Dr Ryan’s Personal Skin Care Regimen

Almost every day, a patient asks me, “What do you do for your skin, Dr Ryan?” The truth is that for years, I did absolutely nothing for my skin. In fact, until I was around 37 or 38, I purposely tanned my face. I remember skiing at Aspen and trying to get as much sun as possible on my face; I would sit on the deck at Bonnie’s having lunch and rotate my body to follow the sun so my face got maximum exposure! My face was almost purplish, it was so sun-damaged.

As someone of Irish heritage, I am what’s classified as a Fitzpatrick skin type II, meaning that I have fair skin and blue eyes and that I burn easily in the sun. My skin issues pertain mainly to dilated (or “broken”) blood vessels and ruddiness. Therefore, I need a skin care regimen that is very gentle so that more blood vessels do not “break,” which would lead to even more ruddiness. On the other hand, many people with olive skin and brown eyes (Fitzpatrick skin types III and above) have issues with hyperpigmentation (i.e., brown spots or patches), not ruddiness and broken blood vessels. Therefore, these patients often need to focus on beaching creams such as hydroquinone or kojic acid. People with significant sun damage, fine lines and brown spots may need to focus more on products that contain ingredients that help to reverse sun damage; these ingredients include kinetin, retinol or acids. In people with sensitive skin, however, some of these ingredients may be irritating.

In the last five years, I have made great strides with my skin and here’s how I did it.

1. Gentle cleanser and moisturizer – Because of my sensitive skin, I require a very mild cleanser and moisturizer. However, I could never find one that met my exact specifications. So I decided to develop my own. Every morning and night, I use the Dr Frank Ryan cleanser and moisturizer. For people who prefer their skin care products to be paraben and sulfate-free, I also have a paraben and sulfate-free cleanser. The products are aloe-based, and contain ingredients like sage and arnica.
   


2. Broad-spectrum, high SPF sunblock – This is the most important thing for good skin. About five years ago, I began using a daily moisturizer with an SPF of 15. After a year or two of doing that, it occurred to me that I should probably use something stronger. So I tried many different sunscreens and concluded that the Skinceuticals SPF 45 was the best, in my opinion. It does not leave the skin white and provides excellent broad-spectrum coverage, since its main ingredient is zinc oxide, still the best sunblock out there in my book. This alone began to improve my skin dramatically. Other excellent sunblocks are made by Epicuren and Fenix. I am currently formulating my own sunblock for the Dr Frank Ryan line.
   


3. Skin Refining Gel – My secret weapon is the Dr Frank Ryan Skin Refining Gel. This product is very difficult to categorize, but in general, it serves to minimize or even eliminate the appearance of pores, fine lines and irregularities in skin texture or tone. It contains several topical vitamins, arnica and alpha-lipoic acid and is lightly tinted. Remarkably, many men are absolutely hooked on this product, because it improves their skin significantly, but is not considered “make-up”. When people comment on my skin, I always confess that I had a little help from my Skin Refining Gel.
   

There are many, many excellent products on the market that I don’t use only because they are not what my skin needs. Product lines like Kinerase and Epicuren are excellent and we carry both lines in my office. Individual products like Renova and Tri-Luma and Cellex-C are all excellent.

Bottom line: each person needs a skin care regimen specifically designed for his or her own skin type. A product like Renova, which would be beneficial for many people, would simply be too strong and irritating for my sensitive skin. On the other hand, a simple, gentle skin care regimen like I use would simply not be strong enough to help someone with severely sun-damaged, weather beaten skin.

Next up: the laser and light therapy devices that I have used – and to continue to use – to improve and maintain my skin.

The Mini-Facelift under Local Anesthesia

For most of my fifteen years in practice, I performed the vast majority of my facelifts under general anesthesia with the patient asleep. About three or four years ago, a very determined young lady practically begged me to do her mini-facelift under local anesthesia, meaning that she would be awake. Because she had a high pain threshold and was stoic by nature, I agreed to do so. The procedure was a breeze and she raved about how easy the process was and how quickly she recovered. After that, I began to do more and more mini-facelifts -- and even more extensive facelifts -- under local anesthesia. I realized that in some cases, I could accomplish the majority of what I needed to accomplish without general anesthesia – the key was to choose the patients carefully and to educate the patient beforehand about what to expect.

When performing a facelift under general anesthesia, we routinely require the patient to obtain preoperative blood work and other tests, including an EKG and a chest X-ray. General anesthesia requires that an anesthesiologist be present, which adds to the expense. Furthermore, there is typically a bit more recovery involved after general anesthesia. Mini-facelifts under local anesthesia, however, usually don’t require the preoperative lab work and an anesthesiologist is not required to be present.

Local anesthesia typically also involves giving an oral medication like Valium; this type of anesthesia is known as “local with oral sedation”. The patient is given Valium approximately 20 minutes before beginning the procedure; that way, the patient is drowsy when he or she is taken into the operating room. Once in the operating room, local anesthesia (lidocaine) is injected into the face, not unlike at the dentist’s office. This is, perhaps, the most uncomfortable part of the entire procedure, more so than the surgery itself. The Valium, however, really takes the edge off this part and most patients say afterward, “The injections really didn’t hurt much at all!” After the local anesthetic has taken effect, the patient typically feels little or no discomfort for the rest of the surgery.

The mini-facelift takes a little over an hour and the patient is walking and talking immediately after the procedure. We typically wrap the face and neck in a light bandage that is removed the next morning when we see the patient in the office. After surgery, we send many of our patients to an after-care facility where they are watched by nurses. However, in some cases, the patient is able to go home if there is a family member or friend who can keep an eye on the patient overnight. Where the patient spends the first night after surgery depends on many variables, including the complexity and length of the surgery and the health and age of the patient. The stitches, located around the ear, are removed in seven to ten days; bruising and swelling is usually minimal. In fact, I am always amazed how quickly patients recover from these procedures. Most are back at work in a week.

In younger patients (30’s and 40’s), the mini-facelift may all they need. In patients in their 50’s and older, other procedures such as a browlift and upper and lower eyelid surgery may also be indicated. As the list of procedures increases, I lean more and more toward general anesthesia.

In older patients, a mini-facelift may still be appropriate. However, these patients need to be educated that a mini-facelift has limits in what it can do. If the neck is extremely saggy, for example, a mini-facelift is probably not the best procedure. Simply put, the mini-facelift can’t accomplish as much compared to what can be accomplished with a more extensive facelift.

In conclusion, the mini-facelift under local anesthesia is a quick and simple procedure that I am incorporating more and more in my practice. The results are excellent and the patients are happy – and that makes me happy.

LATISSE -- The Key to Fuller Eyelashes

Allergan Corporation (the makers of BOTOX and Juvederm) recently released their prescription eyelash booster, LATISSE. When people ask me if it really works, my response is an emphatic YES!

LATISSE is an FDA-approved, once-daily treatment applied to the base of the upper lashes with a sterile, single-use-per-eye dosposable applicator. Most users see significant results in two to four months. If use of LATISSE is discontinued, the lashes simply return to how they were before the treatments were begun.

Latisse has an interesting history. The main ingredeint is based on a glaucoma drug, bimatoprost, and its effects on eyelash growth were discovered by accident.. Several years ago, people who were using LUMIGAN (the glaucoma drug containing bimatoprost) noted spontaneous eyelash growth. Based on those findings, Allergan began investigating the use of this drug for eyelash growth. This history is not dissimilar to that of BOTOX, which was initially used for muscle spasms. When people noticed that it also made wrinkles disappear, it was eventually approved for the elimination of wrinkles as well.

Since LATISSE is from a respected pharmaceutical company such as Allergan, it makes sense that there is solid scientific data to support its safety and effectiveness. In terms of effectiveness, studies have shown that there is, on average, a 25% increase in eyelash length, a 106% increase in eyelash thickness and an 18% increase in eyelash darkness. In terms of side effects, there was a 3.6% incidence of eye redness, a 3.6 %incidence of eye itchiness and a 2.9% incidence of skin hyperpigmentation. Less common side effects included eye irritation, dry eyes and redness of the eyelids. Hyperpigmentation refers to a slight darkening of the eyelid skin, which may or may not be reversible. There is also a possibility of increased brown pigmentation to the iris, the colored part of the eye.

In my experience with Latisse, I have seen only a handful of patients complain of mild irritation or redness or itchiness, but these symptoms were mild enough that none of these patients discontinued the product. In general, the feedback has been overwhelmingly positive.

Many people are familiar with competing over-the-counter products that promise to make the lashes fuller. Many of these competing products worked quite well -- and that's because they were knocking off Allergan's ingredient! However, because bimatoprost is patented and, more importantly, because it is a drug, these companies were skirting the law. They would try to get around these problems by very slightly changing one or two molecules on the drug, but it was only a matter of time until Allergan came on the scene with the real deal.

At this point, why would anyone use anything but the patented, prescription-only LATISSE from Allergan?

Although any physician can prescribe LATISSE, it can be obtained directly from many plastic surgeons and dermatologists, who dispense LATISSE in their offices. The suggested retail price is $120 and one container lasts for up to two months.

More detailed information can be found at www.LATISSE.com.

Footnote: Last Thursday Allergan officially launched LATISSE with an event on La Cienega Boulevard in LA. The room was filled with beauty editors from all the top magazines as well as celebrities like Jewel, Debra Messing, Debbie Mazur, Mandy Moore, Debbie Matenopolous and others. The thing I found interesting was that almost one half of the people I met that night who requested LATISSE prescriptions from me were men -- I have a feeling that the male market for LATISSE will be significant.

Non-Invasive Fat Removal

Erchonia Medical has developed what is considered the Holy Grail of plastic surgery: a non-invasive, painless treatment that melts fat. The Zerona is a low level laser that emulsifies (i.e. liquefies) fat, allowing the body to excrete it naturally. Treatments are performed in thirty minute sessions, every other day for two weeks and are completely painless. After each treatment, we encourage our patients to increase their water intake, which helps to eliminate the emulsified fat. Our aesthetician performs lymphatic massages after each treatment which is also helpful in eliminating the fat. Some patients choose to wear a compression garment after the treatment, similar to what is worn after conventional liposuction.

So far, my office staff has seen some very exciting preliminary results. We have used the Zerona to treat the arms, abdomen, love handles, thighs and knees. We have also treated the jowls and under the chin. One staff member lost ½ inch off her arms and others have lost over an inch off their hips and thighs.

Just a week ago, I had an experience in surgery that convinced me that the Zerona has huge potential. I was performing liposuction on a male patient’s abdomen and love handles. During the procedure, I noticed immediately that the fat that was being removed was coming out very smoothly and was virtually bloodless. It appeared almost melted. Then it occurred to me that this particular patient was the first liposuction patient in my practice to have undergone a preoperative Zerona treatment. It appeared that the Zerona had indeed emulsified and liquefied the fat and that we were suctioning out what the Zerona had liquefied 72 hours earlier!

Currently, we are performing the Zerona on several subjects and accumulating more data.

Check back in a few weeks for an update.

Breast Implant Update

Most people are aware of the difference between saline and silicone breast implants. Most people are also aware of the difference between round and teardrop breast implants. But what about the difference between moderate profile, moderate plus and high profile breast implants? These are terms that Mentor Corporation uses to describe their three different implant profiles. Moderate Profile refers to a less projecting, yet wider implant; High Profile refers to a more projecting, yet narrower, implant. Moderate Plus is somewhere in between these two, with a moderate amount of projection and a moderate width. Projection refers to the degree to which the implants protrude from the chest. The type of implant chosen is largely determined by each patient’s anatomy. The following two examples illustrate how these different implants can be used.

Case #1

Recently, a patient who had undergone breast augmentation came to me complaining that her breasts appeared too wide for her frame. She complained that the implants stuck out under her arms and that her breasts were too close together in the cleavage area. After examining the patient, it was immediately apparent that she was exactly right: her implants were simply too wide for her rib cage. In fact, the patient was very close to having synmastia, where the breast implants touch in the middle, often eliminating the cleavage completely. I explained to her that the combined diameter of the two implants was simply wider than the width of her chest. The solution: narrower implants. Not necessarily smaller (i.e., less volume), but narrower. Since she stated that she wanted to maintain a fair amount of projection, the perfect solution would be the narrower – yet more projecting – high profile implants. So I removed the moderate implants and replaced them with high profile implants, which fit her chest diameter better and maintained the projection.

Case #2

A few months ago, I saw a patient complaining of what she described as a “strange” shape to her breasts following breast augmentation. She couldn’t put her finger on what exactly made the breasts seem strange to her -- she just knew she didn’t like them. Exam revealed very narrow breasts that projected excessively from her chest. She had a very wide rib cage and a very protruding rib cage and it appeared to me, after examining her, that she had high profile implants in place. The combination of narrow, high profile implants in a patient with a wide, prominent rib cage resulted in a strange look indeed: very wide cleavage and breasts that looked like two oranges abruptly jutting off the chest. I explained that we needed to remove the high profile implants and replace them with moderate implants. The extra width and reduced projection would fit this patient’s anatomy perfectly. Sure enough, a simple switch to slightly larger moderate profile implants solved the problem.

The above examples represent cases where simply changing the profile of the implant solved the problem. There are many cases where more needs to be done to solve the problem, such as repairing synmastia or making the pocket smaller to accommodate a smaller implant diameter.
In conclusion, the three different implant profiles available today allow plastic surgeons to take into account variations in breast and chest wall anatomy to produce predictable and satisfactory breast augmentation results.

Jaw Augmentation

A strong jawline (mandible) indicates strength and youth and is an attractive feature in both men and women. Some people are born with a strong jawline, but the definition is slowly lost over time as the aging process takes over. Other people were born with a relatively weak jawline that just tends to get weaker over time. The demarcation between the face an the neck is increasingly obscured as the skin loses its elasticity and as the jowls begin to form.

There are three main areas where the jaw may need augmenting:

1. The angle of the mandible, where the mandible angles sharply below the earlobe;
2. The body of the mandible, midway between the angle and the chin; and,
3. The area between the chin and the jowl, a depression known as the labiomandibular groove.

In the past, mandibular implants were really the only option out there for mandibular augmentation. These implants, usually made of solid silicone rubber, were placed through an incision in the mouth. The implants were often somewhat difficult to position properly and the implants tended to shift with mouth movements such as chewing in some people.

For the past several years, my procedure of choice for augmenting the mandible is fat grafting. Fat grafting is quick and easy and works quite well for this purpose. I usually tell my patients that they may need more than one fat grafting session, but many patients seem to get great results with just one session.

Another filler that I have used quite a bit is Radiesse. Since Radiesse can tend to lump if placed in areas of thin skin (like the nasojugal grooves of the lower eyelid), I use it exclusively in areas where there is a fair amount of soft tissue coverage, such as the mandible . It seems to last a year or more in these areas.

With the recent FDA approval of Arte-Fill, I have been using Arte-Fill more and more for mandibular augmentation. Last week, I placed a few syringes of Arte-Fill into a male patient’s mandibular angle and the results were dramatic. Instantly, he looked more masculine, more handsome and more youthful. Pretty powerful stuff!

The only anesthesia required for mandibular augmentation is numbing cream on the skin. The procedure takes ten minutes and the patients walk out with immediate results. Typically, patients note that that their jaws are slightly sore for a few days, especially when chewing.

The evolution from a surgical procedure (mandibular implants) to a more minor surgical procedure (fat grafting) to a non-surgical procedure mirrors the overall trend in cosmetic surgery: more and more is being done with fillers and other noninvasive methods.

Silicone Breast Implant Update

Since the wide release of silicone breast implants by the FDA in November of 2006, I have not used a single saline implant. In fact, my surgery center is sending our supply of saline implants back to the manufacturer to make room for silicone implants. On the rare occasion in which we need saline implants, we will have them shipped special order from the implant manufacturer.

For the past fifteen years, 90% of the breast implants used in the United States were saline. During that same time period, over 90% of the breast implants placed in much of the rest of the world were silicone. Most plastic surgeons anticipate that in time, over 90% of the implants used in the U.S. will be silicone.

When patients ask me, “Dr. Ryan, which implants are better, saline or silicone?”, I respond that, like everything else in life, they each have their pros and cons, so I can’t say that one is “better” than the other. I tell my patients that before 1992 (when he FDA put restrictions on the use of silicone implants), over 90% of implants placed were silicone and that I anticipate that we will return to close 90% usage in this country.

When patients ask me, “But aren’t silicone implants dangerous?”, I respond “Of course they’re dangerous! We doctors love doing dangerous things to our patients all the time! And the malpractice lawyers love it even more!” I then explain to the patient, after we both finish laughing, that there is no way that I — or any other doctor — would ever do a procedure or use a device that we feel is dangerous. I then recite the many well-done, peer-reviewed scientific studies that refute that there is any link between silicone breast implants and cancer, autoimmune disorders or any number of other diseases that people have tried to link with silicone breast implants over the years.

In summary, it appears that silicone breast implants are here to stay and that the vast majority of surgeons and patients are welcoming their return.