Monday, June 2, 2008

The Ten Minute Eyelift

The Ten Minute Eyelift

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

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

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

by Nelson Lee Novick, MD, FAAD, FAACS


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

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
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

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