I frequently have patients and friends ask what I am using on my skin.  I tend to change things up every few months while sticking to my “recipe” of antioxidants, sunscreen and something to increase cellular turnover.  I am currently LOVING my new routine as I am seeing results.  I battle hyperpigmentation, mild redness and an occasional breakout.  The kind of breakouts women in their forties have, cystic blemishes, around the chin mostly.

Currently my morning routine includes cleansing with a 1% Glycolic cleanser with my Clarisonic brush in the shower. (AGE management systems cleanser) The cleanser is a line we carry at Toccare in 3 strengths. 1%, 8% and 12%.  A glycolic cleanser helps minimize congestion/decrease acne and helps brighten skin. The goal is to work up in strength as tolerated.    When I get out of the shower I dry my skin and apply my CE Ferulic (my antioxidant, SkinCeuticals) and let that absorb before my next step.  I have recently introduced Metacell Renewal B3, also from SkinCeuticals.  This is a emulsifier/hydrator which has 5%  niacinamide and a tri-peptide concentrate that helps promote collagen and elastin.  The niacinamide increases cellular turnover and  minimizes redness.  I think this is the product that I have introduced which is giving me improved results.  It feels “active” (mild tingling) when I apply it and I have seen some mild flaking .  A few pesky brown spots are fading and my overall skin tone is improved. ( less redness, smoother)  Once that has absorbed, which happens quickly, I apply my sunscreen.  I have several sunscreens in rotation right now.  Elta Md Daily SPF 40 (9% Zinc and 7.5% Octinoxate)  and SkinCeuticals Physical Fusion UV Defense SPF 50 (5% Zinc and 6% Titanium).  Both are excellent broad spectrum every day sunscreens.  Rain or Shine, I do not leave the house without sunscreen.

In the evenings I cleanse with the same AGE management systems cleanser.  I frequently also use my Jane Iredale Magic Mitt to remove my makeup.  It really is magic.  It even EASILY removes stubborn  eye products.  I usually throw it in with a load of wash twice a  week and have been using it for several years.  (no more disposable makeup remover wipes) Once my skin is dry I apply SkinCeuticals Resveratrol B E antioxidant night concentrate.  This is also a newer product to my routine.  I have been on board with antioxidants for years during the day so now I have more free radical fighting at night!  I finish with another pump of the Metacell Renewal B3.

I am currently only using my retinoid to spot treat blemishes as needed.  I am finding the Metacell Renewal B3 is providing enough cellular turnover that I am backing off the retinols/retinoids at the moment.


As we age our skin loses collagen and elastin in addition to losing volume.  The combination of skin laxity, fat volume loss and gravity all contribute to sagging and the loss of  facial contours we once had.  I am definitely a proponent of restoring volume as that makes a HUGE difference!   Firming the skin can help quite a bit too.

There are a multitude of skin firming devices on the market.  They all are used to create collagen stimulation (neocollagenesis) in the tissues by delivering a controlled dose of heat to create an injury to which  your body responds by creating new collagen (collagen remodeling).  There are numerous devices on the market that are utilized to deliver this tightening.  More aggressive treatments that are ablative or sub-ablative (meaning the surface of the skin is affected helping with texture and/or pigmentation) are effective in stimulating collagen but have cosmetic downtime.  The devices meant to create skin tightening alone have the benefit of sparing any injury on the surface and having little to no downtime.  Familiar brand names in this category include Thermage® and Ultherapy®, amongst others.  These are the two devices I have personal experience with.

Thermage® utilizes radiofrequency to deliver heat while Ultherapy® utilizes micro-focused ultrasound.  Ultherapy® is the device Toccare offers for skin tightening.  The ideal candidate for Ultherapy® has mild to moderate skin laxity, is a non-smoker and practices effective sun protection.  Ultherapy® is not going to produce surgical results, therefore someone with more severe laxity should not be given any expectations that Ultherapy® will be able to provide adequate results.  Managing expectations with Ultherapy® is key.  The results are natural and subtle for the most part.  Occasionally a really good collagen responder will have more dramatic results but that is not typical.

Ultherapy® is FDA approved for the noninvasive lifting of the eyebrow, neck and under chin.  It is also approved for tightening the skin of the décolletage.

Ultherapy® IS uncomfortable.  We have patients medicate to help take the edge off and get through the treatment.  It is a treatment which takes anywhere from an hour to 3 hours depending on the area/areas treated.  After a treatment there can be mild redness which is generally gone within a few hours.  Some patients report feeling sore for a few days after the treatment.  The results are seen 3-4 months after the treatment as the neocollagenesis takes time.  Many patients report an improvement in the appearance of their skin in addition to the gradual tightening.  For example, pores appear smaller.

After the age of 50 (or so) patients may find it beneficial to have a second treatment to obtain the results they are looking for.  This is because as we age we just don’t generate the new collagen as well as when we are younger.  This varies from patient to patient.

Ideally someone undergoing Ultherapy®  (or any skin tightening) will also be on a supportive topical skin care regimen to optimize their results.


Lymphatic massage can be performed after surgery.  I especially find it helpful after work on the face. (facelift, blepharoplasty, etc)

The lymphatic system is a complicated group of nodes, vessels, ducts and capillaries which drain fluid from the tissues back to the circulatory system via the subclavian veins in the neck.  The lymphatic system is both at the surface in the skin and deep within the organs as well.  The majority of lymphatic massage is performed to assist the drainage of congested fluid in the tissues or skin.

Lymphatic massage is a gentle, pain-free treatment during which the provider massages the tissue in a rhythmic “stretch and release” pattern.  This is done in a specific direction based on and understanding of the physiological principles of lymphatic flow.

Lymphatic massage can enhance recovery after surgery by minimizing the congestion in the treated area.

Most patients experience lymphatic massage as deeply relaxing.


Micro-needling (or Collagen Induction Therapy, CIT) has been around for a number of years but is experiencing a surge in aesthetic medicine due to its efficacy with minimal downtime.  Most skin types can tolerate micro-needling.  The latest incarnations are fully automated pens with a single use tip that a trained professional uses to create micro-injuries in the skin to help stimulate collagen and elastin.  The results lead to thicker epidermis and dermis minimizing the appearance of lines and wrinkles, irregular texture and help firm the skin.  The micro-channels also allow products to penetrate more effectively so the treatment may have add-ons: for instance, growth factors or antioxidants.

Micro-penning or micro-needling can also fade hyperpigmentation, minimize scars (acne, surgical) and minimize the appearance of stretch marks.  Ideally one receives a series of treatments as the cumulative results are where the best results are seen.

The treatment takes approximately 30 minutes and generally is completed after topical analgesic has been allowed to numb the skin. The treatment itself is prickly, almost like a cats tongue.   Following the treatment the skin is  pink and possibly slightly swollen.  These side effects are short lived and generally one can return to regular activities within a day.

Anyone who has a history of cold sores (HSV) should take an anti-viral to help ward off an outbreak.  Additionally, one should avoid the sun for at least two weeks after a treatment.