intense pulsed light. Topical medications such as Retin-A® or Avage® may become part of your daily routine. Skincare products containing antioxidants such as vitamin C and green tea, as well as exfoliation products (such as The Palm Beach Peel® Home Microdermabrasion system) are added to your skincare regimen. Injections at a dermatologist’s office with Restylane®, Perlane®, Botox®, Reloxin®, Hylaform®, Juvederm®, and Captique™ become part of the struggle to fight off wrinkles. Lasers and light based therapies may be used to renovate the outer layers of skin. This decade typically has a metabolic slowdown and some people begin to seek liposuction of fat deposits that were not even there ten years earlier. Smokers should give serious consideration to stopping as doing so will reverse



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many of the bad changes in ones lungs and prevent a lot of wrinkles as well. 40s—Serious skin maintenance begins in earnest in the 40s. Accumulated damage is now apparent in the mirror and under the microscope. Fine lines around the mouth and eyes are an early hallmark of this period. Fortunately, these are easily treated. Loss of subcutaneous elasticity causes the smile lines to become prominent, and the entire face begins to descend. Hormonal changes associated with menopause begin to cause breakouts in women. Menopause may also be the cause of breakouts for men living with women at this point in life. Medications used to treat high blood pressure, diabetes, and increased cholesterol may cause your skin to develop various types of skin problems including hair loss, hyperpigmentation, bruising, rashes, and sensitivity to the sun. Skin cancers begin to appear in fair skinned people as they enter their third and especially their fourth decades. Dermatologic care is now at least an annual affair (usually more likely to be at six month intervals). Treatments mentioned during the 30s are used in greater combinations and quantities. Soft tissue augmentation of smile lines and corners of the mouth in addition to botulinum toxin treatments for frown lines, neck bands, and crow’s feet are routine treatments for my patients in their 40s. Volume replacement becomes a consideration, and volumizers (products that create volume rather than replace it) such as Sculptra® are helpful. Brown spots and capillaries of the face, which result from accumulated sun damage, hormones, and genetics may be safely and effectively treated with lasers, intense pulsed lights, and topical medications and cosmeceuticals. 50s and 60s—The epic struggle begins. If you have worshipped at the altars of good skincare and prevention and



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have a good rapport with your cosmetic dermatologist, you will be well positioned to look and feel great at this point in life. Embrace the 50s and 60s with visits to the dermatologist three to four times per year instead of two. Whereas prior appointments may have required one syringe of filler and 25 units of Botox®, two to three times that amount will now be required. To provide the best surface appearance as well as optimum tone and texture, Retin-A® or Avage® combined with green tea and exfoliation should be part of your daily regimen. Fortunately, the available options increase every year as the technology continuously improves.

“Patients in their 50s and 60s are frequently the most fun for a cosmetic dermatologist to care for because we can make a huge impact.”

If you have not taken care of your skin, or if you have been a sun worshipper or smoker or simply have bad genes, you may require more than fillers and Botox®. In this case, a facelift with ablative laser resurfacing may be needed. Changes seen on the surface of the skin during the 50s and 60s correspond with significant changes seen under the microscope. Oil glands begin to lose their function and the skin becomes drier. The collagen and elastic fibers have become ragged and thin. Epithelial cells damaged by years of sun become disorganized and form small scaly bumps on the ears, nose, and lips. These actinic keratoses—precancerous growths that may progress if they are not treated—are common in sun damaged skin. Put simply, people that spent a great deal of time in the sun will age faster than those who did not. Menopause causes changes in the skin that mirror the hot flashes and night sweats of the rest of the body. Decreasing estrogen levels are associated with skin



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that becomes thinner and dryer. Rational skincare must take these changes into account. In addition to these changes, conditions such as rosacea and seborrheic dermatitis become more noticeable. Supplemental hormones including testosterone may cause abnormal hair growth and acne. With all of these changes, it is common to require a change in your skincare regimen. This may include the addition of prescription medications and the use of products that are milder and more emollient. Medications prescribed for nondermatologic conditions are used with increasing frequency and these may cause side effects including hyperpigmentation, hair loss, and rashes. Volume replacement with fat transfers, Sculptra®, collagen, hyaluronic acids, and Radiesse™ permit restoration of a more youthful appearance. Chemical peels will rejuvenate the outer layers of skin. Lasers and radiofrequency can tighten collagen and elastic fibers. Botulinum toxin treatments with Botox® and Reloxin® previously confined to frown lines and crow’s feet are used to treat the neck, lips, and chin. Palm Beach Peel® products were designed for skin rejuvenation. Green tea, retinol, growth factors, vitamin C, and glycolic acids provide the skin with the nutrients and antioxidants required to help turn back the hands of time.

“If Emeril were a dermatologist, this is when he would ‘Kick it up a notch!’”

70s and beyond– During these years, surgical intervention in the form of a facelift may be required to remove excess skin and reposition a sagging face. Treatments used during the 50s and 60s are utilized with increasing frequency and



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greater volumes. This may include Botox®, fillers, lasers, intense pulsed lights, and chemical peels. Skincare regimens that previously consisted of one or two products may require twice that many. In the following chapters, we will examine both topical treatments, prescription therapies, as well as the most advanced options for rejuvenation on the market today.



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CHAPTER

2

The Sun & Your Skin “Start wearing a broad spectrum sunscreen everyday and your face will love you forever.”


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The leading cause of preventable skin damage is ultraviolet radiation. Since we can prevent and sometimes treat this damage we will begin with a discussion of the effects of the sun on skin and proceed with a discussion of treatment. Common sense dictates that two people with different types of skin will have different results from the same degree of sun exposure. Fair skinned, blue eyed people (Fitzpatrick Skin Type 1) have skin that evolved to live in England, Ireland, Scandinavia, and places without significant ultraviolet exposure. Darker skin with more melanin (Fitzpatrick Type 6) is better adapted to sun exposure and designed for tropical latitudes. These differences in pigmentation translate to requirements for high SPF for people with fair skin and lower SPF for those with darker skin. The requirement for differing degrees of protection depending on skin type is my main fault with skincare moisturizers that include SPF 15 and are marketed as “daily wear.” They are not adequate for the daily activities of most of the people who purchase them. For instance, skin that needs SPF 50 will burn with only an SPF 15 on. My skincare products leave out sunscreen and require the user to choose the sunscreen specific to their location, season, and type of skin. This, I believe, ensures that they get the best protection while enjoying the best products. In order to understand why sun protection is necessary, consider what ultraviolet light does to the skin. Ultraviolet light interacts with the skin by radiating it. Different types of ultraviolet light penetrate to different levels and have interactions with molecules and cells. One significant interaction is with the DNA of the skin. As DNA is affected by sunlight, it is altered and the information contained in the DNA is changed. Most of the time, the damage can be repaired but as we get older our ability to repair DNA decreases and mistakes begin to accumulate. As this occurs, faulty genetic information is translated into defective proteins and abnor-



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malities in the cells are seen. Abnormalities including skin cancer may result from the damage. Ultraviolet radiation also damages collagen and this is seen on the surface as wrinkles. Liver spots are also seen following exposure to sunlight as the body tries to shield itself. However, the sun is not entirely without benefit. Its role in the production of vitamin D as well as producing a generalized feeling of well being has been known to dermatologists for years. How then to reconcile these two conflicting facts? For me, the answer is simple: moderation. Specifically, I believe it is important to avoid sunburns because they inflict significant damage in a short time. Since the number of blistering sunburns correlates with the incidence of melanoma, it is reasonable to do everything possible to avoid blistering sunburns for you and your family. Early sun damage has the most impact on the skin so teach your children about sun protection and use adequate sun block, sunscreen, or sun protective clothing to avoid early skin damage. Although early damage is the most important, later ultraviolet exposure also impacts the skin. Prudent sun protection throughout ones life will help to avoid wrinkles and cancers. I advise my patients not to become hermits (which some in my profession would advocate) and to enjoy themselves but also to be cautious and avoid sunburns and prolonged sun exposures at all costs. One question frequently asked by patients in their 60s and 70s is whether they can have any sun exposure. Usually, these patients want to participate in water sports, golf, or tennis but are worried about skin cancer and wrinkles. I believe that since the risk for wrinkles and skin cancer has largely been determined by sun exposure prior to the age of 60, the benefits of exercising in the sun (including decreased rates of depression and osteoporosis) outweigh the risks at that age. I have found that many of my skin cancer patients, par-

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ticularly those with basal and squamous cell carcinomas, also have macular degeneration. This makes some sense since the same ultraviolet light responsible for damaging the skin also damages the retina. In order to protect against macular degeneration, I recommend that adults and children wear polarized sunglasses (think of them as an SPF 30 for your eyes).

Preventing Sun Damage “The best way to deal with wrinkles is avoidance.”

Preventing sun damage is an important aspect of any skincare program. Although prevention is particularly important when we are young, it plays a part in skin wellness at every age. Using SPF 30 when you are 20 is going to trump using SPF 100 when you are 60, so do everything in your power to avoid sunburns while you are young, and protect your children while they are too young to protect themselves. Sun protection is an evolving concept. One great discussion of photoprotection (protection from the sun) was written by Kullavanijaya and Lim1. They explain that sunlight consists of different components. These include UVA, UVB, and UVC. UVA is the radiation that penetrates deeply but does not produce sunburns. It is the ultraviolet light used by tanning booths to induce the production of melanin. UVB causes sunburns and is responsible for a fair amount of damage seen as wrinkles, liver spots, and thinned skin with bruises (due to damage to the connective tissue). UVC is filtered by the ozone in the atmosphere, and it typically does not affect our skin. Recent holes in the ozone layer are now allowing the dangerous UVC rays to reach the earth’s surface with consequences that will not be known for years. 1 Kullavanijaya, P Lim, H JAAD 2005;52:937-58



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The concept of sun protection has evolved with our understanding of how ultraviolet light interacts with the skin. The leader in this area is Australia. With their fairskinned population and love of outdoor activities, they have become the leaders in many skin cancer treatments. Recently, they have developed the concept of “UV Protection Factor” which is meant to be analogous to SPF. The concept of “SPF” is one frequently used by physicians, manufacturers and consumers when deciding which sunscreen to use. Unfortunately, this concept only measures protection from UVB and was originally designed as a means of avoiding sunburns. SPF has no relevance to UVA—the deeply penetrating radiation. Ultraviolet Protection Factor (UPF), on the other hand, refers to the amount of total ultraviolet filtration a type of clothing provides. This is a much better and more rational scale to use when considering skin protection factors. If you have any doubts about why UVA should be considered, take a look at the 40-year-olds who have been to the tanning beds and been regularly exposed to UVA—they tend to “hit the wall” early and look 20 years older than people who have never used tanning booths. For those who have any lingering doubts about whether behavior influences skin health and appearance, take a look at the people that not only go to tanning beds but also smoke—they look twice their age. These patients are the most difficult to treat because there is not enough Botox®, fillers, or peels to reverse the profound damage that has been done. When considering which sun protection product to use, remember that SPF applies only to UVB and look for products that have UVA protection as well. Unfortunately, there is no agreed upon UVA rating scale and one may need to resort to trial and error. Products that have micronized titanium or zinc dioxide (known as sun blocks or “sensitive skin” prod-

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ucts) have particles that provide physical barriers, and they are good at blocking both UVA and UVB. When selecting sunscreens, I try to use products that offer UVB protection of at least 45 and usually higher (as measured by SPF) and that contain a UVA protection ingredient such as Parsol® 1789, zinc, or titanium dioxides or Mexoryl®—which although not approved in the United States is a great product. I also like and recommend protective clothing sold by Radicool, Solumbra and Columbia. Ignoring, sun protection produces consequences that depend on ones exposure history, genetics, and environment. Given the same degree of sun exposure, light skinned people who do not protect themselves will begin to see signs of premature aging at earlier ages. Wrinkles and thin skin will begin in the late 20s instead of the mid-30s. At about the same time, small scaly lesions will begin to appear on the ears, lips, nose as well as on the hands and arms.These actinic keratoses, are the warning signs that significant damage has resulted in cancerous cells.The topic of skin cancer and actinic keratoses is discussed more in later chapters. Sun protection produces no immediate results but is still an essential part of any good skin wellness and anti-aging program.

“When is comes to sun protection, more is better.”

Sun Protection Factors What does high SPF really mean?

Sunscreens are labeled with SPF numbers meant to serve as a guide to the protection offered by the contents within. SPF ratings are calculated by comparing the time needed to



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produce a burn on skin covered with a given sunscreen compared to unprotected skin. A sunscreen with an SPF 15 would allow skin that would develop a sunburn in five minutes to burn in 75 minutes instead. Despite what your neighbors or relatives (notoriously poor sources of dermatology research) tell you, there are differences between 15, 30, and 60 SPFs. SPF 15 provides 93 percent absorption of UVB, while SPF 30 may absorb 97 percent of the sun’s rays. SPF 50 takes the protection up to 98 percent. Many of my patients select an SPF 60 to minimize the damage from ultraviolet radiation, and I agree with this approach. Even if the difference is only a few percent of protection, more is definitely better. It is also important to consider UVA protection when selecting a product; and one containing Mexoryl®, Parsol® 1789 or titanium/zinc dioxide will afford you the best protection for UVA. Different products are better for different seasons and different activities so do not stay married to one tube or bottle.You will need a different product when fishing in Florida in July than when you are walking your dog in New York in October. I use SPF 50 on my own children. Many dermatologists use this in conjunction with sun-protective clothing for themselves and their families. Choosing the correct sunscreen will not help if you do not use the product correctly. Studies have shown that most people do not apply adequate amounts of sunscreen. The average person requires approximately one shot glass of product to cover them. Another pitfall with sunscreen use is not applying it frequently enough. Many products are designed for about four hours of ultraviolet exposure. Others (such as Neutrogena Sport) are designed for longer exposures. The daily wear products with SPF 15 are not designed for lasting protection, and people who rely on them for protection will get burned. Products designed for water resistance are essential when you plan to swim or sweat. A product that is not water resistant will wash off at the beach,

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pool, or sporting event leaving you and your family without any significant sunscreen. Despite old wives’ tales to the contrary, water provides very little sun protection. Thus, swimming requires the use of waterproof sun protection. Many of my skin cancer patients have skin cancers on their lower legs as a result of sunlight that reflected off sand and water during younger years spent at the beach. Sunscreens (which absorb the sun) must be applied at least 30 minutes before going outside so they have time to become activated. This is in contrast with sun blocks which function as physical barriers to the sun and work instantly.

Sun protection hints: Avoid the sun between 10 a.m. and 4 p.m., as these are the peak hours for harmful UV rays. Wear protective clothing, such as a “French Legionnaire” hat with a large brim and neck and ear coverage to spare your skin.

One final word about sun protection: find a product that you do not hate. You may never love to use sunscreen or sun block but with so many products available, you should at least be able to live with one. Try gels, sticks, creams, and foams until you find one that works well for you. Several great sun protection products are available on my website (www.idealskin.com), and I change my offerings based on the technology available and what my patients want.

Selecting an SPF To help figure out which SPF to use, log onto the Weather Channel’s website www.weather.com each morning and look at the health section. I helped develop this service to provide information about sun hazards in any location, on any day. The site will suggest an SPF based on your skin type and the weather for your location.



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SUN PROTECTION CHECKLIST • Cover up with clothing, including a broad-brimmed hat, long pants, a long-sleeved shirt, and UV-blocking sunglasses • Avoid tanning parlors and all artificial tanning devices • Examine your skin from head to toe once a month. If you notice a change, see a dermatologist • Have an annual skin examination by a dermatologist board certified by The American Board of Dermatology • When outdoors, apply SPF 30 or higher liberally, uniformly, and frequently • Avoid unnecessary sun exposure, especially between 10:00 a.m. and 4:00 p.m • Teach your children good sun protection habits at an early age; the damage that leads to adult skin cancers and wrinkles begins in childhood • Sunscreens may be used on babies over the age of six months (I use chemical-free on my own children) • Year-round sun protection is vital—especially on vacations to the beach or skiing where sun exposure is intermittent and intense • UV radiation can penetrate many types of clothing—one good rule of thumb is to hold clothing up to a bare light bulb. If you can see your hand, it is less than SPF 15 equivalent. I recommend sun protective clothing and hats for children. Many great products are now available from Solumbra or Radicool who make great “French Legionnaire” hats that cover the back of the neck and ears • UV radiation penetrates automobile and residential windows so if you are fair skinned, have children, or live in a high sun exposure environment, you need to have your windows tinted • UV radiation can damage your eyes, contributing to cataracts, macular degeneration, and eyelid cancers • Snow or ice reflect UV radiation, which damage the face and eyes at twice the normal rate

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• Sun protection is important for all skin types; the amount of sun protection depends on your skin type, where you live and the season you are in. Your dermatologist can provide some guidance for you as to what would be reasonable for your situation. In my practice, my patients use a lot of SPF 60 (La Roche Posay Anthelios) and Palm Beach® Esthetic Sunscreens with SPF of at least 15 for basic protection year-round

What to Do If You Get Burned It happens to the best of us. In an effort to spend time with our family or get some exercise, we go outdoors without adequate sun protection. If this happens to you, take an overthe-counter anti-inflammatory such as aspirin or ibuprofen to minimize the redness and inflammation. Blistered skin may be indicative of a second-degree burn and this requires medical attention. Over-the-counter hydrocortisone creams may help soothe the skin and decrease swelling. A severe burn, or one accompanied by fever requires immediate medical attention, as these conditions may be associated with heatstroke.



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CHAPTER

3

Skin Maintenance & Improvement: Damage Control & Repair “This is the dawn of a new day in cosmetic dermatology when we have the ability to make visible and meaningful changes to the skin with topical treatments.”


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A great deal of my professional life is spent discussing creams, injections, lasers, and other techniques to reverse the signs of aging. This chapter is an overview of some areas that will be important for years to come. Included in this discussion are prescription anti-aging creams, glycolic acid products, vitamin C products, green tea products, growth factors, and other topical ingredients with significant promise.

Advancements in Cosmeceutical Skincare The cosmeceutical market consists of products designed to improve appearance.Traditionally, this was the province of prescription medications, but new ingredients have made some great products available to mass consumers. Cosmeceuticals have grown exponentially over the past few years, and this trend is expected to continue.They are the fastest-growing segment of the multi-billion dollar per year personal care industry. For the mass consumer, new products are rapidly appearing that contain the same high-end technology previously reserved for elite prestige brands.This has resulted in a flood of new products on the market and a new, large group of consumers who has access and interest in them. When considering any new product, trust your instincts. Before purchasing a skincare product, learn about it and the company selling it. Decide if it makes sense to invest in the product based on the company’s track record in skincare and the ingredients they are using. This section will serve as a reference for skincare products but it is helpful to consult your dermatologist for specific questions about your individual skincare needs.

Moisturizers Many skincare regimens will occasionally dry out the skin. For this reason, it is important to use a moisturizer that does not irritate your skin. Suggestions include: Theraplex Hydrolotion, Palm Beach Peel® Antioxidant Moisturizing Formula, 46 PALM BEACH PERFECT SKIN


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Eucerin, Neutrogena, SkinMedica, and Clinique.You should be able to find something you like among the products available. When considering several products, understand some basic differences between them.The most basic difference among moisturizers is whether it is an ointment, lotion, cream, or oil. Ointments are the thickest and greasiest.They are used to provide the greatest moisture and the strongest barrier protection. While they might be appropriate for the hands and feet, they would not be great for the face. Creams are lighter than ointments but heavier than lotions.They seal in moisture and may be used on most parts of the body, including the face. Lotions are thinner and lighter than creams.Absorbed rapidly, they tend to be the most commonly used products because they are simple to apply and easy to spread. Oils are easily absorbed when applied to damp skin but are less moisturizing than ointments, creams, or lotions.They are great to apply after bathing.

Cosmeceutical Creams Creams promising eternal youth have been around since Cleopatra. At that time these creams used fermentation to produce glycolic acids to treat wrinkles. Some present day products still use glycolic acid, but many more utilize molecules developed specifically to fight wrinkles. In this section, we will consider some ingredients and products that might be worth a try. Prescription creams, including Retin-A® and Avage®, should be part of any skincare program. Both are retinoids derived from vitamin A (also known as retinol). They cause the epidermis to remodel and rejuvenate. Following several months of use, the underlying dermis becomes more youthful and organized. Changes seen under the microscope reflect changes seen in the mirror. Over-the-counter products that should be considered include those containing antioxidants, vitamins, growth factors, and other biologically active ingredients. Included in this list are green tea (my favorite), licorice (a naturally Skin Maintenance & Improvement


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occurring steroid), glycolic acids, and epidermal growth factors. Newer ingredients such as idebenone (found in Prevage™) are antioxidants now marketed to the mass consumer.

Glycolic Acid Glycolic acids are usually derived from fruits or plants. Results obtained from glycolic acid products depend on the strength of the acid, the duration of contact with the skin, and the type of acid used. These products can remove layers of skin and the depth of penetration depends on the concentration of acid. Glycolic acids improve the appearance of fine lines and wrinkles by causing some mild swelling of the dermis. At lower concentrations (less than 20%), mild exfoliation occurs in the outer epidermal layers. This concentration is typically found in products sold at drug stores and salons. Peels offered in dermatology offices use an increased concentration of acid, and may produce peels that extend into the upper- and mid-dermis. Day spa peels are usually in between the concentrations available in over-the-counter products and peels offered by dermatologists. They may be strong enough to cause burns, particularly when the “medical director” has no training in dermatology. Several people have been permanently scarred by these types of peels performed in a spa environment. When selecting a glycolic acid for home use, it is important to determine the concentration of acid in the product as well as its pH (which has an effect on the concentration of acid). Glycolic acids come in washes (which tend to be mild), lotions and creams (which may be stronger), and pads (which can peel the skin and produce great results when used correctly).

Vitamin C More than a decade ago, vitamin C products became the first “primetime” cosmeceutical. Developed at the Duke University



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Department of Dermatology, they quickly became commercial successes. Clinical research demonstrated that vitamin C stimulates collagen growth and provides some sun protection. Incorporating vitamin C into skincare made perfect sense in retrospect since it had been known for decades to be important for collagen production. Vitamin C remains an essential ingredient in many skincare products to this day.

Growth Factors Growth factors hold a great deal of potential for skin rejuvenation. These compounds attempt to stimulate skin cells to grow and replenish support structures (including collagen) to a more youthful state. One early product from Skinmedica includes epidermal growth factor, which stimulates epidermal cells to grow. More recent products including those made by Neocutis* contain more growth factors, and they are specifically targeting epidermal rejuvenation with their technology. In theory this will produce new, undamaged cells that can replace dead or damaged cells. A fair amount of scientific research went into these products, and patients who have tried them are generally happy with the results. Newer products have increased concentrations of growth factors and molecules that directly stimulate cellular growth. Products on the horizon will likely contain ingredients to prevent chromosomal endcaps (known as telomeres) from unraveling. Overall, this is an exciting time to be involved in cosmeceutical research.

Antioxidants Antioxidants fight many effects of harmful free radicals that damage DNA and result in aging. Although green tea has been part of Eastern medicine for centuries, this rich source of antioxidants has only recently been incorporated into Western medicine and skincare. According to one recent * Disclosure: I serve on the scientific advisory board for Neocutis

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review, multiple ingredients found in green tea inhibit the formation of skin cancers. These ingredients also have anti-inflammatory and anti-aging effects on the skin as well. Unlike black tea, green tea is not fermented and this key difference results in high levels of antioxidant polyphenols contained in green tea. Made from the dried leaves of the camellia sinensis plant, green tea, black tea, and oolong tea are simply processed differently. Populations that consume large amounts of green tea have a lower than expected incidence of oral, bladder, prostate, and colon cancers. Ingredients from green tea reduce damage caused by sunburns when applied to the skin in a topical form. They hold promise as topical anti-cancer drugs and can cause apoptosis (programmed cell death) of malignant skin cells. These numerous beneficial effects of green tea are the reason that I have included it into many of my Palm Beach Peel® products. My patients love these products because of their anti-aging qualities as well as the calming effects the products have on the skin. People using these products have reported an improvement of skin problems, including rosacea and mild dermatitis.

The Palm Beach Peel® System The Palm Beach Peel® System is to cosmetic dermatology what teeth bleaching strips are to cosmetic dentistry. Before the advent of whitening strips, you had to spend considerable time and money in the dentist’s chair to get whiter teeth. Everything from expensive bleaching trays to hightech lasers were utilized in the pursuit of perfect teeth, but all this changed with the arrival of home bleaching kits. As a result, brighter and whiter teeth—once available only to those who had the time and money to see a cosmetic dentist—are now available to everyone. My goal with my skincare products is to make professional skincare available to anyone who wants healthier and more beautiful looking skin. While there is no substitute for 50 PALM BEACH PERFECT SKIN


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a visit with a professional dermatologist, the comprehensive Palm Beach Peel® Skincare System can help you reach your skincare goals. Developed using my years of experience and training, the Palm Beach Peel® Skincare System delivers innovative formulations containing the highest quality ingredients designed to exfoliate, nourish, and moisturize your skin

The Palm Beach Peel® Steps: Exfoliation, Nourishment, Cleansing, Moisturizing & Exfoliation Exfoliation of the outer dead skin cell layer is either minor or major with selected Palm Beach Peel® products. Minor exfoliation is obtained with easy to use Palm Beach Peel® Exfoliation Pads. These pads have strengths of glycolic acid ranging from 10% to 20%, combined with witch hazel to tone the skin. At the higher glycolic acid percentages, these unique pads are comparable to peels obtained in a spa or salon. I recommend starting with the Palm Beach Peel® Exfoliation 10% pads unless your skin is extremely oily. These pads should be used either once or twice daily depending upon the oiliness and sensitivity of your skin. After using one strength for about a month, you can then move up to the next higher strength. Major exfoliation is obtained with the Palm Beach Peel® Home Dermabrasion Formula. This contains self-heating crystals for professional strength microdermabrasion. The crystals, made from micronized bamboo, gently but thoroughly remove dirt, oil, dead skin cells, and surface debris that can clog the pores. Since these crystals provide significant exfoliation, they should only be used once or twice a week and they should not be used on the same day as the Palm Beach Peel® Exfoliation pads. Self-tanning products will look better and last longer when applied after the Home Dermabrasion Formula.



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Skin Nourishment Skin nourishment is a critical component of any effective skincare regimen.The Palm Beach Peel® System has several products designed to provide different types of nourishment to the skin. Each is designed with a different key ingredient for a different type of skin. My products include Eye Rescue Formula, Retinol Recovery Serum, Antioxidant Rescue Serum, and Growth Factor Serum. After reading about the products, you should be able to select a skincare program that will help you obtain skin that looks and feels great. The Palm Beach Peel® Eye Rescue Formula was created especially for the delicate skin under the eyes. This thin skin is one of the most frequent sources for patient consultations, and the Eye Rescue Formula addresses many of the issues unique to this area. Eye Rescue Formula contains hyaluronic acid to hydrate and plump the skin. Also found within this serum are green tea and vitamins to nourish the skin. This serum should be used twice a day (morning and evening) but may be applied more frequently when traveling or in a dry environment. The Palm Beach Peel® Retinol Recovery Serum contains retinol, hyaluronic acid, and green tea. Retinol is the vitamin A derivative that is the precursor to Retin-A®. These ingredients help to minimize the appearance of fine lines and wrinkles and improve skin tone and texture. I have included three strengths of retinol (0.2%, 0.3% and 0.5%). Begin with the 0.2% and increase concentration after about four weeks. If you experience skin irritation, decrease the usage to every other night for about three weeks. The Palm Beach Peel® Green Tea Rescue Serum combines the hydrating qualities of hyaluronic acid with the antioxidant benefits of green tea and caffeine. Although this mix of ingredients may sound like something to order at Starbucks, it has significant levels of antioxidants that help neutralize free radical damage to the skin. This product is the cornerstone for any skin nutrition program. 52 PALM BEACH PERFECT SKIN


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Apply the Antioxidant Rescue Serum after cleansing your skin (or at least twice per day). A small amount (about the size of a pea) is all that is required for the average face or neck. The Palm Beach Peel® Antioxidant Rescue Serum has a dark color due to its high antioxidant content. Rather than add a coloring agent to make it look more attractive, I chose not to dye the product. The Palm Beach Peel® Growth Factor Serum contains the human growth factor TGF-beta1 which stimulates collagen production. Growth Factor Serum should be used on skin that shows signs of moderate to severe aging. It should be applied each evening, when the skin repairs itself. Palm Beach Peel® Growth Factor Serum is available in concentrations of 10% or 15%. Begin with the lower concentration for about one month and then increase the concentration to maximize your results. Cleanser—My soap free Palm Beach Peel® cleanser is an alternative to the harsh, drying soaps that are part of most skincare systems. This unique product gently cleanses and moisturizes the skin while delivering green tea and Coenzyme Q 10 to help nourish the skin. Instructions for using the cleanser are simple. Apply a moderate amount to moistened skin and gently massage the surface with your fingertips or a soft washcloth. Gently dry your skin with a soft towel and apply the antioxidant and moisturizer if your skin tends to be dry. Both of these products will work better when applied to slightly moist skin.To maximize skin hydration, do not allow your skin to dry completely before applying moisturizers. It is much easier to seal moisture into the skin than to replace it once it has been lost. Note: If you are using a prescription acne product, let your skin dry completely before applying this product. If you do not, you greatly increase the risk of irritating your skin. Skin Maintenance & Improvement


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Moisturizer—The Palm Beach Peel® Antioxidant Moisturizing Formula contains the natural emollients squalene and glycerin which attract water to the skin and help soothe and soften. The antioxidants vitamins A, C, E, green tea extract, and CoQ10 are incorporated into this product so that your skin gets the nutrition it needs.

AN OVERVIEW OF COSMECEUTICALS Cosmeceutical Retinoid Precursors & Derivatives

Indications • Treat skin disorders such as acne, psoriasis, and icthyosis • Improve the appearance of aged and photo-damaged skin

Alpha/Beta Hydroxy Acids

• Enhance epidermal shedding • Improve quality of elastic fibers • Increase collagen density

Effects • Reduce wrinkles • Decrease laxity • Bleach hyperpigmented spots

• Reduce signs of aging • Smooth skin • Can increase sensitivity to UV rays

Other Forms • Derivative of vitamin A Retinol • Carotenoids

• Alpha or Beta, depending on molecular structure • AHAs or fruit acid including: glycolic acid, lactic acid, citric acid, mandelic acid, malic, acid and tartaric acid • BHA include salicylic acid

Antioxidants

• Needed to maintain the equilibrium between the pro-oxidants, or damaging agents, and the antioxidants, or protective agents

• Normalize changes caused by photo damage • Repair collagen • Protect cell membrane

• Vitamin C (L-ascorbic acid) • Vitamin E • Panthenol • Lipoic acid • Ubiquinone

• Normalize cell turnover

• Niacinamide



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Cosmeceutical Antioxidants

Indications • Intervene at different levels in the protective process

Effects

Other Forms

• Speed up cell growth, aid in healing process

• Dimethylaminoethanol

• Retard aging process

• Melatonin

• Spin traps

• Catalase • Superoxide dismutase • Peroxidase • Glucopyranosides • Polyphenols • Cysteine • Allantoin • Furfuryladenine • Uric acid • Glutathione

Depigmenting Agents

• Remove excess pigment, reduce discoloration and blotches, sun damage

• Most effective when the increase of melanocytes or melanin is restricted to the epidermis

• Hydroquinone • N-acetyl-4-Scysteanimylphenol • Vitamin C • Kojic acid

• Can irritate the skin • Chemical peels use a combination of these agents to remove excess layers of the skin or excess pigment

• Arbutin • Azaleic acid • Paper-mulberry compound • Tretinoin • Chemical peeling agents • Chemical compounds

Botanicals

• Use ingredients that occur naturally for the same purposes as other cosmeceuticals

• Soothe skin

• Chamomile

• Protect cells

• Avocado

• Stimulate lipids

• Aloe vera • Ginkgo biloba



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Cosmeceutical Glycosaminoglycans

Enzymes

Indications

Effects

• Decreased amounts are present in aged skin so when topically applied, it replenishes lost supply

• Stimulate wound repair

• Chemically digest inter-cellular bonds

• Exfoliate keratotic skin

• Stimulate cell growth and repair

• Hyaluronic Acid

• Rejuvenate skin

• Repair sun damaged skin

Growth Factors

Other Forms

• Treat burns and wounds

• Papain • Deoxyribonucleic acid

• Epidermal growth • Transforming growth factor

Hormones

Peptides

Antimicrobial Agents

• Claim to reverse the skin’s loss of tone and elasticity; not proven

• Claim to heal skin conditions, such as: acne, psoriasis, rosacea, seborrhea, and keratoses; not proven

• Estrogens

• Stimulate collagen and elastin production

• Reduce appearance of fine lines and wrinkles

• Microcollagen pentapeptides

• Fight bacteria associated with skin conditions

• Clear up skin

• Progesterone • Testosterone • Growth hormone

• Copper peptides • Triclosan • Chlorhexidine • Povidone iodine • PCMX (para-chlorometa-xylenol) • Hydrogen peroxide • Antidandruff preparations • Zinc pyrithione • Deodorants • Other antimicrobial preparations



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Cosmeceutical Topical Anesthetics & Antipruritics

Indications • Relieve local discomfort and reduce pruritis (itching)

Effects • Help reduce sunburn and acne

Other Forms • Ethyl aminobenzoate • Benzyl alcohol • Diperodon hydrochloride • Pramoxine hydrochloride • Menthol • Capsaicin

Hair Removal Agents

• Disrupt bonds of hair keratin, causing the hair to break in half and allowing it to separate from the skin • Block the enzymes or hormones that stimulate hair growth

Hair Loss Treatments

• Bind to receptors, preventing the binding of natural androgens to receptors • Increase the diameter of the hair shaft

• Depilatory agents • Eflornithine HCl 13.9% cream • Ketoconazole • Spironolactone, flutamide and cyproterone acetate

• Spironolactone • Cyproterone acetate • Flutamide • Azelaic acid • Ketoconazole

• Induce hair growth • Promote cell growth • Create new hair fibers

• Pinacidil, P-1075, cromakalim, and nicorandil • Tretinoin • FK 506tacrolimus • Cysteine and arginine • Saw palmetto (Serenoa repens)



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Cosmeceutical

Indications

Scar Management

Effects

Other Forms • Silicone gel sheeting • Adhesive microporous hypoallergenic paper tape • Vitamin E • Onion extract cream • Allantoin-sulfomucopolysaccharide gel • Glycosaminoglycan gel • Extracts of Bulbine frutescens • Extracts of Centella asiatica • Topical retinoic acid • Colchicine • Systemic antihistamines



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CHAPTER

4

A Lifetime of Perfect Skin: Why You Need a Cosmetic Dermotologist


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Perfect skin begins with the conscious decision to seek a youthful, healthy appearance. It can be accomplished with sensible living, advanced skincare, and the occasional visit to a cosmetic dermatologist or plastic surgeon. Controlling your diet, stress level, sleep (during which the body and the skin repair themselves), sun exposure, smoking and alcohol consumption will also help you get the best skin possible.

What Is a Cosmetic Dermatologist? Cosmetic dermatology is the branch of medicine devoted to optimizing the health and appearance of the skin. This branch of dermatology is a division of dermatologic surgery, the part of dermatology devoted to surgical treatments of the skin. Cosmetic dermatologists use many techniques, procedures, and products to enhance the appearance of the skin. In this section I will discuss the various procedures and products used by a cosmetic dermatologist. Products used by cosmetic dermatologists are varied; some represent cutting edge skincare while others are traditional products designed to maintain healthy skin. When considering new products it is helpful to think about the research behind them. Do not assume that more expensive products are necessarily better than less expensive ones. Several extremely expensive products are not significantly different than others that are available at less than half the price. A complete skincare program combines in office treatments with products and procedures that are used at home. The home-based portion of my program uses the Palm Beach Peel® pads instead of some office-based chemical peels. The green tea serum, green tea cleansers and moisturizers supplement prescription medications such as Retin-A® or Avage®. A cosmetic dermatology consultation begins with a discussion of your particular goals and an examination of your skin. Discussions of downtime associated with any potential



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procedures as well as any budgetary constraints should also take place at the consultation. If your skin has good tone and even color with minimal sun damage, resurfacing procedures such as TCA (trichloroacetic acid) peels or lasers may not be indicated. Frown lines, crow’s feet or forehead wrinkles can be treated easily and thoroughly with injections of Botox®, Myobloc®, or Reloxin®. Lasers, photodynamic therapy, or intense pulse light devices might be utilized to restore a more youthful appearance to the surface of the skin when there has been a great deal of sun damage. Wrinkles and folds due to loss of soft tissue are treated with soft tissue augmentation. The material selected depends on the goals, area to be treated, budget, and tolerance for downtime. Superficial wrinkles may be treated with Restylane®, Restylane® Fine Line, Juvederm®, Captique™, Hylaform®, or a collagen product. Moderate lines might be treated with Restylane®, Perlane®, Hylaform® Plus or Juvederm®. When loss of volume is the main problem, I might recommend fat transfer, Perlane®, Sculptra®, or Sub Q. Using combinations of treatments enables the cosmetic dermatologist to treat a variety of conditions, and make a great deal of difference. In Palm Beach, perfect skin involves an integrated approach to healthier and more youthful skin. As with any medical procedure, it is important to remember that no two people and no two procedures performed on the same person are exactly the same. It is impossible to obtain perfect results with every patient or with every procedure. If you begin a treatment program that does not live up to your goals, you should discuss this with your dermatologist. Sometimes a minor change in how a product or procedure is used, or an enhancement procedure may give you the results you desire. In some instances the goals rather than the procedure must be adjusted to the reality of a particular situation. One common scenario where goals must be adjusted involves a patient with limited ability to

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undergo a procedure. For instance, he or she can only afford one syringe of Restylane® or 25 units of Botox® and is then not satisfied with the fact that they still have wrinkles. This type of scenario may be minimized during your consultation.

Know Your Skin Type The type of skin that you have has a great deal of impact on the types of treatments and products that your skin needs. Skin types can be categorized in a variety of methods. Two that I find helpful are the Fitzpatrick scale for “fairness” of skin, and a scale that measures the amount of oiliness or dryness of the skin. If one type of skincare product were perfect for all skin types, the cosmetics department of any retail store would consist of one large, expensive bottle. Subtle differences among different skin types make dermatology so fascinating and skincare products so complicated. Understanding your particular skin type and its unique needs will help to maintain ideal skin. The Fitzpatrick grading scale is useful in describing sensitivity to the sun. In general, people with low Fitzpatrick skin types (for example,Type 1 or 2) have different skincare issues than darker skin types. The Fitzpatrick scale breaks skin types into six basic categories. On one end of the spectrum is a Type 1 skin. These people never tan and always burn. They tend to have very sensitive skin, are prone to rosacea, and require significant sun protection in order to maintain ideal skin. The other end of the spectrum is identified as a Type 6 skin type. This is typically an AfricanAmerican skin type that has a great degree of pigment. Sun protection is less important here than it is in Type 1 or fair, thin skin. In addition, this type of skin tends to age better and have fewer problems than lighter toned skin. Toward the middle of the scale are people with olive skin and dark eyes who tan easily. 62 PALM BEACH PERFECT SKIN


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FITZPATRICK CLASSIFICATION Type

Description

I

Very fair skin, I never tan, I burn

II

Light skin, I may tan, but I usually burn

III

Light to medium complexion, sometimes I tan, sometimes I burn

IV

Medium complexion, I usually tan, rarely burn

V

Dark complexion, I usually tan, rarely burn

VI

Black complexion, I never burn

With respect to the degree of oil found in the skin, there are four basic types of skin: normal, oily, dry, and combination. At the two extremes are oily skin and dry skin. Oily skin, common in some Hispanic and Mediterranean skin types, has a greater number of sebaceous glands than dry skin. Interestingly, oily skin tends to have fewer wrinkles than dry skin of the same age and sun exposure. Dry skin typically gets flaky and irritated especially in dry weather. It tends to be more susceptible to sun damage and other environmental injuries. Obviously, products designed for darker, oily skin are not good for lighter, dry skin. For instance, oily skin does quite well with products that contain salicylic acid but sensitive skin does not tolerate this ingredient. These distinctions are also a factor for a dermatologist prescribing medications such as Retin-A® or topical antibiotics. The strength and vehicle must take the skin type into consideration if the product will be used on an ongoing basis. Midway between the oily and dry extremes is normal skin, the skin type shared by most people. Normal skin produces enough oil to retain moisture without appearing shiny or greasy. Pores are medium sized and not prominent. This A Lifetime of Perfect Skin


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contrasts with pores found in oily skin types which tend to be large and prominent. Salicylic acid products such as Palm Beach Esthetic Acne Pads and Wash are helpful for oily skin but would not be appropriate for dry skin. When selecting a sunscreen, a gel based formulation may be appropriate for oily skin. For an antioxidant, the Palm Beach Peel® Green Tea Serum is appropriate for oily skin. Dry skin requires gentle care and a well thought out skincare program. Products and procedures that are fine for normal skin will irritate dry skin. Topical drugs such as RetinA® that are used by many people without a problem will cause dry skin to become red. Cleansers for dry skin must be soap free and moisturizers should not contain high concentrations of glycolic acids or vitamin C (even mild acids may not be tolerated). Bland emollients will help dry skin to maintain its health. Combination skin contains some areas that are oily and others that are dry or normal.The “T-zone” adjacent to the nose is the most frequent combination skin zone and this area may require separate products than the surrounding skin. In my practice, a typical skincare regimen looks like this:

DAY

NIGHT

Cleanser (the type of cleanser used depends on the condition of your skin—astringent based for oily and non-detergent based for dry)

Cleanser

Eye Cream

Toner (optional for oily skin)

Moisturizer

Eye Cream

SPF30 if you are planning to be outside

Thicker moisturizer



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How to Choose an Ideal Skin Regimen When selecting skincare products, choose products that you can live with both emotionally and financially. Select products that you can use month after month without feeling that you need to mortgage your home. Also, choose products that can provide results in a time frame that is acceptable to you.

Before You Buy Answering a few simple questions about your skin will help you choose the best products for you: Identify your skin type—Is your skin predominantly oily, dry, normal, sensitive, or some combination of these? Are you light skinned with blue eyes or dark skinned with dark eyes? (see The Fitzpatrick scale on page 63). Skin that is dry will need products designed to retain moisture, while skin that is oily requires products that are drying. This seemingly obvious statement of fact is frequently overlooked by consumers and salespeople selling skincare products. Once you have begun to understand your skin type, begin to define your goals. Identify your skincare goals—Do you need a wellness program that will forestall aging, or do you need a treatment program for a specific problem such as acne, rosacea, or hyperpigmentation? Defining the issues that are important to you is half of the struggle for perfect skin. Assess your lifestyle—If you smoke, have a poor diet, and spend a lot of time in the sun and you are not willing to change these behaviors, it will be difficult to have optimal skin (or any other part of your body for that matter). If you are too busy to apply moisturizer once a day, it is going to



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be difficult to transition to a program that utilizes five or six steps. Perhaps beginning with one or two products would be a more realistic starting point. A sensible perspective on the quest for perfect skin is as important as the products and dermatologist you select. The best products will not do any good if they sit on a shelf. Adopt a regimen approach—When trying skin products, remember that you should use a one month trial period to allow for fluctuations due to hormones (menstrual cycle for women) and varying environmental conditions. Begin with a combination of three or four products (cleanser, toner, moisturizer, exfoliator, and/or eye cream). Add one new product at a time to determine how it interacts with your skin. This enables you to isolate a problem product if your skin reacts poorly. Another reason to try products for a full month is that the skin cycle takes about 28 days to get cells from the bottom of the epidermal layer to the top of the epidermal layer. Thus, a full cycle is needed in order to give a new regimen a reasonable chance. Most of my patients use our Palm Beach Peel® Home Exfoliation system with Green Tea Cleanser and the Antioxidant Moisturizer. In addition, many use the Eye Rescue Serum and the Retinol Recovery or Growth Serum.

THE BASICS: Six Steps for Ideal Skin 1. Exfoliate using the Palm Beach Peel® 2. Cleanse and/or tone using green tea cleanser 3. Apply medication for dermatologic issues (prescriptions may be necessary) 4. Apply an antioxidant such as the Green Tea Serum 5. Apply a moisturizer 6. Protect from the elements with sun protection products



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1) Exfoliate—As discussed previously, the Palm Beach Peel® is the perfect way to remove debris from the skin. You can control the extent of exfoliation by using this system more or less frequently. As with any part of a good skincare regimen, the key here is moderation—do not scrub so hard that your skin is raw. Other methods of exfoliation available at the dermatologist’s office may be used to augment the Palm Beach Peel®. These include chemical peels and microdermabrasion. Products containing salicylic acid also exfoliate to some degree, and these may be helpful for skin that is oily or prone to acne. 2) Cleanse/Tone—In addition to the peel pads other products are helpful for removing debris from the skin. The green tea cleanser is one such product. Salicylic acid washes may be helpful for oily or acne prone skin. The right cleanser or toner is the one that works for you. There is no perfect product that works for all skin types and all environments. Ask your dermatologist for suggestions based on his or her experience. 3) Apply Medications—Skin conditions that require prescription strength medications require additional care. If your dermatologist is using topical medications to treat acne, eczema, dark spots, precancerous growths, skin cancers, or other skin conditions, you will need to apply this medication before application of other topical products and after the skin has been cleansed. In the event of irritation or other skin reaction, you should discontinue use of all products and check with your doctor. 4) Apply Antioxidants—At the present time, green tea is the richest source of antioxidants and should be used on a regular basis. Other antioxidants such as vitamin C are also important, and you may want to use them as well. As



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new ingredients are developed, they will be incorporated into my skincare products. 5) Moisturize—The amount of moisture required by the skin depends on the amount of oil it produces and how dry the surrounding environment is. Having enough moisture in the skin is vital to maintain an effective barrier and to ensure the integrity of the skin. Some diseases impair the barrier function and these impose increased moisturizing requirements. For the face, the Antioxidant Moisturizer will deliver moisture deep into the skin and it contains antioxidants as well. When considering moisturizers for the body, there are many fine products available. These include Theraplex, Eucerin, Cetaphil, and several others that can replace moisture without causing skin irritation. Different seasons and locations require different products so do not be surprised if you need separate products for the summer and the winter. Women may find that they need different moisturizers at different points in their hormonal cycle. Further complicating skincare is the fact that different parts of the face require different degrees of moisture because they have different densities of oil glands. The “T-zone” frequently requires drying agents, while the eyelid area an inch away needs extra moisture. My suggestion is to try a few products and then discuss your response to each with your dermatologist during an appointment set up for a cosmetic consultation. 6) Protect—All types of skin require protection but the amount of protection depends on genetics as well as internal and external conditions. Protection from the elements ranges from sunscreen and sun block to moisturizers, exfoliating peels, and medications with sun protection in them. A more complete discussion of sun protection is in Chapter 2, so I will summarize by stating that repairing damage without protection from further insults is a fruitless exercise. 68 PALM BEACH PERFECT SKIN


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Doctor’s Advice: Do not try to cram in a cosmetic consultation during a routine skin cancer or eczema evaluation. You will end up frustrating yourself as well as the physician.

Seasonal Skincare Skincare needs to take into account not only your type of skin but also where you live and the time of year. If you are lucky enough to live in San Diego, which enjoys near perfect temperature and humidity, skip this section. When I lived in Chicago, I noticed that many conditions were much worse during the cold, dry winter months and improved during the summer. Many of my patients there needed different products as each season arrived. This made me think about seasonal skincare. Thin moisturizers that were fine in Florida were not sufficient during winters in Chicago. Products that were perfect in January were too thick for the summer months. One frequent problem in dry environments is a type of dermatitis (known as xerotic dermatitis) characterized by dry, cracking skin. Treatment for this required using topical steroids and moisturizers. Other treatments such as Elidel® (Pimecrolimus) and Protopic® (Tacrolimus) may also be helpful. Simple changes can also help your skin when living in dry environments. A humidifier will replenish moisture when placed in the bedroom. Applying moisturizers to skin that is slightly damp will help the skin retain moisture with more efficiency than simply applying products at random. One myth that should be addressed is that drinking more water will increase the moisture of your skin. No matter how much you drink, you will not make a significant difference in your skin’s moisture content unless there happens to be a jar of moisturizer in the bathroom. As winter comes to an end, daylight and humidity increase. As this occurs, it is a good idea to modify your A Lifetime of Perfect Skin


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skincare. You should do so every time you add or remove an hour from your clock at daylight savings time. Increased humidity during spring and summer means that thick moisturizers may be replaced by thinner products. As mold, trees, and flowers begin to come to life, allergies may flare and the skin may experience rashes not seen at other times of the year. During the summer, sun protection is increasingly important. Warmer months may also require astringent and toners to help clear excess oils that may be produced during the summer. In summary, an ideal skincare regimen is different for different types of skin, as well as at different points in life. I recommend re-evaluating your skincare regimen annually and consulting with your dermatologist when you need assistance.



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CHAPTER

5

Maintaining Clear Skin When You Have Acne “Most people are affected by acne at some point in their lives. It is a chronic condition that requires consistent daily maintenance.”


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Over one billion dollars is spent every year on over-the-counter acne products with an estimated $600 million spent on one product touted by telemarketers alone.To put this in perspective, there was only one segment of the skincare industry that spent more than acne: the anti-wrinkle segment.

Understanding Acne Acne is caused by three factors: bacteria, hormones, and sebum (oil). Increased adhesion of the epidermal cells also contributes to acne. Recently, some studies have demonstrated that diet may play a role in acne, although the findings are preliminary and more work needs to be done in this area. Not every pimple is acne, and an occasional breakout should not prompt you to demand Accutane® from a dermatologist. Understanding the various types of acne and the treatments for each will help you to take better care of your skin. Conditions other than acne, including infections with yeast and unusual bacteria, can produce pimples without being acne. Rosacea can mimic acne, and even some dermatologists have difficulty distinguishing between the two. Occupational exposures to chemicals can also lead to conditions that stimulate acne. Only a dermatologist is trained to consider these and a variety of other factors when evaluating your skin. What is acne?

In its most simple form acne consists of blocked hair follicles, which dermatologists call a comedone. Comedones come in two varieties: open and closed. Closed comedones (whiteheads or “zits”) form when a follicle is blocked beneath the surface of the skin. Debris such as oil and dead skin cells build up under the plug. As the pore swells, breaches in the wall of the follicle occur. Material leaks into the adjacent skin and the body produces an inflammatory response. From the outside this appears as pus filled bumps. Open comedones (blackheads) are follicles blocked by dead skin cells and oil. In contrast with closed comedones, 72 PALM BEACH PERFECT SKIN


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the surface of the follicle is open to the air. Dead skin cells and other debris react with the air and gradually change color. This oxidation produces chemicals that turn dark in much the same way that an apple changes color when exposed to the air. Contrary to popular belief, blackheads are not the result of dirt. Scrubbing them in an effort to “clean” them will simply irritate the skin or make the situation worse. Acne may also have predominantly pustular or cystic sub types. Pustular and cystic acne are notable for collections of dead skin cells, bacteria, white blood cells, and oil. These forms of acne may be helped by oral antibiotics, topical antibiotics, IPL, PDT, hormone blockers, or Accutane® and its generic equivalents.

Oral Acne Treatments The most popular acne treatments are oral antibiotics, which kill the p. acnes bacteria found in many acne lesions. P. acnes lives in the skin where it metabolizes sebum (skin oil) to form inflammatory substances. Normal doses of antibiotics have been used for decades in the treatment of acne and they are known to be relatively safe and effective. New data on smaller doses of antibiotics reveal that these doses may also be effective. These low doses avoid many of the common side effects seen with traditional acne treatments. The antibiotic with the longest history of acne treatment is tetracycline. It has been used for decades and remains popular among dermatologists to this day. It may be used for months or years with minimal side effects. Lab tests should be performed on a regular basis when long-term antibiotic usage is prescribed by your dermatologist. In addition, pregnancy should be avoided when antibiotics (or most other medications) are prescribed (especially tetracycline and sulfa based products). Minocycline and doxycycline are derived from tetracycline and are also effective for the treatment of acne. Minocycline may cause blue-gray discoloration of the skin and teeth, headaches, and dizziness. If this happens, Maintaining Clear Skin When You Have Acne


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stop taking the drug immediately and notify your dermatologist. Doxycycline can increase the risk of sunburns, so use caution if you are taking this drug and plan to be outside. Oral erythromycin is one alternative to tetracycline that is considered safe for pregnant women. Sulfa-based antibiotics are used by some dermatologists, but I prefer to avoid them in most cases due to the side effects (known as erythema multiforme) that may rarely occur.

Accutane® and Its Generic Versions Accutane®, a vitamin A derivative, is a cure for severe scarring acne. Generic versions of Accutane® are available, although I tend to use the original because of my experience with this product and the extensive monitoring program that Roche has developed. Recent Congressional inquiries about Accutane® have placed this drug in the regulatory cross hairs. Although I tend to be conservative in my use of drugs, if my children develop severe scarring acne, I will prescribe Accutane® for them. My experience with this drug spans a decade, and I am impressed with the transformation that I have seen in many teens and young adults. Previously introverted people have higher self esteem when they have a better appearance. If you are considering using Accutane®, you must consider the associated risks, and discuss them with your dermatologist before beginning a course of therapy. Accutane® works by decreasing oil in the skin, adhesion of skin cells and bacteria in the follicle. It is the only drug that effectively addresses these different steps in the production of acne. We all know people with deep pockmarks and scars from acne. These permanent scars become a part of the person’s personality. Extensively scarred people may become shy and sometimes even depressed. Fortunately, a variety of dermatologic treatments are available such as laser, dermabrasion, surgery, and injections of Sculptra®, Restylane®, and a variety of other fillers. 74 PALM BEACH PERFECT SKIN


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Depression is one of the major side effects associated with acne. This can occur from time to time in any person, but the incidence of depression in those who have severe scarring acne is significant. People on Accutane® who experience depression should consult their dermatologist and psychiatrist immediately. If you have a history of depression and are considering using Accutane®, you should talk to your dermatologist and/or psychiatrist about whether this treatment is appropriate for you. It is imperative to avoid pregnancy while taking Accutane®, which causes severe birth defects. Two forms of birth control are recommended for any sexually active woman taking Accutane®. The long list of potential problems associated with Accutane®, combined with advertisements by attorneys who want to sue doctors, are the two major reasons that physicians avoid prescribing it. This is a shame because Accutane® can be a miracle drug in the right situation.

Hormonal Therapy Hormones play a key role in the development of acne, and manipulating these hormones can clear up acne. Medications such as birth control pills can trick the body into making less acne inducing male hormones, while other drugs may block the male hormones from binding to their receptors. Dermatologists have known for years that excessive male hormones may cause acne. Any parent can verify this during the teen years when hormones and acne simultaneously flare up. Recent steroid scandals in professional sports have shown a curious connection between steroid use and acne, which can be seen on players at press conferences. The diuretic spironolactone is a mild anti-androgen, and it helps some women (especially those with polycystic ovary disease) combat hormonal based acne. Some birth control pills such as Ortho TriCyclen and Yasmin also fight acne, so they are sometimes included in acne treatments.

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Topical Acne Treatments: Prescription, Over-the-Counter Products, Light Based Treatments and Daily Care for Acne Prone Skin A prescription from a dermatologist

Prescription medications available for topical application include retinoids, benzoyl peroxides, antibiotics, and various combinations of all of the above. The retinoid family consists of Retin-A®, Tazorac® (Allergan), and Differin® (Galderma). These products normalize epidermal turnover, allowing skin cells to slough off more easily. Retinoids may initially cause the skin to appear worse as debris moves through the follicle. Retinoids will also make your skin more sensitive to chemical peels, waxing, microdermabrasion, and facials. Topical antibiotics are available in a variety of formulations including: gels, creams, foams, lotions, and solutions so it should be easy to find a product that is suited to your skin type. Frequently used antibiotics include clindamycin, erythromycin, and sulfa based compounds. Benzoyl peroxides are available in prescription strengths as well as in over-thecounter versions.These products have a long history of safety and efficacy. Like antibiotics, they are available in everything from gels to creams and a variety of formulations in between. Topical prescription medications have a significant role in the treatment of acne as they can frequently deliver antibiotics to the hair follicle without systemic side effects. Non-prescription options

There are many over-the-counter products available to treat acne, and this industry is a large business. Over-the-counter acne medications typically utilize salicylic acid, benzoyl peroxide, or drying agents such as colloidal sulfur. Salicylic acid is frequently used because it can gently unclog pores. This product is available in a variety of formulations including gels and washes, as well as in different concentrations. The most common concentration is two percent. Palm Beach 76 PALM BEACH PERFECT SKIN


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Esthetic Center acne products are medicated and contain benzoyl peroxide or salicylic acid. Light based treatments

These acne treatments use lasers and intense pulsed lights (IPL) to destroy bacteria in the skin. Light energy is converted into heat which kills the bacteria and probably degrades some of the inflammatory materials in the hair follicle. Lasers and IPL may also target oil glands themselves, reducing the production of sebum. Both of these treatments may shrink the size of pores, thereby improving their appearance. These treatment alternatives for acne take about 15 minutes, and may be performed by a dermatologist, a physician’s assistant, or a nurse. Costs vary from $200 to more than $500 per treatment, so it is important to discuss this with the dermatologist before beginning treatments. Many insurance companies cover some types of treatment but not others, so if you use insurance for your dermatologic care, you should find out in advance whether your treatments will be covered.Treatments are repeated at intervals of two and four weeks.

Photodynamic Therapy (PDT) Complications of oral medications have sparked interest into non-antibiotic treatments. Photodynamic therapy combines light or laser with topical dyes to safely and effectively treat acne. The dye used for PDT is known as aminolevulinic acid. This product is painted onto the skin where it is metabolized into a substance (protoporphyrin) that reacts with light. This reaction generates reactive molecules that kill bacteria. Typical schedules for the treatment of acne include monthly treatments for about four to six months. Success rates for this treatment are impressive although more research will most likely increase them even further. For more information on photodynamic therapy, see Chapter 6. Maintaining Clear Skin When You Have Acne


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Daily Care for Acne Prone Skin “Taking care of acne prone skin is complicated and involves coordinating washing and application of many products.”

My recommendation for acne prone skin is to find products that you like and stick with them. Oily skin will typically benefit from a salicylic acid wash and salicylic acid pads used twice a day. Skin that is dry or normal can use a mild, fragrancefree cleanser once or twice daily. Products that are not clearly labeled as being “non-comedogenic” or “non-acnegenic” should be avoided, as they may worsen the very problem you are trying to treat. Products in my Palm Beach Esthetic Center Line include salicylic acid wash and salicylic acid pads, benzoyl peroxide products, and mild cleansers. Non-comedogenic moisturizers are also included for the occasional bout of skin irritation.

DR. BEER’S DAILY ANTI-ACNE REGIMEN 1. Do not squeeze or pick at acne, which can cause scarring. You will not make the lesions go away by scratching them off 2. Gently wash your face once or twice a day with an acne wash such as Neutrogena, Purpose or the Palm Beach Esthetic Center Cleanser. Avoid vigorous scrubbing 3. If your skin is oily or you have a lot of blackheads use an acne treatment pad that has salicylic acid. These are available from a variety of sources including idealskin.com 4. Use only non-comedogenic, non-acnegenic products on your skin 5. Avoid products and foods that cause your acne to flare up 6. Be patient. If your dermatologist is treating your acne with topical or oral medications or photodynamic therapy, give them some time to help your skin. If the medications cause side effects, discuss them with your dermatologist. Do not simply abandon medications, doctors, or procedures. Doing this will simply waste your time and your dermatologist’s time



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CHAPTER

6

Common Conditions That Interfere with the Perfect Skin Plan: Rosacea, Sensitive Skin, Eczema, Psoriasis “At certain times, all skin types may be prone to reactions from various internal and external sources.”


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Rosacea Rosacea is a complicated disease affecting 14 million Americans. Research shows that many of these people do not know that they have rosacea or that treatments are available for this disease. Rosacea is typically seen in people with fair skin such as those with Scotch and Irish skin types. Hormones play a strong role in the development of rosacea, and many women notice rosacea flares around their menses or with the onset of menopause. There are many different sub-types and appearances of rosacea. Most people with rosacea have pus bumps and telangiectasias.These broken capillaries are frequently the most conspicuous and embarrassing aspect of rosacea because of the perception that this disease is linked to excessive alcohol consumption.Telangectasias will worsen with repeated sun exposure, spicy foods, or alcohol consumption. Fortunately, treatments such as lasers and intense pulsed lights are widely available. Treatments for rosacea range from topical antibiotics, to topical Retin-A® to oral medications to meditation to lasers. Most dermatologists will begin treatment with a topical antibiotic such as metronidazole (Metrogel).This product is available in gel, lotion, and cream forms, and it has a long history of safety. Recently, dermatologists have begun to use another topical medication called Finacea with increasing frequency.This drug has been demonstrated to improve many forms of rosacea. Clinical trials combining Finacea with low dose oral doxycycline (Oracea) have begun to see whether this combination will be effective. An interesting new potential treatment was suggested in a recent article by Drs. Michelle Pelle GH Crawford and WD James.2 This article suggests that Retin-A®, which was considered to aggravate rosacea, can actually significantly improve many types of rosacea. Severe forms of rosacea require oral antibiotics.These may include products from the tetracycline family such as doxycyline, minocycline, or tetracycline. As previously discussed in regard to acne, each of these medications is subtly different, and 2 J Am Acad Dermatol. 2004 Oct;51(4):499-512;)



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each has its own risks and benefits. For instance, doxycyline can increase the risk of sunburn and irritate the esophagus, so it should never be taken just before going to bed. Minocycline may cause dizziness, discolor teeth, and make skin appear blue-gray. Tetracycline must be taken an hour before meals or two hours after meals. Oracea is another promising drug for which I have done some clinical trials.This is a low dose of doxycyline, and it works by a mechanism entirely different from the same medication when given at higher doses. In the low (or subantimicrobial) dose, doxycyline inhibits enzymes responsible for rosacea flare ups. More research needs to be done in this area, but this regimen may offer patients the opportunity to avoid the side effects seen with traditional doses of antibiotics. My rosacea patients who start therapy with oral and topical antibiotics are weaned from the oral medications over the span of a few months whenever possible. If you are pregnant, nursing, or planning to become pregnant, you should avoid taking many of the medications used to treat rosacea with the exception of topical erythromycin. Pulsed dye laser and intense pulsed light are great treatments for rosacea.The pulsed dye laser is better for thicker blood vessels but leaves bruising and swelling for a few days, while the intense pulsed light is better for diffuse redness with fine vessels. Future treatments for rosacea may include new low dose antibiotics, photodynamic therapy, and lasers. Fortunately, even though the etiology is not well defined, the treatments for rosacea are very good and most patients control their symptoms with quarterly visits to their dermatologist and daily medications. The large bulbous nose and other excessive oil gland proliferations associated with rosacea may do well with oral and topical antibiotics but sometimes require procedures to remove the excess oil glands. Lasers and electrocautery devices typically do quite well in these cases.

Daily Care for Rosacea Prone Skin Daily care for rosacea prone skin is quite different from daily care for normal skin types. Some types of rosacea will flare Common Conditions That Interfere with the Perfect Skin Plan


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up with application of rich emollients or astringents containing alcohol, and these should be avoided. Utilize mild cleansers such as Neutrogena Foaming face wash, glycerin based soaps, Purpose, or Palm Beach Peel® Green Tea Cleanser. Palm Beach Peel® Green Tea Serum is rich in antioxidants and many patients find that this calms their rosacea and helps them to avoid medications. Products with glycolic acid or a high percentage of alcohol should be avoided as they tend to make your skin redder. A skincare journal may help you to identify triggers that make your skin worse. If you elect to keep a skincare journal, note what foods you eat to see if there is an association with flare ups. To avoid increased prominence of dilated blood vessels, avoid anything that causes your facial skin to become red or irritated. Sun exposure is one leading cause of redness. These products contain minimal alcohol and other chemicals, which tend to irritate the skin. Variants of rosacea are common, and they are commonly misdiagnosed. One of the most widespread variants is known as perioral dermatitis. I usually see people with this condition after their primary care physician has treated them for a few months with various cortisone creams and antifungal medications. Perioral dermatitis is notable for small pimples located around the mouth. The telltale sign of perioral dermatitis is pimples that typically spare a small rim around the lips. Although there are no studies to prove this, many patients benefit when they switch from tartar control toothpaste to Tom’s of Maine or another brand that has few additives. Topical or oral antibiotics are also helpful in treating perioral dermatitis, and they are a cornerstone of my initial therapy.

Sensitive Skin Sensitive skin is easily irritated and frequently red and inflamed. It is prone to blemishes, flakiness, chafing, and cracking. Patients often complain that their inflamed skin feels uncomfortably tight and that it burns or stings. The underlying inflammation may be due to dry skin, psoriasis, sebor82 PALM BEACH PERFECT SKIN


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rheic dermatitis, contact dermatitis, eczema, or any one of a few hundred conditions that result in red irritated skin. Many people with sensitive skin have fair skin that burns easily in the sun and is irritated by products used for treating aging skin or acne (especially those containing glycolic acids or benzoyl peroxides). Allergies may make the skin sensitive. They may be triggered by a neighbor burning poison ivy or sumac, or by the chrysanthemums sitting in a vase at your dining room table. A recent patient had a rash that covered his entire body for over three years. He had seen many dermatologists and had many treatments, none of which helped for more than a few days.The extent of his skin irritation effected his quality of life as well as his health. After speaking with him and performing skin biopsies to rule out psoriasis and some types of skin lymphoma known as mycosis fungoides, I asked him how he spent his day. I inquired about which flowers and plants he had in his house. When he returned the following week, I learned that two of the plants had been irritating his skin because he was allergic to them. He got rid of the plants and the skin irritation. Other patients are irritated by newspaper ink, dyes found in leather, coins in their pockets, and wooden handles from knives in their kitchen. Treatments for sensitive skin are varied and they depend on the cause of the sensitivity. No matter what the etiology of the sensitive skin, scratching is the worst thing to do. Avoid scratching and instead apply ice or Sarna or Aveeno Itch lotions. Oatmeal can be very helpful in soothing irritated skin but do not try to put Quaker Oats into a bathtub (as one of my friends did). Rather, invest in Aveeno Oatmeal for bathing. Depending on the level of sensitivity, your dermatologist may prescribe topical steroids or drugs such as Elidel or Protopic to help calm the skin. In addition, antihistamines and oral steroids may be needed in severe cases. Skincare for sensitive skin should focus on the minimalist approach: less is more. Do not purchase products with a laundry list of ingredients that are not designed for sensitive skin. Use soaps and detergents that are fragrance free (even though some that are labeled as such are not truly fragrance free but Common Conditions That Interfere with the Perfect Skin Plan


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mask the use of a fragrance as a preservative). The fewer the ingredients, the safer you are. Keep a diary of products and your reaction to them to try to help determine a program that works for you. One misconception is that very hot water helps sensitive skin. Hot water will actually remove the natural protective oils of the skin and make the skin more prone to infection and irritation. Warm water and soap-free cleansers used once a day are the best way to minimize irritation if you have sensitive skin. A thin layer of hypoallergenic moisturizer should be applied to the skin while it is still moist. To help maintain the skin’s integrity, sleep in a room with a humidifier when you are in a dry environment.

Eczema (Atopic Dermatitis) Atopic dermatitis or eczema affects between 10 and 20 percent of the world’s population, with about 15 million people affected in the United States, according to the National Institute of Health. Many people with eczema do not even realize that they have the disease. They frequently see a nondermatologist who diagnoses them with “dermatitis” (translation: it itches and we do not know why) and treats them with whatever cream is in fashion that month. Signs and symptoms of eczema include a family or personal history of asthma or hay fever (which frequently accompanies eczema) and itching in folds of the elbows, sides of the neck, and behind the knees. An extra crease in the lower eyelid (known as a Denny-Morgan pleat) and extra lines in the palms of the hands may indicate eczema in children. Many patients with eczema notice small bumps on the sides of their upper arms and thighs. These bumps are known to dermatologists as keratosis pilaris and are actually hair follicles clogged by epidermal cells. Treatments for this condition, which is worse in dry environments, include topical moisturizers with lactic or glycolic acids (AmLactin, Lac Hydrin, Palm Beach Esthetic Center Glycolic Body lotion and cleansers from Idealskin.com). Urea based products as well as topical steroids and Retin-A® may also be helpful for treating this condition. 84 PALM BEACH PERFECT SKIN


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Eczema is a chronic, inflammatory skin disorder resulting from an immune response. Its treatment is evolving. In my practice I rely on oral antihistamines including: Claritin, Zyrtec, Zantac, and others. Drugs such as Singulair (which blocks inflammatory transmitters) are also helpful with eczema and frequently decrease the symptoms of asthma that accompany eczema. I rely on topical medications, including topical steroids and immunomodulators such as Elidel and Protopic, to control eczema in the majority of my patients. Despite recent news reports about Elidel and Protopic, I believe they are safe for use in children when used for appropriate amounts of time. Despite treatment with aggressive oral and topical medications, some people fail to improve. Many of these patients have bacterial infections which limit the skin’s ability to heal. Using antibiotics that treat Staphylococcus and Streptococcus will dramatically improve eczema flares in these patients. Patients with recurring infections will need to have their nostrils cultured because this area is a frequent harbor for bacteria. Topical antibiotics such as Bactroban are helpful in reducing the presence of bacteria for affected patients. Future treatments for atopic dermatitis will target the inflammatory cells that cause the disease and will be more targeted than present therapies. For the many patients with eczema, this will be a welcome relief.

Psoriasis Psoriasis is a chronic autoimmune disease (the body’s immune system is attacking itself) and affects approximately two percent of the American population. Highly visible, thick, red, scaly inflamed patches on the skin are the stigmata of this disease. Because of the huge physical, emotional, and financial burden imposed by this disease, it consumes a great deal of time, effort, and money. Moderate to severe psoriasis may be associated with lowered self-esteem, days lost from work, moderate to severe depression, and debilitating arthritis. Psoriasis is not contagious (despite popular beliefs to the contrary), but it definitely impacts those that help care for patients. Common Conditions That Interfere with the Perfect Skin Plan


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Patches of psoriasis may be small and limited to one part of the body (such as the elbows) or they can be large and cover the entire body. Common sites for psoriasis include the elbows, scalp, knees, buttocks, and nails. However, the disease may have varied presentations and may affect any part of the body including the tongue. Psoriasis is mediated by immune cells known as T lymphocytes. These cells communicate with other immune cells and epidermal cells, signaling them to proliferate in a very abnormal manner. Many treatments for psoriasis work by shutting down parts of the immune system. This explains why so many psoriasis drugs began as drugs used for organ transplantation. Topical steroids, which are still a mainstay of therapy, affect several parts of the immune system. Other topical treatments include vitamin D analogues such as Dovonex. Ultraviolet light treatments function by diminishing the immune cells in the skin, and are effective in treating psoriasis. Light therapy may involve ultraviolet B (either as a broad or narrow band) or ultraviolet A (which is used in conjunction with an oral medication known as psoralen to boost its effectiveness). Newer treatments involve biologic modifiers, which target specific immune cells or molecules used for cellular communication.These drugs (including Enbrel, Raptiva, Amevive, and Remicade) are exciting new therapies for psoriasis, but I do not use these drugs with great frequency as I have some concerns over the long-term safety data of several of them. Methotrexate is a chemotherapy drug that has a long history of effectiveness in treating psoriasis, although it may damage the liver and requires liver biopsies when used for long periods of time. Other medications used for the treatment of psoriasis include cyclosporine, a drug used for suppressing the immune system following organ transplantation. This medication may affect the kidneys which is a frequent limiting factor in its use. Future treatments for psoriasis may involve topically applied biologic modifiers, lasers, or medications that inhibit immune cells as they traverse the skin. 86 PALM BEACH PERFECT SKIN


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CHAPTER

7

Lasers & Light Sources: The New Waves “There will soon come a time when lasers will dominate all cosmetic practices.”


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Laser technology is improving every year, but it is still worth considering the pronouncement of one of the leading laser surgeons, who remarked that: “Lasers are not erasers.” To best understand which lasers or light sources might be helpful in obtaining perfect skin, it is worthwhile to first understand what these devices are and how they work. A laser is a high energy light beam that is extremely focused and capable of delivering high amounts of energy to a small area. These devices have revolutionized cosmetic dermatology by targeting particular colors or molecules. This ability enables dermatologists and plastic surgeons to perform light based surgery at a microscopic level. When undergoing laser treatment, it is important to have the correct device selected since different devices target different molecules. For instance, the red hemoglobin found in blood vessels is best treated by a pulsed dye laser while the brown pigment found in freckles is typically best treated by YAG laser. In order to remove sun damaged skin, lasers absorbed by water might be utilized to vaporize the damaged layers. Other light sources, such as intense pulsed lights, deliver energy capable of treating many different skin problems. However, they are not technically lasers. The popularity of lasers arises from the fact that they are able to provide a high degree of selectivity in cosmetic dermatology. Lasers of different colors (frequencies) and energy levels can treat a variety of skin problems including: unwanted hair, acne, port wine stains, scars, psoriasis, skin cancers, tattoos, blood vessels, wrinkles, laxity of the skin, freckles, scars, and stretch marks. If you are considering laser or intense pulsed light treatment, it is important to consider your goals, your budget, and your tolerance for downtime and risk. Each of these is a factor in deciding which treatment to have, and they should be discussed with your physician prior to beginning a treatment. 88 PALM BEACH PERFECT SKIN


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Lasers for Skin Rejuvenation The two main categories of lasers used for skin rejuvenation are ablative and non-ablative. Ablative techniques utilize CO2 or Erbium light sources to ablate (destroy) the outer layers of skin. These lasers target water found inside the cells of the skin and vaporize them. After this procedure, the skin replenishes itself using epidermal stem cells located deep within the hair follicle. This procedure is a controlled burn, and it has many of the risks associated with a burn, including scar formation, changes in pigment and infection. Used by the right physician on the right patient, CO2 or erbium lasers offer dramatic results. However, the complication rate has curbed enthusiasm among many cosmetic dermatologists and plastic surgeons. Non-ablative (“cold”) techniques use lasers that pass through the skin without vaporizing it.These devices heat collagen and other connective fibers to tighten the skin. Nonablative techniques carry fewer risks than ablative techniques but require several treatments. New non-ablative “miracles” pop on the market about every two years with claims that compare them to facelifts without the surgery.Typically, these devices are popular for a year and are then replaced by the next fad. When considering one of these new “miracle” devices, it is worth asking about which publications back up their claims.This will help to determine which devices merely have good marketing but little to no proof of efficacy. Future directions for laser skin rejuvenation will most likely remove skin layers in a more gentle and precise method and will tighten collagen and elastic fibers to a greater degree and with a better safety profile.

Non-Laser, Light Based Rejuvenation: Intense Pulsed Light, Radiofrequency, Photodynamic Therapy, LED, and Fraxel™ Energy can be delivered to the skin using lasers, light, sound, microwave, and many other sources. The non- laser systems Lasers & Light Sources


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described here tend to rejuvenate with minimal destruction and minimal downtime.

Intense Pulsed Light

Intense pulsed light (IPL) is exactly what it sounds like: intense light. It differs from a laser—which utilizes coherent light of a single color (wavelength)—by using light that is neither coherent nor of a single wavelength. Different wavelengths (colors) of light interact with the skin in different ways. To treat red discolorations of the skin (such as telangectasias or rosacea), light or laser absorbed by the color of hemoglobin (found within the blood vessels) is the best choice. Freckles, brown spots, and unwanted hair may all be treated with light of a different color. Skin tightening is accomplished with lights that tighten the collagen and elastic fibers by gently heating them. To accomplish specific goals, most intense pulsed lights have different hand pieces that emit different colors of light. In my practice we use a device that is so well received that there is a waiting list to get an appointment for treatment. Intense pulsed light is also helpful for treating acne and actinic keratoses, and it may be combined with Levulan for increased efficacy. IPL has also been helpful in treating age spots on the face and hands as well as for the treatment of neck discoloration that is prevalent in Florida. The next generation of IPL devices has the promise to deliver significantly better wrinkle treatments as well as treatment for unwanted hair. Typical IPL treatments are performed every three to six weeks and a series of four to six treatments is recommended. Costs vary depending on the location being treated. An average treatment for the face is approximately $500. Expect to pay more for a quality device used under the supervision of a dermatologist. Minor discomfort—comparable to a rubber



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band snapping on your skin—is typical for treatment with IPL. Following a treatment, dark spots may appear darker as they lift through the skin and migrate off. Red lesions may appear slightly bruised. Treatments for skin tightening or acne may look like a mild sunburn for a few days. Following IPL treatments, you should expect a more even tone and texture. Treatments for acne and rosacea produce gradual improvements over the span of a few months. A note of caution: The use of these devices has become a recent trend among centers run by non-dermatologists and non-plastic surgeons. The risk for problems increases when IPL lasers are used by doctors who do not possess the training to understand how to use these devices properly; so be wary of the gynecologist or allergist who wants to laser your skin.

Radiofrequency Waves

Like light, radio waves may be used to deliver energy to the skin. They have been successfully used for years to tighten the skin, and newer devices appear to have a great deal of potential. Radiofrequency devices deliver a precise amount of energy to an exact portion of the skin without injuring the layers above it. Energy is produced by a radiofrequency generator instead of a light source, and a cooling device delivers coolant to protect the skin. Thermage®, the most recent innovator in this field, uses a computer to create a “layer” of energy with a consistent shape that is delivered to a particular location on the skin. In theory, this means that the energy is precisely delivered to the intended location without interfering with the layers of skin above or below it. Thermage® is a good first step in focused energy delivery. Patients undergoing Thermage® typically describe it

Lasers & Light Sources


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as moderately painful, so oral and topical medications are often used to relieve discomfort. Some of my patients who have had this procedure experienced mixed results, ranging from no appreciable difference to significant changes. I do not know if the variation reflects differences in the experience of the physician using the device, or variations due to patient skin types and settings used.

Syneron Elos™ System Electro-optical synergy (ELOS) delivers energy by combining radiofrequency with light waves. This unique system treats unwanted hair, acne, wrinkles, and telangectasias safely. To date, they are considered “lunch time” procedures with minimal downtime and a mild amount of risk. I believe that this technology has a great deal of promise for the future, including the potential to treat cellulite effectively.

Photodynamic Therapy

Photodynamic therapy (PDT) marries intense light or laser with an energy absorbing chemical.This treatment was first used for precancerous actinic keratoses but is now used to treat acne, wrinkles, sun damage, large pores, and prominent oil glands. In photodynamic therapy, light interacts with Levulan (5 aminolevulinic acid) painted on the skin.This interaction generates reactive oxygen that kills nearby cells.The remodeling that follows replaces the damaged cells with new ones derived from follicular stem cells. PDT is in its infancy. However, I think it will be great for early skin cancers, cancers that are unrelated to the skin, and for cosmetic uses. If you plan to undergo photodynamic therapy, your skin will first be cleaned to remove dirt and oil which can impair



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penetration of the dyes. The Levulan will be painted onto your skin for anywhere from 15 minutes to 12 hours. Then a light (most commonly a specialized device known as Blu U), laser, or IPL will be used to activate the Levulan. Afterwards, the skin will look and feel as though it was burned by the sun. Since the procedure may activate cold sores, it is important to let your dermatologist know if you have a history of outbreaks so that he or she may prescribe medication to decrease the risk of a new outbreak. You should also tell your doctor if you are taking thiazide diruretics or antibiotics (such as doxycycline) that might react with light.

Perfect Skin Hint: Following treatment, mild emollients such as Palm Beach Peel® Green Tea Serum and chemical-free sun block should be used to help the skin heal.

LED Technology

Light emitting diodes (LED) use low light energy to stimulate the skin to promote renewal. This technology is exciting because it does not generate heat or damage the skin. One LED device already on the market is GentleWaves®, and this has been shown to increase collagen production and decrease the activity of enzymes (collagenase) that break collagen down. The procedure lasts only a few seconds, is painless, and has no downtime. It can be used with low dose antibiotics (which also inhibit collagenase), chemical peels, microdermabrasion, fillers, and Botox®. For these reasons, moving into the future I believe that LED will play an increasingly large role in cosmetic dermatology.



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Fractional Resurfacing Including Fraxel™

Fractional resurfacing refers to a process known as fractional photothermolysis to resurface the skin in tiny increments. The first system to do this is known as Fraxel™ and it was made by Reliant. Fraxel™ has been likened to improving the picture on a television screen one pixel at a time. Instead of removing all of the skin, this system uses microscopic laser wounds which spare intervening skin. This enables the skin to repair itself rapidly and reliably. Fraxel™ and other fractional thermolysis systems including those made by Palomar and other manufacturers are in-office treatments. They require topical anesthesia for pain control. Most patients experience a mild sunburn sensation that lasts about an hour after the treatment. The skin remains pink for five to seven days following treatment. Epidermal regeneration is rapid, beginning within 24 hours of the treatment. After a treatment, the use of sun block and antioxidants such as green tea will help to protect and nourish the regenerating skin. Many more fractional thermolysis devices are scheduled for release in the near future, and they should bring interesting improvements with each generation.

SUMMARY OF LASERS, IPL, AND LED DEVICES Device Type

Brand Names

Application

LED

GentleWaves, Omnilux, MediLite, Revitalight

Skin rejuvenation, acne

Erbium:YAG

MediDerm, FriendlyLight, Venus, Profile Contour, Profile S Contour, Burane

Skin rejuvenation, wrinkle reduction

Nd:YAG

Cooltouch, Varia, Vasculight, CT3, CoolGlide XEO, CoolGlide Vantage, Genesis Pulse, SmartEpil II, Acclaim 7000, TriStar,

Skin rejuvenation, vascular therapy, wrinkle reduction, pigmented lesions, veins, hair removal



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Device Type

Brand Names

Application

Nd:YAG

Apogee Elite, Friendly Light, Medlite C3, Lyra I, Gemini, VascuLight Elite, Lumenis One, StarLux System, Profile-ClearScan, Profile ThermaScan, Profile-S ClearScan, Profile –S ThermaScan, Profile-D ClearScan, MYDON, GentleYAG, VARIA, Coolglide Excel, Coolglide Vantage, IPL Quantum DL, Harmony, Profile Consul, Profile 1064 Module, Solo 1.0 + chiller

Pulsed Light

CoolGlide XEO, XEO SA, Genesis Plus, PhotoLight, Quadra Q4, IPL Quantum SR, VascuLight Elite, Lumenis One, Prolite II, EpiCool-Platinum HRSR, MediLux System, EsteLux System, NeoLux LuxY, StarLux System, Profile BBL, Profile-S BBL

Skin rejuvenation, vascular treatment, pigmented lesions, veins

Pulsed Dye

PhotoGenica V, TriStar, Vbeam, N-Lite V, Cbeam

Skin rejuvenation, vascular treatment

Q-Switched Ruby

Medlite C3, Q-switch: YAGk, SINON, Medlite C3

Pigmented lesions, skin rejuvenation, vascular treatment

Diode

LightSheer, Smootbeam, Fraxel™ SR, Galaxy, Polaris WR, Quantel Viridis

Skin rejuvenation, vascular treatment

Alexandrite

GentleLase, Apogee Elite

Pigmented lesions, skin rejuvenation, vascular treatment



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Combination Treatments That Work in Conjunction with Laser, LED & IPL People who want to look better never have a single issue they wish to correct. Each person requires his or her own solution, which is why cosmetic dermatology is never boring.

FREQUENTLY USED COMBINATIONS Combination Therapy

Logic

Botulinum Toxin & Fillers

Wrinkles due to muscle actions are relaxed by botulinum toxin (Reloxin®, Botox®) while fillers puff out the wrinkles caused by tissue loss. Minimal downtime and risk.

Botulinum Toxin & IPLs

IPL helps to improve the tone and texture of the outer layers of skin while botulinum toxins decrease the wrinkling. High yield with low downtime and low risk.

IPLs & Microdermabrasion

Both will help with surface texture and pigment irregularity by using different techniques so adding them together is helpful.

Microdermabrasion & Peels

Microdermabrasion and peels both are used for resurfacing and can be combined to harness some of the benefits for each. Great for skin that has a lot of sun damage.

Botox®, Fillers, IPL,& Palm Beach Peel® Products

The “blue plate special”—this combination addresses lines due to muscle movement, wrinkles from volume loss and sun damage, while providing the tools to maintain the benefits between visits to the office.

Fat Transfer & IPL

Fat transfer allows for large volume restoration while IPL restores the luster to the surface.



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CHAPTER

8

All About Botulinum Toxin “Botulinum toxin revolutionized cosmetic dermatology and dermatologic surgery in ways that few procedures before or since have done.”


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I have learned a great deal about botulinum toxins from some of the leaders in this field including Tom Rohrer, Ken Arndt, Jeff Dover, and Alastair and Jean Carruthers, as they have graciously allowed me to collaborate with them on books such as Procedures in Cosmetic Dermatology (Elsevier 2005). Botox® is the most popular cosmetic procedure for good reason. The drug has a long (approximately 20 year) history of safety and efficacy for many indications. Yet few procedures are more widely misunderstood than the injection of botulinum toxins. To that end, I will attempt to separate fact from fiction regarding botulinum toxin, and clarify what it is and what it can and cannot do.

What Is the Difference Between Botox®, Myobloc® & Refloxin®? Botox®, Reloxin® and Myobloc® are different types of Botulinum toxin. Botox® and Reloxin® are type A, while Myobloc® is a type B. They are different in how long they last, how fast they begin to work, and how much they cost. All botulinum toxins work by relaxing muscles that cause wrinkles. Botox® and Reloxin® are highly purified proteins manufactured the same way as other bio-engineered drugs. Despite what your hair dresser, nail tech, or neighbor says, there are no bacteria in a bottle of either Botox® or Reloxin®. Each product arrives as a freeze-dried powder that must be reconstituted before it can be injected. The container is sealed to make tampering impossible. Each box is also sealed, and there is a holographic image and serial number on each bottle to prevent copying of the product. Botox® and Reloxin® doses are measured in units, not



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syringes. If someone is selling you a “syringe” of Botox® or Reloxin® at a discount, you need to make sure that it is the product you think it is and inquire as to the number of units it contains. Purchasing a cheap treatment that has only a few units is no deal, and unfortunately, some marginal cosmetic injectors will dilute their products to increase their profits. Each bottle of Botox® contains 100 units and each physician dilutes these 100 units differently. Many dermatologists use 2 cc of saline to reconstitute the Botox®. Others use 4 cc, and still others use as much as 10 cc to dilute each bottle. Obviously, the bottle diluted with 10 cc will be able to be used on many more people than the bottle diluted with 2 cc, and each person that gets a “syringe” from the 10 cc bottle will only get 10 units. This results in a Botox® treatment that “does not work”. Any time you have something injected, into your body, common sense dictates that you should find out what the product is, how much of it is being injected and where it came from. Injections of Botox® or Reloxin® should only be done by a dermatologist, plastic surgeon, oculoplastic surgeon or head and neck surgeon who has the knowledge and experience to understand the anatomy of the areas being treated. These simple guidelines will ensure safe and effective treatments.

How Botulinum Toxins Work Once injected, botulinum toxin is taken up by the nerves at the site of injection. After absorption, it blocks transmission of a chemical (acetylcholine) from a particular nerve to the muscle that it controls. Without this signal, the muscle relaxes and the wrinkle it caused begins to fade. No poisoning occurs during this procedure and no infection is



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possible from the material, which is a freeze dried powder. The process is a simple interruption of the communication traffic between a nerve and the muscle it controls. Botox® and Reloxin® are not permanent because the nerves begin to sprout new connections to the muscle after a few months, and the muscle once again begins to contract. Only motor nerves and nerves that control sweating are affected leaving the sensation for the area intact. Wrinkles such as those found in frown lines, crow’s feet, forehead lines, and deep smoker’s lines are caused by muscle contractions. Relaxing the muscles involved allows the wrinkles to relax. Typical injections of Botox® or Reloxin® take about two minutes to perform. Many physicians apply a topical anesthetic prior to injection to minimize any discomfort. An average treatment of the crow’s feet involves about four small injections on each side while treatment of a frown line will involve about five injections. Injecting a forehead is more variable since some people have high foreheads and require a brow lift while others have a low forehead and want flat brows. A Botox® brow lift is performed by injecting muscles that pull the eyebrow downward, allowing opposing muscles to raise the brow. Over the past few years, this has become one of the most popular indications for Botox® injections in my office. Injections of the chin (correction of “scrotal chin”), neck bands, and of down turned mouth corners have also become quite popular. Injections to treat migraines and excessive sweating are commonly done for patients affected by these conditions. Deep “smokers lines” around the lip respond beautifully to a small amount of Botox®, and while most of my patients love the results some dislike the fact that they may not be able to use a straw or participate in other lip intensive activities. In my practice, the most commonly



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injected areas include those around the eyes, forehead, frown lines, and neck. Most of my patients combine Botox® with other fillers to maximize the correction, and I will typically inject both in the same visit. Botox® should be repeated at intervals of about three to four months and fillers need to be repeated depending on the product used. The amount of Botox® injected varies from person to person. An average woman getting treated for frown lines will have 25 units injected in each area treated. Men typically require more (up to 35 units). Foreheads and crow’s feet in women require about 25 units per area while lips typically use about four units for the upper and the same amount for the lower lip. Neck treatments are variable and use anywhere from 25 to 75. The bands of the neck on most people do well with between 25 and 50 units, although some people need more. It is important to realize that Botox® and Reloxin® treatments improve with time and each subsequent injection will, most likely, have a better effect and last for a longer amount of time. However, not every procedure will be perfect, even in the hands of the best injectors. If you have a sub-optimal treatment, discuss the situation with the physician who performed your treatment. Botox® takes at least one week to work fully and may require up to two weeks, so do not despair if your treatment has not worked after a few days. Reloxin® requires less time to work, typically only a few days. Other brands of botulinum toxin are used in Europe and some of these will be approved for use in the United States in 2006. One key difference among the various types of toxins is that they may be different strains. Although each strain works by the same mechanism, each type will perform with greater or lesser efficiency. Pricing for the various products



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is also variable, and this greatly effects how much one should expect to pay for a treatment. Botox® was approved by the FDA in 2002 for the treatment of glabella rhytids (frown lines) and in 2004 for excessive sweating. Reloxin® (Dysport in Europe) will be approved for use in early 2006. Botulinum toxin Type B is used in Europe and may be introduced in the United States. Each of these proteins is slightly different in terms of efficacy, duration, and cost, but the addition of alternative treatments will be welcome by physician and consumer alike.

After an Injection Typically, there is minimal redness and swelling for a few minutes after an injection. Rarely, there may be mild bruising, which can be worse when the areas around the eyes are injected.This may persist for up to one week. I recommend that my patients do not lie down or exercise for four hours after an injection, but this is based solely on intuition. In order to enhance the uptake of the protein into the muscles, exercise the areas treated by smiling and frowning. Complications reported after Botox® injections may include bruising, headaches and flu like symptoms. Fortunately, these are rare and self limiting. One complication that occurs in about two to three percent of patients is a droopy eyelid. This occurs when the injection interferes with muscles that hold the eyelid up. This problem lasts for about two or three weeks, and eye drops will help restore the lid to its normal position. In an effort to avoid this complication, many physicians will not treat the lines immediately above the eyebrow and prefer to stay about one-half inch above that location.



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How to Avoid Problems with Botox® The first rule of avoiding problems with cosmetic treatments is simple: If you cannot afford quality cosmetic dermatology or plastic surgery, do not have a procedure done. Do not shop for a bargain when it comes to injecting something into your body. If you are being injected with Botox®, inquire about the physician’s training and the number of units of Botox® you will receive. Do not get injected by someone who has not graduated from medical school or who is practicing in an area in which they are not trained and certified. In 2004, several patients in Florida ended up on life support after being injected with a toxin that was NOT Botox®, at an office that did NOT have a dermatologist, a plastic surgeon, or a physician who had an M.D. after his or her name. They were injected with a product designed for research but cheaper than Botox®. Although they saved some money, they ended up on life support. The bottom line: get your cosmetic treatments from a reputable physician practicing within the specialty for which he or she was trained, and do not look for bargains when seeking healthcare.

Limitations of Botox®: Where Fillers Are Needed Botulinum toxin is great for relaxing lines caused by muscles, but it does nothing to replace volume lost with aging. One example of this is the nasal labial creases (smile lines) caused by loss of support structure and volume. For patients for whom Botox® type treatments alone will not be sufficient, I combine fillers with botulinum toxins. I frequently use hyaluronic acids, collagens, Radiesse™, and fat. Each has



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it own limitations and indications. For instance, I rarely use Radiesse™ in the lips because I am concerned that it will form nodules. Thin fillers are a good choice for frown lines because thicker ones have an increased risk of complications in this area. Thus, the choice of which filler to use in combination with Botox® depends on many factors.



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CHAPTER

9

Fillers for Facial Rejuvenation “Until recently, facial rejuvenation meant a facelift with the associated risks, pain, and downtime. We are in a new era of cosmetic dermatology when safe and effective fillers offer compelling alternatives to surgery.”


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Fillers work by replacing soft tissue lost during normal aging. To help visualize how they work, imagine that a beach ball that has begun to lose air (to borrow a metaphor from Dr. Gary Monheit). Various fillers have different composition, longevity, side effects, and expenses associated with their use. Previously the high cost and low duration made the fillers approved for use in the United States limited in popularity. Newer products are more durable, cost effective, and forgiving than those from previous generations and with their advent, non-surgical alternatives to facelifts are increasing.

“The key to facial rejuvenation is the “Three ‘R’s”: renovation of the surface texture, restoration of lost volume, and relaxation of wrinkles.”

Before discussing particular fillers in detail, let us begin with a discussion of the history of fillers, how fillers work, and the origin of a wrinkle.

A Brief History of Soft Tissue Augmentation Injection of various products into wrinkles has been performed for at least a century. Early on, the treatment of choice was fat, and this was particularly popular in the early 20th century. Fat transplantation is very popular at the present time as cosmetic dermatologists and plastic surgeons improve techniques enabling patients to have consistent and durable corrections. Paraffin enjoyed a brief window of popularity until its high rate of deforming granulomas became apparent. In the 1940s and ’50s, silicone injections were used to augment soft tissue. The love affair with silicone continued for several decades until complications removed it from the market. Recently, highly purified silicone has returned as a dermal filler. Fillers seem to cycle in and 106 PALM BEACH PERFECT SKIN


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out of popularity, and this is something to consider when deciding which product is appropriate for you. The history of dermal fillers can help you avoid some of the “flavors of the month” that although popular, can be also quite dangerous. Understanding the pedigree of each filler is important since some products may have been used safely and effectively by reputable physicians in Canada and Europe prior to introduction in the United States.This foreign experience often allows American physicians to select products with known safety and efficacy. Other products are used with minimal experience within the dermatologic and plastic surgery communities.These should be avoided. Remember, although FDA approval does not guarantee that a product is appropriate for you, some products are not FDA approved for good reasons. Conversely, there are products which are not approved that are safe and effective.

How Fillers Work Soft tissue augmentation products work by replacing different materials lost over time. Imagine your skin as the beach ball previously mentioned. It gradually loses air over time. Sometimes a little puff can get back the original shape. Other times, an air hose is required. Fillers run the gamut from puff to air hose, and they can either smooth a few wrinkles or fill deep hollows and creases. Each product has its own properties, and your particular needs and skin type will determine which is appropriate for you. For deep wrinkles and creases Perlane®, Juvederm® 30, Restylane® Sub Q, and Radiesse™ might be helpful. More superficial lines might be addressed by Restylane®, Restylane® Touch, Hylaform®, Captique™, or CosmoDerm®. Sculptra® is part of a new category of fillers that stimulate the body to produce its own collagen.This tends to provide a more durable correction than many other products. Isolagen is a new product made from one’s own cells.These cells are grown in culture, and they produce a matrix that can replace collagen and other support structures. Fillers for Facial Rejuvenation


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Before discussing each product in depth, let us answer a few general questions about fillers.

How Long Do Fillers Last? Each product has its own duration. Some are short acting (such as collagen, Hylaform® and Captique™). Restylane®, Perlane®, Restylane® Touch and Juvederm® can last for between six and twelve months (although I have seen Restylane® last for as long as 16 months). Products such as Radiesse™ and Sculptra® may persist for years. Finally, fillers such as silicone and Artefill® are permanent.

What Are the Side Effects? In general, injections are associated with minimal side effects. The most frequent of these is bruising (which can last for about one week) as well as the formation of small bumps. People with a tendency to get cold sores may have a flare up when they are injected and should take antiviral medications such as Valtrex or Famvir before getting injected. Discomfort associated with the actual injection may be minimized by the use of topical anesthetic creams and dental injections to numb the areas being treated. Let your doctor know if you are allergic to sulfa before anything is applied to your skin, as some anesthetics contain sulfa related compounds. Lumps, bumps, and asymmetry may be associated with any injection, no matter how skilled the injector. If these occur with one of the non-permanent products, it will disappear rapidly or can be treated. When lumps and bumps occur with permanent fillers, they are difficult to fix and may need to be surgically removed. Injections into the lips may be associated with swelling that is impressive. This angioedema may be rapidly treated with steroids, antihistamines, and ice. I tend to see bumps most frequently in the lips because the small, corkscrew shaped glands (Fordyce glands) get filled with whatever is being injected. Cleaning out these 108 PALM BEACH PERFECT SKIN


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glands is simple and typically involves making a small nick to extract the material. Subcutaneous papules (small white bumps) may be seen in about three to five percent of people injected with Sculptra®.

How Long Is the Recovery? Recovery time following soft tissue augmentation depends upon the amount of material injected, the location of the injection, and the type of material used. Patients tend to have mild swelling after collagen, Captique™, Radiesse™, or Hylaform®, and slightly more swelling after Restylane®. When more than 2 ml of any product is used, swelling occurs due to the volume of material introduced into the skin. Bruising and swelling are important considerations when scheduling injections—although rare, the rate of complications seems to increase the closer one gets to a major even such as a wedding. If they occur, they can be covered with makeup such as Physician’s Formula Green Cover, Dermablend, or Clinique Continuous Coverage. Taking Advil, Motrin or generic ibuprofen (Costco’s brand is my favorite).

What Goes Where? “Ultimately, the choice of what product goes where is yours. The key to a good outcome is in selecting an experienced injector.”

In general, products such as Restylane®, Perlane®, Juvederm® 30, Sculptra® and Radiesse™ tend to be good choices for deep creases and areas that need long lasting correction, as well as for sculpting cheekbones. Thinner substances such as Restylane® Touch, Juvederm® 18, Captique™, Hylaform®, CosmoDerm®, and Zyderm® are appropriate for fine lines and superficial wrinkles. Thinner products are also appropriate for people with thin skin. Fillers for Facial Rejuvenation


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Before having soft tissue augmentation with any filler, discuss the duration, cost, risks, and benefits of the various options under consideration. It is also important to inquire about the experience and training of the person doing your injections.

Fillers in Detail There are two basic types of fillers: absorbable and nonabsorbable. The former are gradually broken down by the body while the latter are not. Absorbable materials include Hyaluronic Acids such as Juvederm®, Restylane®, Captique™, Hylaform®, Collagen, Sculptra®, and Radiesse™.

Hyaluronic Acids Hyaluronic acid gels have been widely used in Europe, Canada, and South America to treat facial wrinkles and for lip augmentation for about a decade. They are clear, viscous gels made from sugar molecules strung together. These molecules, normally found in skin, subcutaneous tissues, and joint fluid, are a normal part of the skin. During the manufacturing process, the chains of sugar molecules are cross-linked to provide stability. Without the cross-linkage, the molecules would rapidly disintegrate. The density of particles as well as the origin of the molecules account for the differences between various hyaluronic acids. Hyaluronic acid may be manufactured (Restylane®, Juvederm® and Captique™) or harvested from animal sources (Hylaform®). No matter what their source, hyaluronic acid is an ideal replacement for materials lost from aging skin. Restylane®

Restylane® was approved by the FDA in 2004, and its arrival sparked a renaissance in soft tissue augmentation. Before this, no safe and effective long-term correction was available. To date, more than 1.5 million treatments have been performed worldwide, and Restylane® remains twice as popular as the next leading filler. 110 PALM BEACH PERFECT SKIN


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Restylane®, Perlane® and Restylane® Touch are chemically identical gels cut up into different size particles. Perlane® has 10,000 gel particles per ml; Restylane® has 100,000 gel particles per ml; and Restylane® Touch has 200,000 gel particles per ml. In order to understand this concept, imagine a block of Jello being pushed through a screen. If the screen size is larger, the particles will be big (Perlane®). If the screen size is smaller, the size of the Jello particles will be smaller (Restylane®). No matter how you push the gel through the screen, it is the same gel when it comes out. Since all hyaluronic acid products are gels, they are malleable and allow for smoothing of the product after it is injected. Of the Restylane® family of products, only Restylane® is presently FDA approved. It is wonderful for treating nasolabial creases (smile lines), lip augmentation, correcting frown lines, and for scar revision. By injecting Restylane®—and probably other fillers—into the cheek bones, I can perform a “Restylane® facelift”, restoring the mid-face to a more youthful position. Restylane® Touch treats fine lines above the lip (frequently seen in smokers) as well as those around the crow’s feet. When used with tiny amounts of Botox®, dramatic results may be achieved. Perlane® is wonderful for replacing volume and for filling deep creases.Thicker than Perlane® is Restylane® Sub Q, which will be used for deep tissue renovation. As you can see, hyaluronic acid products are varied in their composition and indications, and selecting the correct product for your goals is part of having a great outcome— there are few bad products but lots of bad injectors. A Restylane® treatment begins with cleansing the area and, usually, application of an anesthetic cream or injection of a small amount of lidocaine or Septocaine into the gums. The Restylane® is then gently and slowly injected. Once injected, I mold or sculpt the product into the configuration that I want. Following the procedure, I usually apply ice and tell my patients to take ibuprofen. Fillers for Facial Rejuvenation


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Hylaform® and Hylaform® Plus

Hylaform® and Hylaform® Plus are hyaluronic acids made from rooster combs.They are less dense than Restylane® and tend to be softer and not as long lasting.The difference between Hylaform® and Hylaform® Plus is the size of the molecule. In addition, Hylaform® Plus is indicated for the treatment of deeper wrinkles. In clinical trials, Hylaform® Plus lasted about half as long as Restylane® for the treatment of smile lines. Approximately three months’ duration is typical for Hylaform®. Captique™

Captique™ is the same as Hylaform® except that it is manufactured rather than harvested from roosters. This allows the product to be produced with no animal proteins, limiting the potential for allergic reactions. Captique™ has the same concentration, thickness, and duration as Hylaform®. Juvederm®

Juvederm® is a homogenous hyaluronic gel (in contrast to Restylane® and Hylaform® which are particulate). It is presently approved for use in Europe but not in the United States. Three versions are available: Juvederm® 18, 24, and 30.They vary in the concentration of hyaluronic acid.They also have different indications, ranging from the treatment of deep creases, to lip augmentation, and fine line filling. Juvederm® is presently undergoing clinical trials in the United States, and I am looking forward to using it when it is available.

Collagens Collagen has been used to treat wrinkles since 1982 and it was a revolution for cosmetic dermatology at that time. Since collagen is the main ingredient of the dermal support layer, it seems logical to use it to fill wrinkles. Collagen may be harvested from cows (Zyderm® and Zyplast®), humans (CosmoDerm® and CosmoPlast®), or cultured from the person getting the injection (Isolagen). 112 PALM BEACH PERFECT SKIN


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Zyderm® and Zyplast®

Zyderm®, derived from cows, was approved for use in the United States in 1982. Corrections with this product last between three and five months. Differences in bovine collagen include different concentrations and cross linkage. Zyderm® I has a concentration of 35 mg/ ml. Zyderm® II has a concentration of 65 mg/ml. Zyplast® is cross linked for additional stability. Injection styles also vary with each material. Zyderm® I is injected into the superficial dermis. It is useful for treating fine lines such as those around the lips and eye. Zyderm® II is injected into the mid-dermis, and it is helpful for slightly deeper lines. Zyplast® is placed into the deep dermis and is intended for smile lines and deep wrinkles. Each of these contains lidocaine for anesthetic. One technical aspect of injecting collagen requires more skill than some other products is the overcorrection needed to compensate for liquid mixed into the syringes. Since these collagens are foreign proteins, allergy testing must be performed prior to their use. A collagen injection begins with cleansing of the skin. Injections are made with small needles and the wrinkles are overcorrected by anywhere from 50–100%. The degree of overcorrection depends on the material selected and site of injection. The decision of how much to overcompensate depends on the skill and experience of the injector. Human Collagen

Collagen harvested from cows is obviously foreign and one alternative is human derived collagen. Human collagen may be obtained from either cultured cells (CosmoDerm® and CosmoPlast®), from cadaveric tissue banks (AlloDerm® and Cymetra®), or grown from biopsies taken from the person undergoing the treatment (Isolagen). CosmoDerm®/CosmoPlast®

These are similar to Zyplast® and Zyderm® in concentration Fillers for Facial Rejuvenation


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and cross linkage but are derived from skin cell cultures. They contain lidocaine for anesthetic. One benefit of these products is that, unlike fillers derived from cows, they do not require allergy testing and may be injected on the day of consultation. The duration of correction with these products is between three to four months, making them fairly expensive on an annual basis. CosmoDerm® and CosmoPlast® are injected the same way as Zyderm® or Zyplast®, respectively so an injector skilled with these latter products will be able to inject the former ones with ease. AlloDerm® and Cymetra®

Neither of these has garnered a large share of the soft tissue augmentation market. This is because neither has had stellar results. AlloDerm® is human cadaveric dermis that has been freeze-dried. Originally used for the treatment of burns, it is processed in sheets and may be used for soft tissue augmentation. It requires a surgical procedure to implant, and it lasts about six to twelve months. I have never used this material. Cymetra® is a micronized, injectable form of AlloDerm®. It is reconstituted in the physician’s office with lidocaine. Like AlloDerm®, no allergy testing is required according to the manufacturer, and no known hypersensitivity to the product has been reported. Cymetra® is injected into the dermis to treat deeper rhytids and acne scars. It is also used in lip augmentation and produces a smooth result. According to physicians who use the product, results typically last for between three to six months. I do not use this product either.

Products Derived from Your Body These products utilize cells obtained from a biopsy taken from behind the ear and sent to a facility where it is cultured and expanded. In the future, stem cells will be used to accomplish this, and a more long lasting correction will be obtained.



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Isolagen

Isolagen is made with cultured autologous (derived from the person getting the material) fibroblasts to produce viable connective tissue cells, collagen, and other products needed for dermal support.The process begins with a 3 mm punch biopsy typically taken from behind the ear.The specimen is sent to the manufacturer where it is grown, and then shipped back to the physician’s office where it is injected into the skin. This product makes sense to me, and I think it has great potential for long-term correction of soft tissue defects. Clinical trials are underway that may eventually lead to FDA approval.

Volumizers: Long-Term Soft Tissue Augmentation Sculptra®

Sculptra® is the first of a new category of products that replaces lost volume by stimulating new collagen production rather than by directly filling. Initially used to treat the sunken faces of people with chronic disease, Sculptra® was quickly adopted by cosmetic dermatologists. They realized that it is an almost ideal product for long-term soft tissue augmentation. Sculptra® works well in the temples, nasolabial creases, eyelids (“tear troughs”), scars, cheekbones, and the backs of the hands. It is a sugar based molecule that has been used for decades in the form of absorbable sutures. Sculptra® has been used in Europe for a few years when physicians there realized its potential for cosmetic usage. Sculptra® is profoundly different from other fillers. For instance, there is no way to predict how much filling will occur after an injection since each person produces a different amount of collagen in response to the same injection. In contrast with most injected materials, a Sculptra® treatment is planned as several injection sessions, each spaced about a month apart.



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Another key difference is that a correction obtained with Sculptra® is durable and can last for years. Potentially, Sculptra® may restore volume to areas that have drifted south or sunken in. For instance, it lifts the cheeks upward when injected into the cheekbones. Sculptra®, like Botox®, is mixed by the physician using it, and it does not arrive ready to inject. This provides the physician using it with a variety of ways to mix it. It also means that patients must inquire about the concentration and amount they are receiving. As with Botox®, some physicians will be concerned with providing patients with optimal results while others will be concerned with maximizing profits.Thus it is imperative that you understand exactly what you are getting when you undergo treatment with Sculptra®. Very dilute Sculptra® (or worse, a product that is not Sculptra®) might save some money in the short run but will not give you the results you are looking for. It can lead to complications if the product is counterfeit. A Sculptra® session begins with a thorough skin cleansing using either alcohol or surgical scrub. Anesthetic injections are typically not required because anesthetic is added to the material during the reconstitution process. The patient is usually positioned in an upright, seated position as the material is injected into the deep dermis. Following the injection, there is minimal discomfort or bruising. One unique aspect of Sculptra® injections is the fact that immediately following the procedure, the treated area looks great. This is somewhat deceptive because as the water and lidocaine used to mix the material get absorbed, the areas begin to look as if nothing had been injected. After about the third week, the body begins to make collagen as wrinkles and creases begin to fade. With each additional treatment, the improvement becomes more noticeable. Average Sculptra® treatments require three or four injections and last for several years. When measured on a cost-per-month basis, Sculptra® may be more cost effective than treatments lasting a few months. 116 PALM BEACH PERFECT SKIN


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Facts About Fat Transfer

Autologous fat transplantation was one of the earliest techniques used to erase wrinkles. Under the right circumstances it is great. I compare it to using a broad paintbrush capable of treating large areas. Fat transfer allows the physician to use large amounts of filler, something not practical with small, pre-packaged syringes.

Semi-Permanent & Permanent Fillers “Permanent fillers hold great potential for cosmetic dermatology. In the future, they may be molded, dissolved, or even augmented after implantation.”

Fillers engineered to last for years or even decades are presently in use. Some offer safe and effective treatments that can be repeated. However, there are not many studies on the long-term consequences of most of these products, and I use them cautiously. Despite having FDA approval, I will not use some of these until I am convinced they are safe (my rule is that if I would not inject it into my family, I will not use it on my patients). I am concerned about potential migration with some of these products. I also have serious reservations about how they will look as the face continues to age. Permanent fillers presently in use or under consideration for use include Artefill® and silicone. The semi-permanent filler that is presently having the most impact in cosmetic dermatology is Radiesse™. ArteFill®

ArteFill® is made from polymethylmethacrylate microspheres (PMMA) suspended in bovine collagen. PMMA is chemically similar to acrylic. Following injection, the collagen degrades, leaving behind microspheres as a permanent filler. PMMA has been safely used in dental and orthopedic applications. Its use



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as a cosmetic device has been studied in Europe, Canada, and the United States. Artefill® is implanted into the deep dermis with a needle and then massaged and molded to the contour desired.This product is used for the treatment of acne scars and for correction of creases including the nasolabial folds. Complications include lumps, inflammation, granulomas, localized hardening, rashes, and migration of the microspheres. Although it was approved by an FDA panel, it is presently not approved for use by the FDA. I intend to observe the results obtained with this product for a while before I integrate it into my cosmetic practice. Radiesse™

Radiesse™ (formerly known as Radiance FN™) is composed of calcium hydroxylapatite (CAHA).This material is comprised of calcium and phosphate, and it forms the scaffolding for bones. It is highly biocompatible and has been safely and effectively used for years in non-cosmetic indications. It is approved by the FDA for craniofacial surgery, and it has been extensively used in the United States. Radiesse™ is injected into the deep dermis in locations such as the nasolabial creases, marionette lines, chin, and cheekbones. It is not a good product for lip augmentation or for placement in the crow’s feet, where it has a tendency to migrate and form granulomas (lumps). At the present time, several studies are being conducted to determine the duration of correction obtained with this product when it is used for cosmetic indications (we are involved with some of these). My belief is that the product is safe and effective and that it will provide correction that is durable for at least one year and perhaps longer. An injection of Radiesse™ begins by preparing the area with alcohol or surgical scrub. The patient is seated upright or slightly reclined. Anesthesia is obtained with injections similar to those made by a dentist and then a series of small injections are made. Following the procedures, some bruising or swelling may occur, but typically this is minimal. 118 PALM BEACH PERFECT SKIN


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Injectable Liquid Silicone

Perfect Skin Hint: Stay away from permanent fillers such as silicone unless you are sure that you are pleased with the way you look with fillers in your face. Start a soft tissue augmentation program with an absorbable product to see if fillers are right for you.

Silicones are man-made polymers containing silica. They may exist as solids, gels, or liquids. Liquid silicone has been used for decades to treat wrinkles and scars. Unfortunately, the purity and density have been variable and this has resulted in widely variable results. One attraction of silicone is that it is inert (when pure) and permanent so corrections by using it will last forever. Present formulations of silicone are approved for use inside the eye. They are more pure than prior products and are more suited for dermal injection. Silicone is experiencing a resurgence of popularity among cosmetic dermatologists and several respected dermatologists swear by it. I have had the privilege of authoring an article on silicone with David Duffy, M.D. and Rhoda Narins, M.D., and this experience taught me a great deal about the product. When considering silicone injections it is imperative to make certain that the dermatologist or plastic surgeon has a great deal of experience. Silicone injections, more than any other product, are exquisitely technique dependent. A silicone injection begins with a cleansing of the area to be treated.Tiny injections of silicone (known as “microdroplets”) are injected with small needles.The procedure is repeated every few weeks, gradually building up the treated area. Adatosil-5000 and Silikon-1000 are presently available for ophthalmic usage in the United States.They are being injected into the skin in an “off label” usage by many physicians with differing degrees of success. When considering treatment with silicone, remember that like diamonds, silicone is forever. Fillers for Facial Rejuvenation


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The Spectrum of Dermal Fillers Trade Names

What Is It Made From?

How Long FDA Does It Approval Last?

Restylane®, Perlane1 pt, Captique™

Biocompatible substance found in all living organisms

6–12 months depending on formulation

Restylane® is FDA approved; other forms are under investigation; Captique™ is FDA approved; Juvederm® is under investigation

None; for extensive treatments; up to 48 hours

Hylaform®, Hylaform® Plus

Biocompatible substance found in all living organisms

4–6 months depending on formulation

Hylaform® and Hylaform® Plus are FDA approved

None; for extensive treatments; up to 48 hours

Zyderm®, Zyplast®

Derived from purified bovine (cow) collagen

2–6 months

FDA approved

None

CosmoDerm®, CosmoPlast®

Derived from human collagen

2–6 months

FDA approved

None

Calcium Hydroxly Apatite

Radiesse™

Calcium Hydroxylapatite –the synthetic form of material found in bone and teeth

2–4 years

FDA approved; off-label cosmetic use

None

PolyL-Lactic Acid

Sculptra®/ NewFill®

Polylactic acid, found in suture material

12–24 months


None

Adatosil 5000,

Liquid injectable silicone

Permanent


None

Hyaluronic Acid Bioengineered

Hyaluronic Acid Animal Origin

Bovine Based Colagen

Human Based Collagen

Injectable Liquid Silicone

Silikon 1000

Post-op



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CHAPTER

10

Holding on by a Thread “The experience and skill of the dermatologist or plastic surgeon using threads for facial rejuvenation is critical to achieving a good outcome.”


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Sometimes the search for perfect skin takes unusual twists and turns. One new method for facial rejuvenation involves the placement of tiny threads under the skin. I have recently begun to use this innovative technique that literally lifts the face. Although not as invasive as a traditional face or brow lift, this procedure is more invasive than fillers or Botox®.

Contour Threadlift™ This procedure provides both lifting and shaping by using tiny “barbed” threads that resemble porcupine quills. These threads are inserted into the subcutaneous tissue using a long needle inserted into tiny incisions in the skin. As the needle is withdrawn, the barbed threads engage the skin allowing the dermasurgeon to lift, sculpt, and shape brows, cheeks, and jowls. The effects of the procedure are immediate and the risks and recovery time are minimal. Threads designed to lift the skin come in various forms, each with its own loyal following. In the United States, the leader in thread technology is the Contour Thread, developed by plastic surgeon Dr. Gregory Ruff. The Contour Thread is FDA approved, and it is used by specially trained dermatologic surgeons and plastic surgeons.

Who Is a Good Candidate? Threadlifting is appropriate for patients whose face has begun to sag but whose skin retains good tone and texture. In these individuals, threads can lift the face without the cutting required by a traditional facelift. Ideal candidates for this procedure are typically between 35 and 65.

Who Is Not a Good Candidate? A threadlift is not appropriate for patients with redundant skin that needs to be excised. Poor candidates include patients with unrealistic expectations, uncontrolled medical illnesses, those who are grossly overweight (with heavy faces) or those who have excessively thin skin. 122 PALM BEACH PERFECT SKIN


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What Areas Can Be Lifted? This procedure is appropriate for the forehead, cheeks, jowls, and neck.

How Is the Procedure Performed? Prior to inserting the threads the areas are cleansed with surgical cleanser. Some hair from the hairline must be trimmed to allow for insertion of the threads. Anesthesia is obtained with injections of local anesthetic, and patients are awake during the procedure. The procedure begins with a small incision and insertion of a long, thin needle that traverses the area to be lifted. The needle is removed away from the site of insertion and pulled through to engage the barbs. When lifting the brow, the needle is inserted in the hairline of the temple and removed at the base of the eyebrow. As the quills engage the skin, the forehead is lifted upward. Threads are inserted on each side of the face with results that are symmetric. Two to four threads may be used in each area treated. Each area requires about 15–30 minutes. Costs for the procedure vary depending on the number of threads utilized but average about $500–$700 per thread inserted. An average full face procedure may require 12 to 16 threads.

What to Expect After the Procedure Following a thread lift, patients usually experience minimal discomfort. Most are able to return to work after two days. Many patients experience minor swelling or bruising that lasts for about one week. Strenuous exercise should be avoided for at least one week following the insertion of the threads, as vigorous motion may cause the threads to move.The insertion sites must be kept clean with antibiotic ointment applied for one week after the procedure. It is best for patients to keep their heads elevated on several pillows when in bed and avoid resting on the treated areas for at least two weeks. Aspirin should be avoided for one week after a procedure. Vigorous Holding on by a Thread


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rubbing or washing of the skin may dislodge the threads and should be avoided for two weeks.

How Long Do the Results Last? The threads are plastic and theoretically last forever. However, as the body continues to age wrinkles, and creases will begin to recur. In addition, the threads will stretch over time and additional procedures will be required after several years. After a few years, additional threads can be inserted to “tweak” the original procedure. Threadlift can be used in conjunction with other minimally invasive cosmetic procedures, including Sculptra® and Restylane®, liposuction of the neck and jowls, Botox®, and radiofrequency skin tightening. At the present time, absorbable sutures are being investigated as lifting materials and I believe that this will offer an exciting opportunity for physicians and patients alike.



8/16/06 5:39:39 AM

CHAPTER

11

Tumescent Liposuction “Liposuction, when performed properly, is among the most gratifying procedures offered by cosmetic dermatologists.”


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Liposuction is the most frequently performed cosmetic surgery procedure in the United States with approximately 250,000 procedures performed each year. Despite the popularity of the procedure, there are many misconceptions regarding the safety and efficacy of liposuction, as well as what type of physician should perform the procedure.The procedure is safe when performed using local anesthetic, and it has a very high satisfaction rate.The procedure is not a substitute for weight loss and is a sculpting process that removes pockets of unwanted fat. Put simply, liposuction is the removal of fat through a vacuum. Two basic variations exist and may be classified, for lack of better terminology, as wet and dry. Wet liposuction refers to the tumescent technique of liposuction, which uses large volumes of dilute anesthetic to numb the area and minimize the risk of bleeding. Dry liposuction uses general anesthesia, and is associated with significantly greater risk than the tumescent technique. Tumescent liposuction was developed by dermatologist Jeff Klein, M.D., as a safe and effective alternative to liposuction involving general anesthesia. After the initial skepticism which accompanies any significant advance, the dermatologic surgery community embraced tumescent body sculpting. Dermatologic surgeons typically perform this procedure with mild or no sedation.To further increase patient safety, they do not typically perform liposuction in conjunction with other procedures such as a tummy tuck or facelift. One other safety feature utilized by dermatologists is the avoidance of large volume liposuction.These factors are responsible for the fantastic safety profile of tumescent liposuction when performed by dermatologic surgeons. As with any cosmetic procedure, fads come and go. As an example, a few years ago, ultrasonic liposuction was in high demand, and patients were led to believe that it would melt away excess fat. Results obtained from studies of ultrasonic liposuction demonstrated results that were no better than those obtained with traditional methods. However, the rate of complications increased. At the present time, there is a debate among physicians regarding who should perform liposuction. Although the dis126 PALM BEACH PERFECT SKIN


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cussion is veiled in concerns about patient safety, it is really about money because the safety and efficacy of the procedure performed by dermatologists has been well documented. Despite data to the contrary, plastic surgeons believe that they are the only physicians qualified to perform the procedure. Dermatologists point to the data demonstrating better safety when they do the procedure, and the fact that they pioneered the tumescent technique. I have seen great results from both dermatologists and plastic surgeons, and I believe that outcomes with liposuction depend on the particular physician rather than the specialty. When considering liposuction, it may be helpful to speak with patients who have had the procedure performed by the doctor you are considering. At the very least, you should know how many procedures a doctor performs each year and how long he or she has been doing liposuction. How Safe Is Liposuction?

This question has been asked on numerous occasions, generally following sensational stories in the media about liposuction gone awry.The most comprehensive study evaluating the safety of tumescent liposuction was performed in 2004 (Hanke, William, Cox, Sue Ellen, Kuznets, Naomi & Coleman, William P. (2004) Tumescent Liposuction Report Performance Measurement Initiative: National Survey Results3).The findings of this study demonstrate a remarkable degree of safety and satisfaction of liposuction performed by a dermatologist.The overall complication rate was found to be 0.57 percent, and most of these complications were minor. Major complications included one instance in which a patient required hospitalization. No long-term complications or deaths were reported. Eighty-four percent of the patients surveyed were very satisfied with the outcome of their liposuction. What about the stories reporting deaths from liposuction? Deaths from liposuction were reviewed in a study evaluating 19 months in Florida. During this time eight deaths due 3 Dermatologic Surgery 30 (7), 967-978. doi: 10.1111/j.1524-4725.2004.)

Tumescent Liposuction


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to liposuction occurred. The common denominator in each case was general anesthesia (Coldiron, Brett (2002) Office Surgical Incidents: 19 Months of Florida Data)4. NONE of these deaths could be attributed to liposuction performed only with local anesthetic by a dermatologist (this less sensational news was not reported). If studies show that liposuction is safe and effective, why are there so many stories in the news about procedures gone awry? Simply put, all liposuction procedures, including those done with general anesthesia, are lumped together despite the fact that they have totally different safety profiles. Making matters more confusing is the fact that there are gynecologists, anesthesiologists, and family practice doctors performing the procedure with little or no formal training.

Consider the following: • large volume liposuction has increased risks when compared with low volume • the use of general anesthetic increases the risk of the procedure • combining liposuction with other procedures such as tummy tucks or facelifts increases the amount of time for surgery and simultaneously increases the complication rates

Who Is the Ideal Candidate? The best candidates for tumescent liposuction are close to their ideal body weight (within about 20 percent) who need help getting rid of a few pockets of fat resistant to diet and exercise. Liposuction is not for patients who are greatly overweight unless he or she commits to a program of weight loss and exercise. It is a waste of time, effort, and money to remove between two to five pounds from someone who will not see any change. The ideal liposuction patient is between the ages of 20 and 65, with good skin tone. A woman or man with a good figure 4 Dermatologic Surgery 28 (8), 710-713.doi: 10.1046/j.1524-4725.2002



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and disproportionately large love handles, hips, abdomen, or other part of the body is a great candidate. Patients with one particular area of fat that does not fit with the rest of their body will usually have great results. It is also very important to have realistic expectations and a good self image before undergoing this procedure. A thorough understanding of the procedure is also important for good outcomes. A liposuction consultation begins with a discussion of the risks, benefits and limitations of the procedure. I do this at the outset of the discussion to eliminate patients looking for a quick fix. When I tell people that they can expect about a 50 percent reduction of any pockets of fat that can be grabbed, about 50 percent of the people are no longer interested. I make sure that those who remain are healthy, are free of hernias (a risk factor), are not pregnant, and do not have allergies to any of the materials I plan to use. Most importantly, I try to make sure that the patient and I have a good rapport. I see my patients frequently following the procedure, and it is mutually beneficial to have a positive relationship for the questions and concerns that arise following the procedure. During a consultation, I review the risks, benefits, and limitations of tumescent liposuction. These are also clearly spelled out in a lengthy consent form. A video of an actual procedure is available for those patients who wish to view it (Visit www.palmbeachcosmetic.com). Inevitably, the first question patients ask is;“will the fat simply move to another part of the body after liposuction?”The answer is no. However, if you consume an unhealthy and fattening diet, you will put on weight, and the new fat deposits will settle on your body. A common misconception is that liposuction predisposes you to put on fat in other areas of your body. The reality is that if you maintain a stable body weight after liposuction, your body will not develop new pockets of fat. My staff discusses fees and scheduling for the procedure. My fees are based on the number of areas treated, with a baseline fee for the first area and additional fees for each new area. Fees for liposuction depend on how many areas Tumescent Liposuction


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will be treated, the region of the country in which the procedure is performed, the type of facility utilized, and the individual physician involved. Typical procedures cost upward of $5,000 for multiple areas.

“Never shop for a bargain when you are considering liposuction; choose a doctor who has the experience, personality, and staff that is right for you.”

The Liposuction Procedure Prior to the procedure, I take photographs of the areas that will be treated. Areas to be treated are then cleansed with a surgical cleanser, and outlines of the fat pockets are marked with a marking pen. Diluted anesthetic is then slowly injected to numb the areas.This anesthetic also decreases bleeding. After 15–30 minutes small (3–4 mm) cannulae are introduced under the skin and the fat is gradually removed.The procedure is very quiet, and most patients watch a movie during the procedure. As I remove the fat, I pinch the areas to help find any remaining fat. It is not possible to visualize directly the fat since we use tiny incisions. At some point in the future, I have no doubt that cameras will be placed on the tips of the cannulae, enabling direct visualization of the procedure.The procedure is very gentle when it is performed with the tumescent technique, and patients are generally able to get up and walk following the procedure. After the procedure (which typically takes about 15 to 30 minutes per area treated) I look for areas that may need more attention. When everything looks good, my medical assistants express excess fluid and apply dressings to the sites. Some incisions are sutured while others are left open to drain the anesthetic material. There is no conclusive evidence that either of these approaches is superior.

What to Expect After Liposuction Following the procedure, patients should receive very explicit 130 PALM BEACH PERFECT SKIN


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instructions. Supplies should also be provided so you do not have to run to the store afterward. In my office, printed instructions are provided during the consultation so that patients know exactly what to expect. In addition, we provide a gym bag containing pads, tape, and a body garment designed for the treated areas. Liquid anesthetic typically drains for about 24 hours after the procedure. It is reasonable to resume most normal activities including work. Vigorous exercise may be resumed after about one week. Walking is encouraged almost immediately after the procedure. My patients are routinely surprised by their lack of discomfort. Most return to work in a day or two. It is important not to lie down constantly after any procedure, as this will increase the chance of developing blood clots. Women undergoing liposuction may have irregular periods which tend to begin earlier than normal. Results of liposuction are apparent one month after the procedure. However, the final contour requires between six and 12 months as the body gradually remodels the treated areas. Lumps and asymmetry are commonly noted for between two to 20 weeks but usually disappear after six months. I recommend massaging the treated areas to speed the healing process. Massage should be done daily for about six weeks.

Fat Transplantation The procedure was initially used to disguise spies during World War I. Its ability to mold and sculpt the face became a valuable asset during the War, and soon thereafter, it was introduced for cosmetic use. In the late 1980s, there was a resurgence of interest in the procedure as dermatologists and plastic surgeons demonstrated consistent and durable results. Fat transplantation has seen a renaissance, and many excellent practitioners in the plastic surgery and dermatologic surgery communities perform this procedure daily. Newer variations in technique have rekindled public interest for the procedure. Synthetic fat substitutes are presently available in Europe and will be introduced into the United States in the near future. Tumescent Liposuction


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Fat is one of the most widespread materials used for rejuvenation. This stems from its ability to restore significant volume loss while having no potential for allergic reaction. Fat remains my first choice for patients who need large amounts of volume for facial rejuvenation. The procedure requires several, separate procedures, each spaced between one and three months apart. Fat is harvested from the hips, buttocks, or abdomen using dilute local anesthetic. After it is washed in saline, it is transferred into syringes. Some may be frozen for later use while others are immediately injected into the face or hands. Fat transplantation has many variations. Some physicians centrifuge the fat while others remove solid cores of material. I use gentle suction to remove the fat and wash it with saline prior to either freezing or implanting.

The Fat Transfer Procedure I perform fat transplantation in the office rather than the hospital and begin with a thorough cleansing of the donor and recipient sites. The site from which fat is removed is anesthetized with dilute anesthetic, and the receiving area is then injected with standard lidocaine. Fat is removed using small cannulae especially designed for this procedure. Once cleaned, the fat is ready for injection or storage. Results depend on your overall health, whether or not you smoke, and the method of harvesting and implantation utilized. It is reasonable to expect 50 percent viability of transplanted fat after three injection sessions. Of the fat transferred, some will last for a few months or years. Variations in the viability of transferred fat are difficult to predict and vary not only with the type of procedure but also from individual to individual. Mild to moderate swelling and bruising are common after this procedure. Symptoms that should prompt a call to your physician include fever, chills, pain at the sites of treatment, shortness of breath, or lethargy. Although the risk of infection is quite low, many physicians prescribe antibiotics prophylactically.



8/16/06 5:39:42 AM

CHAPTER

12

Eradicating Veins, Unwanted Hair & Stretch Marks “New technology including lasers and radiofrequency can remove unwanted hair, stretch marks and veins.”


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Perfect skin may be complicated by unwanted hair, blood vessels, and stretch marks. Fortunately, new lasers, light sources, medications, and treatments can eradicate each of these concerns.

Leg Veins These unsightly discolorations are one of the most common causes for visits to a dermatologist. Although I have two different lasers approved to treat blood vessels, I use injections for treating most leg veins because of the superior outcomes it offers. These injections are known as sclerotherapy, and utilize salt water, glycerin, or a detergent. The materials are injected into vessels with very small needles. They cause a low-grade irritation of the vessel wall and this causes them to become inflamed and seal. No matter which agent is selected, multiple treatments are needed. Typical treatments require between three and six visits spaced about a month apart. My preferred injection solution is saline because it is safe and effective. Unfortunately, it is also uncomfortable. When Aethoxysclerol (used in Europe and Canada) is approved by the FDA, this may offer better results with less discomfort. Many dermatologists use Sotradechol, which is approved for use in the United States and is less painful. However, it can cause hyperpigmentation and allergic reactions, so therefore I use it cautiously. One common side effect with any injection is blushing. This occurs when small vessels multiply and the area looks worse. The treatment for blushing is to either continue injections or use a laser to treat the area. Either way, it is important to continue treatment in order to avoid legs that look worse than when the treatments began. If you plan to undergo sclerotherapy, you should not be pregnant or nursing or have a history of blood clots. Before



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beginning sclerotherapy, budget the time, money, and commitment to come to an office for two to ten visits. If you are taking estrogens (such as oral contraceptives), which can stimulate growth of blood vessels, sclerotherapy may not be maximally effective. Although discontinuation of birth control pills is not warranted, some extra visits may be needed to get the desired results. One additional consideration for women who take oral contraceptives and smoke is the increased risk of developing blood clots. Depending on state regulations, sclerotherapy may be performed by a physician, nurse or physician’s assistant. As with any procedure, the outcome depends on the skill of the injector so make sure that the person treating you is qualified and experienced. To date, lasers have not lived up to their promise for treating leg veins because they require such high energy that scarring, hyperpigmentation (increased pigment), and hypopigmentation (decreased pigmentation) may result from treatment. Lasers currently being developed may be able to treat vessels with a low risk of scarring. The most exciting development for erasing leg veins is the use of radiofrequency waves to seal vessel walls. Using ultrasound guidance, dermatologists, vascular surgeons, and radiologists introduce small catheters into blood vessels to heat them. Dilute lidocaine is administered as an anesthetic. Recovery time for this procedure is minimal, and my patients that have had it are thrilled with the results.

Hair Reduction Strategies “Laser hair reduction remains one of the most popular cosmetic dermatology procedures.”

Eradicating Veins, Unwanted Hair & Stretch Marks


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Since humans first stood upright they have been trying to eliminate hair on certain parts of their body while attempting to grow hair on others. Hair desirability is subject to a variety of cultural and personal preferences, but the overall demand for reducing unwanted hair is huge. According to Medical Insight, the market for laser hair removal has now exceeded $2 billion per year. Waxing accounts for another $3.5 billion dollars spent. More than 70 percent of women in the United States use one or more methods to remove unwanted hair. The most common areas for hair reduction in women are the upper lip, chin, cheeks, legs, armpits, and bikini area. Many factors, including genetics and hormones, control hair density in these areas. Some ethnic groups have increased hair density above the lip. Diseases such as polycystic ovary disease and certain medications may also stimulate excessive hair growth in distinctly unfeminine patterns. To understand how to get rid of hair, it is important to understand how hair grows. Hair growth is cyclical and begins with the growth cycle known as anagen. Anagen may last for two to seven years (the duration of this cycle determines the maximum hair length). Following anagen is catagen, a transition cycle that lasts for about 10 to 14 days5. Telogen (the resting phase) follows catagen and lasts from two to four months. According to Barnhill et al, there are about 100,000 hairs on the human head. On an average day, about 100 of these are shed (and hopefully replaced). Hair growth and hair reduction depend on the follicular stem cell, which is responsible for generating hair. This stem cell was discovered by George Cotsarelis, M.D., who I believe will eventually discover how to switch hair growth on and off at will. Shaving is the most basic method of hair removal. Shaving works no matter which part of the cycle the hair is in, and 5 Barnhill R, Textbook of Dermatopathology, p201, 1998 McGraw Hill



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unlike lasers, it does not discriminate based on the color of the hair. The major disadvantages of shaving are that it is time consuming—my sister estimates that using the laser instead of shaving saves her about four to six hours of time per month—and expensive, if you add up all the material used for blades, creams, and band aids. Presently, shaving is the most popular method of hair removal. Complications from shaving are rare except for darker skin which has a tendency to develop “shaving bumps” (keloids). Tweezing is another simple and inexpensive way to remove hair. This process may be acceptable for a small area such as the lip but it obviously is not practical for larger areas, and suggesting it for the bikini may result in bodily harm. Tweezed areas remain free of hair for a few weeks. Potential complications from tweezing are scarring and infection. Avoid tweezing nose hairs; infections in this area are dangerous and may require intravenous antibiotics. Depilatories are chemicals that break up the structure of the hair shaft, causing the hair to fall out. These creams and lotions (such as Nair) provide relief from hair for two to six weeks. The downside to these products is that they may cause skin irritation. Waxing remains one of the more popular methods of controlling hair growth. Application of either hot or cold wax to areas of unwanted hair is followed by removal of the wax and the hair attached to it. In addition to discomfort, occasional infections of the hair follicle irritation may follow this treatment. Sugaring is similar to waxing except that a sugar paste is used instead of wax. It pulls out the hair shaft at the level of the root and lasts for about one to two months. Vaniqa is a topical medication approved for the reduction of hair. This prescription drug inhibits hair growth to some degree, but it is not effective enough for most women to consider it worthwhile. It has been around for several



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years and has never really caught on. Future versions will inhibit hair growth more effectively and probably be more popular. The last hair reduction strategy we will consider is electrolysis, which uses tiny needles inserted into the root sheath of each hair. Electric current is applied to the needle, creating a chemical reaction that releases hydrogen peroxide which kills the hair follicle. This procedure is user dependent ,and the risks and results depend on the skill of the person performing the procedure. When poorly done, the procedure may result in scarring, infection, and pigment irregularity. Electrolysis is time consuming and expensive when applied to large areas, and these limitations preclude widespread use.

HAIR REMOVAL METHODS How It Works

Method

What It Treats

Duration of Results

Side Effects

Shaving

Sharp-edged cutting instrument (razor) or electric device with a vibrating or rotating cutter (shaver) slices off hair

Beards, mustaches, legs, underarms

1–3 days

Minor cuts, irritation, ingrown hairs

Tweezing

Tweezers grasp and remove hair from its root

Eyebrows, facial hair

2–8 weeks

Momentary pain, infected follicles, skin discoloration, ingrown hairs, scarring

Chemical Depilatories

Chemicals in these creams or lotions dissolve hair shafts

Some products for legs only; others for underarms, face, bikini line

Up to 2 weeks

Swollen, itchy, reddened skin

Waxing

Hot or cold wax adheres to

Legs, underarms, bikini line,

2–8 weeks

Momentary pain, irritation,



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How It Works

What It Treats

Waxing

hair, removing hair shafts from roots when peeled off

eyebrows, chin, upper lip, chest, back

Sugaring

Sugar paste adheres to hair, removing hair shafts from roots when pulled off

Eyebrows, upper lip, underarms, legs, arms, abdomen, bikini line

4–6 weeks

Stinging, redness

Mechanical Epilators

Electric device with rubber roller or coiled spring catches hair and pulls it from roots.

Less sensitive areas, especially legs

Up to 1 week

Momentary pain, irritation, missed hair

Eflornithine (Vaniqa)

Chemical in this prescription cream inhibits hair growth

Only approved for slowing down excessive facial hair growth in women

Permanent with continued use; takes 1–2 months to see initial results; can be used with other hair removal methods

Acne, irritation, ingrown hairs

Electrolysis

Electrified needle destroys follicles either by causing a chemical reaction or by burning them

Lips, chin, eyebrows, neck, ears, shoulders, bikini line, abdomen, breasts, arms, underarms

Usually permanent after several treatments, but depends on method and operator

Swelling, redness, permanent skin discoloration, pain and scarring (particularly with home kits); may interfere with pacemaker function

Laser

Laser beam targets dark pigment (melanin) in hair follicle, destroying follicle with heat

Face, upper lip, neck, chest, breasts, underarms, back, abdomen, bikini line, legs

Usually permanent after several treatments

Swelling, redness, burning pain, permanent skin discoloration

Method

Duration of Results

burns from hot wax, infected follicles, skin discoloration, scarring, allergic reactions



Side Effects

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Laser Hair Removal Laser hair removal is a safe, effective way to permanently get rid of unwanted hair. This is technically called reduction rather than removal, because it reduces rather than rids the hair in a given area. Hair reduction is used to mean an 80 percent reduction of the hair density. The principle underlying laser hair removal is known as selective thermolysis, and it was first proposed by Rox Anderson, M.D. Selective photothermolysis refers to a light (or laser) that can target one color or tissue without affecting another. When applied to hair reduction, lasers or strong lights target pigment at the base of the follicle to destroy the matrix stem cells. Present lasers work well when used on light skin and dark hair. This combination allows energy from the laser to pass through the skin and get absorbed by the dark hair. When used on dark skin, the energy gets absorbed by the skin and may cause loss of pigment or scarring without affecting the hairs. Many different lasers can be used to treat unwanted hair. They vary in their use of a cooling device (used to increase comfort and minimize complications) as well as in the wavelength used. When considering laser hair removal, learn about the type of machine being used and whether or not a cooling device is employed. Devices that chill the skin cost more than those that do not since they require continuous supply of coolant. I have used the Candela Gentlase for years, and I have been impressed with its safety, efficacy, and patient satisfaction. Recently I have begun to use the Palomar Starlux system and it has performed quite well.

“Beware of clinics and salons offering hair removal lasers by untrained staff without medical supervision. Find out if there is a true Medical Director on site and if he or she is a dermatologist or plastic surgeon.”



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When considering laser hair removal, do not shop for a “deal”—these tend to be expensive when you factor in the cost of complications. Choose the device and physician’s office that has the experience and knowledge to treat you safely and effectively. As with any cosmetic procedure, be wary of the gynecologist or family practice doctor who dabbles in procedures for which they are not trained. One trend spreading across the United States is the use of “medical directors” to supervise laser clinics. These may be retired physicians, ones who have lost licenses in other states or doctors renting out their licenses. Complications are more frequent in this scenario, and these facilities are the least prepared to handle them.

The Laser Hair Removal Procedure A light beam about the size of a dime is used to treat large areas in minimal time. Treating a face may take 10 to 15 minutes while an average sized back takes about 30 to 45 minutes. Eye goggles are worn whenever a laser is used to protect the eyes from light bouncing off metal objects. Even in the best practices, laser treatments have some risk, and it is important to understand the risks of the procedure before having it. Typical treatment sessions require four to six visits spaced about a month apart. Prior to a laser hair removal procedure, one should not pluck or tweeze hairs for about a month. Chemical depilatories and waxing should also be avoided for the same amount of time. The sensation of laser hair removal has been compared to a rubber band snapping. A hand or foot trigger is used to control the laser. Each patient has individualized settings that depend on his or her skin color, hair color, and degree of sun exposure. Cryogen (a freezing spray) may be used to maintain patient comfort.



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LASER HAIR REMOVAL IN A NUTSHELL • Light is used to heat the base of the hair follicle • Treatments require several sessions spaced about a month apart • The best candidates have light skin and dark hair • Risks include scarring, infection, and increased or decreased pigment of the skin • The procedure may be performed by a physician, nurse, physician assistant, or by a totally untrained technician, depending on state regulations • Laser hair removal centers are proliferating and many offer skincare. Most employ physicians with no dermatology or plastic surgery training

If you are considering laser hair removal, you should minimize your sun exposure for at least one month prior. This will let the skin become as light as possible allowing the laser to pass through it without being absorbed. Following the procedure, it is important to minimize sun exposure to decrease the chances of pigment changes. Sun exposure tends to be a particular problem during the summer (when people typically want the procedure). Various lasers may be used for hair reduction. One of the first was the ruby, which had a tendency to scar and was replaced by lasers using alexandrite. Alexandrite lasers have a wavelength (color) of 755 nm which is absorbed by pigment at the base of the hair follicle. Newer devices utilize intense pulsed light, and unlike lasers, they are able to treat lightly colored hair. I have been using the Starlux IPL system for hair reduction and have been impressed with the results. Complications from laser hair reduction are infrequent and occur in less than five percent of people treated. The



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most common problems are changes in pigment (either increased pigment of decreased pigment). Increased pigment may be treated with medications such as Triluma which contains cortisone, bleaching medication, and tretinoin (RetinA®). Decreased pigment usually resolves spontaneously after a few months. In rare instances, the decreased pigment is due to permanent loss of the pigment cells and this may result in permanent depigmentation. Future directions for laser hair reduction may involve the introduction of medications or pigments that are selectively absorbed by the hair stem cells. These cells could then be targeted by special lasers. As lasers get more selective, the procedure will get increasingly better.

Improving Stretch Marks Stretch marks (striae) are caused by changes of collagen and elastic fibers. These changes tend to occur following pregnancy, weight loss, or exposure of the skin to excess hormones. Although they begin as red or purple stripes, most stretch marks end up as porcelain colored streaks. Common areas for striae include the abdomen, thighs, hips, breasts, upper arms, and lower back. A great deal of time and money are invested in treating stretch marks. Treating striae while they are red or purple can be accomplished with a pulse dye laser. Once the lesions have turned beige, there is less that can be done. Microdermabrasion, Retin-A®, Intense Pulsed Light, and injections of fillers are used on older, pale stretch marks with varying degrees of success. Glycolic acid products and green tea products are also helpful in minimizing the appearance of stretch marks. Treatments presently being developed include lasers that lighten and repigment stretch marks. I anticipate that these will be the first truly effective treatment available.



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If you develop stretch marks without an obvious reason you should consult your dermatologist. Rare hormone abnormalities can cause them, and this may be detected with simple blood tests.



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CHAPTER

13

Advances in the Diagnosis & Treatment of Skin Cancers “Skin cancer is the most common cancer in the United States. When detected and treated early, the rate of cure is almost 100 percent.”



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Detection and treatment of skin cancer has been one of the most significant advances in dermatologic surgery in the past decade. Public awareness regarding skin cancer has increased due to programs sponsored by the American Academy of Dermatology and the American Society for Dermatologic Surgery. Many of my patients come in with a mole or other growth that has changed. These people notice a change in their skin, and if they are not restricted from doing so by managed care, they come in almost immediately. Unfortunately, I also encounter patients who ignore their symptoms, do not recognize that something is wrong, or are told by an ill-informed healthcare provider that watchful waiting (rather than a biopsy) is appropriate. One common denominator for delayed diagnosis or treatment of skin cancer is skincare received from non-dermatologists who tend not to recognize the cancer or, if they do, do not treat it appropriately. An average skin cancer patient comes to me with a “spot” that is changing. Sometimes it is “a bump that will not heal”, “a mole that changed color” or “a sore that is bleeding.” Other times it is a mole that is growing, bleeding, or itching (this signals that the immune system is trying to kill the lesion). For whatever reason, I see a fair number of people who bang their legs on a car door and later develop a skin cancer called keratoacanthoma at that site. When evaluating a lesion, I sometimes use a device known as a dermatoscope to better visualize it. This device provides polarized light and magnification which enables me to see deep into the skin. If the lesion is suspicious, I perform a biopsy (since these tend not to be planned, we usually run a little behind schedule). During a skin biopsy, a small piece of skin (typically smaller than a pencil eraser) is removed. The procedure uses local anesthetic and takes a few minutes. The information obtained from the biopsy allows me to decide whether skin cancer surgery is indi-



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cated. Interpreting skin biopsies is an art form that depends on the skill of the person who looks at the slide. When I am able to do so, I personally evaluate my patients’ biopsies, or I rely on another dermatopathologist to interpret the biopsy.

You should always consider several issues for any biopsy including: • Is the physician reading your biopsy a board certified dermatopathologist? Unfortunately, there is no law mandating that the person evaluating your slide must be trained to do so. • Would your dermatologist trust this same person to look at his or her own skin biopsy?

SKIN CANCER DETECTION HINT As with Voting in Chicago, go early, go often Anything that changes size, shape, color, or begins to itch should be seen by a board certified dermatologist.

Early Detection The best strategy for beating skin cancer is early detection and treatment. Several dermatology organizations, including the American Academy of Dermatology and the American Society for Dermatologic Surgery, recommend monthly skin self exams and annual visits to your dermatologist. During a self exam, you should monitor your entire body for changes in the size, shape, and color of any spots. When you are not certain about a lesion, visit your dermatologist to see if it needs a biopsy. During a skin cancer screening, do not be too bashful to undress completely. Ask your dermatologist about any spots or marks that concern you and remember



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that a biopsy is always a good way to get an answer. Many dermatologists believe that sun exposure is associated with the most common types of skin cancer. Prevailing wisdom says that most damage occurs during early years, and that sunburns are much more damaging than moderate exposure. Common skin cancers include basal cell carcinoma, squamous cell carcinoma, and melanoma. These will be discussed at length in the following section. A brief discussion is presented here for purposes of discussing treatments. Of all types of skin cancer, basal cell carcinoma is the most common. One million of these cancers will be diagnosed in the United States this year. Fortunately, they tend to grow slowly and remain localized. They frequently appear on sun-exposed parts of the body. Common appearances of a basal cell include a fleshy bump with a pearly surface, a scarlike lesion or a bump that bleeds. A more severe but less frequent type of skin cancer is known as squamous cell carcinoma. It frequently appears as a scaly, red patch or nodule that grows. Common locations include the nose, ears, hands, and scalp (especially in men who have lost their hair). Malignant melanoma is the most serious type of common skin cancer. Typically, it appears as a mole that changes size, bleeds, or begins to itch. Most melanomas are asymmetric due to cells growing at different rates. Many have an irregular border, are more than one color, and have a diameter of more than 5 mm. However, not every melanoma follows the rules, and I have seen several melanomas that had no color; I would have missed them had the patient not told me they were changing. If you have a mole that is changing or itching, ask your dermatologist to look at it. If he or she is suspicious, ask for a biopsy. Early detection and prompt intervention by a dermatologist, plastic surgeon, or general surgeon remain the best treatment for melanoma.



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The three most frequent types of skin cancer are melanoma, basal cell carcinoma and squamous cell carcinoma. Actinic keratoses are considered the precursor to squamous cell carcinoma.

Actinic Keratoses (Photo Gallery Page 1) Actinic keratoses are considered precancerous lesions which, if left untreated, can become squamous cell carcinomas. Actinic keratoses are small, scaly lesions typically found in sun exposed areas. These lesions tend to form in groups, and it is not uncommon to find 10 or 15 on the backs of the hands or top of the scalp.

Origins of Actinic Keratoses

Actinic keratoses arise most commonly in sun-exposed areas. It is believed that the ultraviolet radiation from the sun causes damage to the skin cells. Once the damaged cells proliferate, they form scaly bumps known as actinic keratoses. Under the microscope, actinic keratoses appear to be mini-squamous cell carcinomas. Once again, the importance of protecting your skin from sun damage cannot be emphasized strongly enough.

Symptoms of Actinic Keratoses

“Golfers, tennis players, equestrians, and water sports enthusiasts will frequently find these lesions on the backs of their hands.”

Actinic keratoses look and feel like scaly or rough patches. Those most commonly affected have skin types that evolved from northern latitude climates; they have fair skin, light hair,



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and light eyes. The lesions vary in color from beige to red to pink. Patients often complain of itching or irritation at the site of an actinic keratosis. Many patients tell me that after sun exposure they notice a small area that looks different or feels irritated. During a skin examination, I can sometimes discern these lesions by touch rather than sight, and my skin examination often includes touching the nose or ears to feel for rough skin. Another area that is frequently affected by actinic keratoses is the lower lip. In this area, the lip will become rough, and people typically try to use lip balm to help a spot heal. These lesions need to be treated because when they evolve into squamous cell carcinomas, they can be aggressive. The differences between actinic keratoses and squamous cell carcinomas are frequently subtle, one reason why only a board certified dermatologist with the proper training should care for your skin.

Types of Actinic Keratoses

Some actinic keratoses form thick growths and are referred to as hyperkeratotic actinic keratoses. Others may become eroded and thin. When an actinic keratosis is located on the lip, it is referred to as actinic cheilitis.

Treatment of Actinic Keratoses

Treatment of actinic keratoses is varied and changing all the time.The simplest treatment involves the application of liquid nitrogen using a sprayer or applicator at the site.There is typically some blistering which removes the damaged cells, allowing new skin to replace it. When there are numerous actinic keratoses, I frequently use a more global approach and try to fix the entire area.This involves using one of a variety of creams that causes the precancerous cells to be replaced.The most common topical treatment for actinic keratoses involves



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application of a topical chemotherapy know as 5 fluorouracil. This ingredient in found in Effudex, Carac, and a few other medications. It is applied once or twice daily for about 30 days or until the skin looks like hamburger. Although it does a great job of fixing the skin, the unsightly appearance and discomfort are problematic for most patients. In an effort to find a gentler treatment, a cream called Solaraze was developed. It uses a topical form of a non-steroidal anti-inflammatory agent that causes the precancerous cells to remodel. Aldara is another topical medication that works by stimulating the immune system to kill the precancerous cells. Other treatments include photodynamic therapy using aminolevulinic acid and a light source to kill the cells. Novel therapies for actinic keratoses are presently being developed.

Basal Cell Carcinoma Basal cell carcinoma arises in the basal (bottom) cell layer of the skin. The incidence of basal cell carcinoma skin cancers has increased over the past few decades, and the rate of incidence in women in particular has increased. The average age of onset has also steadily decreased. More women have basal cell carcinoma than in the past; yet men still outnumber them greatly.

Origins of Basal Cell Carcinoma

Chronic exposure to sunlight is a major contributing factor for all basal cell carcinomas. It is not a coincidence that they tend to occur most frequently on the face, ears, neck, scalp, shoulders, and back. Basal cell carcinoma can masquerade as acne bumps, eczema lesions, or scars. I recommend that you look at your skin on a monthly basis and notice any changes that occur. In addition, I recommend yearly total body skin exams (more frequently if there are increased risks for skin cancer).



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SYMPTOMS OF BASAL CELL CARCINOMA Some telling signs that a spot on your skin might be a basal cell carcinoma include: • Open Sore that bleeds, oozes, or crusts and remains open for three or more weeks. A persistent, non-healing sore is a very common sign of an early basal cell carcinoma. • Reddish Patch or irritated area, frequently occurring on the chest, shoulders, arms, or legs. Sometimes the patch crusts. It may also itch or hurt. At other times, it persists with no noticeable discomfort. • Shiny Bump or nodule that is pearly or translucent and is often pink, red, or white. The bump can also be tan, black, or brown, especially in dark-haired people, and can be confused with a mole. • Pink Growth with a slightly elevated rolled border and a crusted indentation in the center. As the growth slowly enlarges, tiny blood vessels may develop on the surface. • Scar-Like Area that is white, yellow, or waxy, and often has poorly defined borders. The skin itself appears shiny and taut. Although a less frequent sign, it can indicate the presence of an aggressive tumor.

Types of Basal Cell Carcinoma

Nodular Basal Cells—Under the microscope, these look like a ball of deep blue cells. Sometimes, when I look at the slides, I can see that the biopsy has removed most or all of a nodular basal cell carcinoma, and my treatment of the lesion will be much more conservative. These are relatively slow growing and non-invasive. Infiltrative Basal Cell Carcinoma—These lesions look like an advancing army under the microscope, and I treat them more aggressively, usually with Mohs surgery when they are



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on the face. They may dissect into the deeper planes of the skin and recur. Although they do not normally spread, they can do so in rare instances. Superficial Basal Cell Carcinoma—Superficial lesions are barely getting started and are small foci in the base of the epidermis. Depending on their size and location, they may be treated with excision, freezing, electrodessication, and curettage or with topical Aldara. Pigmented Basal Cell Carcinoma—These look like shiny brown or black bumps and are frequently mistaken clinically for melanoma because of their color and growth pattern. They are treated based on their pattern of growth.

Treatment of Basal Cell Carcinoma

Treatment depends on the type of basal cell carcinoma, the depth to which it has penetrated, the location of the lesion, the size of the lesion, and a variety of other factors including the experience of the dermatologist involved in the care. Most basal cell carcinomas are excised and sutured closed. If they occur on the face, I usually treat them with Mohs surgery to provide the highest cure rate possible. If the lesion is on the trunk or extremities and appears to be almost gone under the microscope, I will curette the lesion out. In rare instances, I will treat the lesions with Aldara, cryosurgery, or radiation (usually in patients who are too old to have surgery or for lesions that are superficial in nature).

Squamous Cell Carcinoma Squamous cell carcinoma is the second most common skin cancer. It affects more than 200,000 Americans each year. It arises from the middle layers of the epidermis and occurs



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on all areas of the body, including the lips and nails. It is most frequently seen in areas that have been exposed to the sun. Squamous cell carcinomas vary in their behavior, and the aggressive subtypes can metastasize with fatal outcomes.

Origins of Squamous Cell Carcinoma

Chronic exposure to sunlight is associated with increased risks of squamous cell carcinoma. As is the case with basal cells, these tumors appear most frequently on the face, neck, scalp, hands, shoulders, arms, and back. The rims of the ear and the lower lip are especially vulnerable. Burns, immune suppression (for example, the use of steroids or drugs for organ transplantation) scars, long-standing sores, radiation, and certain chemicals (such as arsenic and petroleum by-products) increase the incidence of squamous cell carcinoma.

Symptoms of Squamous Cell Carcinoma

Squamous cell carcinomas typically appear as scaly bumps that grow or bleed. They may arise among a field of precancerous growths known as actinic keratoses. Sometimes, they grow rapidly and are painful (the keratoacanthoma subtype), and sometimes they smolder.

Types of Squamous Cell Carcinoma

The least invasive lesion is called an in situ lesion. It is limited to the epidermal layers and does not breach the basement membrane so it is contained. Invasive squamous cell carcinomas vary in the degree of differentiation—the more differentiated, the more they look like normal skin cells. Less differentiation means that the cells are very unsightly under



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the microscope, and they neither appear nor behave like normal skin cells. The keratoacanthoma type of squamous cell carcinomas tends to grow rapidly (over the span of a few weeks) but tends to behave well with few incidences of spreading.

Treatment of Squamous Cell Carcinoma

Treatment of these types of skin cancers is primarily surgical and utilizes the modalities mentioned above. Other treatments are available especially for in situ lesions which may be treated with Aldara, 5 fluorouracil, photodynamic therapy, radiation, or cryotherapy. The appropriate type of treatment depends on the type of squamous cell, the location of the lesion, and the pathologic pattern.

Melanoma Melanoma is the most deadly form of skin cancer. However, if diagnosed and removed while in its early stages, it is almost 100 percent curable. Unfortunately, once it spreads it is difficult to treat and is frequently deadly. Melanoma has increased more rapidly than any other form of cancer during the past decade, with more than 51,000 new cases reported in the United States each year.

The Origin of Melanoma

The cells that give rise to melanoma are known as melanocytes. These cells produce melanin, the pigment responsible for tanning and producing the color of the skin, hair, and eyes. Typically, melanocytes occupy one out of every eight cells of the basement membrane of the skin epidermis. When they proliferate, they may produce freckles or moles. If they become malignant, they produce melanomas.



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Symptoms of Melanoma

Melanomas may have a myriad of possible appearances ranging from an irregularly colored lesion to an unremarkable beige spot. In general, a pigmented spot that is changing should be considered a potential melanoma and be evaluated by a dermatologist.

MELANOMA DETECTION USES THE “ABCD” RULE Lesions that are Asymmetric, have Border irregularity, Color variation (two or more colors), and Diameter equal to or greater than 6 mm are considered to be suspicious.

While these guidelines are valuable, there are always exceptions. I have removed several melanomas that were 4 mm or smaller within the past year. For this reason, when someone tells me that a mole is itching or changing, I usually biopsy it. Recently, I have begun to use a new type of dermatoscope that helps to identify early melanomas.

FOUR BASIC MELANOMA TYPES There are four basic types of melanoma. Each has a similar prognosis for a given depth of invasion: 1. Superficial spreading melanoma is the most common and accounts for about 70 percent of all cases. This melanoma travels along the top layer of the skin horizontally before going vertical where it has access to blood vessels. Superficial spreading melanoma is detected by its irregular borders and color. This type of melanoma may be seen anywhere on the body but is most frequently found on the trunk or backs of men, and on the legs and backs of women. 2. Lentigo maligna is usually seen in fair skinned people with lots of sun damage. A typical patient will say that a brown spot has been present for years, has been slowly growing, and that it has been ignored by other physicians. Usually, these large brown or black patches are on the face and ears. These tend to grow slowly and remain superficial for long periods of time.



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3. Acral lentiginous melanoma occurs on the hands, feet, or nails. They are difficult to diagnose and may require a nail biopsy, so there is often a delay in finding them. Most patients who have discolored nails have a history of dropping something on the nail to injure it. However, some will come in with a brown or black streak in the nail and a cuticle that is discolored. It is the cuticle discoloration that usually mandates a biopsy. Interestingly, this type of melanoma is the most common melanoma in African-Americans and Asians and the least common among Caucasians. 4. Nodular melanoma is invasive at an early stage and usually begins as a black, blue, or pink bump. This aggressive type of melanoma accounts for 10 to 15 percent of cases.

Treating Melanoma

The treatment of melanoma is surgical. In recent years, the recommended margins have changed, but the basic approach has not. If a lesion is not cured with surgery, the survival rate is poor.

Non-Surgical Treatments for Skin Cancer

“Until recently, skin cancer meant surgery. Now, creams and light sources can treat skin cancer without cutting. If you have skin cancer, you should find out if these treatments are appropriate for you.”

Today, treatment for early skin cancers may consist of applying a cream to the lesion. New treatments harness the body’s immune system to avoid cutting. The first product in this class of drugs is Aldara (3M). This drug may be used to treat precancerous growths or actinic



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keratoses, basal cell carcinomas, early squamous cell carcinomas, and in some cases, melanomas. Clinical trials are being conducted on the next generation of topical medications, and these appear to be more effective than those presently on the market. Aldara and similar compounds work by stimulating the body to produce interferon (the “on” switch for the immune system). Once this occurs, the body sees the cancer cells as foreign and tries to kill them. The immune response produces irritation and redness at the treatment sites. Some patients develop fevers as a result of the interferon made by their bodies. Aldara treatment consists of applying medication daily or every other day, for a period of several days to several months. There are no definite rules for how long to use this treatment, and each dermatologist bases his or her regimen on the appearance of the skin as it undergoes treatment. When I treat a skin cancer on the face, I follow the patient closely and may repeat the skin biopsy at the conclusion of the treatment to determine whether the cancer is gone. Another non-surgical skin cancer treatment is photodynamic therapy. This treatment uses a dye known as aminolevulinic acid to make the skin susceptible to light. The dye is painted onto the skin and allowed to incubate from several minutes to several hours. Then a bright light or laser is used to activate the molecule. Photodynamic therapy is used for early squamous cell carcinomas and basal cell carcinomas. It is not presently used for melanomas.

Surgical Approaches to Skin Cancer

“Surgical removal of skin cancers permits an evaluation of the margins of the specimen, which enables the dermatologist to determine whether the skin cancer has been completely removed.”



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Until dermatology became a surgical specialty, the treatment of skin cancer was done by plastic surgeons. However, as dermatology has become surgical in nature, most skin cancers are treated by dermatologists. Cutting out skin cancers remains the treatment of choice for the vast majority of skin cancers diagnosed in the United States.There are many different surgical techniques to treat skin cancer, and we will review the most important ones. Excisional surgery, electrodessication and curettage, and Mohs surgery are the most frequent modalities for treating cancer.

Excisional Surgery

This refers to excising (cutting out with a scalpel) a lesion, and then suturing the defect closed. A dermatopathologist or pathologist evaluates the edges of the tissue removed to determine whether the margins of the specimen are free of cancer. Excisional surgery is performed in a dermatologist’s office using local anesthesia. A typical procedure takes about 15 to 30 minutes. Common cancers treated with excisions include: basal cell carcinoma, squamous cell carcinoma, and melanoma.

Electrodessication and Curettage

This method uses a curette (a rounded metal object with a sharp edge) to scrape out the skin cancer. Electrical current is then used to burn (electrodessicate) the base of the lesion. This process is repeated three times to obtain a margin around the skin cancer. Older dermatologists believe that they can feel the difference between normal skin and skin cancer. I am not a big believer in this ability and prefer to have a pathologist examine the margins for me. I use electrodessication and curettage in my practice for very early skin cancers or skin cancers with very indolent features.



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Warning: Mohs surgery is only performed by dermatologists. Some dermatologists complete training after their residency in dermatology. Others learn the procedure during residency and take courses to supplement their training. The skill of the dermatologist performing Mohs may be quite variable. At the current time, there are no regulations as to who may or may not perform this type of surgery.

Mohs Surgery

Mohs surgery utilizes slides prepared while the patient is in the office to evaluate the margins of a skin cancer specimen. It is performed to minimize the amount of tissue removed from cosmetically important areas such as the face. By definition, the surgeon also functions as the pathologist, and it is his or her responsibility to determine when the cancer is entirely removed. Mohs uses repeated excisions to remove small pieces of cancer from the skin. Each piece is evaluated under the microscope, and the procedure continues until there is no cancer. On average, two to three stages (one stage involves removal of skin, preparation of slides from that skin, and evaluation of the slides) are required to obtained clear margins. Mohs surgery is frequently used to remove skin cancer from the face, ears, and neck. Basal cell and squamous cell carcinoma are the two most frequent skin cancers removed using Mohs surgery. Mohs is also used for skin cancer that has recurred, skin cancer with aggressive pathology or skin cancers that are bigger than 2 cm.



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MOHS SURGERY INVOLVES 5 STEPS 1. Numbing the skin with a local anesthetic 2. Surgical removal of a thin layer of skin containing the skin cancer 3. Dividing the specimen into slices that are numbered, mapped, color-coded, sectioned, and stained in the lab (this is done in the laboratory while you wait). 4. Examination of the tissue by the Mohs Surgeon under the microscope to determine if the entire tumor has been removed 5. If the tumor is removed completely, the skin defect is repaired. Steps 1 through 4 are repeated until the skin is free of cancer

Mohs evaluates nearly 100 percent of the edge of a cancer and this is responsible for the high cure rates. However, the surgery is only as good as the physician performing it, and the laboratory technician making the slides. If either is not very skilled, there may be gaps in the evaluation, which result in recurrences. Following surgery, there are several options to repair the hole left in the skin. In many cases, the dermatologic surgeon will repair the defect using skin from nearby areas (flaps) or skin from a distant area (grafts). Some dermatologists only perform the excision of the skin cancer and leave the repair work to a plastic surgeon. Finally, there are instances when no intervention provides the best outcome, known as secondary intention healing.The decision of who should repair the defect should be made by you in concert with your Mohs surgeon. I tend to repair them myself, unless the patient requests a plastic surgeon.



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“No matter how skilled the physician, a scar is inevitable.”

Each stage of Mohs requires between 30 to 50 minutes for tissue preparation, which means that a Mohs procedure may take the better part of a full day, depending on the extent of the skin cancer. If you are scheduled for this procedure, bring a sweater, some food, and a book.

In Summary Better public education and early detection and treatment have resulted in a mortality rate that has not risen as rapidly as the occurrence rate. To protect yourself and your family from skin cancer, use sunscreens appropriate for your skin type and environment, and learn the signs of melanoma. Non-surgical treatment of skin cancer is the focus of a great deal of research. Vaccines and other experimental treatments offered by the National Cancer Institute, Duke, Dana Farber, Memorial Sloan Kettering and MD Anderson are beginning to offer promise for treatment. In the near future, the treatment of these common skin cancers will most likely involve applying a cream instead of surgery. More information on clinical trials for melanoma and all cancers may be found at www.cancer.gov.



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CHAPTER

14

What the Future Holds in the Quest for Perfect Skin “Our never ending quest for perfect skin is only in its infancy. The future looks bright.”


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Feeling good about your appearance radiates confidence and improves your chances for success. We are fortunate to have so many choices available to achieve these goals, beginning with topical skincare and continuing to dermal fillers, botulinum toxins, resurfacing agents, and cosmetic surgery. The proliferation of non-surgical and minimally invasive procedures has revolutionized the field of cosmetic dermatology. Growth is being driven by scientific advancements and new technologies, as well as consumer demands for less invasive procedures with shorter healing times. New technologies developed over the next few years will enable us to achieve these goals faster, safer, and more effectively. Advances in laser technologies, filler materials, and cosmeceuticals are promising developments. Some of these treatments will stimulate the skin’s own regenerative processes to achieve a younger appearance without relying on invasive surgery. Our ongoing quest for perfect skin is fueling revolutionary treatments. Medicine in general treats all people as if they need the same exact procedures and products. Over the next few years, this will change as therapies for the skin more accurately reflect the requirements of your individual skin type and condition. The trend toward customization and combination therapies will produce perfect skin. The goal of my practice, my skincare products, and my publications is to provide scientifically sound information. I do not embrace trends because they are fashionable; nor do I advocate procedures or products where the risks outweigh the benefits. As a dermatologist, my most rewarding outcomes are happy and satisfied patients. Dermatologic surgeons strive to take our patients’ concerns very seriously. The simplest procedure can take on great significance to the person undergoing it. I hope that my enthusiasm for my profession is transmitted clearly to my staff as well as to my patients



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and colleagues. It is gratifying to me to help my patients look their best and have healthy skin. In an age of tremendous advancement in the knowledge and tools available for treating aging skin, changes in basic science, technology and products come at a rapid pace. The Internet and telemedicine allow us to share experiences and discoveries with colleagues all over the world in real time. Growth within the field of cosmetic dermatology over the past decade has been dramatic and shows no sign of slowing down. It is an evolving specialty limited only by the creativity and talent of those who practice within the specialty.

What the Future Holds in the Quest for Perfect Skin


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Glossary A Ablation—Vaporization of the most superficial layers of skin Acne—A chronic skin condition characterized by an inflammatory eruption of the skin that occurs when a hair follicle gets plugged with sebum and dead cells. Rising hormone levels stimulate oil glands, which cause clogged pores and inflammation Actinic Keratosis—(Solar keratosis) A lesion that is dry, scaly, rough, and tan or pink caused by sun exposure; considered precancerous Alkaline—A non-acid substance with a pH greater than 7 Allantoin—A botanical extract said to heal and soothe. Used in creams and topical preparations for the skin Allergen—A substance that can cause allergic reaction Allograft—A graft from the same species as the recipient; as in human skin Alopecia—A condition of hair loss Alpha Hydroxy Acid—(AHA) A group of acids derived from foods such as fruit and milk, which can improve the texture of the skin by removing layers of dead cells and encouraging cell regeneration. There are many AHAs but the most common forms are Lactic Acid, Glycolic Acid, Pyruvic Acid, Tartaric Acid, and Maleic Acid Anemia—A pathological deficiency in the oxygen-carrying component of the blood; measured in unit volume concentrations of hemoglobin, red blood cell volume, or red blood cell number Antioxidant—A substance designed to prevent a chemical reaction with oxygen, e.g. vitamins C, E, A, grape seed, and green tea



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Arnica—A botanical derived from a mountain plant with antiseptic, astringent, antimicrobial, and anti-inflammatory properties Ascorbyl Palmitate—A synthetic form of vitamin C that can reach tissue areas which ascorbic acid cannot Autologous—Occurring naturally in a certain type of tissue of the body

B Basal Cell Carcinoma—Cancer of one of the innermost cells of the deeper epidermis of the skin Benzoyl Peroxide—An antibacterial ingredient commonly used to treat acne Beta Hydroxy Acid (Salicylic Acid)—A family of acids that enhance cell renewal; found naturally in willow bark Bioactive—Substances that achieve cosmetic results by some degree of physiological action, e.g. fruit acids Bleaching Agents—Substances which slow down or block the production of melanin to lighten age spots and fade areas of hyperpigmentation, i.e. Hydroquinone, Kojic Acid, and Azelaic Acid Botanical—Refers to products derived from plants Botulinum Toxin—A naturally occurring toxin that is injected into facial muscles to paralyze them temporarily and eliminate expression lines of the face, around the eyes, and the neck Buffer—An additive that adjusts the pH balance of a skin preparation

C Capillary—The smallest type of blood vessel in the body; spider veins, for instance, are actually small capillaries commonly found on the face or legs Carbon Dioxide—Laser technology that can be used to resurface moderate to deep facial wrinkles, scars, and can also be used as a cutting tool

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Cauterize—To burn or sear abnormal tissue with a cautery or caustic instrument such as a laser Cellulite—Deposits of fat, toxins, and fluids trapped in pockets beneath the skin; more common in women Chemical Peel—A procedure in which a solution of varying strengths is applied to the entire face or to specific areas, such as around the mouth, to peel away the skin’s top layers. Common peeling agents include—Alpha Hydroxy Acid, Beta Hydroxy Acid,Trichloroacetic Acid (TCA), Jessner’s Solution, and Phenol Co Enzyme Q10—A renewal agent that stimulates natural cell energy production and regenerates vitamin E Collagen—A primary component of human skin that gives it resiliency, suppleness and tone, and breaks down with age due to muscle movement and environmental damage Comedones—Open (blackheads) and closed (whiteheads) formed when pores become clogged with oils and impurities Commissure—The area where two anatomic parts meet, as in the corner of the eye or the lips; typically referring to a fold or crease Corrugator—Muscle that is responsible for causing the glabellar (vertical) lines that form between the eyebrows Cosmeceutical—A substance that falls between the classification of a drug and a cosmetic, i.e. non-prescription over-thecounter formulations that provide pharmaceutical benefits Crust—Surface layer formed by the drying of a bodily secretion Cryosurgery—Surgery in which diseased or abnormal tissue (as a tumor or wart) is destroyed or removed by freezing (as by the use of liquid nitrogen) Cupid’s Bow—The double curve of the upper lip that resembles a curved bow with reversed curve ends

D Dermabrasion—Non-surgical resurfacing procedure in which a hand-held rotary wheel is used to remove the top layer of skin 168 PALM BEACH PERFECT SKIN


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Dermal Fillers—A category of substances that are either injected or implanted to shape and form overlying tissue Dermatitis—An inflammatory condition of the skin that is characterized by itching and redness. Three categories of dermatitis are: atopic, contact, and seborrheic Dermatopathology—Pathology of the skin Dermis—The layer of skin composed of collagen and elastin, lying beneath the epidermis (outer layer) and above the subcutaneous layers Diode—Contact laser technology that cuts and coagulates tissue

E Ecchymosis—The passage of blood from ruptured blood vessels into subcutaneous tissue, marked by a purple discoloration of the skin Echinacea—A natural substance thought to boost the immune system, and have anti-itching and soothing properties Eczema—A chronic skin condition characterized by superficial inflation in areas of the skin and scalp Edema—An excess accumulation of fluid in the connective tissue Elastin—A protein that is similar to collagen and the chief constituent of elastic fibers; also used as a surface protective agent in cosmetics to alleviate dry skin Electrolysis—Use of electric current to permanently destroy the hair’s root bulb Electromyograph—An instrument used in the diagnosis of neuromuscular disorders that produces an audio or visual record of the electrical activity of a skeletal muscle by means of an electrode inserted into the muscle or placed on the skin Electromyography—The diagnosis of neuromuscular disorders with the use of an electromyograph Epidermis—The outermost layer of the skin Glossary


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Epinephrine—A white to brownish crystalline compound isolated from the adrenal glands of certain mammals, or synthesized and used in medicine as a heart stimulant, vasoconstrictor, and bronchial relaxant Epithelialization—Regeneration of the epithelium or superficial layer of the skin, as occurs after laser resurfacing Erbium—YAG: A type of ablative laser that produces energy in a wavelength that penetrates the skin, is readily absorbed by water (a major component of tissue cells), and scatters the heat effects of the laser light Erythema—Redness of the skin, as in post laser or other resurfacing Exfoliant—A material that removes dead surface skin cells Exfoliation—To remove a layer of skin in flakes; peel Extrusion—The erosion of skin that causes an implant (chin, lip, breast, etc.) to become partially exposed

F Fibroblast—A cell from which connective tissue develops Filler—A category of substances that are either injected or implanted to shape and form overlying tissue. Common fillers include—hyaluronic acid gel, bovine collagen, the patient’s own fat or collagen from skin, and human donor collagen. Follicle—A sheath that surrounds the root of the hair Forehead Lift—Also called a brow lift; pulls up droopy brows and upper lids, and improves wrinkling and vertical and horizontal frown lines.The open forehead lift is more invasive than the endoscopic brow lift. An ‘open’ lift means that you have an incision placed at or behind the ear through which excess skin is removed and muscles are tightened. An ‘endoscopic’ lift utilizes from three to five tiny incisions (1/2 to 1 inch) placed behind the hairline to remove muscles that cause frowning and wrinkles and/or elevate your brows Free Radicals—A destructive form of oxygen generated by each cell in the body that destroys cellular membranes 170 PALM BEACH PERFECT SKIN


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Frontalis—The muscle that enables the brows to move up and down, and contributes to the formation of horizontal wrinkles of the forehead

G Glabella—The area between the eyebrows in the center of the forehead where deep vertical lines and creases often develop Graft—A piece of tissue that is totally removed from one part of the body and transferred to another area of the body, e.g. fat, cartilage, bone, and skin Glaucoma—Any of a group of eye diseases characterized by abnormally high intraocular fluid pressure, damaged optic disk, hardening of the eyeball, and partial to complete loss of vision Glycerin—Used in moisturizers due to its water binding capabilities Glycolic acid—An organic substance found naturally in unripe grapes and in the leaves of the wild grape, and produced artificially in many ways, as by the oxidation of glycol Green Tea—An antioxidant rich in catechin polyphenols, particularly epigallocatechin gallate (EGCG)

H Hematoma—A localized accumulation of blood in the skin caused by a blood vessel wall rupture; possible complication of surgery that may have to be drained Hirsuitism—Excessive growth of hair of normal or abnormal distribution Hyaluronic Acid—An acid found naturally in the body and helps retain the skin’s natural moisture Hydrocortisone—A glucocorticoid that is a derivative of cortisone and is used in the treatment of rheumatoid arthritis Hydroquinone—A bleaching agent that slows down or blocks the production of melanin to lighten age spots and to fade darkness and blotchiness Glossary


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Hyperpigmentation—Darkening of certain skin areas through overproduction of melanin Hypertrophic Scar—Thickened, raisedGlycolic acid— or red scar tissue Hypertrophy—Enlarged or thickened area Hypoallergenic—A substance with a low chance of causing allergy or skin irritation Hypopigmentation—Reduction in the pigment cells in the skin resulting in skin lightening Hypoplasia—Incomplete or arrested development of an organ or a part

I Intense Pulsed Light—Very strong light without a light beam that is one wavelength (color) or coherent. Different wavelengths of light are sent into the skin to interact with different targets in different tissues Isolagen—Autologous filler fashioned from collagen from your own skin that is grown in a laboratory, processed and liquefied for later injection into wrinkles and folds

J Jessner’s Solution—Pronounced ‘yes-nerz’; a pre-measured solution formulated with Resorcinol, Salicylic AcidGlycolic acid— and Lactic Acid with Ethanol; originally developed for the treatment of acne

K Keloid—Enlarged, permanentGlycolic acid— and thickened scar formations that are more common in darker skin types, and often run in families Keratin—A surface protective agent with film-forming and moisturizing action Kojic Acid—Natural skin-lightening agent derived from a Japanese mushroom



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L Lactic Acid—A component of the skin’s natural moisturizing factor L-ascorbic Acid—The purest form of vitamin C; when applied topically it is an antioxidant, anti-irritant and antiinflammatory Lentigo—Benign tan or brown colored lesion on the skin from sun exposure Lidocaine—A local anesthetic (trade name Xylocaine) used topically on the skin and mucous membranes Local Anesthesia—Medications (usually in the ‘caine’ family) that are injected into a surgical or treatment site to cause temporary localized numbness Lymphatic System—A network of structures, including ducts and nodes that carry lymph fluid from tissues to the bloodstream

M Malic Acid—A glycolic acid derived from apples Marionette Lines—The vertical creases that form in the corners of the mouth toward the jowls Melanin—The pigment that gives skin its color Melanocytes—An epidermal cell that produces melanin Melanoma—The deadliest form of skin cancer characterized by a black or dark brown pigmented tumor Melasma—A dark skin discoloration found on sun-exposed areas of the face Mentalis—A muscle that originates in the incisive fossa of the mandible, inserts in the skin of the chin, raises the chinGlycolic acid— and pushes up the lower lip Mexoryl®—Broad absorption UVA filter that protects human skin from the effects of repeated suberythemal doses of UVA Micro-Dermabrasion—Also referred to as ‘derma-peeling’ or ‘micro-abrasion’; a mechanical blasting of the face with

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sterile microparticles that abrade or rub off the top skin layer, then vacuum out the particles and the dead skin Microabrasion—A tooth-whitening procedure using an abrasive combined with hydrochloric acid Milia—Tiny skin cysts that resemble whiteheads Mohs Surgery—The destruction of malignant, infected or gangrenous tissue by the application of chemicals.The technique is used successfully to remove superficial skin cancers using fixation with a caustic or corrosive substance such as zinc chloride Monitored Anesthesia Care—Also called ‘local with intravenous sedation’ and ‘twilight’; medications are given intravenously to induce a state of sleepiness and relieve pain, supplemented with local anesthetic injections Musculature—The system or arrangement of muscles in a body or a body part

N Nasion—The depression at the root of the nose that indicates the junction where the forehead ends and the bridge of the nose begins Nasolabial Folds—The region of the face between the nose and the corners of the lip; commonly referred to as ‘smile lines’ Necrosis—Dead skin cells Non-Ablative Laser Resurfacing—A new class of lasers that do not produce a deep burn and provide a much less invasive treatment Non-Comedogenic—Products that are formulated not to clog the pores and cause pimples

O Occlusive—Blocked Orbicularis Oculi—The muscular body of the eyelid encircling the eye and comprising the palpebral, orbital and lacrimal muscles. The palpebral muscle functions to close the eyelid gently; the orbital muscle functions to close it more energetically, as in winking 174 PALM BEACH PERFECT SKIN


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Orbit—The cavity in the skull where the eyeballs, eye muscles, nerves, and blood vessels rest. Outpatient Surgery—Ambulatory surgery in which you are discharged later the same day from the recovery room in a hospital, office surgical suite, or clinic

P PABA—Para-aminobenzoic acid; found in the vitamin B complex; used as an ingredient in some sunscreen products Petrolatum—Used in creams, it softens and soothes skin, and forms a film to prevent moisture loss Ph—The degree of acidity or alkalinity in the solution of products Phenol—Peeling formula applied to the skin to lighten pigment, soften wrinkles, and improve scars; considered to be a deep and more invasive peel Phlebitis—Inflammation of a vein Photo Aging—Damage to the skin due to cumulative exposure to the sun, i.e. wrinkles, age spots, and fine lines Photosensitivity—Chemicals or topical ingredients that cause the skin to be reactive when exposed to sunlight, such as inflammation, hyperpigmentation, and swelling Platysma—A thin sheet of muscle located just beneath the skin of the chin and neck Platysmal Bands—Vertical strands of the muscle of the neck that can become more prominent with age and are often sutured or tightened during a face- or necklift Polyphenol—A polyhydroxy phenol; especially an antioxidant phytochemical (as chlorogenic acid) that tends to prevent or neutralize the damaging effects of free radicals Polysaccharide—Any of a class of carbohydrates, such as starch and cellulose, consisting of a number of monosaccharides joined by glycosidic bonds Pore—Small opening of the sweat glands of the skin Procerus—Muscle that works with the corrugator muscles and contributes to the vertical frown lines between the eyebrows Glossary


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Porphyryl—A light activated photosynthesizer produced by the drug ALA that reduces acne by disrupting activity in the sebaceous glands Psoriasis—A non-contagious inflammatory skin disease characterized by recurring reddish patches covered with silvery scales Ptosis—Pronounced (toe-sis); a term for drooping as in eyelids, breasts, and brows

R Resorcinol—In mild solutions, used as an antiseptic and as a soothing preparation for itchy skin Retin-A® (Tretinoin)—A topical medication derived from vitamin A that is used to treat photoaging and acne Retinol—A gentler non-prescription strength alternative to Retinoic Acid. Retinol is a fast, active form of vitamin A that works deep under the surface of the skin to visibly reduce lines and wrinkles Retinyl Palmitate—The reaction of Retinol and Palmitic Acid, which normalizes skin by significantly changing skin composition to increase collagen, DNA, skin thickness, and elasticity Rhytidectomy (Facelift)—Surgical procedure which rejuvenates the face by tightening the underlying musculature, removing excess fat deposits, and redraping sagging skin of the lower face and neck. Incisions are placed in the hairline and around the ears and/or under the chin Rosacea—A common skin condition of the face, nose, cheeks, and forehead that results in redness, pimples, dilated blood vessels, and occasional pustules

S Salicylic Acid—Used in many over-the-counter acne medications and to treat other skin disorders including dandruff, psoriasis, calluses, corns, and warts



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Saline—Salt water commonly used as a filler for breast implants and in the course of administering intravenous fluids Schirmer’s Test—A test that assesses tear production in the eyes and is helpful in treating dry eye syndrome Sclerotherapy—The injection of one of several solutions through a small needle directly into a vein to cause it to collapse Seborrheic Keratoses—A benign form of skin tumor that commonly appears after age 40. The tumors are usually painless and benign, but may become irritated and itch. They may be cosmetically disfiguring and psychologically distressing as a result Septoplasty—An operation to unblock clogged sinuses in order to improve breathing Septum—The separating wall in the nose between the left and right nasal passages Silastic Sheeting—Patches or strips of silicone that may be applied to the skin for extended time periods to soften and reduce scarring Silicone—A synthetic substance used in a gel-like form in silicone breast implants, in a liquid injectable form for facial areas and in other medical devices SPF (Sun Protection Factor)—A scale used to rate the level of protection sunscreens provide from UVB rays of the sun Spider Veins (Telangiectasias)—Dilated or broken blood vessels near the surface of the skin Squamous Cell Carcinoma—The second most common skin cancer associated with chronic exposure to the sun. It arises in the middle layers of the epidermis and occurs on all areas of the body, including the lips and nails. Aggressive subtypes can metastasize with fatal outcomes Steroids—Any of a large number of hormonal substances with similar basic chemical structure; produced mainly in the adrenal cortex and gonads Glossary


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Stratum Corneum—Surface layer of epidermis Striae—Commonly known as stretch marks; caused by thinning of the underlying skin layer (dermis); appear first as red, raised lines, and then darken and flatten gradually to form shiny whitened streaks Suction Assisted Lipectomy (Liposuction)—A procedure in which localized collections of fat are removed from the face and/or body by using a high vacuum device through small incisions Sun Block—A physical sunscreen or barrier against the sun’s UV rays; available in creams or ointments

T Tartaric Acid—A type of glycolic acid derived from apples Tazarotene—A prescription topical retinoid (vitamin A derivative) approved for treating mild to moderate plaque psoriasis and photo aging Tissue Engineering—The science of production of human tissue ex vivo, (outside of the human body) as in growing cartilage in tissue culture Titanium Dioxide—A non-chemical, common agent used in sunscreen products that works by physically blocking the sun. It may be used alone or in combination with other agents Tocopherol—Chemical name for vitamin E; an antioxidant Tretinoin—A derivative of vitamin A Trichloroacetic Acid—A colorless, deliquescent, corrosive, crystalline compound used topically as an astringent and antiseptic Tumescent—A method of anesthesia where large volumes of local anesthetic and saline solution are injected to swell the area to be operated on; commonly used in liposuction and body contouring procedures T-Zone—The area of the face that consists of the forehead, nose, and the area around the mouth, including the chin



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U Ultrasound—Application of a sound wave, a mechanical vibration of more than 16,000 cycles per second UVA—Long wavelengths emitted by the sun which take longer to produce a burn than UVB but penetrate deeper into the skin to cause sun damage UVB—Short wavelengths emitted by the sun which are known to cause premature aging and skin cancer

V Varicose Veins—Enlarged, swollen, and dilated veins just below the surface of the skin, commonly found in the legs and caused by the valves becoming filled with blood Vermillion Border—The external pinkish-to-red area of the upper and lower lips. It extends from the junction of the lips with surrounding facial skin on the exterior to the labial mucosa within the mouth

W Wavelength—The distance between a given point on one wave cycle and the corresponding point on the next successive wave cycle; the light of the wavelength produces a pure color

X Xanthoma—A fatty deposit in the skin that may appear on the lower eyelids or elsewhere

Y YAG—Abbreviation for yttrium aluminum garnet; a crystal used in some types of lasers

Z Zinc Oxide—Chemical ingredient that has soothing and astringent qualities that can block the sun’s UV rays

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Resources www.asds-net.org www.aad.org www.palmbeachcosmetic.com www.weather.com www.mohssurgery.org



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SKIN PATHOLOGY Micrograph of Atrophic, Aged Skin Here the epidermis has become thinned while the dermis has become disorganized. This skin is prone to bruising and will appear old and thin.

Normal Skin Close Up Oil Gland This is a photomicrograph that demonstrates the various layers of the skin. At the top of the skin is a basket weave layer of dead skin cells known as the stratum corneum. Beneath this lies the viable epidermal layer (purplish in this photomicrograph). Deeper still is the thick organized connective tissue composed of collagen and elastic fibers that support the outer epidermal layer.The vertically oriented white structure is a sebaceous (oil) gland that is associated with a hair follicle.

Micrograph of Actinic Keratosis This photomicrograph demonstrates disorganization of the epidermal cells with early signs of skin cancer. The damage from the sun in the dermis is evident in the discoloration of the normally pink staining collagen which is blue here.

Lines, wrinkles and folds graphically illustrated Courtesy of Medicis

RESTYLANE Lip Augmentation This woman had great shape and contour of her lips but wanted slightly increased volume. I accomplished this by injecting Restylane.

Before

After

LIP AUGMENTATION

Before Lip augmentation may also be performed for individuals with small lips. In this woman, I injected two ml of Hyaluronic acid to increase the size of her upper and lower lips and give her the definition that she desired. This improvement will last for between six and twelve months in most individuals.

After

DEEP WRINKLES

These are before and after photographs of a 28 year old woman treated with Restylane. This treatment significantly reduced her deep wrinkles and makes her look and feel her age.

Before

After

This is the same person seen from the left side. The deep wrinkles are almost completely gone in this view.

Before

After

BOTOX Crows Feet Botox used to treat the crow’s feet. This woman had overactive muscles around her eyes causing her wrinkles to worsen. This made her appear older and fatigued. By using Botox to relax these muscles a more youthful and relaxed appearance is obtained.

Before

After

Wrinkles/Frown Lines Botox used to treat the crow’s feet. This woman had overactive muscles around her eyes causing her wrinkles to worsen. This made her appear

Before

older and fatigued.

After

BOTOX/COMBINATION THERAPIES

Before

Sometimes Botox is not enough and a filler is required to smooth out wrinkles. This is the case in this instance where years of frowning have etched in lines that need to be filled. Fillers that can be used here include collagens, Hyaluronic acids and Radiesse. In this instance, Restylane was used in conjunction with Botox. (Studies show that this combination results in increased duration of correction for each.)

After

LIPOSUCTION

Before

After

Liposuction is a safe and effective method of removing unwanted fat. In this series of photographs, the significant improvement obtained in this woman’s neck and chin was accomplished in my office in about one hour.

Before

After

Other areas that I treat with liposuction include the waist, hips, thighs and arms. Men and women are treated although women tend to be treated more frequently.These photographs show results that I achieved in a middle aged woman that wanted to lose some of the fat from her abdomen. She was not overweight and needed to be sculpted—an ideal patient for liposuction.

SCLEROTHERAPY

Before

After

Sclerotherapy is one of the most popular cosmetic dermatology procedures performed in the United States.These photographs show how injections of saline can safely and effectively eradicate the tiny vessels that appear on the legs.This procedure was performed about four times, spaced one month apart to obtain this result.

Index Accutane®, 7, 72-5 Acne, 7, 15, 17, 29, 30, 33, 53-4, 56-7, 64-5, 67, 71-8, 81, 83, 88, 90-2, 94, 114, 118, 139, 151, 166, 167, 172, 176, 188 cystic, 73 pustular, 73 Actinic keratoses, 11, 23, 32, 40, 90, 92, 149-51, 154, 181 Age spots, 24, 90, 167, 171, 175 Aging skin (See skin.) Aldara, 151, 153, 155, 157-58 AlloDerm®, 9, 113-14 American Academy of Dermatology, 29, 147, 184 Amevive, 86 Aminolevulinic acid, 77, 92, 151, 158 Anagen, 136 Antibiotics, 63, 73-4, 76, 80-2, 85, 93, 132, 137 Antioxidants, 6, 30, 47-49, 52, 54-5, 67-8, 82, 94, 185, 187 Artefill®, 117 Atopic dermatitis, 7, 84-5 Autologous fat, 28, 117 Avage®, 30, 32, 47, 60 Aveeno, 83 Basal cell carcinoma, 11, 14, 24, 149, 151-53, 158-59, 167 Benzoyl peroxides, 76 Blackheads, 72, 73, 78, 168 Botox®, 8, 28, 33, 62, 98-104, Botulinum toxin, 8, 16-7, 28, 31, 33, 96-9, 101, 103, 164, 167, 181 CaptiqueTM, 9, 16-7, 25, 30, 61, 107-10, 112, 120, 181

Carbon dioxide (CO2) laser, 89 Carruthers, Alastair, 98 Carruthers, Jean, 98 Cetaphil, 68 Claritin, 85, 98 Collagen, 9, 15-7, 21, 22, 25-7, 33, 37, 49, 53-4, 56, 61, 89, 90, 93, 103, 107-110, 112-13, 115-17, 120, 143, 168-70, 172, 176, 187 Collagenase, 93 Comedones, 72, 168 Contour ThreadliftTM, 10, 122 Cosmeceuticals, 6, 13, 24, 31, 46-9, 54-5, 164, 168 Cosmetic Boot Camp, 14 CosmoDerm®, 9, 107, 109, 112-14, 120 CosmoPlast®, 9, 112-14, 120 Curettage, 12, 153, 159 Cymetra®, 9, 113-14 Dermasurgeon, 15, 122 Dermatopathology, 14-5, 20, 22, 136, 147, 159, 169, 184 Dermal fillers, 10, 106-7, 120, 164, 169 Dermis, 23-5, 27, 33, 37, 47-8, 55, 113-14, 116, 118, 169, 178 Differin®, 76 Doxycycline, 73, 74, 80-1, 93 Eczema, 7, 17, 67, 69, 79, 83-5, 151, 169 Electrodessication, 12, 153, 159 Electrolysis, 138, 139, 169 Electro-optical synergy (ELOS), 8, 92 Enbrel, 86 Index


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Epidermis, 21-25, 27, 47, 55, 153, 155, 167, 169, 177-78 Erythromycin, 74, 76, 81 Eucerin, 46, 68 Fat, 15, 21, 25-8, 30, 33, 61, 96, 103, 106, 117, 126, 128-32, 154, 168, 170-71, 176-79 Fat transfer, 16-7, 33, 61, 96, 117, 132 Fitzpatrick Classification, 36, 62-3, 65 FraxelTM, 8, 16, 25, 89, 94-5 Gentlewaves®, 93-4 Glycolic acid, 6, 18, 24, 33, 46-8, 51, 54, 64, 82-4, 143, 166, 171, 173, 178, 185, 190 Green tea, 30, 32-3, 46-7, 49-50, 52-4, 60, 66-8, 82, 93-4, 143, 166, 171, 185-191 Hair growth, 33, 57, 136-39 reduction, 11, 135-36, 138, 140, 142-43 removal, 11, 26, 57, 136-42 Hormonal therapy, 7, 75 Hylaform®, 9, 16-7, 25, 30, 61, 107-10, 112, 120 Hylaform® Plus, 9, 16, 25, 61, 112, 120 Hyaluronic acid, 9, 15, 17, 27, 33, 52, 56, 103, 110-12, 120, 17071, 185-87 Hypopigmentation, 135, 172 Ideal Skin, 1, 6, 62, 65-6, 70 Intense pulsed light (IPL), 8, 28, 30, 50, 73, 77, 90-2, 94-6, 130, 134, 140, 142 Isolagen, 9, 16, 25, 66, 107, 112-13, 115, 170, 172 Juvederm®, 9, 16-7, 25, 28, 30, 61, 107-10, 112, 120 Levulan, 90, 93

Liposuction, 10, 15, 17, 30, 54, 124-31, 178, 185-86 Liquid silicones, 10, 119 Melanoma, 12, 14, 25, 37, 148-49, 153, 155-59, 162, 173, 184 Melasma, 173 Mexoryl, 40-1, 173 Microdermabrasion, 24, 30, 51, 67, 76, 93, 96, 143, 186, 190 Minocycline, 73, 80-1 Mohs surgery, 12, 152-53, 159-61, 174, 180, 184 Monheit, Gary, 106 Narins, Rhoda, 119 N-lite, 95 Non-ablative lasers, 89, 174 P. Acnes, 73 Palm Beach Peel®, 6, 18, 30, 33, 50-4, 64, 66-7, 82, 93, 185-91 Peels, 15, 17-8, 24, 27, 29-30, 33-4, 39, 48, 51, 55, 60-1, 67-8, 76, 93, 96 Perioral dermatitis, 82 Perlane®, 16, 25, 28, 30, 61, 107-9, 111, 120 Photothermolysis, 93, 140 Photodynamic therapy, 7, 8, 61, 77, 78, 81, 89, 92, 151, 155, 158 Pigment, 17, 20, 23-4, 31, 33, 36, 54-5, 62, 65, 88-9, 94-6, 134-35, 138-40, 142-43, 153, 155-56, 167, 172-73, 175, 186 Psoriasis, 7, 17, 54, 56, 79, 83, 85-6, 88, 176, 178 RadiesseTM, 10, 16-7, 25, 33, 103, 107-10, 117-18, 120 Radiofrequency, 8, 16, 27, 29, 33, 89, 91-2, 124, 133, 135 Raptiva, 86 Reloxin®, 8, 16, 28, 30, 33, 61, 96, 98-102 Remicade, 86, 153



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Restylane®, 9, 16-7, 25-6, 28, 30, 61-2, 74, 107-12, 120, 124 Restylane® Sub Q, 16, 107 Restylane® Touch, 107-09, 111 Retin-A®, 22, 30, 32, 47, 52, 60, 63-4, 76, 80, 85, 143, 176, 186 Retinoids, 47, 54, 76, 178 Rosacea, 7, 17, 33, 50, 56, 62, 65, 72, 79, 80-2, 90-1, 176, 189 Salicylic acid, 54, 63, 64, 67, 768, 167, 172, 176 Sclerotherapy, 134-35, 177 Sculptra®, 9, 16-7, 25-8, 31, 33, 61, 74, 107-10, 115-16, 120, 124 Seasonal skincare, 6, 69 Sensitive skin (See skin.) Shaving, 136-38 Singulair, 85 Skin cancer, 11, 12, 14-5, 17, 24-5, 39, 31, 37-40, 42-3, 50, 67, 69, 92, 145-49, 151, 153, 155, 157-62, 173-74, 177, 179 Skin layers, 25, 89, 178 Skin type, 6, 36, 43, 44, 62-5, 67, 76, 79-80, 82, 92, 107, 149, 162, 164, 172, 187 combination, 64 normal, 21 oily, 51, 63-5, 67, 78 sensitive, 7, 39, 62-3, 65, 76, 79, 82-4, 139, 189 Skincare, 6, 17-8, 23, 30, 32-4, 38, 46, 50, 52, 60, 65, 67, 69, 70, 72, 83 products, 17, 46, 65 SPF (See sun protection factor.) Spider veins, 17, 167, 177 Squamous cell carcinoma, 12, 14, 38, 148-50, 153-55, 158-59, 177 Stretch marks, 11, 88, 133-35, 137, 139, 141, 143-44, 178 Striae, 143, 178

Subcutaneous tissue, 17, 23, 26-7, 110, 122, 169 Sulfa, 73-4, 76, 108, 189 Sun block, 37, 39, 42, 68, 93-4, 178 Sun damage, 5, 20-3, 27, 31-2, 38, 61, 63, 88, 92, 96, 149, 156, 179 Sun protection factor, 5, 36, 3844, 64, 177, 188, 189 Sunburn, 29, 37-9, 41, 50, 57, 74, 81, 91, 94, 148 Sunscreen, 35-7, 39-44, 64, 68, 162, 175, 177-78 chemical free, 188-89 Tazorac®, 76 Telangectasias, 80, 90, 92 Tetracycline, 73, 74, 80-1 Theraplex, 46, 68 Thermage®, 16, 25, 91 Threading, 10, 121-24 Tweezing, 137-38, 141 Vitamin C, 6, 30, 33, 46, 48-9, 54-5, 64, 67, 167, 173, 187 Weather Channel, 29, 42-3, 63, 180 Wrinkles, 5, 16, 17, 20-2, 25-31, 37-8, 40, 43, 47-8, 52, 54, 56, 61-3, 88, 92, 96, 98, 100, 106-7, 109-10, 112-13, 116-17, 119, 124, 167, 170-72, 175-76, 185-86, 190 creases, 20, 21-22, 26-8, 36, 91, 103, 107, 109, 111-12, 115-16, 118, 124, 128, 130, 171, 173 deep, 5, 20, 27, 107, 113 dynamic, 5, 28 static, 5, 28-9 Zantac, 85 Zyderm®, 9, 109, 112-14, 120 Zyplast®, 9, 112-14, 120 Zyrtec, 85 Index


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About the Author Dr. Kenneth R. Beer grew up in Woodmere, New York. He was an A.B. Duke Scholar at Duke University, where he graduated Phi Beta Kappa. Dr. Beer received his medical degree from the University of Pennsylvania in 1989. After an internship in internal medicine, he completed his dermatology residency and dermatopathology fellowship at the University of Chicago. Dr. Beer is board certified in dermatology by the American Board of Dermatology and is also board certified in dermatopathology. At the present time, Dr. Beer is a clinical instructor of dermatology at the University of Miami. He has published numerous articles in medical journals, is a frequent writer for popular magazines such as Elle and Allure, and can be seen on television news programs. Dr. Beer is a fellow of the American Academy of Dermatology (where he serves on the Melanoma and Recredentialing Committees), the American Society for Dermatopathology, the American Society for Dermatologic Surgery, the American Society for Mohs Surgery, and many other professional organizations.



8/16/06 5:39:56 AM

Appendix The Palm Beach Peel® System Palm Beach Peel® Exfoliation Pads (5%, 10% and 15%)

These convenient and easy to use exfoliation pads contain glycolic acid. By using a gradually progressive three step system, you can take control of your skincare regimen. To help clear the outer layer of dead skins that can clog pores and give the skin a dull appearance, the pads gently exfoliate and remove oil from the surface of the skin. Witch hazel provides astringent to the pads and this will help your skin look and feel refreshed. Exfoliation pads are an integral part of any anti-aging skincare program. Directions for use: Remove a pad from the jar and wipe the textured pad over the desired area to be cleansed, one to two times daily. Palm Beach Peel® Eye Rescue Formula

A nourishing serum formulated for the delicate skin under the eye. There are few products that can effectively help minimize the appearance of fine lines and wrinkles around the eye. Eye Rescue Serum combines the hydrating benefits of hyaluronic acids with antioxidants such as Green Tea Extract, Coenzyme Q10, and liposomal vitamins A, C and E. Directions for use: Apply Eye Rescue Serum at least twice a day. If you are traveling, you should apply the Eye Rescue Serum prior to flying and then at least once every three hours. Palm Beach Peel® Green Tea Antioxidant Cleanser

In order to avoid drying the skin and stripping vital oils

Appendix


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while cleansing, the Green Tea Antioxidant Cleanser is formulated to gently cleanse and moisturize without leaving your skin dry and irritated. I have combined liposomal vitamins A, C and E as well as Green Tea and White Tea with Coenzyme Q-10 in order to nourish the skin while cleansing it. This cleanser should be part of any anti-aging skincare regimen. Directions for use: Apply a tablespoon of cleanser to moistened facial skin and gently massage for one to two minutes. Rinse with lukewarm water and gently pat dry. Cleanse twice a day. Palm Beach Peel® Home Microdermabrasion Formula

We harnessed the power of bamboo to provide self-heating crystals to enable our patients to obtain dermatology quality microdermabrasion at home. The bamboo crystals deliver a soothing wave of cleansing warmth as they remove dirt, debris, oils, and other impurities that can clog the pores. As with other types of microdermabrasion, the Home Microdermabrasion system will help to minimize the appearance of fine lines and pigment irregularities. It is the cornerstone of any anti-aging skincare system. Directions for use: Apply a pea size amount to face once or twice a week. Gently massage into skin in a circular motion, rinse with lukewarm water, and pat dry. Using the Home Microdermabrasion Formula more than recommended may result in skin irritation. Palm Beach Peel® Retinol Recovery Serum (.2%, .3% and .5%)

Retinol is the vitamin A derivative found in many prescription and over-the-counter wrinkle treatments. It is the precursor to Retin-A®. Retinol assists in minimizing the signs of aging by reducing the appearance of fine lines, wrinkles, and mottled pigmentation. Palm Beach Peel® Retinol Recovery Serum also uses green tea hyaluronic acid (which will increase moisture of the skin) to achieve smoother, firmer, 186 PALM BEACH PERFECT SKIN


8/16/06 5:39:57 AM

and more evenly toned skin. Increasing the concentration of Retinol from .2% up to .5% will allow you to control the Retinol Recovery for your skin (caution—higher concentration may cause irritation so proceed gradually). The Retinol Recovery Serum is as close to a prescription strength antiaging cream as possible. Directions for use: Apply to clean skin once every evening. Palm Beach Peel® Antioxidant Rescue Serum

Rescue Serum is a lightweight, fast absorbing formula combining hyaluronic acid with green tea and caffeine. The green tea with caffeine maximizes the amount of antioxidants delivered to the skin while the hyaluronic acid boosts the hydration of the skin. Rescue Serum may help to reduce skin redness and diminish pore size, while leaving the skin smoother and more radiant. Palm Beach Peel® Rescue Serum is recommended for all skin types. Directions for use: Apply a pea size amount to skin after cleansing in the morning and evening. Palm Beach Peel® Growth Factor Serum (10% & 15%)

Human growth factor TGF-beta-1 may help to stimulate collagen synthesis and initiate skin repair mechanisms. I have also included vitamin C (in either a 10% or 15% strength) because this has also been shown to stimulate collagen production. Growth Factor Serum may be slightly irritating when applied. It is intended to be used on skin that has damage due to aging, sun, stress, smoking, or a combination of these. Directions for use: Apply a small amount to face, neck, and chest after cleansing. Palm Beach Peel® Moisturizing Formula

Moisturizing Formula is specifically designed to help add moisture to dry skin. It is great for skin that is normally dry, Appendix


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for when you are flying, or when you are in an area with low humidity. I have included vitamins A, C, E, Green Tea Extract, and Co-Q10 to help nourish your skin while moisturizing it. Glycerin and Squalene, two natural humectants, are included to draw moisture into the skin. Directions for use: Apply any time your skin feels dry.

ANTI-AGING SKINCARE REGIME AM Palm Beach Peel® Green Tea

PM

Antioxidant Cleanser

Palm Beach Peel® Green Tea Antioxidant Cleanser Palm

Beach Peel® Antioxidant Rescue Serum

Palm Beach Peel® Exfoliation Pads

Palm Beach Peel® Antioxidant Moisturizing Formula

Palm Beach Peel® Growth Factor Serum

Palm Beach Peel® Eye Rescue Formula


Chemical Free SPF 30


ACNE SKINCARE REGIME AM

PM

Acne Cleanser

Acne Cleanser

Acne Treatment Pads

Acne Treatment Pads






Palm Beach Peel® Home Dermabrasion Formula



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SENSITIVE SKIN & ROSACEA CARE REGIME AM

PM

Palm Beach Peel® Green Tea Antioxidant Cleanser

Palm Beach Peel® Green Tea Antioxidant Cleanser

Palm Beach Peel® Antioxidant Rescue Serum

Palm Beach Peel® Retinol Recovery Serum




Palm Beach Peel® Home Dermabrasion Formula

Palm Beach Peel® Crystal

INGREDIENTS: Butylene Glycol, Sodium Silicoaluminate, Bambusa arundinacia (Bamboo) Stem Extract, PEG-8, Camellia sinensis (Green Tea), White Tea, Ascorbyl Palmitate, Retinyl Palmitate, Tocopheryl Acetate, Dimethicone, Methyl Gluceth-20, Hydroxyproplcellulose, Hydroxypropylmethylcellulose, Petrolatum, Titanium Dioxide. Palm Beach Peel® Antioxidant Cleanser

INGREDIENTS: Purified Water, Sorbitol, Cetyl Alcohol, Stearyl Alcohol, Ammonium Lauryl Sulfate, Camellia sinensis (Green Tea) Leaf Extract, White Tea, Camellia Sinensis (Green Tea) Polyphenols, Soy Phospholipids, Citrus aurantium dulcis (Orange) Fruit Extract, Retinyl Palmitate, Ascorbyl Palmitate, Tocophenyl Acetate, Coenzyme Q10, Superoxide Dismutase, Ascorbyl Glucosamine, Disodium EDTA, Bisabolol, Methylparaben, Propylparaben, Imidazolidinyl Urea.

Appendix


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Order Form THE PALM BEACH PEEL SYSTEM ORDER FORM Product Name

Price

Quantity

Palm Beach Peel® Exfoliation Pads 10% Convenient easy-to-use pads contain 10% glycolic acid.

$40.00

___________

$40.00

___________

$40.00

___________

Palm Beach Retinol Recovery Serum 2x Retinol assists in minimizing signs of aging. $80.00

___________

Peel®

Palm Beach Exfoliation Pads 15% Convenient easy to use pads contain 15% glycolic acid. Peel®

Palm Beach Exfoliation Pads 20% Convenient easy to use pads contain 20% glycolic acid. Peel® Peel®


___________

Peel®


___________

Palm Beach Peel® Eye Rescue Formula Nourishing serum effectively minimizes the appearance of fine lines and wrinkles around the eye.

$45.00

___________

Palm Beach Green Tea Antioxidant Cleanser Gentle cleanser moisturizes without drying the skin and stripping vital oils. $45.00

___________

Palm Beach Peel® Home Dermabrasion Formula Microdermabrasion at home. A soothing wave of cleansing warmth. $65.00

___________

Peel®

Peel®

Palm Beach Antioxidant Moisturizing Formula Specially designed to help add moisture to dry skin. Contains vitamins A, C, E Green Tea Extract and Co-Q10. $40.00

__________

Palm Beach Peel® 10% Growth Factor Serum Antioxidant serum delivers skin enhancing benefits. $120.00

__________

Peel®

Palm Beach 15% Growth Factor Serum Antioxidant serum delivers skin enhancing benefits. $135.00

__________

Peel®

Palm Beach Green Tea Rescue Serum Serum has a high concentration of antioxidants which may help reverse aging.


$135.00

__________

8/16/06 5:39:58 AM

Product Name

Price

Quantity

$160.00

__________

Palm Beach Peel® Skin Resuscitation Collection Collection includes Palm Beach Peel® Home Dermabrasion, Eye Rescue Formula, Retinol Recovery Serum 5x Green Tea Cleanser $195.00

__________

Palm Beach Peel® Green Tea Collection Collection includes Green Tea Cleanser, Home Dermabrasion Formula, Green Tea Serum and Palm Beach Peel® Antioxidant Moisturizing Formula

Peel®

Palm Beach Ultimate Collection Collection includes Green Tea Antioxidant Cleanser, Growth Factor 10% Palm Beach Peel® Home Dermabrasion, Eye Rescue Formula, Palm Beach Peel® Antioxidant Moisturizing Formula

Order Total Florida Sales Tax (6%) Total Amount Enclosed

$245.00

__________

_______________________________ _______________________________ _______________________________

Billing Address: Full Name __________________________________________________________ Address __________________________________________________________ Address Line 2 _____________________________________________________ City ____________ State/Province _______ ZIP or Postal Code _________ Country __________________________________________________________ Daytime Telephone ______________ Daytime Telephone ______________ E-mail Address ____________________________________________________

Shipping Address (if different from above): Full Name __________________________________________________________ Address __________________________________________________________ Address Line 2 _____________________________________________________ City ____________ State/Province _______ ZIP or Postal Code _________ Country __________________________________________________________

Credit Card Information Name on Credit Card Type Number Expiration Date

____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________

Monthly shipments available. If you elect to do this check here and your credit card will be charged monthly for each shipment. MAIL, FAX, EMAIL or CALL IN YOUR ORDER TO: Kenneth R. Beer, MD Palm Beach Esthetic Center • 1500 North Dixie Highway, Suite 305 West Palm Beach, FL 33401-2717 Phone 561-655-9055 • Fax 561-655-9233 [email protected]


8/16/06 5:39:59 AM

Notes


8/16/06 5:39:59 AM

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