DON’T BE SCARED

injection

I received an email from a client this weekend referencing an article which ran in the New York Post on July 7th.  She asked, “Should I be scared?”

The article, “Doctors warn popular cosmetic procedure may cause blindness”, written by Rebecca Sullivan, addresses some of the worst, and rarest, complications with injectable fillers.

One of these very rare complications is blindness.  There have been approximately 100 cases documented of blindness related to the injection of  dermal filler world wide.  These cases, statistically, are extremely rare.   The incidence has been highest when injections have been performed deep in the glabella area.  (between the eyes)  There have also been cases involving injections into the nasolabial folds and the nose itself.  When filler is injected deeply it can be introduced to one of the facial arteries and then can make its way to the retinal artery, resulting in blindness.  Blindness has not been reversible in the documented cases.  This rare adverse event has been reported with the injection of autologous fat and dermal fillers, such as hyaluronic acid fillers.  (Restylane®, Juvederms®, for example)   The occlusion of an artery can also cause soft tissue damage or tissue death (necrosis) . Although, still very rare, there have been more cases of this adverse event reported than blindness.  Infections have also been reported and are also very unusual.

Just the prospect of any of the above can make someone think twice before pursuing facial injections.  Here are a few pieces of information to put you at ease as a patient.

  • Seek out a provider with experience and an extensive understanding of facial anatomy.
  • Seek out a provider at an established and reputable office, ideally with a physician  on site.
  • Ask your provider if they have hyaluronidase in the office.  This is an enzyme which breaks down hyaluronic acid fillers.  If can be utilized in an emergency, but most often is used in outcomes that the patient or provider want to reverse.
  • Know that the majority of complications (such as swelling and bruising) are mild and self limiting.

Even in the hands of the most experienced injectors, risk still exists.

As a provider:

  • Know your facial anatomy!
  • Avoid deep injections in high risk areas.
  • Have an emergency protocol and kit available should the need arise. (hyaluronidase, nitro paste, ASA)
  • Aspirate before injecting.
  • Inject slowly
  • Only place boluses on periosteum.
  • When appropriate, utilize a cannula, especially in high risk areas of the face.

I have seen several references to this article on social media.  I think it is important to inform the public that facial injections have a long and safe track record.  I think that the article referenced does shed light on the fact that facial injections are not without risk and a patient should be educated and informed.  Choosing a provider wisely is so important.

But, in the right hands, you should not be scared!

 

 

NOT JUST YOUR FACE

We make a considerable effort to protect and care for the skin on our faces but can neglect the skin on our neck, décolleté and hands.  As we officially enter in to these summer months, I wanted to remind everyone to also pay attention to other commonly exposed areas.

Sun screen and antioxidants are the best defense.  Avoiding the high sun hours between 10-2 or even 10-4 is helpful. (although tough to accomplish if you love the outdoors!)

But what if there already is damage?  What can be done?

Pretty much anything that can be done to the face can also be done off face.

hands

chest # 1

IPL (Intense Pulsed Light) is very effective at removing sun spots (hyperpigmentation).  The hands and chest are commonly treated with this modality.  The pigment will return if the area is not protected from the sun though, so invest in a sunscreen with zinc!  Additionally, consider protective clothing if your will be out during hours of the day when the sun is intense.

For those fellas out there (or even women with very thin hair) make sure to protect your scalp as well.  Since I am adding to the list, let me also include ears!  This is not only about hyperpigmentation, skin cancer commonly occurs in all of these areas!

Enjoy these warm summer days!  Safely!

 

SKIN CANCER AWARENESS MONTH

SUNSCREENSMay is Skin Cancer awareness month, so I thought I would do a quick blog on sun protection and skin care in regards to sun exposure.

Approximately 1 in 5 Americans will have some type of skin cancer in their lifetime.  Skin cancers are the most common type of cancer in the United States of America.  Protection from damaging UVA/UVB rays can help improve ones odds significantly.

Some basic tips include avoiding sun exposure between 10-4, wearing broad spectrum sunscreen, wearing protective sunglasses, wearing broad rimmed hats and seeking shade whenever possible.  But when you find yourself in the sun, your choice of sunscreen protection is important.

When purchasing sunscreen look for broad spectrum, meaning, protects against UVA and UVB radiation.   Broadly, UVB rays burn our skin and UVA rays go deeper and damage the skins structure. Both increase cancer risk.  Both contribute to premature aging of the skin.

In the sunscreen market there are chemical sunscreens that are referred to as absorbers.  They absorb the UV rays and convert them to heat.  There are a long list of these chemical agents and some cover either UVA, UVB and some absorb  both.  There are approximately 20 FDA approved agents.  These chemical agents have a maximum amount of absorption and then loose their effectiveness unless reapplied.  Physical agents, such as zinc dioxide and titanium dioxide, reflect the UVA/UVB rays.  I always discourage patients from focusing too much on the SPF factor because an SPF of 15 filters 93% of the UV rays while SPF of 30 filters 97%.  Going to an SPF of 50, 70, 80 or 100 does not significantly improve your protection factor.  Reapplying, however, does.

I am a big fan of physical agents as they are the least likely to cause irritation, work immediately upon application and offer broad spectrum UVA/UVB protection.  When applying make sure not to miss the eye area, ears, backs of legs, feet, lips, and if you are bald or have thinning hair, the scalp.  Sunscreens with zinc and titanium are not the thick greasy kind we remember from our childhood.  They are now micronized and have a cosmetically elegant feel.  Do not under utilize your sunscreen.  When applying to your whole body you should use several tablespoons of sunscreen.

There are increasingly sunscreen garments that can add protection.  Rash guards are increasingly popular and fashionable.  When purchasing sun protection wear make sure it has a UVP rating on the label.  Do not rely solely on this as a means to protect your skin.

Finally, I wanted to review protecting eyes.  Repeated and cumulative UVB/UVA exposure to the eyes can contribute to cataracts and macular degeneration.  Eyelids (upper and lower) are one of the most common sites for non melanoma skin cancers.  The lower lids are more effected than the upper lids.  Sunscreen and sunglasses with UVA/UVB protection are vital.  Skin cancers on the eyelids do not always present the same way as elsewhere on the face.  These types of cancers tend to infiltrate and can effect ocular structures, thus putting site at risk.  Those with light colored eyes and skin are more at risk.   Ideally your eyelid skin is evaluated by your dermatologist yearly.

That brings me to the importance of yearly skin checks.   A yearly skin check should be part of your routine medical evaluation.  Depending on your risk factors a physician may determine if this should be done more or less frequently.  There are also physicians who will skin map you if you are at higher risk.  (take photos to reference back to,  helping to  evaluate changes over time)  I had mine mapped as I am a fair red head who spent part of her childhood in the South Pacific with year round sun exposure and am covered in acquired nevus (brown skin lesions/freckles).   If you feel you have too many spots to keep track of skin mapping may be a good option.

I am a huge fan of the Elta MD® line of sunscreens (thus the photo) and encourage everyone to find their favorite sunscreen.  If you love it you will use it!

Happy Memorial Day weekend!  Protect yourself while having fun out there  🙂

HOW ABOUT THE NECK?

neck

A youthful neck only lasts so long.  It is an area of the body we commonly receive consultations on.  Did anyone read Nora Ephron’s brutally honest and sarcastically funny book, “I Feel Bad About My Neck And Other Thoughts On Being A Woman”?!  She had a thing or two to say about her neck!

But seriously, we tend to take good care of our faces but neglect our necks.  There are many options for our necks.  From topicals creams,  injectables, skin firming treatments, and finally, surgery.  This will be a quick and easy breakdown of modalities to address a variety of issues that can effect the neck.

As we age the skin on our neck becomes thinner, the platysmal bands show, looking  like cords in our neck.

platysmal bands

Platysmal Bands

Our sub mental fat pads can become more apparent and we loose the definition along our jawline, altering our profile.

neck fat

Sub mental fullness

The tissues can become looser, frequently due to repeated pulling of the platysma muscle along with the loss of collagen and elastin.

loose neck

Loose skin/loss of collagen/elastin

Skin can  become discolored.  A condition called Poikiloderma is common in both men and women.  The skin is marked with a combination of hyperpigmentation and redness (from vascular injuries from sun exposure).  Poikiloderma frequently involves the chest in addition to the neck.  Most often the medial neck is not affected.

poikiloderma

Poikiloderma

I think we can agree the first photograph in this blog looks better than all the others!  So, how to get closer to that….

Platysmal bands can be easily corrected with Botox®.  Botox® is injected along the platysmal band and within two weeks the band will relax and not show.  Additionally, doses of Botox® can also be injected along the mandible (jaw bone) to improve the jawline contour.  This is sometime referred to as a Nefertiti Lift.  This is a quick, non-invasive procedure.

Sub mental fullness can be addressed with Kybella® injections.  The injection of this acid breaks down the fat which is then eliminated by the body.  A series is generally recommended.  Other than 48 hours of socially awkward swelling (think bullfrog), this is a low down time procedure.  The procedure is ideally repeated at 4-6 week intervals.  We are noticing patients experience some skin retraction with this procedure as well. (likely as a result of the inflammatory process in which collagen is stimulated)

The loss of skin turgor can be treated with a skin tightening treatment, such as Ultherapy®.  During this treatment heat is delivered deep in the tissues, using ultrasound, creating tightening and lifting.  This is also a low to no down time procedure as most people can receive an Ultherapy® and return to their activities without anyone knowing.  The improvement is gradual over the next 4-6 months as the collagen that was stimulated grows in.

Discoloration, such as Poikiloderman, can be treated with a series of IPL treatments.  Again, other than redness the day of treatment, this is a minimally invasive/no downtime procedure.  We recommend a series of 3-5 treatments.

I do not want to underestimate the importance of good skin care.  Sunscreen is a no brainer.  There are also products specifically formulated to treat the skin of the neck and décolleté.  My current favorite is Neocutis® Microfirm™.   This topical product, utilitzing peptides and glycolic acid,  increases elasticity and improves skins crepey appearance.  It can also help to fade hyperpigmentation.

microfirm

Finally, there comes a time when the tools and products we have in a medical spa are not enough.  There is a time when the neck is best addressed with a skilled surgeon.  A neck lift involves redraping the skin.  Additionally the platysma muscle is reattached and tightened.  You and your skin care provider ideally have honest conversations along the way allowing to make this call when it is appropriate.

Anyway, don’t forget your neck!  Hope this gives you some helpful tips:-)

 

 

DON’T PICK!!!

picking

It is almost impossible to resist the urge to pick at our skin.   When we feel there is something there that shouldn’t be, we are compelled to remove it.  Unfortunately,  picking at a pimple can cause the lesion to worsen by creating an infection and/or eventually leave a scar, called post inflammatory hyperpigmentation. (PIH)

When you “pop” a pimple you can actually cause the localized infection to spread under the skin, leading to more inflammation.  Imagine the sac your body forms around the pus as a self defense mechanism.  (like a blister)   When we open the sac and spread the bacteria and introduce new bacteria, we interrupt the skins self defense and healing mechanism.  The sac does not only open to the surface, it can implode under the surface, spreading the infection and increase inflammation   P. acnes is the bacteria which is commonly in our hair follicles and can mix with dead skin cells and sebum to create inflammation which leads to a pimple, or comedone.   Our body will naturally eventually rid of the lesion by pushing the material to the surface or by reabsorbing the “waste” under the skin.  As tempting as it is to push the process along, don’t.  Let it run its course.  When you pick you are introducing bacteria on your hands, on the skins surface and under your nails to the equation, potentially making it worse.

 

 

pimple 1

There are different types of blemishes.  The above diagram gives you an idea of what is going on under the surface when you have a pimple or blackhead.  You can visualize how the contained papule or pustule can spread in the tissue when forced.

Instead, try an over the counter benzoyl-peroxide product (ideally 10%) or a retinol or retinoid.  These products will dry the comedone out, helping to shorten its lifespan without scarring the surrounding tissue.

If the lesion is persistent and feels more like a cyst under the skin your dermatologist can inject a small amount of a steroid.  These lesions typically shrink within a day or so.  We do not recommend doing this unless necessary as there are times when the steroid injected can create a divot in the skin.

Additionally, your skin care specialist or esthetician can perform an extraction using sterile tools specifically designed to  thoroughly extract a blemish without scarring.   If you suffer from frequent enough breakouts it may be worth having a routine facial with extractions.

Being aware of what is causing the breakouts.  Ingrown hairs can be a culprit if you suffer from coarse facial hair growth.  Some cases of facial acne are actually related to folliculitis.  This is when the hair creates inflammation as it makes its way to the surface.  I have seen some patients see considerable relief with laser hair removal. (the hair needs to be pigmented)

Always thoroughly cleanse your skin before going to sleep at night.  Using a cleanser with glycolic acid can be helpful.  I am a huge proponent of using a retinol/retinoid for its anti-aging benefits as well as its ability to control breakouts.  Make sure the products you are using do not clog your pores.  Our products can be part of the problem.

If you have picked enough to cause PIH a series of IPL’s or peels can help to remove that pigment.  We are having success with our new IPL (Intense Pulse Light) at TOC Medical Spa, the Lumenis M22.

 

 

 

 

MICRO-NEEDLING

Micro-needling, or collagen induction therapy,  has been around for a number of years, but has recently had a new wave of enthusiasm.  I just read an article in the New York Times™ about an at home device called GloPro® which is, apparently, doing very well on the market.

glopro

We have been performing micro-needling in office for a number of years and I thought I would touch on the difference between an at-home device versus a medical grade micro-needling treatment.

An at home device has one setting and is not made to penetrate deeply.  It treats the very surface of the skin.  Most people will have slight erythema (redness) which indicates the body is responding to the stimulation.  I believe over time results can be noticed.  However, not to the same extent as with a more aggressive in office treatment.

Eclipse Micropen Elite

We utilize The Eclipse Aesthetics Micropen® device.  This device is automated with a treatment tip consisting of 12 needles.  The provider can choose how deep to penetrate the tissue depending on the area of the face and  the treatment goals.  We tend to be more aggressive on the fattier parts of the face, such as the cheeks.  We adjust the depth of penetration of the needles for each patient, the treatment area,  the patients goals and the amount of social downtime the patient can afford.  We find that even an aggressive treatment, with pinpoint bleeding, can look presentable the next day.

another micrpen

In addition to being able to adjust and personalize the treatment with depth of penetration, we can also personalize which product to apply to help the treatment tip glide easily over the face.  We utilize both a hyaluronic acid and MicroGlide GF™, a growth factor product.

The other option ,which has received a lot of buzz the last few years, is utilizing the patients own isolated platelet rich plasma (PRP).  This is done by drawing the patients blood, utilizing a centrifuge to separated the plasma and then re-injecting the plasma with the micropen device.   Most people  refer to this type of treatment as a The Vampire Facelift®.

The delivery of an injury to the tissue is what creates the stimulation of the fibroblasts to make new collagen and elastin.  Utilizing growth factors or PRP  further stimulates the induction of collagen and elastin.

Who is an ideal candidate for this treatment?  Virtually anyone wanting to improve the appearance of their skin.  This treatment, when accompanied by a solid skin care routine at home, can make noticeable improvement in the texture, tone and color of the skin.

I think micro needling is here to stay and is an effective modality with little or no downtime.

 

HOW TO COMMIT TO A SKIN CARE REGIME

routine products

We all have the best intentions whether it be related to our diet, exercise program or other goals.  This is about committing to a solid skin care regime.  Just like all other ‘habits’ it can take practice for a new skin care program to become the new normal.   I believe the research shows that it takes 21 days for a new practice to become a habit.  So, how can we make that easier and help insure we will commit?

The easier we can make it for ourselves, the more likely we are to experience success.

First off, decide what your day time skin care should look like for you and what you are trying to target.  Ideally, everyone includes an antioxidant and a sunscreen with zinc every morning.  A night time routine should include a retinol/retinoid and plenty of moisture.  Once you have established which skin care items are going to suite your skin care needs make sure the products are accessible.  It can be easy to want to skip any part of the routine when we are in a rush to get out in the morning or we are exhausted at night.

Have all your must use products easily accessible.  I keep a tray with my current products on the bathroom counter next to my sink.  I am always able to commit in the morning, it is at night, sometimes, when I am exhausted, that I might be less committed.  But once I brush my teeth my products are right there so I rarely skip.

I am a true believer in topical skin care.  I came in to medical aesthetics with pretty sun damaged skin and can honestly say that I turned my skin around.  I once thought tanner was better.  I even used tanning beds back in the day.  Being a pale red head, this was just a bad idea on so many levels.    I believe that what we use topically is a big piece of the “pie” and is worth the money and time.

I tell patients to, at the very least,  commit to an antioxidant, sunscreen and retinol/retinoid.  I am a huge fan of products with multiple peptides these days as well.

Maybe this well help you get on board with a topical skin care routine.

Happy Monday!