We are now offering the Avya Skincare line at TOC Medical Spa.  This line is close to us as one of the creators of the line, Dr. Tanuj Nakra, is one of our physicians.

Avya, “first rays of sun”, in Sanskrit, is a skin care line combining beneficial botanical extracts with medical grade active ingredients.  The line is specifically formulated to help manage pigment and melanin production.  It is appropriate and can be efficacious for all skin tones/types.

Avya contains antioxidants and anti-inflammatories from Peony, Turmeric and Neem.  The Curcumin in the Turmeric is colorless and odorless. (rather than the dark yellow we associate with this extract)

The Avya Skincare line has 5 products: a cleanser, day moisture, night moisture, eye cream, and serum.  The line utilizes Qusome™ technology, which allows the active ingredients to slowly release over time once it has been applied to the skin.

Gentle Cleanser (non foaming)

  • cleanses without stripping skin of natural oils
  • contains Peony essential oil which has a lovely fragrance
  • contains salicylic acid to minimize skin congestion

Day Moisture SPF 20

  • contains chemical free sun protection (zinc) for broad spectrum protection
  • snow mushroom extract for hydration
  • niacinamide (B3) to help brighten and clarify skin
  • Peptides for collagen stimulation and support
  • anti inflammatories from botanical extracts
  • Peony, Turmeric, Neem

Night Moisture (with Vit A)

  • Retinyl Palmitate (Vit A), increasing cellular turnover and collagen support
  • decreases inflammation utilizing botanical extracts
  • Vitamin C
  • Vitamin E
  • Peony, Turmeric, Neem
  • Niacinamide
  • Beta Carotene

Anti-Aging Power Serum (with Vitamin C)

  • Antioxidants
  • anti-inflammatory properties from botanical extracts
  • Antibacterial and antimicrobial effects from Neem
  • Turmeric/Curcumin which  is a potent anti inflammatory and stimulates bodies own antioxidant enzymes
  • Vitamin C in Qusome technology, protecting the fragile antioxidant molecule until application
  • Retinyl
  • Peony, Turmeric, Neem
  • Peptides

Eye Bright Cream- with caffeine

  • minimizes under eye puffiness
  • minimizes under eye dark circles
  • Cassava matrix technology which works like “shrink wrap” for the under eye
  • Retinyl
  • Peony, Turmeric, Neem
  • hydration
  • recognized by Allure® Magazine as a favorite new product May 2018!

This line is efficacious while being cosmetically elegant.  The products have a pleasant smell and lovely texure.  This line does not test on animals, is Dermatologist and Ophthalmologist tested, and does not contain a lot of the ingredients consumers tend to want to avoid.  (for example, parabens)



At times patients express hesitation about moving forward with aesthetic treatments because they worry about looking “done”.  There have been enough procedures performed where a person does not look natural, and almost looks like a caricature of their former self.   We have all seen people with either lips or cheeks that mother nature would not have created.  Even celebrities, with deep pockets who can afford to be treated by the most reputable injectors, have become victims of “too much”.

courtney cox

Unfortunately, these examples give the whole industry a bad name. (the actress in the above photos has admittedly been over treated and has since then had a lot of the filler dissolved)

Most injectors will discuss your goals with you and come up with a plan to make you look restored and rejuvenated,  but not “done” or radically changed.  It can be helpful to bring photos of yourself when you were younger to allow you and your provider to review where age related facial changes have occurred.  You can then come up with your individualized rejuvenation plan.

Neuromodulators can help to balance out your depressor muscles, which pull down, and your levitator muscles, which pull up, or lift.  Treating fine lines and creating balance in the face with neuromodulators can have a rejuvenating effect.  Additionally, restoring lost volume and correcting asymmetries with dermal fillers can further restore or correct changes in your face that may be bothering you.  We often note that an individual has more volume loss and skin changes on the side of the face they predominantly sleep on.  This can be subtly addressed with filler, restoring symmetry.

In addition to injectables, you and your provider may decide that skin rejuvenation with laser or light devices may help to improve the appearance of your skin.  There are lasers that can do an amazing job removing hyperpigmentation, improving skin tone and texture and tightening and lifting the skin.

If you have thought about seeing an aesthetic provider but have shied away because of seeing individuals who look overdone, rethink it.  Medical aesthetics can offer a wide range of options to help you look your best.





As fall is in full swing and the temperatures are dropping, (except here in Texas!) we need to heat our homes.  This is when more people start to complain of dry skin.  SkinMedica® has an answer to dry skin, with their hydrating product, HA5.

HA5 is a clinically tested hydrating serum containing 5 forms of hyaluronic acid.  These different forms of HA work synergistically together to hydrate the skin, diminishing  the appearance of fine lines and wrinkles.  The product packs a punch of hydration for a light weight feeling product.  The HA is in a sustained release formulation which provides hydration throughout the day. Additionally, HA5 supports the skins ability to replenish its own hyaluronic acid.  We lose HA as the years pass.  We have 50% less by the time we are 50 than we did when we were 20.  This product works well with other products and helps to retain moisture in addition to the moisture it provides.  In addition to the hyaluronic acid this SkinMedica® product contains Vitiscensce™ Technology, a combination of stem cell extracts, antioxidants, peptides and plankton extract.

HA5 has a light silky feel.  It is meant to be used twice a day.  Think of it as an additional dose of moisture during these drier months.  It can be used anywhere to boost hydration so don’t forget about your neck and chest!  The results will be softer, smoother skin with fewer lines.  Rough skin will appear markedly softer.


With continued use the skin improves even more,


This product is available at TOC Medical Spa.

Here are the ingredients, for fellow ingredient deck analyzers!

HA5 Ingredient Deck

Water/Aqua, Dimethicone, HDI/Trimethylol Hexyllactone Crosspolymer, Glycerin, Butylene Glycol, Bis-PEG-8 Dimethicone, Polysilicone-11, Sodium Acrylate/Sodium Acryloyldimethyl Taurate Copolymer, Sodium Hyaluronate Crosspolymer, Hydrolized Hyaluronic Acid, Sodium Hyaluronate, Vitis Vinifera (Grape) Flower Cell Extract, Vibrio Alginolyticus Ferment Filtrate, Alteromonas Ferment Extract, Porphyridium Cruentum Extract, Whey Protein, Plankton Extract, Trehalose, Urea, Serine, Algin, Caprylyl Glycol, Pullulan, Disodium Phosphate, Potassium Phosphate, Pentylene Glycol, Polymethyl-silsesquioxane, Glyceryl Polyacrylate, Sodium Citrate, Sea Water, Sucrose Palmitate, Tocopheryl Acetate, Hydroxyacetophenone, Polysorbate 60, Propanediol, Potassium Sorbate, Citric Acid, Isohexadecane, Polysorbate 80, Silica, Decyl Glucoside, Tromethamine, Ethylhexylglycerine, Phenoxyethanol, Disodium EDTA.




Lips are an area that we augment frequently in aesthetic medicine.  Contrary to popular belief, lips can be done to look fuller without looking like a cartoon character or Goldie Hawn in “The First Wives Club”.

We lose volume in our lips with age in addition to a certain amount of inward rotation.  Women frequently complain about the loss of volume and fine lines surrounding the lips in to which lipstick bleeds.  These issues can easily be addressed with dermal fillers such as Juvederm® or Restylane®.    The selection of products keeps growing, allowing you and your provider to select the product which best suits your lips.  The Restylane® family of products has  Restylane®, Restylane® Silk and Restylane® Lyft.  The Juvederm® family of products includes Juvederm® Ultra, Juvederm® Ultra Plus, Juvederm® Voluma and, the newest to the market, Juvederm® Vobella.  These are ALL hyaluronic acid fillers and can be reversed with a product called hyaluronidase if needed.

The fillers differ in characteristics including the mg/ml of hyaluronic acid and the cross linking of the particles.  Some of the products are firmer (more cohesive) and are better for structure while others are softer and more malleable for finer work.  Some of the fillers attract more water, or are more hydrophilic,  than others. Your provider  takes all of these properties in to consideration depending on where the product is being placed and what your goals are.


In terms of the lips we like to add structure and volume.  Redefining the cupids bow and philtral columns in the upper lip can have a dramatic impact without adding any volume to the lip itself.  Our philtral columns tend to flatten with time and we lose the dimensions we had when we were younger.  Your provider will assess with you what you are wanting to achieve while also pointing out to you the anatomy of your lip and where product placement will have the most impact.  The goal is to make your lips look their best, not to make your lips look like somebody else’s lips.  (ie: We have all had patients request Angelina Jolie lips, which would look absurd on most people)

Patients definitely express concern related pain with lip injections.  All of the products contain lidocaine and most providers will numb you with a topical numbing cream prior to injections.  Ice can also be very helpful.  Another option,for those who want to be really numb,is a dental block which numbs the whole region.

Another option around the mouth is small doses of Botox® to weaken the oral muscle that pulls the lip in and creates the fine lip lines.  The dosing needs to be conservative as the goal is to relax the muscle but not paralyze it.

Here is an example of lips before:


And lips after:


The above patient was treated with 1 ml of Restylane® .

If you have ever considered lip filler, hopefully this will help you to better understand what is available and minimize any anxiety surrounding the process.

We inject lips every day at TOC Medical Spa.


Retin a

Retinoids and Retinols (derivatives or metabolites of Vitamin A) have been around for years and are proven to stimulate collagen production.  They  help with diminishing pigmentation, reduce lines/wrinkles, tighten pores, increase blood flow to the skin, fight acne and improve acne scarring.  They can also help diminish the appearance of stretch marks!

Retinoids (tretinoin) are retinoic acid and are available in various strengths.  Retinols are applied and are converted in to retinoic acid in the skin.  The ingredient deck will likely  include retinol or retinyl palimitate.  They are both converted into retinaldehyde and then retinoic acid in the skin.  Products with retinyl palimitate are the weakest and might be appropriate for individuals with very sensitive skin, as they need to go through several conversions to become retinoic acid.

For the history buffs, Retin-A was patented in 1967 after being developed by Dr. James Fulton and Dr. Albert Kligman at The University of Pennsylvania during the 1960s.  Kligman coined the term “photo aging” back in the ’60s. (funny we continued to sun for years and years!)   In skin care we frequently prescribe a topical treatment called Kligman’s Formula which contains a combination of Retin-A, hydroquinone, Fluocinolone and Kojic Acid for photo aging.   Originally Retin-A was for acne and hyperkeratic conditions, such as actinic keratosis.  Over time the anti-aging benefits were realized and a new patent was obtained in 1986 for wrinkle reduction. Additionally, retinoids have been shown to be beneficial for decreasing basal cell cancers.

So, how to introduce a retinoid to your skin care regime?  If you have sensitive skin starting with an over the counter retinol (or even retinyl palimitate if very sensitive) would be beneficial, ideally a 0.1% Retinol.  Once acclimated to the over the counter version a prescription strength product can be introduced as needed.  There are numerous formulas on the market and your dermatologist or skin care provider can help to select which formula would be best for your skin type.  The number one problem with retinoids is compliance.  There tends to be irritation/flaking as the product is introduced (resulting in  increased cellular turnover)  which leads to individuals ceasing the use of the product.  Ideally a product is slowly introduced and frequency of use is gradually increased.  For instance: 2x/week for 2 weeks, 3x/week for 3 weeks, every other night for 4 weeks and then every night if tolerated. Retinoids are applied at night because the sun can destabilize the product.   You may find it beneficial to have a more emollient night cream as the retinoid can dry the skin.  These products do not make you more sensitive to the sun despite this lingering stereotype.  As a matter of fact, many providers find starting a retinol or retinoid in the summer to be beneficial as the more humid air helps with the side effect of skin dryness.

Once on a retinol/retinoid it can take 3 months to acclimate to the product.  It can also take this long to start to realize the results, although I think most people see improvement almost immediately.  If you start on a product and find it too irritating, even with a titrating schedule, you may want to try a weaker formula.

Once on a retinol/retinoid be aware that your skin is more sensitive.  If you wax you should stop using your retinol/retinoid for 5+ days prior to waxing.  If you are having other skin care treatments done make sure to let your provider know you are using a retinol/retinoid.

*Pregnant and breast feeding women should not use these products.






facial changes 2

Our face experiences numerous structural changes over the years and having a general concept of these changes can help approach a customized aesthethic treatment plan.

Changes occur over time with the skin, fat, muscle and bone contributing to our facial changes, most notably, volume loss.

Over time our skin becomes thinner, drier and experiences a reduction in collagen.  The skin becomes less elastic and is likely to sag and wrinkle.  Sun damage contributes and causes skin discoloration as well.

fat 2

Additionally, our facial fat pads atrophy (break down) and shift under the skin leading to facial volume loss.  We tend to lose volume in the temples and mid face while gaining volume around the mouth, jaw and lower face.  The separation in the fat pads results in visible unevenness in our facial contours, where once it was a smooth with the apex at the lateral cheek.

bone 2

Bone loss over the years is another reason for the loss of volume.  Bone resorption over the years causes the overlying structures to loose support.

full face aging changes

The above diagram notes some of the commonly noted changes that individuals eventually seek treatment for.  There is not a one size fits all approach as we all experience age related facial changes differently.

Fillers such as HA’s, (hyaluronic acid) Sculptra® or Radiesse® can be used to return volume where it is lost.  Restoring volume in certain areas can have a nice impact on the contours, restoring a more refreshed appearance.  For instance, mid face.  Mid face volume does not only restore volume to the mid face but tends to have a lifting effect to all the tissues below.  Nasolabial folds, oral commissures and marionette lines all soften with mid face correction.

Some of the lines from repetitive muscle movement are best treated with Botox®, Dysport® or Xeomin®.  (such as the frown lines, crows feet or horizontal forehead lines)


la mer

I wanted to review this particular product as there are countless individuals who use this product and spend a lot of their money on it.  I realize there are numerous products within this line, but I will focus on the original Crème de la Mer.  The smallest jar of this product is $85. (0.5 oz)  I emailed the company and received a current ingredient deck (as it has changed) and will break it down.

The first ingredient in the 40+ ingredient deck is Algae (seaweed) extract.  This is what the product is well known for.  This “miracle broth” is harvested from a particular type of seaweed which they ferment, claiming to enhance the benefits.  Seaweed has been used in beauty and spa products for years and does have beneficial properties, such as vitamins and minerals.

After the Algae extract there are 40 ingredients, including numerous petroleum derived waxes and lubricants.  There are ingredients in the ingredient deck that I think are beneficial to the skin, such as B vitamins, vitamin E, and beta carotene as a precursor to vitamin A.  However, with an ingredient deck with over 40 ingredients all of the ingredients are diluted and in very small percentages.  Almost 10 of the ingredients are fragrances which can be irritating to the skin.  Can you tell I am not a huge fan?

That being said, I realize people love this product.  It does have a pleasant fragrance and is emollient.  However, if you experience irritation it is likely due to the numerous fragrances.  If you experience pore congestion or milia (little hard white bumps)  it is most likely due to the heavy petroleum content.

I would encourage anyone who is willing to spend $85 on 0.5 oz of a product to think about introducing products with a smaller ingredient deck with higher percentages of active ingredients, such as antioxidants.  Seek out products that have ingredients that have been evaluated with clinical trials and are proven in their efficacy.

I have clients who are married to La Mer.  The company (which is now Estèe Lauder) has done a phenomenal job marketing this product.  There has been hype surrounding it for years now.  I think there is some assumption on the consumers side that if a product costs that much it must be effective.   In this case, I believe it is unsupported with any real scientific evidence or clinical reviews.

I have attached the ingredient deck for anyone who would be interested.

Crème de la Mer Moisturizing Cream: