Archive for the ‘Skin Resurfacing | Rejuvenation’ Category
Facial cosmetic surgery is a very personal and monumental decision. Universally, all patients want the best outcomes. In today’s corporatized America, with heavily influential marketing spin, pharmaceutical companies, medical device companies, and even practitioners promote a less is more mentality to push products and services that often over promise and under deliver on the results. In no way can skin creams, injectables, or lasers deliver the types of results once can achieve with surgery. In a similar manner, minimally invasive sounding surgeries are in no way a substitute for time tested peer reviewed procedures that provide quality long lasting results.
Unfortunately not every person will achieve acceptable results with Botox or injectable fillers such as Juvederm, Restylane, and Radiesse. These products have their place in facial aesthetic practices, in properly selected patients, but in general should be viewed as temporary treatments with less impressive results when compared to surgery. Their primary advantage is that they have minimal social while providing a benefit. Botox is being used more and more as a preventative cosmetic medicine that delays wrinkle formation. Fillers camouflage initial signs of aging, but ultimately putting too much filler in a face, the liquid facelift, can alter ones appearance creating an artificial overinflated appearance. Using filler to augment facial structures can be useful to patients wanting to get a general idea of the appearance prior to permanent surgical procedures such as lip and cheek enhancements procedures. Creams reverse the signs of photo aging and contribute to collagen formation and production but are limited in their effectiveness. Lasers are an excellent option to delay the signs of aging and treat sun induced skin photoaging, but in no way can they tighten skin like facial cosmetic surgeries such as a facelift.
Surgical procedures are the best option for impressive endurable results. Rhinoplasty can dramatically affect ones facial appearance in a way that almost no other cosmetic surgery can. The nose can cause undue and unnecessary attention drawing attention away from other attractive facial features. Aging face surgery has many layers of effectiveness based on the surgical techniques used and how they are applied. In general, minimally invasive techniques can produce an artificial appearance and or short-term results. When considering aging face surgery most sophisticated patients are looking for surgeries that will last as long as possible with the most dramatic natural appearing results. There are no shortcuts to achieving optimal results and when applied, shortcut techniques frequently under deliver on the surgical results end.
Becoming an informed patient who understands the benefits of finding the right intervention or surgery for the right patient will ultimately save one time and money over the long haul. Getting things done right the first time is of paramount importance to achieving optimal outcomes with a high degree of patient satisfaction, while avoiding problems and bad outcomes.
Posted by: Benjamin C. Stong MD
Today, the vast majority of surgeons perform lower eyelid blepharoplasty or eyelid lift techniques using a transconjunctival approach with fat removal and a skin pinch to rejuvenate the lower eyelid. Additionally laser treatments or chemical peels may be used to improve skin texture and smooth wrinkles. The evolution of this treatment resulted from concerns of postoperative ectropion or lower eyelid malposition associated with more traditional techniques and lack of familiarity with the measures required to prevent these complications. The transconjunctival approach makes an incision on the inside of the eyelid and while it is a safer approach in less experienced hands, it has also resulted in an incomplete lower eyelid and midface rejuvenation.
The characteristics of the aging process of the lower eyelid and midface include decent of the midface soft tissues and fat pad, elongation of the lower eyelid, pseudoherniation of fat from around the eye resulting in puffiness, formation of the tear trough deformity, and redundancy of the skin and muscle of the lower eyelid. The transconjunctival lower eyelid blepharoplasty with fat removal and skin pinch fails to address several of these issues. Removal of fat from around the eye can lead to a hollowed appearance of the lower eyelid and an abrupt transition from the lower eyelid to the midface that appears unnatural and artificial. Additionally, a skin pinch removal from the lower eyelid fails to remove the excess muscle underneath the skin and shorten the eyelid. When considered in whole there are several problems with this technique and it fails to address several of the issues that occur with age in the lower eyelid and midface.
The skin muscle flap blepharoplasty with fat transposition is the most contemporary technique available in lower eyelid blepharoplasty, and it corrects several of the issues that the transconjunctival blepharoplasty with fat removal and skin pinch fails to address. First, and most importantly, the fat from around the eye is conserved and repositioned in the tear trough (the groove that forms between the eyelid and the nose and midface) obliterating it and resulting in a smoother more natural transition between the lower eyelid and midface. The skin muscle flap blepharoplasty also removes muscle as well as skin for a more natural correction of the redundant soft tissue of the lower eyelid. When the eyelid is properly re-suspended during the procedure the risk of permanent post procedure ectropion is virtually eliminated.
Shortening the lower eyelid is best accomplished by performing a midface lift at the same time as the lower eyelid blepharoplasty. The medical literature supports that by adding a midface lift to a lower eyelid blepharoplasty more skin and muscle can be removed resulting in a shorter more youthful lower eyelid. Most midface lift techniques do not effectively release and re-suspend the soft tissues of the midface. When considering a midface lift it is important to find a surgeon who performs a transtemporal extended subperiosteal midface lift to ensure an excellent outcome. When performing a skin muscle flap blepharoplasty with fat transposition along with a midface lift the aging characteristics of the lower eyelid and midface are more completely addressed resulting in a natural, more complete periorbital and midface rejuvenation.
It is also important to consider adding a skin resurfacing procedure to improve wrinkles and skin texture and quality of the lower eyelid and finish the rejuvenation. This can be accomplished through either chemical peels or ablative laser procedures. Contemporary laser procedures allow for excellent skin resurfacing and rejuvenation with shorter healing periods when compared to chemical peels and more traditional laser procedures. The state of the art laser skin resurfacing techniques combine an epidermal laser peel with a fractionated deep dermal laser resurfacing to treat both superficial and deep wrinkles and brown spots. The Pearl Fusion procedure combines the Pearl and Pearl Fractional procedures to offer the most advanced laser technology while providing the safest outcomes.
Finding a plastic surgeon who understands how the different surgical techniques correct the aging characteristics of the lower eyelid and makes informed recommendations based on the patient’s particular issues is important to achieve superior outcomes and avoid complications. Midface lifts can correct the drop of the cheek soft tissues, efface the nasolabial folds, and shorten the lower eyelid. While a deep plane facelift can also lift the cheek soft tissues and smooth the nasolabial folds, the midface lift offers a greater effect and more permanent change to the midface soft tissues and nasolabial folds. Performing a skin muscle flap blepharoplasty with fat transpositions along with a midface lift offers the most complete periorbital and midface rejuvenation available today.
Benjmamin C. Stong MD
Atlanta, GA
The fourth and fifth decades of life are a time when people often begin to become more aware of age and committed to facial plastic surgery procedures. Accumulated sun damage and prior skin care rejuvenation regimens affect when patients begin to consider blepharoplasty, brow lifts, and facelifts during these decades. Often, patients will also add staged or simultaneous skin resurfacing rejuvenation procedures to maximize and augment surgical results. There is often a misconception that surgery and procedures need to be delayed as long as possible to avoid additional surgeries in the future. The truth is there is no good or bad time to under go surgical and skin rejuvenation procedures; it is only appropriate when a patient becomes bothered enough by the issue to consider surgery and is an intensely personal decision. The most important consideration to avoid bad outcomes and unnecessary surgeries is to find a practitioner who uses techniques that will provide superior, long lasting results.
Eyelid lift surgery or blepharoplasty offers a long lasting procedure and when performed correctly is often not necessary to have repeated in the future. Similarly, Brow Lifts usually only need to be performed once if the surgery addresses the laxity issues in the forehead, upper eyelid, and brow complex and adequately releases and re-suspends these tissues. Minor touch up procedures may be included in future treatments to maintain and maximize results from blepharoplasty and brow lifts. Revision surgery becomes important when considering revising suboptimal results from poor, inadequate techniques and is more difficult due to scar tissue from the previous surgery and is more expensive. Having a procedure performed correctly the first time is of paramount importance.
Facelifts are procedures that can be performed multiple times over a patient’s lifetime. To avoid unnecessary and costly revision surgeries, finding a surgeon who effectively releases and re-suspends the SMAS layer, the primary support layer, of the face is important. Many surgeons believe they get equally effective results with less aggressive work on the SMAS layer, but there is no short cut to providing superior long lasting results. When performed properly, a facelift can provide patient satisfaction for ten years, or more. A facelift addresses an aging jaw and neck line, resetting the clock, but it does not stop the clock from restarting. Some patients who want to be aggressive about hiding their age may choose to undergo two or three facelifts during their life. Another popular misconception is that undergoing multiple facelifts will result in a pulled or windswept look. The truth is that when the skin and deeper SMAS layer are pulled in the correct direction, a facelift can be performed as many times as desired to maintain a more youthful jaw and neck line. An additional misconception is that a comprehensive and thorough jaw, cheek, and neck lift can’t be performed through an abbreviated mini facelift incision. This notion is also false; a thorough facelift can be performed through the short scar, abbreviated, mini, s-lift facelift incisions safely with superior outcomes. Consultation with a knowledgeable facial plastic surgeon will allow for a comprehensive facial rejuvenation plan over the years when a patient is interested and healthy enough for surgical procedures.
Skin resurfacing rejuvenation procedures are important to consider when augmenting and maximizing surgical results. In addition to noninvasive lasers such as IPL LimeLight and YAG Laser genesis procedures, ablative resurfacing procedures become necessary to maintain youthful looking skin. Finding a practitioner who offers the state of the art laser rejuvenation procedures is necessary for excellent outcomes with the shortest healing times. Currently, combining confluent and fractionated laser modalities offers the best treatment for both superficial and deep discolorations and wrinkles as well as stimulating collagen formation. It also avoids complications and prolonged healing times from more traditional chemical peels and lasers. Laser resurfacing rejuvenation procedures can be performed as often as necessary to restore and maintain youthful, vibrant looking skin.
Botox, facial fillers, medical skin care products and other preventative and maintenance therapies should be continued in the forties and fifties to maximize the longevity of surgeries and skin rejuvenation procedures. Consultation with a knowledgeable facial plastic surgeon, who applies a global perspective when discussing patient goals and their future considerations, will put the patient at ease and establish trust that the practitioner is making thoughtful recommendations based on his expertise and training.
Posted by: Benjamin C. Stong MD
The topic of neck rejuvenation requires a discussion of skin rejuvenation, liposuction, facelift surgery, and direct skin excisions. Age related changes in the neck occur simultaneously with the age related changes in the face. These changes include sun damage to the skin, accumulation of excess fat and skin, and the formation of vertical bands. There is no absolute predictable pattern to how a neck will age and is intensely affected by an individual’s anatomy, genetics, diet and exercise patterns, and sun exposure. As such, there is no single way to address a patient’s concerns and a rejuvenation plan must be tailored to a patient’s specific issues.
As with any area of skin, the neck skin accumulates sun damage over years. The skin of the neck is thinner than the skin of the face and is more prone to complications with aggressive rejuvenation procedures such as phenol peels and traditional CO2 laser resurfacing. In general, the goal of laser skin rejuvenation is to be as aggressive as the tissue allows while balancing results with safety. Although most laser companies do not recommend the use of ablative lasers on the neck, clinicians routinely use laser rejuvenation therapies with excellent outcomes. A critical element to good outcomes is to use lower settings on the resurfacing laser or less aggressive chemical peel than in the face.
Many patients believe they are good candidates for liposuction as a sole rejuvenation procedure. In fact, the opposite is true, only a select few individuals are candidates for liposuction in isolation. As we age the skin loses elasticity and subsequently its ability to contract. The ideal candidate for neck liposuction is someone in their 20’s or 30’s with minimal sun damage or excess skin. These individuals usually have skin that will contract back down following liposuction with good results. Once sun damage has occurred and excess skin has accumulated, removal of skin becomes necessary. Excellent liposuction techniques are also critical for great results.
Most patients in their 40’s and 50’s have enough sun damage and excess skin to require removal. There are two primary ways to address this issue. The first is with a facelift or neck lift. An abbreviated mini facelift incision can be used. The neck skin is removed from the portion of the incision placed behind the ear. Some surgeons may offer patients an isolated neck lift procedure using only the portion of the facelift incision behind the ear to avoid more obvious incisions in the neck. Patients must understand that in no way will this address the excess skin and jowling of the face and is performed to avoid placing incision directly in the neck skin. During the facelift or neck lift procedure the vertical bands are addressed by tightening the platysma muscle which acts as a corset for deeper neck fat that protrudes as we age. The second way to address the excess skin of the neck is with a direct neck lift using a direct skin excision technique such as the Grecian Urn or another such procedures. It is offered as a primary procedure almost exclusively in men. Sometimes residual skin following a face or neck lift will be removed with smaller direct neck excision techniques, but in general it is a bad idea in women as a primary procedure because it will leave visible scars. In men, because of their bearded skin, a direct neck excision can be a good alternative to a facelift procedure. During a direct neck excision, the vertical bands should be addressed by tightening the underlying platysma muscle during the skin excision.
Total neck rejuvenation in older patients should include removal of the excess skin by a method the patient and the physician are comfortable with, along with tightening of the platysma muscle and liposuction as indicated. A staged skin rejuvenation procedure may be performed either before or after surgery to complete the rejuvenation. Consultation with a knowledgeable and skilled facial plastic surgeon will help avoid bad outcomes and disappointing results.
Post provided by: Benjamin C Stong MD
Cutera has created a highly competitive advanced multiplatform laser that will leave practitioners and patients very happy with its versatile capabilities. The Xeo system has two intense pulse light systems, a versatile 1064nm YAG laser, an infrared skin tightening device, and an YSGG traditional full surface ablative and fractionated deep dermal laser. The versatility of the laser is unparalleled with a tremendous advantage in the ablative laser technology by combining the benefits and eliminating the problems of more traditional lasers such as erbium and CO2. The Xeo has numerous applications including: laser and intense pulse light hair removal, a 1064nm YAG system for rosacea, vascular lesions, and collagen building therapy, the Titan skin tightening application, and a full face ablative skin resurfacing rejuvenation.
The intense pulse light system also known as broad band light has two applications. The first is called the LimeLight. A LimeLight facial treats dyschromias (brown and red color imperfections), including: melasma, solar lentigines (sun spots), dilated capilliaries, telangectasias, and rosacea as well as stimulates superficial collagen production to improve wrinkling. It is best used during a period when the first signs of aging occur or as maintenance therapy between deeper rejuvenation procedures and is often performed as a series for optimal results. The second intense pulse light (IPL) application is called Prowave and it customizes the wavelengths it emits to specifically perform hair removal in a fast efficient manner.
The 1064nm YAG laser is extraordinarily versatile. It performs traditional YAG capabilities such as single pulsed vascular lesion treatments and hair removal and is called the CoolGlide. It can treat hemangiomas, dilated capillaries, spider veins, and telangectasias. The Laser Genesis uses a revolutionary patent pending millisecond-pulsed technology that allows the YAG to improve rosacea and skin texture, decrease poor size, and build collagen to treat superficial to moderate wrinkles. It is painless and can be performed on all areas of the face during a lunch break with absolutely no downtime. Similar to the LimeLight facial it is usually performed as a series to treat the beginning stages of aging or as maintenance therapy for facelifts and between deeper skin rejuvenation procedures.
Titan is the infrared skin tightening system on the Xeo multiplatform laser system and delivers equivalent results to comparable technologies. Skin tightening systems do not deliver dramatic results like face lift surgery but do provide an intermediary step for patients who are not committed to surgery and have realistic expectations for any non-surgical procedure to provide significant results.
The workhorses of ablative skin resurfacing have traditionally been the erbium and CO2 lasers. There are benefits and drawbacks to each of these lasers. The CO2 generates more thermal energy and has been associated with higher complications including permanent scarring and hypopigmentation, but it also delivers more impressive results. The CO2 has also been associated with much longer periods of healing and erythema or redness. The erbium laser is much safer with fewer permanent complications than the CO2, but is associated with bleeding due to less coagulation ability, interrupting the delivery of energy to skin tissue. Contemporary erbium lasers have improved this problem by using longer pulse durations to increase coagulation, but the problem still persists. Cutera introduced YSGG as a wavelength for ablative resurfacing technology to combine the benefits and eliminate the problems of the CO2 and erbium lasers. It delivers enough energy for excellent coagulation while minimizing thermal injury and complications such as hypopigmentation and scarring.
Fractionated resurfacing technology has provided a critical element to skin resurfacing and rejuvenation. Erbium, CO2, and YSGG lasers now have applications for fractioned resurfacing. Fractionated laser resurfacing uses laser micro-columns to treat a percentage of the skin surface area and penetrates into the deep dermis stimulating a deeper more robust collagen production improving deep dermal discolorations and wrinkles. CO2, Erbium, and YSGG full skin surface ablative technologies are being combined with fractionated procedures to provide the state of the art in total skin rejuvenation.
The Cutera Xeo YSGG total skin resurfacing treatment is called the Pearl. The Pearl Fractional is their fractioned, deep dermal technology. The Pearl Fusion treatment combines these two technologies to deliver optimal total skin rejuvenation results while minimizing the risk of complications. A detailed understanding of laser science and technology is critical to choosing the type of procedure indicated to meet patient expectations. Laser skin rejuvenation is not a substitute for facelift, midface lift, or brow lift surgery and should be viewed as a complimentary procedure. Choosing a facial plastic surgeon that is knowledgeable and experienced in both surgical procedures and laser skin rejuvenation is critical to being able to communicate goals and deliver the best outcomes.
Post provided by: Atlanta Laser Skin Rejuvenation - Benjamin C. Stong MD
Skin rejuvenation can be confusing to even the most informed patients, and understanding how directed and combination therapies act to deliver results is crucial. In general, the degree of effect is directly related to the treatments depth of penetration into the skin. Skin can be conceptually divided into three zones: the epidermis, constituting the superficial zone, and the dermis, the medium and deep zones. Therapies are classified as superficial, medium, or deep based on the depth of penetration into these zones. The three most common treatment modalities used for skin rejuvenation are chemical peels, dermabrasion, and lasers. All three modalities can be used for superficial, medium, or deep rejuvenation.
Medical grade skin care products act to hydrate skin, increase exfoliation, build collagen, and treat superficial skin discolorations and blemishes. Topical vitamin therapy is a common, noninvasive therapy, of which, the most relevant to skin rejuvenation is tretinoin, a vitamin A derivative. Within months, it acts to rejuvenate the skin by thickening the deeper layers of the epidermis and diminishing signs of photoaging, which include: dyschromias and brown spots. With longer courses, it stimulates collagen production in the dermis, with mild to moderate improvement in fine wrinkles. Hydroquinone and Kojic acid are topical bleaching agents that inhibit melanin production, lightening age spots and improving melasma as well as other causes of hyperpigmented blemishes.
Superficial rejuvenation agents primarily consist of glycolic acid, lactic acid, salicylic acid and jessner chemical peels with various combination formulations commercially available. They act on the epidermis, decreasing discolorations and blemishes while allowing the germinal layer of the epidermis to regenerate. Additionally, they also act to increase superficial collagen formation in the dermis, improving fine wrinkles. Lasers can be used to perform “micropeels,” acting on the epidermis only, with benefits similar to the other superficial rejuvenation procedures.
Medium and deep rejuvenation procedures act down to the level of the dermis and are used to treat deeper photoaging elements and wrinkles. By increasing the depth of penetration the overall effect is increased due to improved recruiting of fibroblast activity and collagen deposition. Consequently, there is also an increased risk of complications with deeper rejuvenations, which can include hypopigmentation and scarring, along with prolonged healing times. Medium and deep chemical peels include jessner/TCA combination peels and phenol peels, respectively. Dermabrasion is an effective resurfacing technique that uses brushes or diamond burrs to remove skin, layer by layer. Today, it is largely used for scar revision resurfacing and the treatment of well formed wrinkles around the mouth. The depth of treatment with conventional lasers is primarily controlled by the type of laser used, the power settings, and the number of passes performed. In general, less aggressive settings and a decreased number of passes, result in less down time, a more superficial treatment, and subsequently, less impressive results. In addition to the benefits of a superficial rejuvenation procedure, deeper rejuvenation procedures improve photoaging elements in the dermis along with stimulating deeper, more robust collagen deposition and a more significant wrinkle reduction.
Fractionated laser resurfacing has been introduced to deliver results comparable to traditional lasers, but with decreased healing time. Fractionated lasers work by treating a percentage of the skin surface area, with spaced, deep penetrating, laser microcolumns that leave intact bridges of skin between the treated areas, decreasing the risk of complications associated with conventional full skin resurfacing techniques, while still maintaining the deeper benefits. Thermal energy is delivered to the deeper dermal elements to trigger collagen formation, while treating deeper dyschromias and brown spots, and allowing for faster recovery due to the intact bridges of skin. Today, the state of the art in laser resurfacing techniques combines conventional full skin resurfacing to remove the epidermis, improving the superficial elements, followed by fractionated therapies to treat deeper photoaging and stimulate deeper collagen formation and wrinkle reduction.
Skin rejuvenation therapy must be tailored by the patients, not the physician’s goals. Aggressive therapy can lengthen healing times and increase the risk of complications, but they also have the best results. Maintenance therapy with medical grade skin care products and superficial rejuvenation agents, with interval medium to deep rejuvenation therapy is ideal for optimal outcomes. Skin resurfacing and rejuvenation should be viewed as complimentary to, not a substitute for face lift surgery or midface lift surgery. The choice of resurfacing agents used to achieve the patient’s goal is collaborative and based on the comfort of the patient with the rejuvenation agent and the experience of the physician.
Post provided by: Atlanta Facial Plastic Surgeon – Benjamin C. Stong MD