California Cosmetic Surgery Blog

Fraxel Repair (CO2): A Big Time Winner?

2008-06-30T22:24:24-07:00

We do a lot of cosmetic procedures and most patients are pleased. However, it's not that common for a patient to return for a follow-up visit and give the doctor a hug. That's what happened this past week with a woman who returned for a one month check up exclaiming "The holes in my face are gone!" We've had similar enthusiasm from other patients, such as the man who said "Everyone in Stockton should be lined up outside your door for this treatment."

Of course, not everyone is totally enthusiastic. We've had a couple of patients who had very deep wrinkles or scars who were happy but not thrilled with their results. There are probably several reasons for that. Initially our treatment settings were more conservative than the ones we're currently using, and this may have resulted in less dramatic results. Second, these were the the results seen at one month after treatment, and the best results probably take 6 months to develop. Finally, even though the Fraxel re:pair laser has been marketed as a single treatment device, there are probably some people who are going to require one or more touch-up treatments.
There are some benefits that are relatively unique to the fraxellated lasers. They can be used on the skin off the face to safely repair sun damaged and aged skin. We have had several patients who are interested in this because although their faces have been restored, their chests and necks look terrible. The second benefit that is seen with these lasers is that scars that are lighter colored or even porcelan white will frequently at least partially re-pigment after treatment.
Overall, the Fraxel re:pair laser, and probably some, but not all, of its clones, represents a significant advance in our ability to safely treat conditions that we could previously treat only with difficulty, and with much more risk.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA

The Filler as Time Bomb II

2008-06-26T13:32:51-07:00

Below is an email received today relating a patient's experience with Sculptra. Next is a follow-up email.

Dear Dr. Bock,

Is there any procedure that you may be aware of to remove these horrible "foreign body objects" per the dermo who saw me after the plastic surgeon got done with me.

They appeared five months after my first Sculptra treatment. They are underneath both eyes. Seems they were caused by my "normal healthy" reaction to having three Sculptra injections (Sculpta sounds so much nicer than Polylactic Acid, a better ring).

I'm not an HIV male, just an under-informed and angry (just what I don't want to be) in shock female who remembered when doctors seemed to help not harm.

ps: The Plastic Surgeon did however manage to easily remove $5000 from my wallet but can't do a thing about removing these scars. Sorry about my tone. Truly any safe corrections you may know? Of course, I also had zero results of any increased volume. Guess I have "faulty collagen" too boot! Who knew...

Thanks much for coming out against this product that should should never have been allowed on the market in the first place.

There should be more docs like you who just say no to this scam.

Dear Dr. Bock,

If I didn't live 3000 miles away, I would gladly see you for a consultation. Truly, you were the only doc when I began to research the side effects I was experiencing from Sculptra who spoke out against this latest big drug company scam. They did come up with an amazing story, using gay men to get thru the FDA. Guess the FDA is a very easy group of "guards" to get thru in this administration.

Luckily from a doctor I know well, after nagging him to death to find information on this product after the fact, he finally told me go to pubmed. Imagine I had to "nag" my own husband --- an over-worked, cranky, very intelligent doc just getting by. Like you, he won't go to the dark side for profit.

Thanks,

The King of Fillers?

2008-06-22T00:18:09-07:00

In the June 2008 issue of Dermatologic Surgery there was a review published of the results of the use of Radiesse in 1000 patients, over a 52 month period. The results were remarkable because of the durability of the effect, and the relative lack of problems.

The most commonly injected area was the nasolabial fold, the groove between the corner of the nose and the corner of the mouth. The second most commonly treated area was the marionette lines, the grooves extending downward from the corners of the mouth. Both of these areas are frequent sites of tissue loss, although those of us who are advanced injectors are using this filler in the cheeks as well. The filler persisted from 10 to 14 months, and more than 80% reported persistence of the filer at a year. This is not to say that correction at one year was 100%, but some of the effect was still visible. This is a longer lasting result than that achieved with any of the commonly used fillers, with the exception of Sculptra which may take 6 months or longer to demonstrate full effectiveness.
The safety record of Radiesse was very good, as it has been with most other fillers. The most commonly reported side effects were temporary redness and bruising. Occasionally there were nodules, primarily around the lips. It appears that the persistence of the effect is partially due to the fact that this filler stimulates the body to make new collagen, which substitutes for the filler as it is absorbed. Furthermore, the filler has a very natural feel which is appreciated by patients.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA

An Ounce of Prevention vs. a Pound of Cures

2008-06-18T22:43:57-07:00

There are people who espouse the Phyllis Diller approach to cosmetic procedures: wait until things look really bad and then have some things improved, and everyone will notice and comment on your improvement. Others will take the approach used by many Hollywood actresses: do things early and slowly and you'll continue to look good with little downtime. In my view the second approach is much preferred. However, there's another aspect of this that is rarely emphasized, and that is prevention.

The most essential and easiest aspect of prevention is avoidance of sun exposure. It is now common knowledge that sunlight damages the skin, yet we routinely see people who engage in an outdoor lifestyle ("We are on the boat every weekend") yet fail to take even minimal steps to protect their skin. People are quite familiar with sunscreens, but most are unaware of what they can and cannot do. Sunscreens can protect against ultraviolet A and B rays, but not all sunscreens are equal. The number on the sunscreens only relates to the ultraviolet B rays, while most of the aging changes are due to the ultraviolet A rays. Ultraviolet A is present in both winter and summer, so protection needs to be year round. A high number is recommended for ultraviolet B protection, since no one applies sunscreen as thickly as it is applied to generate the numbers. However, the ultraviolet A protection does not necessarily parallel the ultraviolet B protection, so a higher number sunscreen may still fail to provide good ultraviolet A protection. Furthermore, even the best current sunscreens are far from perfect. Skin that has always been protected by clothing will always look better than skin that has always been protected by sunscreen. Thus a combination of sunscreens and shade, including hats, is best.
Although sunlight is a very important factor in aging skin, it is not the only one. Repeated folding of the skin, by muscle movement or pillows, can make us look older. Botox has a role here. Studies in identical twins have shown that regular use of Botox can prevent the formation of permanent creases on the forehead, and other areas. For someone who really wants to continue to look good, it's best to start Botox early, and to keep it up regularly.
Finally, there loss of deep tissue volume is very important in making us look old. There is now evidence developing that certain fillers not only replace lost volume, but stimulate the body to make new collagen. It is very possible, but not yet proven, that early use of fillers will result in less loss of deep tissue, and a better long term outlook.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA

Lifestyle lift: Medical Breakthrough or Marketing Breakthrough?

2008-06-16T21:54:46-07:00

Today we had in a patient who had previously looked into a "Lifestyle lift". This is not the first patient that we have seen who has gone this route. If you look at the Lifestyle lift web site the terms "revolutionary and groundbreaking" are used. Through careful wording the terms are used to apply to the procedure, but the implication is that these terms apply to the Lifestyle lift, which is somehow unique.

In fact, the Lifestyle lift is the S-lift, which was developed by Dr. P. Ansari of Germany over 30 years ago. It was popularized by Dr. Z. Saylan, also of Germany, who modified the technique. There have been numerous modifications of the technique over the years, and the current state of the art is, in my opinion, the MACS-lift, developed by Dr. Patrick Tonnard and his colleagues from Belgium. All of the modern variants of the S-lift have value, but no one nor any corporation has something unique that is unavailable elsewhere.
When a patient signs up for a Lifestyle lift, they are signing with a corporation, not with an individual physician. The corporation has established its position through an extensive marketing campaign, not by its reputation in the community. The physician who performs the Lifestyle lift in a market one year may not be the same person who is doing the surgery the next year. The continuity of the name does not necessarily mean the continuity of performance, good or bad.
When you choose to have surgery performed by a corporation, you are in essence choosing to have a procedure performed by an unknown. Good marketing does not always equate with good results.
The company claims it has "incredible doctors", a term that is vague and impossible to substantiate. What is clear is that the company is quite skilled at hype. If you look closely at their photos on their web site, you can see that many of the before and after photos are not well matched. There are differences in head position and lighting that can make the results look more impressive. Their prices appear to be low, but these procedures are not the sort of thing that people have done on a frequent basis. It's best, in my opinion, to pay a little more and to deal with an established physician who is a known quantity.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA

Cosmetic Procedures and the Economy

2008-06-15T20:55:18-07:00

We feel we are living in tough financial times. Gas, energy and food prices are up, although most other items are not. Unemployment has risen, although it is still low by historical standards. Credit is tight, and housing prices are down, although they are 1/3 higher than they were in 2000. According to an article in the Wall Street Journal, living standards are the highest they have ever been, including for the middle class and poor. Nevertheless, the media tells us that we are living in a time of crisis, and, in our hearts, we feel that this is so. People want to be cautious.

A recent article in Investor's Business Daily discusses the effect of the economy on cosmetic surgery. Overall, the effect is negative, but it mostly affects the higher priced procedures such as facelifts and liposuction. Lesser priced procedures such as Botox and fillers have been affected much less. While the number of facelifts, liposuction, breast augmentation and laser eye surgery appear to be down, the numbers for Botox and fillers appear to be flat or up slightly. The sales of cosmetic lasers, which are quite expensive, are down significantly.
It has been our experience that, while the number of higher priced procedures are off a bit, most of our patients have stable incomes and they are still interested in continuing to do what they have been doing to improve and maintain their appearance. The main area of exception to this is those individuals who have been employed in the real estate business. Obviously this sector of the economy has been hit quite hard.
We have been fortunate that because of our emphasis on performing procedures under local anesthesia, and because we perform a high volume of procedures, we have been able to pass these savings on to our patients and to remain very price competitive.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA

Lipotourism

2008-06-12T21:17:07-07:00

Every so often we see a patient who has traveled to another country for the purpose of having a cosmetic procedure preformed. They are usually quite proud of getting a bargain compared to US prices, and at times are willing to overlook what would be considered by most people to be unacceptable results. Apparently the number of people going this route is increasing.

Several years ago we saw a woman who had a facelift and body liposuction performed in Central America. She had a very large scar running transversely across her neck. It looked as though someone had tried to cut her throat. The skin above the scar, extending to her jaw, was tight, while the skin below the scar was loose. I asked her how this occurred and she said that during the procedure the surgeon had been unable to get her neck skin tight enough, so he had made the incision across her neck and cut out the loose skin. She was quite happy with the outcome and especially with the bargain price.
In a recent article in the journal Clinical Infectious Diseases the Centers for Disease Control reported a series of 20 patients who had undergone cosmetic surgery in the Dominican Republic, and had developed skin infections with an unusual organism, Mycobacterium abscessus, an organism related to the bacterium that causes tuberculosis. All the patients had abdominoplasty, and some also had liposuction and/or breast reduction or augmentation.
The symptoms began 2 to 18 weeks after the surgery, and presented as skin abscesses. This was after the patients were back in the US. All the patients required prolonged courses of antibiotics and those who received breast implants had to have them removed.
It's important to remember that standards across the world are not necessarily the same as those in the US, and that it's important to choose a cosmetic surgeon who has both the knowledge and the ability to take care of a problem should it develop.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA

Fillers: How Long Do They Last

2008-06-07T13:23:14-07:00

When patients come to the office for filler injection, they frequently ask how long the correction can be expected to last. This is a reasonable question and should be able to be answered in a straight forward manner. However, the answer is more complicated than it seems, and new information is further clouding the picture.

In the past year there have been a number of head to head comparisons of filler duration. These types of studies have, in the past, been uncommon, because many of these studies have been supported by manufacturers and they are reluctant to pay for a study that might shine an unfavorable light on their product. However, it has become clear that Radiesse lasts significantly longer than the hyaluronic acid fillers, Restylane, Juvederm and Perlane. BioForm, the manufacturer of Radiesse has now sponsored published studies that demonstrate that, after one, year patients are significantly more satisfied with the results from Radiesse than with the results from the hyaluronic acid fillers. Thus, the type of filler injected is an important determinant of filler duration.
For many years we've known that the location into which the filler is placed makes a difference in how long the filler survives. Generally the more the tissues in the area move, the shorter the fillers last. Filler in the lips generally lasts half as long as filler in the cheeks
The new observation, that has recently been thrown into the mix, is that the timing of filler injections may play a significant roll in how long a filler lasts. In the June issue of the Journal Dermatologic Surgery the results of an ongoing study using Restylane in the nasolabial folds, the groove running between the corner of the nose and the corner of the mouth, were reported. In a blinded study, all patients had both sides treated initially. Then one side was retreated at 4.5 months and the other side was retreated at 9 months. In both sides the effect of the filler was still present at 18 months from the initial treatment. This is a durability is greater than would have been predicted from previous studies. It suggests that placing more filler, particularly Restylane at this point, before the effect of the initial injection has worn off, significantly prolongs the effect of the filler. One speculation is that this might work by inducing the body to produce new collagen in the area. This could be very important for patients. They may be able to get better and longer lasting results while at the same time save a significant amount of money.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA

Tattoo Tips

2008-06-02T19:42:56-07:00

Most people do not think about removal of a tattoo when they are having a tattoo applied. Nevertheless, the statistics show that 80% of people with tattoos eventually regret having them put on. That means it would be smart to at least give a little thought to the possibility that you might not be totally happy with the tattoo sometime in the future.

Removal of names is one of the most common reasons for tattoo removal. Since approximately 50% of marriages end in divorce, it is reasonable to consider that the name of a loved one may not be what you want to have semi-permanently placed on your body. There are gang and prison associated tattoos. These are not necessarily connections that you will want to make public for the rest of your life. We've had people come in saying that they're no longer associated with that lifestyle, and they want the tattoo removed.
If you're going to have a tattoo, consider where you have it placed. Visible tattoos may unfavorably affect your ability to get a job or be accepted into the military.
Finally give serious consideration to the color of your tattoos. Currently there is no standardized tattoo ink, and a variety of products such as car paint and clothing and furniture dyes may be added to tattoo ink. Some of these may change color when struck by the light from a laser, and can change from a treatable to an untreatable color. The effectiveness of the tattoo removal laser depends on the laser light being absorbed by the tattoo ink. Dark blue, black and red are colors that are relatively easy to treat. Green can be treated by a laser, but it requires a separate laser that is expensive and therefore not widely available. Other colors such as sky blue, white and pastels can be difficult or impossible to get rid of. If you're planning to get a tattoo, it's best to think before you leap.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA

Botulinum Toxin Applied to the Skin?

2008-05-29T22:56:29-07:00

A relatively young company, Revance Therapeutics, is studying the possible effectiveness of topically applied botulinum toxin, which is currently the active ingredient in Botox. The toxin molecule is quite large and generally large molecules will not penetrate the skin. Nevertheless, the possibility is quite interesting.

An initial study of the product's use in the treatment of increased armpit sweating, axillary hyperhidrosis, was published in Dermatologic Surgery in January 2007. Twelve patients were treated in a blinded study with one armpit treated with the active cream, containing Botox, and the other armpit was treated with the cream without any active ingredient. After 4 weeks the treated area had a 65% average reduction in sweating versus a 25% reduction on the side treated with the placebo cream. Studies are proceeding, but there are still more questions than answers. The dose of Botox used per armpit was 200 units. Generally, using injectable Botox, an armpit requires about 75 to 100 units per treatment. Injectable Botox has an effect on hyperhidrosis lasting 6 to 12 months, with close to 100% effectiveness. The duration of the effect of the topical Botox is currently not clear.
Injectable Botox has the advantage, in cosmetic applications, of being able to be directed to a relatively localized area. It seems unlikely that a topically applied product will be able to be targeted as precisely. Currently there are too many unknowns to do anything more than speculate about the eventual success and future role of this product. It does seem to defy previous assumptions and raises many interesting possibilities for other materials. Could a diabetic, sometime in the future, deliver his or her insulin by applying a cream to the skin?

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA