More than any other area of Plastic Surgery the treatment of skin texture, tone and health has changed dramatically over the last 5-10 years. A plethora of new techniques and materials are available to help control facial aging and the visible effects of this. As we age, the sun, weather and time all affect the skin in different ways and as gravity stretches and loosens the skin its texture also changes. A large number of systems are now available for skin care to maintain the moisture, texture and tone of healthy young skin. There are also a number of treatments available for irregularities of pigmentation and color. The other area often of concern to people as they age is the appearance of wrinkles and creases in the skin and there has been a veritable explosion of new fillers to help with this problem. One of the oldest available fillers is collagen, which can be used in a superficial or deep manner. This quickly gave way to Restylane, which is very helpful especially around the mouth and nasolabial areas. There also exists, Radiesse and ArteFill to name but a few. A separate area of fillers is placed beneath the skin for some volume losses that occur with aging and among these are, Scupltra and autologous fat. Another strategy for beating the wrinkles is used with botulinum toxin (Botox) which can paralyze muscles which cause facial wrinkles. Beyond these injectable strategies are techniques for resurfacing the skin and face from a very gentle microdermabrasion through various acid peels up to the more surgical deeper phenol peels or laser skin resurfacing or dermabrasion type techniques.

Skin Care

Of the many available skin care routines we have chosen Obagi Nu-Derm to be our primary skin care regimen. The Retin-A in this produces not only changes that you can notice in your skin but also the biology to a healthier skin type. It can help improve skin wrinkles, large pores and, in general, improves the skin tone. There also are the hydroquinone components of the Obagi Nu-Derm System which can help smooth irregularities of pigmentation, making melasma or lentigines much less noticeable. These active ingredients are also combined with skin exfoliants and moisturizers to help enhance their effectiveness and make the system an easy daily use routine. The Obagi Nu-Derm System is primarily designed for use on the face but is very versatile and can be used over the neck, chest and hand areas if desired. ( www.obagi.com )

To compliment the skin care routines, we also carry a full line of the Gerda Spillman makeup to enhance the quality of your skin. ( www.gerdaspillmann.com )

Injectable Fillers

Collagen: This is what started injectable skin care and still has a place for filling fine lines and wrinkles of the face. Collagen does require allergy testing six to ten weeks prior to starting treatment. Collagen is easily injected in the office setting and can be used in very fine, superficial rhytids or deeper wrinkles, is usually less costly and often less irritating than other fillers, usually needing at least a topical anesthetic and usually does not require nerve blocks. Unfortunately, it is usually more temporary than other fillers and a typical result lasts two to four months. This has prompted the development of other newer fillers with a longer lasting effect.

Hyaluronic Acid (Restylane/hyalaform and others): Hyaluronic acid is a naturally occurring body fluid. It has been engineered to be compatible without skin testing for allergies. It is more durable than collagen for filling fine facial lines and superficial creases, typically lasting about twice as long as collagen would in a similar application. A typical result lasts four to six months. Restylane and other hyaluronic acids tend to be more irritating and can sting or burn during injection, at the site. We recommend that this be done with a nerve block in order to make this procedure more comfortable, especially around the lips and mouth. Restylane can be used in many areas of the face or other areas of the body. Minor redness at the injection site for several hours can be common and mild lip swelling may persist for two to three days; otherwise, no “down time” is expected and people can often return to work immediately after injection. Ideally we would recommend ice and elevation if possible for several hours after injection to minimize risk of bruising at the injection site.

Radiesse: Radiesse is a suspension of small hydroxyapatite microspheres in a gel solution which can also be used for treatment of lines and wrinkles. It has recently received FDA approval for this usage, although it has been approved for use in oromaxillofacial defects and facial bone structure for many years. It is reported to last as long as two to seven years, although effects may disappear as early as six to nine months. Radiesse is usually injected deeper into the deep dermis beneath the skin than Restylane or collagen. It would be useful for longer lasting results.

ArteFill: ArteFill is also a suspension of microspheres, in this case polymethylmethacrylate microspheres in a 3.5% collagen solution. ArteFill is reported to be long lasting enough to be called permanent but like Radiesse, because of the microspheres and the body’s reaction to the microspheres, injections should be done in deeper dermis in thicker areas of skin. The FDA has approved ArteFill for use and we are eagerly awaiting the company’s release of this substance for use as a facial filler.

Sculptra: A slightly different strategy is used by Sculptra in improving facial contour changed by aging. It is a relative newcomer in that its treatment is still “off label” but soon expected to get FDA approval. This is a deeper filler used in the subdermal layer beneath the skin and is used to stimulate collagen growth which is likely to last three to five years. Unlike the skin fillers, it is not used to erase lines in the skin surface but rather larger contour defects such as the hollow beneath the cheek bones and in areas with fat atrophy in normal aging. It is often injected comfortably with a topical anesthetic but nerve blocks may be used if needed. As this relies on autologous collagen creation, it may require two to three injections to achieve the full effect. The injections are usually spaced six or eight weeks apart for optimal correction of contour defects.

Autologous Fat: Autologous fat is fat harvested from elsewhere in your body (usually with liposuction) and then transferred to hollow areas in the face or hands (although almost any area is possible) to help fill defects or hollow areas. As this is the tissue lost with normal aging, it is the ideal replacement, can be permanent for results but is not without its drawbacks. Fat injection is somewhat less predictable than the off-the-shelf fillers discussed above and often requires several injections in order to achieve the optimal or desired result. Often the area requires overfilling and can have significant bruising and swelling after the injection. Harvesting an injection of this is a surgical procedure although one that is usually very well tolerated, usually quite safe and is usually done as an office procedure.

Botox

Botox is a botulinum toxin which paralyzes muscles. When injected appropriately into the skin around wrinkles of the forehead and eyes the paralysis of these muscles smoothes the skin in these areas. Results can last from four to six months and the injections usually take less than 30 minutes and the patient may return to normal activities immediately following the procedure. Great care is taken in our office to make sure that unintended compensatory effects from other muscles are not stimulated by the primary actions of the Botox. Although not a surgical technique, since Botox acts on muscles it is advised that this is best injected by a surgeon who understands the complex facial anatomy and interplay of the muscles of facial expression before modifying them.

Resurfacing

Microdermabrasion: Microdermabrasion is a technique whereby the very outer layers of skin can be removed. Typically this is a spa type treatment and there are many methods of performing this surgery. Our office uses a diamondtome to gently abrade the outer layers of skin. This results in a smoother feel and modest tightening of the skin. This provides temporary relief of very superficial rhytids and is not intended to be a permanent result. Typically this is done in a pleasant, painless procedure and one can return immediately to all normal activities upon leaving the office.

Glycolic Peels: Many degrees of superficial skin peeling also exist to perform slightly more durable results than the microdermabrasion and these are very easily and painlessly administered in the office with very little risk of side effects. Some of the very superficial peels that we perform here in the office are a mandelic/lactic acid mixture, Dermik Aesthetics, company trade name.

TCA: A trichloroacetic acid peel is the next deeper type of peel. This helps improve sun wrinkles, large pores, melasma and keratoses. This is most often performed after a six to eight week interval of Obagi Nu-Derm or other Retin-A treatment with hydroquinone to precondition the skin to minimize any unwanted change in pigmentation and to maximize the benefits of the peel. We advocate the Obagi Blue Peel for its safety and predictability. It can be varied from a very light peel to a significant deep peel with some permanent effects. Generally there will be some skin shedding over the 5^th to 7^th days after the peel, hence, the name. Usually our patients continue all their daily activities during this period and it is unusual to miss any time from work. There may be more frequent face washing or makeup application during this time period but generally this is tolerated very well. The Blue Peel can also be used on the neck, chest and hands and results can vary from being very modest in a light peel to very impressive with deeper layers of peeling.

Phenol Peels, Laser Peels and Dermabrasion: Phenol peels, laser skin resurfacing and dermabrasion are all deeper layers of skin resurfacing and here we really do cross the line from nonsurgical to surgical treatments. There are risks with these deeper techniques of permanent scarring or permanent skin color change and need to be very carefully considered in a long discussion with one of our physicians prior to deciding on this goal of treatment. It is excellent for people with significantly weathered or sun damaged skin. There is usually a two-week time period with significant exfoliation of skin off and requiring 7-10 days for re-epithelialization which leads to a burning discomfort and raw appearance to the skin much like a newly opened blister. When properly performed very dramatic results can be achieved.

Today the technology of medicine and science offers a more sophisticated method of controlling the appearance of the aging process. Over the years as the skin of the face loosens and sags, the texture of the skin also changes. We now have a variety of skin rejuvenation techniques available, enabling us to treat a variety of selected skin problems.

Laser skin resurfacing and phenol chemical peels get excellent results with deep wrinkles and improved skin laxity. Healing occurs over seven to ten days and redness, which can be covered with makeup, persists for several months.

The Obagi Blue Peel improves skin wrinkles, large pores, melasma, and keratoses. The skin sheds much like a sunburn over a five to seven day period. One can continue their daily activities during this period. There is no time lost from work. The Blue Peel can also be used on the neck, chest and hands. It is usually combined with ongoing skin care products that are used daily. The results are very impressive.

Botox is a botulinum toxin which, when injected into the skin around wrinkles of the forehead and eyes, temporarily paralyzes and smooths the skin in these areas. The results last from four to six months. These injections usually take no more than 30 minutes and the patient may return to normal activities immediately following the procedure.

Collagen and Alloderm are used as fillers and are placed to correct depressions, crevices, and deep furrows in the skin, as well as wrinkles and acne scars.

All of these techniques can be used individually or often they are combined with other procedures depending on the patient's problems. They can be done in the office, most take little time, and healing is usually rapid.

For further information on these procedures, our experienced staff would be happy to discuss any further questions.