Lip Lines: Reversing Tissue Loss

We now understand that many of the aging changes are due to loss of deeper tissue. One of the most frustrating forms of this, especially for women, is loss of tissue in the lip. This is something that is visible every time one looks in the mirror, and is often noticed by friends and acquaintances. The fine lip lines form chanels encouraging the migration of lipstick.

Previously we did not have a satisfactory answer for this. Laser resurfacing would eliminate the lines but was associated with considerable down time and considerable risk of permanent color change. Injecting filler into the lines was only a partial solution and not infrequently replaced the line with an elevated ridge.

Now we have thinner fillers available to us. These enable us to spread a thin layer of filler across the entire lip, replacing some of the lost tissue and reducing the lines. Furthermore, the filler also induces the skin to make new collagen, so after one or two treatments the results become longer lasting.

The photo above is before filler was added.

This photo is several weeks after filler was added.

This photo is before filler was added.

This photo was taken several weeks after filler was added. With time the body will create new collagen that will make this result semi-permanent. Furthermore, this approach can be used to repair the skin on other parts of the face where the skin is crepey.

 

Gerald N. Bock MD

California Skin & Laser Center

Stockton & Lodi, CA

The Women with Blue Eyelids

As the use of fillers becomes more widespread and sophisticated, more physicians, and some non-physicians are trying their hands at it. Originally collagen was used as a wrinkle filler and, while there were occasional side effects, for the most part they were limited to some assymetry with the more serious problem of interference of the circulation to the lower mid forehead skin occurring only rarely.

Now the collagen fillers have been replaced by new families of fillers that bring with them new potential problems. The most commonly used fillers are the hyaluronic acid fillers, such as Restylane or Juvederm that, when placed beneith thin skin, can produce a bluish discoloration.

The change in the use of fillers from wrinkle improvers to facial sculptors, replacing facial volume lost with aging, has resulted in the need for more skilled injectors and increased the variety and risks of complications.

Tattoo breakthrough

As tattooing has become more common, the demand for tattoo removal has increased. It is said that 36% of Americans have tattoos. It's difficult to know the percent of people who regret this decision, but the figures quoted online go from 25% up to 80+%. Despite these high numbers, only a small percentage actually get their tattoo removed. The primary reason for this is that tattoo removal takes a long time and is much more expensive than having a tattoo put on. It hasn't helped that there has been no significant advances in tattoo removal machines for many years. Now a recent publication suggests that it is possible to remove tattos much more quickly and less expensively.

 

In an article in the February Journal of the American Academy of Dermatology, researchers from Greece and Boston reported the results of the treatment of 18 tattoos. Each tattoo was divided in half, and one half was treated with traditional treatments, while the second half was treated with 4 traditional treatments on the same day, with each treatment separated by 20 minute intervals. The repeated treatments were associated with increased pain, sometimes requiring local anesthesia.

The multiply treated sides were lighter after the treatment, and in most the tattoo disappeared in 6-10 weeks. In none of the traditionally tattoos did the tattoo disappear completely. With the new method 5 of 8 (63%) of professional tattoos and 6 of 7 amateur tattoos (86%) cleared completely. 

Areas that had been tattoed more than once did not respond as well, and darker skin types and more dense tattoo pigment were associated with more pain. There were no increased side effects associated with the multiple treatments.

Although the study involved a small number of patients it seems very likely that this will open the door to tattoo removal for many who found it impractical before.

Gerald N. Bock MD

California Skin and Laser Center

Stockton & Lodi, CA

Sculptra: An Old Filler Resurrected

 Sculptra is a unique filler that was first approved in the US in 2004, for treating facial lipoatrophy (fat loss) in AIDS patients. It consists of a suspension of particles of poly-L-lactic acid, a material that has long been used in the skin as an ingredient in absorbable sutures. Although it was legally used for cosmetic purposes immediately after its initial approval, it received official FDA approval for this indication in July 2009.

Change Your Eye Color With A Laser?

Currently, if someone wants to change their eye color, they're limited to using colored contact lenses. However, Dr. Gregg Homer, a US physician, is currently testing a laser that will permanently change eye color from brown to blue. 

Topical Botulinum Toxin is Coming!

Botulinum toxin first came into clinical use in the early 1990s. Since then it has become very widely used, and is a billion dollar business. It acts by blocking the transmission of the signal from the nerve to the muscle, so the muscle is not stimulated and does not contract. Fortunately, the product is specific for the motor nerves and it does not affect the sensory nerves. Thus there is no localized loss of sensation or numbness associated with the use of botulinum toxin.

From the onset, the product has been injected into the target muscles. The toxin molecule is large, and it is difficult to get large molecules through the skin intact. Furthermore, in many areas the product must be placed precisely, so as not to affect muscles that would give an undesireable effect. Droopy upper lids or an assymetrical smile are examples of unwanted botulinum toxin effects.

Pan-Facial Filling: The End of the Facelift?

As our understanding of what causes facial aging advances, our approaches to this problem are advancing as well. Gravity as an explanation for the aging changes in the face has been discredited. Three factors are now recognized as important in facial aging: changes in the skin quality, mostly due to insults from the environment, but also due to biological changes that are not fully understood; repeated folding of the skin and loss of volume of the underlying tissues that support the skin. It is the last of these changes that I will discuss here.

For a while we have recognized that the loss of facial soft tissue: fat, muscle and connective tissue, have played an important part in facial aging. More recently it has become clear that loss of bone also plays a very important role. The openngs for the eyes are much larger in the skull of a 50 year old, than in the skull of a 20 year old. The jaw bone of a 20 year old is thicker and wider than the jaw bone of a 50 year old. These changes not only cause deflation of the face, but change the proportions. In the young individual the upper lip occupies 1/3 of the distance from the bottom of the nose to the tip of the chin. In the elderly it takes up 1/2.

Fat Injections: A Boon or a Bust?

The popularity of fat injections has risen and fallen, and appears to be on the rise again. The realization that many of the facial changes of aging are due to the loss of volume of both soft tissue and bone, has dramatically increased the use of fillers. Because the commercially available fillers are relatively expensive, fat grafting has been attractive as a relatively inexpensive source of a large volume of filler material, material that is native to the patient and should not cause allergic reactions.

Liposuction = Weight Loss?

Many people approach liposuction with the hope that this procedure will aid them in controlling their weight. However, ever since the early days of liposuction, and even with some physicians preforming large volume liposuction, it has been clear that people who have liposuction do not end up weighing less. The standard mantra has been that liposuction, and almost certainly Zeltiq as well, are spot reduction measures and not weight reduction measures. However, until now there has not been a good explanation for this. After all, it seems logical that if a pound or two of fat were removed, the patient should end up weighing a pound or two less. A study recently published in the journal "Obesity" provides some explanations.

Tattoo Removal: Improvement with Laser Combinations?

In the early 1990s the Q switched lasers were introduced for the treatment of tattoos. They represented a significant advance over previous treatment methods (dermabrasion, salabrasion, excision etc.) in that they were able to remove pigment with relatively little damage to the surrounding tissue. By using very short, high intensity pulses of light, high levels of energy were delivered to the target (tattoo pigment) causing it to shatter. Since the laser emits a single wavelength of light, a light frequency could be chosen that was absorbed by the pigment but not by the surrounding tissues. The most commonly used frequency has been 1064nm emitted by the NDYag laser. This frequency is well absorbed by dark blue and black pigment, the most frequently used colors in tattoos. When the light frequency is halved to 532nm, a technical trick that is not too difficult, red pigment can also be treated.

Two significant problems remain. First, multiple treatments are necessary. When the laser light interacts with the skin and the pigment, rapid inflammatory changes occur that greatly reduce the transmission of the laser light. Therefore it is necessary to stop the treatment after one or two passes and allow the inflammation to subside before the next treatment.

The second problem is that there has been a proliferation of colors used in tattoos, and these pigments do not react with the 1064 or 532 wavelengths. As a result there are a lot of tattoo colors out there that are difficult or impossible to treat effectively. Green pigment is relatively common, and treatment requires a different wavelength which is delivered by the alexandrite laser. Unfortunately, these lasers cost $60-90,000 and there are very few centers that can afford to buy one for the primary purpose of treating green tattoos. Some colors, such as sky blue, yellows and tans do not respond well to any current laser.

Since the original development of the Q switched lasers, there has been no significant in tattoo removal technology. In the January 2011 issue of Dermatologic Surgery Weiss and Geronemus published preliminary results of their studies on using laser combinations to treat tattoos.