Arguably the most onerous of all aesthetic concerns, wrinkles come in many sizes.
Fine wrinkles respond beautifully to superficial Fraxel Re:store laser treatments, Botox Cosmetic and peels.
Medium sized wrinkles do better with Fraxel Re:pair laser treatments, Botox Cosmetic, fillers and TCA peels.
Since deeper wrinkles are often associated with underlying loss of volume or padding,they respond better to a combination of fillers, BTX, Fraxel Re:pair treatments and facial volume restoration with biostimulatory Sculptra treatments.
Age spots, uneven skin color
Age spots or brown spots are the most common aesthetic complaint among dermatology patients. This is why theIntense Pulsed Light has become the workhorse in aesthetic dermatology. Other approaches include the Pulsed Dye Laser (PDL), the Cynergy Multiplex, a combination PDL and Nd:YAG laser, or a long pulse alexandrite laser such as the GentleLase.
Actinic keratoses or sun spots
Actinic keratoses (AKs) are subtle, persistent rough spots usually found on sun exposed areas. Gone are the days when these were found only in the elderly. Over the past 15 years, we have been amazed to see how many of our patients in their 30s already exhibit these lesions. If left untreated, these can eventually transform into skin cancers called Bowen’s, basal cell carcinoma or the potentially more aggressive squamous cell carcinoma. As a matter of course, we treat every single one of these lesions rather than adopt a “wait and see” approach.
Treatment may include topicals such as 5-fluorouracil (Efudex) or imiquimod (Aldara) cream as well as Photodynamic Therapy.
- Rosacea affects about 14 million people have rosacea in the US.
- It usually starts in the 30s with bouts of redness and acne like lesions, but without blackheads or whiteheads. These eventually become more persistent and longer lasting. In some patients, the skin may become hyper sensitive, thickened, purplish, itchy or hot.
- We distinguish 4 subtypes of rosacea: erythematotelangiectatic (red skin with or without visible vessels), papulopustular (red bumps and pustules), ocular ( itchy, red eyes and/or eyelids) and phymatous (thickened skin, especially the nose)
- Topical treatment consists of gentle skin care, antibiotic creams and gels containing metronidazole and sulfacetamide, and anti-inflammatory creams. Oral antibiotics are used in more refractory cases.
- Laser treatments have made a huge difference in the life of rosacea sufferers. Photodynamic Therapy, the IPLand the Cynergy Multiplex laser treatments represent the cutting edge in the treatment of rosacea.
- The recent discovery of an abnormal protein, called cathelicidin, as another possible causative agent, will hopefully lead to new treatment approaches in the future.
- For further info, click on http://www.skincarephysicians.com/rosaceanet/treatment.html
There is a plethora of “tightening devices” on the market today. However, the one with the largest volume of documented research, patient volume and follow up is undoubtedly the Thermage device. Depending on the area treated, this device uses attachments specifically tailored for the face, eyelids, body, cellulite and stretch marks. Restoring lost contours of the cheeks that often accompanies laxity is best done with fillers.
Often called “broken blood vessels”, these tend to appear most commonly along the nose and the mid cheek area. Rosacea patients are very prone to these. These are best treated with vascular specific lasers such as the Cynergy laser, Pulsed Dye Lasers or an IPL.
95% of leg veins are best treated with sclerotherapy. The rest can be treated with vascular lasers such as the Cynergy Multiplex or GentleLase
- Lasers and light devices are playing an ever increasing role in the treatment of acne.
- PDT or Photodynamic Therapy has been shown to provide results equivalent to oral antibiotics.
- Isolaze is a device which suctions out blackheads. We feel it is too inconsistent to justify the extra expense to patients
- Despite ample documentation of the success of some laser treatments, insurance companies are still vigorously resisting reimbursement to patients.
- The medical term for mole is nevus. Not all growths are nevi. Not all nevi should be lasered. Never have anyone treat a nevus before having it evaluated by a board certified dermatologist. Some nevi are better removed with excision so that their cell type may be evaluated under the microscope.
- Some flat dark moles called lentigos can be treated with the Q switched Nd:YAG and the UltraPulse CO2 lasers laser.
- Freckles and age spots respond beautifully to IPL and the GentleLase long pulse alexandrite lasers.
- During treatment, the laser beam interacts with the pigment in the tattoo and shatters it into small particles which slowly get scavenged away by cells called macrophages. This action can only be achieved with Q switched lasers delivering nanosecond pulses, such as the Q switched Nd:YAG, Ruby and Alexandrite lasers.
- Multiple colors require multiple lasers. The easiest colors to remove are brown and black, the hardest are yellow and green. The more complex the colors are, the more treatment sessions are necessary, varying from 6 to 20 and over. There is never a guarantee that all pigment can be removed. Sessions are repeated every 6 to 8 weeks.
- Professional color tattoos are the hardest to remove, because of the number and density of the colors. Professional tattoo artists pride themselves on mixing their own colors, further complicating their removal.
- Amateur black tattoos respond the fastest.
- Traumatic tattoos involving gravel, gun powder or lead also do very well.
- Cosmetic red tattoos such as lip liner and eyebrow liner immediately turn black upon laser impact. They are very difficult to remove.
- Until now options to treat stretch marks were basically nonexistent.
- Treatment Retin-A cream proved disappointing.
- Pulse Dye Lasers were able to eliminate the red color and turn the marks white, but without improving texture.
- Today, a series of at least 3 Fraxel Re:store laser treatments has been shown to improve both color and texture. Stretch marks are especially responsive when treated early, while still in the pink stage. All stages can respond.
- The impact of the Fraxel laser beam triggers fresh collagen fiber production, filling the depressed ridges and giving the skin a more normal appearance.
Scars come in an infinite variety depending on location, shape, age, origin and skin type. In general, traumatic and surgical scars tend to be more amenable to treatment than others. Keloids are traditionally the most treatment resistant. They develop more likely in darker skin types, over joints and breastbone in lighter skin types and in situations where the scar goes against the grain of the skin.
Treatment modalities include:
- Linear flat red scars:
- – Pulsed Dye Laser (PDL) to clear the red color
- – Fraxel Re:store (FXL-R) to resurface skin texture
- Linear raised red scars:
- – from facelifts, breast surgery, abdominoplasty, cancer sx
- – UPCO2 for flattening
- – PDL for the red color
- – FXL Re:store for retexturing, best done during red phase
- – Silicone gel sheets to enhance or maintain flattening
- Linear white scars: FXL-R
- Ice pick acne scars: Punch excision followed by FXL-Re:store
- Boxcar scars:
- – as seen in acne and chickenpox
- – punch elevation (cutting out the base and elevating the scar)
- – subcision (severing all the attachments under the scar) + filler to keep the
- scar elevated followed by FXL resurfacing
- Atrophic and undulating acne scars:
- – become more apparent in the 40s and 50s
- – FXL-Re:store or FXL Re:pair resurfacing
- – Cooltouch CT3
- – Sculptra to restore fullness of skin
- Hypertrophic scars:
- – due to excessive collagen deposition, they remain confined to the area of
- injury and flatten out within 18 months.- FXL-Re:store treatments are excellent
- – also due to excessive deposition of collagen, but these scars extend beyond
- the area of injury and never disappear. Keloids hurt, itch, contract, pull and
- disfigure. (Accidents, cardio-thoracic surgery)
- – re-excision immediately followed by application of imiquimod
- – re-excision followed by FXL-Re:store resurfacing, started on the day of
- suture removal.
- – FXL-Re:store especially while still red.
- – PDL to decrease the red color.
- – Liquid nitrogen and pressure dressings have poor success rates
- Burn scars, fresh or mature: FXL Re:store laser, preferably while still red.
- Scars due to self mutilation and hesitation marks from attempts at wrist slicing are best treated with the FXL Re:store laser while still fresh.
Laser Hair Removal
- Laser hair removal (LHR) has been around now for almost 15 years and has proven to be safe and effective when performed by qualified operators.
- The treatment is more comfortable today than in the past, but patients can still use a numbing cream if they so desire.
- We use lasers approved by the FDA to treat light and dark skin types as well as tan skin. However, we much prefer to perform LHR on skin that is not tan, i.e. at its lightest. That way, we can use maximally effective light energies.
- During treatment, the laser beam traverses the skin until it reaches the pigment in the hair root. The interaction between the two shatters and partially destroys the hair matrix. Over the ensuing 2 weeks, the pulverized hair is slowly eliminated and the follicle tries to repair. With every subsequent treatment, the hair follicle shrinks and the resulting new hair becomes smaller in diameter and lighter in color until it looks like peach fuzz.
- At any point in time, 30% of hair follicles are dormant and therefore not amenable to treatment. Location of the hair determines the speed of the hair cycle. Facial hair grows much faster than leg hair and therefore requires more frequent and more numerous sessions. Number of sessions may vary from 4 to 10.
- White, gray and red hairs do not respond to LHR.
- Black hair on white skin responds the best.