It is important to understand some basic principles behind sun exposure and ultraviolet radiation in order to understand what the various sunscreens on the market have to offer.
The sun's ultraviolet rays are measured over a spectrum of different wavelengths. Only some of the ultraviolet rays are harmful, namely those between 290 and 400 nanometers. Some of these rays are called UVB rays (290 to 320 nanometers) and some of these rays are called UVA rays (320 to 400 nanometers). The UVB rays are the rays responsible for a sunburn and they are partly responsible for skin cancers. The UVA rays don't cause a sunburn like the UVB rays, but the UVA rays penetrate deeper to damage the skin, leading to wrinkles, brown spots and other indicators of cellular damage. The UVA rays also cause skin cancers.
Many of my patients proudly say to me, "I wear an SPF 50 sunscreen." When I ask them what the ingredients are, 99% don't know. Unfortunately, SPF only refers to the UVB rays. 100% of the UVA rays could be going right through the sunscreen to damage the skin and cause skin cancers, even though one is wearing an SPF 50. Furthermore, the UVA rays penetrate glass and they are just as strong in the morning and afternoon as they are at noon. Luckily, most sunscreens today offer both UVA and UVB protection, but the amount of protection varies from sunscreen to sunscreen.
The best ingredients, in my opinion, are zinc oxide and titanium dioxide, since these substances block almost all of the harmful UV rays. Zinc oxide and titanium dioxide are known as sunblocks, not sunscreens, since they physically block the UV rays. Most other sunscreen ingredients react chemically with the UV rays, as opposed to physically blocking the rays. Therefore, these are called sunscreens.
A sunscreen that has been touted as one of the best for blocking UVA rays is avobenzone (Parsol 1789). However, it is not commonly known by the public that Parsol 1789 breaks down when it is struck by UV rays. Therefore, although Parsol 1789 is an excellent UVA sunscreen, it must be reapplied frequently throughout the day.
Something people always forget is the amount of reflective UV exposure that people get. Everyone realizes that water and snow reflect, but what about sand, concrete and grass?
Finally, many people think that wearing clothing is a fool-proof sunblock. However, anyone who went swimming as a child wearing a T-shirt to prevent sunburn knows that a wet T-shirt is about an SPF 1 or 2. The same applies to thin, gauzy material. Although these materials are cooler, a tightly woven fabric provides far more UV protection.
Tuesday, August 15, 2006
Thursday, August 3, 2006
Juvederm
The FDA recently approved the filler Juvederm (hyaluronic acid) for use in the United States. Juvederm, which has been available in Canada for several years, is similar to Restylane, which was FDA-approved in the U.S. a few years ago. Restylane is made by Medicis and Juvederm is now made by Allergan, the makers of Botox, after Allergan bought out Inamed Corporation earlier this year.
Juvederm is used for the correction of facial wrinkles and folds and there are three formulations of Juvederm available, Juvederm 24HV, Juvederm 30HV and Juvederm 30. Each formulation is designed to correct different types of facial folds and wrinkles. At this point in time, there is only one Restylane formulation that is FDA-approved. However, other Restylane formulations such as Perlane and Restylane Fine-Lines are expected to be approved by the FDA shortly.
The obvious question: which product is superior? At this point, Restylane certainly has the longest track record of the two and Restylane has become the soft tissue filler of choice in the U.S. However, there is some anecdotal evidence that Juvederm may result in slightly less swelling than Restylane, but this has yet to be demonstrated in controlled studies.
For now, Juvederm is another filler to add to our armamentarium and the choice of three different formulations is a definite plus, at least until Restylane adds their other two formulations to the marketplace.
Juvederm is used for the correction of facial wrinkles and folds and there are three formulations of Juvederm available, Juvederm 24HV, Juvederm 30HV and Juvederm 30. Each formulation is designed to correct different types of facial folds and wrinkles. At this point in time, there is only one Restylane formulation that is FDA-approved. However, other Restylane formulations such as Perlane and Restylane Fine-Lines are expected to be approved by the FDA shortly.
The obvious question: which product is superior? At this point, Restylane certainly has the longest track record of the two and Restylane has become the soft tissue filler of choice in the U.S. However, there is some anecdotal evidence that Juvederm may result in slightly less swelling than Restylane, but this has yet to be demonstrated in controlled studies.
For now, Juvederm is another filler to add to our armamentarium and the choice of three different formulations is a definite plus, at least until Restylane adds their other two formulations to the marketplace.
Friday, July 21, 2006
Lip Lift
Although significant attention has been directed toward lip augmentation, there is one situation in which lip augmentation alone may actually make the lips look worse.
In youth, the distance from the nose to the upper lip is generally fairly short, although the length varies significantly from person to person. With age, this distance increases. As the distance increases, the upper teeth are covered by the upper lip. Furthermore, the "pouty" aspect of the lips where the edges of the lips (the vermilion border) evert, diminishes with time, so that the lips appear flatter. Of course, the overall size of the lips also decreases.
Based on these observations, simply enlarging the lips by injecting a filler (e.g., fat, Restylane, Cosmoplast) addresses only one aspect -- the actual size -- of the aging lip. If a young patient already has a nice pout and has a short distance between the nose and the upper lip, simply increasing the size of the lips is all that is needed. However, if an older patient has a lost that pout and the distance between the nose and the upper lip is too long, just increasing the size of the lips may look strange. In fact, many of the odd-looking lips that one sees these days is the result of a doctor augmenting lips that really needed more than just a filler.
An ideal procedure for many of these patients is the lip lift. The lip lift involves a small incision placed where the nose meets the upper lip skin. The incision extends from one nostril to the other and is hidden quite well in the natural crease where the nostrils meet the face. The incision dips into each nostril, where it is easy to hide the incision. Because of the shadowing effect created by the nose, in the vast majority of cases the scar is virtually imperceptible.
I always perform the lip lift procedure in conjunction with a filler. The combination of a shorter upper lip, a poutier upper lip and fuller lips creates the youthful appearance that patients want. Because the lips are also lifted slightly, the upper teeth become more visible, also contributing to the youthful appearance.
When properly executed, the lip lift is an excellent procedure for many patients.
In youth, the distance from the nose to the upper lip is generally fairly short, although the length varies significantly from person to person. With age, this distance increases. As the distance increases, the upper teeth are covered by the upper lip. Furthermore, the "pouty" aspect of the lips where the edges of the lips (the vermilion border) evert, diminishes with time, so that the lips appear flatter. Of course, the overall size of the lips also decreases.
Based on these observations, simply enlarging the lips by injecting a filler (e.g., fat, Restylane, Cosmoplast) addresses only one aspect -- the actual size -- of the aging lip. If a young patient already has a nice pout and has a short distance between the nose and the upper lip, simply increasing the size of the lips is all that is needed. However, if an older patient has a lost that pout and the distance between the nose and the upper lip is too long, just increasing the size of the lips may look strange. In fact, many of the odd-looking lips that one sees these days is the result of a doctor augmenting lips that really needed more than just a filler.
An ideal procedure for many of these patients is the lip lift. The lip lift involves a small incision placed where the nose meets the upper lip skin. The incision extends from one nostril to the other and is hidden quite well in the natural crease where the nostrils meet the face. The incision dips into each nostril, where it is easy to hide the incision. Because of the shadowing effect created by the nose, in the vast majority of cases the scar is virtually imperceptible.
I always perform the lip lift procedure in conjunction with a filler. The combination of a shorter upper lip, a poutier upper lip and fuller lips creates the youthful appearance that patients want. Because the lips are also lifted slightly, the upper teeth become more visible, also contributing to the youthful appearance.
When properly executed, the lip lift is an excellent procedure for many patients.
Wednesday, June 7, 2006
Mesotherapy Position Statement
The American Society for Aesthetic Plastic Surgery (ASAPS) recently issued a "position paper" on the use of mesotherapy. A position paper by an organization such as the ASAPS presents the organization's official stance on a technique like mesotherapy or a device like a new laser. In this way, a plastic surgeon can better form an objective opinion on a new technique or device without listening to biased individuals like the inventor of the technique or the manufacturer of the device.
The ASAPS often forms ad hoc committees specifically to address new techniques like mesotherapy, where the public is inundated with non-scientific information from the media. Because of this media blitz, plastic surgeons are asked about mesotherapy by their patients. The Aesthetic Society Mesotherapy Committee scours the world literature for any and all information on mesotherapy. Is it safe? Is it effective? What exactly is it? Should plastic surgeons consider doing mesotherapy in their practices? How do they learn how do perform mesotherapy? These are all questions that organizations like the ASAPS want to answer through their ad hoc mesotherapy committee.
Here are the recommendations that the ASAPS made to its members, after an extensive investigation into the use of mesotherapy:
ASAPS does not endorse the injection of phosphatydal choline, deocycholate or any other drugs, vitamins, plant extracts, hormones, etc. into subcutaneous fat as practiced in mesotherapy/Lipodissolve treatments. At present, these therapies lack objective proof of safety and efficacy. They also lack FDA approval.
Members should therefore refrain from adopting these procedures until the results of the ASERF [a plastic surgery research organization] study are available to provide proof of safety and efficacy, or lack thereof. If and when patients ask about these treatments, the scientific reality that currently exists should be explained to them, along with the caution to wait until something definitive is known. Until then, patients should be warned about seeking treatments from people who may not be qualified to administer large numbers of injections that require very precise placement.
[Reprinted from the SPRING 2006 issue of Aesthetic Society News, Volume 10, Number 2.]
The ASAPS often forms ad hoc committees specifically to address new techniques like mesotherapy, where the public is inundated with non-scientific information from the media. Because of this media blitz, plastic surgeons are asked about mesotherapy by their patients. The Aesthetic Society Mesotherapy Committee scours the world literature for any and all information on mesotherapy. Is it safe? Is it effective? What exactly is it? Should plastic surgeons consider doing mesotherapy in their practices? How do they learn how do perform mesotherapy? These are all questions that organizations like the ASAPS want to answer through their ad hoc mesotherapy committee.
Here are the recommendations that the ASAPS made to its members, after an extensive investigation into the use of mesotherapy:
ASAPS does not endorse the injection of phosphatydal choline, deocycholate or any other drugs, vitamins, plant extracts, hormones, etc. into subcutaneous fat as practiced in mesotherapy/Lipodissolve treatments. At present, these therapies lack objective proof of safety and efficacy. They also lack FDA approval.
Members should therefore refrain from adopting these procedures until the results of the ASERF [a plastic surgery research organization] study are available to provide proof of safety and efficacy, or lack thereof. If and when patients ask about these treatments, the scientific reality that currently exists should be explained to them, along with the caution to wait until something definitive is known. Until then, patients should be warned about seeking treatments from people who may not be qualified to administer large numbers of injections that require very precise placement.
[Reprinted from the SPRING 2006 issue of Aesthetic Society News, Volume 10, Number 2.]
Tuesday, April 4, 2006
Jowls
One of the signs of the aging face that people object to is jowling. The jowls are areas of fullness along the jawline that tend to increase with age. The straight, strong jawline of youth is gradually replaced by the soft, irregular jawline of the aging face. It is thought that jowls result from the combination of muscle, skin and fat that all begin to sag with age. An area known as the pre-jowl region is located directly in front of the jowl. It is thought that a ligament (the mandibular ligament) attaches the skin to the bone in this region, creating a depression in front of the jowl. Because the ligament doesn't stretch with age, as the howl increases in size with age, the pre-jowl depression becomes deeper and deeper, making the jowl look even bigger.
There are several ways to treat the jowls, both surgical and non-surgical. Surgical options include mainly facelifting and liposuction. During a facelift, the facial soft tissues are pulled upward and backward, thereby raising the jowls upward above the jawline so that they don't hang over the jawline. Adding a mid-face lift may improve things even further, since the mid-face lift pulls the facial soft tissues vertically, raising the jowls even higher above the jawline to hide them even more than with just a facelift alone. These procedures don't remove any jowl tissue, they simply reposition the jowls.
Another surgical option is a facial implant. These pre-jowl implants are similar to chin implants, but the part of the implant over the chin itself is paper thin. The implant then flares out to thicken in the pre-jowl area. The implant minimizes the jowl by filling out the depression that forms in front of the jowl, in the area of the mandibular ligament. With this implant, the jowl is not repositioned or removed, it is simply camouflaged.
Recently, another surgical option has been developed, although the jury is still out on this one. Various suture suspension techniques have been developed over the last few years in an attempt to minimize downtime. Names such as Featherlift and Threadlift have been bandied about in the media for the past few years. There is very little long-term data on these procedures at this time. At a recent plastic surgery conference in Palm Springs CA, the consensus among the surgeons in attendance was that it was too early to tell what role these suture suspension techniques would play. However, it was apparent that the techniques may be appropriate for younger individuals who want a minimal procedure that may last less that a year.
Liposuction, which actually removes some of the jowls, can be performed in conjunction with a facelift or it can be performed as a stand-alone procedure. Many surgeons feel that repositioning alone will not completely eliminate the jowls. These surgeons feel that the jowls need to be reduced in size somewhat in addition to being repositioned. However, liposuction needs to be performed carefully in this region with a very small cannula (1.5 to 1.8 mm diameter) because it is easy to cause irregularities and ridges if this area is liposuctioned too aggressively. Some surgeons use scissors to directly remove the jowls during a facelift, in an attempt to avoid irregularities from liposuction.
Non-surgical options include fillers, Thermage and mesotherapy. Of these, fillers have the longest track record. Any number of fillers can be used, including collagen, Cosmoplast, Restylane, Radiesse and fat. While none of these fillers is permanent, Radiesse and fat potentially last the longest. With the recent FDA approval of Radiesse, this is becoming more and more popular to treat jowling. With any of these fillers, the principle is the same: the filler is placed in the pre-jowl area in order to camouflage the jowl, similar to the pre-jowl implant.
Like the suture suspension techniques, the jury is still out on techniques such as Thermage and mesotherapy. Thermage uses a radiofrequency device to melt the fat and mesotherapy uses a "cocktail" of various ingredients injected into the jowl to melt the fat. The body then absorbs the fat and the skin then shrinks and tightens, theoretically.
Many surgeons, including myself, use a combination of techniques. During surgery, I will often perform a combination of a facelift, midface lift and jowl liposuction. After that, I will inject Radiesee into the pre-jowl area to fill the depression. In the months and years after surgery, I will inject Radiesse every year or so to maintain volume in the pre-jowl area. There may be a role for such things as mesotherapy or Thermage for maintenance, but I am waiting for more solid data before I proceed with these modalities.
There are several ways to treat the jowls, both surgical and non-surgical. Surgical options include mainly facelifting and liposuction. During a facelift, the facial soft tissues are pulled upward and backward, thereby raising the jowls upward above the jawline so that they don't hang over the jawline. Adding a mid-face lift may improve things even further, since the mid-face lift pulls the facial soft tissues vertically, raising the jowls even higher above the jawline to hide them even more than with just a facelift alone. These procedures don't remove any jowl tissue, they simply reposition the jowls.
Another surgical option is a facial implant. These pre-jowl implants are similar to chin implants, but the part of the implant over the chin itself is paper thin. The implant then flares out to thicken in the pre-jowl area. The implant minimizes the jowl by filling out the depression that forms in front of the jowl, in the area of the mandibular ligament. With this implant, the jowl is not repositioned or removed, it is simply camouflaged.
Recently, another surgical option has been developed, although the jury is still out on this one. Various suture suspension techniques have been developed over the last few years in an attempt to minimize downtime. Names such as Featherlift and Threadlift have been bandied about in the media for the past few years. There is very little long-term data on these procedures at this time. At a recent plastic surgery conference in Palm Springs CA, the consensus among the surgeons in attendance was that it was too early to tell what role these suture suspension techniques would play. However, it was apparent that the techniques may be appropriate for younger individuals who want a minimal procedure that may last less that a year.
Liposuction, which actually removes some of the jowls, can be performed in conjunction with a facelift or it can be performed as a stand-alone procedure. Many surgeons feel that repositioning alone will not completely eliminate the jowls. These surgeons feel that the jowls need to be reduced in size somewhat in addition to being repositioned. However, liposuction needs to be performed carefully in this region with a very small cannula (1.5 to 1.8 mm diameter) because it is easy to cause irregularities and ridges if this area is liposuctioned too aggressively. Some surgeons use scissors to directly remove the jowls during a facelift, in an attempt to avoid irregularities from liposuction.
Non-surgical options include fillers, Thermage and mesotherapy. Of these, fillers have the longest track record. Any number of fillers can be used, including collagen, Cosmoplast, Restylane, Radiesse and fat. While none of these fillers is permanent, Radiesse and fat potentially last the longest. With the recent FDA approval of Radiesse, this is becoming more and more popular to treat jowling. With any of these fillers, the principle is the same: the filler is placed in the pre-jowl area in order to camouflage the jowl, similar to the pre-jowl implant.
Like the suture suspension techniques, the jury is still out on techniques such as Thermage and mesotherapy. Thermage uses a radiofrequency device to melt the fat and mesotherapy uses a "cocktail" of various ingredients injected into the jowl to melt the fat. The body then absorbs the fat and the skin then shrinks and tightens, theoretically.
Many surgeons, including myself, use a combination of techniques. During surgery, I will often perform a combination of a facelift, midface lift and jowl liposuction. After that, I will inject Radiesee into the pre-jowl area to fill the depression. In the months and years after surgery, I will inject Radiesse every year or so to maintain volume in the pre-jowl area. There may be a role for such things as mesotherapy or Thermage for maintenance, but I am waiting for more solid data before I proceed with these modalities.
Tuesday, March 14, 2006
Marionette Lines
The lines that extend down from the corners of the mouth toward the chin are known as marionette lines. The marionette lines tend to deepen with age and they give the appearance that one is frowning. Some people have a strong tendency to have marionette lines, even at a young age, whereas some people never develop them. Surgical procedures like facelifts are notoriously ineffective in treating marionette lines.
The most commonly used method to treat marionette lines is to simply fill the lines with a substance known as a "filler". In the past, fillers such as fat, collagen and Cosmoplast were used. Today, fillers such as Restylane and Radiesse are more commonly used, since these fillers last much longer than most of the other fillers previously available. A five minute injection of Restylane can minimize -- or eliminate -- marionette lines. Repeat injections are performed at six to nine months. With Radiesse, repeat injections are necessary at twelve months. Microinjections of silicone, considered controversial by many physicians, is also sometimes done. Finally, permanent implants are sometimes used in this area as well. Implants made of Gor-Tex are sometimes done, but these implants can sometimes be visible or palpable.
I have found that Botox injections can be quite helpful in the treatment of marionette lines. Certain muscles, called the depressor muscles, can pull the corners of the mouth down and contribute to the downward slant to the corners of the mouth, which then leads right into the marionette lines. By injecting Botox into the depressor anguli oris muscle, the corners of the mouth go up slightly, and the n marionette lines are diminished. Typically, with this regimen, the patient will come into the office every three to four months for Botox injections and every six to twelve months for a filler, depending on the type of filler (Restylane v. Radiesse).
There are a few rarely-done surgical options that are designed to address the corners of the mouth directly. A corner lip lift involves cutting a small triangular piece of skin away from the corners of the mouth in an attempt to give an upturn to the corners. However, the scar can be objectionable and the corners can look unnatural. An ever rarer procedure involves cutting the depressor anguli oris muscle in order to deactivate it (like the Botox injections do). But most surgeons feel that the risks out weigh the benefits for this procedure.
The most commonly used method to treat marionette lines is to simply fill the lines with a substance known as a "filler". In the past, fillers such as fat, collagen and Cosmoplast were used. Today, fillers such as Restylane and Radiesse are more commonly used, since these fillers last much longer than most of the other fillers previously available. A five minute injection of Restylane can minimize -- or eliminate -- marionette lines. Repeat injections are performed at six to nine months. With Radiesse, repeat injections are necessary at twelve months. Microinjections of silicone, considered controversial by many physicians, is also sometimes done. Finally, permanent implants are sometimes used in this area as well. Implants made of Gor-Tex are sometimes done, but these implants can sometimes be visible or palpable.
I have found that Botox injections can be quite helpful in the treatment of marionette lines. Certain muscles, called the depressor muscles, can pull the corners of the mouth down and contribute to the downward slant to the corners of the mouth, which then leads right into the marionette lines. By injecting Botox into the depressor anguli oris muscle, the corners of the mouth go up slightly, and the n marionette lines are diminished. Typically, with this regimen, the patient will come into the office every three to four months for Botox injections and every six to twelve months for a filler, depending on the type of filler (Restylane v. Radiesse).
There are a few rarely-done surgical options that are designed to address the corners of the mouth directly. A corner lip lift involves cutting a small triangular piece of skin away from the corners of the mouth in an attempt to give an upturn to the corners. However, the scar can be objectionable and the corners can look unnatural. An ever rarer procedure involves cutting the depressor anguli oris muscle in order to deactivate it (like the Botox injections do). But most surgeons feel that the risks out weigh the benefits for this procedure.
Friday, March 3, 2006
Anastasia Oscar Spa
Anastasia hosted her second annual Oscar Spa on Wednesday, March 1 and Thursday, March 2 at her home in Beverly Hills. Anastasia spa is arguably the most private and exclusive of the increasingly popular pre-Oscar spas, because it is held at her secluded home in the hills, unlike most of the spas which are held in public places like hotels. Because of this privacy and exclusivity, Anastasia attracted the likes of Oprah, Nicolette Sheridan, Eva Longoria, Kelly Preston, Debra Messing, Teri Hatcher the very first year she hosted the Oscar Spa. Of course, most of these people are Anastasia's regular clients as well and they were happy to support her new endeavor.
This year, Anastasia expanded the Spa, so that virtually every room in her house her house was devoted to a different service -- hair and makeup, pedicures and manicures and, of course, eyebrow sculpting by Anastasia. A new addition to the Spa this year was Twin Magic. Jimmy and Daniel performed eyelash extensions after Anastasia finished with the guests' eyebrows. Between treatments, guests lounged by the pool and were served lunch. Attendees this year included Lauren Sanchez, Catherine Bell, Amber Valetta, Garcelle Beauvais, Debra Messing, Molly Sims, Angela Bassett and Jessica Alba.
This year, Anastasia expanded the Spa, so that virtually every room in her house her house was devoted to a different service -- hair and makeup, pedicures and manicures and, of course, eyebrow sculpting by Anastasia. A new addition to the Spa this year was Twin Magic. Jimmy and Daniel performed eyelash extensions after Anastasia finished with the guests' eyebrows. Between treatments, guests lounged by the pool and were served lunch. Attendees this year included Lauren Sanchez, Catherine Bell, Amber Valetta, Garcelle Beauvais, Debra Messing, Molly Sims, Angela Bassett and Jessica Alba.
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