Monday, June 2, 2008

The Ten Minute Eyelift

The Ten Minute Eyelift
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By Nelson Lee Novick, M.D., FAAD, FAACS

Some degree of redundacy and laxity of the eyelids and underlying muscles can be considered a normal part the aging process. When severe, doctors refer to the condition as dermatochalasis, which is simply an excess of skin in the upper or lower eyelids that makes them appear droopy or “hooded.” It most frequently begins in people over 50 and is quite common in the elderly. Genetics may predispose to its development, and frequent allergies, and occasionally prior pregnancy may also contribute.

While we know how the problem develops, we currently have no way of preventing it. From the moment we are born, every blink of our eyes causes the tiniest stretch of the elastic fibers within the eyelid skin and the muscle fibers responsible for elevating the lids (the levator muscles). By the time, we reach our late forties and fifties, the tissues around the eyes have become increasingly stretched, loose and movable. Subject to the unrelenting downward pull of gravity, the lids eventually lengthen and droop. Women are more apt to notice the overhanging skin earlier on, when they begin having difficulty applying makeup to their upper lids.

Sagging eyelids are not just a cosmetic problem, however. When there is an excessive amount of upper eyelid skin, the skin may hang over the eyelashes and cause a loss of peripheral vision. The upper and outer parts of the visual fields are most commonly affected, and the problem may become severe enough to interfere with activities such as reading or driving.

Dermatochalasis, whether for functional reasons to improve peripheral vision or for strictly cosmetic considerations, has been traditionally treated with surgical blepharoplasty (eyelift surgery), and more recently with ablative laser surgery or tissue heating using radiowaves to promote shrinkage.

Blepharoplasty is by no means a no-downtime lunchtime procedure. It is true surgery requiring stitches and often intravenous sedation. The surgery involves reshaping the upper or lower eyelid by the removal and/or repositioning of excess tissue as well as by reinforcement of surrounding muscles and tendons. It is performed through external incisions made along the natural skin lines of the eyelids, such as the creases of the upper lids and below the lashes of the lower lids, or from the inside surface of the lower eyelid.

Following a “bleph,” there is often considerable initial swelling and bruising that may take as much as two weeks to resolve. Moreover, it usually takes at least several months until the final results of the surgery can be fully appreciated. Depending upon individual needs, the operation requires one to three hours to complete. Fees range from $2500 to $7500.

Laser ablation, in which the lids are abraded with laser light, is also not a quick fix. It, too, frequently requires intravenous sedation and a prolonged postoperative course. Persistent redness and permanent loss of pigment are potential complications. Fees range from $2500-$3000.

Although radiowave heating, which spares the epidermis (the skin’s topmost layer), may be performed quickly, and has little downtime, a series of treatments at periodic intervals are typically necessary. The procedure can be uncomfortable enough to require local anesthesia and intravenous sedation. The degree of skin tightening achieved is often only subtle to minimal. Fees average around $1500-$2000/session.

Several years ago, I developed what I dubbed the Ten Minute Eyelift for treating significant upper eyelid hooding. The technique is quite simple. With the patient seated upright, I first mark off the entire length of the lower third of the “underbelly” of the hooded portion of the lids on each side. Next, I numb these areas with a small amount of local anesthetic. Finally, I pass a cautery probe, which imparts an intense amount of heat energy, along the marked stretch of each lid.

Almost immediately, the skin contracts vigorously in response to the probe, drawing the hooded portion of the lid backwards over the surface of the underlying normal lid. As it does so, the underlying eyelid is exposed and restored. Each wound is then covered with only a small amount of antibiotic ointment and left to heal spontaneously.

The entire technique takes about five minutes per side. Healing is usually complete in seven to ten days. Slight bruising and mild swelling are common afterward and may take about a week before becoming less noticeable. Cold compresses can be used in the first 48 hours to minimize the bruising and swelling. This may be supplemented by the oral use of bromelain for three days. Bromelain, an enzyme, is a pineapple derivative that has demonstrated usefulness in preventing bruises and speeding their resolution. Pain medications are seldom necessary, but for some people who experience mild discomfort, acetominophen (Tylenol) is ordinarily adequate. Most people can return to work the following day.

One treatment is ordinarily all that is required. The results are permanent and can be fully appreciated in just two weeks. When fully healed, a faint, narrow, linear ivory or off-white line is often all that can be seen at the treatment site.

The accompanying “before” picture demonstrates how the “hood” of the upper eyelid covers the entire upper lid up until the lid margin (where the lashes begin). In the “after” photo, which was taken two weeks following a Ten Minute Eyelift, you can see how the hood no longer entirely covers the upper lid and has healed into a more youthful, more natural appearance. Fees range from $1000-$1500, depending upon the extent of the problem.

Q. I have droopy bags under my eyes. Can these be treated with The Ten Minute Eyelift?

A. In general, the technique is best reserved for a heavily hooded upper eyelid where the resulting whitish, linear scar will be concealed under the remnant of the hood. However, when there is sufficient redundancy and sagging of the lower lid to cause bags and folding of the tissue, this method may be used cautiously there, as well.

Q. I have heard that there is a limit to the number of times that blepharoplasty may be performed. Does this apply to the Ten Minute Eyelift?

A. While the result of a Ten Minute Eyelift is technically permanent, age-related changes to the delicate tissues surrounding the eyes may eventually result once again in significant hooding. Fortunately, the Ten Minute Eyelift may be repeated as often as necessry. Whenever possible, retreatment is performed directly over the previous scar so that no additional scar tissue is created.

Tattoo Removal

Tattoo Removal

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By Nelson Lee Novick, M.D., FAAD, FAACS

Tattoos are simply permanent drawings or designs made in the skin. They are created when pigment is implanted into the middlemost layer, known as the dermis. In the past, and still today among amateur tattoo artists, the pigment was inserted by pricking the skin with handheld needles that were coated with ink. These days, professional tattoos artists, however, use an electric tattoo machine whose needle tips are coated with the chosen pigment. There are as many as 100 different colored inks to choose from. The needles hammer up and down into the skin with a motion much like that of a sewing machine and drive the pigment down into the desired locations to create what amounts to true works of art upon a canvass of skin.


At one time, the very mention of the word tattoo conjured frightening images of gang members, hardened convicts, right wing hate groups, and bizarre religious cultists. That image changed, however, as tattoos burst into mainstream Americana during the past twenty years. The presence of approximately four thousand tattoo parlors nationwide attests to their enormous popularity, particularly among young people. And, it is estimated that greater than ten million Americans possess at least one tattoo.

With the passage of time, not everyone remains happy with their foray into body art. Perhaps as many as half of all individuals sporting tattoos grow to regret their youthful indiscretion. What appeared cool and “in” on a forearm at age sixteen can prove an impediment to getting hired as an airline stewardess at age twenty-six. And a soaring eagle with its wings spread wide and coarsing up the side of the neck may look macho at seventeen, but altogether unacceptable to a conservative Wall Street brokerage firm at age twenty-seven. And, of course, an “I love Sally” heart-shaped tattoo replete with Cupid’s arrow spread over John’s outer arm is not likely to go over very well with the next love of his life, Jane.

It may be fairly easy to get a tattoo applied, but it’s safe to say, it’s much harder to get one removed, and, for that matter, much more expensive. Prior to the introduction of light-based therapies, a variety of procedures were used for getting rid of them. These included dermabrasion, salabrasion, cryotherapy, chemical peeling. and surgical excision.

Dermabrasion involved the use of a motor-driven wire brush to abrade the skin surface; salabrasion, the use of coarse salt crystals; cryotherapy, freezing with liquid nitrogen; and medium-depth chemical peels, tha application of caustic materials. Each of these techniques relied upon stripping away the epidermis, the topmost layer of the skin, and exposing the pigment-laden dermis. Following exposure, the ink would be extruded as part of the healing process.

Surgical excision skirted the issue of dealing directly with the embedded pigment. Instead, if the lesion were small, it was cut out entirely and the resulting wound sutured together. If it were very large or its location difficult to work with, the removal was done in stages, allowing each surgical wound to heal before proceeding to excise another part. In general, these methods were successful at obliterating the tattoo, but at least some degree of scarring was inevitable. It was a trade-off--an acceptable scar in place a highly visible and undesirable tattoo.

Lasers and other light therapy devices, such as the Infrared Coagulater (IRC), are the treatments of choice today. Lasers work by emitting short, intense pulses of light that pass through the skin and target the ink. The energy from the laser light fragments the large particles of tattoo pigment enabling the body’s natural immune system to more easily scavenge the pigment and carry it away. This process usually takes several weeks, and multiple treatment sessions are often necessary to achieve maximal clearing.

Since black pigment absorbs all wavelengths of light, it is ironically the easiest pigment to remove. Colors, such as green, do not absorb as well, and sometimes a variety of lasers, with varying wavelengths, are needed to effectively treat a multicolored tattoo.

Potential complications include permanent scarring, temporary or permanent loss of pigment or excessive pigmentation. Fees for laser treatments may range from $1000-$3000 or more, depending upon the number of treatment sessions required, and the size, shape, colors, and location of the particular tattoo.

IRC uses non-laser infrared light to heat the area containing the pigment. It is quick and easy to perform, and generally requires fewer treatments than lasers. Most small tattoos can be treated successfully in one to three sessions. IRC’s efficacy also does not depend upon the particular color of the pigments involved. For these reasons, it is my favorite method for dealing with small tattoos.

The procedure is quick and simple. The area is first numbed with local anesthesia. Next, very short pulses of infrared light are directed at the tattoo in a gridlike fashion, leaving tiny spaces between each treated site. Since each burst of energy is just a fraction of second, an entire treatment session requires only a few minutes to complete. It is within the course of the next few weeks, as he wound heals, that the pigment is extruded.

To complete the removal, the intervening spaces are generally treated between two to four weeks later. Fees for a series of three sessions generally run about $1500. As with laser treatments, potential complications include scarring and temporary or permanent pigmentary changes. Most people, however, are quite gratified and relieved to be free finally of their tattoos. The accompanying figure demonstrates a tattoo before and eight weeks following final treatment with IRC.

Q. How much does it hurt to remove a tattoo by light therapies?

A. In most cases, the use of local anesthesia is sufficient to make the procedure painless.

However, despite the anesthetic, some individuals may feel some discomfort, a stinging sensation or what has been likened to the feeling of a thin rubber band snapping back against the skin. The skin may also feel sunburned afterward.

Q. Will my skin look completely normal after my tattoo is gone?

A. Unfortunately, at the present time, no tattoo can be removed without a trace, and, however minor, all tattoo treatments leave a scar. Recently, tattoo pigments have been introduced that are intended to vaporize (rather than break up into smaller fragments) upon exposure to laser light. As these become more widely used, it should be far easier in the future to remove tattoos and with much less chance for scar formation.

Improving Scars

Improving Scars

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by Nelson Lee Novick, MD, FAAD, FAACS

Scars, which are a part of the body’s natural healing processs, are formed when skin is damaged deeply by trauma, surgery, or disease, such as burns and chicken pox,. The more layers of skin destroyed, the more widely extensive the damage, and the longer a wound takes to heal, the greater the likelihood of developing a noticeable scar. Acne is arguably the best known cause for scars, which may result from either the severity of the disease itself or undue delay in obtaining appropriate treatment. Acne scarring is estimated to affect, to a greater or lesser extent, some 95 percent of sufferers.

Abnormalities in color, shape, contour and texture are the reasons that scars are visisble. Although each patient and each scar must be treated individually, it is generally the type of scar and its location that most determine the specific treatment.

Broadly defined, scars fall into three main categories: elevated, depressed, and atrophic. Hypertrophic scars and keloids, which result from an exaggerated healing response, are elevated scars that stand like mountains above the skin surface and cast broad, unsightly shadows. Both are composed of an overabundance of dense fibrous tissue. Hypertrophic scars, also called “proud flesh,” sometimes shrink on their own over time. Keloids, which develop in genetically prediscposed individuals, typically do not and require treament.

A depressed scar, as the name suggests, is sunken below the skin surface. It is especially visible due to the “craters of the moon” effect, where wide shadows are cast across the base of the scar making it stand out from the rest of the skin. While generally level with the remainder of the surface or only slightly depressed, atrophic scars have an ivory-colored or a crinkly, off-color, cigarette-paper like appearance that stands in sharp contrast to its surroundings.

Although all scars are permanent, many that are disfiguring at first become much less visible after several months and require no further treatment. For those that do not, however, we are fortunate to have a variety of miniminally invasive, office techniques for improving their appearance significantly. These include intralesional injections, surgical scar revision and punch-excision or punch grafting, dermaspacing, fillers, buffing (manual dermasanding), chemical peeling, microdermabrasion, and lasers and intense pulsed light (IPL). All are non-invasive or minimally invasive lunchtime beauty fixes that require topical or local anesthesia and engender little or no downtime.

Intralesional injections of an antiinflammatory corticosteroid remains the treatment of choice for both hypertrophic scars and keloids. Most hypertrophic scars respond quite rapidly and will shrink after a series of one to three treatments spaced at monthly intervals. Keloids, on the other hand, may require higher doses and additional techniques, such as pretreatment with cryotherapy to soften the tissue and permit the injections to disperse better, surgical removal to debulk the scar, and subsequent use of certain wound dressings and topical medications to suppress recurrence. In most cases, large unsightly keloids can ultimately be reduced to barely visible, flat, off-white skin discolorations with these methods. Fees for intralesional injections typically range from $150-$300 per session.

Surgical scar revision involves cutting out a scar and reorienting and restitching the resulting wound in such a way as to make the new surgical scar much less visible than the one removed. Fees for this procedure vary depending upon the size of the scar and the anatomic location and typically range from $350-$1000. Punch excision, punch elevation or punch grafting are all variations of surgical scar revision used for treating icepick scars.

The word punch refers to the razor sharp circular cutting instrument used by the dermasurgeons to core out the scar. In punch excision, the scar is extracted and the resulting wound either simply sutured closed or, if small enough, allowed to heal on its own. In punch elevation, the scar is freed up in the same manner, but is not removed. Instead, it is elevated to the surface to eliminate the depression, and then allowed to heal on its own. In punch grafting, a small piece of normal color-matching tissue, usually taken from skin overlying the bone directly behind the ear, is used to replace the cored out scar. Punch procedures often run between $250 and $500 per site.

Depressed scars, such as those from chicken pox or acne must be elevated. Dermaspacing, a technique that uses a small cutting needle to break up scar tissue creates a pocket within the scar under the skin into which fresh collagen can be produced and laid down, thereby elevating the surface of the scar above. The results of dermaspacing have the advantage of being permanent. If necessary, fillers, such as Radiesse, Juvederm or Restylane may also be used, either alone or in combination with dermaspacing to further raise up the depressed areas. Fees for dermaspacing may range from $300-$500 per session.

Icepick scars, which are typically very narrow and penetrate quite deeply and are often numerous, present perhaps the most difficult therapeutic challenge. In my experience, these are best treated by Chemical Reconstruction of Skin Scar (CROSS) technique, which is a modification of a deep chemical peel in which 100 percent trichloracetic acid is carefully placed deep within the pit (rather than applied to the whole face). The resulting wound closes the pit. A series of four to six treatments may be necessary. The accompanying figures represent pit scars of the cheek following a series of six monthly CROSS treatments. Fees vary according to the number of areas treated, and may range from $500 to $750 per session.

When surface irregularities are a prominent feature of a scar, buffing the skin (i.e. manually “sanding”), chemical peels, or light-based therapies, such as intense pulsed light (IPL) may be considered. Buffing the skin with a medical grade, sandpaper-like material and chemical peeling agents abrade and remove the surface of the scar and level out the irregularities. IPL penetrates the skin causing damage below that subsequently results in a thickening of the dermis via new collagen synthesis with a consequent smoothing out of the overlying upper layer of skin. Buffing generally costs about $500 a treatment, and IPL may range from $300-$400 per session.

Dermatologic science can take pride not only in the diversities of the currently available techniques, but even more in the reality that no one with disfiguring scars need any longer throw up his/her hands in despair.

Tackling Cellulite & Stretch Marks

Tackling Cellulite & Stretch Marks

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by Nelson Lee Novick, MD, FAAD, FAACS

Cellulite

The term “cellulite” refers to unsightly, puckered or dimpled skin on the backs and sides of the thighs and buttocks. The appearance has been likened to that of cottage cheese or to a “peau d’orange” (an orange peel). Cellulite is largely seen in women, and current estimates suggest that more than 85 percent of women suffer from it. For this reason, it can perhaps be more aptly viewed as a normal female developmental characteristic.

The exact causes of cellulite are still unknown. Under the microscope we find fat deposits and tissue swelling within the subcutaneous (fat layer) of the skin bound between tight, horizontal fibrous tissue bands. The upward swelling of the fatty tissue is responsible for the puckered appearance and the downward pull of the fibers for the pitted look of the overlying skin.

Contrary to popular misconception, cellulite is not a matter of being excessively overweight, since it can be found in individuals of all body shapes and sizes. However, being overweight may worsen the appearance. A predisposition for the development of cellulite does run in families, and it is also more common in caucasians. While it manifests as early as adolescence, the condition clearly worsens with advancing age as the overlying skin thins.

At present, there is unfortunately no cure for cellulite. Many therapies have been proposed for dealing with it, but rigorous scientific substantiation is lacking for any of them. These include the use of topical agents to decrease tissue swelling and promote lymphatic drainage; massage therapy (manual or mechanical), to break up fatty deposits and fibrous bands; and even liposuction or liposculpture, to remove excess fat and disrupt fibrous tissue. The benefits of any of these tend to be temporary, and maintenance treatment is generally required. More recently, laser and focused ultrasound therapies to promote fat breakdown, resorption, and recontouring have been introduced, but these, too, await further intensive investigation to validate their long-term efficacy.

In my experience, deep dermaspacing, a minimally-invasive office procedure, followed by the injection of a volumizing agent, such as Radiesse, have proven quite helpful for individuals who have multiple, discrete areas of pronounced puckering. Since it stimulates natural collagen production, dermaspacing alone may be helpful for raising up a site the way it does when treating depressed chicken pox or acne scars. I have found, however, that the supplemental use of a volumizing agent, such as Radiesse, is essential for achieving optimal results. .

The procedure is simple. First, approximately ten of the most prominent or deepest dimples and craters are outlined with a surgical marker on each side of the thighs and buttocks.. Next, a small amount of local anesthetic containing epinephrine (for constricting blood vessels and diminishing bruising) is instilled directly underneath each of the spots. A needle-like cutting instrument, or trochar, is then inserted immediately below the dimple and fanned about in all directions to break up the tight fibrous connections encircling the fat bundles and to create a small pocket into which newly synthesized collagen will be deposited.

Finally, the volumizer is injected directly into the newly created pocket. This serves to directly plump up the overlying skin. It also enhances native collagen synthesis. And lastly, it acts a spacer material to prevent the pocket from closing before there is sufficient natural collagen produced to fill it up and raise the pucker above.

Each site requires just a couple a minutes to treat, and the entire procedure may take only twenty to thirty minutes.

Bruising, slight swelling, and discomfort are common and may last for several days. Since the resulting wounds all lie entirely below the skin surface, they are allowed to heal by themselves and require no special wound care. Cosmetic improvement is usually seen in about two to four weeks, the time it takes for new collagen to be laid down. The procedure may need to be repeated one or more times to achieve maximal correction. Fees typically range from $1500-$3000.

Stretch Marks

Stretch marks, or striae distensae, are another common cosmetically-troubling problem for which ideal treatment is still unavailable. Like the American flag, stretch marks come in red, white and blue. Early on, they may be reddish and slightly elevated, later, dusky purple or bluish, and finally, ivory-colored or whitish flattened bands with a wrinkly, crinkly surface. Typically, they appear on the breasts, abdomen, thighs and arms and commonly appear after the skin is excessively stretched as a result of adolescent growth spurt, pregnancy, weight gain and weight lifting. They are estimated to affect seventy percent of adult women and forty percent of young men.

Although much remains to be learned about what causes them, current wisdom suggests that stretch marks result from an overproduction of adrenal glucocorticoid, which accompanies each of the above circumstances. They can also appear following prolonged use of high potency glucocorticoid creams and ointments. Whichever the case, the high level of steroids interferes with the production of collagen and elastin fibers, resulting in a loss of dermal support that leads to tearing when the skin is stretched.

The term stretch marks is actually a misnomer. Although stretching may determine where striae may appear and even in which the direction they run, it does not cause them. In fact, no matter how much you stretch or overstretch, they will not appear unless glucocorticoid steroid levels are increased.

To be effective, treatments must be geared to the particular phase of stretch mark development. Early on, during the reddish-purple phase, therapy must be directed to dealing with dilation of blood vessels and damage to collagen in the dermis. Later, during the white crinkly "mature stretch mark" phase, the approach must address thinning of the epidermis (the topmost layer of the skin) and the inflammation and remodeling of collagen theat leads to the loss of pigment cells or obscuring of normal skin pigmentation.

Unfortunately, we currently do not have any gold standard method for entirely eliminating stretch marks. We do, however, have a number of very effective techniques for improving them. In general, the earlier the mark is treated, the greater the anticipated improvement. Certain lasers and intensed pulsed light therapies (IPL) have proven useful for diminishing the vascular dilation of the early phase and for promoting the production of healthy collagen. Light-emitting diodes (LEDs) in the ultraviolet range have stimulated pigment production. Each of these methods usually requires anywhere from six to ten or more treatments.

I have found that all all stages, daily topical application of high potency retinoids (vitamin A derivatives), such as Avage, along with alpha hydroxy acids, such as Amlactin, has been helpful for promoting new collagen and elastic fiber production and stimulating the turnover of epidermal cells. Here, too, the earlier treatment is begun, the better.

I have also found that a series of microdermabrasion treatments can be helpful for smoothing the surface of stretch marks. In selected cases, I add dermaspacing for breaking up distorted collagen bands and stimulating new collagen production.

Eliminating Spider Veins & "Broken" Blood Vessels

Eliminating Spider Veins & "Broken" Blood Vessels

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by Nelson Lee Novick, MD, FAAD, FAACS

It’s summer. The weather is beautiful, the water warm and inviting. It’s time once again for shorts and swimsuits. “Oh, no!” you grown. “I can’t go out with these ugly old spider veins all over my legs.” Sounds familiar. Well, it’s a common complaint for the millions of people who have these unsightly little blood vessels over their thighs and calves.

Spider veins, so called because the “arms” of these tiny dilated blood vessels appear to project outward from a central denser area like the legs of a spider from its torso, are also called sunburst varicosities, for a similar reason, or telangiectasias (“broken” blood vessels) when they cover the face. In fact, they are simply diminutive, thick venules (literally: little veins) that lie close to the surface of the skin. And because they principally carry deoxygenated blood (blood that is not saturated with oxygen needed by the tissues), they actually serve no useful function. Even nutrition-wise, it is the blood vessels hidden below the surface, within the dermis, that carry nutrients to the skin. In short, spider veins and telangiectasias are just plain, disfiguring nuisances.

The precise cause of these unwanted vessels is still the subject of investigation. However, we believe that they develop as a result of a complex interplay of genetic, hormonal and environmental factors. There is often a strong family history for their formation. You might find, for example, a mother, daughter and sister suffering the same problem. Elevated estrogen levels appear also to aggravate the condition. Not uncommonly, they worsen during pregnancy or while taking birth control pills. Individuals whose jobs require them to be on their feet a great deal, overweight persons, and those who have sustained some kind of injury to the area, including blunt trauma, cuts, lacerations, or even surgical procedures are particularly vulnerable. And while alcohol consumption has been associated with their development on the face, there are many tea totlers who complain of them, as well.

Whatever they are called, and however they come about, countless numbers of women and men want them gone. Despite the advent of lasers, sclerotherapy remains the gold standard treatment and the commonest method for getting rid of them on the legs. Sclero, literally means “scar,” and sclerotherapy works by irritating the lining of the unwanted blood vessels to such an extent that they collapse upon themselves and eventually scar over and disappear from view entirely. For this purpose, your doctor can choose from a number of different sclerosing agents, including super concentrated salt solution (hypertonic saline).

Very tiny, dense “mats” or conglomerations of red blood vessels, known as telangiectatic matting is difficult to treat with sclerotherapy and may respond better to laser or other light therapies. On the other extreme, larger varicose blood vessels are best treated by venous stripping and ligation, ambulatory phlebectomy, and the newer, endoscopic radiofrequency surgical technique.

One of the major advantages of sclerotherapy is that it is fast and simple. A typical treatment session may take only about fifteen to thirty minutes depending upon the size of the area to be treated. A very tiny needle, smaller than most sewing needles, is inserted into the venule and the sclerosing material is then injected until it and the vessels in the region immediately surrounding it fade from view as the solution courses through. Each subsequent site is injected in a similar fashion until the entire area to be treated is completed.

Although mild stinging or burning may accompany the injection, except for the use of a topical anesthetic cream (e.g. EMLA or ELA-MAX), most physicians opt to treat without injecting any “freezing” solution. I have found, however, that combining the sclerosant with small amount of lidocaine coupled with epinephrine, a blood vessel constrictor, not only makes the procedure entirely comfortable, but enhances the cosmetic result by promoting a tighter contact between the blood vessel walls and the sclerosing solution owing to the blood vessel narrowing.

Your doctor may cover the treated sites with compression bandages consisting of cotton balls that are taped in place and left for three days. Others additionally recommend that support hosiery be worn for several days or even weeks afterward. I personally find these measures unnecesary, except when treating larger varicosities.

While some patients obtain a satisfactory outcome after just one treatment, optimal esthetic improvement generally require two or more sessions, spaced at four to six week intervals. Each visit can be expected to yield a 50 percent improvement in appearance, but of course the results are highly individual. Unfortunately, eliminating existing blood vessels does nothing to prevent new ones from developing at a later date that will necessitate additional treatments. Persons with diabetes, heart disease or circulatory problems are not considered good candidates.

Following treatment you might experience some mild leg cramping, bruising, or redness, but in most cases, you will be able return to work or social activities immediately (ie. no “down time”). Occasionally, the skin over the treament sites can become temporarily stained a coffee color, and tiny clots may form under the skin that need to be drained. Tiny skin ulcerations and scarring are rare complications.

Sclerotherapy sessions typically range from $200 to $400, depending amount the number of syringes used or the area covered. The accompany photos demonstrate before and after four treatments to the back of thigh region with hypertonic saline.

Although larger blood vessels, especially around the nose, or on the temples, may likewise be treated by sclerotherapy with good results, facial telangiectasias are generally best treated by other methods. These include the use of radiowaves, electrolysis and light therapies. As with sclerotherapy for the legs, most people require between two to four treated per area with any of these techniques, spaced at two to four week intervals, in order to be able to see a 60%-80% overall cosmetic improvement.

Laser light, which targets and heats up the red hemoglobin pigment within blood cells works by thermal destruction of the tiny blood vessels. With Intense Pulsed Light therapy (IPL), which is not technically a laser, gentle pulses of light penetrate the skin and are absorbed by the abnormal blood vessels, heating them and leading to their destruction and eventual absorption by the body. Patients may experience a transitory stinging during light treatments, as well as some redness in and around the treated sites that may last for a few days.

Electrolysis involves the use of high-frequency electrical current to generate tissue-destroying heat that is discharged into the skin via a tiny probe inserted through the skin to the tiny blood vessels. Before the introduction of lasers, this was the only modality available for dealing with facial capillaries and was quite successful. Since tiny pit scars occasionally develop at treatment sites, electrolysis is a less attractive treatment option than the other methods currently available. Fees per session for any of these techniques parallel those for sclerotherapy.

Radiowaves are my treatment of choice and over the years have yielded consistently gratifying results. A high-tech device using a radio frequency current, similar to the kind used to operate an ordinary radio is used. The radio waves, which work by sealing off the blood supply to the troublesome little vessels, are introduced through an ultrafine probe that is placed directly on the skin surface and moved rapidly from site to site. Sessions usually last no more than ten or fiteen minutes and typically require only the prior application of a topical anesthetic cream. Two to four treatments are generally needed per site for best results.

As opposed to light therapies, it has been my experience that radiowave treatments are less likely to result in prolonged facial redness or long-lasting blotchy brownish discoloration. The average fee is $300 per treatment for the cheeks and nose.

So, if you really can’t stand anymore to see those unsightly strands and networks of blues, purples and reds coursing along your face or your legs, with today’s technologies, now is a great time to see your doctor and do something about it.

Q. After finishing a series of treatments, when will I need to return for further work?

A. In general, those people exhibiting a tendency to make “broken” blood vessels on the face or spider veins on the legs will continue to do so throughout life. It is difficult to predict, but it has been my experience that a whole new batch will crop up every two to five years.

Q. Since broken blood vessels seem to recur every few years, should I just wait until I get a massive batch of them before seeking treatment?

A. Telangiectasia and spider veins are typically part of a large network of interconnected tiny blood vessels that spread out like the limbs of a tree into ever smaller branches. The earlier one is treated, the easier it is to keep the proliferation at bay. In short, sooner is better than later.

Eliminating Discolorations, Shrinking Pores, & Fading Flushing

Eliminating Discolorations, Shrinking Pores, & Fading Flushing
www.skinsavvy.fromyourdoctor.com
By Nelson Lee Novick, M.D., FAAD, FAACS

No doubt you already know a great deal about ways of getting rid of wrinkles, straightening jowls, removing moles, and fixing scars. However, a healthy and youthful appearance hinges on more than the absence of furrows, sagging, and unsightly lumps and bumps. Your skin is like a fabric or a canvass upon which everything sits. If I handed you a hot iron, and asked you to press a frayed, threadbare, and badly wrinkled shirt, you would likely be able to eliminate all the creases, but in the end you would still have a tattered garment, unfit for wearing. So, too, with your skin. In order to be fully restored and revitalized, you must also pay attention to the background fabric, to improve its luster, tone, and texture.


There are unfortunately quite a number of common imperfections that can mar the background fabric of our skin and detract from our appearance. These include sallow complexion, roughened or leathery skin, dark circles under the eyes, persistent facial flush, “liver spots”, freckles, melasma, post-inflammatory hyperpigmentation and dilated pores.

A dull and sallow (sickly yellow) tone can result from long-term photodamage, stress, lack of sleep, ill-health or improper skin care routines. Likewise, coarse, dry, alligator skin has its roots in chronic overexposure to ultraviolet light, chronologic aging, and the overuse of hot water and harsh cleansers. Dark circles under the eyes have been linked both to sun damage-related thinning of the lower lid that increases the visibility of the dark, bluish vessels beneath and to ultraviolet light-induced deposition of melanin within the region. The presence of a persisent, embarassing facial flush is most often an ethnic/familial trait or a manifestation of rosacea.

“Liver spots,” more correctly known as solar lentigines, have nothing whatever to do with the liver. They are small, flat or slightly raised brownish discolorations commonly seen on the face and hands of fair-skinned people who have had a great deal of lifetime tanning. They impart a mottled and uneven look that accentuates whatever lines and wrinkles are present. Another common discoloration, garden variety freckles or ephelides, may seem charming when there are only a few of them scattered over the cheeks and nose. But, when they merge together and become densely packed, they can be quite unattractive.

Then we have melasma, a common, inherited condition of blotchy brown pigmentation that typically affects the cheeks and forhead. Melasma is thought to be provoked by estrogens, birth control pills, the hormones of pregnancy, and sunlight. And finally, there is postinflammatory hyperpigmentation (PIH). Lesions of PIH are those annoying, dark blemishes, the bane of all teenagers, that can persist long after the healing of any intense or prolonged episode of inflammatory skin condition, such as acne or rosacea.

Traditional medium and deep chemical peels using phenol and high concentrations (50% or greater) of trichloracetic acid (TCA) have fallen in popularity in the past couple of decades. Although they are extremely effective for treating chronic sundamage, wrinkles, and pigmentary and surface irregularities, they typically require extended recuperative and recovery periods.
Fortunately, milder chemexfoliation agents, such as low potency TCA, Jessner’s solution, and maximal concentrations of glycolic acid and salicylic acid are available that can achieve many of the same effects without the long downtime. To distinguish these treatments from a chemical peel, the application of these substances is sometimes referred to as skin freshening, skin renewal, or skin rejuvenation. And because they can be performed in a matter of minutes, they have been described as “lunch-hour peels.”

TCA in concentrations of 10%-15% and Jessner’s solution, a preparation composed of lactic acid (an alpha hydroxy acid, see below), salicylic acid, and resorcinol in relatively low concentrations, has a long, proven safety and efficacy record.. A series of six or more peels can be helpful for brightening the skin, adding luster, smoothing roughened areas, and fading dark spots and larger discolored patches.

In my practice, I rely more heavily upon what I have nicknamed “Fruit Washes” and “Beta Washes” for improving brilliance, luster and tone; achieving smoother texture; softening fine wrinkles; minimizing superficial laxity; evening out pigmentary irregularities; and diminishing pore size. Both kinds of peels may be used safely and effectively for the face, neck, chest, and hands.

Fruit Washes are solutions of glycolic acid in its maximum 70% concentration. Glycolic acid is one of several alpha-hydroxy acids (AHAs), a group of naturally occurring substances often referred to as “fruit acids” because they are found in various fruits and other foods. In nature, glycolic acid is a component of sugar cane juice.

Topical anesthesia is seldom necessary before a Fruit Wash, although it may be occasionally needed to numb specific sites, especially the delicate areas under the eyes or around the mouth. Mild stinging, itching and burning are common shortly after application, but are eliminated by plain water or bicarbonate compresses applied after about two minutes. This is followed by a pleasing blush, and most people are delighted by an almost immediate overall improved glow or radiance. For best effect, a series of six to twelve treatments spaced at one to two week intervals is often necessary followed by periodic maintenance treatments as needed. Fees range $100-$150 per session.

Beta Washes contain salicylic acid, a beta-hydroxy acid, in a maximal 30% potency. Salicylic acid has been used safely as a peeling agent for more than sixty years. Prior to treatment, the skin must be thoroughly cleansed and degreased. Here, too, topical anesthesia is rarely required. After application, most people experience an intense stinging and burning sensation, which stops spontaneously in about three minutes without any need for neutralization.

Beta Washes possess several distinct advantages. For one thing, since the skin turns a powdery white as the solution dries, it is easier to be sure of an even and complete application without any skipped areas. Moreover, because it is lipid soluble, a Beta Wash can more easily penetrate follicles to unplug and tighten pores and improve acne prone skin. And, finally, it is especially safe because the peel stops by itself limiting the depth of penetration.

As a rule, Beta Washes more rapidly achieve some of the effects of multiple fruit washes, particularly for smoothing fine lines, lightening darkened skin, and hastening the resolution of active acne. A series of two to four treatments at two to four week intervals is typically required followed by periodic maintenance as necessary. Fees range from $350-$750 per session. The accompanying figures demonstrate melasma of the cheek before and following four Beta Wash sessions spaced at two week intervals.

Immediately after treatment, most people note an incredible smoothness and softness to their skin. However, it usually takes a few days for the surface to completely return to normal. A faint reddish-white appearance and slight puffiness is not unusual for a day or two. And during the next few days of healing, renewal, and repair, the skin may also feel a bit taut. Not infrequently, there will be a mild, sunburn-like flaking of the topmost layer. No particular aftercare is generally necessary, however, and regular makeup can be applied right away.

A variety of ablative and non-ablative lasers have also been used for the treatment of the above conditions. In my opinion, they tend to be more expensive, and none have been shown to be consistently more effective than the peeling methods described. By contrast, electrosurgery, the application of electric current, and radiosurgery, the use of radiowaves, are each useful and relatively inexpensive methods for treating liver spots when they are few in number. Fees typically range from $100-$300 for up to six lesions.

While most people are gratified with the improvement they see in the tightness of their pores after several Beta Washes, others with more dilated pores can profit from the use of trichloracetic acid 100% instilled directly down the shaft of the pore. The resulting irritation of the lining of the follicle leads to its permanent shrinkage with complete healing. This technique known by the acronym CROSS (Chemical Recsonstruction of Skin Skars) was developed for the treatment ice pick scars from acne. Depending upon the number of sites treated, fees may range between $150-$500 per session.

Finally, I find that individuals complaining of a persistent flush to the cheeks (not “broken” blood vessels) can be most effectively treated by a combination of small amounts of Botox injected superficially in a gridlike pattern over each flushed area accompanied by a series of intense pulsed light ( IPL) therapy sessions. The Botox helps to “calm” the overreactive neurons believed to contribute to blood vessel dilation, and the IPL targets and heats the hemoglobin in the minute blood vessels causing them to shrink. Fees for the Botox (usually only one session needed) typically run $400-$600, and for the IPL $350/session for a series of four to six treatments spaced at two week intervals.

Sculpting Away Moles, Growths, & Age Spots Without Stitches

Scupting Away Moles, Growths, & Age Spots Without Stitches
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by Nelson Lee Novick, M.D., FAAD, FAACS

As you age, your skin can become host to a wide variety of cosmetically displeasing, flesh-colored or pigmented bumps and lumps. Which ones develop, when they do, how quickly they appear, and how extensively they cover the canvass of your skin are determined by a combination of your genes and how much sun exposure you have gotten over the years. Often, these often unsightly and unwanted lesions are moles. Lesions is doctor lingo for any spot or lump in the skin that causes concern or differs from normal skin. Moles, or nevi, are dark, oval-shaped “beauty marks” or “birth marks.” Other types of cosmetically troublesome growths include “overgrown oil glands,” little orange-yellow bumps known as sebaceous hyperplasia, warty-looking, skin-toned or brownish age spots called seborrheic keratoses, and skin tags, fleshy growths that hang from tiny, narrow stalks.

If you’ve always wanted to have these things removed, but hesitated because of the fear of stitches, scarring, or the expense of surgery, the quick and simple, minimially invasive, no-stitches-required techniques described below may be just right for you.

Scalpel Sculpting is an excellent method for removing growths elevated above the skin surface. Immediately following the administration of a small amount of local anesthetic just beneath the spot, the doctor uses a scalpel to remove it with a horizontal, back and forth, “sawing” motion of the scalpel blade that essentially “sculpts” the undesirable area away from the surrounding normal skin. The wound underneath is left to heal by itself. Since the cut is so superficial, no sutures (stitches) are needed, and there is little risk of scarring. The cosmetic result is generally excellent, and the whole procedure takes literally under five minutes.

Scissor Excision or scissor removal is essentially a variation of Scalpel Sculpting, except that instead of a scalpel, a very delicate surgical scissors is used to cut away the growth. It is particularly useful for removing skin tags, which can be snipped off right at the base of the stalk. Here again, no stitches are required and the results quite gratifying.

Curettage is another no-stitches sculpting technique. It is a kind of skin scraping performed with a special instrument called a curet, hence the name curettage. A curet is a cutting instrument with a round or oval, loop-shaped cutting edge and a handle, and is available in varying sizes. Largeer curets are used for removing larger growths. Curets are used to “scoop” out or off an unwanted area. If the site to be removed is small, anesthetic may not even be required.

Wire Loop Removal is still another variation. This procedure is once again similar to the other three methods described, except that here a wand with a wire loop at its tip is used to encircle the lesion. A radiosurgical device supplies the radiowave energy necessary for the loop to “melt” through the base of the growth and free it up from the underlying normal tissue and sculpt it away. Radiowaves are the energy source that runs your AM/FM radio.

The accompanying before and after figures illustrate the results of this technique for removal of a mole from the upper eyelid.

Sculpting procedures generally run between $150-$300 for each area, depending upon the size, the exact method used, and the location of the lesion.

Q. Describe the usual healing phase after sculpting procedures.

A. A scab usually forms within the first 48 to 72 hours that eventually falls off sometime between days 14 and 21. Although the wound site is entirely healed by this time, there is usually a pinkish/purplish discoloration that remains temporarily, eventually fading sometime between four weeks and twelve weeks afterward. During this period, the site will ordinarily pass through a series of additional color changes that range from dark brown to fawn colored before returning to normal flesh color.

Q. Can numerous growths be removed in one session?

A. Yes, in an otherwise healthy person there is no reason not to. I have, in fact, removed as many as seventeen moles from a young woman’s face at one time in about half an hour. However, when that many are done at once, it is important to warn the patient that immediately afterward, and until the wound sites completely heal, they will appear as though they had an outbreak of acne.

For this reason, many people who have numerous unsightly facial growths opt to have them removed over a period of several sessions. When only three or four are done at once, it is easier to adequately mask them with coverup cosmetics until all the color changes of the healing phase are gone

Non-Surgical Hand Rejuvenation

Non-Surgical Hand Rejuvenation
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by Nelson Lee Novick, MD, FAAD, FAACS

Next to the face, your hands are the most continuously exposed area of the body. You can’t hide them in clothes or behind high collars, like a chest or a neck, and, if you are lucky enough that your face does not betray your age, your hands can give it away like the rings of a tree. According to an Allure magazine article, it was not that long ago that the hand was called the “last virgin body part” because so little was or could be done to rejuvenate it. Fortunately, all that has all changed.

Arguably, the hands are the most abused part of the body. Since they are exposed to so much sunlight, weathering, and plain wear and tear, they are one of the first areas of your skin to show signs of aging. Genetics, gravity, and the passage of time contribute to the toll. What is clear, however, is that many of the changes we once associated with chronologic aging of the skin are actually the result of shifts or loss in volume in the fatty layer below it, the so-called subcutaneous fat.

The backs of the hands of young people are unwrinkled and plump and are not mottled with dark patches and splotches. By contrast, older-looking hands appear spotted, frail, thin, boney, and wrinkled, with clearly visible tendons, and bulging veins. So, anything we can do to lighten or eliminate dark spots, mask the tendons and bones, and diminish the prominence of the blood vessels can wipe years off the apparent age of your hands.

It is only relatively recently that we have come to appreciate that restoring volume to the backs of the hands is a must for achieving a more youthful appearance. Volume loss around the bones, blood vessels, and tendons is largely responsible for the prominence of these structures over time and the appearance of frailty and wasting.

Autologous fat transfer, a technique in which fat is harvested--by liposuction--from the abdomen, buttocks or thighs and then reinjected elsewhere in the body, was first used for hand rejuvenation more than a decade ago. The downside of fat injections is that they necessitate first a minor surgical procedure, i.e. the liposuction,before the subseqent injections themselves into the hands.

More recently, cosmetic dermasurgeons have turned to newer, synthetic fillers and volumizers to restore aging hands. Perlane and Juvederm UltraPlus, both hyaluronic acid derivatives, are excellent choices for hand rejuvenation. These materials impart a very smooth, pillowy texture and natural appearance, in large measure due to their enormous affinity for attracting and binding large amounts of water within the skin. Radiesse, a semipermanent volumizing agent composed of the bonelike material, calcium hydroxylapatite, has also been sucessfully used for this purpose.

Before treatment, the wrist and the channels between the bones on the backs of the hands are numbed with local anesthesia. The selected material is then injected directly into the troughs between the bones on the backs of the hand to plump and re-elevate them. Finally, the treated areas are massaged and molded into place to ensure smoothness and uniform coverage of the underlying structures. The entire procedure for both hands usually takes no more than fifteen or twenty minutes.

Following treatment, there may be some redness, mild swelling, and tenderness, which can last for about 24 to 48 hours. To minimize swelling, strenous excercise is best avoided during this time and the hands should be kept elevated as much as possible. Slight bruising is also possible, which can persist for several days, but in most cases, the bruises are easily masked with an appropriate coverup makeup. The esthetic benefits of the treatment are immediate, and more than 90 percent of patients are extremely gratified with the results after just one or two sessions.

With hyaluronic acid fillers, improvement generally lasts several months before a touch-up is needed. Results with Radiesse may last between 8 and 12 months. The accompanying figures illustrate the softening of the bony prominences and the blood vessels with the use of Radiesse.to fill the troughs between the digits. Fees for fillers and volumizers range from $1000-$2000, depending upon the material chosen and the region of the country.

Overall, volume replacement by itself is frequently sufficient for masking boneyness, and patent tendons and blood vessels. Occasionally, however, particularly prominent, bulging blood vessels will remain a problem even after sufficient volumizing. In these instances, sclerotherapy can be useful.

Sclerotherapy is just a fancy way of describing the injection of a liquid sclerosing (scar-promoting) agent, directly into the unwanted blood vessels, in order to cause them to shrink and eventually disappear entirely. It does so by irritating the inner lining walls of the blood vessels, which in turn causes them to narrow, then seal, and finally to scar down. Hypertonic saline, a superconcentrated salt solution, is most often used for this purpose, although other sclerosants are now being tried successfully.

Neither topical nor local anesthesia is usually necessary. However, you may experience a slight burning sensation as the sclerosant enters the vessels. Sometimes a tourniquet is applied around the wrist area or an assistant may grip your arm tightly in order to compress surrounding vessels and keep the sclerosant from spreading too far afield of the hands, thus ensuring maximum contact time with the salt solution. Several treatments spaced at monthly intervals may be neccesary to achieve the desired results.

Liver spots, or solar lentigines, which are believed to result from an interplay of genetic predisposition and chronic sun exposure. are unsightly, flat, dark, freckle-like patches that appear gradually on the backs of the hands. They have nothing whatever to do with the liver or diseases of that organ and probably got their nickname from the their deep brown color and the occasional resemblence of their shapes to that of the live. These spots respond to a variety of methods that include cryotherapy (the use of freezing solutions like liquid nitrogen), radiowaves, or laser therapy.

I prefer to treat them with a series of six or more mild chemical peels spaced at two to four week intevals. Glycolic acid and beta hydroxyacids work well for fading mild cases. In my experience, stronger peels, such as the Golden Peel Plus (see article on Non-Surgical Chest Enhancement/Breastlifts) are needed for more stubborn cases and pose little risk of scarring or permanent discoloration (which are risks when alternative medium strength peels are used to treat the delicate skin of the backs of the hands).

Happily, you no longer have to stare at your hands and feel depressed. You needn’t continue to lament, “They can never guess my age until they look at my hands.” A variety of simple, non-surgical techniques now available can go a long way to rejuvenating their appearance and your overall look, in just a matter of minutes.

Non-Surgical Chest Enhancement & Breastlifting

Non-Surgical Chest Enhancement & Breastlifting
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by Nelson Lee Novick, M.D., FAAD, FAACS

Although the harmful effects of sun exposure are usually seen two or more decades later, eighty percent of the lifetime damage to the skin by ultraviolet radiation is believed to occur before the age of eighteen. This includes the development of roughened, coarse, leathery, wrinkled skin, a patchwork of pigmentary loss and unsightly brown spots, and an overall diminution in tone and elasticity owing to depletion and disruption of both the elastic and collagen fibers in the dermis thatgive the skin its resilience and structural support. It also frequently leads to a superimposed proliferation of an intricate, mat-like network of tiny, dilated, reddish, purplish, or bluish blood vessels (telangiectasia), often referred to (incorrectly) as "broken" blood vessels.

In no place are these changes more evident that in the broad, flat expanse of the decollete, the triangularly-shaped area of the chest extending down from the base of the neck to the cleavage between the breasts. Here, the accumulated damage described above bears the tongue-twister medical name of Poikiloderma of Civatte, which is usually evident by the time a woman has reached her late forties or fifties. To compound this picture, the unrelenting downward pull of gravity during periods of pregnancy, nursing and overweight causes the breasts to sag with the passage of time.

If you have despaired of ever again wearing an elegant evening gown with a plunging neckline, or if you have given up on V-necks and resigned yourself to a life of high necklines, or if you have considered a surgical breastlift (mastoplexy) or implants to raise the breasts, but fear surgery, you can take heart. Non-Surgical chest enhancement and breastlifting may be just the answer for you.

As it does elsewhere, Botox Cosmetic has proven effective for diminishing wrinkles, crinkles and crepiness on the chest. A few tiny microdroplets spaced along a straight line just above the tops of the breasts can help to reduce the appearance of vertical wrinkles. Similarly, a number of minute amounts placed along an outwardly directed diagonal line beginning immediately above the inner side of each breast can help to diminish wrinkles that run horizontally. The accompanying photographs illustrate the use of Botox to reduce vertical wrinkle lines directly above and between the breasts.

A series of mild chemical peels may be used to combat widespread tone and texture problems. These include Jessner's solution (a mixture of low-potency acids), mild-strength trichloroacetic acid (10%-25%) and full-strength glycolic acid (70%). All have proven useful for smoothing the skin, lightening dark discolorations, and refreshing the general tone. Four to six in-office treatments spaced at two to four week intervals are usually needed for best effect. I have found salicylic acid (30%) to be the most effective agent for managing decollete, but of course you and your doctor must decide what is best for you.

While some people experience slight redness and mild scaling that may last for a few days, as a rule, there is little or no downtime involved following any of these treatments. Fees for each treatment session may range from $250-$350. When more severe skin damage is present, a Golden Peel Plus, a medium depth peel, (see below) may be required.

Botox can be helpful for sagging breasts. Several different techniques have been developed. The one I favor consists of injecting small amounts of it into three sites along the chest muscles (pectoralis minor) located directly under the collarbone on both sides of the rib cage near the armpits. The slight weakening of these muscle areas that results allows the shoulders to be pulled backward by certain muscles in the back, the posture to be improved, and the the breasts to be elevated.

Breast lifts of up to two-thirds of an inch have been achieved in this way. Two treatments are sometimes needed to maximize the effect, and the benefits may last up to four months. Ideal candidates are trim and fit women between the ages of 30 to 50 who are slightly stooped and round-shouldered. Fees range from $450-$900.

A Golden Peel Plus can also be employed for non-surgical breast lifting, either alone or in combination with Botox. It consists of two steps. The first involves the use of Jessner's solution, (a mixture of several, relatively weak acids), which acts as a kind of "primer" coat. The second is the application of a Golden Peel (Resorcinol 53%) to the entire exterior of the breasts, including the nipple and areola (the red area surrounding the nipple). Both chemicals are left in place for several minutes before neutralizing. Although some women do experience slight burning and discomfort, no local or even topical local anesthesia is typically necessary.

While a Golden Peel Plus can be performed over a lunch break, and may be considered a "lunchtime beauty fix," the results are not immediate, and there is a short healing period. Immediately afterward, the skin may be a bit red and slightly swollen. Three days later, the treated areas discolor to a reddish or light brown, and about two days thereafter, they form thick, dry, dark brown scales that take several additional days to fall off.

A series of four Golden Peel Plus treatments at two week intervals may raise the breasts by as much as two-thirds of an inch, which is a particularaly gratifying improvement in cases of mild breast flaccidity. Fees per treatment range between $300 and $400.

Although lasers and intense pulsed light (IPL) have each been employed successfully for treating "broken blood vessels, I prefer the use of radiowaves and have enjoyed great success with this modality over the years. With this method, a small amount of radiowave energy, akin to the type that is used by a regular AM/FM radio, is delivered through a hand-held probe and focused on the tiny capillaries. The disruption of the tiny capillaries that results leads to their ultimate disappearance. Hundreds of blood vessels can be treated in this fashion in one sitting in a matter of minutes. Most people require only topical anesthesia to reduce the "sting" that may be felt as the radiowave penetrates the skin.

Approximately 75 percent of people can expect to see an average of about 75 percent overall cosmetic improvement following two to four treatment sessions scheduled at intervals of two to four weeks. Fees may vary between $300-$400 per session.

Finally, there is nipple enhancement if you are looking to go bra-less again. Flat or inverted nipples, or nipples stretched by breast-feeding can be quickly restored using either of the two available hyaluronic acid filling agents, Juvederm or Restylane. Following local anesthesia, a small amount of the material can be instilled directly under the nipples to give them what has been referred to as a "perk up." Results may last anywhere from six to twelve months, and a treatment generally runs between $750 and $1000.

With today's non-surgical chest enhancement and non-surgical breast lift techniques, you may once again be able to sport that riske neckline without risking surgery.

Non-Surgical Neck Lifts

Non-Surgical Neck Lifts
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by Nelson Lee Novick, M.D., FAAD, FAACS

The face is by no means the only area of our body that reflects the ravages of the passage of time. The neck, too, is vulnerable to assault from long-term ultraviolet exposure, the dictates of our genetics, gravitational effects, and changes in muscle mass and elasticity with chronological aging. The interplay of these factors gives rise to several cosmetically troublesome hallmarks of the aging neck. The somewhat playful names "turkey gobbler neck," "turkey wattle," or "chicken neck" describe the effects of both sagging skin under the chin and the presence of long, vertically-aligned and parallel, ropey-looking cords that stretch north to south along the front of the neck. An equally fanciful term, "necklace lines," refers to parallel bands of wrinkles that encircle the neck like a series of thin chains.


Striving for balance and symmetry between the face and the neck can be as critical for attaining overall cosmetic improvement (i.e. the appearance of "total" rejuvenation) as it is for achieving these goals when concentrating only on the face. If you restore fallen cheeks, for example, but ignore prominent tear troughs under the eyes or heavily drooping brows, you will no doubt look better. But an apparent age discrepancy and aesthetic asymmetry between the cheek region and the eye unit can sometimes result. In the same way, neglecting to treat the aging neck and focusing exclusively on the face may give rise to a similar incongruity in appearance. Put another way, if your face looks refreshed and youthful, but the neck weather-beaten, the results may appear odd and jarring, the way it is when you spot someone with severely wrinkled skin who has dyed his hair and left no hint of gray. It also becomes a dead give-away that cosmetic work was done on the face – a fact that you may not wish to share with friends (or family, for that matter).

A variety of surgical options exist for dealing with neck problems. These include full lifts, mini-lifts, minimal incision lifts, and S-Lifts. All are predicated on removing excess skin, shoring up the underlying tissue, and reinforcing the long, thin, sheet-like muscle layer, known as the platysma. This muscle extends from our jaws down to the upper chest and is responsible for much of the structural support and elasticity of the neck. For this reason, a surgical neck lift procedure is referred to as platysmaplasty.

But all these methods of repair are true surgery, which are expensive, postoperatively painful, and demand protracted recuperative times away from work and social activities. Happily, a number of completely non-surgical approaches, several of which I have either improved upon or developed myself, may be used to get rid of unsightly necklace lines and turkey necks.
Since the platysma is after all a muscle, once again the unique muscle-relaxing properties of Botox Cosmetic can be marshaled to play an important role.

Micro droplets of Botox can be implanted along (and sometimes above and below) the necklace lines at approximately half inch intervals. The immediate appearance of the treated areas looks like a series of tiny mosquito bites strung like beads around the neck. These little bumps are quickly and completely absorbed usually in the next twenty-four hours. For most people, diminution or elimination of the lines is seen somewhere between twenty-four hours and two weeks afterward. Benefits tend to last up to six months, after which touch-ups for maintenance may be given as needed.

Combining Botox Cosmetic and volumizers is best for dealing with the vertical neck cords. In order to accentuate the ropeyness of the neck, you will first be asked to grit your teeth tightly together. Next, tiny amounts of Botox are injected down the entire stretch of each cord to slightly weaken the underlying muscle sheet. This allows the platysma to redrape itself over the length of the neck, diminishing the appearance of the cords. To supplement the effect, small amounts of Botox can also be injected along the underside of the jaw line. This serves to dampen the downward pull of the uppermost portion of the neck muscles. It gives the facial musculature immediately above the jaw line just enough of a competitive edge to act like a sling and pull the neck upward on both sides of the lower face.

To enhance and to prolong the improvement, Radiesse a calcium hydroxylapatite-containing volumizer can be instilled along the jaw line, into the depression immediately under the chin, as well as horizontally and vertically as needed along the angle between the neckline and chin line (about a half-inch above the Adam's apple). The pull exerted in all directions by volumizing these regions further reinforces the sling effect created by the Botox. Radiesse not only imparts immediate volume to the treatment areas, but stimulates native collagen production several months later on, which serves to lengthen the duration of the overall improvement to somewhere between nine and eighteen months in my experience. Juvederm UltraPlus and Perlane, two heavy-duty hyaluronic acid fillers, have also been used successfully for this purpose, with results lasting between eight and twelve months.

The choice of which agent to use will depend upon a number of factors. If budgetary considerations come into play, if you are unsure of how you will like the effect, or if you have a big business or social event very shortly afterward, you would do well to choose the hyaluronic acid products. They are less expensive, are less likely to cause significant bruising or swelling immediately afterward, and offer a relatively shorter period of time in which to "try out" the new look. If you are not completely satisfied, Radiesse may be used instead the next time for longer-term improvement.

The accompanying images illustrate a dramatic “before” and “after” of a non-surgical neck lift using Botox and Radiesse. In this case, the “after” was taken immediately following treatment. The relatively minor redness toward the center of the neck from the injections of the volumizer was easily masked with a cover up makeup, and disappeared in a few days.

Fees for the procedure may range from $2,000 - $3,000, depending upon locale and the type and amounts of materials used. These days, with non-surgical neck lifting, you will have ample reason to hold your head up high.

Non-Surgical Lip Enhancement

Non-Surgical Lip Enhancement
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by Nelson Lee Novick, M.D., FAAD, FAACS

After the upper third of the face, particularly the eyelids and brows, the lower third is considered the next most important cosmetic unit of the face. And the lips are the showpieces of the region. Any improvements made to them enhance the entire area, even if no other changes are made to the chin, the nose, or the skin immediately above and below them. As it does with the eyes, rejuvenation in this location contributes significantly to an overall look of health, well-being, and youthfulness of the entire face.

The lips, like other areas of the face and neck, change with age, typically shrinking slowly over time and losing the sharp definition of their borders along with much of their bulk. Even the philtrum, the so-called Cupid’s bow, located centrally above the upper lip and below the nose, becomes more flattened and less defined. When full and plump, the lips convey youthful softness and sensuality. By contrast, when thin and asymmetric, they may contribute to an appearance of sternness, meanness, or even untrustworthiness. The literary expression "pursed lips" speaks to a close association between our mouths, our emotions, and how we may be perceived by others.

To conform to the “ideals” of beauty in Western culture, your lips must be of a certain size, shape and proportion to one another. Lips like those of Angelina Jolie may not be quite your thing, but in general when it comes to them, size does matter. The width of the mouth should be no wider than the distance between the inner colored portions of your eyes. And the upper lip must be no more than three-quarters the fullness of the lower lips in order to assure that a protruding pout is maintained, regardless of just how plump or full each of the lips is individually.

Finally, in profile, there should be a gentle S-shaped curve between the bottom of the lower lip and the chin with an approximately one-fifth of an inch rounded depression between the base of the lower lip and the chin. If these measurements are not respected, the mouth may not only look out of proportion, but downright odd-looking.

The loss of lip mass with age may also give rise to several other aesthetic problems. Thinning lips can create the illusion that the upper lip (or actually the space between the upper lip and the base of the nose) is elongated. In addition, the volume loss can accentuate the vertical, so-called “lipstick bleeding” lines above and below the mouth. These wrinkles are sometimes referred to as “smoker’s lines, although they are quite common in non-smokers. Taken together, the changes can impart an aged, withered, and stern appearance to the lower face.

A number of surgical methods for lip augmentation have been devised to address these problems. In general, they rely upon the insertion of synthetic implants, such as Gore-Tex or Softorm. These products are non-dissolving, non-organic substances that are manufactured from the same material from which some forms of permanent surgical sutures are currently made.

Alternatively, implantable tissue for the lips may be harvested from elsewhere in the person’s own body. This is known as an autologous graft and may be obtained from tissue removed when the individual undergoes another surgical procedure, such as a tummy tuck or breast reduction. If this is not available, a small piece of the patient’s dermis (skin stripped of the epidermis) or fascia (the tissue layer covering muscles, usually the temple muscle) can be surgically retrieved for grafting. Dermis derived from donor tissue (Alloderm) has also been implanted. But whatever the material chosen, it must be shaped and then surgically threaded through the lip from one side to the other. To reach the desired plumpness, several strips of material often must be inserted into each lip.

Non-surgical lip enhancement addresses the problems of aging lips without the need for any cutting. Lip enhancement is not restricted to replenishing volume loss within the red portions of the lips, what doctors call the vermilion. It can also be used to restore the integrity of the lip boundaries, the vermilion border, which is the white, hair-free line that outlines the margins of the lips and separates them from the skin immediately above and below.

A variety of volumizing injectables have been tried for the lips, including collagen. However, the hyaluronic acid fillers have proven to impart a smooth effect with little chance of any lumpiness. Restylane is my personal favorite for the vermilion and vermilion border.

The procedure is quick and simple. The lips, being especially sensitive, are first sprayed with a topical numbing agent, such as Cetacaine, that dentists use before injecting gums. Afterward, they are anesthetized locally with lidocaine. Following this, the borders of the lips are filled along most of their length. Doing this simultaneously softens the appearance of any vertical lip lines, reducing the need to outline the borders of the lips with lip lining pencils. Next, the body of the lips themselves is plumped to the desired shape and configuration, keeping the proportions mentioned above in mind. If desired, the lines of the Cupid’s bow can also be accentuated with filler, creating the so-called “Paris Lip” that was all the rave about a decade ago.

If the vertical lipstick lines are especially long and numerous, each may be filled with a tiny amount of Restylane or another hyaluronic acid filler, such as Juvederm Ultra, and then two micro droplets of Botox Cosmetic can be instilled on each side of the upper and lower lips to complement and prolong the effects of the filler.

The entire procedure generally takes no more than about ten minutes. Slight swelling and bruising are common afterward, but these usually disappear within a few days. Lipstick can be applied immediately afterward. Results usually last about four to six months. When all of the above is performed, the cost may range from $750 to $1500, depending upon the kinds and amounts of materials used.

The accompanying images demonstrate the lips before and after treatment with Restylane alone. In this person, only the vermilion lip border and the body of the lip were treated. Note how much more vibrant, healthy, and youthful the lips are following treatment. So, what’s stopping you? Pucker up.
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Non-Surgical Eyelifts/Browlifts

Non-Surgical Eye Lifts
www.skinsavvy.fromyourdoctor.com
by Nelson Lee Novick, M.D., FAAD, FAACS

While some may argue whether "the eyes are the window to the soul," few would argue their enormous aesthetic importance to our overall appearance. In Western culture, unlike some Far Eastern societies, we relate to each other by looking first into the other person's eyes. The familiar expression, "seeing eye to eye," attests to the significance of relating to one another through our eyes. For this reason, whatever improvements we make in the aesthetic appearance of our eyes carries a disproportionate benefit, a total effect that goes above and beyond the mere improvement of the eye areas. In other words, just by making the areas surrounding them healthier-looking, more attractive, and more youthful, we are taking a long stride in the direction of rejuvenating our entire face.

With the passage of time, the eye unit, which comprises the upper eyelids, lower lids, and eyebrows, suffers from a number of different aesthetic problems that result from chronic sun damage, genetics, gravitational changes, improper nutrition, smoking, and alcohol or substance abuse. In an article on non-surgical facelifts, I describe how over the decades, the heart-shaped pad of fat that sits squarely over the cheekbone in youth shrivels and slides slowly down off the cheek and heads inward toward the nose, leading to accentuation of the smile lines and "parentheses" lines around the sides of the nose and on the lower cheeks, and the sad lines surrounding the mouth and chin.

But the sinking fat pads may also give rise to profound effects in the appearance of the lower eyelid region. When they are in their proper place, the plump fatty tissue serves to physically intercede between the surface of the skin and the dark-colored blood vessels located below. So when they shrink and move downward, dark circles appear under the eyes.

When robust and present, they also buoy up the skin above and stretch it tightly. With their loss, the skin of the lower lid may become grainy and sunken-looking, and “tear troughs” may begin to appear. The tear trough (what doctors call the nasal-jugal groove) is a fanciful description for the channel-like region located between uppermost portion of the cheek and the bottommost section of the lower lid.

Having lost much of its youthful elasticity, the skin under the eyes fails to redrape itself smoothly and tightly. Instead, like a balloon that has lost all its air after a long period of inflation, the skin there may appear wrinkled and crinkly, like crepe paper. To make matters worse, an age-related weakening of the tiny, strap-like muscles located directly under the eyes may allow small amounts of the fat deposits that are normally hidden below them to herniate (stick out), giving rise to what doctors call "festooning," or, in lay language, bulging below the eyes. Dark, "panda-eye" circles, puffiness of the lower lid, crepe-like quality, wrinkles, and "tear troughs" are the unhappy result of all the above changes.

Fortunately, a combination of Botox Cosmetic and an appropriate volumizer, a volume replacement material, can significantly improve each of these problems. Two tiny drops of Botox instilled directly into the baggy tissue below the eyelids has been demonstrated in many cases to diminish or soften the wrinkling and crepe-like quality. Using a technique bearing the cumbersome name of suborbital augmentation, the tear trough deformity as well as the sunken area immediately above it may be inflated with Radiesse (Juvederm Ultra Plus or Perlane can also be used). Suborbital augmentation not only can raise the trough (the depressed area itself) but is also capable of compressing the crinkly area just above it (the region immediately under the eye) to diminish wrinkles and the crepe-like quality and level out any bulges. At the same time, by revolumizing the entire area, the blood vessels located below once again become much less visible through the surface, diminishing the appearance of dark circles.

Not being immune to the aging process, the upper eyelids suffer their own problems. Excessive or redundant (sagging) skin on the upper lid, known as dermatochalasis, can not only be an aesthetic liability, but when severe can actually interfere with vision. In most cases, however, it just makes the eyes look hooded and tired.

The position of the eyebrows is another casualty of father time. In young women, the inner half of the eyebrow lays directly over the rim of the bony orbit. Two-thirds of the way across in the direction of the temples, the brows flare upward above the brow line buttressed by an outwardly projecting mound of fat. When this fatty tissue shrivels and flattens with age, the outer brows sink to level of the rim of the orbit or even below it. The now downwardly directed outer third resembles the shape of the normal male brow and imparts a sterner look to the female countenance.

To remedy these changes, Botox Cosmetic may used for what has been called a "chemical brow lift." To weaken the downward traction of the muscles in this area that is in part responsible for the fallen eyebrow, Botox is injected directly under the outermost segment of the hairs of the eyebrows. By, in essence, giving an advantage to the upwardly pulling counterparts of the treated muscles, the sagging outer brow is lifted back up to its original position ABOVE the bony rim of the orbit. Finally, the volumizers, Juvederm UltraPlus and Perlane, each have been used successfully to both restore youthful fullness directly below the outer brow and complement the effects of the Botox. Consistently gratifying results (for both patient and doctor) in restoring the eyelids and brows (as well as cheeks, jowls, noses and lips) using these materials and techniques have led some cosmetic dermatologists to refer to these treatments by the acronym RAVE, which stands for Regional, Aesthetic, Volume Enhancement.

The accompanying images demonstrates non-surgical rejuvenation both of the lower and upper eyelids and eyebrows. In the "after" shot, which was taken immediately following treatment, note that the trough is no longer visible below the eye. In addition, the brow has been lifted sufficiently to diminish sagging, to give more “show” to the upper lid, and to reproduce the youthful flare of the outer brow. Consequently, the eye appears wider.

Fees for lower lids and brows generally range between $750 and $1500 each. Lids and brows together usually takes no more than ten minutes to treat, and the results may last from eight to twelve months before a touch-up may be needed.

Non-Surgical Nose Jobs

Non-Surgical Nose Jobs
www.skinsavvy.fromyourdoctor.com
by Nelson Lee Novick, MD, FAAD, FAACS

You’ve stared at your nose in the mirror for years wishing that something could be done to improve the bump on the bridge, eliminate the indentations along the surface, or raise up a downturned tip. But, you could never gather up the courage or the money for a surgical “nose job,” or what doctors call “rhinoplasty.” Or maybe you just couldn’t bear the thought of a long, painful recovery or afford the added expense of a two-week recuperative downtime away from work. Now, with a completely non-surgical nose job, you just might be able to have your cake and eat it.

A state-of-the-art, soft-tissue volumizing material, Radiesse, and the fillers, Juvederm, and Restylane, may be just the answer for you. All three are FDA-approved materials, and each material’s safety has been well established in extensive human use in the United States as well as in many parts of the world where they were available long before their introduction here.

Your doctor may choose to use only one of these materials or may combine them. Radiesse, for example, may be injected more deeply to supply support to overlying tissue, while the hyaluronic acid products may be selected in order to achieve more superficial, finer shaping.

The precise combination chosen will often depend upon physician preference and the specific types of irregularities being treated. Since the risk of local allergy is so low, neither Radiesse, a synthetic bone-like material made up of calcium hyroxylapatite, nor Juvederm and Restylane, synthetically produced hyaluronic acid derivatives, require pre-treatment skin testing. If you wish, you may literally be treated at the time of your initial consultation, something I frequently do in my practice.

Prior to the procedure, the area to be treated is injected with a mixture of diluted volumes of lidocaine, a fast-acting local anesthetic, and epinephrine, a blood vessel constrictor. The addition of the epinephrine serves to reduce the likelihood of oozing from the injection sites and of bruising afterward. Once the area is numb, the volumizer or filler is injected and then molded like clay into place to correct the deformity or irregularity. The whole procedure usually takes only about five minutes to complete, and to the delight of the patient, in most cases, the results are immediate. Afterward, you may experience some redness, mild swelling, and tenderness, which may last one to three days. Occasionally, despite the epinephrine, you may develop some bruising that can take several days to fade, but is easily coverable with proper masking makeup.

For a drooping nasal tip, a very common occurrence with aging or following pregnancy, tiny droplets of Botox Cosmetic, which have been used so successfully to treat the dynamic wrinkles of the face, are injected directly into the crevasses on each side of the nose as well as to the base of nose where it joins the upper lip. This gently weakens those muscles responsible for pulling the nose downward and permits the small muscles higher up along the nose to draw the tip upward unopposed. The net result is that the tip is repositioned to a more youthful appearance.

Next, a small amount of Radiesse placed along the base of the nose serves to buttress the tip upward and reinforce the effects of the Botox Cosmetic, contributing to a much longer-lasting result than would be achieved with Botox alone.

To smooth a bump or hump on the bridge of the nose, Radiesse is my augmenting agent of first choice. A tiny amount layered between bridge and the root of the nose can straighten a bent or hooked appearance with immediate and often dramatic improvement. The before and after photos shown here were taken just ten minutes apart.

The results with Radiesse may last twelve to eighteen months and those of Juvederm and Restylane for eight to twelve months before a touchup may be necessary. Depending upon the area of the country and what materials are used, a non-surgical nose job may cost between $750 and $1500.

Your doctor will discuss with you whether non-surgical rhinoplasty is appropriate for you, the benefits of each agent, and the best material or combination of injectables for your particular needs. So what are you waiting for?
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Nelson Lee Novick, M.D.
www.skinsavvy.fromyourdoctor.com

Non-Surgical Facelifts
by Nelson Lee Novick, MD, FACP, FAACS

For more than two decades, bovine (calf-derived) collagen injections, Zyderm, and Zyplast, were the only augmenting materials available in the United States for treating wrinkles and furrows, and I was one of the first cosmetic dermatologists to use them when they were first introduced in 1983. From the outset, injectable collagen treatments were fraught with drawbacks.

For one thing, while adequate for treating fine wrinkles, they were often inadequate for dealing with deeper wrinkles and furrows, and they were certainly of little value for facial volumizing and contouring. Moreover, nearly 3 percent of people were allergic to the products, and two pre-treatment skin tests spaced a month apart were required before actual treatment could begin. Finally, the benefits lasted between three and six months only before retreatment was necessary. For severe wrinkles, jowls, and sagging, going under the cosmetic surgeon’s knife, with all its risks and downsides, remained the only recourse.

Happily, the past five years has witnessed a literal explosion in the number of FDA-approved, injectable filling and volumizing agents in the United States – fillers for fine and moderate wrinkles, and volumizers for correcting sunken areas, recontouring surface irregularities and restoring fullness to the skin. Along with Botox Cosmetic (not technically a filling agent, but certainly a premier injectable for improving all kinds of expression line, movement-related wrinkling), which received its FDA-approval in 2002, many non-collagen fillers and volumizers were introduced. These included hyaluronic acid products, such as Hylaform, Captique, Elevess, Restylane, and Juvederm, and volumizers, such as Radiesse and Sculptra. Unlike collagen, these substances, largely synthetically produced (with the exception of Hylaform that is derived from the cockscomb of roosters), did not require any prior allergy testing. This meant a person could literally walk in off the street and be treated the same day. What’s more, their results lasted far longer, especially for the volumizers, whose benefits may persist between 12 to 24 months or even longer. For that reason, they are labeled as semi-permanent, rather than temporary filling materials.

Between 2000 and 2005, the use of soft tissue filling agents and volumizers for non-surgical rejuvenation procedures increased by an astonishing 34 percent, and not surprisingly, the number of surgical facelifting procedures decreased by a whopping 20 percent during roughly the same time period. The “liquid facelift” had come of age.

I want to make it perfectly clear that I am not asserting that there is no place anymore for aggressive, surgical facelifting, technically known as “rhytidectomy” or “rhytidoplasty.” For extreme cases of large jowls, excessively sagging and redundant skin, and deep furrows, the facelift remains an appropriate therapeutic option. I am saying, however, that we now have the tools to parallel many of the benefits of facelifting without ever touching a scalpel to the face. Moreover, we can even improve appearance in many ways that traditional surgery could not.

We have recently discovered that shrinkage of underlying dermal tissue, shifts in fat deposits, and alterations in bone and cartilage as we age are responsible for many of the changes we see in facial aging. In short, the robust, heart-shaped fat pads that sat directly over our cheekbones and gave our face fullness when we were younger not only shrink with time, but sink downward and inward toward the nose, leaving the tell-tale signs of their descent in their wake. When this happens, we find hollow-looking, darkened and crinkly or bulging lower lids, and pronounced smile lines on the sides of our noses. The weight of this fall also accentuates the unsightly jowls along the jaw line.

A traditional surgical facelift, by simply pulling taut the skin, may soften the lines around the nose and mouth and lift the jowls, but it does nothing to address the underlying volume loss and displacement. In fact, we very often saw people appearing “skeletonized” by the operation. They were left with unnaturally tight-looking skin that was a sure sign of “Oh, she’s had a facelift.”
Of course, it goes without saying that true, surgical facelifts are real surgery entailing the risks of general or intravenous anesthesia, significant post-operative pain, bruising and swelling, prolonged recuperation times (two weeks out of work and several months before all swelling finally goes away), scarring, and a considerable financial outlay. Contrary to popular belief, the benefits of facelift surgery are not permanent. The surgery may be repeated once or twice in a lifetime.

Non-surgical facelifting, combining Botox Cosmetic with fillers and volumizers, goes to the heart of the underlying problems: dynamic wrinkles (wrinkles caused by the muscles of facial expression), and the replacement of lost or displaced volume. A few micro droplets of Botox is quite efficient for eliminating or softening the horizontal “worry” lines across the forehead, the crow’s feet lines on the sides of the eyes, and the scowl (or “frown”) lines between the eyes. It can also alleviate the crinkly “bunny” lines along the bridge of the nose and a “pebbly” chin. For deeper wrinkles, the effects of Botox may be supplemented with the use of fillers, like Restylane or Juvederm. This combination has been found to be particularly effective, and the benefits of combination therapy last far longer than when each material is used alone. These same fillers can be injected to elevate the smile lines and the sad lines.

Jowls along the jaw line can be softened with Radiesse by adding volume to the notched areas surrounding the jowl, eliminating the appearance of the jowl and contouring the jaw line back to the smooth, straight line of youth. And finally, volume may be restored and recontoured over the cheekbones with Radiesse.

To minimize discomfort, the designated areas are “frozen” beforehand with a small amount of local anesthetic, usually lidocaine, a faster acting anesthetic than novocaine traditionally used by dentists. Although I personally find it unnecessary, some doctors choose to employ a nerve block, i.e. to anesthetize the larger branches of the nerves that supply the face, to supplement the local anesthetic.

Once the treatment area is numb, the volumizer or filler is injected and then molded like clay into place to correct the deformity or irregularity. The whole procedure usually takes only about thirty minutes to complete, and to the delight of the patient, in most cases, the results are immediate. Afterward, you may experience some redness, mild swelling, and tenderness, which may last one to three days. Occasionally, you may develop some bruising that can take several days to fade, but is easily coverable with proper masking makeup.

The accompanying photos show a before and after of a completely non-surgical “liquid” facelift in a 72 year old woman. In the “after” photo, note the dramatic improvements in the jaw line, absence of jowls, the fuller cheeks, and the improvement in the wrinkles around the nose and mouth. This shot was taken immediately following treatment and serves to emphasize that non-surgical facelifts, which are done entirely under local anesthesia, demand little or no downtime and cause minimal bruising, swelling, or tenderness. You may have noticed that the tip of her nose is upturned in the “after” photo. She also had a non-surgical nose job (the subject of another article in this library) done at the same time. This patient headed for a social luncheon directly afterward – proof that the day of the non-surgical facelift has definitely arrived.
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